Delayed Posttraumatic Hydrocephalus Secondary To An Aqueductal Web Treated With Endoscopic Third Ventriculostomy: A Case Report.

摘要

BackgroundDelayed posttraumatic hydrocephalus is typically communicating secondary to arachnoid villi insufficiency, due to a reactive inflammatory response to blood products. Acute obstructive hydrocephalus secondary to an aqueductal clot or midbrain contusion has been published; however, no previous publications of delayed obstructive posttraumatic hydrocephalus have been found. Case descriptionWe present a case report of delayed obstructive hydrocephalus secondary to an aqueductal web. The patient was successfully treated by an endoscopic third ventriculostomy. ConclusionTo our knowledge, this is the first description of delayed obstructive posttraumatic hydrocephalus secondary to an aqueductal web, and we discuss the pathophysiological cause, and relevant treatment options. Introduction In the vast majority of instances post-hemorrhagic hydrocephalus is the result of extraventricular obstruction of CSF absorption, hence communicating hydrocephalus. The treatment options available in this setting are often limited and placement of a ventriculoperitoneal shunt is often required [1-4]. In rare instances, post-hemorrhagic hydrocephalus is due to obstruction within the ventricular system. The cerebral aqueduct, being the smallest caliber conduit for CSF flow, is particularly vulnerable to obstruction by intraventricular blood, or by compression from expansive lesions within the tectum or tegmentum [5].A wider array of treatment options is available for hydrocephalus caused by obstruction of the cerebral aqueduct. Increasingly, endoscopic techniques, including third ventriculostomy, and aqueductoplasty with or without stent placement, have been used [6-9]. We describe a case of acquired aqueductal obstruction due to a severe closed injury with a focal hemorrhagic contusion of the midbrain tegmentum and tectum. Performance of an endoscopic third ventriculostomy (ETV) allowed for durable radiographic and clinical improvement without the need for shunt placement. Case Report HistoryA 23-year-old man presented in extremis following a high speed motor vehicle accident. He was the unrestrained driver in a single vehicle, high speed accident, wherein the car struck a utility pole. Endotracheal intubation was performed at the scene. Upon arrival to the emergency department, neurological examination revealed bilateral dilation of the pupils, which were minimally reactive. Motor responses were extensor. Glasgow coma scale was 4T. Computed TomographyCT scan of the brain demonstrated diffuse shearing injuries involving the pons, mid-brain, splenium of the corpus callosum and bilateral frontal and left parietal subcortical regions. A small hemorrhage was seen in the occipital horn of the right lateral ventricle, and along the posterior interhemispheric fissure.