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Thread: hydrocephalus and cure

  1. #1
    Senior Member dr_bubo's Avatar
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    hydrocephalus and cure

    Dear experts,

    I heard that the little boy also has hydrocephalus because of the accident. DOes it affect any application of a possible future cure of SCI ?
    Is hydrocephalus usual in case of neck break?

    Can it be fixed in any way ot just treated?
    Thanks
    Bubo

  2. #2
    bubo, hydrocephalus is not usual after spinal cord injury but is more common after head injury. About 25% of people with cervical spinal cord injuries and a higher percentage of kids with spinal cord injury also have head injury. Note that brain injury also causes brain swelling or edema. Hydrocephalus can be distinguished from edema in that the former has enlarged ventricles while the latter has small ventricles. Usually, the word hydrocephalus implies that the reason for the swellling is due to inability of the arachnoid to absorbed fluids. It may be a result of hemorrhage into the arachnoid space; this causes inflammation of the arachnoid can reduce the ability CSF absorption. The treatment is to shunt the ventricles, to keep pressure from building up. I hope that it is temporary and will resolve. Many kids have shunts to treat hydrocephalus. It is effective although troublesome because the shunts have a tendency to clog.

    Wise.

  3. #3
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    Dear Professor Young,
    Thank you for the info. As far as I know this kid has a valve built up by surgey into his neck to drain the brainwater. I do not know if this status is permanent or temporary.
    My question also was, does it affect in any way of the application of any future possible SCI cure/regeneration process?

    If I can get the full medical report of this boy, can I send it to you for your expert opinion?
    Thank you
    Bubo

  4. #4
    dr. bubo, unfortunately, it seems that many kids who require shunting do not become shunt independent. Although I was unable to find a study that documented the number of kids that manage to get off of shunting, the statistics of shunt revisions give us an idea that it is still required years after placement of the shunt, i.e. the person would not require revision of the shunt if he/she no longer needs it.

    Cochrane & Kestle (2002) described 5,947 cases of shunt placement and found an incredibly high rate of shunt infections of 8.6% and it apparently depends on the experience of the surgeon. In meningomyelocoele patients, the incidence of infection and requirement for revisions is even higher, on the order of 15% and more than half of the patients required a shunt revision (Tuli, et al., 2003). Recently, surgeons have been using endoscopic placement of shunts but the jury is still out regarding whether the use of endoscopy improves shunt revision rates (Villavicencio, et al. 2003).

    The requirement for ventricular shunts after traumatic brain injury varies greatly from less than 1% to 29% but most of these have been in adults. Licata, et al. (2001) reported 98 cases out of 4044 (2.4%). Tribl & Oder (2000) suggests that shunt placement improves outcome in about half of patients where the shunt was elected. Sometimes, in kids, the cause of the increased cerebrospinal fluid collection may resolve spontaneously but this appears to be rarer after traumatic brain injury (Nishimura, et al. 1996).

    I think that there is a need for more and better research on this subject, aiming at improving CSF absorption as opposed to just shunting.

    Wise.


    • Cochrane DD and Kestle J (2002). Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989-2001. Eur J Pediatr Surg 12 Suppl 1:S6-11. Summary: INTRODUCTION AND PURPOSE: Ventricular shunting remains the principle and most generally applicable method to treat hydrocephalus in children. This paper describes the demographics of this treatment in English Canada during the period of 1989 to March 2001. METHODS: Hospital discharge records were obtained for patients less than 18 years who had a shunt inserted or revised. A database was constructed relating patients and procedures to hospital discharges based on scrambled patient identifiers, year of birth, sex, postal code and diagnoses. OBSERVATIONS: 5,947 patients underwent ventricular shunting procedures for hydrocephalus in this period. 261 surgeons working in 73 institutions provided 12,106 interventions (Shunt insertions: ventriculoperitoneal--5009, ventriculoatrial--119, ventriculopleural--28. Revisions: 6,950). Infection was deemed to have occurred in 1,059 procedures. Over the study period, the median number of procedures performed per surgeon per year was 2, with 75 % of surgeons performing 5 or fewer procedures in children per year. Although many surgeons operated on children throughout the thirteen years of the study, many did not acquire substantive cumulative experience. Overall infection rate was 8.6 %. Surgeon infection rates were greater than or equal to 20 % during the first four years of practice and thereafter they fell to and remained in the 10 % range. The mean shunt survival at 12 months of individual surgeons varied between 50 - 60 %, regardless of the number of years of experience of the surgeon; however, performance variability as measured by the standard deviation of 12 month survival rates for all surgeons, adjusted for years of experience, ranged widely until the fifth year of practice. The average number of procedures per year for treating hospitals was 2 with 75 %, providing 12 or fewer services annually. Over the entire study, 50 % of institutions provided 10 or fewer procedures. The mean institutional infection rate was 11.4 % (SD 23, median--6.0). CONCLUSIONS: Quality monitoring of infection rate and duration of shunt function remains critical as many surgeons and hospitals provide care to children with hydrocephalus infrequently. Variability in infection rates and shunt survival at 12 months are a function of surgeon experience, measured by years in practice. Variability in outcome decreases with increasing surgeon experience. Department of Surgery, University of British Columbia and Children's and Women's Health Center of British Columbia, Vancouver BC, Canada. dcochrane@cw.bc.ca

    • Tuli S, Drake J and Lamberti-Pasculli M (2003). Long-term outcome of hydrocephalus management in myelomeningoceles. Childs Nerv Syst Summary: BACKGROUND. The cerebrospinal fluid (CSF) shunt remains an important ongoing management problem in myelomeningocele (MMC) patients. We reviewed the long-term shunt treatment outcome in a prospectively followed group of MMC patients from a single institution. METHOD. Patients prospectively entered into a hydrocephalus database with a diagnosis of MMC from the years 1987 to 1996 were selected. All data was verified from the medical records and additional details about the shunt surgery were collected. The outcome of shunt failure was categorized as shunt obstruction, shunt infection, presence of loculated ventricles, overdrainage, and other. All deaths were recorded and causation identified. Univariate analysis for shunt failure risk factors was accomplished using Log rank statistics. Multivariable analysis was performed for each repeated failure level using a conditional Cox regression model. RESULTS. One hundred and twenty (64%) out of 189 MMC patients experienced a first shunt failure with a median time of 303 days; 29 (24%) of the failures were due to shunt infection (the procedure infection rate being 15%). Sixty-one patients experienced a second shunt failure, 38 a third and 36 had four or more. Multivariable analysis of risk factors failed to demonstrate any clear risk factors for either first or subsequent shunt failure. Fifteen patients died, 13 from either shunt or Chiari 1 complications. CONCLUSION. Shunt complications remain an important cause of morbidity and mortality in MMC patients, particularly shunt infection. Department of Neurosurgery, The Brigham and Women's Hospital, Harvard Medical School, One Brookline Place, Suite 227, MA 02445, Brookline, USA.

    • Villavicencio AT, Leveque JC, McGirt MJ, Hopkins JS, Fuchs HE and George TM (2003). Comparison of revision rates following endoscopically versus nonendoscopically placed ventricular shunt catheters. Surg Neurol 59:375-9. Summary: Endoscopic placement of ventriculoperitoneal (VP) shunt catheters in pediatric patients has been increasingly used in an attempt to minimize the unacceptably high rates of revision. Although this procedure carries an increased expense, there is currently no evidence to support an improved long-term outcome. This paper compares the rates of revision following ventricular catheter placement for shunted hydrocephalus with and without the use of endoscopy.We retrospectively reviewed the records of all pediatric patients who had undergone shunt placement for hydrocephalus between April 1992 and February 1998. All shunts placed before March 1995 were performed without the endoscope; all subsequent shunts were placed endoscopically. The independent effect of endoscopic versus nonendoscopic shunt placement on subsequent shunt failure was analyzed via multivariate proportional hazards regression model. Multiple logistic regression analyses were used to determine the independent effect of endoscopic placement on subsequent etiology of failure (infection, proximal obstruction, distal malfunction) in the 511 failing shunts.There were 447 pediatric patients who underwent a total of 965 shunt placements or revisions. Six hundred and five (63%) catheters were placed with the use of the endoscope. Three hundred and sixty (37.3%) were placed without the use of the endoscope. Neuroendoscopy did not independently affect the risk of subsequent shunt failure [Hazard Ratio (95% Confidence Interval) = 1.08 (0.84-1.41)]. Endoscopic placement independently decreased the odds [Odds Ratio (95% Confidence Interval) = 0.56 (0.32-0.93)] of proximal obstruction, increased the odds of distal malfunction [1.52 (1.02-2.72)], and was not associated with infection [1.42 (0.78-2.61)].Endoscopic assisted ventricular catheter placement decreased the odds of proximal obstruction but failed to improve overall shunt survival in this 6 year experience. Pediatric Neurosurgery Service, Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA


    • Licata C, Cristofori L, Gambin R, Vivenza C and Turazzi S (2001). Post-traumatic hydrocephalus. J Neurosurg Sci 45:141-9. Summary: BACKGROUND: Surgical treatment of ventricular dilatation following severe head trauma (GCS <8) remains controversial due to the difficulty to distinguish brain atrophy-related ventriculomegaly from active, symptomatic ventricular dilatation. Consequently, the reported incidence of post-traumatic hydrocephalus in literature varies greatly from 0.7-29%. The presence of ventricular dilatation following severe head trauma should be considered and demands investigation, based also on satisfactory results obtained with cerebrospinal fluid [CSP) shunting, METHODS: Ninety-eight patients with post-traumatic hydrocephalus undergoing CSF shunting were selected for this study among 4,044 patients with severe head trauma treated from 1972 to 1999 at the Department of Neurosurgery at the City Hospital of Verona. Patients included 82 [84%) males and 16 [16%) women, ranging from one month to 83 years [mean age; 39 years). In 24 [24%) cases, the brain trauma lesion was single, while in 74 [76%) cases the patient suffered multiple cranio-cerebral lesions. The total number of lesions was 230 including 214 [93%) supratentorial and 16 [7%) posterior cranial fossa [PCF) lesions. Seventy-nine operations were performed on 59 [60%) patients. The onset of hydrocephalus was immediate after trauma in 14 [14%) cases, whereas a delayed onset was observed within 30 days in 44 [45%) cases, between one-four months in 30 [31%) cases and between four-six months in 10 [10%) cases. Of the 98 patients in this study, 15 were treated with an external CSF shunt and 83 underwent internal CSF shunting. RESULTS: Long-term results of the 15 patients with external shunts demonstrated good recovery in 13% while 87% of cases resulted in death. In the 83 cases of internal shunts, despite severe preoperative conditions [75% in coma or persistent coma), the results were as follows: good recovery in 37 [45%) patients, partial disability in nine [11%), persistent coma in 29 [35%) and death in seven [8%) cases. CONCLUSIONS: Post-traumatic hydrocephalus is a complication that must always be considered in cases of severe head trauma [GCS <8) in young patients presenting added neurological deficits, ceased clinical improvement [ceased improvement after initial improvement), increased hypertonia, surgical flap tension or CSF accumulation. The results of this study suggest the necessity to treat post-traumatic ventricular dilatation with aggressive surgery and CSF shunting, based on favorable outcome seen even in coma and persistent coma patients. Department of Neurosurgery, City Hospital of Verona, Verona, Italy.

    • Tribl G and Oder W (2000). Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus. Brain Inj 14:345-54. Summary: OBJECT: Post-traumatic hydrocephalus (PTH) is considered a frequent complication after severe head injury (HI). There is little known about outcome following shunt implantation. METHODS: A hospital-based retrospective cross-over study investigated the outcome of 48 patients after severe HI, who had undergone ventricular shunt implantation due to PTH (40 males, mean age at injury 36 years, mean duration from HI to shunt implantation 27 weeks). Telephone interviews with the patients or with caring family members by means of a detailed questionnaire were performed after a mean observation period of 3.3 years after shunt implantation. Outcome was categorized using the Glasgow Outcome Scale (GOS): I: 12 patients, II: 7, III: 16, IV: 9, V: 4 at follow-up. CONCLUSIONS: 52.1% had a clear-cut benefit from shunt implantation, whereas 47.9% had not. Post-traumatic seizures were observed in 31 of 48 patients. Other complications after shunt implantation occurred in 20) patients. Revision of shunt implantation was performed in 15 patients (nine due to technical failure, three haemorrhage, one delayed primary wound closure, and two unknown). Two patients clearly deteriorated after operation (one severe frontal bleeding, one sepsis). The best predictive parameter for outcome after shunt implantation was the pre-operative status, patients in a better clinical condition (pre-operative GOS score 3-severe disabled vs 4-persistent vegetative state) had a better outcome. Patient's age at injury did not seem to influence the outcome. Clinical and computertomographic findings were of rather moderate predictive value as regards short- and long-term outcome after shunt implantation. Cisternography does not seem to be of additional help in the establishment of definite diagnosis of PTH. Neurological Department, University of Vienna, Austria.


    • Nishimura K, Mori K, Sakamoto T and Fujiwara K (1996). Management of subarachnoid fluid collection in infants based on a long-term follow-up study. Acta Neurochir (Wien) 138:179-84. Summary: We report the natural history and management of subarachnoid fluid collections in infants and their management based on a longterm follow-up study in 20 cases. These subarachnoid fluid collections were resolved spontaneously in 17 of 20 patients and only 3 by surgical intervention at the age of 2. In our 20 patients the natural history of subarachnoid fluid collection in infants was benign unless the patients sustained head trauma. Surgical treatment was performed in the cases where a subarachnoid fluid collection developed into a subdural haematoma. Head trauma may precipitate subdural haematoma in patients with subarachnoid fluid collection. All patients except one who underwent the placement of subdural-peritoneal shunt, attained normal psychomotor development in time. During the follow-up period of 3 to 10 years after resolution of the fluid collection, no patient has had a recurrence once it resolved. Department of Neurosurgery, Nishimura Hospital, Tokyo, Japan.

  5. #5
    Senior Member dr_bubo's Avatar
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    Dear professor Young,

    Thank you for the answer.

    Does hydrocephalus affect any application of any possible fiture SCI cure? For example does it make the surgery more difficult? (I mean the surgery for SCI repair)
    Thank you
    Bubo

  6. #6
    Dr. Bubo, hydrocephalis is a very specific problem. The arachnoid does not absorb cerebrospinal fluid that is being produced by the choroid plexus. The fluid accumulates in the ventricles or in arachnoid cysts that then can compress the brain or the spinal cord. The problem is how to get the arachnoid to start absorbing fluid again. Hydrocephalus frequently occurs when the arachnoid has been damaged by meningitis or blood in the subarachnoid space. Most of the efforts at treatment have focussed on shunting rather than rebuilding or restoring the arachnoid so that it can absorb fluid. Perhaps stem cells will one day help this problem. I just did a literature search and could not find any papers on the subject. Wise.

  7. #7
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    Dear Professor Young,

    You misunderstood my question or it may be due to my bad english.
    My question was that any surgery for the spinal cord innjury repair (not for the hydrocephalus cure) can be done if hydrocephalus present, or can any surgery be made near C1 for SCI REPAIR if the shunt present?

    Meaning: if treatment will be available for C1 spinal cord injury, would doctors refuse to make the surgery saying it is too risky because of the hydrocephalus?

    Thank you
    Bubo


    Originally posted by Wise Young:

    Dr. Bubo, hydrocephalis is a very specific problem. The arachnoid does not absorb cerebrospinal fluid that is being produced by the choroid plexus. The fluid accumulates in the ventricles or in arachnoid cysts that then can compress the brain or the spinal cord. The problem is how to get the arachnoid to start absorbing fluid again. Hydrocephalus frequently occurs when the arachnoid has been damaged by meningitis or blood in the subarachnoid space. Most of the efforts at treatment have focussed on shunting rather than rebuilding or restoring the arachnoid so that it can absorb fluid. Perhaps stem cells will one day help this problem. I just did a literature search and could not find any papers on the subject. Wise.

  8. #8
    Senior Member dr_bubo's Avatar
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    By the way, I am not doctor, I just use this nick. Dr. Bubo is a cartoon character, an owl which cures animals in the forests, and many funny things happen during that... It is one of the best hungarian cartoons. (many of those people who made it now working for Csupo (also Hungarian) for making the simpsons and other cartoons.) I am a chemical engineer.

  9. #9
    bubo, thanks. I don't think a shunt would interfere with any future therapies that I know of. The possibility that a shunt will interfere with a future curative procedure should be the least of the family's worries right now. Besides, they really do not have much of a choice. A shunt is currently the only way to treat hydrocephalus. I believe that one should worry about those things that one can do something about. For example,

    1. Motor development. While there is a general perception that babies who get spinal cord injury recover better, I think that they generally do not recover as much as teenagers or adults in part because the injury interferes with their motor development. At the Shriner's Hospital in Philadelphia, they have been trying to address this problem by implanting functional electrical stimulation systems earlier after injury in kids.

    2. Getting off the respirator. It has been my experience that a majority of kids of high cervical spinal cord injuries can be weaned off the respirator. If it cannot, then phrenic pacing must be instituted as soon as possible. The reason is that the diaphragm undergoes atrophy even after a few months of non-use (i.e. respirator). While the diaphragm can be rebuilt by electrical stimulation, the longer one waits, the harder it will be to get the child off the respirator. Incidentally, it is particularly hard to get a child of a respirator because the person gets hypoxic during the weaning and the feeling of being short of breath is intensely uncomfortable. However, there is much data from animal and human studies suggesting that hypoxia itself strongly stimulates plasticity in the respiratory nervous system. There are few places, even in the United States, that has the teams with a great deal of experience in weaning babies from the respirator.

    3. Ensuring intellectual development. Care must be taken to not allow the spinal cord injury and hospitalization to interfere with the intellectual development of the child, including speech and communication. The latter is obviously crucial to quality of life. It is difficult to learn how to speak with a respirator and there are some non-obvious technology that can be used to help. I don't know if there are doctors or clinics in Hungary that have experience with this but it is obviously important for the family to get involved with a center that has a lot of experience with young children on respirators.

    Wise.

  10. #10
    Senior Member dr_bubo's Avatar
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    2. Getting off the respirator. It has been my experience that a majority of kids of high cervical spinal cord injuries can be weaned off the respirator. If it cannot, then phrenic pacing must be instituted as soon as possible.
    ----

    This procedure (phrenic spacing) is NOT available in Hungary. In USA it takes about 2000-4000 USD/day+travel+recovery. That is the problem I am talking here all about...
    Bubo

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