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