a case of hydrocephalus with failed shunt revision and failed evt(endoscopic ventriculostomy)
DESCRIPTION
Revisional treatments for curing a evisional ETV Failure for shunt structions of a shunt-dependent ydrocephalusTRANSCRIPT
Case (5) (天津病人-武艳丽)
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