T HE relief of obstructive hydrocephalus

Transcription

1 J. Neltrosttrg. / Volume 29 / December, 1968 Hypothalamc Ventrculostomy wth Catheter* Techncal Note SYLVIO ORJAZ, M.D., NELSON MARTELLI, M.D., AND NILTON LATU, M.D. Neurosurgcal Unt, Department oj Surgery, aculty o/ Medcne o[ RberSo PrEto, Unversty oj $6o Paulo, RberSo PrEto, Brazl T HE relef of obstructve hydrocephalus by the puncture of the floor of the thrd ventrcle s ndcated as a permanent treatment for chldren wth congental lesons, and as a pallatve procedure for patents wth noperable lesons of the bran stem. Moreover, t s useful for preoperatve control of ntracranal hypertenson. Ths operaton was orgnally conceved by Dandy n 1922Y He approached the floor of the thrd ventrcle by a subfrontal route, dvdng the optc nerve and elevatng the chasm. In 1932 he descrbed the alternatve subtemporal approach? In 1936, Stookey and ScarW descrbed a subfrontal approach through the lamna termnals and the hypothalamus to the lumen of the thrd ventrcle. Scarff ~ publshed a revew of 527 patents subjected to ths operaton by both the subtemporal and the subfrontal procedures as reported by many authors. The over-all operatve mortalty was 15% and the permanent arrest of hydrocephalus was obtaned n 70% of the survvors. References to hypothalamc dysfunctons were surprsngly few, probably because of the preexstent hypothalamc atrophy assocated wth hypertensve hydrocephalus? In Brazl we often deal wth problems of obstructve hydrocephalus consequent to cerebral cystcercoss. Sometmes the obstructon of the pathways of the cerebrospnal flud s caused by the cystcercotc vescles themselves, but more often by nflammatory reactons and resdual subarachnodal adhesons. The aquaduct of Sylvus, the fourth ventrcle, and the csterna are the most frequent stes of obstructve lesons Receved for publcaton January 21, Revson receved May 23, * Presented at the llth Latn Amercan Congress of Neurosurgery, Sao Paulo, Brazl, August, 1965, at the 6th Congress of the Brazlan Socety of Neurosurgery, Sao Paulo, Brazl, July, 1966, and at the 12th Latn-Amercan Congress of Neurosurgery, Lma, Peru, October, whch are often found at some dstance from the parastc locaton. The surgcal removal of these vescles (the rupture of whch s mpossble to prevent), debrdement of adhesons, and other maneuvers are neffectual and often lead to fatal exacerbaton of the dffuse nflammatory reactons. We now thnk that t s better to avod any drect attack on these lesons, and to releve the ntracranal hypertenson by thrd ventrculostomy. Snce 1962 we have been usng central pneumoventrculography to renforce the dagnoss of aqueductal, fourth-ventrcular or csternal block. Catheterzaton of the thrd ventrcle wth a blunt metallc needle passed through the cortex, the lateral ventrcle, and the foramen of Monro s an mportant step n our technque for ths radologcal examnaton. We were mpressed by the fact that f the prevously postoned ventrcular needle was advanced a few mllmeters the floor of the thrd ventrcle could be easly punctured. We realzed that ths procedure would avod the more elaborate and traumatc technques reported by Dandy'-' and Stookey and Scarff5 Several patents were submtted to ths puncture. They had a varety of obstructve lesons stuated caudad to the thrd ventrcle, and all experenced mmedate reducton of the subjectve and objectve symptoms of the ntracranal hypertenson. In two, however, these symptoms recurred after 15 to 20 days. Supposng that the recurrence was caused by healng retracton of the ventrcular floor, we decded to mprove our technque by leavng n place a permanent multperforated No. r. 7 Nelaton catheter (g. 1) passed through the hypothalamc puncture. We have now used ths operaton on 15 patents. Technque Under local anesthesa a 2.5 cm parasagttal ncson s made, 2 fnger breadths to the

2 656 Sylvo orjaz, Nelson Martell and Nlton Latuf TABLE 1 Hypothalamc centrculostomy; clncal summaly of15 cases ('ase Aeg 2' Dagnoss Date Ventrculostomy Postoperatve Perod ollow-up Other Operatve Procedures and Results 1 53 Obstructve cyst- 9 M cercoss 7/29/65 Intracranal hypert, re- Sept., 1966: leved. Dscharged 41st asymptomatc J 3 26 ourth ventrcular ependymmna Left cerebellar astrocytoma 9/29/65 7/ 4/66 8/ 8/ Obstructve cyst- 8/11/66 j cercoss 6 7 Obstructve cyst- 9/ 9/66 cercoss 7 5 Astrocytoma of 12/ 8/66 mths thalamus nvadng M hypothalamus and bran-stem Intracranal hypert, re- Not revewed Prevous posteror fossa leved. Dscharged 29th cranotomy wth debrdement neffectual (May, 1965) Somnolent frst 3 days. In- Cerebellar symptoms Partal excson cerebellar neotracranal hypert, releved, recurred May, 1967, plasm July27, Dscharged Dscharged 38th wthout ntracranal Aug. 11, Reoperaton on hypertenson. May 22, (Partal excson of recurrent cerebellar neoplasm) lntracranal hypert, re- Cerebellar neoplasm excson leved from 6th to 16th Aug. 25, Death 3rd Posteror fossa cranotomy Necroscopy: postoperatve 17th fourth ventrcular hematoma. Intracranal hypert, re- Not revewed Prevous posteror fossa eranleved. Dscharged 9th otomy wth debrdement neffectual (Aprl 7, 1965) Dscharged 51st Dec. 1966: asymptomatc Intracranal hypert, releved Torkldsen procedure: Jan. 3, untl 12th Accdental Death 1st postoperatve wthdrawal of catheter on Necroscopy: Bran-stem the 12th Intracr. hy- edema, thalamo-hypotfalamo pert. recurrence, penduncular gloma. 8 5 M Recurrent astrocytoma of cerebellum 12/20/66 Intracranal hypert, re- Sept. 1967: Prevous partal excson of leved. Dscharged 11 th asymptomatc cerebellar astrocytoma (Sept. 1963) Congental hydrocephaly. Dandy- Walker syndrome 2/ 1/67 Intracranal hypert, not releved. (Death 19th postoperatve Autopsy : catheter dslocaton) Tracheotomy, eb., 1967! 5/24/67 Dscharged 3rd Re-examned Aug., -- Sept., 1967 : asymptomatc, but for vs- ual defct. J ;2116 ourth ventrcular (sold) and cerebellar-(cystc) hemangoblastoma Obstructve cystcercoss of csterlla 5/29/67 6/ 1/67 Persstence of cerebellar symptoms and vomtng. Dscharged 55th Re-examned Jan., 1968 : no symptoms of ntracranal hypertenson. Intracranal hypert, re- Aug., 1967, leved. Dscharged 7th asymptomatc Partal excson of fourth ventrcular neoplasm, June, Cerebellar symptmns and vomtng releved /18./67 Dscharged 23rd Amenorrhea on Aug., Negatve test for pregnancy. Sept., 1967 : asymptomatc 14 I 56 l I M 15 6! M nlagna 8 ~24/67 8,/24,/67 Dscharged 27th Dscharged 27th dab'.!

3 Hypothalamc Ventrculostomy 657 IG. 1. No. r. 7 Nelaton catheter wth many small holes n ts dstal porton. rght of the mdlne, and a burr hole s made just over the coronal suture. The dura mater s opened and the lateral ventrcle tapped wth a blunt needle. The floor of the lateral ventrcle s recognzed by touch. Wth small gentle angular dslocatons, the foramen of Monro s catheterzed, and the ventrcular canula passes nto the thrd ventrcle and on untl t touches the ventrcular floor. Half axal (Towne) and lateral skull radographs control the correct postonng of the dstal end of the ventrcular needle. On the halfaxal projecton the tp of the needle must be precsely n the sagttal mdlne plane of the skull. On the lateral, t must be 1 to 3 mm behnd and above the projecton of the tp of the posteror clnod processes. Mnmal dsplacements of the tp of the needle n the sagttal plane are possble wthout wthdrawng t. The extremty of the needle s now n contact wth the mdlne of the tuber cnereum, whch s usually dstended and atrophc because of the preexstng nternal hydrocephalus. Now, as the surgeon apples gentle pressure on the needle, he can feel t puncture the floor of the thrd ventrcle (g. 2 left). A new radographc control shows the tp of the ventrcular canula n the sagttal plane of the nterpeduncular cstern, behnd the dorsum sellae. The metallc needle s wthdrawn and replaced by a No. r. 7 Nelaton catheter rectfed by a metallc stylet (g. 2 rght), and wth many small holes n ts 5 cm dstal segment (g. 1). After a fnal radographc control (g. 3 left) the metallc stylet s wthdrawn and the proxmal end of the Nelaton catheter s cut, closed wth a slver clp, and sutured to the coronal perosteum (g. 3 rght). The cerebrospnal IG. 2. Case 1. Lelt: Ventrcular cannula touchng the thrd ventrcle floor after catheterzaton through the foramen of Monro. Rght: Dstal end of the Nelaton catheter wth rectfed metallc stylet ntroduced nto the nterpeduncular cstern.

4 658 Sylvo orjaz, Nelson Martell and Nlton Latuf ro. 3. Case 1. Nelaton catheter rectfed by metallc stylet wth ts dstal end n the nterpeduncular cstern. rontal projecton. Rghl: Nelaton catheter left n place through the tuber cnereum, after wthdrawal of metallc stylet. flud then crculates from the thrd ventrcle to the nterpeduncular cstern through the Nelaton catheter. Dscusson All the patents had severe ntracranal hypertenson wth paplledema n the adults and macrocephaly wth bregmatc bulk and tenson n the chldren (Cases 7 and 9). Etologcal dagnoss was confrmed by surgcal exploraton and hstopathologcal examnaton of bopses n Cases 2, 3, 6, 8, and 11. Three patents ded (Cases 4, 7, and 9), and permsson for autopsy was obtaned. Cystcercotc etology was confrmed by postve serologcal tests on the cerebrospnal flud of patents 1, 2, 5, 6, 10, 13, and 15. Etologcal dagnoss of patents 12 and 14 was not satsfactory; they are under followup control and have shown no sgns of clncal aggravaton. The dagnoss of obstructve nternal hydrocephalus was corroborated n all of the patents by radologcal examnaton (pneumoventrculography). The blockng leson was localzed caudad to the anteror porton of the thrd ventrcle, the only excepton beng n Case 7, a neoplasm nvadng the hypothalamus. In ths case the floor of the thrd ventrcle was abnormally resstant to perforaton and, after an accdental wthdrawal of the Nelaton catheter, we could not get a new perforaton. We tred the Torkldsen procedure, but the patent ded on the frst Autopsy revealed neoplastc nvason of the hypothalamus, edema of the bran stem, but no sgns of postoperatve surgcal complcatons n the nterpeduncular cstern. Ventrculostomy provded all patents but one wth actual permanent relef from ntracranal hypertenson. Paplledema subsded after 2 or 3 weeks. Patent 9, wth a "Dandy-Walker" syndrome, was not helped and ded wth ntracranal hypertenson. The autopsy confrmed wrong postonng of the ro. 4. Case 4. Autopsy specmen, frontal secton of bran, Nelaton catheter n place.

5 dstal end of the catheter; t had been placed 2 cm down nto the nterpeduncular cstern, and the mechansm of dranage was neffectual. Another patent (Case 4) ded after partal excson of a cerebellar neoplasm, as a consequence of postoperatve hematoma. Ths operaton was done 16 days after preventatve ventrculostomy. Autopsy ruled out any partcpaton of hypothalamc perforat!on n the cause of death (g. 4). Patent 3 was readmtted n May, 1967, wth recurrent ependymoma of the fourth ventrcle. After the frst operaton (partal neoplasm excson, July, 1966), she had not had any clncal symptoms of ntracranal hypertenson; on readmsson her vsual acuty was preserved and she dd not have paplledema. Successve examnatons of the remanng 12 patents confrmed the permanent relef of ntercranal hypertenson. A low-grade fever and slght somnolence durng the frst 2 or 3 days after ventrculostomy were observed n every case. Patent 13 had transent postoperatve amenorrhea and galactorrhea. Pregnancy tests were negatve and 2 months later her endocrne condton was entrely normal. Summary We have presented a new technque for thrd ventrculostomy. The puncture of the hypothalamus s made wth a blunt ventrcu- Hypothalamc Ventrculostomy 659 lar cannula through a coronal trepanaton, the lateral ventrcle, and the foramen of Monro, wth radographc control. The needle s then replaced by a No. 7 r. Nelaton catheter wth many holes n ts dstal end, rectfed by a metallc stylet; after wthdrawal of the stylet the Nelaton catheter s left n place. The procedure has been used on 15 Izat!ents wth good results. References 1. AZAMBUJA, N., ARANA INIQUEZ, R., and GAR- ClX GUELr, A. Central ventrculography. Acta neurol, latnoam., 1956, 2: DANDY, W. E. An operatve procedme for hydrocephalus. Bull. Johns Hopkns Hosp., 1922, 33: DANDY, W. E. Surgery of the bran. In: Lews' practce of surgery. Lews, D., Ed., Hagerstown, Md.: W.. Pror Co., Inc., 1932, vol. 12. (See pp ) 4. SCAR, J.E. Treatment of hydrocephalus: an hstorcal and crtcal revew of methods and results. J. Neurol. Neurosurg. Psychat., 1963, 26: SCAR, J.E. Treatment of obstructve hydrocephalus by puncture of the lamna termnals and floor of the thrd ventrcle. J. Neurosurg., 1951, 8: SCAR, J.E. Thrd ventrculostomy by puncture of lamna termnals and the floor of thrd ventrcle. J. Neurosurg., 1966, 24: STOOI(EV, B., and SCAR, J. E. Occluson of the aqueduct of Sylvus by neoplastc and nonneoplastc processes wth a ratonal surgcal treatment for relef of the resultant obstructve hydrocephalus. Bull. neurol. Inst. N.Y., 1936, 5: