Pseudotumor Cerebri, Ventricular Drainage, and Neurosurgery

Risk factors

• Female sex

• Overweight

Sinus thrombosis

Endocrinological causes

• Addison’s disease

• Cushing’s disease

• Hypothyroidism

• Hypoparathyroidism

Metabolic causes

• Hypervitaminosis A

Pharmaceutical drugs

• Lithium

• Tetracyclines

• Phenytoin

• Nitrofurantoin

• Sulfamethoxazole

• Phenothiazines

• Chlorpromazine

• Indomethacin

• Amiodarone

• Estrogens

• Corticosteroids

• Growth hormone

• Cyclosporine

• Tamoxifen

Other causes

• Chronic renal failure

• Systemic lupus erythematosus

Diagnosis

Cranial MRI and lumbar puncture. Diagnostic procedures include cranial MRI combined with venous MR angiography (to rule out any space-occupying lesion or sinus thrombosis) and lumbar puncture (to measure CSF pressure):

• Slit ventricles seen on cranial MRI may indicate pseudotumor cerebri, but a normal ventricular width does not exclude the condition.

• Lumbar puncture is performed to detect an increase in intracranial pressure. Opening pressure is greater than 200 mmH₂O; in an overweight person, it is greater than 250 mmH₂O. It is important to measure the pressure with the patient in lateral decubitus. Apart from the increased pressure, the CSF is normal.

Laboratory analysis. Subsequent laboratory tests are necessary to exclude systemic vasculitis (Chap. 10, “Systemic Vasculitis and Connective Tissue Diseases”) and thrombophilia (Table 12.2); the latter is found with a similar frequency as in thrombosis of the sinuses and cerebral veins. As a sign of the slowed turnover of CSF, an increased albumin quotient in the ventricular CSF is expected (Chap. 21, “Proteins”).

External Ventricular Drainage, Ventriculoatrial and Ventriculoperitoneal Shunts

Application

Ventricular drainage is used as follows:

• External ventricular drainage is used to treat acute obstruction of CSF flow, e. g., ventricular tamponade in cases of intracerebral hemorrhage with ventricular invasion, infratentorial space-occupying lesions, or obstructive hydrocephalus due to subarachnoid hemorrhage or meningitis.

• Internal drainage systems (ventriculoperitoneal, ventriculoatrial, and lumboperitoneal shunts) are used to treat chronic obstructions of CSF flow. Drugs may be administered into the CSF system by means of special systems such as the Ommaya reservoir.