Neurosurgery

presence of intraventricular extension or ventricular enlargement. The presence of blood and its breakdown products within the CSF may lead to an ependymal reaction, with blockage at the narrower points of the CSF circulation, such as the aqueduct or the outlet foramina of the fourth ventricle with the subsequent development of an obstructive (non-communicating) hydrocephalus. More commonly, the blood products cause an obstruction at the level of the subarachnoid space and arachnoid villi, leading to a communicating hydrocephalus.

Increasing head circumference and progressive ventricular enlargement indicate the need for intervention. A number of therapeutic options are available. The presence of heavy blood staining or excessive amounts of pro-teinaceous materials and cellular debris in the CSF precludes the early insertion of a shunt. Moreover, in the premature, low-birth-weight infant, the high risk of shunt infection is an additional concern (see above). Temporizing measures may include serial lumbar punctures or ventricular taps via the fontanelle. If repeated ventricular taps are necessary, there is a risk of causing damage to the cerebral mantle, producing areas of porencephaly. This risk can possibly be minimized by the placement of a ventricular catheter and subcutaneous reservoir. CSF can then be aspirated from the reservoir, thus avoiding repeated cerebral puncture. Recent review of the literature has not found evidence to support the use of repeated lumbar puncture or ventricular taps as a means of either reducing death or disability or the need for shunt placement [4a].

Medical measures to control the ventricular dilation are also employed. Acetazolamide, alone or in combination with furosemide, has been used and some have even suggested that such a regime may avoid the need for subsequent shunt placement. Recent evidence, however, has questioned the clinical efficacy of such regimes [5].

Lately, it has been suggested that intraventricular fibrinolytic therapy, instituted soon after the hemorrhage is diagnosed, may prevent the chemical arachnoiditis that develops in response to intraventricular hemorrhage and thus reduce the number of these infants requiring shunt insertion.

Whatever method of treatment employed, it is important that progress is monitored by means of regular clinical evaluation, head circumference measurements and ultrasonogra-

phy. If progressive hydrocephalus is present, then once the CSF is clear of blood products, a shunt procedure can be performed.

Cure Your Yeast Infection For Good

Cure Your Yeast Infection For Good

The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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