Diagnose & Treatment
Diagnosis of Hydrocephalus and Intracranial Cysts
Hydrocephalus and intracranial cysts may be caused by other conditions, which is why an accurate diagnosis is critical to determining the most effective treatment. In addition to a physical examination and complete medical history, a neurological examination is typically performed to identify alterations in your child’s brain function and mental status. This exam consists of assessing eye movements, vision, hearing, swallowing, motor function, sensation, balance, and coordination.
Your child will also likely be referred for imaging tests such as magnetic resonance imaging (MRI) or computerized tomography (CT) scans which produce detailed images of the brain and spine. MRI offers very detailed information based on specific imaging sequences that your neurosurgeon may request. Frequently, an additional MRI scan is requested even though one has already been done. These special sequences can be used to visualize flow, tiny structural lesions, webs of tissue, cyst membranes, inconspicuous tumors, and cyst composition. This detail is crucial for an accurate diagnosis and selecting the best for of treatment.
In infants, ultrasound may also be used as part of the diagnostic work-up taking advantage of the open soft spot through which the ultrasound waves can travel. For this procedure children do not require sedation; however, the images are far less detailed than either CT or MRI.
Our experienced pediatric neurosurgeons recommend the study that’s best for your child. The study is performed in a Pediatric Neurosurgery Center with technology and safe sedation programs designed for children and their unique needs.
Treatment for Hydrocephalus
If a hydrocephalus diagnosis has been made, there are rarely options other than surgery for treatment. If a definable mass is causing the obstruction of CSF flow, it may be possible to remove the mass and allow for normal flow and resolution of the hydrocephalus. However, more often than not, the blockage cannot be removed, and surgical intervention to reroute the fluid is needed.
Shunt Placement
Surgery for hydrocephalus often means implanting a shunt, a small tube that drains the excess fluid from the brain to another location in the body, usually the abdominal cavity, for reabsorption. A device called a ventriculoperitoneal shunt drains the excess CSF from the brain to the abdominal cavity. These shunts are very effective in relieving hydrocephalus, but they do carry a risk of infection or blockage. The placement of a shunt is compatible with a normal life extending well into adulthood in most cases.
Endoscopic Third Ventriculostomy
More recently, treatment for obstructive (non-communicating) hydrocephalus involves an advanced minimally invasive endoscopic approach called endoscopic third ventriculostomy (ETV) that is safe and short, lasting approximately 30 minutes. It's a minimally invasive surgical alternative to shunt placement.
This minimally invasive “shunt free” technique involves the use of small caliber endoscopes. ETV involves making a small (just 3 or 4 mm) opening between the third ventricle and the subarachnoid space, therefore re-establishing normal CSF flow. The majority of patients stay in the hospital for only one night. Because there is no implanted device there is no risk of shunt infection or mechanical malfunction.
Follow-up Treatment
It is important for the doctors taking care of a child with hydrocephalus to have expertise in determining whether the problem has resolved or requires additional treatment. Resolved hydrocephalus may leave behind enlarged ventricles that are stable. It can sometimes be difficult to distinguish between enlarged, stable ventricles and unstable ones. Often the decision about whether additional treatment is necessary will be based on many factors, including symptoms, neurological exam findings, changes in level of activity or school performance. In addition to this, often the child will have serial radiographic exams to look for changes in the ventricles.
Treatment for Intracranial Cysts
An intracranial cyst that does not cause any symptoms may not require treatment at all — a neurosurgeon might typically recommend follow-up imaging every so often to monitor the cyst’s growth.
If a cyst is causing symptoms, however, it may be necessary to operate. If left untreated, an intracranial cyst may not only continue to cause headaches and other symptoms, it may also create pressure against healthy brain tissue and lead to neurological damage.
There are three surgical options for treating an intracranial cyst:
Shunt Placement
Permanent drainage system is a type of shunt to drain fluid from the cyst and reduce pressure from the cyst on the brain. Shunt placement is a minimally invasive procedure and may be appealing due to the simplicity of the operation.
Craniotomy Fenestration or Removal
An open surgical procedure called fenestration is more complex than the surgery to install a shunt, but the success rates are very good. In a fenestration, the pediatric neurosurgeon opens the skull to gain access to the cyst, then opens the cyst to release pressure allowing the contents to be absorbed naturally by the brain. Opening the cyst is usually a permanent solution, and it avoids the need to permanent implanted shunt hardware.
Endoscopic Cyst Fenestration
Our surgeons have championed the application of endoscopic surgery for cyst fenestration. Endoscopic cyst fenestration is an advanced technique that has the benefits of fenestration without requiring open surgery, combined with the simplicity of shunting without the risk of shunt complications. It’s a short, safe procedure in which the neurosurgeon uses an endoscope (a type of tube with a camera), to drain the cyst internally. The procedure takes much less time and patients can usually return home the following day.
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