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.