A historical glimpse into treating childhood hydrocephalus

Pituitary enlargement in patients with cerebrospinal fluid drainage due to ventricular shunt insertion: know the condition and do not mistake for adenoma

OBJECTIVE

Childhood hydrocephalus patients treated by ventriculo-peritoneal (v.-p.) shunting are sometimes referred years after this therapy for evaluation of suspicious pituitary enlargement. Since pituitary size has been shown to depend on cerebrospinal fluid (CSF) pressure, we assume this phenomenon to be caused by shunt overdrainage. Therefore, we studied pituitary size and morphology in shunted hydrocephalus patients with radiological signs of high CSF drainage.

PATIENTS AND METHODS

Retrospective study of pituitary size and morphology in 15 shunted patients with non-tumoral hydrocephalus and 7 shunted hydrocephalus patients due to childhood brain tumor compared to a population mean. In five brain tumor patients also pre- and postsurgical comparisons were performed.

RESULTS

Pituitary mid-sagittal size and pituitary volume were significantly higher in both hydrocephalus groups, compared to the population mean (midsagittal size t = 5.91; p < 0.001; pituitary volume, t = 3.03; p = 0.006). In patients available for pre- and postoperative comparison, there was also a significant increase in pituitary size and volume postoperatively (mean preoperative midsagittal height 2.54 ± 1.0 mm vs. 6.6 ± 0.7 mm post-surgery; mean pre-operative pituitary volume 120.5 ± 69.2 mm³ vs. 368.9 ± 57.9 mm³ post-surgery).

CONCLUSION

Our results confirmed a significant increase in pituitary size and volume, mimicking pituitary pathology, after v.-p. shunt insertion. This phenomenon can be explained by the Monro-Kellie doctrine, stating that intracranial depletion of CSF-as caused by v.p. shunting-leads to compensatory intracranial hyperemia, especially in the venous system, with the consequence of engorged venous sinuses, most likely responsible for enlargement of the pituitary gland.

Fetal therapy for congenital hydrocephalus-where we came from and where we are going

Despite unfavorable outcomes during the early experience with in utero intervention for congenital hydrocephalus, improvements in prenatal diagnosis, patient selection, and fetal surgery techniques have led to a renewed interest in fetal intervention for congenital hydrocephalus. Research studies and clinical evidence shows that postnatal cerebrospinal fluid diversion to release intraventricular pressure and cerebral mantle compression usually arrives late to avoid irreversible brain damage. Make sense to decompress those lateral ventricles as soon as possible during the intrauterine life when hydrocephalus is antenatally detected. We present a historical review of research in animal models as well as clinical experience in the last decades, traveling until the last years when some research fetal therapy groups have made significant progress in recapitulating the prenatal intervention for fetuses with congenital obstructive hydrocephalus.