massive intracranial fluid collection
TRANSCRIPT
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
1/29
MASSIVE INTRACRANIAL
FLUID COLLECTION
-hydrocephalus-
BY: Aiza Qen S. De Monteverde
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
2/29
OBJECTIVES:
To define Hydrocephalus, its types,causes, diagnostics and treatment
Points on how to assesshydrocephalus
Awareness of signs and symptoms ofvp shunt malfunction
Points on medical and surgicalmanagement of hydrocephalus andnursing interventions
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
3/29
DESCRIPTION:
-Is an imbalance of CSF absorption
or production caused bymalformation, tumors, hemorrhage,
infection or trauma.
-results in head enlargement andincreased ICP.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
4/29
FUNCTIONS OF CSF
buffers the brain to protect it from normal
movements of the head
cushions the spinal and brain from jolts.
it helps maintain normal chemical balance
it assists in the maintenance of the blood-
brain barrier.
Protects brain from chemical intrusion fromthe rest of the body.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
5/29
O
nce formed, (in the choroid plexus) CSF circulates throughout theventricular system, exits the foramen of Magendie and Luschka circulates
through the subarachnoid space of the spinal cord and brain, and is then
absorbed.
(Normal production of CSF in adults: 500 ml per day and in a child 25 ml per
day.)
NORMAL CSF FLOW
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
6/29
The term hydrocephalus is derived from the Greek, hydor (water) and kephale
(head). Hydrocephalus is an accumulation of cerebrospinal fluid (CSF) in the
ventricles, which results in dilatation of the ventricles. As fluid volume increases,
pressure increases within the intracranial vault.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
7/29
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
8/29
TYPES:
NONCOMMUNICATING:Obstruction of
cerebrospinal flow within
the ventricular system
occurs. "obstructive"
hydrocephalus - occurs
when the flow of CSF is
blocked along one or more
of the narrow pathways
connecting the ventricles.
COMMUNICATING:Hydrocephalus occurs as
a result of impaired
absorption within the
subarachnoid space.
Interference of the
cerebrospinal fluid within
the ventricular system
does not occur. CSF is
blocked after it exits fromthe ventricles
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
9/29
Congenital hydrocephalus
The cranial bones fuse by the
end of the third year of life. Forhead enlargement to occur,hydrocephalus must occurbefore then. The causes areusually genetic but can also beacquired and usually occur
within the first few months oflife, which include 1)intraventricular matrixhemorrhages in prematureinfants, 2) infections, 3) type IIArnold-Chiari malformation, 4)
aqueduct atresia and stenosis,and 5) Dandy-Walkermalformation.
Acquired hydrocephalus
This condition is acquired as aconsequence of CNS-infections,meningitis, brain tumors, headtrauma, intracranial hemorrhage(subarachnoid orintraparenchymal) and is usually
extremely painful for the patient.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
10/29
Arnold-Chiari malformation is a congenital anomaly of
the brain in which the cerebellar tonsils are elongatedand pushed down through the opening of the base of the
skull (see foramen magnum), blocking the flow of
cerebrospinal fluid (CSF).
Under surface of the cerebellum.
(Tonsil visible at center right.)
Sagittal section of the cerebellum, near thejunction of the vermis with the hemisphere.
(Tonsil visible at bottom center.)
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
11/29
Dandy-Walker syndrome (DWS), or Dandy-Walker complex, is a
congenital brain malformation involving the cerebellum and the fluid
filled spaces around it.
The Dandy-Walker complex is a genetically sporadic disorder that
occurs one in every 25,000 live births, mostly in females.
All of the black in the middle is water and the brain matter is the rim of white
along the outside of the skull.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
12/29
Causes of hydrocephalusHydrocephalus develops when there is impedance to CSF flow or
absorption.
Rarely hydrocephalus will occur due to the overproduction of CSF, as inchoroid plexus papilloma.
Congenital anomalies, including aqueductal stenosis, Chiari I and IImalformation, and Dandy-Walker malformation. (Most common causes ofhydrocephalus during the neonatal and early infancy period.)
Acquired hydrocephalus problems in infancy are most commonly secondary tointraventricular hemorrhage due to prematurity (Greenberg, 2001).
Infections in utero also are a factor in some cases of neonatal hydrocephalus,and are caused by viruses or bacteria.(Guinea pigs, rabbits, and cats areknown to be vectors for viruses that can cause asymptomatic infection inpregnant women. However, the virus crosses the placenta to cause potentially
catastrophic neurologic problems in the developing fetus (Wright et al., 1997).Therefore, pregnant women should be counseled to avoid exposure to theseanimals.
Masses such as tumors, vascular malformations or cysts, and hematomasecondary to trauma.
Infectious processes such as meningitis can impede reabsorption of CSF at
the level of the arachnoid villi resulting in hydrocephalus (Greenberg, 2001).
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
13/29
DIAGNOSIS:
-Ultrasonography
-CT Scan
-MRI (MRI cine is a new investigation used to evaluate
hydrocephalus. Its value is not established yet.)
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
14/29
Medical Care:
Medical treatment is used to delay surgical intervention. It may be
tried in premature infants with post hemorrhagic hydrocephalus (inthe absence of acute hydrocephalus). Normal CSF absorption
may resume spontaneously during this interim period.
Medical treatment is not effective in long-term treatment of chronic
hydrocephalus. It may induce metabolic consequences and thus
should be used only as a temporizing measure.
Medications affect CSF dynamics by the following mechanisms:
Decreasing CSF secretion by the choroid plexus -
Acetazolamide and furosemide
Increasing CSF reabsorption - Isosorbide (effectiveness isquestionable)
Decadron may be administered to decrease edema
secondary to increased ICP.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
15/29
Acetazolamide (ACZ) and furosemide (FUR) treat posthemorrhagic hydrocephalus in
neonates. Both are diuretics that also appear to decrease secretion of CSF at the level
of the choroid plexus. ACZ can be used alone or in conjunction with FUR. The
combination enhances efficacy of ACZ in decreasing CSF secretion of the choroid
plexus. If ACZ is used alone, it appears to lower risk of nephrocalcinosis significantly.
Medication as treatment for hydrocephalus is controversial. It should be used only as a
temporary measure for posthemorrhagic hydrocephalus in neonates.
Drug Category: Carbonic anhydrase inhibitors -- These agents inhibit an enzyme found
in many tissues of the body that catalyzes a reversible reaction in which carbon dioxide
becomes hydrated and carbonic acid dehydrated. These changes may result in a
decrease in CSF production by the choroid plexus.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
16/29
ASSESSMENT:
1. INFANT:Increased head circumference. > 98th
percentile of age
Thin, widely separated bones of the headthat produce a cracked spot sound(Macewens sign) on percussion.
Anterior fontanel tense, bulging, and nonpulsating.
Dilated scalp veinsFrontal bossing
Sun setting eyes
2. CHILD:
Behavior changes such as irritability andlethargy.
Headache on awakening
Nausea and vomiting
Ataxia
Nystagmus
Papilledema: if the raised ICP is not treated,this can lead to optic atrophy and visionloss.
Failure of upward gaze: This is due topressure on the tectal plate through thesuprapineal recess.
Macewen sign: A "cracked pot" soundis noted on percussion of the head.
Unsteady gait: This is related tospasticity in the lower extremities.
Large head: Sutures are closed, butchronic increased ICP will lead to
progressive abnormal head growth. Unilateral or bilateral sixth nerve palsy
is secondary to increased ICP.
LATE SIGNS: a high and shrill cry and seizure
activities
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
17/29
NURSING MEDICAL
INTERVENTIONS:
Monitor vital signs
Assess for any progression of headcircumference. Monitor any change or increase inthe head circumference, change in feeding
patterns etc (as written on the previous slide)Administer medications as prescribed
Utilize aseptic and or clean technique in anyprocedure to prevent infection
Assess nutritional status of patientProvide comfort and safety
Provide emotional support to patient and family
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
18/29
Drug Name
Acetazolamide (Diamox) -- Noncompetitive reversible inhibitor of enzyme
carbonic anhydrase, which catalyzes the reaction between water and carbon
dioxide, resulting in protons and carbonate. This contributes to decreasing CSF
secretion by choroid plexus.
Pediatric Dose 25 mg/kg/d PO tid; not to exceed 100 mg/kg/d
Contraindicatio
ns
Documented hypersensitivity; hepatic insufficiency, hyponatremia, hypokalemia,
hyperchloremic acidosis, severe renal insufficiency, nephrocalcinosis, adrenal
gland failure
Interactions
Alkalizes urine and may decrease excretion of amphetamines, procainamide,
quinidine, flecainide, anticholinergics, and mecamylamine; may increaseexcretion and lower plasma levels of salicylate, phenobarbital, and lithium; can
increase cyclosporine levels and decrease primidone levels; concurrent
salicylates may increase accumulation and toxicity, including CNS depression
and metabolic acidosis
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions
Can cause hyperglycemia in diabetics; concurrent digoxin can increase
susceptibility to ACZ-induced hypokalemia; in patients taking other diuretics,
ACZ can aggravate hypokalemia; can aggravate preexisting acidosis, which can
be prevented by initiating prophylactic electrolyte replacement; this may consist
of sodium citrate starting at 8 mEq/kg/d titrated, keeping serum bicarbonate
levels >18 mEq/L and sodium and potassium within reference ranges
Obtain baseline CBC prior to initiating therapy; recheck regularly during therapy
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
19/29
Drug Category: Loop diuretics -- These agents increase excretion of water by
interfering with the chloride-binding cotransport system, which results from inhibition of
reabsorption of sodium and chloride in the ascending loop of Henle and distal renal
tubule.
Drug Name
Furosemide (Lasix) -- Mechanisms proposed for lowering ICP
include lowering cerebral sodium uptake, affecting water transport
into astroglial cells by inhibiting cellular membrane cation-chloride
pump, and decreasing CSF production by inhibiting carbonic
anhydrase. Used as adjunctive therapy with ACZ in temporary
treatment of posthemorrhagic hydrocephalus in neonates.
Pediatric Dose 1 mg/kg/d IV
Contraindications
Documented hypersensitivity to drug or sulfonylureas, hepatic
coma, anuria, severe electrolyte depletion, concurrent ethacrynic
acid (may cause ototoxicity), or lithium (may cause lithium toxicity)
Interactions
May increase ototoxic potential of aminoglycoside antibiotics; may
increase salicylate toxicity if given with salicylate; may decreasearterial response to norepinephrine
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions
Excessive use can cause dehydration and circulatory collapse; can
cause electrolyte imbalance as hypokalemia, hyponatremia,
hypochloremic alkalosis, hypomagnesemia, and hypocalcemia;
therefore, monitor serum electrolytes; may increase blood glucosein patients with diabetes; may cause photosensitivity
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
20/29
Drug Category: Corticosteroids-are a class ofsteroid hormones that are produced in the adrenal cortex.
Corticosteroids are involved in a wide range ofphysiologic systems such as stress response, immune
response and regulation ofinflammation, carbohydrate metabolism, protein catabolism, blood electrolyte
levels, and behavior.
Drug Name
Decadron is an steroid and it comes in Intravenous as well as oral tablets. Intravenous
form is used for immediate action and result and tablets are used to maintain the effect
of Decadron
Pediatric DoseThe range of initial doses is 0.02 to 0.3 mg/kg/day in three or four divided doses (0.6to 9 mg/m2bsa/day).
Contraindications
Systemic fungal infections (see WARNINGS,Fungal infections).DECADRON tablets are contraindicated in patients who are hypersensitive to any components of thisproduct.
Interactions
This drug should not be used with the following medications because very serious interactions may
occur: live vaccines, mifepristone. Before using this medication, tell your doctor or pharmacist of allprescription and nonprescription/herbal products you may use, especially of: aminoglutethimide, largedoses of aspirin and aspirin-like drugs
Precautions
Do not have immunizations, vaccinations, or skin tests unless specifically directed by your doctor. Livevaccines may cause serious problems (e.g., infection) if given while you are using this medication.Avoid contact with people who have recently received oral polio vaccine or flu vaccine inhaled throughthe nose.This medication may mask signs of infection or put you at greater risk of developing very seriousinfections. Report to your doctor any injuries or signs of infection (e.g., persistent sore
throat/cough/fever, pain during urination, muscle aches) that occur while using this medication orwithin 12 months after stopping it.Before using this medicine, consult your doctor or pharmacist if you have: current fungal infections.Caution is advised when using this drug for a long time in children. This medication may temporarilyslow down a child's rate of growth, but it will probably not affect final adult height. Monitor your child'sheight periodically.A preservative (benzyl alcohol) that may be found in some dexamethasone products, which are notpreservative-free, can infrequently cause serious (sometimes fatal) problems if given in large amounts(more than 100 milligrams per kilogram daily) to an infant during the first months of life. The risk is also
greater with low-birth-weight infants. Symptoms include sudden gasping, low blood pressure, or a veryslow heartbeat. If you notice any of these symptoms in your newborn, report them to the doctorimmediatel . If ossible use the reservative-free form of this dru when treatin newborns.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
21/29
SURGICAL INTERVENTIONS:
1.The goal of surgical treatment is to preventfurther CSF accumulation by bypasing theblockage and draining the fluid from the ventriclesto a location to where it maybe absorbed.
2. In ventriculoperitoneal shunt, the CSF drainsinto the peritoneal cavity from the lateral ventricle.
3. In an atrioventricular shunt, CSF drains into theright atrium of the heart from the lateral ventricle,bypassing the obstruction (used in older childrenand in children with pathological conditions of theabdomen.)
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
22/29
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
23/29
NURSING INTERVENTIONS
POST OPERATIVELY:
Monitor vital signs and neurological signs.
Position the client on the un-operated side to prevent pressureon the shunt bulb.
Keep the child flat as prescribed to avoid rapid reduction ofintracranial fluid.
Observe for increased ICP; if increased ICP occurs, elevate thehead of the bed to 15 to 30 degrees to enhance gravity flowthrough the shunt.
Monitor for signs of infection and assess dressing for drainage.
Measure head circumference.
Monitor intake and output.
Provide comfort measures; administer medications as
prescribed, which may include diuretics, antibiotics, oranticonvulsants.
Instruct parents on how to recognize shunt infection ormalfunction.
In a toddler, headache and a lack of appetite are the earliestcommon signs of shunt malfunction.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
24/29
COMPLICATIONS:Related to progression of hydrocephalus
Visual changesOcclusion of posterior cerebral arteries secondary to downward transtentorial herniation
Chronic papilledema injuring the optic discDilatation of the third ventricle with compression of optic chiasm
Cognitive dysfunction
Incontinence
Gait changes
Related to medical treatmentElectrolyte imbalance
Metabolic acidosis
Related to surgical treatmentSigns and symptoms of increased ICP can be a consequence of undershunting or shunt obstruction ordisconnection.
Subdural hematoma or hygroma is secondary to overshunting. Headache and focal neurological signsare common.
Treat seizures with antiepileptic drugs.
Shunt infection occasionally can be asymptomatic. In neonates it manifests as alteration of feeding,
irritability, vomiting, fever, lethargy, somnolence, and a bulging fontanelle. Older children and adultspresent with headache, fever, vomiting, and meningismus. With VP shunts, abdominal pain may occur.
Shunts can act as a conduit for extraneural metastases of certain tumors (eg, medulloblastoma).
Hardware erosion through the skin occurs in premature infants with enlarged heads and thin skin wholie on 1 side of the head.
VP shunt complications include peritonitis, inguinal hernia, perforation of abdominal organs, intestinalobstruction, volvulus, and CSF ascites.
VA shunt complications include septicemia, shunt embolus, endocarditis, and pulmonary hypertension.
Lumboperitoneal shunt complications include radiculopathy and arachnoiditis.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
25/29
Symptoms of Shunt
Malfunction/Hydrocephalus
A shunt infection can also cause the shunt not towork properly and cause CSF to backup, leadingto enlarged ventricles. Signs and symptoms ofshunt infection also relate to signs of shunt
malfunction. In addition, other signs andsymptoms related to shunt infection include:
Fever.
Redness, tenderness, skin breakdown, or fluidcollection noted at the shunt on the scalp or
anywhere along the shunt tract.
Drainage at the incisional areas related to theshunt.
Abdominal pain, tenderness, or refusing to eat or
drink
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
26/29
INFANTS
Enlargement of thebabys head
Fontanel is full and
tense when the infant
is upright and quiet
Vomitting, Irritability,
Sleepiness, downward
deviation of the eyes Seizures
TODDLERS
Head enlargement
Vomitting
Headache
A loss of previousabilities (sensory of
motor function)
Seizures
Lack of apetite
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
27/29
OLDER CHILDREN
Vomiting
Vision problems
Irritability and or tirednessLoss of coordination and balance
Difficulty in waking up or staying
awakeSeizures
Decline in school performance
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
28/29
For the most part, shunts function well. However,there are complications that can occur. Ablockage or obstruction of the shunt is the most
common complication of the system. Obstructionmay occur at any point along the path of theshunt. The opening at the ventricular end maybecome plugged with brain, choroid plexustissue, or blood. The peritoneal end may alsobecome blocked by scar tissue. An obstructedshunt causes an increased volume of CSF in theventricular system of the brain. This can lead tothe same symptoms as those listed below forhydrocephalus. The shunt can be repaired(shunt revision) in surgery lasting about 1 2hours.
-
8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION
29/29
Reference
Medical Surgical
textbooks: Bruners
and Sudarths,Saunders
Internet
Nurse Avenue
Medscape