a case of hydrocephalus with failed shunt revision and failed EVT(endoscopic ventriculostomy)

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Revisional treatments for curing a evisional ETV Failure for shunt structions of a shunt-dependent ydrocephalus

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  • Case (5) (-)

    Revisional treatments

    for curing a revisional ETV Failure for shunt

    bstructions of a shunt-dependent

    hydrocephalus

    Copy rihgt: www.csfneurosurg.com

  • Case 5: Failed Neuroendoscopic revision of tumor-related

    hydrocephalus with Shunt-dependency

    (Case 1,female,27 years old)

    1. When at the age being 13 years old ): a first V-P shunt of her hydrocephalus due to a benign pineal

    mass

    2. At 10/?/ 2009(14 years after the shunting):

    Her delivery of a male baby by Caesarean operation

    3. At 7/?/2010(9 months after the delivery ): 1. Abdominal pain (abdominalgia ) suspected due to

    appendicitis 2. Its resolution by intravenous antibiotics for several days

    4. At 8/18/2010(more severe symptoms arose 1 month later): 1. dizziness ,Urination incontinence, vomiting;

    2. Recurred Hydrocephalus suggested by MRI;

    3. Treatment by intravenous antibiotics for 11days with vomiting resolved but remaining a symptom of inability of eyes up-movement

    4. Discharge at 8/29/2010

    5. At 9/9/2010(10 days after discharge): Abdominal pain, dizziness and vomiting appeared again and

    progressively worsened

    After ventricular drainage in emergency, all above symptoms resolved and be explained by normal ventricles showed MRI

  • Wrong diagnosis or judgment

    As the original shunt obstructed:

    1. Closing drain for several days after 5 days of CSF drainage : 1. Test for only 1 day to see if there was any need for keeping original shunt

    and ventricular drain any longer

    2. (Maybe with a incorrect idea that the original shunt already had been obstructed )

    2. At 6th day of ventricular drainage by successful Test: 1. Removal of both ventricular drain and original shunt : in order to avoid

    intracranial infection caused by long-term ventricular drainage and shunt

    2. successful Test: there were not significant worsening of symptoms 3. An unsuccessful response after several hours of the removal surgery:

    1. An unsuccessful response: " Bad symptoms related to intracranial hypertension appeared again

    4. Emergent CT: ventricular enlargement again and

    with blooding in it

    3. An emergent ventricular drainage performed on the other side of head soon:

    After the ventricular drainage: all bad symptoms disappeared again

  • An Failed EVT as a planed radical treatment of

    hydrocephalus and intracranial hypertension

    1. An EVT performed only after several hours of the Ventricular drainage :

    1. With a purpose of EVT as a radical treatment of hydrocephalus and intracranial hypertension

    2. With a better clinical result for only 1 day under the condition of the

    same Ventricular drainage after the EVT : recovered speaking

    again but still in a bad condition;

    2. A lumbar CSF drainage added to the prior ventricular

    drainage 1day after EVT( under the usage of both

    ventricular and Lumbar drainages ):

    1. Speaking ability lost soon after the CSF drainage

    2. Clinical conditions worsening again 1day after the CSF drainage :

    Unconsciousness and lost ability of eating but only under a nasogastric feeding

  • But: clinically failed EVT with a temporarily

    successful response of neuroimmagings for 20 days

    9/18/2010: removal of both V- &L- drains after CT scan

    9/21/2010

    9/23/2010

    9/30/2010

    9/25/2010

    10/5/2010

    10/9/2010

    Normal ventricles For 10 days

    Small ventricles for 10 Days

  • Why The EVT Failed? 2 related factors?

    with surgical results of a immediate bad clinical

    but a 20 days- temporarily successful response

    of neuroimmagings : why? 1. EVT performed under intracranial infection: causing the

    infection and clinical symptoms worsen

    2. EVT causing communicating hydrocephalus happen or worsen:

    10/12/2010:

    CT V-graphy

    10/13/2010( by accident )

    1day after the V-graphy:

    Reduced absorption of CSF

    communicating hydrocephalus So ,shunting

    needed

    Patency conformed

    through 3rd V-floor

  • More and more worsening of infection

    after the CT ventriculography

    1. In the day (10/12/2010)after CT ventriculography: 1. Her clinical condition became a sort of better (maybe due to CSF

    reduced by the procedure)

    2. Body temperature went up to 380 for a short time

    2. In 1st day (10/13/2010)after CT ventriculography: 1. Body temperature went up to 39.2 0 five hours after lumbar

    drainage at noon time

    2. Brain CT san In the night due to fever and vomiting: contrast medium still be kept intracranial with a normal size of ventricles

    3. In 2nd day (10/14/2010)after CT ventriculography: 1. Fever can be controlled down to 380 by antipyretic drugs

    combined with physical methods for fever

    2. Turbid or clouded CSF discovered by lumbar puncture; (suggesting a intracranial infection)

  • Continued Lumbar drainage every day failed

    after 1 month of its progressive effectiveness

    10/16/2010 10/22/2010

    10/27/2010 11/3/2010

    11/13/2010: failed lumbar drainage

    Lumbar drainage failed

  • Ventricular drainage after failed lumbar

    drainage causing a even worse state:

    at admission in our Unit : 1.In a life-threatening state;

    2. The behaviors of four extremities

    resembling Parkinson's syndrome

    3.Both feet in a state of Ballet dancing

  • The total recovery to original work as a international tour guide

    in 6 months after the end of our systemic CSF treatments

    4/8/2011: 3 months after discharge

    1/6/2011 at discharge 1 year after discharge

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