Heareradiolegv

Neuroradiology 16, 261 - 265 (1978)

© by Springer-Verlag1978

Post-Traumatic Hydrocephalus in Patients with Severe Head Injury P.R.S. Kishore, M.H. Lipper, J.D. Miller, A.K. Girevendulis,D.P. Becker, and F.S. Vines Departments of Radiology and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia, USA Summary. Computerized tomography was performed on 100 consecutive patients suffering from severe head injury, on admission, after 3, 5, 14, and 90 days and 1 year. Ventricular enlargement was evaluated in the surviving patients based upon serial CT examinations. The presence or absence of ventricular enlargement was correlated with the clinical outcome. The study indicates that a significant correlation does exist between the outcome and ventricular size. Hydrocephalus was seen in only four out of the 29 patients who developed ventriculomegaly.

Ventricular enlargement is a well-recognized delayed complication of head injury [5, 15]. This enlargement may be secondary to diffuse brain injury, to obstruction in the CSF pathways or a combination of the two. Focal enlargement may also occur following infarction. The incidence of ventricular enlargement due to hydrocephalus or other causes following head injury is variously reported in the CT literature to range between 1.5% and 8% [2, 10, 12]. The CT reports are, however, based upon an analysis of findings in patients with varying degrees of head injury. Furthermore, CT was performed at varying time intervals following head trauma. Thus, an accurate assessment of the incidence of ventriculomegaly and its relationship to clinical outcome is not possible from these reports. We have undertaken a study to evaluate the development of ventricular enlargement due to hydrocephalus or diffuse brain damage following severe head injury in 100 consecutive patients using serial computed tomography. The purpose of this communication is to discuss the incidence of post-traumatic ventricular enlargement and its relationship to the ultimate clinical outcome.

(within hours after injury), on days 3, 5, 14, and 90 and 1 year after injury. The degree of neurologic deficit encountered in this series varied from an inability to obey simple commands to deep coma with loss of pupillary light reflexes and oculovesti.bular response~ Ventricular enlargement~wasevaluated~by comparing the size of the ventricles as seen on CT in the first week after injury with the size on days 14 and 90and after 1 year if this sttidy was available. These patients were all admitted to a head injury program in which patients were managed according to a standardized protocol. Five of the patients had to be excluded from this study because an admission CT had not been performed due to equipment malfunction or because of an incomplete CT examination. The examinations were initially performed using the EMI scanner with a 160 x 160 matrix and during the last 2 months of the study, a Delta scanner with a 256 X 256 matrix was used. A 14-day CT was performed on 74 patients who survived the first 2 weeks after injury. Fifty-five patients had a 3-month CT and 25 of these underwent a 1-year follow-up examination. Hydrocephalus was diagnosed by the presence of the 'distended' appearance of the anterior horns of the lateral ventricles, enlargement of the temporal horns and third ventricle, and normal or absent sulci [1, 4, 14]. Periventricular decreased density when present was taken as confirmatory evidence of communicating hydrocephalus [13]. Other criteria used for the detection of hydrocephalus included enlargement of the basal cisterns and fourth ventricle. The diagnosis of atrophy was made from the presence of diffuse enlargement of the lateral ventricles without distension or periventricular lucency, with associated sulcal enlargement. The clinical outcome was graded according to the scale proposed by Jennett and Bond [9] (Table 1). The ventricular enlargement was correlated with the clinical outcome on days 14 and 90 and at 1 year. In 19 cases, the increase in ventricular size at 14 days was used for correlation either because enlargement was

Table 1. Clinical grading of outcome 1. Good recovery

Return to normal activities, may or may not have minor neurologic or psychological deficit

2. Moderate disability

Disabled but independent for daily activities Conscious but disabled, needs daily support

3. Severe disability

Materials and Methods One hundred consecutive patients who sustained severe head injury were studied serially by CT performed on admission

4. Vegetative 5. Death

O028-3940/78/0016/0261/$01.00

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P.R.S. Kishore et al.: Post-Traumatic Hydrocephalus in Patients with Severe Head Injury

Fig. 1. CT image of 45-year-old male on admission (left) and after one year (right) following head injury. Initial CT shows normalsized ventricles (containing air from ventriculography) and normal subarachnoid spaces. One-year examination shows diffuse enlargement of lateral ventricles without distended appe~ance together with enlarged subarachnoid spaces

fully evident at this stage or because the 90-day CT was not performed. Ninety-day CT was lacking where the patient succumbed or was not due for follow-up.

Table 2. Ventricular enlargement and clinical outcome

Enlarged ventricles 29

Moderate or worse disability Good recovery

Normal ventricles 44

25 4

Moderate or worse disability

10

Good recovery

33

Results A total o f 29 p a t i e n t s d e v e l o p e d ventricular e n l a r g e m e n t in our series. Evidence o f d i l a t a t i o n was p r e s e n t o n the 14th day CT in all cases e x c e p t for t w o w h e r e the enlarge-

P.R.S. Kishore et al.: Post-Traumatic Hydrocephalus in Patients with Severe Head Injury

263

whose ventricles remained normal or unchanged in size after admission, 33 made a good recovery. One was lost to follow-up after a 14-day CT at which time he had completely recovered from his head injury. The remaining 10 had a poor outcome showing moderate disability or worse. Twenty-five patients had a normal CT examination on admission and were normal at the 3month or 1-year follow-up. Twenty-one of these made a good" recovery, only three of this group being moderately disabled (one was lost to follow-up after 14 days). An additional 12 patients with a normal initial CT went on to develop ventricular enlargement (Fig. 1). Only two of these patients made a good recovery, the other 10 having a poor outcome. Four of the 29 patients with ventricular dilatation m e t the CT criteria for hydrocephalus (Fig. 2). Two of these had a normal initial CT, a third had a subdural and an intracerebral hematoma for which a craniotomy was performed, and the remaining patient underwent a right frontal lobectomy for contusion. The clinical course and the outcome of these patients is shown in Table 3. None of these four was considered to have extraventricular obstructive hydrocephalus on clinical examination. Patients 2 and 3 died several weeks after discharge from the hospital.

Discussion

Fig. 2. Case 1. CT images on admission (top), 5th day (middle), and 14th day (bottom), in a 48-year-old female with head injury, showing slit-like ventricles secondary to edema on 5th day. Fourteenth day CT shows marked hydrocephalus with periventricular lucency

ment was only seen at the end of 1 year and in one where it was evident after 3 months. In 44 patients, the ventricular size was either normal or remained unchanged from the size o n admission. The incidence of ventricular dilatation and clinical outcome is shown in Table 2. In the 29 patients with ventricular dilatation, the clinical outcome was significantly worse; 25 of these patients suffered from moderate or more severe disability and the remaining four made a good recovery. Of the 44 patients

Delayed development of ventricular enlargement following head injury is a well-recognized complication. The accurate incidence of such hydrocephalus is not known, as only patients with symptomatic hydrocephalus were evaluated neuroradiologically in the past. With the advent of CT, it became possible to assess this incidence and to attempt a prediction of the ultimate clinical outcome in patients with diffuse brain injury. Such an analysis is not possible without serial study of a large number of patients in a particular clinical category. Several reports in the CT literature on head injury have shown the value o f C T in detecting post-traumatic hydrocephalus. These reports, however, do not indicate the frequency of incidence of hydrocephalus or its relationship to clinical outcome. In some large head injury series, the incidence of hydrocephalus ranged from 1.5 to 4% of the patients [10, 12]. In one report, 25 out of 316 patients were considered to have developed ventricular enlargement following head injury [2]. These results, however, are based upon the evaluation of findings on CT performed after varying intervals of time on patients with varying degrees of head injury. Lewin (1968) has reported on one of the largest series of patients with ventricular dilatation following severe head injury [11]. In 59 patients with generalized ventricular dilatation in his series, 20 showed evidence of obstruction in the basal cisterns on pneumoencephalography. Eight of the 20 showed evidence of increased intracranial pressure and six of them were treated with shunting procedures. In all cases the pressure was re-

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P.R.S. Kishore et al.: Post:Traumatic Hydrocephalus in Patients with Severe Head Injury

Table 3, Clinical course in four patients with hydrocephalus

1. M.M.

48F

Initial course

Outcome

Normal CT. Decerebrate posturing, uncontrollable raised intracranial pressure; inappropriate antidiuretie hormone

Death after 6 weeks Autopsy: diffuse massive edema, multiple cavitating infarctions, and uncal herniation Death after some months No autopsy

2. M.D. Right frontal craniotomy for frontal 18F and temporal intracerebral hematomas followed 8 days later by g~am-negative meningitis 3. J.J. Left temporoparietal craniotomy for 65 M intracerebral hematoma. Progressive improvement and discharged to nursing home 4. D.E. Normal CT. Decerebrate, no change 28 M in neurologic status until death

Death after some months No autopsy Death at 17 days Autopsy: multiple necrotic areas'in braifi a~d brain stem Pulmonary edema

lieved, with two making dramatic recoveries, and in the other four the severity of the primary brain injury was said to be a major factor for the operation not affecting the patients' prognosis. Of the two patients not operated upon, the phase of increased pressure subsided spontaneously in one, and the other patient died. Of the 12 patients with evidence of extraventricular obstructive hydrocephalus but with normal CSF pressure, six proceeded to make a practical recovery without a further surgical procedure. In two of these patients, serial studies showed that the CSF pathways had gradually opened up once more. Hawkins et al. (1976) analyzed the pneumoencephalographic findings in 93 patients with a history of severe head injury [7]. Pneumoencephalography was performed after periods ranging from weeks to years following head injury. Most of the studies were, however, performed 4 - 6 weeks after the injury. They found ventricular dilatation to be present in 45 out of 93 patients. The ventricutar dilatation was evaluated by using the ventricular index as measured on the brow-up AP fdm of a pneumoencephalogram. Twenty of the patients were considered to have extraventricular obstructive hydrocephalus based upon the PEG criteria of failure of the air to pass over the cerebral hemispheres after 24 hours. They also used other criteria of hydrocephalus such as a callosal angle of less than 110 degrees, a distended appearance of the lateral ventricles, and enlarged temporal horns. The 33% incidence of hydrocephalus in Lewin's series and the 44% incidence in the series of Hawkins et al. in patients with ventricular enlargement is higher than that of 15% in our series. It must be realized, however, that it is probably not possible to make an accurate comparison between PEG and CT findings. Of interest, however, is the fact that none of our patients was considered to have extraventricular obstructive hydrocephalus by clinical criteria. Except for patient 3 (Table 3), who was dis-

Charged to a nursing home and not followed subsequently, all patients were considered to have persistent disability secondary to diffuse brain injury. Isotope cisternography as described by Front and his associates and other authors may have resulted in the detection of the presence of co-existing communicating hydrocephalus [3, 6, 81. Our preliminary results indicate that a high degree of correlation exists between ventricular enlargement and residual clinical disability. A similar correlation was shown by Hawkins et al. Our study indicates that if ventricular enlargement was going to develop, it would have been evident on CT by the 14th or 19th day at the latest. A statistically significant relationship is noted between morbidity and the presence or absence of ventricular enlargement by day 90 in patients with an initially normal scan (P < 0.001). A definite trend can be recognized and this should give us some indication as to the ultimate outcome in patients demonstrating a similar sequence of CT findings. Further experience with a larger number of patients studied by serial computed tomography combined with the evaluation of hydrocephalus by isotope cisternography may help us to establish prognostic criteria in patients with severe head injury. Acknowledgement. Supported by Grant No. 1 P 50 NS 12587, National Institutes of Health, Bethesda, MD.

References

1. Epstein, F., Naidich, T., Kricheff, K., Chase, N., Lin, J., Rans0hoff, J.: Role of computerized axial tomography in diagnosis, treatment, and followup of hydrocephalus. Childs Brain 3, 91-100 (1977) 2. French, B.N., Dublin, A.B.: The value of computerized tomography in the management of 1000 consecutive head injuries. Surg. Neurol. 7,171-183 (1977)

P.R.S. Kishore et al.: Post-Traumatic Hydrocephalus in Patients with Severe Head Injury 3. Front, D., Becks, J.W.F., Georganas, C.L., Beekhuis, H., Penning, L.: Abnormal patterns of cerebrospinal fluid flow and absorption after head injuries: Diagnosis by isotope cisternography. Neuroradiology 4, 6-13 (1972) 4. Greitz, T., Grepe, A.: Encephalography in the diagnosis of convexity block hydrocephalus. Acta Radiol. (Diagn.) 11, 232-242 (1971) 5. Gurdjian, E.S., Fisher, R.A.: Post-traumatic hydrocephalus in head injury. In: Head injury conference proceedings, pp. 550-555 (ed. W.F. Caveness). Philadelphia: Lippincott 1966 6. Harbert, J.C, McCullough, D.C., Schellinger, D.: Computed cranial tomography and radionuclide cisternography in hydrocephalus. Semin. Nucl. Med. 12, 197-200 (1977) 7. Hawkins, T.D., Lloyd, A.D., Fletcher, G.I.C., Hanka, R.: Ventricular size following head injury: A clinico-radiological study. Radiology 27,279-289 (1976) 8. James, A.E., New, P.F.J., Heinz, E.R., Hodges, R.J., DeLand, F.H.: A cisternographic classification of hydrocephalus. Am. J. Roentgenol. 115, 39-49 (1972) 9. Jennett, B., Bond, M.R.: Assessment of outcome after swere brain damage. Lancet 1975 I, 480-484

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10. Koo, A.H., LaRoque, R.L.: Evaluation of head trauma by computed tomography. Radiology 123,345-350 (1977) 11. Lewin, W.: Preliminary observations on external hydrocephalus after severe head injury. Br. J. Surg. 55, 747-751 (1968) 12. Merino-de Villasante, J., Taveras, J.M.: Computerized tomography (CT) in acute head trauma. Am. J. Roentgenol. 126,765-778 (1976) 13. Mori, K., Murata, T., Nakano, Y., Handa, H.: Periventricular lucency in hydrocephalus on computerized tomography. Surg. Neurol. 8,337-340 (1977) 14. New, P.F.J., Scott, W.F., Schnur, J.A., Davis, K.R., Taveras, J.M.: Computerized axial tomography with EMI scanner. Radiology 110, 109-123 (1974) 15. Shillito, J., Jr., Ojeman, R.G.: Hydrocephalus. In: Neurological surgery, 1, p. 585 (ed. J.R. Youmans). Philadelphia: W.B. Saunders 1973 P.R.S. Kishore, MD Department of Radiology Box 728, MCV Station Richmond, VA 23298, USA

Post-traumatic hydrocephalus in patients with severe head injury.

Heareradiolegv Neuroradiology 16, 261 - 265 (1978) © by Springer-Verlag1978 Post-Traumatic Hydrocephalus in Patients with Severe Head Injury P.R.S...
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