Treatment of hydrocephalus at the Wessex Neurological

Centre

Mr Ryan WatersPhD FRCS (Neuro Surg)

Consultant Neurosurgeon

Philosophy• To provide the highest quality service

– Outcomes– Patient experience

• Collaborative approach– Network partnerships with;

• Our referring Trusts• Oxford Children’s Hospital (Children’s Hospital Network)

– Third largest unit in the UK

Southampton Staff• Owen Sparrow• Nijaguna Mathad• Aabir Chakraborty• Ryan Waters• Christine Ward (Nurse practitioner)• 13 Paediatric Neurosciences nurses• Peter Gladwell (Surgical Practitioner)

Hydrocephalus• “An abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain”• but not the whole story?

Classification• Non-communicating/obstructive

– CSF flow obstruction

– Aqueduct stenosis– Tumour– Haemorrhage

• Communicating– Absorption problem

– Haemorrhage– Infection– Tumour– Inflammation

– ‘normal pressure hydrocephalus’– IIH

Common causes of hydrocephalus

Causes

Post head injury

Tumour

Patient Assessment-History & Examination

Is the child Unwell?

VomitingDrowsinessHeadachesSchool

performanceHead

circumferenceFontanelleBradycardia/

apnoeasSquintSunsetting

Treatment options• Treat the underlying cause• Temporary CSF drainage

– Lumbar puncture– Ventricular tap– EVD

• Endoscopic IIIrd ventriculostomy• Shunt

– VP– VA– VPleural

ETV

Shunt

Shunt hardware

Proximal and Distal Tubing Selection

Antibiotic impregnated catheters

Bactiseal

Silverline

More than 20 studies on Bactiseal

Some evidence that Bactiseal reduces shunt infections

Need for a multicentre randomised controlled study - BASICS

Shunt Blockage

Southampton Children's Hospital

Shunt Malfunction

Shunt Disconnection

Southampton Children's Hospital

Southampton Children's Hospital

Diagnostic Shunt Tap

• Aseptic Technique• Measure Opening

Pressure• If Possible Remove

Adequate Volume of CSF

• Send Specimens to Chem, Micro & Culture

NB Facilitated by System with

ReservoirSouthampton Children's Hospital

Normal Pressure Hydrocephalus• Generally seen in older adults• Communicating hydrocephalus

• Clinical triad– Cognitive decline– Gait disturbance– Urinary incontinence

• Ventriculomegaly on imaging

Investigation at WNC• MDT with neurology, neuropsychology, neurosurgery

• Assessment– Neuropsychology– Walking test– CSF infusion test– CSF drainage

Treatment at WNC• VP shunt

– Programmable valve– Risk of overdrainage and subdural formation

Idiopathic Intracranial Hypertension• Not ‘hydrocephalus’ but often treated with a shunt

– A venous disorder• Multidisciplinary approach; neurology, neurosurgery and neuroradiology

– Venography, manometry and stenting where possible

– but shunts still used to control ICP