Post-traumatic Hydrocephalus Research Articles

Cause of Post-Traumatic Hydrocephalus Because of Traumatic Aqueduct Obstruction in Two Cases

Cause of Post-Traumatic Hydrocephalus Because of Traumatic Aqueduct Obstruction in Two Cases

Magnetic resonance imaging flow void changes after cerebrospinal fluid shunt in post-traumatic hydrocephalus: clinical correlations and outcome

The assessment of the flow-void in the cerebral aqueduct of patients with post-traumatic hydrocephalus on magnetic resonance imaging (MRI) evaluation could concur the right diagnosis and have a prognostic value. We analysed prospectively 28 patients after a severe head injury (GCS<or=8), with radiological or clinical suspicion of post-traumatic hydrocephalus and a fast flow-void signal in the cerebral acqueduct on T2-weighted and proton density MRI. Twenty-two patients were shunted (n=19) or revised (n=3). Six patients were followed-up without surgery. Twenty out of 22 shunted patients (91%) showed variable reduction of the fast flow-void. Eighteen of the operated patients (82%) presented a significant clinical improvement at 6-month follow-up. All patients (n=2) who had no change of the fast flow-void after surgery did not clinically improve. The six non-shunted patients did not present any clinical or radiological improvement. In head-injured patients, fast flow-void in the cerebral aqueduct is diagnostic for post-traumatic hydrocephalus and its reduction after ventriculo-peritoneal shunt is correlated with a neurological improvement. In already shunted patients, a persistent fast flow-void is associated with a lack of or very slow clinical improvement and it should be considered indicative of under-drainage.

Complications of Missile Craniocerebral Injuries during the Croatian Homeland War

Complications of penetrating craniocerebral injuries in war can be early (during the first week after wounding) or late (after that period). Postoperative hematomas, infections, seizures, and cerebrospinal fluid fistulas (CSFFs) are counted among the early complications, whereas foreign bodies migrating intracranially, seizures, infections, and posttraumatic hydrocephalus represent late complications. A total of 176 patients with well-defined head injuries from missiles, sustained during the Croatian Homeland War (1991-1995), developed a total of 61 (34.5%) complications. A retrospective statistical analysis of the medical records of the patients in our series was performed to determine the risk factors for the onset of complications, which have unfavorable effects on outcomes. There were a total of 28 (15.9%) infections (deep or superficial), 21 (11.9%) cases of CSFFs, 9 (5.11%) cases of early epilepsy, and 3 cases of post-traumatic hydrocephalus. A total of 47.6% of patients with CSFFs developed intracranial infections. Of eight patients with meningoencephalitis, five had CSFFs and four had intracranially retained foreign bodies. Only one patient developed a cerebral abscess. Two patients died because of infectious complications (13.3%). Post-traumatic hydrocephalus (1.7%) required shunt placement. For 60% of patients with deep-seated intracranial infectious complications and 76% of patients with CSFFs, reoperations had to be performed, whereas this was the case for only 8% of patients without infections (chi2 = 43.6, p = 0.00001). Intracranially retained foreign bodies, wound age, wound site, and operations performed outside the neurosurgical services were the main risk factors for the development of complications. Complications themselves exerted a very unfavorable influence on outcomes. The development of complications reflects very reliably the neurosurgical technique applied.

Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome

Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 2003;84:1637–41. Objectives To detect the clinical and radiologic characteristics of posttraumatic hydrocephalus (PTH), to define its prognostic value, and to assess the effects of shunt surgery. Design Correlational study on a prospective cohort. Setting Brain injury rehabilitation center. Participants One hundred forty patients with severe traumatic brain injury (TBI) referred to an inpatient intensive rehabilitation unit of primary care in a university-based system. Interventions Not applicable. Main outcome measures The Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), FIM™ instrument, and Neurobehavioural Rating Scale (NRS), as well as single-photon emission computed tomography (SPECT) and magnetic resonance imaging. Results PTH was found in 45% of patients. Risk factors for PTH were as follows: age ( P<.04), duration of coma ( P<.0001), and decompressive craniectomy ( P<.0001). PTH correlated with the degree of hypoperfusion in the temporal lobes ( P<.001). Patients who showed clinical deterioration improved after surgery. PTH correlated significantly with GOS, DRS, FIM, and NRS ( P<.0001) 1 year after the trauma, and it influenced the appearance of posttraumatic epilepsy ( P<.02). Conclusions PTH concerns about 50% of patients with severe TBI. It influences functional and behavioral outcome and the appearance of posttraumatic epilepsy. The selection of patients for surgery can be defined principally on a clinical basis. SPECT may be helpful for differentiating ventricular enlargement due to cortical atrophy and hydrocephalus.

Missile injuries of brain - An experience in northern sector

During a period of one year, from Jan 99 to Dec 99, 60 cases of missile injuries were treated at our centre. 59 were males and one was a female and their average age was 25 years. 43 patients had suffered splinter injuries, 12 had gunshot wounds and 5 had suffered injuries by improvised explosive devices. Glasgow coma scale was <5 in 8 patients, 5-8 in 14, 8-12 in 30 and 13-15 in 8 patients. Extensive comminution of skull bones was found in 10 patients. 35 patients had more or less clear penetration of the skull and the rest had orbito-cranial or facio-cranial wounds. CT scan revealed small haemorrhagic contusion with in-driven bones without mass effect in 15, contusion with mass effect in 36 cases, cortical contusions without in driven bones (tangential injuries) in 3, distant intracranial contusions in 4, intraventricular haemorrhages in 5, multilobar injuries in 14, and unilobar injury in 40. 52 patients were operated upon at our centre of which 30 were operated within 24 hours, 10 between 24 to 48 hours, 12 between 48-72 hours. Six patients were treated conservatively and 2 required only simple closure of scalp wound. Craniectomy was done in 10 and craniotomy in 42 patients. Two patients developed wound sepsis, one each developed aspiration pneumonia, septicemia, deep vein thrombosis and post-traumatic hydrocephalus. On follow up at 6 months, outcome as per Glasgow outcome scale was as follows : good outcome - 42, moderate disability in 7, severe disability in 6 and death in 5 patients. Retained bone fragments were found in 40% on follow up CT scan but none had brain abscess.

Poster 14: Hypertension as the sole indication of posttraumatic hydrocephalus: a case report

Setting: Inpatient rehabilitation ward in pediatric hospital. Patient: A 7-year-old girl with traumatic brain injury. Case Description: The patient was admitted after being hit by a truck while she was walking. She lost consciousness and had an admission Glasgow Coma Scale score of 3. Her initial head computerized axial tomography showed diffuse axonal injury in her left parietal white matter, along with intracerebral, intraventricular, and brainstem hemorrhage. She was admitted to the intensive care unit for increased intracranial pressure (ICP), pneumonia, and multiple fractures, which were managed medically. Her ICP monitoring was eventually discontinued. On transfer to the rehabilitation ward she had a Rancho Los Amigos (RLA) level of 3. She was agitated and confused with a blood pressure of 104/74mm/Hg. A week after transfer, the patient was noted to have hypertension with systolic blood pressure in the 130 range, with occasional readings in the 150 range and diastolic blood pressure in the 90 range. Cardiac work-up was negative. The patient was started on propranolol and showed minimal improvement in blood pressure. Head computed tomography showed interval development of marked ventriculomegaly involving the lateral, third and fourth ventricles, compatible with communicating hydrocephalus. She underwent ventriculoperitoneal shunt placement. Assessment/Results: Within 3 days of the shunt placement, her hypertension improved. Propranolol was switched to atenolol, which was weaned over next 7 days. Her hypertension was alleviated. The patient continued to improve cognitively with a discharge RLA level of 6. Discussion: This is the first reported case, to our knowledge, of minimally elevated blood pressure as a sole sign of posttraumatic hydrocephalus. Conclusions: Physicians should be highly suspicious of hydrocephalus in posttraumatic brain injury cases. A minimally elevated blood pressure may be the only sign of it.

Complicaciones de los traumatismos craneoencefálicos en una unidad hospitalaria de rehabilitación: serie de 126 casos

The consequences of traumatic brain injuries (TBI) are devastating, whether it is in the personal, family, health care or social spheres. Sufferers will have to follow a rehabilitation programme in which we are going to be faced with a large number of medical, neurological and orthopaedic problems that will exert an influence on that programme. The aim of this study is to determine the epidemiological data and the gravity of the cases of TBI admitted to our Rehabilitation Unit, to identify medical and orthopaedic problems that occurred during the time patients were in hospital, and also to determine factors and variables that could have an effect on the onset of such complications. A retrospective descriptive study was conducted in which we surveyed and collected data from 126 case histories chosen at random from the 210 patients admitted to our Rehabilitation Unit between 1999 and 2001. Mean age, 29 years (interval 4 67), ratio of males to females, 4:1. The TBI were due to motorcycle accidents (40%), car accidents (30%) and falls (11.5%). Neurological problems appeared in 63%, the most frequent of which was psychomotor agitation. 14% displayed post traumatic hydrocephalus, and 8% presented post traumatic seizures. Gastro intestinal problems were seen in 41%, the most frequent being constipation. Respiratory problems were found in 36%, and 15.6% of the patients suffered from pneumonia. 8% displayed para articular ossifications. The number of days spent in the ICU and the days in coma were the more highly statistically significant variables associated with the onset of these complications. The problems presented by TBI patients during their stay in a Hospital Rehabilitation Unit are diverse and complex; the number of days spent in the ICU and the days they are in coma are the variables that can be of most use in predicting the onset of such complications.

Post-traumatic hydrocephalus

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy’s report in 1914. The incidence of symptomatic PTH ranges from 0.7%-29%. IfCT criteria of ventriculomegaly are used the incidence has been reported to be from 30%-86%. Differences in diagnostic criteria and classification have contributed to the variation in reported incidence. The diagnosis of PTH is established using a combination of clinical, imaging and physiologic data. Symptomatic PTH is to be distinguished from post-traumatic ventriculomegaly resulting from atrophy. Symptomatic PTH patients are likely to improve when treated by shunting. Ventriculomegaly secondary to atrophy is less likely to respond to shunting. A series of traumatic brain injury patients at Wayne State University has been followed since 1989. The overall incidence of shunt placement in this group is 3.65%. Future studies of PTH should be aimed at refining diagnostic classification and criteria. Analysis of a large PTH population may then identify alterable risk factors in the early post-traumatic brain injury period. Minimizing these factors will help prevent subsequent PTH and obviate the need for shunting. [Neurol Res 2000; 22: 25-28]

Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus

Object : Post-traumatic hydrocephalus (PTH) is considered a frequent complication after severe head injury (HI). There is little known about outcome following shunt implantation. Methods : A hospital-based retrospective cross-over study investigated the outcome of 48 patients after severe HI, who had undergone ventricular shunt implantation due to PTH (40 males, mean age at injury 36 years, mean duration from HI to shunt implantation 27 weeks). Telephone interviews with the patients or with caring family members by means of a detailed questionnaire were performed after a mean observation period of 3.3 years after shunt implantation. Outcome was categorized using the Glasgow Outcome Scale (GOS): I: 12 patients, II: 7, III: 16, IV: 9, V: 4 at follow-up. Conclusions : 52.1% had a clear-cut benefit from shunt implantation, whereas 47.9% had not. Posttraumatic seizures were observed in 31 of 48 patients. Other complications after shunt implantation occurred in 20 patients. Revision of shunt implantation was performed in 15 patients (nine due to technical failure, three haemorrhage, one delayed primary wound closure, and two unknown). Two patients clearly deteriorated after operation (one severe frontal bleeding, one sepsis). The best predictive parameter for outcome after shunt implantation was the pre-operative status, patients in a better clinical condition (pre-operative GOS score 3-severe disabled vs 4-persistent vegetative state) had a better outcome. Patient's age at injury did not seem to influence the outcome. Clinical and computertomographic findings were of rather moderate predictive value as regards short- and long-term outcome after shunt implantation. Cisternography does not seem to be of additional help in the establishment of definite diagnosis of PTH.

2-06-02 Late post-traumatic hydrocephalus: A frequent and misdiagnosed complication in severe brain-injured patients

2-06-02 Late post-traumatic hydrocephalus: A frequent and misdiagnosed complication in severe brain-injured patients

Usefulness of spinal drainage for post-traumatic external hydrocephalus: report of two cases

An 8-year-old girl presented with symptoms of increased intracranial pressure on the 18th day after removal of an occipital epidural haematoma. A 69-year-old woman exhibited the same symptoms on the 6th day after the removal of a left frontal subdural haematoma. Computed tomography (CT) revealed that both patients were suffering from external hydrocephalus. Spinal drainage, maintained for 18 days in the former case and for 7 days in the latter, not only relieved those symptoms but also cured the external hydrocephalus. Recurrence of external hydrocephalus has not been observed in either case for several years since discontinuation of spinal drainage. Usefulness of spinal drainage for post-traumatic external hydrocephalus is discussed.

Posttraumatic ventriculomegaly: hydrocephalus or atrophy? A new approach for diagnosis using CSF dynamics.

Cerebrospinal fluid (CSF) dynamics were correlated to the changes in ventricular size during the first 3 months posttrauma in patients with severe head injury (Glasgow Coma Scale score < or = 8, 75 patients) to distinguish between atrophy and hydrocephalus as the two possible causes of posttraumatic ventriculomegaly. Using the bolus injection technique, the baseline intracranial pressure (ICP), pressure volume index, and resistance for CSF absorption (R0) provided a three-dimensional profile of CSF dynamics that was correlated with ventricular size and Glasgow Outcome Scale (GOS) score at 3, 6, and 12 months posttrauma. Patients were separated into five different groups based on changes in ventricular size, presence of atrophy, and CSF dynamics. Group 1 (normal group, 41.3%) demonstrated normal ventricular size and normal ICP. Group 2 (benign intracranial hypertension group, 14.7%) showed normal ventricular size and elevated ICP. Group 3 (atrophy group, 24%) displayed ventriculomegaly, normal ICP, and normal R0. Group 4 (normal-pressure hydrocephalus group, 9.3%) had ventriculomegaly, normal ICP, and high R0. Group 5 (high-pressure hydrocephalus group, 10.7%) showed ventriculomegaly and elevated ICP with or without high R0. The GOS score in the nonhydrocephalic groups (Groups 1, 2, and 3) was better than in the hydrocephalic groups (Groups 4 and 5). It is concluded from these results that 44% of head injury survivors may develop posttraumatic ventriculomegaly. Posttraumatic hydrocephalus, as identified by abnormal CSF dynamics, was diagnosed in 20% of survivors and their outcome was significantly worse. This study demonstrates the importance of using CSF dynamics as an aid in diagnosis of posttraumatic hydrocephalus and identifying those patients who may benefit from shunt placement.

Post-traumatic hydrocephalus: incidence and outcome following screening of consecutive admissions: Emily J. Yu, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD; Corwin Boake, PhD

Post-traumatic hydrocephalus: incidence and outcome following screening of consecutive admissions: Emily J. Yu, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD; Corwin Boake, PhD

Use of the distal double-slit valve system in children with hydrocephalus

Shunts with distal slit valves have been in use for almost three decades for children with hydrocephalus. Drawbacks of this device include shunt obstruction, infection and overdrainage. One-piece shunts have been used widely for ventriculoperitoneal insertion because they are easy to place, do not need manipulation of connecting parts during surgery, and rarely disconnect. Disadvantages of these shunts, however, include a relatively higher risk of distal obstruction than with the open-ended peritoneal tube and a tendency for overdrainage. With these disadvantages in mind, we hypothesized that using double-distal-slit valves could increase the survival rate of the shunt. For the past 2 years we have been using a one-piece shunt with double-distal-slit valves and an elliptical reservoir under a strict protocol. The study showed the following (1) Among the children operated on, 30.3% required shunt revisions (0.9 revisions per patient). Children with intraventricular hemorrhage-posthermorrhagic hydrocephalus had a three times higher risk of shunt revision than children with posttraumatic hydrocephalus (55.4% vs 18.8%). (2) The so-called slit-ventricle syndrome was observed in only 4 children (8.5%), who subsequently required surgical attention. Most of the children with other forms of the overdrainage phenomenon continued to do well without clinical problems. (3) Of the 155 children, 7 (4.5%) experienced infections after the initial shunt installation. (4) Of the 136 shunt revisions, 90.4% (123 procedures) were related to obstruction. Distal obstruction (47.1%) was more frequent than proximal obstruction (36.6%). (5) In 8 children, the shunt was still working through the proximal set of valves when the distal set of valves was completely obstructed.(ABSTRACT TRUNCATED AT 250 WORDS)

Shunting in chronic post-traumatic hydrocephalus: Demonstration of neurophysiologic improvement

The neuronal metabolic state that forms the cellular basis for cognitive functioning and motor behavior is dependent on cerebral perfusion. As intracerebral pressure increases, cerebral perfusion is compromised. The management of acute hydrocephalus after head trauma has been extensively described. In this article, we present evidence of clinical, cerebral perfusion, and neurophysiologic improvement in a 19-year-old patient with chronic post-traumatic hydrocephalus. Lethargy, gaze palsy, torticollis, and triplegia were noted 2 years postinjury in a neurologically stable patient. Computed axial tomography (CAT) scan confirmed marked enlargement of the third and fourth ventricles with a prominent subgaleal fluid collection. Intraoperative cerebral spinal fluid pressure was 26cm H2O despite hyperventilation. A ventriculo-peritoneal shunt was placed. Postoperatively, marked improvement in clinical exam, cerebral perfusion (SPECT scan), and evoked potentials correlated with the reemergence of the cerebral mantle on CAT scan and magnetic resonance imaging (MRI). Chronic obstructive hydrocephalus should be suspected and aggressively pursued in chronic head injury.

Posttraumatic Hydrocephalus

Posttraumatic hydrocephalus presents a diagnostic and therapeutic challenge. In the setting of a recent head injury with progressive ventricular dilatation on serial computed tomograms and typical clinical findings, placement of a shunt is the treatment of choice. Ancillary confirmatory tests may be used when the patient is a high-risk surgical candidate, has a more remote injury or superimposed atrophy, or is unable to demonstrate classic physical signs.

Updates on the diagnosis and management of posttraumatic hydrocephalus

Updates on the diagnosis and management of posttraumatic hydrocephalus

Intragastric Migration of a Ventriculoperitoneal Shunt Catheter

A child developed bacterial meningitis and shunt dysfunction 2 years after the insertion of a ventriculoperitoneal shunt for posttraumatic hydrocephalus. The distal end of the shunt catheter had penetrated the gastric wall. We found no other report of intragastric shunt catheter migration with successful treatment.

Intragastric migration of a ventriculoperitoneal shunt catheter

A child developed bacterial meningitis and shunt dysfunction 2 years after the insertion of a ventriculoperitoneal shunt for posttraumatic hydrocephalus. The distal end of the shunt catheter had penetrated the gastric wall. We found no other report of intragastric shunt catheter migration with successful treatment (Neurosurgery 21: 255-257, 1987)

Traumatic Huge Acute Subdural Hematoma of the Posterior Fossa in a Child

Acute subdural hematoma of the posterior fossa is rare, occupying 0.5% to 1.6% of all acute subdural hematomas. In children, it is extremely rare. There has been only 11 cases reported in the literature, excluding neonatal cases. Herein a case was reported of an acute subdural hematoma of the posterior fossa in a child who survived after an emergent surgical exploration. A 6-year-old female was involved in a motor vehicle accident. She fell to the ground, hitting the left occipital region. After a semi-lucid interval several hours, her consciousness deteriorated and she was brought to the hospital. On examination, the patient was comatose, and showed decerebrate posture with bilateral pin-point pupils. Computed tomography scan revealed a huge hematoma which occupied the left posterior fossa and moderate obstructive hydrocephalus. A left suboccipital emergency craniectomy was performed, and an occipital bone fracture was confirmed. Then, subdural hematoma was confirmed, which seemed to be caused by bleeding from a cerebellar cortical small artery. Most of the clots were removed, and hemostasis was achieved. The postoperative course was favourable. The patient became alert 2 weeks later, and was discharged with a very mild ataxic gait 2 months later. No post-traumatic hydrocephalus is seen as yet.