Acta Neuroehirurgica 33, 173--181 (1976) 9 by Springer-Verlag 1976

Clinique Neuroehirurgieale - - t-I6pital de la Piti6, Paris, France

Temporary External Valve Drainage in Hydrocephalus with Increased Ventricular Fluid Pressure (Experiences wit~ 202 Cases) By

B. Pertuiset, R. Van Effenterre, and g. Horn With 3 Figures

Summary When the ventricular fluid pressure has reached a level of 120 to 150 m m H20, there is a risk of rapid internal herniation. The effects of cortieoids and hyperosmolar drugs on this are not as striking as they are on brain oedema. The only efficient therapy is the establishment of an external ventricular drainage system proposed for the first time in 1941 by Ingraham and Campbell and regulated with a valve system by White et al. 1967. From our experience of 202 eases we review the technique, the indications, and the complications of ED. W h e n e v e r i n t r a v e n t r i e u l a r pressure rises the p a t i e n t ' s life is e n d a n gered b y the risk of s u d d e n i n t e r n a l h e r n i a t i o n s irrespective of the degree of v e n t r i e u l a r enlargement. F r o m our experience of 202 eases we estimate t h a t the danger starts w h e n t h e pressure is over 150 m m I-IaO, or 20 m m tIg*. This shows the necessity for v e n t r i e u l a r fluid drainage as a n emergency measure before radical surgery, t h e final result of which is b e t t e r when t h e I C P is close to a n o r m a l level a t the t i m e of operation. The mear~ v a l u e for v e n t r i eular fluid pressure in the r e c u m b e n t position is considered to be above n o r m a l at 14.4 -4- 1.8 m m Hg, according to Miller a n d Leech. ~Then the p a t i e n t ' s condition is poor, w h e n there is infection, or when drainage is t e m p o r a r y , e x t e r n a l drainage (ED) is preferred to a n i n t e r n a l s h u n t because its control is easier. * CSF pressure corresponding figures: 10O m m tI20 = 13 m m I-Ig. Acta Neurochirurgica, Vol. 33, Fase. 3--4

12

174

B. Pertuiset et aI. : Characteristics of the Hydrocephalus 1. Ventricular Dilatation

This can be shown by computerised X-ray scanning but, since it is not in general use, the average neurosurgeon has to use a different approach. In an unconscious patient the safest and the quickest way to ascertain if there is hydrocephalus is to tap the ventricle. A carotid angiogram takes time and m a y aggravate the patient's condition. With a conscious patient carotid angiography is performed first, and then a ventricle is tapped, if necessary. We consider that the degree of ventricular enlargement can only be estimated correctly by I)imer X or amipaque ventriculography. 2. Intraventricular Pressure

I n the operating room craniotomy is performed with a twist drill (4.5 mm diameter and 15 mm length) after a short incision has been made in the scalp under local anaesthesia, with the patient lying in the recumbent position. The site of the craniotomy is anterior to the frontoparietal suture and 2 one lateral to the neidline. The dura is first coaguluted with a coated electrode and then a ventricular troear with a two way valve is introduced into the ventricle perpendicular to the skull surface (Fig. 1). The pressure is recorded with a Claude water neanometer until it is stabilised. When it is over 150 mm H20 we consider that drainage is necessary. When it is under 100 mm H20, drainage is not considered urgent. If it is between 100 and 150 mm H20 an autoinfusion test is performed by recording the pressure while the abdomen or jugular veins are compressed. This results in a rapid rise in ventricular pressure to 300 nem 1-I20 or more. The rise in pressure is higher when the conscious patient strains as if at stool. The test is positive, indicating necessity for drainage, when the pressure does not return to its previous level once the compression is released. This test has been routinely used in the last 35 cases of this series. I n our experience drainage of patients in coma who have gross hydrocephalus, normal ventricular pressure, and a negative response to the autoinfusion test has not improved the prognosis. Monitoring of the ventricular pressure over 24 hours did not help in eases with high pressure, and is not recommended because it delays efficient drainage. I n patients with a pressure between 100 and 50 mm H20 it can show a decrease in pressure during the day and an increase during the night. When this increase rises above 150 mm H20, it has been considered that drainage was necessary.

Temporary External Valve Drainage in Hydrocephalus

175

Fig. 1. Measuring ventrieular pressure with a gauge recording in centimeters of water

Fi E. 2. Medium

pressure Spitz Holier valve attached to scalp. Scalp wounds over twist drill holes closed with silk

12"

176

/3. Perguise~ et al. :

3. Aetiology o/the Hydrocephalus I t is absolutely necessary to be informed previously to any drainage, if the high pressure hydrocephalus is unilateral or bilateral. Therefore a twist drill craniotomy will be performed on both sides to check the permeability of both foramen of Monro and inject, when necessary, a water soluble contrast media. The fact that this hydrocephalus is so called communicating or not communicating do not affect ED indication.

Fig. 3. Plastic drainage bag attached to head of bed. The valve is outside the dressing under view eontroI

External Yentrieular Drainage 1. Technique During the last four years 202 external drainages have been performed, as emergency operations in the operating room under conditions of strict asepsis. A graduated trocar introduced into the frontal horn of the right lateral ventricle shows tile length of ventricular catheter required.. Using the Spitz Holter set we introduce an angled catheter through the twist drill craniotomy and connect it to a medium pressure valve. A long rubber tube with silastic covering is connected to the other end. of the valve both ends of which are then attached to the scalp with silk sutures (Fig. 2). The apparatus is filled with CSF by pumping the valve, anc~ the d.istal tube is put into a sterile plastic bag. We recommend looping this tube two or three times to allow for move-

Temporary Ext.ernai Valve Drainage ia Hydrocephalus

177

ments of the patient. The scalp incision is short and it is not necessary to close it. A classical sterile dressing is applied to the head. The length of the tube between the dressing and the bag is not less than 500 ram. Once the patient is in bed, it is necessary to fix the distal end of the tube at the level of the ventricle to ensure normal drainage to the valve. The CSF flow will diminish or increase with elevation or lowering of the bag. The quantity of CSF drained is usually between 250 and 400 ml daily but it m a y v a r y from a few ml to 1000 to 2000 ml a day. Actually we are using a new technique with the Spitz-ttolter valve outside the dressing. This arrangement allows a closest control of the fluid drainage especially in cases of ventricular haemorrhage (Fig. 3).

When a normal communication between both lateral ventricles is not obvious, and if the condition of the patient is poor bilateral external drainage is established. We consider that the apparatus can be removed when monitoring of tl~e ventricular pressure over 48 hours shows normal figures in conscious patients, or when an improvement in the patient's condition is observed once the distal end of the tube is elevated so tila6 drainage is stopped for 48 hours. The removal of the tube is carried out in the patient's bed. The skin incision is closed, with a silk suture through the entire thickness of the scalp. Indications 1. Intracrania~ Turnouts

a) Preoperative drainage (97 eases) In. an unconscious patient with bilateral papilloedema and stiffness of the neck we consider it desirable to tap the ventricles and to establish drainage if the pressure is above the level previously mentioned. If normal consciousness is not regained in 24 hours we assume t h a t this is evidence of midbrain or thalamohypothalamic impairment. In a conscious patient ED is indicated only with cerebellar turnouts associated with high pressure hydrocephalus. I n patients with a cerebellopontine angle turnout we prefer internal drainage. When a turnout of the third ventricle is present the indication for ED depends on its location. Posterior tumours require internal drainage before radiotherapy on direct surgical attack once it has been proved t h a t no tumourM cells are present in the ventrieular fluid. Anterior tumours need ED (unilateral or bilateral) when tomopneumoeneephalography is required in addition to Dimer X ventrieulography (13 eases).

178

B. Pertuiset et al. :

I n stuporous patients it is our opinion t h a t hydrocephalus must be drained externally as an emergency. When a patient has an external drain radical operation is performed after two or three days. When the patient is operated upon in the sitting position it is necessary to stop the drainage two hours previously. After operation drainage is continued for 48 hours, and then the plastic bag is elevated. Drainage is discontinued 48 hours after the patient's condition has become satisfactory. If drainage is needed after the seventh postoperative day the external drain is replaced b y an internal shunt two days later. This timing is recommended as a result of experience and continuous monitoring in several eases. If the operation cannot be radical it is advised t h a t the E D is replaced b y an internal shunt. b) Postoperative drainage (7 eases) When a posterior fossa tumour, such as a medulloblastoma or an astroeytoma, cannot be removed entirely from a patient whose hydrocephalus did not require E D prior to operation we advocate postoperative drainage. I n such eases it is easier to fix the drainage set three to four hours after the patient wakes up, when the ventrieular fluid pressure has regained a normal level. This drainage is maintained for a week, t h a t is to say during the period of oedema. We think t h a t this preventive regime is far better than regular tapping of the ventricles after operation. 2. Subarachnoid Haemorrhage (47 Cases) I t has been shown t h a t hydrocephalus with increased ventrieular pressure can develop rapidly after subarachnoid haemorrhage (SAH) especially when it is due to aneurysmal rupture. This is why, during the last three years we have routinely tapped the ventricles of all patients suffering from SAH and admitted within the first week after the haemorrhage. I n these cases external drainage was used when the ventricular pressure was over 120 m m H20. This level has been chosen because the hydrocephalus is acute and a rapid increase in the pressure to 120 m m is more dangerous than a slow increase to 200 ram. Once E D has been established it has been inspected frequently because small clots can stop CSF flow. Some neurosurgeons prefer in such cases to use drains without valves. We think t h a t the regulation of drainage through a valve is safer, but we agree t h a t a simplified valve might be efficient and cheaper. Experience has taught us that when E D was necessary before operation the hydrocephalus often persists after radical cure of the aneurysm. This is why, in such cases, we perform an internal shunt at the end of the operative procedure and remove the ED. We do not recommend E D when the ventricular fluid is bright red in co]our

Temporary External Valve Drainage in Hydrocephalus

179

(nine cases). The ventricular system needs washing out before ED is established.

3. Brain Trauma (4 Cases) We have observed in post traumatic brain oedema increased ventrieular pressure without any enlargement of the ventricles on the Dimer X Ventriculograms. I n such cases EC is of no use because the ventricular cavities collapse rapidly under the pressure of brain oedema. In midbrain contusions we have not seen acute hydrocephalus.

4. In/ection (19 Cases) a) Ventrieulitis (2 eases) ED of ventricular fluid is considered to be part of the treatment of ventriculitis whatever its origin. In such eases the ED is maintained until the ventricular fluid becomes sterile and this may take up to two months. b) Hydrocephalus secondary to meningitis (10 cases) Unless the ventricular and lumbar fluids are sterile ED is necessary and is replaced by an internM shunt only after CSF has been sterile for two weeks and when the patient's condition and temperature remMn in the normal range. c) Internal shunt inlections (7 cases) Atrial and peritoneal shunts must be removed a few days after the establishment of an effective ED. A new internal shunt may be inserted two weeks after the CSF and blood have become sterile and the temperature has become normal. External drainage is discontinued, and the ED apparatus is removed a week later. In these cases ED can be used for as long as two months. Internal shunts should only be used when the ventricular fluid protein level is below 0.7 g/100 ml.

5. Acute Mal/unetion o/ an Internal Shunt (10 Cases) The ED should only be removed when the neurosurgeon is sure of the patency of the new internal shunt.

6. Cerebral Aqueduct Stenosis Hydrocephalus (21 Cases) ED was established as an emergency operation in patients admitted in poor condition with an increased ICP. These patients were thought to have posterior fossa tumours at the time of ED but Dimer X ventriculography showed aqueduct stenosis. Internal shunts were inserted.

180

B. Pertuiset et al. :

7. Pseudo Turnout Cerebri (6 Cases) ED was used after ventricular fluid pressure monitoring before the insertion of internal shunts. Results were disappointing.

External Drainage Complications 1. In/eetion o/ CSF We have observed four examples of ventricular and meningeal in~ection in 202 external drainages during the first year of our study. I n three cases the cause of the infection was the injection into the ventricular system of a contrast medium (lipiodol or Dimer X) in the neuroradiologicM department. Infection was obvious 24 hours later. One of the patients died from pyocyaneus meningitis, but the two others were cured. I n the fourth case infection resulted from disconnection of the valve from the distal catheter in a n agitated patient who had a subarachnoid haemorrhage. I n such a case it is better to replace the whole assembly. For three years now we have not encountered any infection, due to the maintenance of strict asepsis during the operation and a high standard of nursing care.

2. CSF Leakage after Removal o/ the Drainage System When the application of varnish or plastic does not help, and when the CSF is sterile, we consider this to be an indication for internal drainage.

3. Subdural Haematoma or Hygroma We have no examples of these complications in this series but recently we have onserved a subdural haematoma locMised to the frontM area on the side of the ED which had been used for 10 days after the removal of a posterior fossa hemangioblastoma. The surgeon was alerted b y a rapid decrease of the visual acuity; the subdural haematoma was seen on a carotid angiogram, and the evacuation of the blood was followed b y a rapid recovery.

4. Intraventricular Haemorrhage Blood in the external drainage fluid is an indication for the removal of the E D assembly. I n eases with this complication the ventricles have usually regained their normal sizes.

5. Culmen Herniation We have observed one case of culmen herniation in a patient suffering from midbrain haemorrhage. The herniation was obvious on the preoperative vertebral angiogram and therefore was not a result of ED.

Temporary External Valve Drainage in Hydrocephalus

181

References

Ix~graham, F . D . , Campbell, J . B . , An apparatus for closed drainage of the ventricular system. Ann. Surg. 11~ (1941), 1096--1098. Miller, J. D., Leech, P., Effects of mannitol and steroid therapy on intracranial volume pressure relationships in patients. J. Neurosurg. 42 (1975), 274--281. Pertuiset, B., Houtteville, J. P., George, B., Margent, P., Dilatation ventrieulaire pr~coce et hydroc6phalie secondaire aux ruptures des angvrysmes art6riels sus tentoriels (diagnostic, mgeanisme et traitement). Neurochirurgia 15 (1972), 113--126. White, 1~. J., Dakter, S. J., Young, H., Yashon, D., Verdura, J., Albin, M. S., Continuous control of CSF volume and pressure with an externalized valve-drainage system. Trans. Am. Soe. artif, intern. Organs 13 (1967), 332--333. Authors' address: Prof. Dr. B. Pertuiset, Dr. i~. van Effenterre, and Dr. Y. Horn, Clinique Neuroehirurgieale, HSpita] de la Piti6, F-15 Paris 13 e, France.

Temporary external valve drainage in hydrocephalus with increased ventricular fluid pressure. (Experiences with 202 cases). (Experiences with 202 cases).

Acta Neuroehirurgica 33, 173--181 (1976) 9 by Springer-Verlag 1976 Clinique Neuroehirurgieale - - t-I6pital de la Piti6, Paris, France Temporary Ext...
981KB Sizes 0 Downloads 0 Views