Permanent Ventricular Shunt Research Articles

Permanent Ventricular Shunts: Normal Appearance and Complications

Permanent Ventricular Shunts: Normal Appearance and Complications

Permanent Ventricular Shunts: Normal Appearance and Complications

Hydrocephalus is a common condition that is primarily treated with ventricular shunting, most commonly with a ventriculoperitoneal shunt. However, a ventriculoperitoneal shunt may be contraindicated, requiring an alternate shunt system. The various ventricular shunts are associated with both similar and unique adverse events. This article reviews the various types of ventricular shunt systems and their associated complications.

Factors Associated with the Need for Ventriculoperitoneal Shunting in Patients with Spontaneous Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

Abstract Introduction Intracerebral hemorrhage (ICH) is a serious medical condition that is frequently complicated by acute hydrocephalus, necessitating emergency cerebrospinal fluid (CSF) diversion in a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. The present study aimed to determine factors associated with the need for permanent ventricular shunt placement in these patients. Methods A total of 309 consecutive patients who underwent emergent CSF diversion with external ventricular drain (EVD) as a treatment for ICH between July 2009 and July 2018 were studied retrospectively to assess the factors that might be correlated with shunt-dependent chronic hydrocephalus. A binary logistic regression model was designed to identify independent related factors of shunt-dependent hydrocephalus after ICH. Results Of 309 patients included in this study, 102 (33.00%) required permanent ventricular CSF shunting before discharge. In univariate analysis, age,ventriculitis, ICP elevation >30 mm Hg, ICH evacuation, the Graeb score, days of EVD in place, and CSF protein levels were significantly associated with the requirement for permanent CSF diversion (p < 0.05). The age and ICH evacuation were protective variables and the ventriculoperitoneal (VP) shunt possibility was reduced by 22.6 and 63.5%, respectively. Conclusion Our results showed that higher Graeb score, ICP elevation >30 mm Hg, more days of EVD in place, and higher CSF protein levels were associated with permanent CSF diversion in these patients. Advanced age and ICH evacuation decreased the possibility of VP shunting in our study.These factors may help in predicting which patients will need permanent CSF diversion and could ultimately lead to improvements in the management of these patients.

P94 Ventricular subgaleal shunting is a safe and effective temporising measure for the treatment of neonatal post haemorrhagic hydrocephalus

ObjectivesThe use of a temporising device to facilitate neonatal maturation prior to permanent ventricular peritoneal shunt (VPS) remains gold standard treatment for neonatal posthaemorrhagic hydrocephalus (PHH). The relative superiority of ventricular access device (VAD) or ventricular subgaleal shunt (VSG) remains contentious.DesignRetrospective case note review.Subjects49 neonates born between Sept 2012 to April 2018: (M:F 34:15); Average: gestation 26+3 (23 to 32+5); birth weight 870 g (±355 g); Papile grade 3:4 (ratio ≈ 1:2).MethodsComputer records from neonatal VSG at a single tertiary care children’s hospital reviewed.ResultsEarly complications associated with VSG seen in 13 cases (27%). Migration of shunt n=3, infection n=2, inadequate control of ventricular volume n=5, decompression haemorrhage n=2, wound leak n=1. All patients managed on NICU with an average inpatient stay of 5 days (range 2 to 15). 5 outcome groups defined: 1. Patient died (non neurological cause) (n=4) 2. VSG in situ for <1 year (n=7) 3. VSG and no VPS (n=6 16%) 4. VSG and VPS X1 never revised (n=17 45%) 5. VSG and VPS with revisions (n=15 39%) Rate of shunting in patients with VSG >1 year=84%. All patients that needed permanent VPS were operated within the first year. The average time elapsed prior to VPS was 86 days with over 80% of cases shunted within 100 days.ConclusionsVSG remains a safe method of temporary CSF drainage for the treatment of neonatal PHH with rates of shunting in line with the published literature.

Prediction of Shunt Dependency After Intracerebral Hemorrhage and Intraventricular Hemorrhage.

Spontaneous intracerebral hemorrhage is a disease with high morbidity and mortality. Extension of the hemorrhage into the ventricles is associated with the development of acute hydrocephalus and a poor outcome. Although it can be managed by external ventricular drainage (EVD), a subset of these patients require placement of permanent ventricular shunts. This study aimed to examine the factors on admission that can predict shunt dependency after EVD management. Seventy-two patients who underwent EVD were included in this study. Seventeen of these patients underwent placement of a ventriculoperitoneal shunt. Variables analyzed included age, intraventricular hemorrhage (IVH) score, bicaudate index, acute hydrocephalus, initial Glasgow Coma Scale scores, and blood volume in each ventricle. In univariate analysis, IVH score (p = 0.020), bicaudate index (p < 0.001), blood volume in lateral ventricles (p = 0.025), blood volume in the fourth ventricle (p = 0.038), and the ratio of blood volume in lateral ventricles to that in third and fourth ventricles (p = 0.003) were significantly associated with persistent hydrocephalus. The best multiple logistic regression model included blood volume parameters and bicaudate index as predictors with the area under a receiver operating characteristic curve of 0.849. The variance inflation factor (VIF) showed that collinearity was not found among predictors. Patients diagnosed with acute hydrocephalus had less blood volume in the lateral ventricles (OR = 0.910) and had more blood volume in the third ventricle (OR = 3.174) and fourth ventricle (OR = 2.126). These findings may promote more aggressive monitoring and earlier interventions for persistent hydrocephalus after intraventricular hemorrhage in patients at risk.

Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage

Intraventricular hemorrhage requiring ventriculostomy placement is a frequent complication of spontaneous intracerebral hemorrhage. Although a subset of patients will require permanent ventricular shunt placement, little is known about contemporary practices regarding the timing of ventriculostomy and ventricular shunt placement after intracerebral hemorrhage. Using the 2010-2012 National Inpatient Sample, we identified patients with International Classification of Diseases, Ninth Revision codes for intracerebral hemorrhage, excluded secondary causes, and examined procedure dates. Of 35,899 patients with primary intracerebral hemorrhage, 2443 (6.8%) received ventriculostomy, 93% within the first 3 days of admission and 66% within the first day. Permanent shunt placement occurred in 173 (7.1%) patients following ventriculostomy at a median interval of 15 days (interquartile range: 11-20). Among those remaining alive and in hospital at 14, 21, and 28 days, 5%, 11%, and 15%, respectively, underwent shunt placement following ventriculostomy, and 24% of those with multiple ventriculostomy insertions required permanent shunt by 4 weeks of hospitalization. Multiple ventriculostomies, tracheostomy, and black race were associated with longer time to permanent shunt. A wide variation in delay to permanent shunt placement is present, with substantial and increasing prevalence with time in hospital. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Abstract TP327: Timing of Ventriculostomy and Ventricular Shunting for Intracranial Hemorrhage: A National Inpatient Sample Study

Background: Intraventricular hemorrhage requiring ventriculostomy (EVD) placement is a frequent complication of spontaneous intracerebral hemorrhage (ICH). Urgent EVD may be warranted for management of acute hydrocephalus, and a subset of these patients will require permanent ventricular shunt (VS) placement. In contrast to hydrocephalus following sub-arachnoid hemorrhage, less is known about the frequency and timing of EVD and VS placement after ICH. Methods: Using the 2010-2012 National Inpatient Sample, we selected patients with ICD-9 codes for ICH, excluded secondary causes, and examined procedure dates for EVD and VS placement. Results: Of 35,991 primary ICH patients, 2,392 (6.7%) received an EVD, 89% within the first 3 days of admission and 64% within the first day. Placement of a VS occurred in 268 patients (0.7%) overall. VS placement occurred in 143 of 2,129 (6.7%) of those receiving an EVD in the first 72 hours and 34 of 263 (12.9%) receiving an EVD after 72 hours (p&lt;0.001). Median time to shunt placement following EVD was 15 days (IQR 11-21) vs 16.5 (IQR 13-21) for those with EVD within vs after 72 hours (p=0.2). 82 (0.2%) received a VS without an initial EVD at a median of 14 days (IQR 9-18). Kaplan-Meier analysis revealed that among those remaining alive and in hospital at 14 and 21 days, 5% and 11%, respectively, underwent shunt placement following EVD. To analyze the effect of VS timing following EVD, we compared those undergoing VS in the first two weeks versus later than two weeks. Following multivariate logistic regression, only age 70 -80 was associated with early shunt placement (OR 4.8, 95%CI 1.2-19). No effect on mortality or rate of home discharge was seen. Length of stay was shorter in those with early versus later VS (20 vs 32 days, p&lt;0.001) Conclusion: Persistent hydrocephalus following EVD placement for ICH is rare overall but VS is required in up to 12% of a subset of patients. EVD placement after the initial 72 hours was associated with an increased rate of VS, while older age was associated with earlier VS placement after EVD. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Persistent Brain Herniation after Decompressive Hemicraniectomy: Role of Lumbar Drainage for Cranioplasty. Case Report

Hydrocephalus and ex-vacuo ventricular dilatations which cause persistent brain herniation with impossibility to perform cranioplasty, are well known late complications after decompressive hemicraniectomy; concerning the physiopathologic mechanism leading to these complications, there are several theories. We report the particular case of a patient suffering from persistent brain herniation after decompressive hemicraniectomy, due to development of subdural hygroma, intraparenchymal multiple liquoral cysts and only mild enlargement of frontal horn of right lateral ventricle. A fifty-five years old male patient was treated with decompressive right hemicraniectomy for acute hemispheric swelling consequent to right internal carotid artery dissecation. After several months, evaluating the patient for cranioplasty, brain herniation was clinically evident and brain MRI confirmed it due to subdural hygroma, intraparenchymal multiple liquoral cysts and mild enlargement of frontal horn of right lateral ventricle. According to several reported theories, communication between right frontal horn of lateral ventricle, intraparenchymal liquoral cysts and subdural hygroma was supposed, and CSF lumbar drainage was placed. Regression of brain herniation was achieved and cranioplasty was possible; after few days lumbar drainage was removed: neither operative, nor short and long follow-up period complications were observed. Temporary CSF lumbar drainage resulted effective to obtain regression of a particular case of persistent brain herniation developed after decompressive hemicraniectomy; moreover this safe procedure, not previously described to forerun cranioplasty surgery to our knowledge, allowed performing cranioplasty in absence of complications and avoiding temporary or permanent ventricular shunts which present a major rate of risks and possible complications.

Trends in hospitalization of preterm infants with intraventricular hemorrhage and hydrocephalus in the United States, 2000-2010.

OBJECT Even with improved prenatal and neonatal care, intraventricular hemorrhage (IVH) occurs in approximately 25%-30% of preterm infants, with a subset of these patients developing hydrocephalus. This study was undertaken to describe current trends in hospitalization of preterm infants with posthemorrhagic hydrocephalus (PHH) using the Nationwide Inpatient Sample (NIS) and the Kids' Inpatient Database (KID). METHODS The KID and NIS were combined to generate data for the years 2000-2010. All neonatal discharges with ICD-9-CM codes for preterm birth with IVH alone or with IVH and hydrocephalus were included. RESULTS There were 147,823 preterm neonates with IVH, and 9% of this group developed hydrocephalus during the same admission. Of patients with Grade 3 and 4 IVH, 25% and 28%, respectively, developed hydrocephalus in comparison with 1% and 4% of patients with Grade 1 and 2 IVH, respectively. Thirty-eight percent of patients with PHH had permanent ventricular shunts inserted. Mortality rates were 4%, 10%, 18%, and 40%, respectively, for Grade 1, 2, 3, and 4 IVH during initial hospitalization. Length of stay has been trending upward for both groups of IVH (49 days in 2000, 56 days in 2010) and PHH (59 days in 2000, 70 days in 2010). The average hospital cost per patient (adjusted for inflation) has also increased, from $201,578 to $353,554 (for IVH) and $260,077 to $495,697 (for PHH) over 11 years. CONCLUSIONS The number of neonates admitted with IVH has increased despite a decrease in the number of preterm births. Rates of hydrocephalus and mortality correlated closely with IVH grade. The incidence of hydrocephalus in preterm infants with IVH remained stable between 8% and 10%. Over an 11-year period, there was a progressive increase in hospital cost and length of stay for preterm neonates with IVH and PHH that may be explained by a concurrent increase in the proportion of patients with congenital cardiac anomalies.

Reversible Obstructive Hydrocephalus from Hypertensive Encephalopathy: A Condition that Neurosurgeons Must Know

The vasogenic edema in structures of posterior fossa secondary to elevated hydrostatic pressure can cause obstructive hydrocephalus, a condition called “reversible obstructive hydrocephalus from hypertensive encephalopathy.” A case of a 27-year-old woman with arterial hypertension and sign of raised intracranial pressure is reported. Her radiologic studies have showed vasogenic cerebellar edema without structural lesion. This edema leads to obstruction of the cerebral aqueduct. We discuss the clinical and therapeutic aspects of this condition. In this clinical situation, the accurate control of blood pressure is the main goal on medical care, and the need of permanent ventricular shunt is quite infrequent.

Abstract T P403: Permanent Ventricular Shunting In Subarachnoid Hemorrhage And Intracerebral Hemorrhage Patients Requiring Temporary Ventriculostomy

Background and Purpose: Aneurysmal subarachnoid hemorrhage (SAH) and spontaneous intracerebral hemorrhage (ICH) frequently lead to obstructive and/or communicating hydrocephalus. A permanent ventricular shunt is required in cases with failure to wean ventriculostomy. Large-scale studies comparing rates of ventricular shunting after SAH and ICH are lacking. Therefore, we studied the rates of shunting among SAH and ICH requiring ventriculostomy. Methods: We analyzed the Nationwide Inpatient Sample, a 20% sample of non-federal hospitalizations in US from 2002 to 2011 to select adults with ICH (ICD-9 code 431) and SAH (430) undergoing ventriculostomy (02.2, 02.21). We excluded patients surviving &lt;7 days after ventriculostomy. We compared rates of ventricular shunting (02.32-02.34) between SAH and ICH after adjusting for baseline characteristics using logistic regression. Population estimates were obtained using sample weighting. Results: 23,541 cases with ICH (median age 59 y) and 31,883 cases with SAH (median age 56 y) were included. Unadjusted shunting rate was higher in SAH compared to ICH (19.9% vs 11.4%, P&lt;0.001), and it remained higher in SAH in multivariate analysis (adjusted OR: 1.69; 95% CI: 1.45-1.98, P&lt;0.001). There was no difference in the interval between ventriculostomy and shunting between SAH and ICH (mean: 18.9 +/- 11.8 [SD] vs 18.1 +/- 10.9 days, P=0.196). Among SAH cases, shunting rate was higher with coiling compared to clipping (23.8% vs 18.1%, P&lt;0.001). There was a significant trend toward higher shunt utilization over time among SAH patients (16.3% in 2002-03 to 21.4% in 2010-11, trend P&lt;0.001). The shunting rate remained unchanged among ICH patients (11.3% in 2002-03 to 11.5% in 2010-11, trend P=0.363). Patients requiring ventriculostomy within 24 hours of admission comprised 61.8% of all cases, and had higher shunting rate (adjusted OR: 1.17; 95% CI: 1.07-1.28, P=0.001). Conclusions: SAH compared to ICH has higher rates of failure to wean ventriculostomy requiring permanent ventricular shunting. Increasing trend in shunt utilization after SAH is co-incident with increase in aneurysm coiling during recent years.

Trends in hospitalization of preterm infants with intraventricular hemorrhage and hydrocephalus in the United States, 2000-2010

OBJECT Even with improved prenatal and neonatal care, intraventricular hemorrhage (IVH) occurs in approximately 25%–30% of preterm infants, with a subset of these patients developing hydrocephalus. This study was undertaken to describe current trends in hospitalization of preterm infants with posthemorrhagic hydrocephalus (PHH) using the Nationwide Inpatient Sample (NIS) and the Kids’ Inpatient Database (KID). METHODS The KID and NIS were combined to generate data for the years 2000–2010. All neonatal discharges with ICD-9-CM codes for preterm birth with IVH alone or with IVH and hydrocephalus were included. RESULTS There were 147,823 preterm neonates with IVH, and 9% of this group developed hydrocephalus during the same admission. Of patients with Grade 3 and 4 IVH, 25% and 28%, respectively, developed hydrocephalus in comparison with 1% and 4% of patients with Grade 1 and 2 IVH, respectively. Thirty-eight percent of patients with PHH had permanent ventricular shunts inserted. Mortality rates were 4%, 10...

Reduced ventricular shunt rate in very preterm infants with severe intraventricular hemorrhage: an institutional experience

Although survival for extremely low gestational age newborns (ELGANs) has improved in the past 3 decades, these infants remain prone to complications of prematurity, including intraventricular hemorrhage (IVH). The authors reviewed the outcomes for an entire cohort of ELGANs who suffered severe IVH at their institution during the past 12 years to gain a better understanding of the natural history of IVH and frequency of ventriculoperitoneal (VP) shunt placement in this population. Data from the neonatal ICU (NICU) database, neurosurgery operative log, and medical records were used to identify and follow up all ELGANs who suffered a severe IVH between 1997 and 2008. Trends between Period 1 (1997-2001) and Period 2 (2004-2008) were analyzed using the Pearson chi-square test. Between 1997 and 2008, 1335 ELGANs were admitted to the NICU at the authors' institution within 3 days of birth, and 111 (8.3%) of these infants suffered a severe IVH. Survival to 2 years, incidence of severe IVH, neonatal risk factors (gestational age, birth weight, and incidence of necrotizing enterocolitis), ventriculomegaly on cranial ultrasonography, and use of serial lumbar punctures for symptomatic hydrocephalus were all stable. Infants from period 2 had a significantly lower incidence of bronchopulmonary dysplasia and sepsis than infants from Period 1 (both p < 0.001). All ELGANs with severe IVH and ventriculomegaly underwent long-term follow-up to identify shunt status at late follow-up. Twenty-two ELGANs (20%) with severe IVH required a temporary ventriculosubgaleal (VSG) shunt. Three infants with VSG shunts showed spontaneous hydrocephalus resolution, and 2 infants died of unrelated causes during the neonatal admission. The temporary VSG shunt complication rate was 20% (12% infection and 8% malfunction). Sixteen percent of all ELGANs (18 of 111) with severe IVH eventually required permanent ventricular shunt insertion. Six (35%) of 17 infants with a permanent VP shunt required at least 1 permanent shunt revision during the 1st year. The proportion of ELGANs with severe IVH who required a temporary VSG (35%) or permanent VP shunt (30%) during Period 1 decreased by more than 60% in Period 2 (10% [p = 0.005] and 8.3% [p = 0.009], respectively). The authors report for the first time a marked reduction over the past 12 years in the proportion of ELGANs with severe IVH who required surgical intervention for hydrocephalus. Using the NICU database, the authors were able to identify and follow all ELGANs with severe IVH and ventriculomegaly. They speculate that the reduction in ventricular shunt rate results from improved neonatal medical care, including reduced infection, improved bronchopulmonary dysplasia, and postnatal steroid avoidance, which may aid innate repair mechanisms. Multicenter prospective trials and detailed analyses of NICU parameters of neonatal well-being are needed to understand how perinatal factors influence the propensity to require ventricular shunting.

Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion

Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population. The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay. Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present. Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.

Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury

Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. To quantify the need for permanent CSF diversion in patients with TBI. Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

Clipping or Coiling of Ruptured Cerebral Aneurysms and Shunt-Dependent Hydrocephalus

Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. Hospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated. One hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients ( p = 0.5 ), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p = 0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24 +/- 14 versus 15 +/- 8, 20.5 +/- 9 versus 11 +/- 7, and 30 +/- 13 versus 16 +/- 11 days, respectively; p <or= 0.01). In a logistic regression model, VS was independently associated with rebleeding, external ventricular drain placement, coiling, and UHC-expected LOS (odds ratios, 95% confidence interval 12.1, 2.3 - 62.6, 6.9, 1.6 - 30, 6.25, 1.3 - 29, and 1.1, 1.02 - 1.14, respectively). One-third of patients admitted with aneurysmal SAH require temporary or permanent CSF diversion. Permanent shunting was found to be associated with coiling in our patient population.

Systemic Hemostasis With Recombinant-Activated Factor VII Followed by Local Thrombolysis With Recombinant Tissue Plasminogen Activator in Intraventricular Hemorrhage

A 51-year-old woman on warfarin thromboprophylaxis for transient ischemic attacks developed sudden onset nausea, vomiting, and decreased mental status, rapidly becoming comatose. Head computed tomography (CT) showed intracerebral hemorrhage, extending into all ventricular chambers, and acute obstructive hematocephalus requiring urgent ventricular drainage. CT angiogram showed no evidence of an aneurysm or vascular malformation. The pretreatment international normalized ratio (INR) of 4.9 was rapidly corrected with recombinant activated factor VII and an external ventricular drain was placed. Despite accurate positioning, the ventriculostomy thrombosed and became nonfunctional. Recombinant tissue plasminogen activator was given intraventricularly and resulted in partial ventricular decompression within 24 hours, with dramatic improvement in the patient's level of consciousness. Repeated intraventricular fibrinolysis resulted in further reduction of the intraventricular hematoma within a few days and a good patient outcome. The patient did not require permanent ventricular shunt. To our knowledge, this is the first reported case of combined systemic enhancement of hemostasis and local fibrinolysis as a life-saving measure in intracranial hemorrhage.

A RETROSPECTIVE STUDY OF THE EXTERNAL VENTRICULAR DIVERSION OF CSF PERFORMED IN A LOCAL NEUROSURGICAL UNIT IN HK

Introduction: External ventricular diversion (EVD) of cerebrospinal fluid (CSF) is a simple neurosurgical procedure for the temporary relief of acute hydrocephalus due to various intracranial pathologies.In Tuen Mun Hospital, the ventricles are drained usually via a frontal burr hole on the ipsilateral side into a close ventricular drainage system. The distal end of the drain is passed through a skin‐tunnel of 3–5 cm long and anchored to the skin. The system is handled with great care and full aseptic technique is exercised during CSF sampling. Apart from prophylactic antibiotic prior to surgery, no antibiotic is given during the course of drainage.Because of the large bore size of the catheter, the drainage is usually more tolerant to thick clot or high protein content in the CSF during acute situations. If the patient remains shunt dependent, the external drainage is later taken over by a permanent ventricular shunt at a suitable time.Method: Clinical records of the 107 cases of EVDs done between the period of March 1998 and September 2000 were reviewed, targeting at:1) the local epidemiology of the EVDs we have performed, and2) the outcomes and complications.Results: EVD was very often done following spontaneous intracerebral haemorrhage/ intraventricular haemorrhage (36%) and as an adjunct to surgical clipping of aneurysms (33%). Only 38 patients (35%) eventually needed a permanent shunt.It was evidenced that the longer the placement of EVD, the more the complications.Among these complications, EVD infection was of the greatest significance. EVD infection, which was diagnosed by positive CSF culture, was found in 9 cases (8.4%) of the 107 primary drainage.Chest infection (50%) was the commonest co‐existing systemic infection, followed by urinary tract infection (20%).Conculsion:External ventricular diversion is a safe procedure if precaution is taken to avoid infection. In two third of cases, permanent shunt is not required precluding the morbidity of foreign body implantation.

Tratamiento fibrinolítico de la hemorragia intraventricular cerebral

Spontaneous cerebral intraventricular hemorrhage (SCIVH) is associated with hydrocephaly which requires ventricular drainage as treatment. Maintenance of adequate debit through the drainage system contributes to reduce morbid mortality. When the drain becomes obstructed, intermittent irrigation is necessary. This causes increased intracranial pressure and risk of infection. We propose the use of recombinant plasminogen tissue activator (r-tPA) in the treatment of SCIVH and associated hydrocephaly.We gave two patients with SCIVH 4 cc/day of r-tPA intraventricularly, at a concentration of 1 mg/ml over 4 consecutive days. Daily computerized tomography (CT) series were done. In both cases there was complete resolution of the SCIVH, with no complications related to the treatment. The ventricular drainage systems maintained a constant debit, did not become obstructed and required no revision. The patients did not subsequently require permanent ventricular shunts. One patient died of an unrelated septic condition. The other patient, a year later, could walk unaided, had motor dysphasia and on CT had neither intraventricular blood nor hydrocephaly.The intraventricular administration of r-tPA is a valid therapeutic tool in selected cases. It contributes to lysis of the intraventricular clot, permits permeability of the drainage, and may reduce the incidence of chronic hydrocephaly requiring a permanent ventricular shunt.

Neurosonography of hydrocephalus in infants.

Transfontanel cranial ultrasonography reliably delineates ventricular size and anatomy in small infants. In these children, it is an excellent primary imaging technique for evaluation of the many clinical problems related to ventricular dilatation. Sonography can be useful for: detecting ventriculomegaly, differentiating nonobstructive ventricular dilatation from obstructive enlargement (hydrocephalus), determining the cause of hydrocephalus; aiding in the temporary management of patients with hydrocephalus; and aiding in the management of patients with permanent ventricular shunts.