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Casado Pellejero J, Moles Herbera J, Vázquez Sufuentes S, Orduna Martínez J, Rivero Celada D, Fustero de Miguel D. Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:1-8. [PMID: 34998487 DOI: 10.1016/j.neucie.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/01/2020] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option. METHODS We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified. RESULTS We identified five patients with diagnosis of acute negative-pressure hydrcephalus. In four of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in two patients (50%); the other two required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome. CONCLUSIONS The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.
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Affiliation(s)
| | - Jesús Moles Herbera
- Servicio de Neurocirugía, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - David Rivero Celada
- Servicio de Neurocirugía, Hospital Universitario Miguel Servet, Zaragoza, Spain
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Casado Pellejero J, Moles Herbera J, Vázquez Sufuentes S, Orduna Martínez J, Rivero Celada D, Fustero de Miguel D. Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy. Neurocirugia (Astur) 2020; 33:S1130-1473(20)30133-0. [PMID: 33384225 DOI: 10.1016/j.neucir.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/14/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option. MATERIAL AND METHODS We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified. RESULTS We identified 5patients with diagnosis of acute negative-pressure hydrcephalus. In 4 of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in 2 patients (50%); the other 2required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome. CONCLUSIONS The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.
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Affiliation(s)
| | - Jesús Moles Herbera
- Servicio de Neurocirugía, Hospital Universitario Miguel Servet, Zaragoza, España
| | | | | | - David Rivero Celada
- Servicio de Neurocirugía, Hospital Universitario Miguel Servet, Zaragoza, España
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Custom Shunt System for Increased Baseline Intracranial Pressure in a Patient with Idiopathic Intracranial Hypertension. World Neurosurg 2020; 136:318-322. [PMID: 31996337 DOI: 10.1016/j.wneu.2020.01.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Standard treatment of idiopathic intracranial hypertension (IIH) involves reduction of intracranial pressure (ICP) to normal range, often via a ventriculoperitoneal shunt (VPS). We describe a case of a middle-aged man who presented with symptoms consistent with IIH. After ICP was normalized with a VPS, the patient had neurologic deterioration into a coma. He completely recovered after a month when his ICP was allowed to increase and remain above the normal range. CASE DESCRIPTION A 50-year-old man presented with daily headaches, visual loss (right > left), and increased lumbar opening pressure consistent with IIH. A VPS was inserted using a Strata II valve with a pressure setting of 1.5, lowering ICP into the normal range. The patient initially had a normal postoperative course, but then became comatose and developed imaging signs consistent with intracranial hypotension. A Codman Certas valve was placed at a setting of 7 and a distal slit-cut peritoneal catheter was used (as opposed to standard open output). This custom system drained at pressure >26 mm Hg based on intraoperative manometry. The patient tolerated this well and is currently planned for a gradual reduction in ICP with valve setting adjustments as an outpatient. CONCLUSIONS In patients with chronic IIH, reduction to normal ICP may unexpectedly lead to encephalopathic changes. Personalized shunts may facilitate reduction of ICP to still elevated but tolerable levels in these patients.
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Diaz-Romero Paz R, Avendaño Altimira P, Coloma Valverde G, Balhen Martin C. A Rare Case of Negative-Pressure Hydrocephalus: A Plausible Explanation and the Role of Transmantle Theory. World Neurosurg 2019; 125:6-9. [DOI: 10.1016/j.wneu.2019.01.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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Smalley ZS, Venable GT, Einhaus S, Klimo P. Low-pressure Hydrocephalus in Children: A Case Series and Review of the Literature. Neurosurgery 2017; 80:439-447. [PMID: 28362957 DOI: 10.1093/neuros/nyw046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/12/2016] [Indexed: 11/14/2022] Open
Abstract
Background Low-pressure hydrocephalus (LPH) is a rare phenomenon characterized by a clinical picture consistent with elevated intracranial pressure (ICP) and ventricular enlargement, but also a well-functioning shunt and low or negative ICP. Objective To report our experience in evaluating this challenging problem. Methods Patients with LPH were identified from several sources, including institutional procedural databases and personal case logs. Electronic medical records were reviewed to collect demographic, clinical, surgical, and radiographic data to determine the presence of LPH. Each patient's clinical course, including presentation, management, and outcome, is reported. Results Thirty instances of LPH were identified in 29 patients. Eleven cases (37.9%) of LPH were after lumbar puncture (LP), and 19 cases (62.1%) occurred without any preceding spinal procedure. Among the post-LP patients, conservative measures alone were successful in 3 cases (27%); lumbar blood patch was successful in 2 cases (18%); and 6 cases (55%) required external cerebrospinal fluid (CSF) drainage. Of the spontaneous cases, 5 patients did not receive the full spectrum of treatment because of terminal prognosis. Of the remaining 14 patients, 11 (78.6%) required external CSF drainage. Post-LP patients required fewer days of external CSF drainage (median, 4 [range, 0-12] vs median, 11 [range, 0-90]) and had a shorter hospital stay (median, 2 [range, 2-16] vs median, 8 [range, 0-26]). Conclusion This study represents the largest series of LPH. Although its pathophysiology remains a mystery, there are a variety of management options. Multiple procedures and a protracted hospital stay are often required to successfully treat LPH.
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Affiliation(s)
- Zachary S Smalley
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Garrett T Venable
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stephanie Einhaus
- Department of Neuro-surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Paul Klimo
- Department of Neuro-surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Le Bonheur Children's Hospital, Memphis, Tennessee, USA
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Strand A, Balise S, Leung LJ, Durham S. Low-Pressure Hydrocephalus: A Case Report and Review of the Literature. World Neurosurg 2017; 109:e131-e135. [PMID: 28962963 DOI: 10.1016/j.wneu.2017.09.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The entity of low-pressure hydrocephalus remains poorly understood and thoroughly debated. Symptomatic improvement accompanied by decrease in ventricular size after prolonged subatmospheric drainage has been well documented, and this method has been considered the criterion standard of management. Few studies have examined alternative treatment options, either to avoid the risks associated with prolonged external ventricular drainage or because of the failure of traditional methods. OBJECTIVES This study compiled and examined reported cases of low-pressure hydrocephalus in an attempt to provide an up-to-date summary of the condition. METHODS A literature search was conducted by use of Ovid Medline and PubMed filtered for the past 25 years with specific key terms, inclusion criteria, and exclusion criteria. Selected case studies and case series were then compared, and statistical analysis was performed where appropriate. RESULTS Over 25 years, 17 articles met our criteria. In addition to our case, 90 cases of LPH were reported. Magnetic resonance elastography (MRE) has proved to be an effective means of studying the viscoelastic properties of the brain. Endoscopic third ventriculostomy (ETV) appears to be a strong alternative, or additional, treatment. CONCLUSION MRE may prove to be effective in studying LPH because of its ability to quantify viscoelastic properties in response to therapy. Additionally, ETV should be considered in cases of LPH, although there is little evidence in the current literature to support its use. There are suggestions that it may lead to fewer shunt-dependent patients. Future studies are needed because there are few documented examples.
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Affiliation(s)
- Adam Strand
- Division of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Stephen Balise
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
| | | | - Susan Durham
- Division of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont, USA
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Cheng Z, Wang W, Han Y, Liu J, Wang Z, Zhou Y, Li F, Huang Y. Low pressure hydrocephalus: clinical manifestations, radiological characteristics, and treatment. Br J Neurosurg 2017; 31:410-414. [PMID: 28264586 DOI: 10.1080/02688697.2017.1297383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Low pressure hydrocephalus (LPH) is a rare type of hydrocephalus with low intracranial pressure and ventriculomegaly. The recognition of LPH is important, and the treatment is difficult and very complicated. An understanding of how to drain cerebrospinal fluid when the intracranial pressure is lower than the opening pressure of the value represents a critical issue. Seven patients who suffered from the pain of hydrocephalus syndrome and were diagnosed with LPH were retrospectively reviewed. A ventricle peritoneal shunt was applied to all patients, and the valve system was adjusted to the lowest pressure; however, the clinical manifestations of hydrocephalus in five of seven patients did not improve over one week. Intermittent pressing of the valve in combination with the maintenance of a semi-reclined position were subsequently implemented. The symptoms of hydrocephalus began to improve from three days to two months following the initiation of intermittent valve pressing in combination with the maintenance of a semi-reclined position. At the twelve months follow up, six of seven patients (85.7%) showed good recovery to minimal disability. Intermittent valve pressing in combination with a semi-reclined position is an effective and easy method to drain cerebrospinal fluid when the intracranial pressure (ICP) is lower than the opening pressure of the value and improve hydrocephalus symptoms.
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Affiliation(s)
- Zhe Cheng
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China.,b Department of Neurosurgery , The Second Affiliated Hospital of Bengbu Medical college , Bengbu , Anhui , China
| | - Wenhua Wang
- c Department of Neurosurgery , Traditional Chinese Medicine Hospital of Kunshan , Suzhou , Jiangsu , China
| | - Yong Han
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China
| | - Jiangang Liu
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China
| | - Zhong Wang
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China
| | - Youxin Zhou
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China
| | - Fengen Li
- d Department of Neurosurgery , Taizhou Second People's Hospital , Taizhou , Jiangsu , China
| | - Yulun Huang
- a Department of Neurosurgery , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , China
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