Aqueductal obstruction has been an interesting entity among hydrocephalic patients because of its possible permanent cure by interventriculostomy alone,-eliminating the need of -external shunt problem.
Recently we have experienced four; such-cases as. following.
Case 1: A 21 years old female was admitted due to headache and deteriorating visual acuity.
Positive neurolWic findings were bilateral papilledema and - rapidly deteriorating visual acuity.
Conray ventriculogram revealed bilateral symmetrical hydrocephalus with obstruction at the distal portion of the aqueduct.
Suboccipital craniectomy was performed. Cisterna magna and fourth ventricle were dried.
With 3.5 cm upwards advancementt of Nelaton tube from the orbex, resistence was felt.
And with further advancement, giving sensation of membrane rupture was felt. We confirmed good passage of C.S.F. and closed without the tube remained.
The patient was discharged two weeks later with much improvement clinically.
Case 2: A 20 years old male was admitted due to sudden onset of coma.
Positive neurologic findings were bilaterally dilated pupil, increased DTRs, and positive toe signs..
Conray ventriculogram revealed marked hydrocephalic pattern with cupping like obstruction at the distal portion of the cerebral aquedct.
Operative findings were the same as in case 1, but rubber catheter was remained in the cerebral aqueduct.
Post-operative course revealed high fever due to pneumonia, but much clinical improvement was achieved until discharge.
Case 3: A 6 years old girl was admitted due to unsteady gait and headache. Neurologic
findings were bilateral papilledema, hyperactive DTRs, -positive toe signs and generally disturbed cerebellar function.
Radiologic and surgical findings were the same as in case 1, but a tube was remained´ in situ. Post-operative state revealed satisfactory.
Case 4: A 14 years old boy was admitted due to headache and unsteady gait. Positive neurologic findings were hyperactive DTRs, positive toe signs and disturbed lt. cerebellar function.
Conray ventriculogram revealed marked hydrocephalus and obstruction at the mid-portion of aqueduct. Proximal aqueduct was markedly dilated. Suboccipital craniectomy was performed, when 3.7 cm adavancement of the tube, resistance was felt, but giving sensation,of membrane rupture was not felt. So the tube was remained in situ.
Post-operative state revealed drowsy consiousness, right lateral gaze palsy and transient C. S. F. leakage.
Surgical mortality was zero, and the complications of case 4 were supposed due to inadequate placement of the tube.
From these, we feel that simple membraneous puncture without catheter tube placement may be better if surgeon feels the giving sensation of membrane puncture when the tube advancement to make C. S. F. passage. Otherwise, the catheter may be well left in situ.
|