From the Guidelines
Hydrocephalus after a massive hemispheric infarct should be managed with the placement of a ventricular drain, as this has been shown to be useful in patients with acute hydrocephalus secondary to ischemic stroke. The management of hydrocephalus in this context is critical to prevent further neurological deterioration and improve outcomes. According to the guidelines for the early management of patients with acute ischemic stroke by the American Heart Association/American Stroke Association 1, the placement of a ventricular drain is a recommended intervention for acute hydrocephalus secondary to ischemic stroke, classified as Class I with a Level of Evidence C.
Key Considerations
- The development of hydrocephalus after a massive hemispheric infarct is a complication that requires prompt recognition and treatment to avoid worsening neurological outcomes.
- The use of a ventricular drain is supported by guidelines as a useful intervention for managing acute hydrocephalus in the context of ischemic stroke 1.
- Decompressive surgery for malignant edema of the cerebral hemisphere is also an effective and potentially lifesaving intervention, although decisions regarding its use must consider factors such as patient age and achievable outcome states 1.
- Medical management strategies, including the use of osmotic agents to reduce intracranial pressure, may be employed temporarily while preparing for definitive surgical intervention.
Management Approach
- Early neurosurgical consultation is essential for the optimal management of hydrocephalus after a massive hemispheric infarct.
- Close neurological monitoring, including frequent assessments of consciousness, pupillary responses, and serial imaging, is crucial for detecting signs of neurological worsening.
- The placement of a ventricular drain should be considered as part of the initial management strategy for acute hydrocephalus secondary to ischemic stroke, based on the guidelines 1.
From the Research
Hydrocephalus after Massive Hemispheric Infarct
- Hydrocephalus can occur after a massive hemispheric infarct, which is a devastating disease associated with significant mortality and morbidity 2.
- The management of large hemispheric infarction includes airway management, mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control, as well as surgical management of cerebral edema 2, 3.
- Decompressive craniectomy is an important treatment option for patients with large stroke at high risk for deterioration 3.
- Hydrocephalus can be treated with various methods, including ventricular access devices, external ventricular drains, ventriculosubgaleal shunts, or lumbar punctures 4.
- Endoscopic third ventriculostomy (ETV) is considered a treatment of choice for obstructive hydrocephalus, but its use in premature infants with posthemorrhagic hydrocephalus is not recommended due to insufficient evidence 5, 4.
- Acetazolamide has been suggested as a treatment for normal pressure hydrocephalus, with some studies showing improvement in patients with this condition 6.
- However, the use of acetazolamide and furosemide as methods to reduce the need for shunt placement in premature infants with posthemorrhagic hydrocephalus is not recommended due to high clinical certainty that they are not effective 4.