Cases reported "Hydrocephalus"

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1/90. Low-pressure shunt 'malfunction' following lumbar puncture in children with shunted obstructive hydrocephalus.

    Most shunt malfunctions present with signs and symptoms of high intracranial pressure, and computed tomography scans demonstrate ventricular enlargement. However, several authors have described a rare 'low-pressure' hydrocephalic state in which ventricular enlargement can occur in the face of low, or even negative, intracranial pressures. We report 2 children with obstructive hydrocephalus in whom this 'low-pressure state' followed a lumbar puncture; in both children, the shunts were functioning properly despite increased ventricular size on computed tomography scans, and all symptoms resolved (and the ventricles returned to baseline) following a period of enforced recumbency without shunt revision. We hypothesize that subarachnoid cerebrospinal fluid leakage through the puncture site in the lumbar theca decreases the intracranial pressures globally to a point below the opening pressures of the shunt valves. The ventricular cerebrospinal fluid, unable to be drained through either the subarachnoid space or the shunt, accumulates within the ventricular system under low pressure. One consistent feature in our 2 patients has been the postural nature of the headaches. We recommend enforced recumbency and, if necessary, a blood patch to seal the lumbar leakage. Shunt revision or prolonged external ventricular drainage appears to be unnecessary in these patients. Finally, neurosurgeons should be aware of this potential complication.
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2/90. Benign aqueductal cyst causing bilateral internuclear ophthalmoplegia after external ventricular drainage. Case report.

    The introduction of magnetic resonance (MR) imaging to the field of neuroimaging has allowed detection of various lesions that cause aqueductal stenosis. The authors report the case of a 3-year-old boy in whom a benign ventricular cyst developed in the aqueduct. The patient became drowsy after having complained of headache and vomiting; MR imaging revealed mild triventricular dilation and a normal-sized fourth ventricle. Repeated MR imaging performed 1 week later revealed an aqueductal cyst that had markedly enlarged during the intervening period. An external ventricular drainage system was installed, but recovery of consciousness in the child was unsatisfactory and a new bilateral internuclear ophthalmoplegia developed. Fenestration of the cyst wall and placement of a ventriculocisternostomy in the third ventricle were performed simultaneously by using a flexible neuroendoscope. By 2 weeks postsurgery, the patient's neurological symptoms had completely resolved. This case illustrates that simple rerouting of ventricular cerebrospinal fluid (CSF) can aggravate the symptoms of this rare lesion by causing severe compression of periaqueductal structures by a cyst that maintains a high intracystic pressure. Endoscopic surgery was an excellent choice of treatment to achieve both cyst fenestration and normalization of intracranial CSF pressure by creating a ventriculocisternostomy.
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3/90. basilar artery occlusion due to mucormycotic emboli, preceded by acute hydrocephalus.

    A rare case of brain stem infarction caused by mucormycotic emboli, preceded by acute hydrocephalus, is reported. The patient, who had suffered from leukemia and had undergone bone marrow transplantation several months before, presented initially with seizure and persistent disturbance of consciousness. A head CT scan revealed marked ventricular dilation and diagnosed as acute hydrocephalus. The patient received emergent ventricular drainage. Despite the aggressive treatment, the patient did not survive. autopsy revealed systemic mucormycosis occluding and invading various arteries including basilar artery and its branches, causing fatal brainstem infarction. Although early diagnosis remains difficult in the cases of systemic mucormycosis, prompt initiation of treatment is mandatory; one must have in mind the possibility of presence of fungal infection when treating patients with acute neurological deterioration who have underlying debilitating diseases, even though fungi themselves are hard to detect in most cases.
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4/90. Blake's pouch cyst: an entity within the Dandy-Walker continuum.

    Abnormal cerebrospinal fluid (CSF) collections within the posterior fossa are defined by the Dandy-Walker complex (DWC) and by arachnoid cysts (AC). The DWC includes the Dandy-Walker malformation (DWM), the Dandy-Walker variant (DWV) and the mega-cisterna magna (MCM). In addition, Tortori-Donati et al. added persistent Blake's pouch cyst (BPC) as an independent entity within the DWC. BPC represents a posterior ballooning of the superior medullary velum into the cisterna magna. All of these malformations are overlapping developmental anomalies characterized by varying degrees of malformation of the medullary vela, the cerebellar vermis and hemispheres, the fourth ventricle choroid plexus, the posterior fossa subarachnoid cisterns and the enveloping meningeal structures. We present two cases of persistent BPC detected in two adult women without history of gestational or subsequent growth problems. They underwent neuroradiological investigation because of headache and because of recurrent episodes of loss of consciousness, respectively. The MRI findings included tetraventricular hydrocephalus, wide communication of the fourth ventricle and the cystic posterior fossa (i.e. BPC), inferior posterior fossa mass effect with or without hypoplasia of both the cerebellar vermis and the medial aspects of the cerebellar hemispheres, and absence of communication between fourth ventricle and the basal subarachnoid space in the midline posteriorly. Persistent BPC is defined by a failure of embryonic assimilation of the area membranacea anterior within the tela choroidea associated with imperforation of the foramen of Magendie. Typically this condition becomes symptomatic early in life. In the current cases the normal function of the laterally positioned foramina of Luschka probably helped to maintain some CSF flow between intraventricular and subarachnoid spaces, with the establishment of a precarious equilibrium characterized by a compensatory enlargement of the cerebral ventricular system (i.e. hydrocephalus).
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5/90. A case of balamuthia mandrillaris meningoencephalitis.

    balamuthia mandrillaris is a newly described pathogen that causes granulomatous amebic encephalitis, an extremely rare clinical entity that usually occurs in immunosuppressed individuals. We report a case of pathologically proven Balamuthia encephalitis with unusual laboratory and radiologic findings. A 52-year-old woman with idiopathic seizures and a 2-year history of chronic neutropenia of unknown cause had a subacute illness with progressive lethargy, headaches, and coma and died 3 months after the onset of symptoms. Cerebrospinal fluid (CSF) glucose concentrations were extremely low or unmeasurable, a feature not previously described (to our knowledge). Cranial magnetic resonance imaging scans showed a single large temporal lobe nodule, followed 6 weeks later by the appearance of 18 ring-enhancing lesions in the cerebral hemispheres that disappeared after treatment with antibiotics and high-dose corticosteroids. The initial brain biopsy specimen and analysis of CSF samples did not demonstate amebae, but a second biopsy specimen and the postmortem pathologic examination showed Balamuthia trophozoites surrounded by widespread granulomatous inflammation and vasculitis. The patient's neutropenia and antibiotic use may have caused susceptibility to this organism. Amebic meningoencephalitis should be considered in cases of subacute meningoencephalitis with greatly depressed CSF glucose concentrations and multiple nodular lesions on cerebral imaging. Arch Neurol. 2000;57:1210-1212
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6/90. hydrocephalus in coccidioidal meningitis: case report and review of the literature.

    OBJECTIVE AND IMPORTANCE: coccidioidomycosis was once confined to the southwest united states and northern mexico. It has become a larger concern because of the concentration of military bases in these areas, the increasing mobility of populations, and the rising population of immunocompromised persons. Outside endemic areas, the diagnosis is rarely considered. patients with coccidioidomycosis may develop occult basilar meningitis progressing to communicating hydrocephalus and death. CLINICAL PRESENTATION: A 60-year-old white man presented with a 1-month history of vertigo, falls, and vomiting. Computed tomography of the head revealed mild hydrocephalus. Lumbar puncture results were remarkable for 1065 mg/dl protein; acid-fast bacillus stain, Gram's stain, and culture results were negative. Postgadolinium magnetic resonance imaging demonstrated enhancement of basilar and cervical meninges, suggesting inflammation, and communicating hydrocephalus. For 48 hours, the patient's level of consciousness decreased progressively. INTERVENTION: A ventriculoperitoneal shunt was placed, and antifungal agents were initiated on an emergent basis. CONCLUSION: coccidioidomycosis should be considered in the differential diagnosis of occult basilar meningitis. The diagnosis is established by the discovery of a high (>1:2) titer of complement-fixing antibody in the cerebrospinal fluid. Communicating hydrocephalus is a common complication of untreated coccidioidal meningitis, and it may develop during appropriate treatment (oral fluconazole, 200-400 mg/d, continued indefinitely). patients with hydrocephalus and evidence of increased intracranial pressure require a shunt.
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7/90. Complications of venous insufficiency after neurotologic-skull base surgery.

    OBJECTIVE: To characterize the incidence and complications resulting from venous insufficiency after neurotologic-skull base surgery. STUDY DESIGN: Retrospective case review of >3,500 cases. SETTING: Tertiary referral center, inpatient surgery. patients: Six patients: four with complications related to chronic venous insufficiency and two with complications related to acute venous insufficiency. INTERVENTION(S): Medical (steroids, acetazolamide, hyperventilation, mannitol) and surgical (lumboperitoneal shunt, optic nerve decompression, embolectomy) interventions were undertaken. MAIN OUTCOME MEASURE(S): Chronic venous insufficiency: nonobstructive hydrocephalus manifested by headache, disequilibrium, and papilledema with resultant visual loss. Acute venous insufficiency: acute nonobstructive hydrocephalus resulting in mental status abnormalities in the postoperative period. CONCLUSIONS: (1) incidence of 1.5 per 1,000 cases. (2) Acute and chronic forms with different pathogenesis. (3) Acute form presents postoperatively with change in consciousness and herniation, and may proceed to death. (4) Chronic form presents months or years postoperatively with headache, disequilibrium, and visual changes from papilledema. (5) Occurs almost solely in patients with preoperative abnormalities of the venous collecting system. (6) Causes mental status changes postoperatively.
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keywords = consciousness
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8/90. Critical shunt-induced subdural hematoma treated with combined pressure-programmable valve implantation and endoscopic third ventriculostomy.

    The authors present 2 patients with VP shunt-induced subdural hematomas (SDH) treated with pressure-programmable valve implantation and endoscopic third ventriculostomies (TV). The first patient is an 11-year-old girl who developed a shunt-induced SDH. Revision of the shunt valve with a higher-pressure valve resulted in a prolonged deterioration of her consciousness. External ventricular drainage at low pressure led to clinical improvement. A pressure-programmable valve set at 50 mm H(2)O was implanted, and the pressure gradually increased. At a pressure of 120 mm H(2)O symptoms recurred, even though the subdural collection was beginning to decrease in size. An endoscopic TV was performed, and the valve pressure was then increased to 200 mm H(2)O without any neurological symptoms. The second patient, a 7-year-old boy with shunt-induced SDH, had recurrent SDH, even after shunt revision with placement of a higher-pressure valve, which resulted in prolonged lethargy. A pressure-programmable valve was implanted with concurrent endoscopic TV. Gradual valve pressure increases up to 200 mm H(2)O could be performed without recurrent symptoms. Eventually, the shunt system was ligated to resolve residual positional headache, and the TV has been patent for more than 3 years. In both patients, the pressure-programmable valve was useful, since the optimal CSF drainage pressure changed during the period of recovery from symptomatic subdural collections. Concurrent TV appeared to enable increasing the valve pressure gradually without any neurological symptoms. The advantages of this combined approach are discussed.
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9/90. Investigation of hydrocephalus with three-dimensional constructive interference in steady state MRI.

    We report four patients with various types of hydrocephalus in whom constructive interference in steady state (CISS) MRI disclosed the cause of the hydrocephalus. The imaging clearly delineated an abnormal contour of the ventricular system and intraventricular septa, essential information for surgical planning, including endoscopic surgery. Postoperative CISS images were useful for showing not only regression of hydrocephalus but also the patency of small fenestrations.
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10/90. Giant basilar bifurcation aneurysm presenting as a third ventricular mass with unilateral obstructive hydrocephalus: case report.

    We report a rare case of a non-ruptured basilar bifurcation aneurysm presenting as a third ventricular mass producing unilateral obstructive hydrocephalus. This is the first reported case of its kind. A 70 year old woman presented with a giant basilar bifurcation aneurysm in which the aneurysm protruded into the third ventricle as a mass causing unilateral left hydrocephalus. The patient gradually became disoriented and developed a right hemiparesis and global aphasia. The right vertebral artery was occluded by placing coils intravascularly followed by an endoscopic septostomy. The patient's neurological state dramatically improved immediately. One month after the septostomy, however, the aneurysm ruptured and the patient eventually died. Treatment of the hydrocephalus only was selected instead of direct surgery or an intravascular procedure on the aneurysm, which eventually ruptured. The mechanisms for the unilateral hydrocephalus and the rupture of the aneurysm are described. The treatment strategy for these lesions is also discussed.
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