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Pediatric Hydrocephalus

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ANATOMY

 

PATHOPHYSIOLOGY

  • CSF production of 300-500cc/day
  • Recycle CSF approximately 3x/day
  • CSF production = CHOROID PLEXUS + ependyma + ECF + brain + arachnoid
  • CSF absorption = ARACHNOID GRANULATIONS + ependyma + blood vessels + brain + ECF
  • CSF underabsorption causes >98% of hydrocephalus

INCIDENCE AND ETIOLOGY

Incidence = 1-2/1,000

COMMON ETIOLOGIES

Congenital: TORCH, X-linked, cysts, developmental(e.g. venous outflow obstruction or webs)

Acquired:  IVH, infectious, traumatic, tumors

PRESENTATION IN INFANCY

  • Rapid Skull Growth
  • Full Fontanelle
  • Split Cranial Sutures
  • Poor Feeding
  • Irritability
  • Apnea
  • Bradycardia
  • Macrocephaly
  • Setting Sun Sign

PRESENTATION IN CHILDRENAND ADULTS

  • Head-ache
  • Nausea and Emesis
  • Alteration in Level of Consciousness
  • Behavioral Changes
  • Worsening Work/School Performance
  • Spasticity
  • Papilledema
  • Irritability

NORMAL PRESSURE HYDROCEPHALUS

At first, the symptoms in normal pressure hydrocephalus are usually very subtle. They worsen very gradually.

Dementia symptoms

  • Memory loss
  • Speech problems
  • Apathy (indifference) and withdrawal
  • Changes in behavior or mood
  • Difficulties with reasoning, paying attention, or judgment

Walking problems

  • Unsteadiness
  • Leg weakness
  • Sudden falls
  • Shuffling steps
  • Difficulty taking the first step, as if feet were stuck to the floor
  • “Getting stuck” or “freezing” while walking

Urinary symptoms

  • Inability to hold urine
  • Inability to hold stool, or feces (less common)
  • Frequent urination
  • Urgency to urinate

TREATMENT OPTIONS

  • VENTRICULO-PERITONEAL SHUNT
  • THIRD VENTRICULOSTOMY
  • VENTRICULOATRIAL SHUNT
  • OTHER DIVERSIONARY SHUNTS
  • MEDICATIONS (SHORT TERM REDUCTION OF CSF PRODUCTION WITH ACETAZOLAMIDE)     

VALVE OPTIONS

  • PRESSURE CONTROLLED
  • FLOW REGULATED
  • ANTI-SIPHON DEVICE
  • PROGRAMMABLE

PRE-OP MRI of Acqueductal Stenosis

 

OR POSITIONING

 

OR PREP

 

PASSING THE SHUNT

 

VENTRICULAR CATHETER

 

SNAPPING THE SHUNT

 

PERITONEAL TROCHAR

 

PERITONEAL CATHETER

 

SHUNT COMPLICATIONS

  • SHUNT OBSTRUCTION – UP TO 40% IN 3 MONTHS
  • SHUNT INFECTION – 3-5%, HIGHER IN PREMATURE INFANTS OR WITH CONCURRENT INFECTION
  • SEIZURES - >30% INCIDENCE OF EPILEPSY
  • SLIT VENTRICLE SYNDROME
  • SECONDARY SYNOSTOSIS
  • SUB-DURAL HEMATOMA
  • BRAIN INJURY – 1/40,000
  • WOUND DEHISCENCE

EVALUATION OF SHUNT INFECTION

  1. History – Fever, chills, N/V, redness around incision, revision<6months ago
  2. Examination – Fever, tachycardia, dehydration, drainage or erythema about shunt, peritoneal or meningeal signs
  3. Radiology doesn’t assist in the diagnosis of shunt infection
  4. Lab work – CBC with diff, CSF from shunt tap for glucose, protein, cell counts, gm stain & cx

TREATMENT OF SHUNT INFECTION

  • Antibiotics alone are not adequate
  • Shunt must be removed and, usually, CSF must be externally drained(as an abscess) while anti-biotics are ongoing
  • Need 3 negative cultures prior to re-implantation
  • Try to replace shunt on opposite side
  • Risk of infection now twice rate of previously uninfected

EVALUATION OF SHUNT FAILURE

LISTEN TO THE PATIENT AND FAMILY

  1. History – head-aches, N/V, poor feeding,   lethargy, swelling around shunt
  2. Examination – fontanelle, papilledema, level of consciousness, lack of other sources, e.g. flu
  3. Radiology – head CT and shunt series(comparison films are essential)
  4. If fear of shunt failure continues, shunt tap
  5. If good flow but still concerned, abdominal ultrasound vs CT

TREATMENT OF SHUNT FAILURE

  • Surgery is only option
  • Replacement of failed part

Or

  • 3rd ventriculostomy in appropriate patient

CT COMPARISON

 

CT COMPARISON

 

INFECTION RATES

  • Ventriculo-peritoneal shunts are the most commonly infected implants in neurosurgery and among the most commonly infected implants in any specialty
  • Shunt infection rates have varied from 0-75% in previous publications

OUTCOMES BASED MEDICINE

 

KNOWN RISK FACTORS THAT INCREASE VENTRICULO-PERITONEAL SHUNT INFECTION RATES

Age1

Associated Diagnoses2

Antibiotic Prophylaxis3

Length of Hospital Stay4

1 Tuli et al J Neurosurg. 2004 May;100(5 Suppl Pediatrics):442-6  
2 Vinchon et al Childs Nerv Syst. 2006 Jul;22(7):692-7.
3 Pattavilakan et al J Clin Neurosci. 2007 Jun;14(6):526-31.
 
4 CID 2003:36 (1 April) • McGirt et al.

POSSIBLE RISK FACTORS THAT INCREASE VENTRICULO-PERITONEAL SHUNT INFECTION RATES

  • Time of Day Procedure Starts
  • Duration of Surgery
  • Number of Assistants
  • Use of Home Laundered Scrubs
  • Experience of Surgeon

METHODS

  • Prospective patient data collection was performed using hospital and practice data bases.
  • Literature review was used to create the shunt protocol.
  • SHUNT PROTOCOL
  • MINIMIZE SURGICAL PERSONNEL(<4)
  • NO SURGICAL ASSISTANCE
  • MINIMIZE SURGICAL TIME(<15 MINUTES)
  • USE UNITIZED ANTI-BIOTIC IMPREGNATED SHUNT(BACTISEAL SHUNT WAS USED, WITH 70 OR 100mmHg FIXED PRESSURE VALVES IN MOST CASES)
  • MINIMIZE USE OF PROGRAMMABLE VALVES
  • PERFORM SHUNTS AS FIRST CASE, IN TERMINALLY CLEANED ROOM, WHEN POSSIBLE
  • USE NEURO TEAM(RN AND TECH), WHEN POSSIBLE

RESULTS: PATIENT VARIABLES

 

NO STATISTICALLY SIGNIFICANT VARIATION IN ANY OF THE ABOVE

RESULTS: PROTOCOL VARIABLES

 

RESULTS: INFECTION RATES

 

CONCLUSION

  • With stringent adherence to a strict protocol, <2% ventriculo-peritoneal shunt infection rate is an attainable mark.
  • 0% should be our goal.

WHERE DO WE GO FROM HERE?

  • First described in Dandy WE: An operative procedure for hydrocephalus. Johns Hopkins Hosp Bull 33:189–190, 1922
  • Endoscopic 3rd ventriculostomy is gaining popularity due to minituarization and improved optics.
  • However, there is a significant learning curve, both for the surgeon and the OR staff concerning the procedure.
  • It is one of the few procedures in neurosurgery in which the surgeon may not be able to immediately control bleeding.

3RD VENTRICULOSTOMY

Benefits: Shunt independence

  • Minimal risk of infection
  • Reduced failure rate in selected patients

Risks:  Injury to the basilar artery

  • Failure to make adequate hole(closure)
  • Forniceal injury(memory)

WHO ARE THE RIGHT PATIENTS FOR A 3RD VENTRICULOSTOMY?

Obstructive hydrocephalus

  1. Spina Bifida
  2. Tumor
  3. Acqueductal stenosis
  • No infection/injury to arachnoid granulations
  • Big enough head to allow for navigation(over 2 years of age)

ANATOMY

 

ENDOSCOPE WITH FOGARTY BALLOON

 

INTRA-OPERATIVE VIEW

 

OTHER OPTIONS?

  • We’ve tried other alternatives and other ventriculo-peritoneal shunt materials, none with greater success than ventriculo-peritoneal shunts and 3rd ventriculostomies.
  • Putnam TJ: Treatment of hydrocephalus by endoscopic coagulation of the choroid plexus. N Engl J Med 210:1373–1376, 1934.

ULTIMATE GOAL