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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 254-255

Subdural collections complicating third ventriculostomy: Over-drainage or failure of ventriculostomy?


Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Submission12-Jan-2012
Date of Decision18-Mar-2012
Date of Acceptance28-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
Pravin Salunke
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96433

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How to cite this article:
Salunke P, Savardekar A, Chhabra R, Mathuriya SN. Subdural collections complicating third ventriculostomy: Over-drainage or failure of ventriculostomy?. Neurol India 2012;60:254-5

How to cite this URL:
Salunke P, Savardekar A, Chhabra R, Mathuriya SN. Subdural collections complicating third ventriculostomy: Over-drainage or failure of ventriculostomy?. Neurol India [serial online] 2012 [cited 2021 Sep 20];60:254-5. Available from: https://www.neurologyindia.com/text.asp?2012/60/2/254/96433


Sir,

Chronic subdural collection following third ventriculostomy has been attributed to over-drainage. [1],[2] However, the following cases illustrate that on occasions they may represent non-functioning ventrinulostomy rather than over-drainage.

Case 1: A six-month-old child underwent endoscopic ventriculostomy for congenital obstructive hydrocephalus. Postoperative computed tomography (CT) head showed mild decrease in the size of ventricles. A month later the child presented with a bulge at the operative site and CT revealed an ipsilateral subdural collection with midline shift. The subdural collection was tapped and clear fluid was drained. A contralateral medium-pressure ventrciulo-peritoneal (VP) shunt was done with which there was resolution of subdural collection and hydrocephalus [Figure 1].
Figure 1: Day 0- the axial MRI images of a 4-month-old child showing enlarged ventricles. Day 1-CT images following endoscopic third ventriculostomy. The tract of endoscopy is seen in the right frontal lobe. Day 30- CT image of the same child, a month after the endoscopic third ventriculostomy showing right-sided subdural collection with mass effect. Day 40- CT image of the same child after shunt showing resolution of the subdural collection

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Case 2: A 45-year-old male presented with subarachnoid hemorrhage with intra-ventricular hemorrhage due to ruptured anterior communicating artery aneurysm. Patient underwent left transsylvian clipping of aneurysm and opening of lamina terminalis and was discharged in a conscious state, with mild left lower limb paresis. Postoperative imaging was unremarkable [Figure 2]. Two months later he presented with gradual worsening of left lower limb paresis, memory disturbances and urinary incontinence. CT head showed mild increase in ventricular size with a significant right subdural collection with mass effect. With a presumptive diagnosis of right chronic subdural hematoma, patient underwent a right fronto-parietal burr hole and evacuation of xanthochromic fluid. There was no clinical improvement and serial postoperative CT head showed pneumo-ventricle and re-collection of subdural fluid [Figure 2]. A left VP shunt (medium pressure) surgery led to resolution of symptoms within three months and follow-up CT scan showed resolution of subdural collection and reduction in ventricular size [Figure 2].
Figure 2: Day 0- Immediate postoperative CT scan of a patient operated through the left peritoneal approach for subarachnoid hemorrhage and intraventricular hemorrhage due to anterior communicating artery aneurysm bleed. The lamina terminalis was opened as evident by the pneumoventricle. Day 60-CT scan of the same patient, two months later showing left subdural collection with mass effect. Day 61- CT following tapping of subdural collection that showed pneumoventricle. Day 65- CT after VP shunt showing resolution of hydrocephalus, subdural collection and mass effect

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Chronic subdural collections following endoscopic third ventriculostomy (ETV) can be hematoma or hygroma. The hematoma may be caused by rupture of subdural veins due to sudden decompression. Rarely, cerebrospinal fluid (CSF) collection is seen in the subdural space following ETV and more commonly with aneurysm surgeries, the majority of them regressing spontaneously. [3],[4] At times, these collections may increase a few weeks after the procedure, giving rise to mass effect. Such collections as a complication of third ventriculostomy have been attributed to over-drainage. Abrupt changes of intracranial pressure in a short period of time, in patients suffering from chronic longstanding intracranial pressure, interfere with the CSF regulation system and lead to development of subdural hematoma. [1],[5] Besides, abrupt drainage of CSF during ETV may create a large space between the dura and the brain enabling the development of subdural or epidural fluid collections. [5] The CSF absorption rate does not increase as rapidly as the increases in CSF volume in the subarachnoid space following ETV, resulting in these collections. [1] Traumatic rupture of the arachnoid due to sudden decompression of ventricles serves a valvular function between the low-pressure subdural space and high-pressure subarachnoid space, leading to subdural CSF collections. [1] CSF collection in subarachnoid/subdural space that progressively increases may actually suggest failure of the ventriculostomy. If it were due to over-drainage in our patients, it would have disappeared with time or would remain asymptomatic. In our first patient, CSF would have tracked along the endoscopy tract into the subdural space which suggests resistance at the level of stoma. Jung et al., [4] have suggested blocking the coritcotomy site with fibrin glue and gelfoam and have shown reduction in the incidence of subdural collections following surgery for ventricular lesion. In our second patient, CSF under pressure in the ventricles leaked through the opened lamina terminalis and the dissected right sylvian fissure into the right subdural space and due to poor absorption resulted in a collection. Both the patients suggest failure of ventriculostomy, either at the stoma or at the site of absorption. Hence, the hydrocephalus masqueraded as chronic subdural collection with increasing mass effect. Had our hypothesis been wrong, VP shunt in our patients would have accentuated the over-drainage.

In our patients subduro-peritoneal shunt was not considered because of: (a) higher chance of blockade after expansion of parenchyma with obliteration of the subdural space; (b) the unregulated drainage; and (c) the basic pathology of the hydrocephalus would have been untreated. The nature of subdural collection is a clue for the underlying etiology. Symptomatic chronic subdural CSF collections following third ventriculostomy may represent a non-functioning ventriculostomy rather than over-drainage. On the other hand, the collections following overdrainage may have chronic blood.

 
  References Top

1.Kim BS, Jallo GI, Kothbauer K, Abbott IR. Chronic subdural hematoma as a complication of endoscopic third ventriculostomy. Surg Neurol 2004;62:64-8.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Sgaramella E, Castelli G, Sotgiu S. Chronic subdural collection after endoscopic third ventriculostomy. Acta Neurochir (Wein) 2004;146:529-30.  Back to cited text no. 2
    
3.Bouras T, Sgouros S. Complications of endoscopic third ventriculostomy. J Neurosurg Pediatr 2011;7:643-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Jung TY, Jung S, Jin SG, Jin YH, Kim IY, Kang SS, et al. Prevention of postoperative subdural fluid collections following transcortical transventricular approach. Surg Neurol 2007;68:172-6.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Beni-Adani L, Siomin V, Segev Y, Beni S, Constantini S. Increasing chronic subdural hematoma after endoscopic III ventriculostomy. Childs Nerv Syst 2000;16:402-5.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  


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