1
This commit is contained in:
Ross
+301
@@ -0,0 +1,301 @@
|
||||
---
|
||||
title: "Extraventricular Obstructive Hydrocephalus"
|
||||
docid: "a0886d4c-f504-4165-bb52-2400e2385f68"
|
||||
authors:
|
||||
- key: "a25c450b-3d34-4f64-bba3-cc0834813df6"
|
||||
value: "Miral D. Jhaveri, MD, MBA"
|
||||
breadcrumbs:
|
||||
-
|
||||
name: "Brain"
|
||||
slug: "brain"
|
||||
treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
|
||||
-
|
||||
name: "Diagnosis"
|
||||
slug: "diagnosis"
|
||||
treeNodeId: "51c00394-446e-4a38-94af-d3b1d14d34e8"
|
||||
-
|
||||
name: "Anatomy-Based Diagnoses"
|
||||
slug: "anatomy-based-diagnoses"
|
||||
treeNodeId: "529d3e33-f508-498c-bc70-cf962e81e629"
|
||||
-
|
||||
name: "Ventricles and Cisterns"
|
||||
slug: "ventricles-and-cisterns"
|
||||
treeNodeId: "33b267f0-908c-4c77-81f8-f6135d1bc592"
|
||||
-
|
||||
name: "Hydrocephalus"
|
||||
slug: "hydrocephalus"
|
||||
treeNodeId: "9ce86e3b-fab6-4657-9e51-5f47bb1a51b5"
|
||||
-
|
||||
name: "Extraventricular Obstructive Hydrocephalus"
|
||||
slug: "extraventricular-obstructive-hydro-"
|
||||
treeNodeId: null
|
||||
category: "Brain"
|
||||
documentVersionId: "244d0107-0a80-48b5-96b6-e095c226c02a"
|
||||
imageCount: 9
|
||||
lastUpdated: "08/20/20"
|
||||
pageDescription: "Extraventricular Obstructive Hydrocephalus"
|
||||
pageKeywords: "Brain, Diagnosis, Anatomy-Based Diagnoses, Ventricles and Cisterns, Hydrocephalus, Extraventricular Obstructive Hydrocephalus"
|
||||
pageTitle: "Extraventricular Obstructive Hydrocephalus | STATdx"
|
||||
enhancedTitle: "Extraventricular Obstructive Hydrocephalus"
|
||||
type: "DX"
|
||||
references: true
|
||||
breadcrumbs:
|
||||
- "Brain"
|
||||
- "Diagnosis"
|
||||
- "Anatomy-Based Diagnoses"
|
||||
- "Ventricles and Cisterns"
|
||||
- "Hydrocephalus"
|
||||
- "Extraventricular Obstructive Hydrocephalus"
|
||||
---
|
||||
# KEY FACTS
|
||||
|
||||
- ## Terminology
|
||||
|
||||
|
||||
- Extraventricular obstructive hydrocephalus (EVOH): Enlarged ventricles due to obstruction located outside ventricular system
|
||||
- Synonym: "Communicating" hydrocephalus
|
||||
- ## Imaging
|
||||
|
||||
|
||||
- Impaired absorption of CSF distal to 4th ventricle outlet foramina
|
||||
- Ventricular size varies with duration of obstruction
|
||||
- All ventricles enlarged with no intraventricular obstructive cause
|
||||
- Lateral, 3rd, and 4th ventricles dilated
|
||||
- ± periventricular white matter interstitial edema
|
||||
- ± abnormal density/intensity of cisternal CSF ± leptomeningeal enhancement
|
||||
- ## Top Differential Diagnoses
|
||||
|
||||
|
||||
- Intraventricular obstructive hydrocephalus
|
||||
- Ventricular enlargement 2° to parenchymal loss
|
||||
- Normal-pressure hydrocephalus
|
||||
- ## Pathology
|
||||
|
||||
|
||||
- Hemorrhage → fibrosis/obstruction of subarachnoid space
|
||||
- Most common cause of EVOH
|
||||
- Other etiologies include suppurative meningitis, neoplastic or inflammatory exudates
|
||||
- Subarachnoid hemorrhage (SAH), exudates may fibrose/occlude subarachnoid space, reduce CSF pulsations
|
||||
- ## Clinical Issues
|
||||
|
||||
|
||||
- Headache, papilledema
|
||||
- Nausea, vomiting, diplopia (cranial nerve palsy)
|
||||
- ## Diagnostic Checklist
|
||||
|
||||
|
||||
- EVOH: Generalized ventricular enlargement with abnormal density/intensity in basal cisterns ± leptomeningeal enhancement
|
||||
|
||||
# TERMINOLOGY
|
||||
|
||||
- ## Abbreviations
|
||||
|
||||
|
||||
- Extraventricular obstructive hydrocephalus (EVOH)
|
||||
- ## Synonyms
|
||||
|
||||
|
||||
- "Communicating" hydrocephalus
|
||||
- ## Definitions
|
||||
|
||||
|
||||
- Enlarged ventricles due to obstruction located outside ventricular system
|
||||
|
||||
# IMAGING
|
||||
|
||||
- ## General Features
|
||||
|
||||
|
||||
- ### Best diagnostic clue
|
||||
|
||||
|
||||
- Lateral, 3rd, and 4th ventricles all dilated
|
||||
- ± abnormal density/intensity of cisternal CSF ± leptomeningeal enhancement
|
||||
- ### Location
|
||||
|
||||
|
||||
- Obstruction distal to 4th ventricle outlet foramina
|
||||
- ### Size
|
||||
|
||||
|
||||
- Bifrontal horn to intracranial diameter ratio > 0.3
|
||||
- Temporal horn width > 3 mm
|
||||
- ### Morphology
|
||||
|
||||
|
||||
- All ventricles enlarged
|
||||
- Generally proportionate, symmetrical increase
|
||||
- No intraventricular obstructive cause
|
||||
- ## CT Findings
|
||||
|
||||
|
||||
- ### NECT
|
||||
|
||||
|
||||
- Variable ventricular dilatation ± basal cisterns effaced
|
||||
- If subarachnoid hemorrhage (SAH), look for hyperdense CSF
|
||||
- ### CECT
|
||||
|
||||
|
||||
- Look for sulcal/cisternal enhancement
|
||||
- ## MR Findings
|
||||
|
||||
|
||||
- ### T1WI
|
||||
|
||||
|
||||
- "Dirty" CSF, ventricular dilatation
|
||||
- ### T2WI
|
||||
|
||||
|
||||
- Dilated ventricles ± periventricular white matter interstitial edema
|
||||
- Effacement of cortical sulci
|
||||
- Hypointense CSF-SAH, exudates
|
||||
- ### FLAIR
|
||||
|
||||
|
||||
- ± periventricular white matter interstitial edema better delineated than T2
|
||||
- ### T1WI C+
|
||||
|
||||
|
||||
- ± enhancement of basal cisterns/sulci
|
||||
- Meningitis, carcinomatosis, etc.
|
||||
- 3D CISS/FIESTA
|
||||
- Exquisitely delineates CSF spaces and helps to exclude intraventricular obstruction
|
||||
- ## Imaging Recommendations
|
||||
|
||||
|
||||
- ### Best imaging tool
|
||||
|
||||
|
||||
- MR with T1WI C+
|
||||
- 3D CISS/FIESTA
|
||||
- ## Other Modality Findings
|
||||
|
||||
|
||||
- Isotope cisternography may show ventricular reflux, stasis (EVOH)
|
||||
|
||||
# DIFFERENTIAL DIAGNOSIS
|
||||
|
||||
- ## Intraventricular Obstructive Hydrocephalus
|
||||
|
||||
|
||||
- Global/focal enlarged ventricles due to obstruction proximal to 4th ventricle outflow
|
||||
- ## Ventricular Enlargement Secondary to Parenchymal Loss
|
||||
|
||||
|
||||
- Neurodegenerative disease, cerebritis, hypoxia/ischemia
|
||||
- Diffuse/focal enlargement of sulci, cisterns
|
||||
- [Normal-Pressure Hydrocephalus](/document/normal-pressure-hydrocephalus/ba3f857d-58de-4f21-8463-1631b4cb9972)
|
||||
- Ventricular enlargement with normal CSF pressure
|
||||
- Sulci normal/minimally enlarged
|
||||
- Progressive dementia, gait disturbance, incontinence
|
||||
|
||||
# PATHOLOGY
|
||||
|
||||
- ## General Features
|
||||
|
||||
|
||||
- ### Etiology
|
||||
|
||||
|
||||
- Obstruction to CSF flow at level of basal cisterns or arachnoid villi
|
||||
- Also reduced CSF pulsations reduce venous resorption of CSF
|
||||
- SAH: Most common cause of EVOH
|
||||
- Other etiologies include suppurative meningitis, neoplastic inflammatory exudates
|
||||
- All lead to subarachnoid scarring, reduced CSF pulsations
|
||||
- ## Gross Pathologic & Surgical Features
|
||||
|
||||
|
||||
- Generalized ventricular dilatation
|
||||
- SAH, exudates in basal cisterns & convexity sulci
|
||||
- Meningeal fibrosis, arachnoid adhesions
|
||||
|
||||
# CLINICAL ISSUES
|
||||
|
||||
- ## Presentation
|
||||
|
||||
|
||||
- ### Most common signs/symptoms
|
||||
|
||||
|
||||
- Headache, papilledema
|
||||
- Nausea, vomiting, diplopia (cranial nerve palsy)
|
||||
- ## Natural History & Prognosis
|
||||
|
||||
|
||||
- Usually progressive unless shunted and primary cause treated
|
||||
- ## Treatment
|
||||
|
||||
|
||||
- CSF diversion (shunt); directed to primary cause
|
||||
|
||||
# DIAGNOSTIC CHECKLIST
|
||||
|
||||
- ## Consider
|
||||
|
||||
|
||||
- EVOH: Generalized ventricular enlargement with abnormal density/intensity in basal cisterns ± leptomeningeal enhancement
|
||||
|
||||
94b03593-3810-49dd-a698-ad9f46f7ba1f
|
||||
|
||||
## References
|
||||
|
||||
# Selected References
|
||||
|
||||
1. [Capone PM et al: Neuroimaging of normal pressure hydrocephalus and hydrocephalus. Neurol Clin. 38(1):171-83, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31761057%5Bpmid%5D)
|
||||
1. [Farb R et al: Hydrocephalus and CSF disorders. Diseases of the brain, head and neck, spine 2020-3: Diagnostic Imaging. Cham (CH): Springer; 11-24, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32119247%5Bpmid%5D)
|
||||
1. [Fowler JB et al: Ventriculoperitoneal shunt. Treasure Island (FL): StatPearls Publishing, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=29083724%5Bpmid%5D)
|
||||
1. [Roth J et al: The added value of magnetic resonance imaging cisternography and ventriculography as a diagnostic aid in pediatric Hydrocephalus. Pediatr Neurosurg. 54(3):165-72, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30870836%5Bpmid%5D)
|
||||
1. [Fink KR et al: Imaging of nontraumatic neuroradiology emergencies. Radiol Clin North Am. 53(4):871-90, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26046515%5Bpmid%5D)
|
||||
1. [Flannery AM et al: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: introduction and methodology. J Neurosurg Pediatr. 14 Suppl 1:3-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25988777%5Bpmid%5D)
|
||||
1. [Grunwald IQ et al: Aneurysmal SAH: current management and complications associated with treatment and disease. J Invasive Cardiol. 26(1):30-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24402809%5Bpmid%5D)
|
||||
1. [Krähenbühl AK et al: Endoscopic temporal ventriculocisternostomy: an option for the treatment of trapped temporal horns. J Neurosurg Pediatr. 11(5):568-74, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23521153%5Bpmid%5D)
|
||||
1. [McAllister JP 2nd: Pathophysiology of congenital and neonatal hydrocephalus. Semin Fetal Neonatal Med. 17(5):285-94, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22800608%5Bpmid%5D)
|
||||
1. [Feng F et al: Evaluation of radionuclide cerebrospinal fluid scintigraphy as a guide in the management of patients with hydrocephalus. Clin Imaging. 33(2):85-9, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19237049%5Bpmid%5D)
|
||||
1. [Yamada S et al: Visualization of cerebrospinal fluid movement with spin labeling at MR imaging: preliminary results in normal and pathophysiologic conditions. Radiology. 249(2):644-52, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18936318%5Bpmid%5D)
|
||||
1. [Greitz D: Paradigm shift in hydrocephalus research in legacy of Dandy's pioneering work: rationale for third ventriculostomy in communicating hydrocephalus. Childs Nerv Syst. 23(5):487-9, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=-1%5Bpmid%5D)
|
||||
1. [ter Laan M et al: Improvement after treatment of hydrocephalus in aneurysmal subarachnoid haemorrhage: implications for grading and prognosis. Acta Neurochir (Wien). 148(3):325-8; discussion 328, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16328775%5Bpmid%5D)
|
||||
1. [Greitz D: Radiological assessment of hydrocephalus: new theories and implications for therapy. Neurosurg Rev. 27(3):145-65; discussion 166-7, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15164255%5Bpmid%5D)
|
||||
1. [Kehler U et al: Extraventricular intracisternal obstructive hydrocephalus--a hypothesis to explain successful 3rd ventriculostomy in communicating hydrocephalus. Pediatr Neurosurg. 38(2):98-101, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12566844%5Bpmid%5D)
|
||||
1. [Biedert S et al: [Extraventricular obstructive hydrocephalus.] Fortschr Neurol Psychiatr. 62(11):405-8, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=7829027%5Bpmid%5D)
|
||||
|
||||
|
||||
## Images
|
||||
|
||||
|
||||
### Selected Images
|
||||
|
||||
|
||||
*Axial NECT shows acute subarachnoid hemorrhage <img src='/img/arrows/CC.png'/> in the basal cisterns and early extraventricular obstructive hydrocephalus with dilatation of all the ventricles and subtle periventricular hypodensity <img src='/img/arrows/CO.png'/> due to interstitial edema.*
|
||||
|
||||
|
||||
*Axial NECT shows acute subarachnoid hemorrhage <img src='/img/arrows/CC.png'/> in the basal cisterns and early extraventricular obstructive hydrocephalus with dilatation of all the ventricles and subtle periventricular hypodensity <img src='/img/arrows/CO.png'/> due to interstitial edema.*
|
||||
|
||||
|
||||
*Axial FLAIR MR images (top) in a patient with breast carcinoma leptomeningeal metastasis shows dilatation of the ventricles <img src='/img/arrows/CS.png'/> with mild periventricular interstitial edema <img src='/img/arrows/CO.png'/>. Axial T1 C+ MR (bottom) shows extensive leptomeningeal enhancement <img src='/img/arrows/CC.png'/> along the cerebellar folia.*
|
||||
|
||||
|
||||
*Axial T2 MR in a 21-year-old patient with a remote history of meningitis shows chronic "compensated" extraventricular communicating hydrocephalus with marked dilatation of the lateral <img src='/img/arrows/CC.png'/> and 3rd ventricles <img src='/img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
*Sagittal T1 MR in the same patient shows a patent widened cerebral aqueduct <img src='/img/arrows/CC.png'/> and foramen of Magendie <img src='/img/arrows/CS.png'/> with dilatation of the 4th ventricle <img src='/img/arrows/CO.png'/>. In longstanding "compensated" hydrocephalus, there is no periventricular interstitial edema around the ventricles, as in this case.*
|
||||
|
||||
|
||||
### Additional Images
|
||||
|
||||
|
||||
*Axial T1WI C+ MR demonstrates subtle leptomeningeal enhancement in the left sylvian fissure <img src='/img/arrows/CO.png'/> in this patient with tuberculous meningitis. There is mild dilatation of the lateral ventricles <img src='/img/arrows/CS.png'/> due to extraventricular obstructive hydrocephalus.*
|
||||
|
||||
|
||||
*Coronal T1WI MR in a toddler with rapid head growth for 4 months shows enlarged ventricular trigone on the left and enlarging subarachnoid spaces at an age when they should be shrinking. MR venography showed occlusion of both transverse sinuses.*
|
||||
|
||||
|
||||
*Axial NECT shows hyperdense material in the basal cisterns <img src='/img/arrows/BS.png'/> and sylvian fissures <img src='/img/arrows/BO.png'/> in acute subarachnoid hemorrhage. There is early dilatation of the ventricles <img src='/img/arrows/CO.png'/> with mild periventricular edema <img src='/img/arrows/CS.png'/> due to interstitial edema.*
|
||||
|
||||
|
||||
*Axial NECT shows acute subarachnoid hemorrhage in the basal cisterns <img src='/img/arrows/CC.png'/> and sylvian fissures <img src='/img/arrows/CS.png'/>. There is early extraventricular obstructive hydrocephalus with mild periventricular hypodensity <img src='/img/arrows/CO.png'/> due to interstitial edema.*
|
||||
|
||||
|
||||
*Axial T1WI C+ MR shows extensive leptomeningeal enhancement of the basal cisterns in neurosarcoidosis <img src='/img/arrows/CS.png'/>. Notice the early communicating hydrocephalus with the dilated 3rd ventricle <img src='/img/arrows/CC.png'/> and temporal horns <img src='/img/arrows/CO.png'/>.*
|
||||
|
||||
Reference in New Issue
Block a user