Obstruction Of Cerebrospinal Fluid Pathways Research Articles

Spinal neurocysticercosis

Worldwide, cysticercosis is the most common parasitic infection of the central nervous system. In endemic regions, the incidence of neurocysticercosis (NCC) approaches 4% of the general population. The disease is predominantly intracranial, the authors of most series generally report the incidence of spinal NCC as only 1.5 to 3% of all cases. Although spinal NCC is relatively rare, it represents a distinct clinical entity that can have devastating consequences for the patient. Because of the limited size of the spinal canal, the mass effect of these lesions is poorly tolerated. Most spinal NCC occurs in the subarachnoid space where mass effect can cause spinal cord compression, although obstruction of cerebrospinal fluid pathways due to scarring of the subarachnoid space can also cause symptoms. The authors treated six patients with spinal NCC. In five cases the lesions were located in the subarachnoid space, and in one the lesion was intramedullary. All patients with subarachnoid spinal NCC required excision of the symptomatic lesions; in two cases initial medical therapy had failed. The patient with intramedullary spinal NCC experienced mild symptoms and underwent steroid therapy. All patients experienced variably improved outcomes and were eventually ambulatory. Medical therapy should be carefully considered in selected patients in whom symptoms are stable and nonprogressive. Surgical intervention is required when severe or progressive deficits occur to prevent permanent injury. In some patients recovery may be limited as a result of inflammatory injury to the spinal cord or arachnoidal adhesions.

Neuroendoscopic approach to intraventricular lesions

Object. The purpose of this study was to determine the efficacy of endoscopic treatment in patients with intraventricular tumors. Methods. A series of 30 patients with endoscopically treated intraventricular lesions is reported. The lesions included seven colloid cysts, six astrocytomas, three subependymomas, two ependymomas, and one each of the following: pineoblastoma, pineocytoma/pineoblastoma (intermediate type), epidermoid cyst, pineal cyst, medulloblastoma, arteriovenous hemangioma, cavernoma, choroid plexus papilloma, pituitary adenoma, craniopharyngioma, melanoma, and germinoma. Total tumor resections, partial resections, biopsies, stent implantations, septostomies, and third ventriculostomies were performed. In two cases (two subependymomas > 2 cm in diameter), piecemeal endoscopic resection was ineffective because of the very firm consistency of the tumors. Therefore the endoscopic procedure was discontinued and the tumors were removed microsurgically. In the remaining cases the procedures were completed as planned. Even in the presence of difficulties such as poor orientation or significant bleeding, there was no need to abandon the endoscopic procedure. A total of 28 strictly endoscopic interventions were performed, in which the average duration was 85 minutes (range 35-170 minutes). All colloid cysts and the epidermoid lesion were completely evacuated and the capsules were widely resected. Total extirpation of solid tumors was achieved in five cases, whereas most astrocytomas were partially resected. The hydrocephalus-related symptoms resolved in all of the 22 patients with cerebrospinal fluid pathway obstruction. There were no endoscopy-related deaths. In two cases, major bleeding occurred and was controlled endoscopically. The authors observed one case of meningitis, one of mutism, two of memory loss attributed to forniceal injury, one of transient trochlear palsy after a biopsy specimen of an aqueductal tumor was obtained, and one of transient confusion after a biopsy specimen of a germinoma was obtained. Conclusions. In the authors' preliminary experience, the endoscopic approach was found to be safe and effective. In this series, it was possible to achieve relief of noncommunicating hydrocephalus, tumor resections, and even complete tumor removals by using endoscopic techniques. Based on the results, the authors believe that endoscopic techniques should be considered in the treatment of selected intraventricular lesions.

Neuroendoscopic approach to intraventricular lesions.

The purpose of this study was to determine the efficacy of endoscopic treatment in patients with intraventricular tumors. A series of 30 patients with endoscopically treated intraventricular lesions is reported. The lesions included seven colloid cysts, six astrocytomas, three subependymomas, two ependymomas, and one each of the following: pineoblastoma, pineocytoma/pineoblastoma (intermediate type), epidermoid cyst, pineal cyst, medulloblastoma, arteriovenous hemangioma, cavernoma, choroid plexus papilloma, pituitary adenoma, craniopharyngioma, melanoma, and germinoma. Total tumor resections, partial resections, biopsies, stent implantations, septostomies, and third ventriculostomies were performed. In two cases (two subependymomas > 2 cm in diameter), piecemeal endoscopic resection was ineffective because of the very firm consistency of the tumors. Therefore the endoscopic procedure was discontinued and the tumors were removed microsurgically. In the remaining cases the procedures were completed as planned. Even in the presence of difficulties such as poor orientation or significant bleeding, there was no need to abandon the endoscopic procedure. A total of 28 strictly endoscopic interventions were performed, in which the average duration was 85 minutes (range 35-170 minutes). All colloid cysts and the epidermoid lesion were completely evacuated and the capsules were widely resected. Total extirpation of solid tumors was achieved in five cases, whereas most astrocytomas were partially resected. The hydrocephalus-related symptoms resolved in all of the 22 patients with cerebrospinal fluid pathway obstruction. There were no endoscopy-related deaths. In two cases, major bleeding occurred and was controlled endoscopically. The authors observed one case of meningitis, one of mutism, two of memory loss attributed to forniceal injury, one of transient trochlear palsy after a biopsy specimen of an aqueductal tumor was obtained, and one of transient confusion after a biopsy specimen of a germinoma was obtained. In the authors' preliminary experience, the endoscopic approach was found to be safe and effective. In this series, it was possible to achieve relief of noncommunicating hydrocephalus, tumor resections, and even complete tumor removals by using endoscopic techniques. Based on the results, the authors believe that endoscopic techniques should be considered in the treatment of selected intraventricular lesions.

Occlusive hydrocephalus complicating tuberous sclerosis: report of two cases

Two patients-6 and 14 years old-with tuberous sclerosis are presented. Both developed a subependymal giant cell astrocytoma from nodules located near to the foramen of Monro. They caused obstruction of the cerebrospinal fluid pathways. Signs of raised intracranial pressure were detected in both patients, and one of them had also developed infantile spasm-Blitz-Nick-Salaam seizures. Cutaneous stigmata being characteristic for this entity were observed in both cases, but their mental development was unaffected. Diagnosis was based on computed tomography. Angiography did not reveal pathological vessels. The tumours were completely excised through transcallosal exposure in both cases. The patients have been symptom-free during the follow-up time of 1 and 2 years. Although the incidence of malignant transformation of tuberous sclerosis is less than 15% the disease generally has a poor prognosis which can be ascribed to sudden increase of intracranial pressure caused by obstruction of cerebrospinal fluid pathways by paraventricular tumours. However, regular follow-up of paraventricular nodules and maintenance of patency of cerebrospinal fluid pathways by microsurgical methods in patients suffering from mild cerebral disorders offers a better chance of survival.

Rapid enlargement of ventricles within seven hours after head injury

We report a case of acute enlargement of the ventricles within 7 hours after head injury that was documented by repeated computerized tomography. It is suggested that the pathophysiological mechanism for this rapid enlargement of ventricles may be due to the raised intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid pathways by subarachnoid hemorrhage, in addition to the elevation of ICP aggravated by frequent focal convulsive seizures.

The central (spinal) canal in congenital murine hydrocephalus: morphological and physiological aspects.

Obstruction of cerebrospinal fluid pathways produces changes in the parenchyma of the brain and spinal cord. A murine model of hydrocephalus (hy-3) used to study changes in the central canal of the spinal cord and these changes are correlated with events occurring in the intracranial compartment. The central canal is enlarged and subependymal interstitial edema is produced by cerebrospinal fluid at the same time as the intracranial ventricular system is expanding. Plugging of the obex results in collapse of the central canal. Ferritin tracer studies demonstrate transependymal flow of cerebrospinal fluid throughout the central canal.

CSF-circulation pathways in experimental hydrocephalus of the rat (author's transl)

Experimental hydrocephalus of the rat was produced by cisternal injection of Kaolin-solution. Intraventricular injection of India ink disclosed obstruction of cerebrospinal fluid pathways at the tentorial incisura in the hydrocephalic rat, while the same injection to the normal rat showed diffuse spreading of the dye over whole subarachnoid space of the brain. The injection of the dye into the cerebral subarachnoid space showed obstruction of the dye at the tentorial incisura in the hydrocephalic rat, while sufficient communication was observed between supratentorial and infratentorial subarachnoid spaces in the normal rat. There were however no remarkable differences between the normal and the abnormal rats about distribution of India ink over the cerebrum under macroscopic and microscopic observations. Obstruction at the tentorial incisura was caused by arachnoid fibrosis and granulation and not by tentorial herniation. Considering experimental findings of paucity of adhesive arachnoiditis over the cerebrum and clinical reports of reversibility of the cerebral subarachnoid space, much effort should be made to promote CSF absorption over the cerebrum, instead of external drainage.

Hydrocephalus secondary to hemorrhage from a basilar artery aneurysm. With a note on embolization technique.

A case of hydrocephalus secondary to hemorrhage from an aneurysm of the bifurcation of the basilar artery is presented. The surgical treatment of the aneurysm and the hydrocephalus is described. The site of the cerebrospinal fluid pathway obstruction was verified at craniotomy.

Radioiodinated serum albumin (RISA) cisternography in the diagnosis of incisural block and occult hydrocephalus.

Symptomatic occult hydrocephalus with normal cerebrospinal fluid pressure has recently received considerable attention in the neurological literature. Clinically this syndrome may be manifested by progressive dementia, psychomotor retardation, memory impairment, spasticity, and gait disturbance (1, 9–11). Messert and Baker (11) suggested that its cause may be either “idiopathic or nonobstructive” white matter degeneration or obstruction of cerebrospinal fluid pathways by a variety of lesions. Treatment usually consists of shunting cerebrospinal fluid from the ventricular system to the heart or the pleural cavity. Dramatic improvement of symptoms following shunting procedures has been reported, thus adding impetus to the need for accurate diagnosis (1, 10, 11, 13). The diagnosis of occult hydrocephalus is best made by pneumoencephalography. This study deals with the diagnosis of cerebrospinal fluid obstruction at the level of the tentorial incisura (incisural block). The obstruction of the cerebrospinal fluid pathway at the level of incisural notch of the tentorium may be a sequel of any inflammatory process, such as meningitis, encephalitis, or spontaneous or post-traumatic subarachnoid hemorrhage (13). The inflammatory process produces local or diffuse meningeal adhesions (8, 11). The tentorial incisura is the most vulnerable area for a block because of its dependent basilar position and relatively narrow cerebrospinal fluid spaces. The characteristic findings in pneumoencephalography in incisural block are generalized ventricular dilatation, failure of air to pass above the incisural level, and nonfilling of the supratentorial subarachnoid spaces and the convexity of cerebral hemispheres (2, 14). The accuracy of pneumoencephalography in the diagnosis of incisural block depends, however, not only on the skill and diligence of the operator, but also on the specific anatomic peculiarities of the area under investigation. At times even exhaustive attempts to fill the supratentorial subarachnoid spaces and the convexity of cerebral hemispheres with a small amount of air will be unsuccessful and may not be indicative of pathology (6). Di Chiro (4) introduced radioiodinated serum albumin (RISA) cisternography to study cases of cerebrospinal fluid rhinorrhea. This method is easily carried out, and serial observations should demonstrate the dynamics of flow of the cerebrospinal fluid which cannot be studied by air. Bell (2) observed only one patient in whom mild hyperpyrexia developed after the intra-ventricular injection of RISA. Detmer and Blacker (3) reported a case of aseptic meningitis secondary to intrathecal injection of RISA; the symptoms and signs disappeared four days after the onset of meningitis. Di Chiro (4, 7) reported that none of his patients had untoward effects referable to the placement of RISA within the cerebrospinal fluid.

Neurological abnormalities in achondroplastic children

The neurological manifestations of achondroplasia are reviewed. Enlargement of the head accompanied by mild dilatation of the ventricles is usually present with no other clinical evidence of increased intracranial pressure. Head growth curves parallel the normal slope, although at higher values. Significant hydrocephalus when it occurs is probably due to obstruction of cerebrospinal fluid pathways at the level of the foramen magnum and is usually associated with other neurological signs related to cord compression at this level. Mental retardation may be inferred mistakenly in infancy and early childhood because of delayed acquisition of motor skills. The neurological manifestations of achondroplasia are reviewed. Enlargement of the head accompanied by mild dilatation of the ventricles is usually present with no other clinical evidence of increased intracranial pressure. Head growth curves parallel the normal slope, although at higher values. Significant hydrocephalus when it occurs is probably due to obstruction of cerebrospinal fluid pathways at the level of the foramen magnum and is usually associated with other neurological signs related to cord compression at this level. Mental retardation may be inferred mistakenly in infancy and early childhood because of delayed acquisition of motor skills.