Changes in cerebrospinal fluid hydrodynamics following endoscopic third ventriculostomy for shunt-dependent noncommunicating hydrocephalus

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Object. The aim of this study was to analyze physiological changes in cerebrospinal fluid (CSF) dynamics following endoscopic third ventriculostomy (ETV) for shunt-dependent noncommunicating hydrocephalus.

Methods. Clinical data obtained in 15 patients treated with ETV for shunt malfunction were analyzed. Magnetic resonance imaging studies demonstrated the obstruction of the ventricular system preoperatively. After ETV, the existing shunt system was removed and a continuous extraventricular drain, set at 30 cm H2O in height, was installed to measure daily amounts of CSF outflow. Cerebrospinal fluid dynamics after ETV were also evaluated using 111In-diethylenetriamine pentaacetic acid radioisotope cisternography in six of 15 patients within 1 month of the procedure. Three patients underwent cisternography at 6 months after ETV. Cisternograms were obtained at 1, 5, 24, and 48 hours after injection of the radioisotope. To study CSF absorptive capacity, ratios of radioisotope counts at 48 and 5 hours after injection were calculated (C48:C5). Seven of 15 patients had daily outflows of CSF of less than 20 ml; this volume decreased quickly within a few days. The other eight patients demonstrated an outflow of more than 150 ml of CSF for several days, three of whom had signs of transiently increased intracranial pressure. Their CSF outflow volume decreased gradually and symptoms improved within 1 week. Ratios of C48:C5 were within normal limits in five of six patients who had undergone cisternography 1 month after ETV. These ratios were decreased in all three patients who had undergone cisternography at 6 months after ETV compared with that measured at 1 month after the procedure.

Conclusions. Our data suggest that CSF dynamics convert from a shunt-dependent state to a shunt-independent state within 1 week following ETV in patients with shunt-dependent noncommunicating hydrocephalus. Nonetheless, intraventricular pressure does not decrease quickly in certain cases. Cerebrospinal fluid absorptive capacity or CSF circulation through the subarachnoid space may show further improvement several months after ETV.

Article Information

Address reprint requests to: Kenichi Nishiyama, M.D., Department of Neurosurgery, Brain Research Institute, Niigata University, 1 Asahimachi, Niigata, 951 Japan. email: nishiken@d4.dion.ne.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph demonstrating the daily amount of CSF from continuous external ventricular drainage (EVD). Patients were categorized according to their experience of a quick volume decrease or a gradual volume decrease during the 1st week post-ETV.

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    Graph depicting the results of a comparative analysis between the duration of shunt dependency and duration of EVD after ETV. These factors were not statistically correlated.

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    Graph depicting the results of a comparative analysis between patient age at first shunt placement and duration of EVD after ETV. These factors were not statistically correlated.

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    Graph illustrating C48:C5 ratios of radioisotope counts.

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    Radioisotope images obtained 1 week and 6 months after ETV in a patient with congenital aqueductal stenosis, demonstrating changes in radioisotope activity.

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