Posttraumatic ventriculomegaly: hydrocephalus or atrophy? A new approach for diagnosis using CSF dynamics

1996 ◽  
Vol 85 (6) ◽  
pp. 1026-1035 ◽  
Author(s):  
Anthony Marmarou ◽  
Montasser A. Abd-Elfattah Foda ◽  
Kuniaki Bandoh ◽  
Masaaki Yoshihara ◽  
Takuji Yamamoto ◽  
...  
Keyword(s):  
Head Injury ◽  
Normal Pressure ◽  
Volume Index ◽  
Injection Technique ◽  
Benign Intracranial Hypertension ◽  
Ventricular Size ◽  
Csf Dynamics ◽  
Content Type ◽  
Group 5 ◽  
Fine Print

✓ Cerebrospinal fluid (CSF) dynamics were correlated to the changes in ventricular size during the first 3 months posttrauma in patients with severe head injury (Glasgow Coma Scale score ≤ 8, 75 patients) to distinguish between atrophy and hydrocephalus as the two possible causes of posttraumatic ventriculomegaly. Using the bolus injection technique, the baseline intracranial pressure (ICP), pressure volume index, and resistance for CSF absorption (R0) provided a threedimensional profile of CSF dynamics that was correlated with ventricular size and Glasgow Outcome Scale (GOS) score at 3, 6, and 12 months posttrauma. Patients were separated into five different groups based on changes in ventricular size, presence of atrophy, and CSF dynamics. Group 1 (normal group, 41.3%) demonstrated normal ventricular size and normal ICP. Group 2 (benign intracranial hypertension group, 14.7%) showed normal ventricular size and elevated ICP. Group × (atrophy group, 24%) displayed ventriculomegaly, normal ICP, and normal R0. Group 4 (normal-pressure hydrocephalus group, 9.3%) had ventriculomegaly, normal ICP, and high R0. Group 5 (high-pressure hydrocephalus group, 10.7%) showed ventriculomegaly and elevated ICP with or without high R0. The GOS score in the nonhydrocephalic groups (Groups 1, 2, and 3) was better than in the hydrocephalic groups (Groups 4 and 5). It is concluded from these results that 44% of head injury survivors may develop posttraumatic ventriculomegaly. Posttraumatic hydrocephalus, as identified by abnormal CSF dynamics, was diagnosed in 20% of survivors and their outcome was significantly worse. This study demonstrates the importance of using CSF dynamics as an aid in diagnosis of posttraumatic hydrocephalus and identifying those patients who may benefit from shunt placement.

Subtle deterioration in shunted childhood hydrocephalus

1986 ◽  
Vol 65 (2) ◽  
pp. 211-216 ◽  
Author(s):  
Arno Fried ◽  
Kenneth Shapiro
Keyword(s):  
Buffering Capacity ◽  
Volume Index ◽  
Shunt Revision ◽  
Pressure Waves ◽  
Ventricular Size ◽  
Csf Shunts ◽  
Content Type ◽  
The Mean ◽  
Childhood Hydrocephalus ◽  
Fine Print

✓ Eighteen hydrocephalic children who presented with subtle deterioration when their shunts malfunctioned were studied during shunt revision by means of the pressure-volume index (PVI) technique. Bolus manipulation of cerebrospinal fluid (CSF) was used to determine the PVI and the resistance to the absorption of CSF (Ro). Ventricular size was moderately to severely enlarged in all the children. Steady-state intracranial pressure (ICP) at the time of shunt revision was 17.5 ± 7.3 mm Hg (range 8 to 35 mm Hg). Pressure waves could not be induced by bolus injections in the 8- to 35-mm Hg range of ICP tested. The mean ± standard deviation (SD) of the predicted normal PVI for this group was 18.5 ± 2.7 ml. The mean ± standard error of the mean of the measured PVI was 35.5 ± 2.1 ml, which represented a 187% ± 33% (± SD) increase in volume-buffering capacity (p < 0.001). The ICP did not fall after bolus injections in three children, so that the Ro could not be measured. In the remaining 15 patients, Ro increased linearly as a function of ICP (r = 0.74, p < 0.001). At ICP's below 20 mm Hg, Ro ranged from 2.0 to 5.0 mm Hg/ml/min, but increased to as high as 21 mm Hg/ml/min when ICP was above 20 mm Hg. This study documents that subtle deterioration in shunted hydrocephalic children is accompanied by abnormally compliant pressure-volume curves. These children develop ventricular enlargement and neurological deterioration without acute episodic pressure waves. The biomechanical profile of this group differs from other children with CSF shunts.

Biomechanical and hydrodynamic characterization of the hydrocephalic infant

1985 ◽  
Vol 63 (1) ◽  
pp. 69-75 ◽  
Author(s):  
Kenneth Shapiro ◽  
Arno Fried ◽  
Anthony Marmarou
Keyword(s):  
Steady State ◽  
Ventricular Volume ◽  
Volume Index ◽  
Injection Technique ◽  
Infantile Hydrocephalus ◽  
Content Type ◽  
Two Factors ◽  
The Mean ◽  
Fine Print

✓ The pressure-volume index (PVI) technique of bolus manipulation of cerebrospinal fluid (CSF) was used to measure neural axis volume-buffering capacity and resistance to the absorption of CSF in 16 hydrocephalic infants prior to shunting. The mean steady-state intracranial pressure (ICP) was 11.7 ± 5.7 mm Hg (± standard deviation (SD)), representing a modest elevation of ICP in infants. The mean measured PVI was 28.1 ± 1.5 ml (± standard error of the mean (SEM)) compared to the predicted normal level for these infants of 12.1 ± 2.7 ml (± SD) (p < 0.001). This resulted from an enhanced volume storage capacity in the hydrocephalic infants. The PVI was not related to ventricular size in these hydrocephalic infants. Although absorption of the additional bolus of fluid did not occur at steady-state ICP, it was readily absorbed once ICP was raised above a mean threshold pressure of 16.0 ± 5.0 mm Hg (± SD) in 13 of the 16 infants. Above this pressure, the mean CSF absorption resistance was 7.2 ± 1.3 mm Hg/ml/min (± SEM) which is twice the normal values as measured by the bolus injection technique. The biomechanical profile of infantile hydrocephalus described in this study indicates that two factors are required for progression of ventricular volume. While an absorptive defect may initiate the hydrocephalic process, progressive volume storage requires an alteration in the mechanical properties of the intracranial compartment.

Cerebral blood flow and metabolism in severely head-injured children

1989 ◽  
Vol 71 (1) ◽  
pp. 63-71 ◽  
Author(s):  
J. Paul Muizelaar ◽  
Anthony Marmarou ◽  
Antonio A. F. DeSalles ◽  
John D. Ward ◽  
Richard S. Zimmerman ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Head Injury ◽  
Severe Head Injury ◽  
Cerebral Blood Volume ◽  
Closed Head Injury ◽  
Volume Index ◽  
Content Type ◽  
Gcs Score ◽  
Fine Print

✓ The literature suggests that in children with severe head injury, cerebral hyperemia is common and related to high intracranial pressure (ICP). However, there are very few data on cerebral blood flow (CBF) after severe head injury in children. This paper presents 72 measurements of cerebral blood flow (“CBF15”), using the 133Xe inhalation method, with multiple detectors over both hemispheres in 32 children aged 3 to 18 years (mean 13.6 years) with severe closed head injury (average Glasgow Coma Scale (GCS) score 5.4). In 25 of the children, these were combined with measurements of arteriojugular venous oxygen difference (AVDO2) and of cerebral metabolic rate of oxygen (CMRO2). In 30 patients, the first measurement was taken approximately 12 hours postinjury. In 18 patients, an indication of brain stiffness was obtained by withdrawal and injection of ventricular cerebrospinal fluid and calculation of the pressure-volume index (PVI) of Marmarou. The CBF and CMRO2 data were correlated with the GCS score, outcome, ICP, and PVI. Early after injury, CBF tended to be lower with lower GCS scores, but this was not statistically significant. This trend was reversed 24 hours postinjury, as significantly more hyperemic values were recorded the lower the GCS score, with the exception of the most severely injured patients (GCS score 3). In contrast, mean CMRO2 correlated positively with the GCS score and outcome throughout the course, but large standard deviations preclude making predictions based on CMRO2 measurements in individual patients. Early after injury, there was mild uncoupling between CBF and CMRO2 (CBF above metabolic demands, low AVDO2) and, after 24 hours, flow and metabolism were completely uncoupled with an extremely low AVDO2. Consistently reduced flow was found in only four patients; 28 patients (88%) showed hyperemia at some point in their course. This very high percentage of patients with hyperemia, combined with the lowest values of AVDO2 found in the literature, indicates that hyperemia or luxury perfusion is more prevalent in this group of patients. The three patients with consistently the highest CBF had consistently the lowest PVI: thus, the patients with the most severe hyperemia also had the stiffest brains. Nevertheless, and in contrast to previous reports, no correlation could be established between the course of ICP or PVI and the occurrence of hyperemia, nor was there a correlation between the levels of CBF and ICP at the time of the measurements. The authors argue that this lack of correlation is due to: 1) a definition of hyperemia that is too generous, and 2) the lack of a systematic relationship between CBF and cerebral blood volume. The implications of these findings for therapeutic modes of controlling ICP in children, such as hyperventilation and the use of mannitol, are discussed.

Correlation between decreased ventricular size and positive clinical outcome following shunt placement in patients with normal-pressure hydrocephalus

2004 ◽  
Vol 100 (6) ◽  
pp. 1036-1040 ◽  
Author(s):  
Ullrich Meier ◽  
Sven Mutze
Keyword(s):  
Clinical Outcome ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Ventricular Volume ◽  
Communicating Hydrocephalus ◽  
Ventricular Size ◽  
Content Type ◽  
Shunt Placement ◽  
Postoperative Change ◽  
Fine Print

Object. It is well known that in patients with communicating hydrocephalus or normal-pressure hydrocephalus (NPH), ventricular size decreases following implantation of shunts with differential pressure valves. The aim of this study was to determine whether ventricular size correlates with a positive clinical outcome following shunt placement. Methods. Hydrostatic valves (dual-switch valves) were implanted in 80 patients with NPH at Unfallkrankenhaus, Berlin, between September 1997 and January 2002. One year postoperatively, these patients underwent computerized tomography scanning, and their ventricular size was ascertained using the Evans Index. Among 80% of the patients who showed no postoperative change in ventricular volume, 59% nonetheless had good to excellent clinical improvements, 17% satisfactory improvement, and 24% no improvement. Furthermore, a moderate reduction in ventricular size was observed in 14% of patients in this cohort. Among these, 36% experienced good to excellent clinical improvements, 28% satisfactory improvement, and 36% unsatisfactory improvement. A marked reduction in ventricular size was observed in 6% of the patients. Of this latter group, 60% demonstrated good to excellent outcomes, whereas 40% had unsatisfactory outcomes. Conclusions. Favorable outcomes following the implantation of a hydrostatic shunt in patients with NPH did not correlate with decreased ventricular volume 1 year after surgery. In fact, better clinical outcomes were observed in patients with little or no alteration in ventricular size, compared with those in patients with a marked decrease in ventricular size. A postoperative change in ventricular volume should be assessed differently in patients with NPH compared with those suffering from hypertensive hydrocephalus.

Volumetric measurements in the detection of reduced ventricular volume in patients with normal-pressure hydrocephalus whose clinical condition improved after ventriculoperitoneal shunt placement

2002 ◽  
Vol 97 (1) ◽  
pp. 73-79 ◽  
Author(s):  
Richard C. Anderson ◽  
Jessica J. Grant ◽  
Robert de la Paz ◽  
Steven Frucht ◽  
Robert R. Goodman
Keyword(s):  
Clinical Improvement ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Ventricular Volume ◽  
Ventricular Size ◽  
Content Type ◽  
Shunt Placement ◽  
Lateral Ventricles ◽  
Fine Print ◽  
Volumetric Measurements

Object. The syndrome of normal-pressure hydrocephalus (NPH) refers to the clinical triad of gait disturbance, dementia, and urinary incontinence in association with idiopathic ventriculomegaly and normal intracranial pressure. Ventriculoperitoneal (VP) shunt placement often yields significant clinical improvements, sometimes without apparent reduction of ventricular size. The authors hypothesized that careful volumetric measurements would show a decrease in ventricular volume in these patients. Methods. Twenty consecutive patients with NPH underwent placement of VP shunts equipped with programmable valves. In 11 patients pre- and postoperative neuroimaging was performed, which allowed volumetric analysis. Volumetric measurements of the lateral ventricles were calculated in triplicate by National Institutes of Health image-processing software to assess standard computerized tomography (CT) scans (eight patients) or magnetic resonance (MR) images (three patients) obtained before and after shunt placement. Ventricular volumes were also assessed by an independent neuroradiologist. Postoperative studies were performed at a time of clinical improvement, between 1 and 9 months postsurgery (mean 5 months). Preoperative and postoperative Unified Parkinson's Disease Rating Scale evaluations were performed in four patients. Significant clinical improvement occurred in all patients after shunt placement (mean follow-up period 17.5 months). Although 10 (91%) of 11 patients demonstrated a calculable decrease in volume in the lateral ventricles (mean decrease 39%), formal interpretation of neuroimages indicated a definite decrease in lateral ventricular volume in only three (27%) of 11 patients. Conclusions. Volumetric measurements obtained to compare preoperative and postoperative CT or MR studies obtained in patients with NPH in whom clinical improvement was seen after shunt placement surgery show a demonstrable decrease in ventricular size. Volumetric measurements may be helpful in clinical assessment postoperatively and in guiding programmable valve pressure settings.

Variations of intraventricular pressure during pneumoencephalography

1974 ◽  
Vol 40 (1) ◽  
pp. 101-106 ◽  
Author(s):  
Jacques Philippon ◽  
Bernard George ◽  
Jean Metzger
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypertension ◽  
Normal Pressure Hydrocephalus ◽  
Initial Pressure ◽  
Normal Pressure ◽  
Intraventricular Pressure ◽  
Csf Dynamics ◽  
Content Type ◽  
Fine Print

✓ Intraventricular pressure was studied in eight patients during and after diagnostic pneumoencephalography. In cases with normal initial pressure and normal cerebrospinal fluid (CSF) dynamics, variations in pressure were moderate, immediate, and disappeared at the end of the examination. In cases of normal-pressure hydrocephalus, there was a slow but relatively important elevation that continued for at least 24 hours. In cases with intracranial hypertension, there was a rapid significant increase; return to normal depended principally upon the flow from a large CSF compartment.

Relationship between compliance and resistance to outflow of CSF in adult hydrocephalus

1989 ◽  
Vol 71 (1) ◽  
pp. 59-62 ◽  
Author(s):  
Joseph T. J. Tans ◽  
Dick C. J. Poortvliet
Keyword(s):  
Disease Type ◽  
Volume Index ◽  
Clear Correlation ◽  
Constant Flow ◽  
Ventricular Size ◽  
Content Type ◽  
Duration Of Disease ◽  
Two Parameters ◽  
The Relationship ◽  
Fine Print

✓ Resistance to outflow of cerebrospinal fluid (Rcsf) was determined by constant flow infusions and pressure-volume index (PVI) using bolus infusions in 114 patients with various types of hydrocephalus. A clear correlation was found between PVI and Rcsf and, to a lesser degree, between these two parameters and baseline pressure. The PVI was not related to patient's age, duration of disease, type of hydrocephalus, or ventricular size, indicating that the relationship between PVI and Rcsf was genuine and not caused by patient selection. It is concluded that, in adult hydrocephalus, compliance is not an independent parameter but chiefly determined by Rcsf.

Posttraumatic cerebral hemispheric swelling

1988 ◽  
Vol 68 (3) ◽  
pp. 417-423 ◽  
Author(s):  
Ramiro D. Lobato ◽  
Rosario Sarabia ◽  
Francisco Cordobes ◽  
Juan J. Rivas ◽  
Angel Adrados ◽  
...  
Keyword(s):  
Head Injury ◽  
Severe Head Injury ◽  
Mass Effect ◽  
Normal Pressure ◽  
Neurological Status ◽  
High Dose ◽  
Complete Disappearance ◽  
Content Type ◽  
High Incidence ◽  
Fine Print

✓ The authors have analyzed the clinical course and intracranial pressure (ICP) changes in 55 severely headinjured patients presenting with bulk enlargement of one cerebral hemisphere within a few hours after trauma. These patients represent 10.5% of a series of 520 patients with severe head injury studied with computerized tomography (CT). Cerebral hemispheric swelling has the highest mortality rate and the shortest survival period after trauma in all series of severe head injury. In this series, it was associated with an ipsilateral subdural hematoma of variable size in 47 patients (85%) or with a large epidural hematoma in five patients (9%); in three patients (5.4%) it occurred as an isolated lesion. Evacuation of an associated extracerebral hematoma, which was performed within 4 hours after injury in only 20% of cases, scarcely changed the patients' preoperative neurological status. The high incidence of arterial hypotension and/or hypoxemia at admission (47% of cases) and the severity of the clinical presentation (82% of patients scored 5 points or less on the Glasgow Coma Scale, 74% had unilateral or bilateral mydriasis, and 80% had an initial ICP above normal) correlated with a very poor final outcome (87% mortality). Only one of the 11 patients with normal initial ICP continued to have normal pressure throughout the course. High-dose thiopental failed to control severe intracranial hypertension in 24 patients (51%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 15 patients (31.4%) and definitive control in eight patients (17%), among whom were the seven survivors in this series. In the authors' experience, once ICP is controlled, barbiturate administration should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

Pressure-volume relationships in shunt-dependent childhood hydrocephalus

1986 ◽  
Vol 64 (3) ◽  
pp. 390-396 ◽  
Author(s):  
Kenneth Shapiro ◽  
Arno Fried
Keyword(s):  
Normal Pressure ◽  
Buffering Capacity ◽  
Volume Index ◽  
Content Type ◽  
Proximate Cause ◽  
Volume Curve ◽  
Pressure Volume Curve ◽  
Neural Axis ◽  
The Mean ◽  
Fine Print

✓ The pressure-volume index (PVI) technique of bolus manipulation of cerebrospinal fluid (CSF) was used to measure neural axis volume buffering capacity and resistance to absorption of CSF (Ro) in 20 shunt-dependent hydrocephalic children acutely ill from shunt malfunction. All children had had ventricles that were near normal or subnormal in size when the shunts were functioning. The mean intracranial pressure (ICP, ± standard deviation (SD)) at the time of revision was 10.6 ± 6.4 mm Hg. The mean measured PVI (± standard error of the mean) was 18.4 ± 1.1 ml compared to the normal PVI of 17.5 ± 4.4 ml (± SD) predicted for these children. According to paired t-tests, these measured values were similar to those predicted on the basis of neural axis volume for each child, indicating that these children had normal neural axis volume buffering capacity. While the study was in progress, abrupt increases of ICP were documented in all children. These waves were observed spontaneously as well as in response to the addition of volume to the neural axis. In each child a specific threshold pressure along the pressure-volume curve corresponded to the appearance of unstable ICP. The threshold pressures at which this occurred corresponded to a mean neural axis compliance of 0.32 ± 0.07 ml/mm Hg (± SD). The Ro varied as a function of ICP. The Ro measured at ICP's below 15 mm Hg ranged from 2 to 7.5 mm Hg/ml/min and rose to 12 to 30 mm Hg/ml/min at pressures in the 20 to 25 mm Hg range. The results of this study indicate that neural axis volume buffering capacity is normal in shunt-dependent children who respond to shunting by reconstitution of the cortical mantle. This study indicates that the proximate cause of their abrupt clinical deterioration is unstable ICP, which occurred at a similar point on the pressure-volume curve of all children studied. The correlation of Ro to ICP suggests that CSF absorption does not increase in these children as ICP rises, resulting in movement along relatively normal pressure-volume curves. The functional implications of these parameters are discussed.

Cerebral blood flow in patients with normal-pressure hydrocephalus before and after shunting

1987 ◽  
Vol 66 (3) ◽  
pp. 379-387 ◽  
Author(s):  
Sissel Vorstrup ◽  
John Christensen ◽  
Flemming Gjerris ◽  
P. Soelberg Sørensen ◽  
Anne Marie Thomsen ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Ct Scan ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Low Flow ◽  
Ventricular Size ◽  
Content Type ◽  
Before And After ◽  
Fine Print

✓ Cerebral blood flow (CBF) was measured by xenon-133 inhalation and single photon emission tomography in 17 demented patients with normal-pressure hydrocephalus before and after shunt treatment. All patients had a decreased conductance to outflow (Cout) of cerebrospinal fluid as measured by lumboventricular perfusion (COut < 0.12 ml ⋅ mm Hg−1 ⋅ min−1). Computerized tomography (CT) scanning, clinical assessment, and neuropsychological grading were performed pre- and postoperatively. The preoperative CBF studies revealed abnormal flow patterns in all patients. Fourteen patients showed moderate-sized, large, or very large central low-flow areas, and four patients had reduced flow bilaterally in the occipital and contiguous temporoparietal regions. After shunting, six patients had a significant reduction in the size of the central low-flow area on the CBF map, agreeing well with the changes of ventricular size on the CT scan. All six patients showed an improvement in either clinical or neuropsychological grading. In 10 of the remaining 11 patients flow patterns were essentially unchanged; one patient deteriorated further. Four of these 11 patients improved on postoperative clinical or neuropsychological testing. Thus, a positive correlation was found between the changes in CBF and the reduction of the ventricular size on the CT scan, but changes in CBF as measured by the present technique did not accompany improvement in the functional state in all patients.

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