Rehabilitation for a complex patient following cerebellar hemorrhage and obstructive hydrocephalus: A case report.

BACKGROUND AND PURPOSE: Inpatient rehabilitation facilities play an integral role in patient progress post-stroke. Cerebellar hemorrhages are an infrequent type of stroke and are therefore less discussed in the literature; however, inpatient rehabilitation continues to be an integral part of patient recovery. The purpose of this case report is to discuss the physical therapy interventions, challenges, and successes for a complex patient with a large cerebellar hemorrhage with obstructive hydrocephalus. Case Description: The patient is a 32-year-old male admitted to an inpatient rehabilitation facility. Prior to admission, the patient spent 1 month at a local hospital following a complicated recovery status post cerebellar hemorrhage with obstructive hydrocephalus. Interventions: The patient participated in at least 3 hours of combined therapy a day, split into 30- and 60-min sessions, and divided between physical, occupational, and speech therapy. Physical therapy interventions focused on various gait and coordination activities. Outcomes: The patient spent 47 days in an inpatient rehabilitation facility and demonstrated improvements in all aspects of the Functional Independence Measure®. The patient improved from an 18 to a 90 on the total FIM® score, allowing the patient to ultimately be discharged home with family able to provide 24/7 supervision.

Early Progressive Mobilization of Patients with External Ventricular Drains: Safety and Feasibility.

BACKGROUND/OBJECTIVE: Early mobilization of critically ill patients has been shown to improve functional outcomes. Neurosurgery patients with an external ventricular drain (EVD) due to increased intracranial pressure often remain on bed rest while EVD remains in place. The prevalence of mobilizing patients with EVD has not been described, and the literature regarding the safety and feasibility of mobilizing patients with EVDs is limited. The aim of our study was to describe the outcomes and adverse events of the first mobilization attempt in neurosurgery patients with EVD who participated in early functional mobilization with physical therapy or occupational therapy. METHODS: We performed a single-site, retrospective chart review of 153 patients who underwent placement of an EVD. Hemodynamically stable patients deemed appropriate for mobilization by physical or occupational therapy were included. Mobilization and activity details were recorded. RESULTS: The most common principal diagnoses were subarachnoid hemorrhage (61.4%) and intracerebral hemorrhage (17.0%) requiring EVD for symptomatic hydrocephalus. A total of 117 patients were mobilized (76.5%), and the median time to first mobilization after EVD placement in this group of 117 patients was 38 h. Decreased level of consciousness was the most common reason for lack of mobilization. The highest level of mobility on the patient's first attempt was ambulation (43.6%), followed by sitting on the side of the bed (30.8%), transferring to a bedside chair (17.1%), and standing up from the side of the bed (8.5%). No major safety events, such as EVD dislodgment, occurred in any patient. Transient adverse events with mobilization were infrequent at 6.9% and had no permanent neurological sequelae and were mostly headache, nausea, and transient diastolic blood pressure elevation. CONCLUSION: Early progressive mobilization of neurosurgical intensive care unit patients with external ventricular drains appears safe and feasible.

Endoscopic Third Ventriculostomy to address hydrocephalus in Africa: A call for education and community-based rehabilitation.

PURPOSE: Endoscopic Third Ventriculostomy (ETV) and Choroid Plexus Cautery (CPC) are low-cost, safe, and promising interventions for spina bifida-associated hydrocephalus (SBHCP). The purpose of this review was to explore and describe these efforts in Africa in order to upscale surgical training and rehabilitation services. METHODS: A PubMed search for articles on ETV and CPC as management of SBHCP in Africa was performed. Two authors appraised the results for key themes in content: indications, technique, outcomes, complications, education, and rehabilitation. RESULTS: Twenty of 47 articles identified were included for appraisal. Twelve described indications, ten and seven outlined technique and complications, respectively, and four described predictors of operative success. Fourteen studies describe outcomes, including operative and neurodevelopmental outcomes. Only two outlined educational efforts. Half of the literature stems from a single site in Uganda; in total, only six countries were represented. No articles described significant post-operative rehabilitation services or related training. CONCLUSION: The experience of ETV and CPC in Africa is promising, however, efforts to train and empower local staff in surgical technique and methods to upscale post-operative community-based rehabilitation services remain as a key to long-term success.

Elaborative encoding through self-generation enhances outcomes with errorless learning: Findings from the Skypekids memory study.

Errorless learning has demonstrated efficacy in the treatment of memory impairment in adults and older adults with acquired brain injury. In the same population, use of elaborative encoding through supported self-generation in errorless paradigms has been shown to further enhance memory performance. However, the evidence base relevant to application of both standard and self-generation forms of errorless learning in children is far weaker. We address this limitation in the present study to examine recall performance in children with brain injury (n = 16) who were taught novel age-appropriate science and social science facts through the medium of Skype. All participants were taught these facts under conditions of standard errorless learning, errorless learning with self-generation, and trial-and-error learning after which memory was tested at 5-minute, 30-minute, 1-hour and 24-hour delays. Analysis revealed no main effect of time, with participants retaining most information acquired over the 24-hour testing period, but a significant effect of condition. Notably, self-generation proved more effective than both standard errorless and trial-and-error learning. Further analysis of the data revealed that severity of attentional impairment was less detrimental to recall performance under errorless conditions. This study extends the literature to provide further evidence of the value of errorless learning methods in children with ABI and the first demonstration of the effectiveness of self-generation when delivered via the Internet.

Blazing a trail.

These are challenging times in the NHS,' says RCN north west regional director Estephanie Dunn. 'We are endeavouring to safeguard already diminishing budgets and services while there are increasing pressures on staff.

Changes of White Matter Diffusion Anisotropy in Response to a 6-Week iPad Application-Based Occupational Therapy Intervention in Children with Surgically Treated Hydrocephalus: A Pilot Study.

Objective Our aims were (1) to test whether diffusion tensor imaging (DTI) could detect underlying white matter (WM) changes after a 6-week iPad application-based occupational therapy (OT) intervention in children with surgically treated hydrocephalus (HCP); and (2) to explore the association between WM changes and performance outcomes. Methods Five children (age range: 6.05-9.10 years) with surgically treated HCP completed an intensive iPad-based OT intervention targeting common domains of long-term deficits in children with HCP. The intervention included 6 weekly sessions in an OT clinic supplementing home-based program (1 hour/day, 4 days/week). DTI and neuropsychological assessments were performed before and after the intervention. Observation After the therapy, significant increases in fractional anisotropy (FA) and/or decreases in radial diffusivity were found in extensive WM areas. All participants demonstrated an increased perceptual reasoning index (PRI, Wechsler Abbreviated Scale of Intelligence: 2nd edition, PRI gains = 14.20 ± 7.56, p = 0.014). A significant positive correlation was found between PRI increase and the increase of FA in the right posterior limb of the internal capsule and the right external capsule (both p < 0.05). Conclusion This study provides initial evidence of DTI's sensitivity to detect subtle WM changes associated with performance improvements in response to a 6-week OT intervention in children with HCP.

Hydrocephalus during rehabilitation following severe TBI. Relation to recovery, outcome, and length of stay.

BACKGROUND: Post traumatic hydrocephalus (PTH) is a frequent complication during rehabilitation following severe TBI. However, the diagnosis of PTH is not straightforward and despite shunting recovery may be delayed. OBJECTIVE: To study the influence of PTH on recovery and outcome during rehabilitation. METHODS: We studied 417 patients with severe TBI admitted consecutively to a single hospital-based neurorehabilitation department serving Eastern Denmark between 2000 and 2010. Demographics (age and gender) and clinical characteristics (length of acute treatment, post traumatic amnesia (PTA), level of consciousness, injury severity (ISS), and admission FIM™), and PTH were related to recovery (discharge FIM™), outcome (GOS), and length of rehabilitation stay. RESULTS: Patients with PTH were older, brain injury more severe, and acute treatment was longer. At discharge they had more disability, longer rehabilitation stays, and unfavorable outcome. However, after adjusted multiple regression analyses PTH was not associated with disability at discharge or outcome. Instead, PTH was associated with longer stay for rehabilitation. CONCLUTIONS: Shunting for PTH does not affect recovery and outcome per se, but prolongs lengths of stay by almost 3 weeks. Therefore, patients treated for PTH are as likely to benefit from rehabilitation as patients without, but require longer rehabilitation stays.

Hydrocephalus following severe traumatic brain injury in adults. Incidence, timing, and clinical predictors during rehabilitation.

OBJECTIVE: To investigate timing and clinical predictors that might predict hydrocephalus emerging during rehabilitation until 1 year following severe traumatic brain injury (TBI). BACKGROUND: Posttraumatic hydrocephalus (PTH) may lead to clinical deterioration and poor outcome if untreated. However, PTH can be successfully treated if detected. Nevertheless, PTH is easily overlooked during rehabilitation, particularly in severe cases. METHOD: We prospectively followed all patients (n = 444) in Eastern Denmark (population 2.5 mill) sustaining severe TBI, who required lengthy rehabilitation between 2000 and 2010. All patients with PTH were tracked retrospectively. Demographics, surgery, injury severity, consciousness level, and disability were compared for patients with versus without PTH. Independent predictors of PTH during rehabilitation were identified through multiple logistic regression models. RESULTS: PTH occurred in 14.2% and 3/4 emerged during rehabilitation. Patients with PTH were older, had more severe brain injuries, were more frequently in vegetative state, and needed longer rehabilitation stays. After adjusted analyses, however, only older age and low level of consciousness were independently associated with PTH. CONCLUSION: Most cases of PTH emerge during rehabilitation. Therefore, attention towards this complication should be present also beyond the acute stage after TBI, particularly among older patients and patients with severe disordered consciousness.

Shunted hydrocephalus has a significant impact on quality of life in children with spina bifida.

OBJECTIVE: To determine which clinical (health status) and nonclinical (demographic) factors may affect perceptions of quality of life in children with spina bifida and their parents. DESIGN: A prospective study by using a validated questionnaire. SETTING: A multidisciplinary spina bifida clinic at a pediatric tertiary referral center. PATIENTS: Thirty-three children with spina bifida aged 5-18 years and 41 parents of children with spina bifida aged 2-18 years completed questionnaires after informed consent was obtained. METHODS: The Peds QL 4.0 Short Form 15 questionnaire was administered to children with spina bifida and their parents. Additional data were collected, including socioeconomic status, self-reported ethnicity, insurance status, ambulatory status, presence of shunted hydrocephalus, and continence. All completed questionnaires were included in the final analysis. RESULTS: Self-reported physical and psychosocial health scores for patients in our study were lower than previously published scores from healthy children. Patients with a shunted hydrocephalus had significantly lower self-reported physical health scores compared with those without shunted hydrocephalus (61.4 versus 39.3; P = .015). Self-reported physical health score in those with shunted hydrocephalus improved with age (Spearman ρ = 0.42; P = .017). Shunted hydrocephalus remained significant on multivariate analysis. Ethnicity, insurance, socioeconomic status, ambulatory status, and urinary and fecal continence were not associated with self-reported physical or psychosocial scores. Parent-reported scores were not associated with any of the variables of interest. There was excellent correlation between parent-reported and self-reported psychosocial health scores (Spearman ρ = 0.636; P < .001) but not physical health scores (Spearman ρ = 0.023; P = .905). CONCLUSIONS: Shunted hydrocephalus has a negative impact on the perception of quality of life, an effect that may be attenuated by age. Further study and more-specific measurement tools are needed to better understand health-related quality of life in children with spina bifida.

Cochlear implantation in patient with Dandy-walker syndrome

Introduction: Dandy Walker Syndrome is a congenital abnormality in the central nervous system, characterized by a deficiency in the development of middle cerebelar structures, cystic dilatation of the posterior pit communicating with the fourth ventricle and upward shift of the transverse sinuses, tentorium and dyes. Among the clinical signs are occipital protuberances, a progressive increase of the skull, bowing before the fontanels, papilledema, ataxia, gait disturbances, nystagmus, and intellectual impairment. Objectives: To describe a case of female patient, 13 years old with a diagnosis of this syndrome and bilateral hearing loss underwent cochlear implant surgery under local anesthesia and sedation. Case Report: CGS, 13 years old female was referred to the Otolaryngological Department of Otolaryngology Institute of Parana with a diagnosis of "Dandy-Walker syndrome" for Otolaryngological evaluation for bilateral hearing loss with no response to the use of hearing aids. Final Comments: The field of cochlear implants is growing rapidly. We believe that the presence of Dandy-Walker syndrome cannot be considered a contraindication to the performance of cochlear implant surgery, and there were no surgical complications due to neurological disorders with very favorable results for the patient who exhibits excellent discrimination. It has less need for lip reading with improvement in speech quality...

Complication during postacute rehabilitation: patients with posttraumatic hydrocephalus.

The objective of this study was to determine the incidence of posttraumatic hydrocephalus (PTH) among patients in our rehabilitation unit for traumatic brain injury. Furthermore, we aimed to assess the effect of shunt implantation and to identify the postoperative complication rate. This is a retrospective cohort study, in which between 2000 and 2009, data were collected from inpatients with traumatic brain injury complicated by PTH. During this period, 55 patients in our unit presented with PTH; all of these patients underwent ventricular shunt implantation. The incidence of PTH treated with shunt implantation was 4.8%. The mean age of the patients was 32 years (range 14-75 years). In 22 cases, the hydrocephalus was diagnosed in our rehabilitation unit (40%). Other patients were diagnosed and shunted before being transferred to our department. The median time of shunting was 80 days (range 20-270 days) after brain trauma. On the basis of scores of the functional independence measure, improvement could be observed in 43 cases (78%), the mean score improvement was 40 (2-81). Postoperative complications were seen in 10 patients (18%): four due to infections and six due to shunt failure. Revision was necessary in all 10 cases. Almost half of the diagnoses of PTH were established in the postacute rehabilitation unit, and all complications after shunt implantation were also recognized there. Precise clinical observation is necessary for diagnosis of PTH. Early diagnosis and treatment are important to prevent secondary complications. Teamwork and good cooperation between acute and postacute care are necessary for successful rehabilitation of patients with traumatic brain injury.

Promoting physical activity in an adolescent and a young adult with physical disabilities.

BACKGROUND: We sought to describe the design of the Active Lifestyle and Sports Participation (ALSP) intervention for adolescents and young adults with physical disabilities, and to present the first 2 cases. METHODS: A 17-year-old boy with myelomeningocele and hydrocephalus and a 23-year-old woman with unilateral cerebral palsy were enrolled into the ALSP intervention, a personalized intervention designed to improve physical activity and fitness levels. Main outcome measures were self-reported physical activity and aerobic fitness. Fitness was determined by submaximal 6-minute walk or wheel test and by maximal cycle or arm ergometer-exercise test. Participants rated satisfaction with the intervention on a Likert-type numeric scale from 1 to 10. RESULTS: Improvements in self-reported physical activity were 51% and 75% for the male and female participant, respectively. Respective improvements in submaximal exercise were 16% and 9%. Maximal exercise increased 39% in the male participant but did not increase in the female participant. Satisfaction with the intervention was rated moderate-good to excellent. CONCLUSION: Data for the first 2 cases suggested that ALSP intervention seemed feasible to offer in an outpatient rehabilitation department, and the effectiveness may be promising. Future studies should determine the short- and long-term effectiveness of the intervention.

An algorithm to assess the rehabilitation potential in patients with chronic hydrocephalus.

OBJECTIVE: In clinical practice, it is often necessary to judge the probability of clinical benefit of invasive ancillary tests given to patients with chronic hydrocephalus before they are performed. The aim of the current study was to establish a screening tool for such prediction. MATERIAL AND METHODS: A total of 125 patients with chronic hydrocephalus were assessed using a clinical (HHS) and comorbidity (CMI) grading. These patients were shunted and followed-up for at least one year. The statistical tools of ANOVA, CHI-squared, Spearman, Kuskal-Wallis, and Wilcoxen-U-Test were applied. RESULTS: The variables discovered to be of use in prediction were age (p = 0.02), anamnesis duration (p = 0.04), CMI (p < 0.000) and HHS (p = 0.001). A decision tree using solely HHS and CMI was established allowing outcome prediction of sufficient power. Interestingly, in patients who had favourable preconditions, older age impeded not a favourable prognosis. CONCLUSION: With our proposed decision tree, a minimum of data allow a clinician to sufficiently judge whether shunting will be of benefit to a patient, which may help to decide whether invasive ancillary tests are justified.

The influence of foot orthoses on the function of a child with developmental delay.

BACKGROUND AND PURPOSE: Foot orthoses may lead to improved function when used to control faulty foot biomechanics. The purpose of this case report was to describe the influence of modified stabilizing foot splints (SFSs) on the function of a child with developmental delay. CASE DESCRIPTION: The participant was a 19-month-old girl with hypotonia and developmental delay due to hydrocephalus and congenital absence of the corpus callosum. INTERVENTION: Modified SFSs were created with the child's feet held in a subtalar neutral position. OUTCOMES: Five items from the Peabody Developmental Motor Scale II (rise to stand, standing, lowering, cruising, and stepping forward) were tracked over three weeks, under three conditions: with shoes and orthoses, shoes only, and barefoot. The ability to perform these items was improved when wearing shoes and orthoses. CONCLUSION: The outcomes indicate that future study of the modified SFS as an intervention is warranted.

Questionnaire for assessing parents' concerns about their child with hydrocephalus.

The many concerns of parents of children with hydrocephalus have not previously been assessed using a reliable, quantitative measurement. The development and preliminary use of a questionnaire to measure the concerns of these parents is reported. A general health status measure for hydrocephalus was developed concurrently. Items were generated primarily from parent focus groups resulting in a comprehensive list of 22 unique parental concern items. The most important of these items, as selected by another sample of parents of 60 children (27 females, 33 males; mean age 8y 4mo, [SD 4y 6mo]) were retained for the final questionnaire. This 9-item parental concerns questionnaire was tested for reliability and construct validity (by assessing correlations with various independent measures of health status, including Health Utilities Index-2 and Impact-on-Family Scale) using a cohort consisting of the parents of 80 children (39 females, 41 males; mean age 10y, [SD 3y 6mo]). An exploratory analysis was performed to determine which patient variables were associated with greater parental concern. The parental concerns questionnaire demonstrated excellent test-retest reliability (0.86, 95% CI 0.77-0.92) and internal consistency (Cronbach's alpha=0.89). As expected, interrater reliability was somewhat lower (0.67, 95% CI 0.49-0.79). Construct validity was demonstrated by consistently moderate Pearson's correlations with several independent measures of the child's health. The presence of epilepsy and younger patient age appeared to be significantly associated with greater parental concern. This new questionnaire has demonstrated very good psychometric properties. It can be used to broaden the scope of future clinical research in pediatric hydrocephalus to include the impact on parents.

[Endoscope-guided placement of the ventriculoperitoneal shunt: technique and applications]. / Metoda endoskopowego umieszczania drenu komorowego zastawki--technika i zastosowanie.

INTRODUCTION: The routine surgical procedure for placement of the ventricular shunt catheter is straightforward. However, the topography of the ventricular system in complex hydrocephalus is so distorted that orientation on the basis of standard external topographic points does not ensure satisfactory positioning of the drain. AIMS: 1. To test the clinical efficiency of endoscope-guided placement of the ventricular catheter in cases of complex hydrocephalus. 2. To present and popularize the surgical technique of endoscope-guided placement of the ventricular shunt catheter which hitherto was not published in the Polish literature. MATERIAL AND METHODS: This study was done in 38 patients aged 2 days to 45 years (mean 7 years and 5 months). Multiloculated hydrocephalus was found in 7, lateral ventricle isolation in 14, fourth ventricle isolation in 3, intraventricular cyst accompanied hydrocephalus in 6, and adherent ventricular catheter of the shunt implanted previously in 8 cases. Endoscopy was performed through coronal or occipital burr hole. Peelaway sheath was used for placement of the catheter in the desired position. Computerized tomography was performed within 24 hours after surgery, after 6 months, and subsequently every 12 months during follow-up. The time of follow-up ranged from 1 to 5 years (mean 27 months). There were eight cases (15.78%) of postoperative occlusion of the ventricular catheter. In two of them, occlusion was caused by catheter tip displacement. In the remaining cases, occlusion was caused by growing membranes of the multiloculated hydrocephalus (four cases) or by infection (two cases) and was not related to the catheter position. There were no cases of catheter position change during follow-up. DISCUSSION: In complex hydrocephalus, proper placement of the ventricular catheter without direct visual control is very difficult if not impossible. Therefore, use of the endoscope facilitates proper catheter placement in multiloculated hydrocephalus, hydrocephalus complicated by isolation of the ventricle or intraventricular cyst. CONCLUSIONS: 1. The technique of endoscope-guided placement of the ventricular catheter is relatively simple and useful for reliable positioning of the drain in the right location. 2. Our cases show that the method is clinically effective. However, comparison with the conventional method will require a controlled and matched trial.

Quality of life and psychomotor development after surgical treatment of hydrocephalus.

The purpose of this report is to analyse the long-term outcome in hydrocephalic children treated by shunt insertion, in particular their psycho-intellectual development and quality of life. We studied 46 patients aged 3 - 21, who had been operated on in the Department of Paediatric Surgery of the Medical University of Bialystok between 1982 - 2000 and had had ventriculo-peritoneal shunts inserted during their first year of life. Data from anamnesis and medical documentation were analysed. Age-appropriate psychomotor development and IQ tests were carried out: Wechsler Intelligence Scale for Children, Revised (WISC-R) (for children between the ages of 6 and 16), Wechsler Adult Intelligence Scale, Revised (WAIS-R PL) (for adults), Brunet-Lezine psychometric scale (early childhood), and Terman-Merril intelligence scale (children younger than 3). The final IQs were above 90 in 30 % of children, between 70 and 90 in 24 %, between 50 and 70 in 26 %, and lower than 50 in 20 %. 69 % of patients presented with neurological deficits and visual or auditory deficits were found in 22 %. Integration into normal schools was possible for 58.7 % of the children, one of whom is now a second year medical student. A relationship between shunt malfunction and the children's development was observed. An essential aspect of caring for hydrocephalic children is their rehabilitation and integration into society. Early physical rehabilitation, stimulation of psychological development, and continued monitoring by a paediatric surgeon to ensure proper functioning of the shunts will improve the independence of such children in their families and among their peers.

Recovery of brain in hydrocephalus

A retrospective study on a case of pediatric patients with hydrocephalus due to meningitis was treated at Tay Duc Paediatric Hospital – Haiphong City. Results shows that: hydrocephalus is non-malignant except brain tumour. Symptoms in children under one year of age: head circumference is enlarged rapidly, fontanel’s and skull bones bulging, thin-haired, venae under head skin emerged clearly, eyes are turned downwards. Symptoms in older children and adults including headache, quick reduction of vision. To have better treatment results, it should be detected and operated early. For hydrocephalus caused by brain tumour, placement surgery of a abdominal-ventricular catheter should be done before operation to help reducing pressure for laparoscopic surgery, minimizing mortality rate and having recupation for better surgical condition later. If the tumour had bad prognosis not be operated, placement of a abdominal-ventricular.

An intervention to reduce disruptive behaviours in children with brain injury.

This study investigated the effectiveness of a behavioural intervention programme in reducing disruptive behaviours in children with brain injury. The behavioural package included programme rules, a token economy with response cost and mystery motivators. Participants were three male patients in an after-school programme at a rehabilitation hospital who were identified as having both a brain injury and disruptive behaviours in the classroom setting. Two control composites were formed, one with children who behaved appropriately and one with children who behaved in a disruptive manner. This study employed a multiple baseline design across individuals. The participants' disruptive behaviour decreased during the intervention phase by an average of 69%; the effect size of each participant's improvement was 'large'. The comparisons' disruptive behaviour was unchanged. This pronounced decrease in disruptive behaviours for the three participants was maintained in the follow-up phase. This short-term, easily implemented package altered important programme and social behaviours positively, were well received by children and staff and resulted in long-term improvements to behavioural deficits secondary to brain injury. These results are discussed in terms of theoretical disagreements, methodological issues and practical community-based interventions in brain-injured children.