Hypothalamic obesity due to hydrocephalus caused by aqueductal stenosis

Changes in cerebral perfusion hormone profile and cerebrospinal fluid flow across the third ventriculostomy after endoscopic third ventriculostomy in patients with aqueductal stenosis: a prospective study. Clinical article

OBJECT

The object of the present study was 3-fold: 1) to study regional cerebral perfusion before and after endoscopic third ventriculostomy (ETV) in patients with obstructive hydrocephalus by using (99m)Tc ethyl cysteinate dimer SPECT: 2) to study any correlation between clinically successful third ventriculostomy and CSF flow across the third ventriculostomy; and 3) to determine any changes in hormone profile following ETV.

METHODS

The authors prospectively studied 15 patients with aqueductal stenosis who underwent ETV during the last 2 years. All the patients underwent pre- and postoperative MR imaging, brain (99m)Tc ethyl cysteinate dimer SPECT, and hormone profile studies.

RESULTS

Eight patients were infants. The mean follow-up duration was 17.6 months. Thirteen patients (86.7%) exhibited clinical improvement after surgery. In all patients with clinical improvement the studies documented CSF flow through the ventriculostomy site. Clinical progress could be correlated with SPECT changes in 14 cases (93.3%). In the 13 clinically successful cases, 12 were substantiated by improvement on SPECT scans, whereas in the 2 failed cases, SPECT images revealed no improvement of perfusion defects. Hormone analysis conducted in 14 patients revealed hyperprolactinemia in 8, low triiodothyronine values in 2 patients, and hypocortisolemia in 1, which was reversed after ETV.

CONCLUSIONS

Clinical improvement is not well correlated with a decrease in ventricular size following ETV. Brain SPECT is a valuable tool for the follow-up of patients with hydrocephalus after ETV, particularly in cases in which MR imaging findings are not clear. There are subtle hormonal changes in patients with hydrocephalus that may improve following ETV.

Aspects cliniques des syndromes hypothalamiques idiopathiques : étude rétrospective et revue de la littérature

Hypothalamic obesity is usually induced by tumoral or genetic alterations such as craniopharyngioma or Prader-Willi syndrome, respectively. However, few cases have been reported without recognized etiology, this syndrome is also called idiopathic hypothalamic syndrome.

OBJECTIVES

To improve definition and frequency of complications associated with this syndrome.

POPULATION AND METHODS

A retrospective cohort study was performed in French endocrine paediatric departments and was associated with a literature review.

RESULTS

We report five cases of idiopathic hypothalamic syndrome. This syndrome is correlated with a high mortality (one of our five cases, 25% in the literature) by neurovegetative dysfunction (breathing or thermal alteration). Obesity began before six years old because of compulsive eating and resulted in social behaviour disorders. Abnormal endocrine secretions were characterized by early hyperprolactinemia, permanent but later somatotrope deficiency and 80% of thyreotrope deficiency. Puberty abnormalities included hypogonadotropic hypogonadism as well as precocious (one of our cases, three cases including literature) or normal puberty. Neurogenic hypernatremia and water and electrolytic disorders were also responsible of acute neurological alterations.

CONCLUSION

This largest study ever reported of idiopathic hypothalamic syndrome emphasizes the need of a multidisciplinary coordination to provide the best care of these patients.

How should primary aqueductal stenosis in adults be treated? A review

In 10% of adult patients with hydrocephalus, the cause is because of aqueductal stenosis (AS), causing enlargement of the lateral and third ventricles. There are currently two alternate forms of surgical treatment for AS; shunt surgery and ventriculostomy. Shunt surgery is associated with high complication rates and many patients need revisions, but the effectiveness is high. Endoscopic third ventriculostomy (ETV), re-establishing a physiological route of CSF dynamics, has become the treatment of choice for AS in most neurosurgical centers. ETV has fewer complications and revisions are rare, but some patients need shunt surgery to improve despite a patent ventriculostomy. There are today no common criteria for patient selection to either ETV or ventriculo-peritoneal shunt surgery.

High serum levels of somatomedin-C and diabetes mellitus caused by obstructive hydrocephalus: case report

OBJECTIVE AND IMPORTANCE

This case demonstrates a relationship between hydrocephalus with a huge diverticulum of the third ventricle and high serum levels of somatomedin-C. Somatomedin-C levels become high when the secretion of growth hormone from the adenohypophysis increases, and previous reports state that hydrocephalus decreases the secretion of growth hormone.

CLINICAL PRESENTATION

The patient suffered from diabetes mellitus and obesity, and serum somatomedin-C levels were high. A pituitary adenoma or ectopic growth hormone-producing tumor was suspected. Magnetic resonance imaging did not reveal either of these abnormalities but indicated hydrocephalus with a diverticulum of the third ventricle.

INTERVENTION

After ventriculoperitoneal shunt placement, the blood glucose and serum somatomedin-C levels of the patient decreased toward normal. Six months later, the shunt tube became obstructed and serum somatomedin levels increased. The levels decreased again after shunt revision.

CONCLUSION

To our knowledge, this is the first published report of obstructive hydrocephalus with a diverticulum of the third ventricle compressing the hypothalamus and increasing the serum levels of somatomedin-C.

[Primary amenorrhea revealing congenital hydrocephalus]

Among the various endocrine manifestations of chronic hydrocephaly, amenorrhea is not exceptional, whereas late puberty and obesity are the most frequent. The hypothalamic gonadotropic function usually returns to normal within the few months following the ventricular shunt.

CASE REPORT

A 16 year-old girl, with a von Recklinghausen's disease, developed amenorrhea 2 years after the onset of puberty. X-rays of her skull showed an enlarged sella turcica and a diagnosis of hydrocephalus due to aqueductal stenosis was finally made. As her head circumference was retrospectively shown at +3 SD as early as the first month of life, the stenosis was certainly congenital, a feature known to occur in 2% of patients with von-Recklinghausen's disease.

CONCLUSION

In symptomatic forms of aqueductal stenosis, the preferred surgical procedure is ventriculocisternostomy under endoscopy. Recovery of intellectual functions is often incomplete. Early diagnosis of hydrocephalus is of paramount importance; ultrasonography through anterior fontanel should be proposed to any infant with head circumference reaching +3 SD.