Idiopathic Hydrocephalus Research Articles

Endoscopic treatment of patients with idiopathic hydrocephalus with extraventricular cisternal obstruction of the cerebrospinal tract

The possibility of developing extraventricular CSF pathways obstruction was demonstrated in the mid-20th century. The development of neuroimaging (mainly MRI) and endoscopic techniques made it possible to plan and perform minimally invasive surgeries in a narrow anatomical corridor and achieve the regression of neurological symptoms. Purpose of the study: to determine the effectiveness of endoscopic surgery for hydrocephalus due to idiopathic extraventricular CSF pathways obstruction. Materials and methods. Sixty-five patients with signs of extraventricular obstruction underwent examination and surgical treatment at the Center of Neurosurgery from 2007 to 2020. The preoperative Kiefer Scale score was 6.8±3.3 (0-15) points, and the Rankin Scale score — 2.2±1 (0-5) points. Endoscopic third ventriculocisternostomy was performed as the first operation in 42 (64.6 %) patients. Ventriculoperitoneal shunting was performed in 17 (26.1 %) patients. Six (9.2 %) patients were not operated on. Results. After endoscopic surgery, the condition of the patients significantly improved (p < 0.001) after 2 and 12 months. Complete or partial regression of symptoms was noted in 85 % of the patients 1 year after surgery. After shunt surgery, the trend was comparable. The only radiological parameter that changes and correlates with the patients’ condition is the position of the premammillary membrane and the flow void. The remaining indicators of the CSF system of the brain did not actually change. In all cases of the endoscopic surgery, an additional membrane conglomerate that corresponded to preoperative tomograms was found under the premammillary membrane. Conclusion. The high efficiency of endoscopic third ventriculocisternostomy allows recommending this technique as the primary one in patients with extraventricular CSF pathways obstruction, with the exception of cases of anatomy abnormalities of the third ventricular fundus area (short premammillary membrane in combination with a high-lying basilar bifurcation) and cisterns of the posterior cranial fossa base (narrow cisterns, whose dimensions do not allow inserting an endoscope under the premamillary membrane).

Neuroradiological characteristics of hydrocephalus due to idiopathic extraventricular CSF pathways obstruction

The development of research on CSF flow disorders made it possible initially to divide hydrocephalus into «communicating» and «non-communicating», and subsequently to distinguish the concepts of «intraventricular» and «extraventricular» obstruction. Improvement of radiological imaging technologies has allowed determining the exact level of CSF obstruction. In some cases, CSF flow disorders combine signs of different forms of hydrocephalus. Their correct classification allows selecting the type of surgical treatment, which reduces the rate of complications and patient»s dependence on the doctor. Purpose of the research: To study the radiological signs of hydrocephalus in idiopathic obstruction at the level of the posterior cranial fossa cisterns. Materials and methods. This study included adult patients (18 years old and over) whose disease was idiopathic in nature. From 2007 to 2020, 289 patients diagnosed with idiopathic hydrocephalus were treated at the N. N. Burdenko National Medical Research Center of Neurosurgery. Of these, 65 patients (18.7 %) had clinical and radiological signs of extraventricular obstruction. The male to female ratio was 25 and 40 (38.5 % and 61.5 %), respectively. A variety of radiological signs were assessed and their origin and occurrence in various forms of idiopathic hydrocephalus were determined. Results. FOHR was the highest (compared with other forms of idiopathic hydrocephalus (mean 0.52)). Other ventricular indices were also high. None of them correlated with the patient»s condition. Ventral dislocation of the premamillary membrane was detected in 89.2 %. Turkish saddle was of normal size in 51 (78.4 %) patients, while its enlargement was found in 13 (20 %) patients. A change in the periventricular signal was noted in 18.4 %. Aqueduct and IV ventricle outlets were patent in all cases as evidenced by CSF pulsation artifacts in T2 3D CUBE. The cerebral aqueduct was dilated in 63 (96.9 %) patients. Enlargement of the cisterna magna associated with hypotrophy of the caudal cerebellum was noted in 90.7 %, and this sign was significant for extraventricular cisternal obstruction (p <0.001). In addition to the T2 mode, the presence of sagittal sections in cisternography modes (FIESTA or CISS) was a prerequisite. By means of these modes, the ventral dislocation of the premamillary membrane was more clearly visualized, the presence of obstacles to the CSF flow in the cerebral aqueduct was excluded, and, most importantly, it was possible to determine the presence of additional membranes in the subarachnoid spaces between the ventral surface of the brain stem and the clivus. These were found in 100 % of the patients, which was also a significant pathognomonic sign (p < 0.001). Conclusion. The MRI picture of hydrocephalus with obstruction at the level of the posterior cranial fossa cisterns has specific signs. It combines the signs of other forms of hydrocephalus, chronic disease in combination with symptoms of the CSF pathways obstruction. It can be classified into a separate form and both endoscopic and shunt surgery can be used for treatment.

Clinical picture of hydrocephalus due to extraventricular cisternal CSF pathways obstruction

Introduction. The variety of clinical symptoms of hydrocephalus due to obstruction at the level of the posterior cranial fossa cisterns, or extraventricular obstructive hydrocephalus (EVOH), frequently goes against radiological semiotics and causes difficulties in developing patient management tactics.Materials and methods. Analysis of 65 patients treated for idiopathic hydrocephalus due to cisternal CSF pathways obstruction at the FSAI N. N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of Russia. All symptoms the patients complained of, which could be caused by hydrocephalus, were evaluated. Results. Extraventricular obstructive hydrocephalus has a longer history of illness compared to other forms of hydrocephalus and averages almost 4 years. The most common symptoms of the onset of the disease are headaches (41.5 %) and gait disturbances (29.2 %). When diagnosing, the main symptoms of the disease are gait disturbances (76.9 %), memory loss in relation to current events (76.9 %), headache (63 %), and pelvic disorders in the form of incontinence (46.1 %). Dizziness, nausea, arm tremor, amenorrhea, vomiting, pyramidal symptoms, and syncope are significantly less common. The clinical picture of patients under 60 years is characterized by common cerebral symptoms and mild signs of the Hakim-Adams syndrome. However, there is a different dependence for elderly patients. Endoscopic or shunt surgery can help to achieve complete or partial recovery. Conclusion. Thus, the EVOH clinical picture is diverse and often has completely non-specific manifestations, which match the anatomical changes in different brain structures according to MRI, but the sequence of occurrence of some symptoms is not explained. Each of the EVOH clinical manifestations, individual or in combination with other symptoms, should be considered as an indication for surgical treatment.

Surgical aspects of classification and neuroimaging characteristics of idiopathic hydrocephalus in adults

Background. Hydrocephalus can be developing by a traumatic brain injury, intracranial hemorrhage, tumor, meningitis of congenital malformation of the central nervous system. When the cause of the hydrocephalus is unclear it is supposed as idiopathic hydrocephalus. The most important classification features are the etiology and level of CSF obstruction. The classification was improved and developed with diagnostic and surgical methods simultaneously. Currently, the neurosurgeons have the possibility for usage of various methods and techniques of surgical treatment with their advantages and disadvantages. Systematization of radiological parameters is necessary to make a decision about the type of the surgery.Aim. To analyze and systematize the neuroimaging characteristics of various forms of idiopathic hydrocephalus in adults, to assess the possible classification of idiopathic hydrocephalus.Materials and methods. Between October 2011 and March 2021 290 patients with idiopathic adult hydrocephalus were operated at the N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of Russia: onset of symptoms in adulthood; no indications of the etiology of hydrocephalus and congenital hydrocephalus. The age of the patients was 50 ± 18.2 (18–85) years. The magnetic resonance images of patients were evaluated for the size of the ventricles, condition of convexital and basal subarachnoid spaces, obstruction of the CSF pathways, and changes in the position of the premamillary membrane, septum pellucidum, the roof of the 3rd ventricle and the tonsils of the cerebellum, the size of the sella turcica, the angle of the corpus callosum. The frequency of each of these parameters is statistically estimated for each form of idiopathic hydrocephalus.Results. Aqueduct stenosis has become the most frequent form of idiopathic hydrocephalus. Hydrocephalus in obstruction of the foramen of Monroe, aqueduct, foramen of Magendie, and cisterns of the posterior cranial fossa was significantly more characteristic of young people (p <0.05). Hydrocephalus with obstruction of convexital CSF spaces can be called hydrocephalus of the elderly (p <0.001). Hydrocephalus without verified signs of occlusion CSF pathways occurs equally in all age groups. The FOHR index was significantly more important, and only in case of cisternal obstruction. Enlargement one or both lateral ventricles and flattening of the roof of the 3rd ventricle is characterized for Monro’s foramen obstruction (p <0.001). The membrane at the outlet of the 4th ventricle and the absence of the “flow void” was typically only for patients with obstruction of the foramen of Magendie (p <0.001). Ventral dislocation of the premamillary membrane was characteristic of obstruction of the cerebral aqueduct, the foramen of Magendie, and cisterns of the posterior cranial fossa. Compression of the convexital CSF spaces occurred in case of obstruction of the aqueduct, the foramen of Magendie, but CSF spaces of the posterior cranial fossa – only with obstruction of the foramen of Magendie. Dilation of the 4th ventricle was significantly associated with obstruction of the foramen of Magendie and cisterns of the posterior cranial fossa (p <0.05). DESH symptom was significantly associated with obstruction of convexital CSF spaces (p <0.001). Additional membranes in the cisterns of the posterior fossa were found only in cases of cisternal obstruction (p <0.001). Cerebellar tonsils herniation was observed with obstruction of the foramen of Monroe, cerebral aqueduct, and foramina of Magendie.Conclusion. Because of statistical analysis, general signs found in all types of hydrocephalus, and private ones, characterizing only specific signs of the type of the disease, both were found. The classification is logical and justified, it is well applicable in neurosurgical and radiological practice. It allows rational planning of diagnostic evaluation and treatment of patients. A modern magnetic resonance imaging protocol should include T2 scans (with “flow void”) and FIESTA/CISS scans in the required planes, axial FLAIR scans.

Surgical treatment of patients with idiopathic obstruction of the foramen of Monro

Introduction. Idiopathic obstruction of the foramen of Monroe is an extremely rare pathology in adults and accounts for 1 % of all forms of occlusive hydrocephalus. The largest described series of patients with such pathology includes 4 adult patients. Four types of the foramen of Monro obstruction have been distinguished: type A – atresia, or stenosis, type B – morphological obstruction (membrane), type C – functional obstruction, type D – patent foramen. These patients usually undergo endoscopic or shunting surgery. Currently no algorithm exists for the treatment of such patients.Materials and methods. From 2004 to 2019 year 251 adult patients with idiopathic hydrocephalus were treated at the N. N. Burdenko National Medical Research Center of Neurosurgery. Of these, 11 people (4.4 %) had signs of obstruction at the level of the foramen of Monro. The average age of the patients was 41.9 years (25–67 years). The condition was more prevalent among women (8 female, 3 male patients). The most common symptoms were headaches and nausea. None of the patients showed signs of intracranial hypertension upon examination of the fundus. Magnetic resonance imaging of the brain demonstrated expansion of one or both of the lateral ventricles, stenosis of foramina of Monro, or their occlusion by membranes.Results. Patients were divided into 3 groups depending on the type of foramen of Monro obstruction. Type A obstruction was observed in 8 patients: in patients with unilateral obstruction (3 patients), only septostomy was performed, while among the patients with bilateral obstruction, 3 patients underwent septostomy followed by reconstruction and stenting of the right foramen of Monro (1 of these patients later required a shunting procedure), and in 2 patients, a shunting procedure was performed at initial presentation. Type B obstruction was observed in 2 patients: a patient with unilateral obstruction underwent septostomy and dissection of the membrane, and 1 patient with bilateral obstruction underwent septostomy, dissection of the membrane, and foraminal stenting. In a patient with type C obstruction, a septostomy and stenting of the right foramen of Monro were performed. Based on postoperative MRI data, the dimensions of the ventricles of the brain decreased or did not change. Most patients showed a complete regression of symptoms or their significant reduction, while one patient’s condition stabilized after surgery. There were no fatal outcomes or persistent complications. The follow-up period ranged from 4 to 60 months (29.4 months on average).Conclusion. In cases of idiopathic obstruction of the foramen of Monro, endoscopic surgery can be used as the treatment of choice.

Differential diagnosis of dementia in idiopathic normotensive hydrocephalus

Idiopathic normotensive hydrocephalus (iNPH) is a disease that affects the elderly, characterized by the classic triad of gait apraxia, urinary incontinence, and minor cognitive impairment or dementia, and cerebral imaging scans show the presence of ventriculomegaly and normal fluid pressure in the fluid c normal puncture. This disease must be in the list of differentiated diagnosis of patients presenting with the above manifestations. If the diagnosis of iNPH is confirmed, it should be treated at an early stage.

Experience of Application of Magnetic Resonance Myelography Methods in Patients with Neurological and Neurosurgical Pathology

Purpose — to study the possibilities of clinical application of MR-myelography techniques in static and dynamic modes in patients with various neurological and neurosurgical pathologies accompanied by CSF dynamics disorders. On the Philips 1.5 and 3.0 T MRI scanners, an extended protocol for examination of patients with cerebrospinal fluid disorders was presented. The protocol includes, in addition to routine sequences (T1-, T2-WI, FLAIR), thin-slice MP-myelography in a static mode (CSF-DRIVE, 3DMYUR) with soft tissues signal suppression. Also, a cinema-technique of MR myelography (CSF-PCA) in the optimal projection and a phase-contrast method with a quantitative assessment of the cerebrospinal fluid flow at the pathology level and at adjacent levels were performed. The assessment of the diagnostic significance of the proposed research protocol was carried out. The extended study protocol was applied in patients with idiopathic normotensive hydrocephalus, obstructive hydrocephalus, Chiari malformation type I, in patients with syringomyelia at the level of the cervical spinal cord and showed high efficiency in assessing of cerebrospinal fluid dynamics in patients with a neurological and neurosurgical profile. The use of extended approach allows to more fully evaluate the state of the cerebrospinal fluid system, the patency of the cerebrospinal fluid (the presence of additional septa / membranes, partial / complete stenosis and narrowing), as well as preand postoperative morpho-functional changes.

VP Shunt With Recurrent Malfunction in Two Pediatric Patients: Is the Hydrocephalus Truly Idiopathic?

VP Shunt With Recurrent Malfunction in Two Pediatric Patients: Is the Hydrocephalus Truly Idiopathic?

Technical Report: Durable efficacy of an endoscope-assisted syringo-panventriculoatrial shunt for concurrent hydrocephalus and syrinx

The management of syringomyelia in association with hydrocephalus can be a challenging pathology to treat with durable results. We present a durable treatment of a patient with symptomatic, idiopathic hydrocephalus, Chiari type I malformation, and syringomyelia with an endoscope-assisted placement of a single syringo-panventricular multiperforated shunt catheter via a transfrontal transaqueductal approach with simultaneous endoscopic third ventriculostomy (ETV). We discuss the technical details required for this single-shunt approach to a complex pathology, and indications for appropriate use of this novel approach in experienced hands. The patient rapidly improved radiographically and symptomatically, with a functioning shunt twelve years postoperatively. For surgeons well-versed in endoscopic techniques, this approach can be safe, durable, and obviate the need for an otherwise complex shunting system with multiple catheters, or a more traditional invasive craniovertebral decompression, in a patient with idiopathic hydrocephalus and a syrinx.

Идиопатическая гидроцефалия взрослых: современное состояние проблемы

The term "idiopathic hydrocephalus" in adults is a broader concept that includes larger spectrum of patients compared to "idiopathic normotensive hydrocephalus". It includes both young and elderly patients with various forms of the disease, patients with various levels of obstruction. Th ere is no general classification and general approach to treat patients with such a pathology. Endoscopic triventriculostomy in idiopathic aqueductal stenosis and cerebrospinal fluid shunting after a positive test of cerebrospinal fluid (tap test) evacuation in idiopathic normotensive hydrocephalus are proved to be effective. In patients with other forms of cerebrospinal fluid pathway obstruction, treatment approach is represented by the opinions of some surgeons. At the same time, most surgeons consider the use of cerebrospinal fluid shunting operations to be effective and justified, and they use endoscopic techniques as an option for examining ventricular system and for performing auxiliary manipulations. The high frequency of various complications of bypass surgery and slightly lower efficiency of endoscopic operations indicates the need to systematize patients; to improve selection criteria and to expand the indications for the use of endoscopic surgical techniques.

Complications associated with ventriculoperitoneal shunts in dogs and cats with idiopathic hydrocephalus: A systematic review.

BackgroundSeveral case series and case reports have been published about idiopathic hydrocephalus treatment in dogs and cats using ventriculoperitoneal shunts (VPS).ObjectivesTo determine the risk and type of complications in dogs and cats after VPS placement.AnimalsSixteen papers were included. Sixty dogs and 13 cats with idiopathic hydrocephalus treated by VPS placement were identified.MethodsThe databases CAB, Scopus, and Medline were used. Idiopathic/congenital hydrocephalus, feline/canine patients, ventriculoperitoneal shunting, complications, and outcomes were inclusion criteria. The focus was on complication type and time frame within which they arose.ResultsComplications in dogs (n = 60) were shunt obstruction (6/60; 10%), pain (4/60; 5.5%), shunt infection (3/60; 4.1%), disconnection (3/60; 4.1%), excessive shunting (2/60; 2.7%), and kinking (1/60; 1.6%). Complications in cats (n = 13) were coiling of the shunt in the SC tissue (2/13; 15.4%); kinking (1/13; 7.7%); and shunt obstruction (1/13; 7.7%). Complications were most likely during the first 6 months after shunt placement.Conclusion and Clinical ImportanceVentriculoperitoneal shunting is considered a viable treatment option for patients with hydrocephalus. Potential complications should be discussed with the owner. Early diagnosis of complications is essential.

Symptomatologie psychotique et hydrocéphalie : à propos d’un cas

IntroductionPsychiatric symptoms in patients suffering from chronic hydrocephalus raise specific etiological and therapeutical questions we will discuss in the following clinical case. CaseWe report the case of a 43-year-old woman who presents chronic idiopathic hydrocephalus with intracranial hypertension. Ten years after being diagnosed with hydrocephalus, the patient experienced two episodes of delirium within fourteen months of each other. DiscussionAlthough the clinical picture points to schizophrenia, some elements suggest however that the psychotic symptoms occurred after chronic hydrocephalus. These observations are discussed in the light of existing literature about the links between psychiatric disorders and chronic hydrocephalus, and neuroimaging studies which show ventricular hypertrophy among patients suffering from schizophrenia. ConclusionThere is a close connection between hydrocephalus and psychotic symptoms. A better understanding of these ties could improve our knowledge about the etiopathogenesis of schizophrenia.

Long-term outcomes of adult chronic idiopathic hydrocephalus treated with a ventriculo-peritoneal shunt

IntroductionAdult chronic idiopathic hydrocephalus (ACIH) is a cause of dementia that can be treated by implanting a ventriculo-peritoneal shunt (VPS). We aim to study clinical and functional outcomes in patients with ACIH corrected with a VPS. Subjects and methodsObservational cohort study of patients diagnosed with probable ACIH (Japan Neurosurgical Society guidelines) and undergoing shunt placement between 2008 and 2013 in a centre of reference for neurosurgery in Spain. Clinical improvement was classified in 4 categories (resolution, partial improvement, equivocal improvement, and no improvement); functional outcome was assessed on the modified Rankin scale (mRS). ResultsThe study included 29 patients with a mean age of 73.9 years; 62.1% were male and 65.5% had hypertension. Clinical improvement (complete or partial) was observed in 58% after one year and in 48% by the end of the follow-up period (mean follow-up time was 37.8 months). Older age, presence of hypertension, and surgery-related complications were more prevalent in the group responding poorly to treatment. One patient died, 20.7% experienced severe complications, and 69% were dependent (mRS≥3) by the end of the follow-up period. Age at diagnosis was independently associated with poorer clinical response at one year and a higher degree of dependency by the end of follow-up. ConclusionSymptomatic benefits offered by VPS were partial and transient; treatment was associated with a high complication rate and poor functional outcomes in the long term, especially in the oldest patients.

Evolución a largo plazo de la hidrocefalia crónica del adulto idiopática tratada con válvula de derivación ventrículo-peritoneal

IntroductionAdult chronic idiopathic hydrocephalus (ACIH) is a cause of dementia that can be treated by implanting a ventriculo-peritoneal shunt (VPS). We aim to study clinical and functional outcomes in patients with ACIH corrected with a VPS. Subjects and methodsObservational cohort study of patients diagnosed with probable ACIH (Japan Neurosurgical Society guidelines) and undergoing shunt placement between 2008 and 2013 in a centre of reference for neurosurgery in Spain. Clinical improvement was classified in 4 categories (resolution, partial improvement, equivocal improvement, and no improvement); functional outcome was assessed on the modified Rankin scale (mRS). ResultsThe study included 29 patients with a mean age of 73.9 years; 62.1% were male and 65.5% had hypertension. Clinical improvement (complete or partial) was observed in 58% after one year and in 48% by the end of the follow-up period (mean follow-up time was 37.8 months). Older age, presence of hypertension, and surgery-related complications were more prevalent in the group responding poorly to treatment. One patient died, 20.7% experienced severe complications, and 69% were dependent (mRS ≥ 3) by the end of the follow-up period. Age at diagnosis was independently associated with poorer clinical response at one year and a higher degree of dependency by the end of follow-up. ConclusionSymptomatic benefits offered by VPS were partial and transient; treatment was associated with a high complication rate and poor functional outcomes in the long term, especially in the oldest patients.

Predictive value of [123I]FP-CIT-SPECT on surgical outcome in idiopathic adult chronic hydrocephalus: A pilot study

Predictive value of [123I]FP-CIT-SPECT on surgical outcome in idiopathic adult chronic hydrocephalus: A pilot study

Cerebrospinal Fluid Tap Test in Idiopathic Hydrocephalus Patient with an Evans' Index Less Than 0.3

A 73-year-old man presented with progressive gait impairment. He exhibited slow, shuffling, and unstable gait. A formal neuropsychological evaluation revealed memory deficits with frontal dysfunction. Brain MRI revealed communicating hydrocephalus with an Evans’ index of 0.27. After cerebrospinal fluid (CSF) removal by lumbar puncture, the patient exhibited a marked improvement in gait. A CSF tap test after careful clinical examination may need to be considered in the diagnosis of idiopathic hydrocephalus with an Evans’ index of <0.3. J Korean Neurol Assoc 33(2):106-109, 2015

Syndrome of hydrocephalus in young and middle-aged adults: Review of the literature and illustrative cases

Introduction: A multitude of underlying reasons result in hydrocephalus (HC), and its classification remains controversial. The current study looks at patients with the Syndrome of Hydrocephalus in Young and Middle-Aged adults (SHYMA) through a case series. Patients and methods: We report 35 patients with HC referred to St. Anna Multiprofile Hospital during the period 2008-2012. Inclusion criteria were decompensated congenital hydrocephalus, (DCH), acquired hydrocephalus (AHC), or idiopathic hydrocephalus (IHC) in the age range of 16-55 years, treated with a ventriculo-peritoneal shunt (VPS)- 17 patients were treated with Strata Adjustable Delta Valve ('Strata' group) and 18 patients had Medtronic Orbis Sigma valves inserted ('Orbis Sigma' group). Results: Eight patients (22.86%) had DCH, 14 (40%) had AHC, and 13 (37.14%) had IHC. Regardless the underlying cause for HC, all the patients had similar symptoms, mainly related to gait in 26 (74.3%), cognition in 30 (85.7%), bladder control in 20 (57.14%) and chronic headaches in 24 patients (68.57%). Symptomatic improvement was achieved in 34 of the shunted 35 patients (97.14%), but the postoperative complications rate was found to be significantly lower in the 'Strata' group. Conclusion: The clinical presentation of hydrocephalus in the age 16-55 years has common features presenting with syndrome of hydrocephalus in young and middle-aged adults as separate clinical entity. VPS is a feasible treatment option in SHYMA. Due to the excessive, long standing ventriculomegaly, thus sensitive compliance of brain parenchyma and high tendency to develop subdural hematomas, adjustable VPS are advisable option.

Hidrocefalia crónica del adulto: diagnóstico, tratamiento y evolución. Estudio prospectivo

At present, chronic hydrocephalus or normal pressure hydrocephalus (NPH) has a controversial diagnosis in which multiple diagnostic and therapeutic techniques have been used with variable degrees of postoperative success. The aim of our study is to evaluate a number of patients diagnosed with adult chronic idiopathic hydrocephalus who were treated with a CSF shunt at our centre between 2006 and 2009 through clinical scales and radiological controls pre- and postoperatively.We prospectively analysed 40 patients. The diagnosis of idiopathic NPH was established when patients met 3 criteria: (i)clinical; (ii)radiological (Evans >0.3), and (iii)hydrodynamic (Katzman infusion test with Rout >12) or pathological ICP monitoring (B waves in over 20% of a nocturnal registration). We used a low-pressure DVP 5/35 GAV in all cases. Clinical assessments were conducted at 3, 6 and 12 months and radiological assessments at 6 months postoperatively. The clinical improvement of patients was assessed with the NPH, modified RANKIN and modified PFEIFFER rating scales.The study of risk factors (age, gender, smoking, drinking, arterial hypertension, diabetes mellitus, dyslipidemia) did not establish statistically significant relationships. A statistically significant improvement was observed (P<.01) in the NPH and RANKIN tests at 3, 6 and 12 months. Clinical improvement values obtained were: NPH 73%, 74% and 64%, and RANKIN 54%, 72% and 56%, respectively. The PFEIFFER scale only showed a significant improvement at 12 months. These improvements were classified into various levels (high, moderate, mild and no improvement). The initial mean Evans index was 0.385, and 0.3675 postoperatively. There was only one infection of the valvular system (2%) without further complications. Morbidity and mortality related to the procedure were 0%.An appropriate selection of patients through clinical, radiological, hydrodynamic and ICP monitoring criteria enables us to obtain good results and a low complication rate.

Congenital idiopathic hydrocephalus of infancy: the results of treatment by endoscopic third ventriculostomy with or without choroid plexus cauterization and suggestions for how it works

The traditional bulk flow model of communicating hydrocephalus does not support treatment by endoscopic third ventriculostomy (ETV), but successful treatment is reported in adults. This study is the first to report long-term success of ETV +/- choroid plexus cauterization (CPC) for infants with congenital idiopathic hydrocephalus (CIH). The results are interpreted in the context of current models for hydrocephalus. The CURE Children's Hospital of Uganda prospective database was reviewed for the years 2001-2006 to identify children <24months of age meeting the criteria for CIH who underwent ETV with or without bilateral CPC. Kaplan-Meier method was used to assess treatment success survival. Gehan-Breslow-Wilcoxin and logrank tests were used to determine significance of survival differences. Fisher's exact test was used to determine the significance of differences between groups. Sixty-four infants (mean/median age, 6.1/5.0months) met the inclusion criteria. Sixteen consecutive patients were treated by ETV alone, and the subsequent 48 by ETV/CPC (mean/median follow-up 34.4/36.0months). ETV was successful in 20% and ETV/CPC in 72.4% at 4years (p < 0.0002, logrank test; p = 0.0006, Gehan-Breslow-Wilcoxin; hazard ratio 6.9, 95% CI 2.5-19.3). ETV/CPC was significantly more successful than ETV alone in treating CIH. The primary effect of ETV, as a pulsation absorber, and of CPC, as a pulsation reducer, may be to abate the net force of intraventricular pulsations that produce ventricular expansion. ETV alone may be less successful for infants because of greater brain compliance. ETV/CPC should be considered an effective primary treatment option.

Surgical Technique, Postoperative Complications and Outcome in 14 Dogs Treated for Hydrocephalus by Ventriculoperitoneal Shunting

To report frequency and type of complications, and outcome in dogs with severe neurologic signs secondary to internal, suspected obstructive hydrocephalus treated by ventriculoperitoneal (VP) shunting. Case series. Dogs (n=14). Medical records (2001-2006) was reviewed for dogs that had VP shunting. Inclusion criteria were complete medical record, progressive forebrain signs unresponsive to medical treatment, normal metabolic profile, negative antibody titers and/or cerebrospinal PCR for Toxoplasma gondii, Neospora caninum, and canine distemper virus, magnetic resonance images of the brain, confirmed diagnosis of VP shunting, and follow-up information. Hydrocephalus was idiopathic in 5 dogs and acquired (interventricular tumors, intraventricular hemorrhage, inflammatory disease) in 9 dogs. Four dogs developed complications 1 week to 18 months postoperatively, including ventricular catheter migration, infection, shunt under-drainage, kinking of the peritoneal catheter, valve fracture, and abdominal skin necrosis. Three of these dogs had 1 or more successful revision surgeries and 1 dog was successfully treated with antibiotics. All, but 1 dog, were discharged within 1 week of surgery, and had substantial neurologic improvement. Median survival time for all dogs was 320 days (1-2340 days), for dogs with idiopathic hydrocephalus, 274 (60-420) days and for dogs with secondary hydrocephalus, 365 (1-2340) days. VP shunting was successful in relieving neurologic signs in most dogs and postoperative complications occurred in 29%, but were resolved medically or surgically.