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Deborah Mann Lake

David Emerson was beginning to get irritated at the co-worker who kept poking his head into his office and asking if he was feeling all right.

“I didn’t feel bad but he kept saying, ‘You don’t look too good. You ought to think about going home,’ so I finally said OK,” Emerson recalls. “I started to get a headache and took a pain reliever. When I went to stand up, I couldn’t. I sat back down and got sick at my desk.”

Then everything went dark.

Emerson could hear his co-workers but he couldn’t see them.

He didn’t know it yet but the 51-year-old Emerson had classic symptoms of hydrocephalus, a dangerous condition in which cerebrospinal fluid builds up in the brain.

Cerebrospinal fluid surrounds the brain and spinal cord, cushioning them, providing nutrients and removing waste. Too much fluid dilates the spaces in the brain called ventricles, which are connected by narrow pathways. The result is too much pressure on brain tissue and, if left untreated, death.

In children, the cause of hydrocephalus may be environmental influences during fetal development or genetic predisposition. It is estimated that 1 in 500 children are affected by hydrocephalus.

In adults, the most common causes are tumors and infections. In some cases, a low-grade infection and ensuing inflammation may have resulted from a virus, experts say, and it may take months or years for it to affect the pathways between the ventricles.

According to the National Institute of Neurological Disorders and Stroke, symptoms can include headache followed by vomiting, nausea, vision problems, poor coordination, urinary incontinence, lethargy, drowsiness, irritability and changes in personality or cognition including memory loss.

“When they realized I couldn’t see, they called EMS and when EMS arrived, they wanted to cut my shirt off. I came to and told them no, I would take it off because it was a new shirt from Brooks Brothers,” Emerson said. “Then they debated about what hospital to take me to and that is the last I remember.”

Fortunately for Emerson, they took him to Memorial Hermann-Texas Medical Center where he was treated by Aaron Mohanty, M.D., assistant professor of neurosurgery at The University of Texas Medical School at Houston.

Redirecting the flow

The typical way to treat hydrocephalus is by surgically inserting a shunt, which directs fluid from the brain into another area such as the abdominal cavity. Complications of a shunt, however, include mechanical failure, infections and obstructions. Overdraining, in which the shunt takes away too much fluid from the ventricles, can cause them to collapse, resulting in fluid or blood accumulating outside the brain. Underdraining can make the symptoms of hydrocephalus recur.

But Mohanty is highly experienced in an alternative surgical procedure called endoscopic third ventriculostomy, which is particularly appropriate for one of the most common causes of hydrocephalus, “aqueductal stenosis.” In aqueductal stenosis, the already natural narrow channel known as an aqueduct between the third and fourth ventricles, becomes blocked.

In the endoscopic procedure, a tiny camera mounted on an endoscope is used to locate the floor of the third ventricle, where a small opening is made, allowing fluid to flow out of the brain, where it resumes circulating around the brain.

“There’s a 90 percent success rate with this procedure in Mr. Emerson’s age group. His surgery was over at 11 a.m. and by 1 p.m., he was talking on the phone and very functional,” Mohanty says. “The endoscopic ventriculostomy is essentially a bypass procedure. The obstructed fluid is basically diverted before the obstruction to the normal pathway. It is as if one had an accident or a road block on the freeway and an ambulance takes the feeder road to bypass all the cars and then gets back on the freeway.”

Emerson, who was brought into the emergency room unconscious, woke up later that night feeling great. When he asked nurses when he would be released, they had to explain that there was a tube inserted into his brain to drain the excess fluid and he wouldn’t be going anywhere soon.

Mohanty described the surgery to him the next morning, and Emerson didn’t hesitate.

“I thought I would rather have him open up what was a natural pathway for the fluid rather than a shunt that sends it to my abdomen,” Emerson says. “I had it on a Monday, was released on Tuesday and was up and about by Friday.”

Infants and hydrocephalus

The endoscopic third ventriculostomy is less successful in infants, where for unknown reasons, the fluid after the bypass does not get absorbed.

But faced with a child who had compartmentalized ventricles, Mohanty decided to perform a third ventriculostomy accompanied by an endoscopic stent placement across the aqueduct.

The infant, Haylie Castillo, is Monica Castillo’s fourth child. Doctors in an outlying hospital recognized that the infant’s enlarged head indicated hydrocephalus and transferred her to Children's Memorial Hermann Hospital.

When she was three weeks old, Mohanty and neurosurgeon Stephen Fletcher, M.D., associate professor of surgery at the UT Medical School, combined the third ventriculostomy with an insertion of a stent across the aqueduct to connect the compartmentalized fourth ventricle with the rest of the ventricular system. However, the third ventriculostomy did not function adequately, so a shunt was also inserted.

At her two-week checkup, Mohanty carefully removed her stitches and noted that her head had the normal little dent of an infant where the skull hasn’t closed yet—a good sign that the remaining fluid was not under pressure.

“At six months, when the child begins to have developmental milestones, we’ll be able to tell if there is any damage,” Mohanty explains. “But the sooner you intervene, the better the outcome.”

Light-headed (in a good way)

Now, more than a year after his surgery, life has returned to normal for Emerson. He has even returned to flying his high-performance Mooney airplane after getting clearance from the Federal Aviation Administration.

“I didn’t know it at the time I made the decision to do the endoscopic surgery, but it turns out that gave me the best shot at being approved for flying again because a shunt can potentially get blocked,” Emerson says. “I feel so good now.”

UPDATED: 8-22-2007

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