Diagnosing early upward cerebellar herniation by computed tomography: A diagnostic boom, a savior

Singla, Navneet; Kapoor, Ankur; Chatterjee, Debajyoti

doi:10.4103/2152-7806.185009

Cited by 1 publication

(5 citation statements)

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“…[4] Although it is a common presenting pattern the optimal management of hydrocephalus with posterior fossa tumor is still a controversial topic and it can include CSF diversion before tumor resection in the form of ETV/EVD/VPS or doing the definitive surgery from the outset [5] A rare but feared complication is upward herniation +/-intra tumoral bleeding which leads to sudden clinical deterioration and often death. [15] A study in Egypt tried to evaluate the rate of posterior fossa complication after CSF diversion done for acute obstructive hydrocephalus from posterior fossa tumor and the risk of deterioration was 2.3% [6]. Which is less than our findings of 8.9%.…”

Section: Discussioncontrasting

confidence: 55%

“…Similarly, ETV is helpful by avoiding the need of a permanent shunt, with the disadvantage being the loss of control of CSF diversion. [3] Inserting VPS for the management of obstructive hydrocephalus with posterior fossa tumor is a common method used to stabilize patients prior to definitive craniotomy. In a study that tried to evaluate the complication rate of patients with posterior fossa tumors with hydrocephalus (total number of patients 345) which tried to compare shunted (165 patients) from non-shunted group, the mortality rate was 10% in the shunted group which was higher than the nonshunted group and 9 patients developed hematoma after shunting of which 2 of them died.…”

Section: Literature Reviewmentioning

confidence: 99%

“…[11] Many have debated that immediate tumor removal may normalize CSF dynamics as well as control ICP and doing CSF diversion before the primary surgery comes with early risks of intratumoral bleeding and upward herniation, as well as late complications like infection and potential seeding of the tumor via the diversion route. [15] Ascending trans-tentorial herniation (upward herniation) is a life-threatening event where space occupying lesion in the posterior fossa cause superior displacement of superior part of the cerebellum through the tentorial notch. [4], new intra tumoral hemorrhage and effacement of quadrigeminal cistern on imaging have been used to assess herniation [15], this often leads to sudden clinical deterioration, with decreased level of conscious, respiratory deterioration [15] and often death.…”

Section: Literature Reviewmentioning

confidence: 99%

“…[15] Ascending trans-tentorial herniation (upward herniation) is a life-threatening event where space occupying lesion in the posterior fossa cause superior displacement of superior part of the cerebellum through the tentorial notch. [4], new intra tumoral hemorrhage and effacement of quadrigeminal cistern on imaging have been used to assess herniation [15], this often leads to sudden clinical deterioration, with decreased level of conscious, respiratory deterioration [15] and often death. Displacement of the cerebellum through the tentorial incisura is more likely to occur when the mass originates near the incisura, when drainage of the lateral ventricles relieves obstructive hydrocephalus and reduces pressure above, and when the opening in the tentorium is large.…”

Section: Literature Reviewmentioning

confidence: 99%

“…From this group of patients only 1 survived in vegetative state while the rest died. [6] Ascending trans-tentorial herniation can be assessed using imaging which show flattening of quadrigeminal cistern, obliteration quadrigeminal cistern [15] and superior cerebellar cistern, spinning top appearance of midbrain from bilateral compression of posterior part of midbrain, infarction of posterior cerebellar artery and superior cerebellar artery and hydrocephalus form compression to the cerebral aqueduct. [17,18,19] The incidence of upward trans-tentorial herniation is rare, 3% after ventriculoperitoneal shunt insertion and the most commonly attributed lesion is a cerebellar mass in 65% followed by lesions in the cerebello-pontine angle (CPA) 13%, pones 11% and the fourth ventricle.…”

Section: Literature Reviewmentioning

confidence: 99%

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Acute Complications of Pre-Resection CSF Diversion in Posterior Fossa Tumors with Hydrocephalus

Moges

2023

SVOANE

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Study background and significance: Posterior fossa tumors are a common pathology worldwide and often present with obstructive hydrocephalus. In the year 2021 CSF diversion for acute hydrocephalus from brain tumors was the most common performed emergency procedure in Tikur Anbessa hospital. It is a clinical dilemma choosing the mode of management for the hydrocephalus as it could be a lifesaving procedure but with a risk of unfortunate and devastating outcome. Objective: The aim of the study will be to evaluate the acute complications that occur with CSF diversion procedures that are done for obstructive hydrocephalus in the presence of posterior fossa mass before tumor resection. Method: It will be prospective observational study conducted at Tikur anbessa specialized hospital, which will be held from March 2021 up to October 2022. The research will involve all patients who have undergone CSF diversion procedure for obstructive hydrocephalus from posterior fossa tumors prior to tumor resection and patients will be followed for the first 48 hours post operatively. Patient’s presentation, nature of the posterior fossa tumor on imaging, post-operative clinical status and post op imaging will be taken to account. Result: In the study time frame of 18 months there were 89 patients who came with acute obstructive hydrocephalus from posterior fossa of which all underwent CSF diversion procedure before tumor resection. 52.8% were pediatrics and 47.2% where adults. The most common tumor location was vermian (31.5%) followed by cerebellar hemisphere (29.2%), 4th ventricular (25.8%) and the rest 9% account for cranial nerve and extra axial location. The largest tumor was 9.8cm but the median was 5.1cm. Based on the size they were categorized in to 3 groups, 71.9% were tumor size 4-6cm, 22.5% had a tumor size of >6cm and there were 5.6% with tumor size <4cm. Of the CSF diversion procedures performed 93.3% were VPS, EVD and ETV account for 3.4% each. All were followed for 48 hours post op and 8 patients had clinical deterioration after CSF diversion was done, and all patients with clinical deterioration underwent urgent non -contrast CT scan. They were found to have upward herniation, intra-tumoral bleeding, intraventricular hemorrhage or a combination of these findings. Of the 8 patients that deteriorated 5 died without successful resuscitation. The rest 3 improved and underwent definitive surgery. The risk for postoperative deterioration was 8.9% and 48-hour mortality was 5.6%. Variables were chosen to check association with the outcome (post-operative deterioration). Variables tested include age of the patient, tumor size and tumor location, all did not have statistically significant relationship with outcome (post-operative deterioration and 48-hour mortality). The association between the type of intervention and outcome could not be checked as there were not enough samples representing ETV/EVD performed, and majority (93.3%) were VPS. Conclusion: Through our research we tried to investigate the causes of acute deterioration after CSF diversion done for obstructive hydrocephalus from posterior fossa tumors by assessing the tumor size, location the type of intervention. Through our research we were not able to find any association from investigated factors and post-operative deterioration. Because of our limitation (the low number of sample size and not having enough number of ETV and EVD in the study population) we recommend further research is needed to have more information in this problem.

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