Acute two-compartment low pressure hydrocephalus—a case report

Abstract

A case of an 8-year-old-boy with shunt-dependent occlusive hydrocephalus after resection of a cerebellar medulloblastoma is presented, who experienced repeated episodes of severe neurologic deterioration with signs and symptoms of raised intracranial pressure after spinal tapping. However, intracranial pressure was recorded within low ranges, only up to the opening pressure of the implanted adjustable shunt valve. Multiple shunt revisions were performed, until the condition was recognized as acute normal pressure hydrocephalus. Either enforced recumbency and downadjustment of the valve system to 0 cm H(2)O alone or external ventricular drainage seems to be successful to resolve the critical condition, depending on severity of the symptoms. The case illustrates that acute pathologic enlargement of the ventricular system is not always associated with increased intracranial pressure, even when typical signs and symptoms are present. The very rare entity of acute normal pressure hydrocephalus by two separated compartments is postulated based on the pulsatile vector force theory of brain water circulation.

Low-Pressure Hydrocephalus and Shunt Malfunction Following a Lumbar Puncture in an Adult Reversed by an Epidural Blood Patch

“…7 LPH may either occur spontaneously or as a result of CSF egress from the skull base, spinal intradural procedures, or lumbar punctures. [2][3][4][5]10,11 Patients usually present with symptoms similar to those seen in the more prevalent high-pressure hydrocephalus. Headaches, nausea, cranial neuropathies, disturbances in mental status, and decreased consciousness are often seen.…”

“…Many patients have a less than effective communication between the subarachnoid, ventricular, and spinal compartments. [5][6][7] The drop in ICP following a lumbar puncture is considerably smaller in those patients with a block at the cisterna magna, since the amount of CSF that actually passes through the obstruction is negligible. 18 Barami et al 19 studied the pressure volume index in 20 shunted patients with hydrocephalus and demonstrated that the shift of cerebral subarachnoid CSF into the spinal canal is too small to account for the necessary drop in ICP needed to modify the CSF to venous pressures relationships.…”

“… 7 LPH may either occur spontaneously or as a result of CSF egress from the skull base, spinal intradural procedures, or lumbar punctures. 2 , 3 , 4 , 5 , 10 , 11 …”

“…Subsequently, several case series of shunted patients with LPH occurring either spontaneously or following cerebrospinal fluid (CSF) loss were published. [2][3][4][5][6][7] Egress of cerebral subarachnoid CSF from the lumbar theca with a subsequent decrease in ICP has been suggested as the cause of post-lumbar punctures LPH. 4 More recently, the hypothesis that cerebral venous overdrainage plays a major role in the pathogenesis of LPH has emerged, 8 although its connection to spinal CSF loss has not been contemplated yet.…”

“…Subsequently, several case series of shunted patients with LPH occurring either spontaneously or following cerebrospinal fluid (CSF) loss were published. 2 , 3 , 4 , 5 , 6 , 7 …”