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Neurology > Lecture 32 CSF, Hydrocephalus, Lumbar Puncture > Flashcards

Lecture 32 CSF, Hydrocephalus, Lumbar Puncture Flashcards

1
Q

Define Hydrocephalus

A

Excess CSF within the intracranial space specifically interventricular spaces and causes dilation of ventricles

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2
Q

Where is majority of CSF produced

A

Choroid plexus

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3
Q

What type of process is CSF production

A

Metabolically active
Requires ATP
Sodium is pumped into the subarachnoid space and water follows from the blood vessels

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4
Q

Where is the choroid plexus located in the ventricles

A

Lateral- temporal horn roofs
3rd- posterior roof
4th- caudal roof

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5
Q

The average adult produces how much CSF everyday

A

450-600 cc’s

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6
Q

At any given moment how much CSF is present in the average adult

A

150 cc’s

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7
Q

How much of the CSF present at any given time is in the brain ventricles

A

25 cc’s

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8
Q

Describe the CSF pathway

A
  1. Lateral ventricle
  2. Foramen Munro
  3. 3rd ventricle
  4. Aqueduct of Sylvius/Cerebral aqueduct
  5. 4th Ventricle
  6. Medial-Magendie
  7. Lateral-Luschka
  8. Subarachnoid space
  9. Arachnoid villi (Arachnoid granulations) along dural venous sinuses
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9
Q

Where are arachnoid villi locaed

A

Arachnoid granulations

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10
Q

What is the function of the arachnoid villi

A

Pressure dependent one way valves that open when the ICP is 3 to 5 cm greater than dural venous sinus pressure

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11
Q

What type of process if CSF resorption

A

Passive

Driven by the pressure gradient between the ICP and venous system

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12
Q

What are the 2 categories of Hydrocephalus

A

Non-communicating- obstructive

Communicating- non-obstructive

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13
Q

What is the main problem in communication Hydrocephalus

A

Problem with CSF resorption or less commonly overproduction of CSF

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14
Q

What is the name of the disease that causes overproduction of CSF

A

Choroid plexus Papilloma

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15
Q

Name signs and symptoms seen in communicating hydrocephalus is young children

A

o Disproportional increase in head circumference compared to rest of body
o Failure to thrive

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16
Q

Name signs and symptoms seen in communicating hydrocephalus is adults

A 
Increased ICP
Papilledema
Gait disturbances
CN VI nerve palsy
Upgaze difficulty
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17
Q

What is the aetiology of communication hydrocephalus

A

Infection-bacterial meningitis
Post-operative
Head trauma

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18
Q

What is the main problem in non-communicating hydrocephalus

A

Physical obstruction at any point along the interventicular pathway

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19
Q

What are the causes of non-communication hydrocephalus

A
  • Aqueductal stenosis
  • Tumors/Cancers/Masses
  • Cysts
  • Infection
  • Hemorrhage/hematoma
  • Congenital malformations/conditions
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20
Q

What is the likely cause of non-communicating hydrocephalus if the symptoms are gradual

A

Mass

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21
Q

What is the likely cause of non-communicating hydrocephalus id the symptoms are acute and there is rapid mental decline

A

Intraventicular bleed

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22
Q

What would you see during radiography to suggest the patient had hydrocephalus

A

Dilation of the temporal horns of the lateral ventricles- normally not visible in younger people
3rd ventricle necked ballooned

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23
Q

What calculations are used to see whether someone has Ventriculomegaly

A

Evans ratio

Ventricular index

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24
Q

What ratio suggests vetriculomegaly

A

Ratio greater than 3

25
Treatment for Hydrocephalus
External Ventricular Drain | Shunt
26
How would you treat communicating hydrocephalus
Shunt placement Ventricle-peritoneal Lumbar-perioneal Ventricular-atrial
27
How would you treat non-communicating hydrocephalus
Removal of obstructing lesion Shunt Third ventriculostomy
28
A colloid cyst at anterior 3rd ventricle would cause obstruction where
Foramen of Monro
29
A pineal region tumour causes compression where
Cerebral aqueduct
30
An ependymoma would cause blockage where
4th ventricular CSF outlets
31
VP shunts can fail due to
``` o Mechanical failure from occlusion/disconnection o Migration o Over drainage/underdrainage o Infection o Skin erosion ```
32
Describe Normal pressure hydrocephalus
• Rare preventable/reversible causes of dementia
33
Presentation of Normal Pressure Hydrocephalus
• Classic Triad (Wet, Wobbly and Wacky) o Urinary incontinence o Gait disturbances (wide stance, short, shuffling steps) o Quickly progressive dementia
34
What would you discover from LP in Normal Pressure Hydrocephalus
o Normal opening pressure o Symptoms improve with CSF removal o Gait assessment (time walk and turns) and MMSE
35
What is the treatment for NPH
VP shunt | LP shunt tends to lead to over drainage and are difficult to assess and revise
36
What is the prognosis of NPH
* Chance of outcome is improved if symptoms have been present for shorter period of time * Meaning that failure to recognize these patients delays their treatment and lessens their chances * Most likely symptom to improve is gait>incontinence>memory
37
Indications for Lumbar Puncture
* Meningitis * Meningoencephalitis * Subarachnoid hemorrhage * Malignancy – diagnosis and treatment * Idiopathic Intracranial Hypertension * Other neurologic syndromes * Infusion of Drugs or contrast
38
Contraindications for Lumbar Puncture
* Unstable patient with cardiovascular or respiratory instability * Localized skin/soft tissue infection over puncture site * Evidence of unstable bleeding disorder-increased chance of spinal haematoma * Platelets < 50,000 or clotting factor deficiency * Increased intracranial pressure
39
Equipment for Lumbar Puncture
Anaesthetic: Topical (EMLA, Elamax, Zylocaine ) or Injection (Lidocaine 25 gauge needle) • Drapes, gauze, and bandages • Manometer, stopcock and tubing in non-infant kits • Spinal needle, usually 22 gauge o 1.5 in for < 1 yr o 2.5 in for 1 year to middle childhood o 3.5 in for older children and adolescents o Larger for large adolescents • Atraumatic needles, less spinal headaches (pencil point)
40
Describe the Lateral Decubitus Position
L3-L4 or L4-L5 | Widens gap between spinous process
41
What do you use to cleanse the skin before a lumbar puncture
Iodine | Radially out to 10cm and allow to dry
42
How do you insert the needle for a lumbar puncture
• Aim towards umbilicus directing needle slightly cephalad • Hold needle firmly • A “pop” of sudden decrease in resistance indicates that ligamentum flavum and dura are punctured • Remove stylet and check for flow of spinal fluid • If no fluid, then: o Rotate needle 90° o Reinsert stylet and advance needle slowly checking frequently for CSF
43
When measuring Manometry what pressure would suggest a possible herniation
>25cm of water
44
How many tubes do you collect of CSF during a lumbar puncture and how long for
3 1ml each o Tube 1: culture & gram stain o Tube 2: glucose, protein o Tube 3: cell count & differential
45
What are the 2 positions a patient can sit during a Lumbar Puncture
Sitting position Lateral Decubitus Position Paramedian (Lateral) Approach
46
When is the Paramedian (lateral) approach used during lumbar punctures
• Use for patients who have calcifications from repeated LPs or anatomic abnormalities • Needle passes through erector spinae muscles, and ligamentum flavum o Bypasses supraspinal and interspinal ligaments • Less incidence of spinal headache
47
What causes spinal headaches
CSF leakage
48
What are the complications of a Lumbar Puncture
``` Headache Apnea Back pain Bleeding Fluid leak Infection, pain, hematoma Subarachnoid epidermal cyst Ocular muscle palsy (transient) Nerve Trauma Brainstem herniation ```
49
Whats the most common complication of a lumbar puncture
Spinal headache
50
What are the risk factors for a spinal headache
``` Female 18-30 yrs Lower BMI history of headaches Prior spinal headaches ```
51
How is a spinal headache managed
Hydration Caffeine Epidural blood patch
52
How can spinal headaches be prevented
o Passing needle bevel parallel to longitudinal fibers of dura o Replacing stylet before removing needle o Using small diameter needles o Using atraumatic needles
53
What are the features of nerve root trauma/irritation
Electric shocks Dysesthesias Back pain Disc Herniation
54
if Nerve Root Trauma/Irritation persists what can be done
Start corticosteroids | • Electromyogram/nerve conduction velocity studies should be scheduled if pain persists
55
Clinical features of Herniation
* Manifests initially as altered mental status, followed by cranial nerve abnormalities and Cushing triad (Irregular, decreased respirations (caused by impaired brainstem function) Bradycardia. Systolic hypertension (widening pulse pressure)) * May be rapidly fatal.
56
How do you manage Herniation
* Immediately remove needle and raise the head of bed to 30-45° improve venous return from the brain. * Mannitol or 3% Saline * Intubate patient and hyperventilate * Emergent neurosurgical consult
57
What is the cause of an Epidermal Inclusion Cyst
• Occurs when a core of skin is driven into spinal or paraspinal space with hollow needle
58
If Lumbar Puncture fails what can be done
* Have someone else try * Anesthesia * Neurology * Bedside ultrasound for difficult LPs * Radiographic guided procedure * Fluoroscopy * Ultrasound * CT * Cisterna Magna tap

Neurology (44 decks)

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