Prieto Ruth, Soriano Matias Cea, Ortega Celia, Kalantari Teresa, Rabanal Alberto Pueyo
Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain.
Department of Surgery, Puerta de Hierro University Hospital, Madrid, Spain.
Surg Neurol Int. 2020 Dec 22;11:451. doi: 10.25259/SNI_620_2020. eCollection 2020.
Subdural fluid collection in patients with internal cerebrospinal fluid (CSF) shunts has generally been linked to overdrainage and more rarely to pus accumulation. The authors present a previously unrecognized condition leading to extra-axial CSF accumulation: shunt underdrainage. Treatment of coexisting subdural fluid collection and hydrocephalus, disorders that have previously only been reported concurrently following head trauma or subarachnoid hemorrhage, is controversial. In addition, we intend to provide insight into the physiopathology of abnormal CSF accumulation within both the subdural space and ventricles simultaneously.
A 42-year-old female with a history of hypothalamic glioma and obstructive hydrocephalus during childhood presented with headache, vomiting, and gait disturbance. Following the insertion of her first ventriculoperitoneal shunt (VPS) by the age of 8, she underwent several surgeries due to shunt failure, all of them associating ventriculomegaly. Ventricles remained notably enlarged following insertion of her most recent VPS, and the computed tomography scan performed 2 months later at her admission showed a large subdural collection. Afterward, a malpositioned distal catheter causing shunt blockage was confirmed. Both, the subdural accumulation and hydrocephalus, were resolved following adequate placement of the peritoneal catheter.
This case demonstrates that subdural fluid accumulations may occur following VPS underdrainage with hydrocephalus. Development of such extra-axial collection was probably caused by pressure related to CSF spillage from the ventricles into the subdural space. Our case also supports that a mass-effect subdural accumulation with hydrocephalus can be satisfactorily treated with adequate VPS alone, without directly treating the subdural collection.
颅内脑脊液（CSF）分流患者的硬膜下积液通常与引流过度有关，而与脓液积聚的关系较少。作者介绍了一种此前未被认识的导致轴外脑脊液积聚的情况：分流引流不足。同时存在硬膜下积液和脑积水的治疗存在争议，此前仅在头部创伤或蛛网膜下腔出血后同时出现这些疾病的情况下有过报道。此外，我们旨在深入了解硬膜下间隙和脑室同时出现异常脑脊液积聚的病理生理学。
一名42岁女性，有儿童期下丘脑胶质瘤和梗阻性脑积水病史，出现头痛、呕吐和步态障碍。她在8岁时首次插入脑室腹腔分流术（VPS），此后因分流失败接受了几次手术，所有这些手术都伴有脑室扩大。在插入她最近的VPS后，脑室仍然明显扩大，入院时2个月后进行的计算机断层扫描显示有大量硬膜下积液。随后，证实远端导管位置不当导致分流堵塞。在适当放置腹膜导管后，硬膜下积液和脑积水均得到解决。
该病例表明，VPS引流不足伴脑积水时可能会出现硬膜下积液。这种轴外积液的发生可能是由于脑脊液从脑室溢出到硬膜下间隙所产生的压力所致。我们的病例还支持，对于伴有脑积水的硬膜下积液的占位效应，仅通过适当的VPS就可以得到满意的治疗，而无需直接治疗硬膜下积液。
