Journal List > Korean J Neurotrauma > v.8(2) > 1058887

Observations on the Activation of Chronic Compensated Hydrocephalus in Adult Patients

Abstract

Objective:

There is a broad spectrum of compensated hydrocephalus. Various terms such as long-standing overt ventriculomegaly in adult (LOVA) has been coined, however, even such terms leave diverse aspect of this condition out of account. We have experienced compensated hydrocephalus cases which were considered to be activated after a long time period of quiescent state, and tried to compare their clinical characteristics with the relatively well described entity of LOVA.

Methods:

We conducted a retrospective review of 206 patients who underwent ventriculoperitoneal shunt (VPS) between February 2001 and May 2012. Of these, 6 patients had chronic compensated hydrocephalus. The clinical and radiological characteristics are evaluated.

Results:

Definite triventriculomegaly was observed in two patients. Macrocephaly was observed in two cases, one with aqueductal stenosis (AS), the other with unknown status of aqueduct. All of the cases with triventriculomegaly were normoce-phalic. Spinal causes were thought as aggravating factor in two. Two endoscopic third ventriculostomy and eight VPS were performed in five patients. Four patients responded well but one took a very complicated course.

Conclusion:

The relationships between macrocephaly, triventriculomegaly, and AS suggested in other studies were inconsistent. Blockage or narrowing of cerebrospinal fluid pathways were observed at various sites. Disturbances of spinal arachnoid pathways were related to the activation in some cases. Treatment is to be tailored individually considering various reigniting event. It is suggested that this entity is to be evaluated for better nomenclature reflecting diverse aspects of this condition. Further study is needed to elucidate underlying pathophysiology and effective management.

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FIGURE 1.
CT/MRI axial scans demonstrating ventriculomegaly with relatively well-identified sulci. Periventricular edema is observed in case 4 which suggest acute aggravation of quiescent long-standing hydrocephlalic process. CT: computed tomography, MRI: magnetic resonance imaging
kjn-8-139f1.tif
FIGURE 2.
T2-weighted sagittal MRI showing persistent T10-L2 segmental arachnoid cyst (A), MRI taken before ETV show AS, sellar enlargement, upwardly stretched corpus callosum and periventricular edema (B), ETV was performed and the fenestration was enlarged using a 3-French Fogarty balloon catheter. Unexpectedly, third ventricular floor was very narrow and the membrane was thick (C, arrow). AS: aqueductal stenosis, ETV: endoscopic third ventriculostomy, MRI: magnetic resonance imaging.
kjn-8-139f2.tif
FIGURE 3.
Preoperative MRI demonstrating triventriculomegaly, empty sella and abrupt narrowing distal to the aqueduct (A, arrow). Thoracic spine MRI revealed about 18 cm length epidural lesion (B). MRI: magnetic resonance imaging.
kjn-8-139f3.tif
FIGURE 4.
MRI showing ventriculomegaly and abrupt narrowing at the foramen of Magendie level (arrow) suggesting obstructive hydrocephalus (A). Radioisotope cisternography shows communicating type hydrocephalus (B).
kjn-8-139f4.tif
TABLE 1.
Summary of cases
Case No Sex/ Age PHx Chronic ICP Sx Macrocephaly IQ Sellar enlargement Triventri-culomegaly AS 2nd hit Operation Follow-up (months) mRS
1 M/29 Meningitis at 3 YO None Y Subnormal Y ± NA EDH Craniotomy 24 0
2 M/43 None Headache N Normal Y Y Y Spinal operation, omental adhesion Pr-valve, spinal op, GAV, Pro-GAV+Pudenz, ETV+pro-GAV removal 5 4
3 F/61 None None N Normal Y N N SAH, spinal Infection (?) Embolization, pro-GAV, spinal op 16 1
4 F/65 None None N Normal Y Y ± Nontraumatic spinal hemorrhage GAV 15 0
5 M/23 None Headache, nausea N Normal ± N N NA ETV, GAV 2 0
6 M/66 None None Y Normal Y N N NA Pro-GAV 10 0

AS: aqueductal stenosis, EDH: epidural hematoma, ETV: endoscopic third ventriculostomy, F: female, GAV: gravity assisted valve, ICP: intracranial pressure, IQ: intelligence quotient, M: male, mRS: modified Rankin score, N: no, NA: not available, No: number, op: operation, PHx: past history, pr-valve: pressure regulated valve, ProGAV: programmable GAV, Sx: symptom, Y: yes, YO: years old, ±: indefinite, SAH : subarachnoid hemorrhage

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