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Clinical evaluation of
adult hydrocephalus
Youmans 6th editon
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Out line
• Classification and etiology• Pathophysiology , Sign and Symptom• Normal pressure hydrocephalus• Neuroradiologic features of hydrocephalus• Physiologic testing of cerebrospinal fluid
dynamics• Management• Shunt
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Classification and etiology
• Greek : Hydro(water) + Kefale(skull)• The state of excessive intracranial
accumulation of CSF that results from excessive production, circulation, or absorption of CSF
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Classification and etiology
• Communicating Hydrocephalus• Panventricular dilation and occurs as a
result of obstruction to the flow of CSF in the subarachnoid space, distal to the foramina of Luschka and Magendie
• Noncommunicating or ObstructiveHydrocephalus• Pattern of ventricular dilation that reflects
the site of obstruction
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Classification and etiology
• Long-Standing Overt Ventriculomegaly in Adults• This form of hydrocephalus develops
during childhood, with symptoms being manifested during adulthood
• Normal-Pressure Hydrocephalus• Gait disturbance, dementia, incontinence
with normal CSF pressure and dilate ventricles
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Classification and etiology
• Isolated Fourth Ventricle Syndrome• fourth ventricle no longer communicates
with the third ventricle• prolonged infection or multiple shunt
operations
• Arrested Hydrocephalus• Hydrocephalus reach a state in which
ventricular size remains unchanged in the absence of a shunt or in the presence of a nonfunctioning one
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Pathophysiology
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Pathophysiology
• CSF obstruction transpendymal passage of CSF(periventricular edema ) + edematous white matter white matter damage cerebral atrophy
• Ventricular enlargement progress • distortion of tissue, white matter, blood vessel
damage ischemia• Loss elasticity tissue pressure gradient between
ventricle and periventricular tissue failure drainage of toxic metabolite
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Initial feature of hydrocephalus
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Normal Pressure hydrocephalus
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Clinical finding
• Gait disturbance• Common initial symptoms : unsteadiness,
recurrent falls, shuffling, and reduced walking speed
• Advanced symptoms : difficulty initiating gait and imbalance on turning
• DDx : Parkisonism – tremor, lead pipe rigidity, poker face
• NPH : mobilize with a relatively preserve arm swing• UMN sign : cervical myopathy, lumbar canal stenosis
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Clinical finding
• Urinary incontinence• Cognitive impairment
• memory loss, reduced attention, difficulty planning,
slowness in thought, and apathy• Ddx : Alzheimer’s disease –
neurolopsychological testing, aphasia, apraxia, agnosia
• Binswanger’ disease : frontal cognitive disteriotation , gait disturbance
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Neuroradiologic features
• Evans’ index : maximal width of the anterior ventricular horn / maximal width of the calvaria at the level of Foramen of Monroe
• >0.3 ventricular enlargement
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Neuroradiology features
• Bicaudate ratio : minimal
intercaudate distance / by the
brain width along the same line• > 0.25
ventriculomegaly
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Neuroradiology features
• One of the following support• enlargement of the temporal horns of the lateral
ventricles not entirely attributable to hippocampus atrophy
• callosal angle of 40 degrees or greater• evidence of altered brain water content,
including periventricular signal changes not attributable to microvascular ischemic changes or demyelination
• aqueductal or fourth ventricular flow void on MRI
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Supplementary Prognostic testing
• Lumbar puncture “tap test”• Specifity 100 % , Sensitivity 26 %
• External lumbar drainage• specificity 80% , sensitivity 50-80%
• Measures of CSF outflow resistance• specificity 87% ,sensitivity 46%
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Neuroradiologic features of hydrocephalus
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Physiologic testing of cerebrospinal fluid dynamics
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Cerebrospinal Fluid DrainageandDynamics
• Communicating hydrocephalus• Intrathecal injection of radioisotropes• Ventricular > 48 hr ventricular stasis
or reflux
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Mathematical Modeling of the Cerebrospinal Fluid Circulation—a Platform forInterpretationof Pressure-Volume
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Monitoring of Intracranial pressure
• Overnight monitoring : Lundberg “B waves.”• B waves are slow waves of ICP lasting 20 seconds to 2 minutes• Intraparenchymal probe• Normal : < 15 mmHg• Vasogenic wave : greater • than 25 mmHg, for a period • around 10 min
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Monitoring of Intracranial pressure
• The average overnight RAP index should be less than 0.6 in patients with good compensatory reserve.
• The overnight magnitude of slow waves is considered increased when their average value is greater than 1.5 mm Hg.
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Clinical tests of cerebrospinal fluid dynamics
• The computerized infusion test
• Resistance to CSF outflow
= Plateau P – Resting P infusion rate
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NPH and Brain atrophy
NPH Brain atrophy1.Baseline ICP2.Resistance to CSF outflow3.AMP4.RAP5.Elastance coefiicient
normal (<18 mmHg)
Increase (>13 mmHg/ml /minute)
Correlated with Mean ICP
Good (< 0.6 )Increase (E > 0.2
1/ml)
Low (<12 mmHg)Low (<12
mmHg/ml /minute)Low (<2mmHg)
Good (<0.5)Low (E < 0.2 1/ml)
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NPH and Brain atrophy
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NPH and Brain atrophy
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Noncommunicating and acute hydrocephalus
Noncommunicating
acute hydrocephalus
1.Baseline ICP increase increase
2.Resistance to CSF outflow
increase increase
3.AMP increase increase
4.RAP > 0.6 normal
5.Elastance coefiicient
high low
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Testing of Cerebrospinal Fluid Dynamics in Shunted Patients
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Testing of Cerebrospinal Fluid Dynamics in Shunted Patients
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Management
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Management
• Surgical Management• Shunt insertion• Endoscopic third
ventriculostomy
• Medical Management• Acetazolamide• Repeated lumbar
puncture
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Shunt insertion
• VP shunt : most common• Lumboperitoneal shunt• Lumbopleural shunt• Ventriculoatrial shunt
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Endoscopic third ventriculostomy
• Obstructive hydrocephalus• Passage an endoscopre through lateral
ventricle to third ventricle create stoma at floor of 3rd ventricle
• Advantage : prevent shunt infection, lifelong risk for revision
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Shunt
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Mechanism of Shunt
• Fixed differential pressure valves• Adjustable differential pressure valves• Flow-regulating valves• Accerory device
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Valve classification
• 1. Silicon membrane
• 2. Ball-on-spring • 3. Miter valve • 4. Proximal or distal slit valves.• 5. Moving diaphragm
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Shunt
• Magnetric programming : prevent magnetric field near
• Overdrainage : dependence on diameter and length of the distal drain
• Membrane device : impede CSF flow by skin tense
• A flow –regulating : may permanent increase hydrodynamic resistance
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Complication
• Surgery• Infection• Bleeding• CSF leakage• Seizure• Neurological deficit
• Intracerebral hemorrhage
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Complication
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Complication
• Excessive drainage SDH 2-17% neurological deficit,coma,death• Conservative c serial scanning• Symptomatic : evacuation, ligation of shunt
tubing
• Shunt malformation• blockage, malpositon from peristalsis,
disconnect in movement disorder or seizure• Revision surgery
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Complication
• Shunt infection• Meningtis, peritonitis,subacute bacterial
endocarditis follow
• Shunt hardware adverse effect• Intestinal obstruction or volvulus• Wound breakdown• CSF leakage• Hernias
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Thanks you