Permanent CSF Diversion Research Articles

Lumbar subcutaneous shunt: a novel technique for therapeutic decision making in normal pressure hydrocephalus (NPH) and benign intracranial hypertension (BIH)

Selecting patients who will benefit from a permanent CSF diversion procedure in benign intracranial hypertension (BIH) or communicating hydrocephalus due to normal pressure hydrocephalus (NPH) has inherent problems. The percutaneous introduction of a lumbar subcutaneous shunt (LSS) under local anaesthesia facilitates both a prolonged CSF drainage under aseptic conditions and also elicits an adequate clinical response. We describe the technique of a lumbar subcutaneous shunt and our experience with its use in patients with BIH and NPH. Postprocedure changes in the patients' clinical status were noted. Patients with a transient clinical improvement underwent a subsequent definitive CSF diversion; those with a sustained clinical improvement or no change in symptoms had no further procedure.

Extrapyramidal signs in normal pressure hydrocephalus: an objective assessment

BackgroundBeyond the classic Normal Pressure Hydrocephalus (NPH) triad of gait disturbance, incontinence, and dementia are characteristic signs of motor dysfunction in NPH patients. We used highly sensitive and objective methods to characterize upper limb extrapyramidal signs in a series of NPH subjects compared with controls. Concentrated evaluation of these profound, yet underappreciated movement disorders of NPH before and after techniques of therapeutic intervention may lead to improved diagnosis, insight into pathophysiology, and targeted treatment.MethodsTwenty-two (22) consecutive NPH patients and 17 controls performed an upper limb motor task battery where highly sensitive and objective measures of akinesia/bradykinesia, tone, and tremor were conducted. NPH subjects performed this test battery before and more than 36 h after continuous CSF drainage via a spinal catheter over 72 h and, in those subjects undergoing permanent ventriculo-peritoneal shunt placement, at least 12 weeks later. Control subjects performed the task battery at the same dates as the NPH subjects. Statistical analyses were applied to group populations of NPH and control subjects and repeated measures for within subject performance.ResultsTwenty (20) NPH subjects remained in the study following CSF drainage as did 14 controls. NPH subjects demonstrated akinesia/bradykinesia (prolonged reaction and movement times) and increased resting tone compared with controls. Furthermore, the NPH group demonstrated increased difficulty with self-initiated tasks compared with stimulus-initiated tasks. Following CSF drainage, some NPH subjects demonstrated reduced movement times with greater improvement in self- versus stimulus-initiated tasks. Group reaction time was unchanged. Resting tremor present in one NPH subject resolved following shunt placement. Tone measures were consistent for all subjects throughout the study.ConclusionClinical motor signs of NPH subjects extend beyond gait deficits and include extrapyramidal manifestations of bradykinesia, akinesia, rigidity, and propensity to perform more poorly when external cues to move are absent. Objective improvement of some but not all of these features was seen following temporary or permanent CSF diversion.

Surgical management of ruptured aneurysms in the eighth and ninth decades.

The surgical management of elderly patients with aneurysmal subarachnoid haemorrhage (SAH) is controversial. The present study was performed to more clearly define issues facing elderly SAH patients undergoing surgical repair of their aneurysms. Between 1990 and 2000, 100 patients, aged 70 years or older, were managed consecutively with aneurysmal surgical repair at Verona City Hospital. Ninety-seven of these were analysed with regard to age, clinical grade on admission, radiological features, and specific management components (3 patients were excluded from further analysis because of inadequate follow up data). Surviving patients were followed up for a minimum of 6 months and clinical outcome was assessed. Hydrocephalus requiring permanent CSF diversion occurred in 44% of cases surviving beyond 10 days from their SAH. The development of hydrocephalus requiring shunting was delayed more than 6 weeks in 7% of these cases. Medical complications occurred in 22% of cases. Clinical grade of haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.03) were significantly associated with poor outcome. Clinical vasospasm was not a major determinant of outcome in this group. The need for permanent CSF diversion was significantly associated with increasing age (p=0.03), intraventricular haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.05). Elderly patients experience a different range of complications following aneurysmal subarachnoid haemorrhage than their younger counterparts. Clinicians should remain alert to the development of hydrocephalus, especially of delayed onset.

Colloid cysts--a review including 19 own cases.

Between 1974 and 1987 19 patients harbouring colloid cysts of the third ventricle have been treated in our department. There were 12 male and 7 female patients with an average age of 34 years (ranging from 17 to 58). Eighteen of the 19 patients underwent direct microsurgical removal of the space occupying lesion using the transcortical-transventricular approach. One patient had placement of a ventriculoperitoneal shunt and declined further treatment. There were no deaths in the entire series and no permanent neurological deficits were observed postoperatively. Surgery was successful in unblocking CSF pathways in 12 patients; six patients required permanent CSF diversion. Considering the advantages and disadvantages of various surgical modalities for the treatment of the lesions we recommend the microsurgical removal of the colloid cyst using the transcortical-transventricular approach.