¿Cuál es la presión de drenaje óptima en hidrocefalias tumorales obstructivas? Análisis de factores subyacentes al sobredrenado valvular, revisión de casos y desarrollo de protocolo quirúrgico / What is the optimal drainage pressure in obstructive tumors hydrocephalus? Analysis of factors underlying valve overdrainage, case review and development of surgical protocol

Introducción: La hidrocefalia es una complicación frecuente dentro de la patología tumoral del SNC. La colocación de válvulas de derivación ventrículo-peritoneal (VDVP) en estos casos es, al día de la fecha, la práctica estándar para tratar esta patología y prevenir las complicaciones y comorbilidades que esta conlleva. Al momento, no existe un protocolo ni una presión valvular inicial establecida para estos pacientes, en los cuales hemos observado una tendencia al sobredrenado de líquido cefalorraquídeo (LCR). El objetivo de este trabajo es analizar nuestra experiencia en el tratamiento de hidrocefalias obstructivas secundarias a patología tumoral, determinar factores relacionados al advenimiento de sobredrenado, el manejo terapéutico del mismo y subsiguientemente protocolizar de manera sencilla y económica la colocación de este tipo de prótesis así como identificar una presión terapéutica que reduzca el riesgo de sobredrenado. Materiales y métodos: Estudio monocéntrico, analítico, retrospectivo de una cohorte de pacientes operados en nuestra institución por hidrocefalia obstructiva secundaria a patología tumoral entre los años 2013-2022.Se analizaron historias clínicas, imágenes y protocolos quirúrgicos. Se identificaron aquellos pacientes que desarrollaron sobredrenado. Subsiguientemente se analizaron mediante un modelo estadístico explicativo multivariado aquellas variables demográficas, clínicas y terapéuticas implicadas en el mismo.En una segunda etapa se propone un protocolo rápido, sencillo y económico a fin de determinar la presión óptima dentro de cada caso en particular. Resultados: Dentro de los 56 pacientes incluidos, 32 pacientes (57%) presentaron sobredrenado; 10 pacientes (18%) presentaron higromas en imágenes postoperatorias, y de estos, 3 pacientes (5.4%) requirieron intervenciones quirúrgicas. El 94% de los sobredrenados ocurrieron a presiones menores o igual a 160 mmH20. Así mismo, 8 de los 11 pacientes con VDVP de presión fija media (100-110 mmH20) no regulable presentaron sobredrenado.En un 27% de los pacientes debió aumentarse la presión valvular como consecuencia de hallazgos clínicos o radiológicos de sobredrenado. Conclusión: Las hidrocefalias secundarias a patología tumoral presentan un comportamiento distinto al de las normotensivas. La tasa de sobredrenado en estos pacientes es superior y por consiguiente debe ser tenida en cuenta como una posible complicación relevante. Dada la heterogeneidad de tumores, cada paciente presenta presiones de LCR distintas y por ende debe individualizarse el tratamiento. Proponemos el uso del protocolo de medición intraquirúrgica de presión a fin de colocar la VDVP a la presión óptima para cada paciente, y evitar de esta manera el sobredrenado de LCR

Background: Hydrocephalus is a common complication in CNS tumors pathology. The placement of ventriculoperitoneal shunt in these cases is, to date, the standard practice to treat this pathology and prevent the complications and comorbidities that it entails. At present, there is no protocol or initial valve pressure established for these patients, in whom we have observed a tendency toward overdrainage of cerebrospinal fluid (CSF).The objective of this work is to analyze our experience in the treatment of obstructive hydrocephalus secondary to tumor pathology, determine factors related to the occurrence of overdrainage, its therapeutic management and subsequently protocolize in a simple and economical way the placement of this type of prosthesis as well as identify a therapeutic pressure that reduces the risk of overdrainage. Methods: Monocentric, analytical, retrospective study of a cohort of patients operated on at our institution for obstructive hydrocephalus secondary to tumors, between the years 2013-2022.Medical records, images and surgical protocols were analyzed. Those patients who developed overdrainage were identified. Subsequently, the demographic, clinical and therapeutic variables involved in it were analyzed using a multivariate explanatory statistical model.In a second stage, a quick, simple, and economical protocol is proposed to determine the optimal pressure within each case. Results: Among the 56 patients included, 32 patients (57%) presented overdrainage; 10 patients (18%) presented hygromas on postoperative images, and of these, 3 patients (5.4%) required surgical interventions. 94% of overdrains occurred at pressures less than or equal to 160 mmH20. Likewise, 8 of the 11 patients with non-adjustable medium fixed pressure shunt (100-110 mmH20) presented overdrainage.In 27% of patients, valve pressure had to be increased because of clinical or radiological findings of overdrainage. Conclusion: Hydrocephalus secondary to tumors presents a different behavior than normotensive ones. The rate of overdrainage in these patients is higher and therefore must be considered as a possible relevant complication. Given the heterogeneity of tumors, each patient has different CSF pressures and therefore treatment must be individualized. We propose the use of the intrasurgical pressure measurement protocol to place the shunt at the optimal pressure for each patient, and thus avoid CSF overdrainage

Remote Hemorrhage after Burr Hole Drainage of Chronic Subdural Hematoma / 대한신경손상학회지

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.

Cervical Myelopathy Caused by Engorgement of the Epidural Venous Plexus due to Cerebrospinal Fluid Overdrainage: Case Report and Review of the Literature

This is a case report of a 33-year-old woman with cervical myelopathy caused by an enlargement of the cervical venous plexus, after she was submitted to a ventriculoperitoneal (VP) shunt that evolved to overdrainage. Magnetic Resonance Imaging (MRI) revealed an epidural venous enlargement within the spinal channel, with a 50% narrowing from C2 to C5, and spinal cord compression. A shunt revision was performed using a programmable drainage system, and a second MRI revealed the absence of the venous enlargement, resulting in cervical spinal cord decompression and remission of neurological symptoms. Compressive myelopathy consequent to the enlargement of the epidural venous plexus related to the overdrainage of the ventriculoperitoneal shunt system without typical signs of intracranial hypotension may result in misleading etiological diagnoses. Acknowledging this disorder is important to distinguish it from neoplastic processes or hematomas, for which surgical intervention may be needed.

Este é um relato de caso de uma paciente de 33 anos de idade que apresentou mielopatia cervical devido a alargamento do plexo venoso cervical, após ser submetida a uma derivação ventriculoperitoneal que evoluiu com hiperdrenagem. Exame de Ressonância Nuclear Magnética (RNM) revelou alargamento do plexo venoso epidural no canal espinhal, com estreitamento de 50% em C2 a C5, e compressão da medula espinhal. Uma revisão da derivação foi feita com um sistema de drenagem programável, e uma segunda RNM revelou ausência de ingurgitamento venoso, resultando em descompressão medular e remissão dos sintomas neurológicos. Mielopatia compressiva consequente ao alargamento do plexo venoso epidural relacionado à hiperdrenagem do sistema de derivação ventriculoperitoneal sem sinais típicos de hipotensão intracraniana pode resultar em diagnósticos incorretos. O conhecimento dessa patologia é importante para distingui-la de processos neoplásicos ou hematomas, nos quais intervenções cirúrgicas podem ser necessárias.

Clinical Experience with the Programmable Valve for Hydrocephalus Patients

OBJECTIVE: The goal of this study is to establish the value of the programmable valve system. METHODS: The authors conducted a single center retrospective study of 41 consecutive patients who had undergone ventriculoperitoneal shunt with programmable valve for hydrocephalus of various etiology from March 1999 to February 2002. RESULTS: In 10 patients(24%), valve pressure adjustment was required at least 3 times or more for the reason of underdrainage or overdrainage. The range of pressure reprogramming was 10 to 120mmH2O. The clinical symptoms improved in 37 patients(90%). The radiologic improvement was obtained in 88%. Shunt was minimally functioning in 3 cases without any clinical effect at the pressure of 30mmH2O. CONCLUSION: The programmable valve has been particularly useful in changing ventricular size for the correction of overdrainage or underdranage by the easy control of valve pressure without any invasive procedure. The authors' preference is to use the programmable valve system for all conditions.

Delayed Cerebellar Hemorrhage after Supratentorial Burr-Hole Drainage

We report two cases with delayed cerebellar hemorrhage developed after supratentorial burr-hole drainage, and review the literature. Burr-hole drainage was performed at both sides of bilateral chronic subdural hematomas. The total amount of drainage per day was more than 300ml of hematoma mixed with cerebrospinal fluid(CSF) and the differences in doses between the two sides were significant in both cases. The symptoms improved after drainage but abrupt deterioration of neurological status occurred with the development of cerebellar hemorrhage on postoperative day 4 and 5, in each case. Although both patients were elderly, 75 and 86 years old, they did not have any coagulation defect or episode of severe increase in their blood pressures during drainage. We believe that suprate-ntorial CSF overdrainage can cause cerebellar upward shift, with resultant injury of weakened cerebellar vessels in old age.

Sequential Multiple Epidural Hematomas Following Ventriculoperitoneal Shunt

For the treatment of a hydrocephalic patient, the ventriculoperitoneal shunt operation has been widely accepted, and although extra-axial hematomas are a well-known complication of ventricular shunting, epidural hematomas are uncommon in this setting. We report an unusual case of sequential multiple epidural hematomas in a 24-year-old man with hydrocephalus treated by ventriculoperitoneal shunt. For the evacuation of hematomas which had developed at different sites, the patient required three craniotomies. Possible etiologies have been examined, and the mechanism for the development of epidural hematoma after shunt operation is thought to be due to the rapid lowering of intracranial pressure and separation of the dura from the skull, causing oozing from small dural vessels ; to avoid this complication, the sudden perioperative lowering of intracranial pressure should be prevented. In addition, the literature is reviewed and discussed.

Comparative Study with Flow Regulated Valve and Differential Pressure Valve in Ventriculo-Peritoneal Shunt

In the management of hydrocephalus by shunts, two valve types are currently available:1) differential pressure valves(DPV) which provide a constant resistance and allow CSF flow when the proximal hydrostatic pressure exceeds the valve's present closing pressure, and 2) the newer variable resistance flow regulated valve(FRV). Eighty one cases of hydrocephalus were reviewed in this study to compare the two devices. Forty two patients were operated with FRV and 39 patients were operated with DPV. This study compared the preoperative and postoperative KPS score, ventricular size, periventricular low densities, and the frequency of complications. We have conclude that 1) In group 1(KPS score 50-70), FRV is useful and in group 2(KPS score 20-40), DPV is useful, 2) FRV is useful in dealing with excessively reduced ICP caused by over-drainage of a ventricular shunt;it can prevent postshunt subdural hygroma and symptomatic slit ventricles. 3) For evaluation of the effectiveness of FRV, the decrease of periventricular low densities is a more valuable index than the change of ventricle size(Hydrocephalus index).

Acute Epidural Hematoma Following Ventriculo-Peritoneal(V-P) shunt Operation

Ventriculo-peritoneal(V-P) shunt operation has been accepted as the most effective and safe procedure for the relief of increased intracranial pressure in hydrocephalic patients of various etiologies. A variety of complications have been reported in association with these relatively easy surgical procedures. Overdrainage induced effusions occur commonly in the subdural and rarely in the epidural spaces. Six cases of epidural hematoma(EDH) have been reported thus far in the literature following shunt operation remote from the catheter implantation. We report another case of this extremely rare complication of such procedures in a 16-year-old girl.