This study is an attempt to establish that CSF shunt infection has a role in the aetiology of multiloculated hydrocephalus. The authors carried out a review of 12 cases of multiloculated hydrocephalus who were treated at King Khalid University Hospital between 1988-1994. The multiloculation appears to have developed following the shunt infection in all cases. The hydrocephalus was related to an intraventricular haemorrhage (IVH) in 9 patients and was congenital in 2 patients and post-meningitic in 1 patient. The shunt infection was caused by a gram-negative organism in 8 patients and duration of external ventricular drainage ranged from 9-24 (median 13) days. The diagnosis of multiloculated hydrocephalus was made on average 2 months after the shunt infection. In three patients endoscopic fenestration of intraventricular septations was attempted but was effective in only one case. The other patients were managed by two shunts (9 patients) and three shunts (2 patients). At a mean follow-up of 15 months, the shunt revision rate of the patients was 0.4/year. One patient died of multiple brain abscesses and 6 patients remain severely disabled. The poor outcome may also be related to the original IVH as well as the multiloculated hydrocephalus. The study also shows that patients with post-haemorrhagic hydrocephalus, who develop a shunt infection due to gram-negative organisms and in whom the CSF fails to be cleared of the infection following 12 days of external drainage appear to be at risk of developing multiloculated hydrocephalus.

Intracranial mycotic infections requiring neurosurgical intervention are being diagnosed more frequently. This study is a review of 17 cases of intracranial mycotic infections that were treated in a neurosurgical unit in Saudi Arabia over an 8-year period. A primary focus of infection was identified in 41% of patients while 18% of patients had a predisposing factor. Forty-seven percent of patients presented with a brain abscess (solitary 29%, multiple 18%) while 35% had a granuloma. 18% meningitis and ventriculitis and 12% hydrocephalus. The Aspergillus species and Ramichloridium machenziei were the commonest pathogens. Following the appropriate surgical and antimicrobial treatment, the mortality rate was 41% and there was evidence of residual disease at follow-up in 18%. The reason for a fatal outcome was failure to consider a fungal aetiology and to obtain a tissue diagnosis early-because of late referral (2 cases), as well as failure to respond to antimycotic therapy (4 cases) and rupture of the internal carotid artery due to Aspergillus arteritis (one case). It is concluded that an early tissue diagnosis is crucial in the management of intracranial mycotic infection so that the appropriate surgical and antimycotic treatment can be started early.

Massive bilateral infarcts due to deep venous system thrombosis are extremely rare and poorly documented. We present a case with computed tomographic evidence of both thrombosis and infarction of the whole deep venous system. A previously healthy 30-year-old woman who had taken oral contraceptives for 3 years complained of recurrent headaches and transient visual obscuration. Three months later, she suddenly became comatose and was found to have papilledema. She rapidly worsened, became decerebrate, and died within 48 hours. Noncontrast computed tomographic scan showed the spontaneous hyperdensity of the thrombosed deep veins and a massive bilateral centrobasilar hypodensity suggestive of a deep venous system infarction. This case shows that cerebral venous thrombosis can masquerade during 3 months as benign intracranial hypertension and then make a dramatic extension to the deep cerebral veins. It illustrates extensive thrombosis of the deep venous system as a possible cause of rapid coma and decerebration and stresses the importance of computed tomographic scan to show both the thrombosed veins and the venous infarct, which allows delineation of the deep venous system territory.

Two cases of orbito-cranial injury caused by foreign bodies (FBs) penetrating the lateral wall and roof of the orbit are described. In the first patient, a long rusted nail acted as a missile and was only detected by X-rays and CT scan. The nail penetrated the orbit, the eyeball, the lateral orbital wall, and the temporal lobe of the brain. Lodged partly in the orbit and partly in the brain, this nail caused leakage of cerebrospinal fluid (CSF) through eye and led to orbital cellulitis and localized meningitis. The foreign body (FB) was removed through an extradural pterional approach with rapid resolution of orbital cellulitis and meningitis. In the second patient, large metallic FB, having penetrated the orbital roof was lodged intracranially above the chiasma. This was removed via frontal craniotomy. Mechanism of such injuries and appropriate surgical approaches are described as well.

The authors calculated the shunt revision rate for 77 consecutive patients with tumoural obstructive hydrocephalus. At a mean follow up of 23.7 months, the annual revision rate was 0.06 which is significantly lower than the annual revision rate of 0.39 for other hydrocephalic patients treated during the same period. Shunted patients who had total excision of their lesions had a significantly lower revision rate than patients who had a partial excision or a biopsy. It is therefore, suggested that cases with tumoural obstructive hydrocephalus may represent a subset of hydrocephalic patients who are associated with a relatively low risk of shunt complications. The observation has to be addressed when the role of endoscopic third ventriculostomy in these patients is being considered.