Upward transtentorial herniation: A new role for endoscopic third ventriculostomy

Background: The placement of external ventricular drainage (EVD) to treat hydrocephalus secondary to a cerebellar stroke is controversial because it has been associated to upward transtentorial herniation (UTH). This case illustrates the effectiveness of endoscopic third ventriculostomy (ETV) after the ascending herniation has occurred. Case Description: A 50-year-old man had a cerebellar stroke with hemorrhagic transformation, tonsillar herniation, and non-communicating obstructive hydrocephalus. Considering that the patient was anticoagulated and thrombocytopenic, an EVD was placed initially, followed by clinical deterioration and UTH. We performed a suboccipital craniectomy immediately after clinical worsening, but the patient did not show clinical or radiological improvement. On the 5th day, we did an ETV, which reverses the upward herniation and hydrocephalus. The patient improved progressively with good neurological recovery. Conclusion: ETV is an effective and safe procedure for obstructive hydrocephalus. The successful resolution of the patient’s upward herniation after the ETV offers a potential option to treat UTH and advocates further research in this area.

Magnetic Resonance Image Findings and Surgical Considerations in T1-2 Disc Herniation

ABSTRACT:Objective:To report a case of disc herniation at Tl-2.Clinical presentation:A 57-year-old man presented with hand weakness, Horner's syndrome, and pain radiating along the medial aspect of one upper extremity. Magnetic resonance imaging demonstrated extruded Tl-2 disc herniation with upward herniation of a sequestrated fragment.Intervention:An anterior approach was used to excise the disc, that was compressing the spinal cord and the Tl nerve root. All the patient's symptoms resolved completely, including Horner's syndrome.Conclusion:Anterior discectomy may be the simplest and most effective method for disc excision and relief of spinal cord and Tl nerve root compression.

Hydrocephalus and infratentorial tumors

✓ One may consider that the child with hydrocephalus complicating a primary brain tumor has two distinctly different diseases: 1) a neoplasm, and 2) hydrocephalus. The hydrocephalus may be obstructive, communicating, or (in the case of choroid plexus papilloma) hypersecretory. This paper presents the incidence, symptomatology, and management of hydrocephalus associated with infratentorial brain tumors in 156 children and with pineal tumors in 21 children, all treated by the first author during the period 1967 to 1979. Medulloblastoma was the most commonly encountered tumor. Of 117 children with cerebellar-fourth ventricle tumors, 110 had hydrocephalus, whereas 11 of 34 with brain-stem tumors and all 21 with pineal tumors presented with hydrocephalus. Of the total 143 patients with hydrocephalus, shunts were inserted before craniotomy in 123, with the interval between shunt insertion and craniotomy for tumor removal ranging from 1 to 21 days. Eighteen of these children required shunt revisions after craniotomy; 36 of 80 patients followed for 6 months or more had their shunts permanently removed, but it was necessary to reinsert the shunt from 5 days to 13 months later in 30% of these patients. Only 25 patients remained permanently shunt-free. It is considered that the placement of shunts before craniotomy is justified by the extraordinarily high incidence of papilledema and visual impairment associated with hydrocephalus. “Upward herniation” and dissemination of neoplastic cells through the shunting system are theoretical contraindications to precraniotomy shunt insertion, although the former is rare (3%), and there is no statistical evidence to support the latter.

Pediatric Posterior Fossa Tumors

Many neurosurgeons recommend a “preoperative” shunt for children with posterior fossa tumors. It has been reported that the definitive surgery is simplified and the postoperative course is more benign as a result of the cerebrospinal fluid diversion. The present report documents complications as a result of upward herniation and hemorrhage within the tumor after shunt placement. On the basis of this experience, we conclude that a shunt is potentially hazardous and should be restricted to that selected group of patients who are acutely ill from increased intracranial pressure that is refractory to temporizing pharmacological management.