贺晓生-脑积水课件

1、 Shunt for hydrocephalus: analysis and treatment on its complications贺晓生第四军医大学西京医院神经外科 西安Common view on diagnosis and treatment of hydrocephalus Actually in quite divergence and disputeYangzhou. Apr. 2012Beijing. Mar. 2013Hydrocephalus(narrow sense，enlarged ventricles)Mechanism obstructive communica

2、ting compensatingICP increased/ normalSize mild/ moderate/ severeAge pediatric/ adult/ oldCSF circulationCSF: secrete/flow/discharge/absorbCSFProtective water cushion for brain Size (volume)a: Largest distance between the anterior angle of two lateral ventriclesb: largest internal diameter of the sk

3、ull at the same axial planec: Evans index = a/b (normal 22%-32%)Evans index: 30%CT MRI Intracranial pressure(ICP)Adult normal: 80-180mmH2O (5-15 mmHg) increased: 200mmH2O decreased: 904 yrsV-P shuntEarly stage post v-p partial perception of light raise head turn neck turn over the body1 yr follow-up

4、 shrinkage of head (scalp swelling) increased muscle strength improvement of IQPrognosisBest time early surgery if diagnosed Ideal effect if V-P shunt performed within postnatal 3 yrs Time for V-P shunt 2012-11-282013-3-19M, 2yrsObstructive hydrocephalus due to tumorRadiotherapy after shuntV-P shunt

5、Fenestrating or shunt?Tc-99m-DTPA3 days post v-pF, 34Supersellar cyst associated with hydrocephalusF, 82015-03-132015-07-152017-03-16Endoscopic V-C fenestratingM, 22016-02-252017-05-03closure of fistula?Surgical factors that affect shuntAlternative puncture site at cortex bone hole4cm above and 4cm

6、behind upper ear tip puncture direction: perpendicular to cortex3-4cm above external occipital protuberance puncture direction: point to eyebrow midpoint point to outer canthus3cm anterior to coronal suture 3cm lateral to sagittal suture puncture direction: (perpendicularly to two ear connection)Inc

7、orrect puncture directionLack of anatomical recognitionVentricle shift due to intra-operative CSF lossWrong installation Damage to the relative closeness of shunt systemEnds of bump or reservoir conflicting with catheter “Drawing” is preferred to “pushing ” Prevent the formation of Z-like pathAir em

8、bolism in shunt catheterReverse installation shunt system (rare) Not placed in abdomen (rare)Hydrocephalus associated with Chiaris malformation Principle of treatment shunt or not？ decompression via posterior route (PR)？ one-stage operation for both? Which is first?Hydrocephalus reversed by decompre

9、ssion via PR? shunt not requiredSymptoms of Chiaris malformation mitigated by shunt decompression via PR not requiredCase enlightenment decompression via PR inducing brain hernia mechanism: acute CSF exit Hydrocephalus associated with typeChiaris malformation (syringomyelia)M, 29 yrsSuggestedShunt f

10、or hydrocephalusFistula or shunt for syringomyeliadecompression for ChiariPost-shunt strategiesStrong activity be avoided to prevent CSF over-shuntRepeated press of shunt pump not necessary unless suspected shunt blockade Medtronic shunt engineer: William D. Sugleris (middle)Normal pressure hydrocep

11、halus (NPH)Secondary NPH (compensating hydrocephalus) brain injury cerebral hemorrhage cerebral infarction or atrophyIdiopathic NPH (iNPH) DESH non-DESHClinical manifestations for iNPH Elderly patients Dementia Urinary incontinence Gait disturbance Ventricular dilation Without other diseasesVentricu

12、lomegaly Superior and inferior subarachnoid space distributed disproportionately Sylvian fissure or basal cistern dilation Tight high convexity narrowed subarachnoid spaceDisproportionately enlarged subarachnoid space hydrocephalus (DESH) LP shuntCommunicating hydrocephalusIdiopathic intracranial hy

13、pertensionNPHSpect/CT required?Complication 1：over shuntClinical manifestations chronic subdural hematoma chronic subdural effusion slim ventricular syndromes acute subdural hematomaTreatment avoidance of post-shunt activities at early stage Increase threshold (or stop temporally shunt) CSF Overdrai

14、nage2010-01-10pre v-p shunt2013-03-18post v-p shunt 2013-03-20post external drainageF, 10yrsSubdural external drainageInfusion of enough salineRemoval of chronic subdural hematoma due to v-p shunt at 5yrs (organization、calcification)CSF OverdrainageM, 15yrs (complaining chronic headache)Armature sku

15、ll ：5 cases reported 1978 (2) ：Tvete S Larsen JL 1982 (1) ：Mori N 1983 (1) ：Ganolfi A 1987 (1) ：Spadaro A Giant calcified chronic subdural haematoma: a long term complication of shunted hydrocephalus Journal of Neurology, Neurosurgery and Psychiatry 2005; 6 (3) : 367 He Xiaosheng, et al. 2004CSF Ove

16、r shunt6 years laterM, 9mNo symptomsCSF Over shunt2017-04 M, 4yrs2013-12 M, 6mSlim ventricles without obvious symptomsM, 43yrs2015-11 Chronic headache2017-01 (symptomatic)2017-04 (asymptomatic)CSF Over shuntPrecautionsEvaluation of mechanism and pressureUse of shunt system with appropriate pressure

17、thresholdAvoid unintentional valve pressure change High ICP higher threshold V-P shunt system Moderate ICP lower threshold V-P shunt system NPH low threshold V-P shunt system if idiopathic,V-P shunt and L-P shuntTo shunted hydrocephalusHydrostatic pressure caused by position changeSiphon due to hydr

18、ostatic pressure Over drainage because of siphonProblemSo, a valve with an appropriate threshold is necessary controlling CSF flow. supineHealthy adultNormal ICP change between： +10 -5cmH2O PIV(intraventricular pressure)mild negative pressure-20-1001020PIV010203040PIVRelation: body position and vent

19、ricular CSF pressurestandingAnglesinOVP00300,510450,714600,8617.2901203060900ProGav=20 cmH2OOpen Valve Pressure changes with body position (cmH2O)0PHPIVPIVPAPAPH= 0PV + PA = PIV + PHPV = PIV + PH - PASupine：PV = PIV + PH - PA = 10 + 0 5 = 5cmH2OStanding：PV = PIV + PH - PA = -5 + 40 5 = 30cmH2OWhat p

20、ressure to open an valve?PIV: intraventricular PPH: hydrostatic PPA: intra-abdominal PPV: valve-opend PShunt systemFixed pressure valveAdjustable valveAntisiphon device independentAdjustable valve mixed with antisiphon device Sophysa Polaris (V-P、L-P) SiphonX Codman Hakim Medtronic Strata Aesculap-M

21、iethke ProGavAntimagnetic Sophysa Polaris、Aesculap-Miethke ProGavAntiinfectiousWhat is good shunt system?Evaluate the prognosis of hydrocephalus by shuntGood symptoms: improved or disappeared structural Images(Evans index): reduced ventriclesBetter improved symptoms with unchanged ventriclesBad unch

22、anged ventricles without improved symptomsWorsen aggravated symptoms Severe pediatric hydrocephalusNormal pressure hydrocephalusBrain compliance reducedshunt valve with an inappropriate thresholdApproaching ideal shuntUnderstanding the mechanism of hydrocephalusPursuing physiological and mental stab

23、ilityIntellectualized shunt system dynamic monitoring CSF pressure regulate and control CSF flowProblemMedical conditionEconomic situationComplication 2: Obstruction at ventricular sectionReason obstruction at the lateral holes by flocculent precipitate of CSF invasion of choroid plexus into the cat

24、heter via lateral holesTreatment adjustment of ventricular catheter choice of new cortex puncture CSF protein level ? catheter path and direction? Complication 3: Obstruction at peritoneal top Reason peritoneal top covered by inflamed tissue or a cystic cavity reversed flow of inflamed fluid into th

25、e catheter kink of abdomen catheterTreatment surgery for abdomen exploration and catheter adjustment Exit holes?F, 8m. V-P shunt. A A year later Abdomen end: cystic encapsulationComplication 4: Perforation of hollow organs Reason fixation of peritoneal top of shunt system long-times stimuli to the h

26、ollow organs intestine：splenic flexure of colon thoracic cavity：diaphragmClinical manifestation protrusion off from anal pleural effusion Treatment open the peritoneal cavity and explore remove the tube immerged in the hollow organ careful disinfection and good replacement of the residual section of

27、 peritoneal catheter F, 6yrsComplication 5 Separation and disconnection of shunt systemReasonIntense neck movement body growthfatigue of catheters: surgical factorsSeparation loose fixation between pump and catheterDisconnection two ends of pump catheter at connecting partIntegrated shunt system (lo

28、wer occurrence relatively)Prevent intra-operative avoidance strong drag of catheters bending two connectorsPain post shunt!Complication 6 Hernia of catheter via peritoneal incisionReason loose abdomen wall increased abdomen pressure loose suture of peritoneal incisionExamination catheter touched at

29、abdomen wall wave of fluid perceived bad healing of incision outward leakage of CSF x-ray: circuity of catheter underneath abdomen wallPrevention tight suture of peritoneal incision elastic force appliedComplication 7: CSF leakage via bellybutton Reason Peritoneal incision near to bellybutton weak b

30、ellybutton in infantsStrategies make a new opening into peritoneal cavity repair the bellybutton leakage of CSFComplication 8: Failed replacement of peritoneal tubeReason local or diffuse inflammation peritoneal scar diathesis peritoneal dialysis required Treatment shunt via transverse sinus, sigmoid sinus, superior vena, and cardiac atrium shunt via shallow vein at neck L-P shuntComplication 9: Post shunt hemorrhag