Hydrocephalus in children. Eva Brichtova, M.D., Ph.D., Department of Pediatric Sugery, Orthopaedics and Traumatology, University Hospital Brno

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1 Hydrocephalus in children Eva Brichtova, M.D., Ph.D., Department of Pediatric Sugery, Orthopaedics and Traumatology, University Hospital Brno

2 Ventricle system

3 Ventricle system, cerebral cisterns

4 Hydrocephalus taxonomy hypersecretion hyporesorbtion internal external obstructive (non-communicating) communicating (non-obstructive) congenital acquired posthaemorrhagic postinfekctious posttraumatic active arrested

5 Signs and symptoms Makrocephaly, fontanelle bulging, setting sun sign, Parinaud sy Intracranial hypertension cephalea diffuse, valve headache, reverse Tinnel s sign vomitus explosive, no nausea vertigo seazures unconsciousness respiratory and cardiac arrhytmia

6 Hydrocephalus

7 Diagnosis of hydrocephalus Neurology examination Neuroimaging modalities ultrasound CT MRI Ocular fundus

8 Cerebral ultrasound examination

9 Cerebral CT

10 Cerebral MRI

11 Posthaemorrhagic hydrocephalus ultrasound imaging

12 Posthaemorrhagic hydrocephalus CT imaging

13 Hydrocephalus treatment Medical Surgery

14 Hydrocephalus treatment temporary Medicamentose (diuretics) Spinal tap Ventricular punction Ventricular drainage Lumbar drainage

15 Posthaemorrhagic hydrocephalus temporary treatment

16 Surgical treatment of hydrocephalus Drainage shunting VA, VP, (Nulsen, Spitz, Holter, Pudenz) Neuroendoskopy techniques

17 Surgical treatment of hydrocephalus A. Eliminating of obstruction cause (e.g. tumor exstirpation) B. Arteficial CSF communication (neuroendoskopy, Stoockey Scarff) C. CSF drainage

18 Drainage Most common surgery performed Communication between the ventricles and CSF resorbtion space

19 Drainage modifications Ventriculo peritoneal VP (pic. 1) Ventriculo atrial VA (pic. 2) Lumbo peritoneal (pic. 3) 1 2 3

20 Drainage modifications Ventriculo subgaleal Ventriculo pleural Torkildsen

21 V-P drainage Ventricular catheter Valve Peritoneal catheter

22 Insertion of ventricular catheter Dorso-frontal Parieto-occipital

23 Valves non programmable Valve opening pressure: low pressure 50 mm H 2 O middle pressure 100 mm H 2 O high pressure 150 mm H 2 O

24 Programmable valves system Codman

25 Programmable valves system Strata Medtronic

26 Surgery drainage VP shunt patient positioning

27 Surgery - drainage - VP shunt

28 Surgery - drainage - VP shunt

29 Surgery - drainage - VP shunt

30 Surgery - drainage - VP shunt

31 Surgery - drainage - VP shunt

32 Shunt malfunction Neurological examination Fundus oculi Percutanneous valve test Velve pressure resetting (programable valves only)

33 X-rays system Codman valve markers

34 Laboratory examinations FW, blood count, inflammation markers, serum osmolarity CSF examination valve punction (bakcteriology, biochemistry, cytology)

35 X-rays

36 X-rays

37 Ultrasound

38 CT

39 MRI Cave programmable valves

40 Central (ventricular) catheter malfunction blood clot obturation

41 Central (ventricular) catheter malfunction chorioideal plexus adhesions

42 Central (ventricular) catheter malfunction malposition

43 Central (ventricular) catheter malfunction Surgical treatment catheter repositioning or replacement

44 Valve malfunction Blood clot obturation Elevated CSF viscosity (inflammatory process) Slit ventricle syndrom

45 Distal catheter malfunction Unsufficient catheter lenght due to pts growth (X rays) Distal catheter malfunction causes: Continuity cut-off Peritoneal adhesion Peritoneal pseudocyst septic aseptic Peritonitis due APE Hyporesorbtion ascites Catheter intolerance, catheter expulsion Displacement to subcutaneous tissue Intestine perforation Hernia inguinalis, umbilicalis Atrial catheter malfunction causes Catheter thrombus (heart ultrasound)

46 Unsufficient catheter lenght due to pts growth

47 Continuity cut-off Diconnection Disruption

48 Treatment immediate surgery Re-connection if possible Catheter replacement (removing the displaced one)

49 Peritoneal catheter distal end - pseudocyst Ultrasound Septic: elevated CRP, FW, leukocytosis

50 Peritoneal adhesions Localized laparoskopy, catheter deliberation, replacement Difffuse temporary external drainage Intraluminal catheter replacement

51 Laparoskopy 3D, system Viking

52 Infectious complication Drainage extraction Temporary external drainage Antibiotics

53 Neuroendoscopy 1923 Mixter first 3rd ventriculostomy 80. neuroendoskopy techniques (flexible endoskopy, assisted endoskopy)

54 Neuroendoskopy

55 Neuroendoskopy Exstirpatio and biopsy of intra or periventricular expansions Cyst marsurpialisation Aqueductoplasty Third ventriculostomy

56 Indications for Neuroendoskopy Obstructive hydrocephalus Ventricular catheter implantation or replacement Ventricular (paraventricular) tumors Arachnoideal cyst Subdural space revision

57 Neuroendoskopy complications Haemorrhagy Hyperthermia (aseptic) Pneumocephalus Periventricular tissue damage CSF fistula Infection SD haematoma

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