Case Description:
A seven-year-old patient reported to opd with complaints of drowsiness,
gait disturbances and episodic loss of consciousness accompanied by a
history of irrelevant mumbling for two weeks. Furthermore, sleep
irregularities and disturbed behaviour were present. The patient’s
weight was measured to be 14 kg. On enquiring further, a past surgical
history of a ventriculoperitoneal (VP) shunt procedure done two years
ago, in view of traumatic hydrocephalus, was elicited. During this
episode, the patient reportedly had symptoms of sudden loss of
consciousness and postprandial vomiting. On admission and evaluation,
the diagnosis of post-traumatic hydrocephalus was made, and prompt
elective surgical intervention was done. The patient recovered and was
alert and playful post-surgery. No postoperative complications were
documented.
On examination, the patient Glasgow Coma Score at presentation was E4 V3
M5 (13/15) with normal tone and reflexes. On visual examination, both
eyes were normal.
A CT scan was performed, which revealed a hyper dense opacity in the
posterior cranial fossa. It was initially thought to be a cystic lesion,
and tumour resection via craniotomy was planned. As a confirmatory
investigation, MRI was performed, which revealed that it was not a
cystic lesion but, in fact, the fourth ventricle which was distended,
and the patient was found to have a TFV [figure-1].
After clinching the diagnosis, intravenous (IV) antibiotic cefoperazone
+ sulbactam (1 gm) twice a day, anti-epileptic in the form of
levetiracetam (250 gm) IV twice a day and dexamethasone (1 mL) IV four
times a day were administered, and the appropriate management for
pyrexia and vomiting was planned. After obtaining consent and
preoperative preparation, open posterior fenestration of the midline of
the fourth ventricle along with arachnoid dissection (adhesiolysis) was
done.
Postoperatively, the patient was found slightly irritable due to a mild
headache. No seizures or other post-procedural complications were noted,
following which oral intake was started after 12 hours. Post-operative
CT was performed, and the location of the shunt as well as the status of
the ventricles was ascertained [figure-2]. IV cefoperazone +
sulbactam and levetiracetam for seizure prophylaxis were prescribed,
before discharging, on discharge medications including cefoperazone +
sulbactam (1 gm) IV twice a day and syrup sodium valproate (250 mg/5 ml)
twice a day. Adequate counselling to the family about home care
measures, the importance of compliance with medication and follow-up was
given.