Secondary Obstructive Hydrocephalus Research Articles

Giant cerebellar cavernous malformation in children: A case report and literature review.

Giant cerebellar cavernomas in children are rare and must be differentiated from hemorrhagic cerebellar tumors. The diagnosis and treatment of giant cerebellar cavernomas is challenging, but complete surgical resection can lead to favorable outcomes and complete neurological recovery in most cases. We present a case of eight months old baby who was diagnosed with a giant cavernoma resulting in secondary obstructive hydrocephalus with neuropsychiatric presentations. The patient underwent a paramedian craniotomy surgery with a suboccipital approach and complete surgical resection of the cavernoma was done. Over nine months of observation, the child showed improvement in their ability to walk and fully recovered from a neurological perspective. We also conducted a literature review to identify eleven cases of giant cerebellar cavernomas in children, including our case. The data were analyzed to determine the clinical features, treatment, and outcomes of giant cerebellar cavernomas in children.

Breast Cancer Brain Metastases and Secondary Obstructive Hydrocephalus: Considering the Role of Aromatase.

Breast Cancer Brain Metastases and Secondary Obstructive Hydrocephalus: Considering the Role of Aromatase.

An indolent presentation of brain abscess due to a slow growing organism

Propioni bacterium propionicum is an anaerobic gram positive bacteria. It’s rarely described as to cause brain abscess. We report the isolation of this organism from a brain abscess and emphasise the problems associated with it’s diagnosis. A 62 year old lady with a history of acromegaly underwent emergency surgery for recurrent pituitary lesion felt to be apoplexy. Four weeks later she presented with headache and confusion. Co morbidities included autoimmune diseases on long term steroids and previous use of immunosuppressants. Clinical examination showed neck stiffness. Brain MRI demonstrated an enhancing lesion in the fourth ventricle causing secondary obstructive hydrocephalus requiring endoscopic third ventriculostomy. Blood tests, CSF analysis and whole body PET scan were unable to differentiate between infection and malignancy. Excision of the lesion was felt very high risk as deep in the tectal area. A sporadic trial of antibiotics, high dose steroids and immunotherapy was tried. Patient developed worsening headache with progression of the lesion. Underwent craniotomy and pus was found which isolated P. propionicum sensitive to penicillin and betalactams. Treated with intravenous meropenem for a year. There was significant reduction in the size of the abscess and hydrocephalus on brain MRI at 8 months post-diagnosis. P. propionicum has been isolated and associated with lesions of the lacrimal glands, lung and abdomen. We could find only two case reports of brain abscess due to P. propionicum. Identification of P.propionicum in the microbiology laboratory can be difficult requiring anaerobic growth conditions and extended cultures. Treatment is prolonged antimicrobial therapy.

A Case Report of Lhermitte-Duclos Disease in a 10-Month-Old Child Presenting with Hydrocephalus

Lhermitte–Duclos Disease is a rare entity characterized by diffuse or focal enlargement of cerebellar folia. Clinical manifestations are usually related to a mass effect and secondary obstructive hydrocephalus. Increased intracranial pressure symptoms and cerebellar symptoms are the most frequent patient complaints. We present a 10-month-old male child with his mother who presented to the outpatient department with complaints of enlargement of size of head since the last one week. Magnetic Resonance Imaging scan revealed the features of Lhermitte–Duclos Disease involving the right cerebellar hemisphere with marked post contrast gyral enhancement. He underwent endoscopic third ventriculostomy. Lhermitte–Duclos Disease is very rare in early childhood and should be considered in the differential diagnosis of posterior fossa lesions.

The role of radiosurgery in the acute management of fourth ventricle compression due to brain metastases.

Background:Approximately 20–30% of all intracranial metastases are located in the posterior fossa. The clinical evolution hinges on factors such as tumor growth dynamics, local topographic conditions, performance status, and prompt intervention. Fourth ventricle (V4) compression with secondary life-threatening obstructive hydrocephalus remains a major concern, often requiring acute surgical intervention. We have previously reported on the application of adaptive hypofractionated Gamma Knife Radiosurgery in the acute management of critically located metastases, a technique known to us as rapid rescue radiosurgery (3R). We report the results of 3R in the management of posterior fossa lesions and ensuing V4 decompression.Case Descriptions:Four patients with V4 compression due to posterior fossa metastases were treated with 3R by three separate gamma knife radiosurgical sessions (GKRS) over a period of seven days. Mean V4 volume was 1.02 cm3 at GKRS 1, 1.13 cm3 at GKRS 2, and 1.12 cm3 at GKRS 3. Mean tumor volume during the week of treatment was 10 cm3 at both GKRS 1 and 2 and 9 cm3 at GKRS 3. On average, we achieved a tumor volume reduction of 52% and a V4 size increase of 64% at the first follow-up (4 weeks after GKRS 3). Long-term follow-up showed continued local tumor control, stable V4 volume, and absence of hydrocephalus.Conclusion:For this series, 3R was effective in terms of rapid tumor ablation, V4 decompression, and limited radiation-induced toxicity. This surgical procedure may become an additional tool in the management of intractable posterior fossa metastasis with V4 compression.

ENDOSCOPIC THIRD VENTRICULOSTOMY VERSUS VENTRICULOPERITONEAL SHUNT IN TREATMENT OF OBSTRUCTIVE HYDROCEPHALUS COMPLICATING PEDIATRIC POSTERIOR FOSSA TUMORS

Background:Posterior fossa tumors are the most common solid tumors found in the pediatric population. Approximately, 70–90% of patients with posterior fossa tumors present with hydrocephalus. This presents an interesting problem to pediatric neurosurgeons for which there remains no consensus: What is the best management strategy for hydrocephalus at the time of the initial presentation of the patient? Objective: This multicenter prospective cohort study compared endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of pediatric patients with secondary obstructive hydrocephalus due to posterior fossa tumors. Patients and Methods: Sixty four patients with posterior fossa tumors (24 medulloblastoma, 12 ependymoma, 27 astrocytoma and 1 schwannoma) associated with secondary hydrocephalus were divided into two equal groups according to the treatment procedure done to the secondary hydrocephalus either ETV or VP shunts, with a follow-up period of 6 months, were prospectively studied in this work. Results: Both procedures (ETV and VP shunt) proved to be effective clinically and radiographically. Endoscopic third ventriculostomy (ETV) proved to be superior due to shorter duration of surgery (17 min versus 58 min), no mortality (0% versus 6.25%), and lower incidence of procedure failure (15.6% versus 21.9%) with highest success rate of 100% was for astrocytomas followed by 80% for ependymomas and 63.6% for medulloblastomas. Conclusion: Both procedures (ETV and VP shunt) proved to be effective clinically and radiographically in the treatment of secondary obstructive hydrocephalus in pediatric patients with posterior fossa tumors. For ETV, the safety, simplicity, a more physiological of internal shunting, a significantly shorter surgery duration, absence of mortality, lower significant complications rate, a lower rate of procedure failure, the significant advantages of not becoming shunt dependent and avoidance of hardware complications (malfunction, obstruction, infection) and making safe handling and resection of the posterior fossa tumors feasible, all the previous factors made the ETV to be recommended as the first choice in the treatment of pediatric patients with obstructive hydrocephalus due to posterior fossa tumors.

IMAGING DIAGNOSIS-MAGNETIC RESONANCE IMAGING OF A NEURONAL HETEROTOPIA IN THE BRAIN OF A CAT.

A domestic shorthair kitten was presented for evaluation and further treatment of seizures. Magnetic resonance imaging of the brain revealed a large multilobulated mass in the third ventricle extending into the right lateral ventricle with secondary obstructive hydrocephalus. The mass was homogeneously isointense to gray matter on T2W, T2-FLAIR, T2* W, T1W, and ADC images, and hyperintense on DW-EPI. There was no appreciable contrast enhancement. Seizures were managed medically and with subsequent ventriculoperitoneal shunt placement. Clinical status later deteriorated and the cat was euthanized. Histopathology confirmed that the mass was the result of neuronal heterotopia. To the authors' knowledge this is the first report of neuronal heterotopia in a cat.

Biopsy of Brainstem Gliomas Using Flexible Endoscopes.

To describe our experience and the results obtained in performing transventricular brainstem biopsy with the use of flexible neuroendoscops. We identified patients who underwent a neuroendoscopic procedure with brainstem lesion biopsy to obtain histopathologic diagnosis and to treat obstructive hydrocephalus. All patients had follow-up examinations at months 1, 3, 6, and 12 postsurgery and then annually. Seven patients had a transventricular biopsy of the brainstem performed. Of those, five were pediatric patients. The median age was 10 years (range: 3-26 years). Five of them were female and two male. Four patients presented with secondary obstructive hydrocephalus. The main clinical presentations were intracranial hypertension syndrome in four patients, motor neuron disease in four patients, two with decreased state of alertness, two with gait ataxia, and one with Parinaud syndrome. The types of tumors found in the histopathology and their location were one ventral (pons) and one aqueductal anaplastic astrocytoma, two ventral, one aqueductal, and one attached to the floor of the fourth ventricle pilocytic astrocytoma and one ventral low-grade astrocytoma. The route taken to approach the ventral tumors was made through premammillary fenestration. The tumors of the aqueduct and floor of the fourth ventricle were approached transaqueductally. The use of flexible endoscops for biopsy of ventral, dorsal (tectum lamina quadrigemina), and diffuse brainstem tumors is a useful, effective, and safe procedure that also allows to treat obstructive hydrocephalus secondary to the tumors.

MENINGOENCEPHALITIS WITH SECONDARY OBSTRUCTIVE HYDROCEPHALUS CAUSED BY PROBABLECOCCIDIOIDESSPECIES IN A BUFF-CHEEKED GIBBON (NOMASCUS GABRIELLAE)

An 8-yr-old male buff-cheeked gibbon (Nomascus gabriellae) acutely developed abnormal behavior, decreased appetite, and dull mentation. Mild generalized muscle wasting and weight loss were the only other abnormalities noted on examination. Routine immunodiffusion serology for Coccidioides spp. were IgG and IgM positive. Magnetic resonance imaging of the brain was suggestive of an infectious meningoencephalitis with secondary obstructive hydrocephalus. A ventriculoperitoneal shunt was placed in standard fashion to reduce the imminent risk of mortality from increased intracranial pressure. Postoperative treatment included oral fluconazole, a tapered course of prednisolone, and physical therapy. Clinical signs improved steadily and the gibbon was fit to return to exhibit 8 wk post-shunt placement. This case of coccidioidomycosis demonstrates the complications that can occur with dissemination to the central nervous system and its management. It is the first published report describing the use of ventriculoperitoneal shunt placement in this species.

Cerebellar toxoplasmosis in HIV/AIDS infant: case report and review of the literature

Cerebellar mass lesion is an uncommon presentation of toxoplasmosis. The authors report one rare case in an 11-month-old HIV/AIDS female infant who presented with deterioration in her developmental milestones. CT scan revealed a ring-enhancing mass lesion in the right cerebellar hemisphere with secondary obstructive hydrocephalus. A ventriculoperitoneal shunt was inserted prior to posterior fossa decompression and biopsy of the lesion. The specimens obtained were divided into two. One specimen was sent for histological diagnosis immediately after surgery while the second specimen was preserved until the release of the histology report. The initial histopathology report indicated a neoplastic process. Immunohistochemical stains were attempted but interpreted with difficulty due to severe tissue necrosis. After waiting for close to 6 weeks without a definite histological diagnosis, the preserved second specimen was sent for histological analysis as a fresh specimen, and reported a diagnosis of toxoplasmosis. This case presented diagnostic challenges to the authors whose radiological impressions of either a neoplastic lesion or a tuberculoma (based on our local neuroepidemiology) were reinforced by intraoperative findings highly suggestive of tuberculoma but which contrasted with the histological report, first as a neoplastic lesion and later toxoplasmosis. Although cerebellar toxoplasmosis is a rare complication of HIV/AIDS, this case report shows that toxoplasmosis should not be overlooked as a differential diagnosis of ring-enhancing cerebellar masses in HIV/AIDS patients irrespective of the patient's age and the absence of constitutional symptoms of toxoplasmosis.

Cerebral salt wasting syndrome: postoperative complication in tumours of the cerebellopontine angle

Cerebral salt wasting (CSW) is a rare complication in posterior fossa tumour surgery. We present two patients with cerebellopontine angle (CPA) tumours who developed cerebral salt wasting postoperatively. Both patients deteriorated in spite of intensive fluid and salt replacement. On CT scan the patients presented mild to moderate ventricular dilation, which was treated with an external ventricular drainage. After the resolution of hydrocephalus, fluid balance rapidly returned to normal in both patients and the clinical status improved. Identification and treatment of secondary obstructive hydrocephalus may contribute to the management of CSW associated to posterior fossa tumour surgery.

Brainstem Ganglioglioma

Gangliogliomas are usually benign slow-growing neoplasms, seen mainly in the first 3 decades of life and are prevalently located supratentorial, mostly in the temporal and frontal lobe. The authors present a rare case of a brainstem ganglioglioma in an 11-year-old boy who was referred to their hospital complaining of episodes of blurry vision, loss of memory, gait disturbances, and morning headache with vomiting, lasting for over a month. Computed tomography and magnetic resonance imaging scans revealed a mass on the dorsal surface of the brainstem, compressing the brainstem and producing secondary obstructive hydrocephalus. The patient was operated upon, and the histopathology revealed the presence of a ganglioglioma grade II (World Health Organization classification). On follow-up examination after 1 year, a minor gait imbalance was the only finding. A total resection should be always attempted, where possible in brainstem gangliogliomas. Close follow-up is mandatory, and re-resection or radiotherapy should be considered in case of tumor recurrence.

Upward Transtentorial Herniation, Hydrocephalus, and Cerebellar Edema in Hypertensive Encephalopathy

Edema of the cerebellum with secondary obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy. The authors report an unusual case of isolated posterior fossa swelling with upward transtentorial herniation and hydrocephalus causing neurologic deterioration. These patients are often initially evaluated by a neurologist because of the acute neurologic symptoms. Prompt diagnosis with aggressive blood pressure control may obviate the need for emergent cerebrospinal fluid (CSF) diversion. This is a case report of a 26-year-old man who presented to the emergency room with confusion and somnolence over a 2-day period. His initial blood pressure was 175/110 mmHg. On examination he was disoriented, with a Glasgow Coma Scale score of 12 points, opening his eyes only to loud verbal stimuli, verbalizing inappropriately, and he was only able to follow simple commands. Neuroimaging revealed edema of the cerebellar folia with noncommunicating hydrocephalus and upward transtentorial herniation. Differential diagnoses of posterior fossa tumor, rhombencephalitis, and hypertensive encephalopathy were entertained. A thorough literature review is included with the discussion of this case. The patient underwent emergent ventriculostomy for CSF drainage and prompt blood pressure control with nitroprusside. After 48 hours of CSF drainage and correction of his hypertension, his neurologic examination normalized. Repeat imaging revealed near resolution of the obstructive hydrocephalus and cerebellar edema. Isolated edema of the cerebellum with upward transtentorial herniation and obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy and should be considered in patients with an acute hypertensive crisis and mental status changes. This entity responds to prompt blood pressure control; however, emergent ventriculostomy by a neurosurgical team should be entertained for neurologic deterioration secondary to significant obstructive hydrocephalus, as illustrated in this case.

Primary Intra-axial Leiomyosarcoma with Obstructive Hydrocephalus in a Young Dog

A female Chihuahua dog aged 2 months had a 3-week history of progressive neurological signs (abnormal behaviour, disorientation, left-sided circling, and incessant whimpering). Necropsy revealed a primary leiomyosarcoma in the midline of the posterior thalamus with secondary obstructive hydrocephalus of the lateral ventricles. Grossly, an infiltrative, grey-white tumour had partly invaded the third ventricle. Histologically, the tumour formed hypercellular, interlacing bundles of neoplastic spindle cells with blunt-ended nuclei. Neoplastic cells were strongly immunoreactive for vimentin and both muscle-specific and α-smooth muscle actin; MIB-1 immunoreactivity indicated a proliferative index of up to 5%. Leiomyosarcoma should be included in the differential diagnosis for primary brain tumours and hydrocephalus in young dogs.

Concentrations of fosfomycin in the cerebrospinal fluid of neurointensive care patients with ventriculostomy-associated ventriculitis.

The present study was performed to test the ability of fosfomycin to penetrate into the CSF of neurointensive care patients with ventriculostomy-associated ventriculitis. Six patients requiring neurointensive care monitoring, including extraventricular drainage due to secondary obstructive hydrocephalus, were enrolled into the study. All patients received 8 g of fosfomycin intravenously three times a day over a period of at least 5 days. Concentrations of fosfomycin in the CSF and plasma were measured after single-dose administration and at steady state. Mean values of the fosfomycin area under the time-concentration curves for the dosing interval of 8 h (AUC(8)) were 929 +/- 280 and 225 +/- 131 mg.h/L for plasma and CSF after single-dose administration, respectively (P < 0.03). The ratios of the AUC(8) for CSF to the AUC(8) for plasma were 0.23 +/- 0.07 after a single dose and 0.27 +/- 0.08 following multiple doses (P > 0.05, not significant). Additional in vitro experiments have shown that fosfomycin exerts non-concentration-dependent microbial growth inhibition. At steady state, the time above MIC (t > MIC) values were 98%, 92% and 61% for pathogens with MIC values of 8, 16 and 32 mg/L, respectively. The present pharmacokinetic study indicates that 8 g of fosfomycin three times per day should provide sufficient antimicrobial concentrations in the CSF for the overall treatment period. Thus, the co-administration of fosfomycin could be useful for the treatment of ventriculitis caused by susceptible pathogens.

Management of hydrocephalus resulting from acoustic neuromas

Patients with large acoustic neuromas may have secondary obstructive hydrocephalus and occasionally significant neurologic deficit develops. At the House Ear Clinic, we have managed patients with hydrocephalus by translabyrinthine tumor removal without preoperative ventriculoperitoneal shunting. Forty-three patients with documented hydrocephalus who underwent acoustic neuroma removal have been reviewed. Six patients had neurologic deficit resulting from raised intracranial pressure before surgery. In each of these six cases, the deficit resolved after tumor removed without requiring shunting. Two patients had had ventriculoperitoneal shunts inserted because of neurologic deficit before referral for tumor removal. Two other patients underwent postoperative shunting for neurologic deficit --one at 2 weeks and one at 2 years. Cerebral or cerebellar herniation was not noted in any case. Cerebrospinal fluid leak occurred in five patients (11.6%) and culture-positive meningitis in two patients (4.6%). We conclude that decompression by translabyrinthine tumor removal is a safe method of management for patients with hydrocephalus resulting from large acoustic tumors.

Der maligne Kleinhirninfarkt

Three patients with cerebellar infarcts and secondary obstructive hydrocephalus (hydrocephalus occlusus) are described, the condition being due to the space-occupying action of the ischaemia and oedema zone with compression and displacement of the fourth ventricle and/or obstruction of the aqueduct. Possible brain stem compression and danger of cerebellar tonsillar herniation were present. From the acute deterioration of the clinical picture, particularly of the state of consciousness, as well as from the findings obtained via computed tomography showing a widening of the inner ventricular space, it was imperative to perform emergency pressure-relieving drainage surgery with ventriculo-atrial shunts in all the cases described. The first two patients could be discharged postoperatively with successful treatment, only slight neurological disturbances remaining. This leads to the conclusion that a (malignant) cerebral infarct should be treated as an emergency case, in a somewhat similar way as in cases of cerebellar haemorrhage or other space-occupying lesions in the posterior fossa of the skull. To recognize the life-threatening exacerbation, sufficient observation and supervision will be necessary. Rapid deterioration in consciousness should be considered a sign of increasing intracranial pressure progressing with the development of hydrocephalus internus occlusus. After neuroradiological diagnosis, especially after verification via computed tomography, this should be interpreted as an indication for immediate neurosurgical intervention. This is the only way to keep the mortality rate satisfactorily low. Dichotomy of cerebellar infarcts into a benign type with spontaneous decrease of symptoms and signs, and a malignant type with development of hydrocephalus internus and increased intracranial pressure, such as in the cases described here, is suggested.

Neuro-ophthalmologic Signs and Symptoms of Cysticercosis

Fifty-six patients with cysticercosis and neuro-ophthalmic signs were examined by me during an 11-year period. Their symptoms generally reflected increased intracranial pressure caused by hydrocephalus, subacute meningitis, cerebral masses or a combination of these effects. Papilledema (37 patients) was the commonest sign, with pupillary abnormalities (16 patients) and nystagmus (12 patients) frequently encountered. Cysticercosis is a relatively benign, although episodic, disease, as long as secondary obstructive hydrocephalus is promptly diagnosed and treated by CSF shunting procedures.