Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
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In 14 children with indwelling ventriculoatrial or ventriculoperitoneal shunts, the need for continued shunt treatment was judged to be uncertain based on clinical symptoms and signs and CT scans. Ventricular outflow resistance (R0) was determined by implantation of a ventricular catheter and steady state infusion of artificial cerebrospinal fluid (CSF) according to the formula R0 = (Pp - P0)/Infusion rate, where P0 is the opening pressure in the lateral ventricle and Pp the plateau pressure recorded at that particular infusion rate. R0 was determined during general anesthesia and steady state ventilation was ensured by mechanical ventilator. ⋯ Seven children demonstrated increased R0 values even after shunt unclamping. Their shunts were replaced, and clinical improvement has been observed in 6 of them. Ventricular infusion tests appear useful to evaluate shunt dependence and function in difficult cases.
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An 8-year-old girl developed mutism after removal of a vermian medulloblastoma. The mutism was not accompanied by long tract signs or cranial nerve palsy. The girl started to regain her speech 2 weeks postoperatively, showing marked improvement 2 months after the operation, after passing through a dysarthric phase. ⋯ In all patients the recovery of speech started to appear 4 days to 4 months postoperatively, and all patients passed through a monotonous, dysarthric phase. The absence of long tract or other brain stem signs, together with the presence of dysarthria during the recovery of speech, suggested a cerebellar cause of the transient mutism. Various hypotheses advanced to explain the pathogenesis of this speech disorder are analyzed.
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If the cerebrospinal fluid (CSF) is considered to be all the fluid (liquid), other than blood or the derivatives of its breakdown, that is normally contained within the brain, its cavities, and its spaces, this could be regarded as "brain fluid" in its most elemental form. "Pathological increases in intracranial CSF volume, independent of hydrostatic or barometric pressure", then, could be considered a definition of hydrocephalus. The observation of significant episodic variation in intracranial pressure (ICP) suggests the necessity of substituting the concept of "time-related pressure variations" for the older one of "level of pressure" in patients with defective ICP control mechanisms. It has been assumed that the subarachnoid channels are the first CSF compartment to dilate in response to the hydrocephalic process, reducing the CSF pressure and thereby establishing an equilibrium. ⋯ Thus, it becomes obvious that the term internal hydrocephalus is of little significance, since increases in intraparenchymal fluid--cerebral edema--cause the same volumetric changes as increases in intraventricular fluid volume. I suggest that hydrocephalus is a pathologic increase in intracranial CSF ("brain fluid") volume, whether intra- or extraparenchymal, independent of hydrostatic or barometric pressure. It may be classified as (1) intraparenchymal (cerebral edema) and (2) extraparenchymal, with the extraparenchymal types subclassified into subarachnoid, cisternal, and intraventricular forms.
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Comparative Study
Intracranial pressure monitoring in children: comparison of external ventricular device with the fiberoptic system.
Several intracranial pressure monitoring devices have been developed in the past several years. We have recently adopted the Camino fiberoptic device that permits subdural, intraparenchymal, and intraventricular monitoring. In this report we compare experiences in monitoring a group of pediatric patients with severe craniocerebral trauma and coma, grouped according to severity of Glasgow Coma Scale score. ⋯ The study demonstrated that the fiberoptic device and the ventricular catheter have the same accuracy and reliability. The fiberoptic method correlates very closely with the ventriculostomy method, but the pressure values are always 3 +/- 2 mmHg lower than those obtained with the conventional pressure transducer system, especially in more critically ill patients. This new technique is also easier to implant, safer to use, has minimal drift, and is minimally invasive, which particularly speaks for its use in pediatric patients.
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Ventriculoperitoneal shunts are the most common procedure for the treatment of hydrocephalus. Ventriculoatrial shunts are effective but are subject to a higher incidence of potentially serious complications. ⋯ Ventriculo-gallbladder shunts are safe, effective, and technically easy to perform. We recommend their use when ventriculoperitoneal shunts have failed or the peritoneal cavity is not adequate for shunting.