Hydrocephalus of the brain in an adult: causes, symptoms, consequences. Treatment in Moscow

Hydrocephalus is an excessive accumulation of cerebrospinal fluid in the cranial cavity, which results in an increase in the size of the subarachnoid spaces, basal cisterns, and ventricles of the brain. All conditions have been created for the treatment of patients with hydrocephalus at the Yusupov Hospital. The neurology clinic employs candidates and doctors of medical sciences, doctors of the highest category. Neurologists have the knowledge and experience to quickly diagnose the disease and provide adequate therapy.

Causes of hydrocephalus

Hydrocephalus develops due to the accumulation of cerebrospinal fluid in the cerebrospinal fluid system of the brain in the event of the production of an excess amount of cerebrospinal fluid, impaired absorption or disturbance of the circulation of cerebrospinal fluid. In case of exposure to damaging factors on the fetal brain during intrauterine development, congenital hydrocephalus occurs. Acquired hydrocephalus develops under the influence of various pathological mechanisms after the birth of a child.

The following causes of congenital hydrocephalus are known:

intrauterine infections (hydrocephalus, toxoplasmosis, cytomegaly, syphilis);
birth injury;
defects in the development of the cerebrospinal fluid system (atresia of the foramina of Magendie and Luschka, stenosis of the Sylvian aqueduct, structural defects of the subarachnoid space, Dandy-Walker syndrome);
developmental anomalies of the skull and spine (congenital basilar impression, Chiari malformation).

Acquired hydrocephalus occurs as a result of inflammatory processes of the brain and its membranes, traumatic brain injuries, acute and chronic vascular disorders. Hydrocephalus in adults often develops against the background of a colloid cyst of the third ventricle and intracerebral tumors (germinomas, astrocytomas, ganglioneuromas) growing into the ventricles of the brain or compressing the cerebrospinal fluid tract, disrupting the normal circulation of cerebrospinal fluid and its outflow from the cranial cavity.

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Liquor shunt interventions

CSF shunting is the installation of elastic silicone implant systems to remove cerebrospinal fluid outside the central nervous system. The systems are equipped with catheters in the form of flexible hollow tubes, as well as valves with an anti-siphon (reverse) mechanism and with fixed or adjustable opening pressure.

The operation can be performed in various ways. But surgeons consider ventriculoperitoneal (the most commonly used method) or ventriculoatrial shunting to be the most successful in terms of safety. Interventions are performed under endotracheal anesthesia, manipulations are controlled by intraoperative fluoroscopy, CT, and ECG.

Ventriculo-peritoneal shunt. The principle of the procedure is based on the implantation of silicone catheters, through which an excess of CBF goes into the intra-abdominal cavity, where it is resorbed between the intestinal loops.

A ventricular catheter is introduced through the created access, its end is placed in the lateral ventricle of the brain.
The valve element is implanted in the area of the auricle (at the back or slightly above). The ventricular (ventricular) and distal catheter (DC) are fixed to it.
Next, the neurosurgeon places a distal catheter into the abdominal cavity through a specially formed subcutaneous channel.
Upon reaching the desired abdominal area, the specialist makes a small incision (no more than 10 mm) and inserts the end of the DC into the abdominal cavity.
The procedure ends with thorough disinfection of the surgical field, followed by closing the wound areas with antiseptic dressings (sutures are applied if necessary).

Ventriculoatrial shunting. The essence of this operation is to divert cerebrospinal fluid through installed shunts from the ventricle of the brain into the right atrium.

Dissection of tissue in the neck along the anterior sternocleidomastoid muscle is performed to open the common facial or internal jugular vein.
The atrial catheter is removed into one of the indicated veins, fixing it with specially designed ligatures.
The shunt is directed through the catheterized vein to the right atrium. The end of the atrial shunt is generally located in the superior vena cava.
For the installation area of the distal end of the vascular catheter, yes, the superior vena cava is often preferred. Here the blood flow is turbulent, and this reduces the likelihood of thrombosis of the drainage system by blood clots.
The cranial part of the intervention, when the ventricular element of the system is implanted, a valve and two catheters are connected to it, is identical to VP shunting.

For adults, shunts are permanently implanted. In childhood, they are periodically replaced with elongated models. We emphasize that patients after surgery with shunt implantation are shunt-dependent people.

Types of hydrocephalus in adults

There are open (communicating), closed (occlusive) and replacement hydrocephalus. Open hydrocephalus of the brain in adults involves free communication of spaces through which cerebrospinal fluid circulates. It develops when there is an imbalance in production and reabsorption of cerebrospinal fluid. There are hyperproductive, aresorptive and mixed forms of hydrocephalus.

Replacement hydrocephalus can be a consequence of physiological aging of the body or develop in pathological conditions of the central nervous system, accompanied by atrophic changes (Alzheimer's disease, Creutzfeldt-Jakob disease). This form of the disease does not refer to true hydrocephalus, caused by impaired cerebrospinal fluid dynamics, but occurs as a result of the filling of “free” spaces inside the skull with cerebrospinal fluid.

In accordance with the location of the expanded cerebrospinal fluid spaces in relation to the brain tissue, the following types of hydrocephalus in adults are distinguished: internal (intraventricular), external (subarachnoid) and mixed. Depending on the level of intracranial hydrocephalus, hypertensive and normotensive hydrocephalus are distinguished. In functional and clinical aspects, progressive (increasing), stabilized (not changing over time) and regressive (decreasing) hydrocephalus are distinguished. Progressive hydrocephalus can be decompensated or subcompensated.

In acute hydrocephalus, no more than three days pass from the moment of the first symptoms of the disease to severe decompensation. Subacute progressive hydrocephalus develops within one month from the onset of the disease, and chronic hydrocephalus develops within a period of 3 weeks to 6 months.

Preparatory activities

Bypass surgery in the head requires preparation. The doctor prescribes a comprehensive diagnostic examination, which allows you to confirm the diagnosis and identify possible contraindications to surgery. Instrumental studies include MRI of the head, electrocardiogram, ultrasound of the abdominal cavity, and chest x-ray. The patient is given a blood test. It is necessary to take a urine test.

During a planned operation to bypass the cerebral arteries, studies of the circulatory system of the brain are carried out - angiography, Dopplerography, duplex scanning. Photos of intracranial structures allow you to accurately confirm or refute the alleged diagnosis, as well as determine the area of the upcoming surgical intervention. The process of preparing for surgery involves removing hair from the surface of the head in the area where the incision is planned to be made.

Symptoms of hydrocephalus in an adult

The accumulation of an excess amount of cerebrospinal fluid in a limited space of the cranium leads to an increase in intracranial pressure, which causes the most typical signs of hydrocephalus: intense headache that cannot be relieved by analgesics, nausea and vomiting, a feeling of pressure on the eyeballs.

These symptoms of hydrocephalus in an adult patient can occur acutely or increase gradually, having a transient nature at the onset of the disease. Replacement hydrocephalus often occurs without signs of increased intracranial pressure. Neurologists at the Yusupov Hospital detect it only after additional examination of the patient. Hydrocephalus of the brain in an adult in the photo has characteristic signs: an increase in the volume of the head and frontal bone.

In most cases, hydrocephalus in adults is accompanied by neurological symptoms. It is caused both by compression of brain structures by expanded cerebrospinal fluid spaces and by the underlying disease, which is the cause of the development of hydrocephalus. With hydrocephalus, vestibular disorders are observed: gait instability, dizziness, noise in the ears and head, nystagmus. Visual function is impaired: there is a significant decrease in visual acuity and loss of certain areas of the visual field. During ophthalmoscopy, ophthalmologists identify congested optic discs. With prolonged hydrocephalus, atrophy of the optic nerves develops.

Hydrocephalus in adults can occur with disturbances in the motor and sensory spheres:

paresis and paralysis;
decrease or complete loss of all types of sensitivity;
increased tendon reflexes and muscle tone;
formation of spastic contractures of the limbs.

Occlusive hydrocephalus, caused by impaired circulation of cerebrospinal fluid in the posterior cranial fossa, is characterized by symptoms of cerebellar ataxia: changes in handwriting, large-scale disproportionate movements, impaired gait and coordination.

Patients suffering from hydrocephalus develop mental disorders over time, manifested by disorders of the emotional-volitional sphere: neurasthenia, emotional instability, causeless euphoria with a rapid transition to a state of apathy. With a sharp increase in liquor pressure, patients begin to behave aggressively.

Rehabilitation after carotid artery surgery

After successful restoration of the course and shape of the carotid artery, the patient usually notes a significant improvement in general condition. In most cases, the complaints that occurred before the operation go away. The scar on the neck and the presence of areas of reduced sensitivity in the area of the postoperative scar may cause concern. To prevent the formation of a rough scar, surgeons at our clinic use an intradermal suture, and they try to place the incision itself in a skin fold. In the first month after surgery, it is necessary to treat the postoperative scar area with Contratubeks ointment. Control examinations after resection of pathological tortuosity are carried out after 6 months and include mandatory ultrasound examinations of the reconstructed arteries. After a correctly performed operation, no relapses or problems with the patency of the restored carotid artery were observed.

Diagnosis of hydrocephalus

Neurologists at the Yusupov Hospital conduct a comprehensive examination of patients with hydrocephalus. Computed tomography currently occupies a dominant position among methods for diagnosing hydrocephalus. The procedure is carried out to determine the size and shape of the ventricles, identify developmental anomalies and neoplasms, cysts.

Magnetic resonance imaging allows you to determine the shape and severity of hydrocephalus. Using this diagnostic method, the cause of cerebral hydrocele is determined. Neurosonography helps assess the degree of expansion of the ventricles of the brain. The procedure is used only when diagnosing the disease in children with an open fontanelle, since the skull blocks ultrasound. Neurosonography is used to diagnose hydrocephalus in utero.

Cisternography is a research method in which a radioactive substance is injected into the cerebrospinal fluid. It is used to clarify the type of hydrocephalus and determine the direction of cerebrospinal fluid flow. During an angiography, a contrast agent is injected into the arteries that supply blood to the brain. After some time, anomalies at the level of blood vessels and pathological processes are detected. Doctors at the Yusupov Hospital use innovative methods for diagnosing cerebral vascular diseases - magnetic resonance angiography, which does not require the administration of contrast agents. A neuropsychological examination involves conducting a survey to identify abnormalities in the functioning of the brain.

Operation options

Redressing the internal carotid artery - the operation involves isolating the artery from the adhesions, straightening all bends and fixing the artery to the surrounding tissues in a straightened position.

Resection of a tortuous carotid artery with end-to-end anastomosis - this option involves isolating a loop, excision of the altered area and suturing the artery end-to-end. This option is used when the loop is located high from the mouth of the internal carotid artery and with the same diameters of the efferent and adductor ends of the artery.

Resection with redressing of the internal carotid artery is performed when the bends are located near the mouth of the carotid artery. The artery is cut off from the common carotid artery, after which the excess is resected and the artery is sutured to its old place.

Resection of pathological tortuosity with prosthetics of the carotid artery - the tortuous area is excised, and an artificial vessel or the own saphenous vein is sewn in place of this area. This type of operation is used when there is a sharp change in the arterial wall, or when tortuosity is combined with severe atherosclerosis of the artery.

Treatment of hydrocephalus

Neurologists at the Yusupov Hospital take a differentiated approach to treating patients with hydrocephalus. In case of a regressed form of the disease, drug therapy is not used. To reduce cerebrospinal fluid pressure, patients are prescribed diuretics: Diacarb, mannitol, Lasix. Nootropics, venotonics and angioprotectors improve the functional activity of the brain.

For progressive hydrocephalus, neurosurgeons at partner clinics of the Yusupov Hospital perform shunt operations. If there is an obstacle to the outflow of cerebrospinal fluid, the space-occupying lesion is removed or the adhesions are cut. If a hematoma is present, it is removed surgically.

An innovative method of treating hydrocephalus is endoscopic surgery:

endoscopic ventriculocisternostomy of the bottom of the third ventricle;
endoscopic installation of a shunt system;
septostomy;
aqueductoplasty;
ventriculocystocysternostomy;
endoscopic removal of intraventricular brain tumor.

Endoscopic operations have a number of advantages compared to bypass interventions: they restore the physiological flow of cerebrospinal fluid, are less traumatic, and improve the patient’s quality of life.

Treatment with endoscopic methods

Endoscopic treatment of hydrocephalus, or dropsy of the brain, is a priority in neurosurgery, since this disease is common among both children and adults. Hydrocephalus of the brain occurs due to impaired absorption of cerebrospinal fluid into the venous system.

Endoscopic surgery

Endoscopic interventions for hydrocephalus of the brain are used to reduce intracranial pressure. Surgeries for dropsy are most effective in comparison with drug therapies, which help slow the progression of the disease, but do not eliminate it. Endoscopic surgery for hydrocephalus, the cost of treatment of which is determined by the severity of the disease, is divided into several types:

Septostomy;
Ventriculocisternostomy of the floor of the third ventricle;
Ventriculocisternostomy;
Installation of the shunt system endoscopically;
Removal of intraventricular tumors endoscopically;
Aqueductoplasty.

The most widely used is endoscopic ventriculocisternostomy of the bottom of the third ventricle. The main task of the surgeon with this technique is to create pathways for the outflow of cerebrospinal fluid from the ventricles into the cisterns of the brain, through which the cerebrospinal fluid is absorbed into the vascular walls, as in a healthy person.

Advantages of endoscopic operations

Endoscopic surgery can only be effective if it is performed by a good specialist. One wrong move by the surgeon during brain surgery can lead to irreparable, severe consequences. When shunts are installed, they are often blocked by blood clots, tumor cells, etc. During endoscopy, no foreign objects remain in the body, and accordingly, the development of such complications is excluded.

In severe cases, patients are given brain drains. Such an event is very dangerous, since the infection can easily penetrate the brain through the drainage. With endoscopic intervention this complication does not occur.

Bypass surgery

Many people who have been diagnosed with the disease wonder where to treat hydrocephalus: in a public medical institution or a modern clinic. Yusupov Hospital is equipped with the latest equipment. Doctors regularly improve their skills and master new treatment methods. The clinic staff ensures a comfortable stay for patients.

Shunt surgery for hydrocephalus in adults, the price of which varies depending on the characteristics of the disease, is performed safely and efficiently at the Yusupov Hospital. Installation of a shunt system ensures the removal of cerebrospinal fluid. The procedure lasts about 90 minutes and is performed under general anesthesia for patients of any age.

Bypass surgery is a safe intervention, but there are certain risks when using it, which the neurologist informs the patient about. For example, a reaction to anesthesia or bleeding may develop. Shunt surgery allows the patient to restore normal brain function.

Possible complications

According to the literature, the following complications are possible after surgery on the carotid artery:

Bleeding from the surgical site is a very rare complication, occurring in no more than 0.2% of all operations. If detected in a timely manner, the wound is opened, the source of bleeding is identified and it is finally stopped.
Postoperative ischemic stroke - after surgery for pathological tortuosity is quite rare, not more than 1% of all surgical cases. Most often associated with thrombosis of the reconstructed carotid artery. If a cerebral circulatory disorder is detected in a timely manner, repeated surgery to remove the blood clot can restore cerebral blood flow.
Damage to the recurrent or hypoglossal nerve. When the recurrent nerve is injured, hoarseness occurs. The recurrent nerve may be damaged by stretching the wound during access or accidentally cut. In the first case, the voice disorder will be reversible, in the other case it will be permanent. If the hypoglossal nerve is damaged, the tongue deviates to the side and choking occurs when eating liquid food. The only way to prevent these complications is an impeccable technique for operating the carotid arteries. In our clinical practice, such complications were not encountered.
Suppuration of a postoperative wound is an extremely rare complication that can develop in patients with chronic purulent processes in the lungs and mediastinum and weakened immunity. We have not encountered this in our practice.

Blockage

The main type of complication is blockage of the system. Blockages can occur at any level of drainage. The holes in the ventricular catheter may become clogged with brain tissue or villous plexus tissue. It can also be blocked due to excessive contraction of the ventricular cavity due to too intense drainage of fluid from the ventricular cavity (constricted ventricle syndrome). Intestinal loops or necrotic tissue may adhere to the peritoneal catheter. Shunts inserted into a ventricle of the heart can become blocked by blood clots, pieces of brain matter, or tumor cells.

The shunt system may also be disconnected by disconnection of various elements of the shunt or by changes in the position of the catheter caused by the growth of the child. X-rays are necessary to check the integrity of the shunt.

Partial blockage of the system parts provokes the appearance of symptoms of increased intracranial pressure. Episodic headaches, nausea, apathy and decreased sensory functions may occur. Decreased performance at school or at work is the most common phenomenon in these conditions.

In case of complete blockage, symptoms develop more quickly (headaches, nausea, vomiting, blurred vision, loss of coordination and confusion). The patient falls into a stupor or coma. In such cases, urgent hospitalization is necessary for observation and appropriate treatment.

The surgeon performs a series of tests to locate and determine the extent of drainage blockage. Sometimes it is necessary to remove and replace part or all of the system.

Excessive drainage

Excessive drainage of cerebrospinal fluid occurs when the valve is incorrectly selected according to the pressure parameter. If the valve opening pressure is too low, it can cause excessive drainage, causing the cerebral ventricle to compress and deforming the brain tissue. The patient experiences headaches that are most severe when standing.

In addition, nausea, vomiting, drowsiness and nervous system disorders, in particular double vision, appear. School-age children experience a decline in mental abilities.

Anatomy and physiology

In order to better know and understand the disease, we will give you some information about the anatomy of the skull, the structure of the brain, as well as the process of formation and absorption of cerebrospinal fluid (Fig. 1). The brain occupies most of the cranial cavity. It is penetrated by a large number of blood vessels and is surrounded by cerebrospinal fluid as a buffer. The fluid is located in 4 cavities (ventricles) located inside the brain. The ventricles have delicate structures known as villous plexuses (choroid plexuses). These structures produce a significant amount of CSF - about 500 ml per day. The fluid circulates continuously and contains a large number of substances essential for nutrition and ensuring the normal functioning of the nervous system.

CSF also provides a protective cushion for the brain. CSF circulates in the ventricular system and is removed through 3 holes in the 4th ventricle and then enters the subarachnoid space surrounding the brain and spinal cord.

CSF constantly circulates in the brain and spinal cord, constantly being in the process of a) formation, b) circulation and c) absorption. In a healthy body these processes are balanced. Hydrocephalus develops if CSF is not cleared from the ventricular system through the cerebrospinal fluid tract. Less commonly, hydrocephalus is caused by excess production of CSF, such as with villous plexus papilloma.