and congenital hydrocephalus: Center Of ExcellenceFetal and Congenital Hydrocephalus Top 10 Japan Guideline 2011 Shizuo Oi & Takayuki Inagaki & Masaki Shinoda & Satoshi Takahashi & Shigeki Ono & Isao Date & Sadahiro Nomura & Tomoru Miwa & Takashi Araki & Susumu Ito & Hisaaki Uchikado & Osamu Takemoto & Reizo Shirane & Hiroshi Nishimoto & Yuzuru Tashiro & Akira Matsumura & COEFetal and Congenital Hydrocephalus Top 10 Japan Study Group Received: 24 July 2011 / Accepted: 25 July 2011 # Springer-Verlag 2011 Abstract Introduction Hydrocephalus does not indicate a single clin- ical entity, but includes a variety of clinicopathological conditions caused by excessive cerebrospinal fluid (CSF) based on the disturbed circulation. Recent progress in prenatal neuroimagings such as MRI and ultrasound echoencephalog- raphy on fetus enables to understand clinicopathological conditions of CSF circulation disorder in conjunction with morphological changes in the central nervous systemproperly. It has been revealed that the CSF dynamics develop in the theory of evolution from the immature brain, as in the animals with the minor CSF pathway predominance, towards matured adult human brain together with the completion of the major CSF pathway: the Evolution Theory in CSF Dynamics. Now, we can analyze CSF circulation dynamically and also analyze the flow velocity and direction of CSF movement. S. Oi (*) Health Sciences Asia Executive Dean Office, Japan International University, 2-18-1 Nakoji, Amagasaki, Hyogo 661-8530, Japan e-mail: shizambroi@aol.com T. Inagaki Department of Neurosurgery, Kansai Medical University, 10-15, Fumizono, Moriguchi, Osaka, Japan M. Shinoda Department of Neurosurgery, St. Lukes International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan S. Takahashi Department of Neurosurgery, Keio University, 35 Shinano machi, Shinjuku-ku, Tokyo, Japan S. Ono : I. Date Department of Neurosurgery, Okayama University, 1-1-1 Tsushima naka, Kita-ku, Okayama, Japan S. Nomura Department of Neurosurgery, Yamaguchi University, 1-1-1 Minamiogushi, Ube, Yamaguchi, Japan T. Miwa Department of Neurosurgery, Jikei University, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, Japan T. Araki Department of Neurosurgery, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan S. Ito Department of Neurosurgery, Kanagawa Childrens Medical Center, 2-138-4 Mutsugawa, Minami-ku, Yokohama, Kanagawa, Japan H. Uchikado Department of Neurosurgery, Kurume University, 67 Asahi, Kurume, Fukuoka, Japan Childs Nerv Syst (2011) 27:15631570 DOI 10.1007/s00381-011-1541-7 Center of ExcellenceFetal Hydrocephalus Top 10 Japan A- long with this technical improvement, the standards of clinicopathological evaluation of hydrocephalus as well as the classification and concept of hydrocephalus shall undergo a major upgrade. Based on such remarkable improvement in the recent practical diagnostic evaluation of fetal hydrocephalus, it is now required to update the guideline for management and treatment of fetal and congenital hydrocephalus, and a nationwide study group; Center of ExcellenceFetal Hydrocephalus Top 10 Japan, was organized in 2008 in Japan. The retrospective analysis of 333 cases of congenital hydrocephalus indicated a fact that 43% of these cases were diagnosed prenatally, and the majority of cases were treated in these top 10 institutes in Japan. Now, congenital hydrocephalus diagnosed immedi- ately after birth is regarded as to be based on embryonic stage; brain disorder in patients with congenital hydroceph- alus should be considered in conjunction with neuronal mature process of embryonic stage. The fact is supported by the current trends in hydrocephalus research represented by Perspective Classification of Congenital Hydrocephalus and Multi-categorical Hydrocephalus Classification. The ultimate goal of hydrocephalus treatment remains achieving arrested hydrocephalus by shunt surgeries. In the future, to achieve arrested hydrocephalus, minimum quantity of CSF to be drained should be elucidated. Consideration for accurate operative indication of ETValong with new neuro- endoscopic device development and analysis of CSF circulation is expected in the future. The data in this prospective multicenter analysis in this guideline are credited in Oxford Evidence level 2b (Grade II). Keywords Hydrocephalus . Fetal hydrocephalus . Guideline . Prenatal diagnosis . Postnatal outcome Introduction Progress of prenatal radiological diagnosis in the field of hydrocephalus research gives us a lot of novel insights. With the modality, now we can understand hydrocephalus from their embryological aspects along with chronological change of their pathophysiology. Clinically, it has been also utilized to make guidelines based on prospective data collection or to build up a medical team that can manage patients with hydrocephalus from prenatal periods. This is the guideline that was built up based on the data collected by means of prospective, multicenter, and blinded manner. Material and method The aim of this study is to understand the incidence and type of fetal hydrocephalus in Japan. We sent the questionnaire to the educational hospitals in Japan to know the annual number of the patients of hydrocephalus they diagnosed at year 2008. The retrospective analysis of 333 cases of congenital hydrocephalus indicated a fact that 43% of these cases were diagnosed prenatally, and the majority of cases were treated in these top 10 institutes in Japan. We then selected 10 institutes according to the number of hydrocephalus patients treated. We collected the data from those institutes afterwards. We carefully examined the medical records we collected. Inclusion is the patient diagnosis in utero and the diagnosis was made until 1 year of age. Classification of hydrocephalus was made based upon the neuroradiological findings and obtained informa- tion. Perspective Classification of Congenital Hydrocepha- lus (PCCH) and Multi-categorical Hydrocephalus Classification (McHC) was used. The timing of onset or diagnosis of hydrocephalus, the classification of the hydrocephalus, associate anomalies, timing of operation, and development quotient (DQ) during the follow-up was analyzed prospectively. Center of ExcellenceFetal and Congenital Hydrocephalus Top 10 Guideline 2011 The institutes selected for this study are the following 10 institutes: Osaka Medical Center and Research Institute for Maternal and Child Health, Kanagawa Children's Medical Center, Kansai Medical University, Kurume University, National Center for Child Health and Development, O. Takemoto Department of Neurosurgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodou, Izumi, Osaka, Japan R. Shirane Department of Neurosurgery, Miyage Childrens Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, Miyagi, Japan H. Nishimoto Department of Neurosurgery, Saitama Childrens Medical Center, 2100 Ooaza-Magome, Iwatsuki-ku, Saitama, Japan Y. Tashiro Department of Neurosurgery, Shizuoka Childrens Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Japan A. Matsumura Department of Neurosurgery, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaragi, Japan 1564 Childs Nerv Syst (2011) 27:15631570 Saitama Children's Medical Center, Sizuoka Children's Hospital, Tsukuba University, Tokyo Jikei University, and Miyagi Children's Hospital. The total number of patients and the detailed information obtained was 107 (Fig. 1). Fifty-five patients were diagnosed in utero (51.4%). The period of diagnosis was from 16 to 37 weeks of gestation (mean, 26.1 week). Remaining 52 patients were diagnosed after birth. The timing of diagnosis was from 0 day to 12 month after birth (mean, 59.1 day). In one case, father has the history of hydrocephalus. Three cases had the chromosomal abnormalities. Two cases had gene abnor- malities. The cause of hydrocephalus varied (Fig. 2). Myeloschisis and post-hemorrhagic hydrocephalus are the most common cause of hydrocephalus in this series. It was almost the same incidence of previously reported Japanese congenital hydrocephalus study. Eighty-four patients were operated with reservoir placement, shunt placement and/or neuroendoscopic surgery (78.5%). Seventy-four patients out of 84 required shunt placement. Shunt repair was performed in 24 out of 74 cases (28.6%), so far (Fig. 3). The DQ was also measured. There is a tendency that the patients with epilepsy have low DQ compared with the patients without epilepsy. Slow progressive or arrested hydrocephalus patients have high DQ (Figs. 4 and 5). Cerebrospinal fluid and its circulation in fetus and neonates In adults, CSF is generated by filtration or secretion from ventricular colloid plexus or blood vessels, and is absorbed in venous sinus via pacchionian body or blood vessels in subarachnoid space. CSF is generated approximately 500 to 600 ml a day. The total amount of CSF in the subarachnoid space is known to be approximately 10% of cranial volume. CSF is totally replaced thrice to four times a day. There are two types of CSF pathway; those are major CSF pathway (consisted of ventricular system and sub- arachnoid space) and minor CSF pathway (consisted of brain and spinal parenchyma, vascular system, nerve root sheath, and pia matter) In pediatric populations, circulation velocity of CSF is faster than adult, and CSF replacement interval is shorter than adult. Pacchionian body, a major player in CSF absorption in major CSF pathway does not appear until infancy. In infancy, pacchionian body gradually appears and starts to acquire function of CSF absorption. CSF pathways of fetus, neonates, and infants are mainly consisted of minor CSF pathway. Major CSF pathway starts to develop gradually from infancy. In animals, birds, rodents, and mammals like Macaca fuscata, the develop- ment of pacchionian body is not observed and CSF circulation is mainly consisted of minor CSF pathways. We herein propose a hypothesis that the CSF dynamics develop in the theory of evolution from the immature brain, as in the animals with the minor CSF pathway predomi- nance, towards matured adult human brain together with completion of the major CSF pathway: the evolution theory in CSF dynamics [5] (Fig. 6). We also herein propose a new aspect of classification for hydrocephalus with special reference to the CSF circulation in the minor CSF pathway, i.e., minor pathway hydrocephalus. The high incidence of failure to arrest hydrocephalus by neuroendoscopic ventriculostomy in fetal, neonatal, and infantile periods was explicable by the specific CSF dynam- ics, in which the major CSF pathway has not developed and the minor pathway has a significant role [8]. Findings of ventriculo-cisternography in a patient with non-communicating hydrocephalus due to aqueduct stenosis treated by endoscopic third ventriculostomy (ETV) in combination with EAP: after outlet of third ventricle was released and aqueduct was re-canalized, congestion of contrast enhanced material inside ventricles and around ventricular ependymal is observed even 4 days after operation. Proposal of classification of fetal hydrocephalus and congenital hydrocephalus Classification of hydrocephalus is in variety. Congenital and acquired hydrocephalus is usually classified independently based on the timing of onset in conjunction with co-existing disease or its pathophysiology. From their pathophysiological aspects, hydrocephalus is classified as communicatingnon-commu- nicating or high pressurenormal pressure based on the changes in CSF dynamics. Most frequently discussed controversy in the field of hydrocephalus is controversy in their classification. Classifi- cation of hydrocephalus such as normal pressure hydroceph- alus, arrested hydrocephalus, or external hydrocephalus should be considered from their chronological change. Hydrocephalus is a pathological state that may change chronologically. In the definition of communicating/non-communicating hydrocephalus by Dandy, communicating hydrocephalus is the form of hydrocephalus in which the injected dye could be detected from the spinal subarachnoid space, and in non- communicating hydrocephalus dye did not reach the spinal Fig. 1 Graph showed the distribution of the patient; approximately 51.4% of the patients were diagnosed in utero Childs Nerv Syst (2011) 27:15631570 1565 subarachnoid space [1]. The concept is different from the concept of obstructive/non-obstructive hydrocephalus by Russell [10]. In the definition of Russell, the obstruction in obstructive hydrocephalus can be at any region in the major CSF pathway including the ventricular system and entire cistern/subarachnoid space, so that the cause or condition for non-obstructive hydrocephalus is limited to either CSF overproduction by choroid plexus papilloma or CSF malabsorption due to sinus thrombosis. Nowadays, the two classifications are sometimes used with confusion. The term normal pressure hydrocephalus (NPH) was firstly proposed by Hakim and Adams in 1964 and 1965. They defined this type of hydrocephalus as a syndrome with surgically treatable specific clinical features such as dementia, urinary incontinence, and gait disturbance [6]. They named the clinical entity as NPH from its pathophys- iological aspects, but nowadays, recent research revealed that the intracranial pressure in patients with NPH is not always uniformly normal pressure. On the other hand, intracranial pressure in pediatric and neonatal population is physiologically lower than in adults. It is controversial whether or not pathophysiological states like NPH exist in pediatric populations or not. Some classifications that describe specific forms of hydrocephalus such as longstanding overt ventriculomegaly in adult (LOVA), hydrocephalus-parkinsonism complex, or hydromyelic hydrocephalus have been proposed. It has not been elucidated until now whether these types of hydro- cephalus existed in pediatric populations or not [7, 9]. As for LOVA, it is estimated that the states of pre-LOVA that is presented as merely enlargement of head circumference without neurological abnormality may exist before it has become clinically relevant LOVA. Multicenter study of pediatric hydrocephalus in Japan recently revealed the existence of pre-LOVA but the pathophysiology of pre-LOVA has not been fully determined yet. Patients with pre-LOVA are considered to show normal DQ and intelligence quotient (IQ). From these findings, to classify hydrocephalus in fetus and neonates, it is important to pay attention to when hydroceph- alus occurs and how it would change chronologically. We recommend using PCCHthat focuses on the timing of onset of hydrocephalus and their chronological change [2]. There exists hydrocephalus which can be classified to multi-categorical subtypes. To explain the features of Fig. 4 Difference in DQ between progressive and slow-progressive or arrested hydrocephalus (based upon McHC classification) Fig. 3 Graph indicates the shunt survival Fig. 2 The graph showed the number of cases according the cause of hydrocephalus (since some cases were classified more than two categories, one of the main was shown on the graph) 1566 Childs Nerv Syst (2011) 27:15631570 hydrocephalus individually in detailed exposition, Multi- categorical Hydrocephalus Classification (McHC) is ex- tremely useful. [3, 4]. McHC classification of hydrocephalus classify hydroceph- alus by 10 headings consisted of three subjects of patients characteristics, CSF, and treatment. It is the most detailed classification of hydrocephalus ever proposed that can classify hydrocephalus into as many as 72,576,000 types. It involves many previously proposed classification of hydrocephalus from classical classification of communicating/non-communi- cating hydrocephalus and obstructive/non-obstructive hydro- cephalus to modern classification of evolution theory of CSF dynamics and hydrocephalus chronology in adults. It is recommended to perform intrauterine MRI at least once in 4 weeks to evaluate the progression of hydroceph- alus. Certainly, there exist some cases with fetal hydro- cephalus in that the hydrocephalus progresses in rush. In that case, PCCH stage of the patient should be determined from pathophysiological change of hydrocephalus in the patient. Acase with PCCH stage II fetal hydrocephalus which showed rapid progression of progressive hydrocephalus Proposal concerning about treatment of fetal/congenital hydrocephalus To change progressive pathophysiology of hydrocephalus into the state of arrested hydrocephalus is the aim in the treatment of hydrocephalus. Progressive hydrocephalus will rarely change into arrested hydroceph- alus spontaneously; however, in many cases, shunt proce- dures are required. Many patients with hydrocephalus, other than patients with non-communicating hydrocephalus, due to third ventricular brain tumor have brain tumor removal to cure hydrocephalus and maintain their brain function relying on shunt system. There are many types of shunt system nowadays. Most frequently used shunt system is the three-piece shunt system that consists of three parts: these are the flushing device, valve, and chamber. Shunt system should not be specified in any guideline, and it should be selected depending on the pathophysio- logical states of hydrocephalus in each patient. Pathophys- iological states of hydrocephalus in each patient should be determined depending on categories VI and VII of McHC classification of hydrocephalus. When to operate patients with hydrocephalus varies in each patient; however, it should be conducted before without epilepsy with epilepsy Fig. 5 There is the significant difference in development between the cases with and without epilepsy Fig. 6 Showed the CSF dynamics maturation, so called evolution theory of CSF dynamics (5) Childs Nerv Syst (2011) 27:15631570 1567 irreversible change would be occur to brain parenchyma. Especially in smaller children, the neurosurgeon should pay attention not to miss the timing of surgery. ETVis only effective in patients with non-communicating hydrocephalus. In pediatric patients who are less than 1 year old, CSF circulation mainly depends on minor CSF pathway. ETVis useful only in patients whose CSF circulation mainly depends on major CSF pathway; however, some specialists do not recommend performing ETV to this patient population (Fig. 7). Main principle of treating patients with hydrocephalus is aiming to arrest hydrocephalus considering normal physi- ological function of CSF. In this context, endoscopic surgical ablation of colloid plexus aiming to the reduction of CSF production may result in impairment of CSF flow, thus its usability remains to be controversial for now. Complication of shunt surgery: concepts and classifica- tion Complication of shunt surgery can be classified into four major categories: those are shunt malfunction, infection, over drainage, and surgical complication. One of the factors that greatly affects surgical outcome is shunt management after operation. Chronological change in physiology of hydrocephalus should be stressed in the management of shunt system. A great variety of complications associated with shunt system including shunt closure or infection have been reported so for. Complications associated with shunt systems or surgical procedures have been also documented so far. Obstruction of shunt device is known to be caused by the following reasons. Major causes of obstruction in ventricular side are connective tissue, inflammatory tissues, necrotic tissues, and colloid plexus. On the contrary, major causes of obstruction in abdominal side are greater omentum and cystic change of tissues. Clinical manifestation of shunt malfunction varies depending on pathophysiology of hydrocephalus and patients' age. To diagnose shunt malfunction with only flushing device compression findings is difficult. Shunt malfunction is not always presented with ventricular en- largement. In those patients continuous ICP evaluation is extremely useful. Shunt obstruction should be treated by shunt reconstruction as soon as possible. Number of shunt reconstructions does not affect prognosis. Clinical manifestation of shunt infection varies accord- ing to types of shunt surgery. Typical signs of shunt infection after VA shunt are fever and cough, and sign of shunt infection after VP shunt is abdominal pain. When the signs and symptoms of meningitis presents, a diagnosis of shunt infection is definitive; however, only one third of all the patients with shunt infection present the sign of meningitis while around 80% of the patients present fever. As many as two thirds of shunt infection occur within 4 months from shunt surgery; however, more than 20% of shunt infection may occur after more than 1 year from shunt surgery. A flare or swelling of the skin along with shunt tube tract should be regarded as the sign of infection. Increased cell counts and protein level in conjunction with decreased glucose level in CSF is the typical findings for shunt infection. Sometimes, CSF culture would be exam- ined in an attempt of identify pathogenic bacteria. In cases in which infection is localized at the site of wound or shunt tube tract, CSF findings can be within normal limit. Shunt tube in patients suffering from shunt infection should be removed, and external ventricular drainage should be placed instead. Keep ICP within normal range Fig. 7 Showed the case in which the ETV did not improved the patient's condition 1568 Childs Nerv Syst (2011) 27:15631570 with ventricular drainage, administrate antibiotics, and wait until infection disappears. After infection disappears, ventricular drainage should be removed and shunt recon- struction should be done. Subdural hematoma after shunt surgery: CSF over drainage after shunt placement sometimes results in slit ventricle syndrome. In this situation, deterioration of brain compliance resulted in laceration of brain surface vein and may cause subdural hematoma. In patients with slit ventricle syndrome, ICP may raise without ventricular enlargement. In these situations, surgeries that can decrease the amount of drained CSF should be considered. Pathophysiology of isolated fourth ventricle syndrome is considered to be aqueduct stenosis after shunt placement in patients with obstruction of outlet of fourth ventricle. There are various opinions in terms of functional aqueduct stenosis in this clinical entity (Fig. 8). Prognosis of fetal/congenital hydrocephalus Both patients and therapeutic factors define prognosis of hydrocephalus. Recent data shows that the frequency of super high IQ patients is statistically higher in patients after hydrocepha- lus treatment. As for prognosis of hydrocephalus, prognosis of simple hydrocephalus is usually good. On the contrary, DQ in patients with syndromic hydrocephalus remains to be poor. Progressive ventricular enlargement and existence of convulsion are shown to be negative prognostic factors. From these findings, we think that McHC classification based on PCCH stage can predict prognosis of pediatric patientswith hydrocephalus (from the result of prospective study of COE top 10 Japan). In hydrocephalus patients without brain anomaly, progno- ses are not always pessimistic, and patients can showDQover 80 with adequate treatment timing and proper management after surgery. As noted, our present data shows that there is no statistical significant difference in the prognosis of patients with communicating hydrocephalus and those of patients with non-communicating hydrocephalus. Underlining lesion of hydrocephalus and existence of convulsion are proved to be statistically significant prognostic factors. Shunt malfunction In terms of mechanical obstruction, major causes of obstruction in ventricular side of VP shunt are connective tissue, inflammatory tissues, and colloid plexus. On the contrary, major causes of obstruction in abdominal side of VP shunt are connective tissue, inflam- matory tissue, necrotic tissue, and fibrous tissue. Even if there is no obstruction inside the shunt tube, bending, laceration, or relative shortening (according to growth) of shunt tube can cause shunt malfunction. Ventricular end of shunt tube should be placed apart from colloid plexus. Factors such as patients' age or underlining lesion for hydrocephalus also affect shunt closure. In immature brain, shunt obstruction occurs more frequently. Shunt obstruction Fig. 8 The heavily-T2-weighted fast-spine-echo MR image demon- strated severe triventricular hydrocephalus, likely due to aqueductal stenosis, at 27 weeks in gestational age (a, c, e). The fetal MR images follow up at 33-weeks gestational age (b, d, f) disclosed more expanded ventriculomegaly and macrocephalus with more severely comparessed/thinning brain mantle suggesting a fact of rapid progression of fetal hydrocephalus before birth [4] Childs Nerv Syst (2011) 27:15631570 1569 frequently occurs within 5 months from shunt placement. As for location, it occurs more frequently in abdominal end compared to ventricular end. Most frequently identified pathogenic bacteria at the time of shunt infection is known to be Staphylococcus epidermidis, and when the second frequently identified pathogenic bacteria, Staphylococcus aureus is added, they occupy 70% of all the pathogenic bacteria that cause shunt infection. Breakdowns of remaining 30% are consisted of mainly gram-negative bacteria and gram-positive bacteria other than the two above-described bacteria. Shunt infec- tion rates in pediatric populations is reported to consider- able variety; 2% to 30%. References 1. 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Oi S, Honda Y, Hidaka M, Sato O, Matsumoto S (1998) Intrauterine high-resolution magnetic resonance imaging in fetal hydrocephalus and prenatal estimation of postnatal outcomes with perspective classification. J Neurosurg 88: 685694 7. Oi S, Kim DS, Hidaka M (2004) Hydrocephalus-parkinsonism complex: progressive hydrocephalus as a factor affecting extra- pyramidal tract disorderan experimental study. Childs Nerv Syst 20:3740 8. Oi S, Luedemann W, Samii W, Samii M (2009) Evolution theory in cerebrospinal fluid dynamics: a hypothesis for failure of neuroendoscopic ventriculostomy in treatmen of hydroceph- alus in fetal, neonatal and early infantile periods. J Hydroceph 1:210 9. Oi S, Shimoda M, Honda Y, Togo K, Shinoda M, Tsugano R, Sato O (2000) Pathophysiology of long-standing overt ventriculome- galy in adults. J Neurosurg 92:933940 10. Russell D (1949) Observation on the pathology of hydrocephalus, Medical Research Council Special Report Series No. 265., His Majesty's Stationary Office: London. pp. 112113. 1570 Childs Nerv Syst (2011) 27:15631570 Copyright of Child's Nervous System is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.