Ventriculocisternostomia de Torkildsen no tratamento do hidrocefalo não comunicante: resultados em 67 casos

Silva, José A. Gonçalves da; Schuermann, Kurt; Dietz, Hermann

doi:10.1590/S0004-282X1975000300005

Resumo

Sixty-seven cases of non-communicating hydrocephalus treated according to the Torkildsen's procedure are reported. The spinal fluid blockage was caused in 55 cases by supratentorial and in 10 cases by infratentorial tumors; in the remaining cases the spinal fluid interruption was due to non-tumoral causes. Ventriculography was the most important examination performed as far as the local diagnosis was concerned. 15 patients in this series disclosed lethal complications with signs of brain stem lesions. Patient survival was 3.9 years with variation ranging from 1 to 9 years. The following conclusions were drawn: 1) Ventriculocisternostomy is a valious method for the treatment of non-communicating hidrocephalus for it allows a more physiological drainage of the spinal fluid besides favouring the exploration of the posterior fossa in cases of doudtful pre-operative diagnosis. This procedure is of low cost and involves a relatively simple tecnique as compared with other procedures which demand the use of special valves. 2) According to the review of the pertinent literature the best results have been accomplished in cases where there is a non-tumoral aqueduct stenosis as well as in inoperable tumors of the third ventricle. 3) Bilateral drainage is mandatory in cases of bilateral obstruction of Monro's foramina. It has also been indicated in all cases as a precaution due to the possibility of occlusion of one catheter. 4) Ventriculocisternostomy should also be indicated as a prophylactic treatment of non-communicating hydrocephalus in cases of inoperable tumors of the sela or the basal ganglia with compression of the third ventricle but without completly blockage of the ventricle system. 5) Ventriculocisternostomy should be indicated with some reserve in cases of infratentorial tumors as well as in great supratentorial space-occupying lesions. It is however contra-indicated in cases of large tumors and in the inflammatory process involving the posterior fossa. 6) In the present series the obstruction of the draining-system was very uncommon being observed in only three patients. 7) No cases of spinal fluid fistula or meningitis were observed in the present study.

Ventriculocisternostomia de Torkildsen no tratamento do hidrocefalo não comunicante. Resultados em 67 casos

Ventriculocisternostomy of Torkildsen in the treatment of non-communicating hydrocephalus: report of 67 cases

José A. Gonçalves da Silva^I; Kurt Schuermann^II; Hermann Dietz^III

^IProfessor contratado de Clínica Neurológica e Neurocirúrgica da Faculdade de Medicina da Universidade Federal da Paraíba

^IIDiretor Prof. Dr. med. H.C. der Neurochirurgischen Klinik der Johannes Gutenberg, Universitaet Mainz

^IIIProf. Dr. med. der Neurochirurgischen Klinik der Medizinischen Hochschule Hannover

SUMMARY

Sixty-seven cases of non-communicating hydrocephalus treated according to the Torkildsen's procedure are reported. The spinal fluid blockage was caused in 55 cases by supratentorial and in 10 cases by infratentorial tumors; in the remaining cases the spinal fluid interruption was due to non-tumoral causes. Ventriculography was the most important examination performed as far as the local diagnosis was concerned. 15 patients in this series disclosed lethal complications with signs of brain stem lesions. Patient survival was 3.9 years with variation ranging from 1 to 9 years.

The following conclusions were drawn: 1) Ventriculocisternostomy is a valious method for the treatment of non-communicating hidrocephalus for it allows a more physiological drainage of the spinal fluid besides favouring the exploration of the posterior fossa in cases of doudtful pre-operative diagnosis. This procedure is of low cost and involves a relatively simple tecnique as compared with other procedures which demand the use of special valves. 2) According to the review of the pertinent literature the best results have been accomplished in cases where there is a non-tumoral aqueduct stenosis as well as in inoperable tumors of the third ventricle. 3) Bilateral drainage is mandatory in cases of bilateral obstruction of Monro's foramina. It has also been indicated in all cases as a precaution due to the possibility of occlusion of one catheter. 4) Ventriculocisternostomy should also be indicated as a prophylactic treatment of non-communicating hydrocephalus in cases of inoperable tumors of the sela or the basal ganglia with compression of the third ventricle but without completly blockage of the ventricle system. 5) Ventriculocisternostomy should be indicated with some reserve in cases of infratentorial tumors as well as in great supratentorial space-occupying lesions. It is however contra-indicated in cases of large tumors and in the inflammatory process involving the posterior fossa. 6) In the present series the obstruction of the draining-system was very uncommon being observed in only three patients. 7) No cases of spinal fluid fistula or meningitis were observed in the present study.

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Hospital Santa Izabel 58000 João Pessoa, PR Brasil.

Trabalho elaborado na Clínica Neurocirúrgica da Universidade de Mainz

1. ALMEIDA, G. M. Ventriculo-atriostomia no tratamento da hidrocefalia infantil. Tese de docente livre de Clínica Neurológica do Departamento de Neurologia da F.M.U.S.P., São Paulo, 1968.
2. ALMEIDA, G. M. & PEREIRA, W. C. Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia do lactente. Arq. Neuro-Psiquiat. (São Paulo) 27:308, 1969.
3. ALMEIDA, G. M.; PEREIRA, W. C. & FACURE, N. O. Ventrículo-auriculostomia nos bloqueios ao trânsito do líquido cefalorraqueano na cisticercose encefálica. Arq. Neuro-Psiquiat. (São Paulo) 24:163, 1966.
4. ALMEIDA, G. M.; PEREIRA, W. C. & FACURE, N. O. Complicações infecciosas da ventrículo-aurieulostomia. Arq. Neuro-Psiquiat (São Paulo) 24:169, 1966.
5. BEHN-ESCHENBURG, H. Erfahrungen ueber 93 in der Zuericher Neurochirurgischen Klinik ausgefuehrten Ventrikulostomien nach Scarff-Stookey und Torkildsen. Inaugural Dissertation, Zuerich, 1956.
6. CHARRAVORTY, B. Modified ventriculoperiotneal shunt in the treatment of hydrocephalus. J. Indian med. Ass. 44:293, 1965.
7. DANDY, W. E. The diagnosis and treatment of hydrocephalus resulting from strictures of the aqueduct of Sylvius. Surgery Gynec. Obst. 31:340, 1920.
8. DANDY, W. E. An operative procedure for hidrocephalus. Johns Hopkins Hosp. Bull. 33:189, 1922.
9. DANDY, W. E. Diagnosis and treatment of strictures of the aquedut of Sylvius causing hydrocephalus. Archs Surg. (Chicago) 51:1, 1945.
10. DAVIDOFF, L. M. Treatment of hydrocephalus. Historical review and description of a new method. Arch. Surg. (Chicago) 18:1737, 1929.
11. DECKER, K. Zur Technik der Torkildsen Operation. Zentbl. Neurochir. 9: 3C9, 1949.
12. DE GROOD, M. P. A. M. Indications, technique and results of the Torkildsen ventriculocisternostomy. Arch. chir. Nederlandicum 1:130, 1949.
13. ENDERLEN, P. Zur Behandlung des Hydrocephalus. Beitr. klin. Chir. 76: 889, 1911.
14. FACURE, J. J. Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia infantil: contribuição ao estudo do seu valor. Tese de Doutoramento (São Paulo, Campinas), 1971.
15. FASIANI, G. M. & QUARTI-TREVANO, M. Sulla ventrículo-cisternostomia di Torkildsen nel trattamento degli idrocefali obstruttivi. Chirurgia (Milano) 5:81, 1950.
16. FINCHER, E. F.; STREWLER, G. J. & SWANSON, H. S. The Torkildsen procedure: a report of 19 cases. J. Neurosurg. 5:213, 1948.
17. FISCHER, W. Symptomatologie und Diagnostik der Tumoren des Kleinhirnraume; Johann Ambrosius Barth, Leipzig, 1985.
18. FORREST, D. M.; LAURENCE, K. M. & MACNAB, G. H. Ventriculo-subdural drainage in infantile hydrocephalus. Lancet 1:1274, 1957.
19. GERLACH, J. Spaetergebnisse der Torkildsen Drainage. Auswertung einer Sammelstatistik. Acta neurochir. 9:581, 1961.
20. GROESCHEL, D. & MARGUTH, F. Ergebnisse der Ventrikulozisternostomie nach Torkildsen. Zentbl. Neurochir. 23:262, 1963.
21. GUND, A. Bemerkungen zur Technik der Torkildsen Drainage. Acta neurochir. 9:608, 1961.
22. HAYNES, I. S. Congenital internal hydrocephalus: its treatment by drainage of the cisterna magna into the cranial sinuses. Ann. Surg. 57:449, 1913.
23. HEILE, B. Zur Behandlung des Hydrocephalus mit Ureter-Duraanastomose. Zentbl. Chir. 54:1859, 1927.
24. HERLIN, L. Ventriculocisternostomy according to Torkildsen: a report of 22 cases. J. Neurosurg. 7:403, 1950.
25. HUGO-OSSWALD, H. Der Hydrocephalus occlusus und seine chirurgische Behandlung. Inaugural Dissertation, Univ. Klinik Frankfurt, Main, 1944.
26. HYDMAN, O. R. Hydrocephalus: a contribution related to treatment. J. Neurosurg. 3:426, 1946.
27. INGRAHAM, F. D.; MATSON, D. D.; ALEXANDER, E. & WOODS, R. P. Studies in the treatment of experimental hydrocephalus. J. Neuropath. exp. Neurol. 7:123, 1948.
28. JACKSON, I. J. & SNODGRASS, S. R. Peritoneal shunts in the treatment of hydrocephalus and increased intracranial pressure. J. Neurosurg. 12:216, 1955.
29. KAUSCH Die Behandlung des Hydrocephalus der kleinen Kinder. Arch. klin. Chir. 87:709, 1908.
30. LANG, W. & PIA, H. W. Prognose und Indikation zur Ventriculocisternostomie (Torkildsen Operation). Dt. Z. Nerv-Heilk. 182:176, 1961.
31. LAZORTHES, G.; ANDUZE-ACHER, H.; CAMPAN, L. & ESPAGNO, J. La Ventriculocisternostomie transcalleuse. Neuro-Chirurgie 3:59, 1957.
32. LE BEAU, J. & DAUM, S. L'ouverture de la corne temporale droite dans le traitement des hydrocephalies. Rev. neurol. (Paris) 73:140, 1941.
33. LEKSELL, L. A surgical procedure for atresia of the aquaeduct of Sylvius. Acta psychiat. neurol. scand. 24:559, 1949.
34. LORENZ, R. Liquorfisteln nach Operationen im Bereich der hinteren Schaedelgrube. Zentbl. Neurochir. 27:125, 1966.
35. LORENZ, R. Komplikationen nach Torkildsen Drainagen. Acta neurochir. 14:246, 1966.
36. MERREM, G. Hirnkammerdrainage nach Torkildsen. Zentbl. Chir. 81:1499, 1956.
37. MILHORAT, T. H.; HAMMOCK, M. K. & CHANDRA, R. S. The subarachnoid space in congenital obstructive hydrocephalus: microscopic findings. J. Neurosurg. 35:7, 1971.
38. MILHORAT, T. H.; HAMMOCK, M. K. & DI CHIRO, G. The subarachnoid space in congenital obstructive hydrocephalus: cisternographic findings. J. Neurosurg. 35:1, 1971.
39. MLETZKO, J. Hat die Ventrikulo-Cisternostomie nach Torkildsen heute noch ihre Berechtigung? Arch. klin. Chir. (Langenbecks Arch. klin. Chir.) 300:581, 1962.
40. NAKATA, M.; SAKAI, T. & SOMA, Y. Posterior-superior third ventriculostomy (a new operation method for occlusive hydrocephalus). Folia psychiat. neurol. jap. 4:225, 1950.
41. NIXON, H. H. Ventriculo-pleural drainage with a valve. Cerebr. Palsy Bull. (Develop. Med. Child Neurol.) 4:301. 1962.
42. NULSEN, F. E. & SPITZ, E. B. Treatment of hydrocephalus by direct shunt from ventricle to jugular vein. Surg. Forum 2:398, 1952.
43. PAINE, K. W. & KISSOCK, W. Mc. Aqueduct stenosis: clinical aspects and results of treatment by ventriculocisternostomy (Torkildsen's operation). J. Neurosurg. 2:127, 1955.
44. PAYR, E. Drainage der Hirnventrikel mittelst frei transplantierter Blutgefaesse; Bemerkungen ueber Hydrocephalus. Arch. klin. Chir. (Langenbecks Arch. klin. Chir.) 87:801, 1908.
45. PAYR, E. Ueber Ventrikeldrainagen bei Hydrocephalus. Verh. dt. Ges. Chir. 40:515, 1911.
46. PEREIRA, W. C; ALMEIDA, G. M. & FACURE, N. O. Ventriculo-auriculostomia nos bloqueios inflamatórios e tumorais à circulação do líquido cefalorraqueano. Arq. Neuro-Psiquiat. (São Paulo) 24:111, 1966.
47. PIA, H. W. Zur Frage der Umgehungsdrainage nach Torkildsen. Zentbl. Neurochir. 13:102, 1953.
48. PIA, H. W. Klinik, Differentialdiagnose und Behandlung der Verhuegelgeschwuelste. Dt. Z. Nerv Heilk. 172:12, 1954.
49. PUDENZ, R. H. Experimental and clinical observations on the shunting of cerebrospinal fluid into the circulatory system. Clin. Neurosurg. 5:98, 1957-58.
50. PUDENZ, R. H. Experiences with the ventrículo atrial shunt operation for hydrocephalus. Neurol. Medicochir. 6:1, 1964.
51. PUDENZ, R. H. The ventriculo-atrial shunt. J. Neurosurg. 26:602, 1966.
52. PUDENZ, R. H.; RUSSEL, F. E.; HURD, A. H. & SHELDEN, C. H. Ventriculo-auriculostomy: a technique for shunting cerebrospinal fluid into the right auricle. J. Neurosurg. 14:171, 1957.
53. RAIMONDI, A. J. & MATSUMOTO, S. A simplified technique for performing the ventriculo-peritoneal shunt. J. Neurosurg. 26:357, 1967.
54. RIECHERT, T. Ueber eine Operation zur Beseitigung des Hydrocephalus occlusus. Dt. Z. Nerv Heilk. 160:290, 1949.
55. RIECHERT, T. & UMBACH, W. Die operative Behandlung des Hydrocephalus. In OLIVECRONA, H. & TOENNIS, W. Handbuch der Neurochirurgie IV/I. Springer Verlag, Berlin, 1960, pg. 599, 672.
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60. SCOTT, M.; WYEIS, H. T.; MURTACH, F. & REYES, V. Observations on ventricular and lumbar subarachnoid peritoneal shunts in hydrocephalus in infants. J. Neurosurg. 12:165, 1955.
61. STOOKEY, B. & SCARFF, J. E. Occlusion of the aqueduct of Sylvius by neoplastic and non-neoplastic processes with a rational surgical treatment for the relief of the resultant obstructive hydrocephalus. Bull. neurol. Inst. N.Y. 5:348, 1936.
62. SWANSON, H. S. & PERRET, G. Bilateral Torkildsen procedure. Its application in instances of occlusion of both foramina of Monro. J. Neurosurg. 7:11, 1949.
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Datas de Publicação

Publicação nesta coleção
05 Abr 2013
Data do Fascículo
Set 1975

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[1] 1. ALMEIDA, G. M. Ventriculo-atriostomia no tratamento da hidrocefalia infantil. Tese de docente livre de Clínica Neurológica do Departamento de Neurologia da F.M.U.S.P., São Paulo, 1968.

[2] 2. ALMEIDA, G. M. & PEREIRA, W. C. Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia do lactente. Arq. Neuro-Psiquiat. (São Paulo) 27:308, 1969.

[3] 3. ALMEIDA, G. M.; PEREIRA, W. C. & FACURE, N. O. Ventrículo-auriculostomia nos bloqueios ao trânsito do líquido cefalorraqueano na cisticercose encefálica. Arq. Neuro-Psiquiat. (São Paulo) 24:163, 1966.

[4] 4. ALMEIDA, G. M.; PEREIRA, W. C. & FACURE, N. O. Complicações infecciosas da ventrículo-aurieulostomia. Arq. Neuro-Psiquiat (São Paulo) 24:169, 1966.

[5] 5. BEHN-ESCHENBURG, H. Erfahrungen ueber 93 in der Zuericher Neurochirurgischen Klinik ausgefuehrten Ventrikulostomien nach Scarff-Stookey und Torkildsen. Inaugural Dissertation, Zuerich, 1956.

[6] 6. CHARRAVORTY, B. Modified ventriculoperiotneal shunt in the treatment of hydrocephalus. J. Indian med. Ass. 44:293, 1965.

[7] 7. DANDY, W. E. The diagnosis and treatment of hydrocephalus resulting from strictures of the aqueduct of Sylvius. Surgery Gynec. Obst. 31:340, 1920.

[8] 8. DANDY, W. E. An operative procedure for hidrocephalus. Johns Hopkins Hosp. Bull. 33:189, 1922.

[9] 9. DANDY, W. E. Diagnosis and treatment of strictures of the aquedut of Sylvius causing hydrocephalus. Archs Surg. (Chicago) 51:1, 1945.

[10] 10. DAVIDOFF, L. M. Treatment of hydrocephalus. Historical review and description of a new method. Arch. Surg. (Chicago) 18:1737, 1929.

[11] 11. DECKER, K. Zur Technik der Torkildsen Operation. Zentbl. Neurochir. 9: 3C9, 1949.

[12] 12. DE GROOD, M. P. A. M. Indications, technique and results of the Torkildsen ventriculocisternostomy. Arch. chir. Nederlandicum 1:130, 1949.

[13] 13. ENDERLEN, P. Zur Behandlung des Hydrocephalus. Beitr. klin. Chir. 76: 889, 1911.

[14] 14. FACURE, J. J. Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia infantil: contribuição ao estudo do seu valor. Tese de Doutoramento (São Paulo, Campinas), 1971.

[15] 15. FASIANI, G. M. & QUARTI-TREVANO, M. Sulla ventrículo-cisternostomia di Torkildsen nel trattamento degli idrocefali obstruttivi. Chirurgia (Milano) 5:81, 1950.

[16] 16. FINCHER, E. F.; STREWLER, G. J. & SWANSON, H. S. The Torkildsen procedure: a report of 19 cases. J. Neurosurg. 5:213, 1948.

[17] 17. FISCHER, W. Symptomatologie und Diagnostik der Tumoren des Kleinhirnraume; Johann Ambrosius Barth, Leipzig, 1985.

[18] 18. FORREST, D. M.; LAURENCE, K. M. & MACNAB, G. H. Ventriculo-subdural drainage in infantile hydrocephalus. Lancet 1:1274, 1957.

[19] 19. GERLACH, J. Spaetergebnisse der Torkildsen Drainage. Auswertung einer Sammelstatistik. Acta neurochir. 9:581, 1961.

[20] 20. GROESCHEL, D. & MARGUTH, F. Ergebnisse der Ventrikulozisternostomie nach Torkildsen. Zentbl. Neurochir. 23:262, 1963.

[21] 21. GUND, A. Bemerkungen zur Technik der Torkildsen Drainage. Acta neurochir. 9:608, 1961.

[22] 22. HAYNES, I. S. Congenital internal hydrocephalus: its treatment by drainage of the cisterna magna into the cranial sinuses. Ann. Surg. 57:449, 1913.

[23] 23. HEILE, B. Zur Behandlung des Hydrocephalus mit Ureter-Duraanastomose. Zentbl. Chir. 54:1859, 1927.

[24] 24. HERLIN, L. Ventriculocisternostomy according to Torkildsen: a report of 22 cases. J. Neurosurg. 7:403, 1950.

[25] 25. HUGO-OSSWALD, H. Der Hydrocephalus occlusus und seine chirurgische Behandlung. Inaugural Dissertation, Univ. Klinik Frankfurt, Main, 1944.

[26] 26. HYDMAN, O. R. Hydrocephalus: a contribution related to treatment. J. Neurosurg. 3:426, 1946.

[27] 27. INGRAHAM, F. D.; MATSON, D. D.; ALEXANDER, E. & WOODS, R. P. Studies in the treatment of experimental hydrocephalus. J. Neuropath. exp. Neurol. 7:123, 1948.

[28] 28. JACKSON, I. J. & SNODGRASS, S. R. Peritoneal shunts in the treatment of hydrocephalus and increased intracranial pressure. J. Neurosurg. 12:216, 1955.

[29] 29. KAUSCH Die Behandlung des Hydrocephalus der kleinen Kinder. Arch. klin. Chir. 87:709, 1908.

[30] 30. LANG, W. & PIA, H. W. Prognose und Indikation zur Ventriculocisternostomie (Torkildsen Operation). Dt. Z. Nerv-Heilk. 182:176, 1961.

[31] 31. LAZORTHES, G.; ANDUZE-ACHER, H.; CAMPAN, L. & ESPAGNO, J. La Ventriculocisternostomie transcalleuse. Neuro-Chirurgie 3:59, 1957.

[32] 32. LE BEAU, J. & DAUM, S. L'ouverture de la corne temporale droite dans le traitement des hydrocephalies. Rev. neurol. (Paris) 73:140, 1941.

[33] 33. LEKSELL, L. A surgical procedure for atresia of the aquaeduct of Sylvius. Acta psychiat. neurol. scand. 24:559, 1949.

[34] 34. LORENZ, R. Liquorfisteln nach Operationen im Bereich der hinteren Schaedelgrube. Zentbl. Neurochir. 27:125, 1966.

[35] 35. LORENZ, R. Komplikationen nach Torkildsen Drainagen. Acta neurochir. 14:246, 1966.

[36] 36. MERREM, G. Hirnkammerdrainage nach Torkildsen. Zentbl. Chir. 81:1499, 1956.

[37] 37. MILHORAT, T. H.; HAMMOCK, M. K. & CHANDRA, R. S. The subarachnoid space in congenital obstructive hydrocephalus: microscopic findings. J. Neurosurg. 35:7, 1971.

[38] 38. MILHORAT, T. H.; HAMMOCK, M. K. & DI CHIRO, G. The subarachnoid space in congenital obstructive hydrocephalus: cisternographic findings. J. Neurosurg. 35:1, 1971.

[39] 39. MLETZKO, J. Hat die Ventrikulo-Cisternostomie nach Torkildsen heute noch ihre Berechtigung? Arch. klin. Chir. (Langenbecks Arch. klin. Chir.) 300:581, 1962.

[40] 40. NAKATA, M.; SAKAI, T. & SOMA, Y. Posterior-superior third ventriculostomy (a new operation method for occlusive hydrocephalus). Folia psychiat. neurol. jap. 4:225, 1950.

[41] 41. NIXON, H. H. Ventriculo-pleural drainage with a valve. Cerebr. Palsy Bull. (Develop. Med. Child Neurol.) 4:301. 1962.

[42] 42. NULSEN, F. E. & SPITZ, E. B. Treatment of hydrocephalus by direct shunt from ventricle to jugular vein. Surg. Forum 2:398, 1952.

[43] 43. PAINE, K. W. & KISSOCK, W. Mc. Aqueduct stenosis: clinical aspects and results of treatment by ventriculocisternostomy (Torkildsen's operation). J. Neurosurg. 2:127, 1955.

[44] 44. PAYR, E. Drainage der Hirnventrikel mittelst frei transplantierter Blutgefaesse; Bemerkungen ueber Hydrocephalus. Arch. klin. Chir. (Langenbecks Arch. klin. Chir.) 87:801, 1908.

[45] 45. PAYR, E. Ueber Ventrikeldrainagen bei Hydrocephalus. Verh. dt. Ges. Chir. 40:515, 1911.

[46] 46. PEREIRA, W. C; ALMEIDA, G. M. & FACURE, N. O. Ventriculo-auriculostomia nos bloqueios inflamatórios e tumorais à circulação do líquido cefalorraqueano. Arq. Neuro-Psiquiat. (São Paulo) 24:111, 1966.

[47] 47. PIA, H. W. Zur Frage der Umgehungsdrainage nach Torkildsen. Zentbl. Neurochir. 13:102, 1953.

[48] 48. PIA, H. W. Klinik, Differentialdiagnose und Behandlung der Verhuegelgeschwuelste. Dt. Z. Nerv Heilk. 172:12, 1954.

[49] 49. PUDENZ, R. H. Experimental and clinical observations on the shunting of cerebrospinal fluid into the circulatory system. Clin. Neurosurg. 5:98, 1957-58.

[50] 50. PUDENZ, R. H. Experiences with the ventrículo atrial shunt operation for hydrocephalus. Neurol. Medicochir. 6:1, 1964.

[51] 51. PUDENZ, R. H. The ventriculo-atrial shunt. J. Neurosurg. 26:602, 1966.

[52] 52. PUDENZ, R. H.; RUSSEL, F. E.; HURD, A. H. & SHELDEN, C. H. Ventriculo-auriculostomy: a technique for shunting cerebrospinal fluid into the right auricle. J. Neurosurg. 14:171, 1957.

[53] 53. RAIMONDI, A. J. & MATSUMOTO, S. A simplified technique for performing the ventriculo-peritoneal shunt. J. Neurosurg. 26:357, 1967.

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