CSF dynamics analysis in patients with post-traumatic ventriculomegaly

Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion

Background

The aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery.

Methods

52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC.

Results

The median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12-15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group.

Conclusion

The ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.

Assessment of CSF Dynamics Using Infusion Study: Tips and Tricks

Idiopathic normal pressure hydrocephalus, secondary chronic hydrocephalus, and other cerebrospinal fluid (CSF) disorders are often challenging to diagnose. Since shunt surgery is usually the only therapeutic option and carries significant morbidity, optimal patient selection is crucial. The tap test is the most commonly used prognostic test to confirm the diagnosis but lacks sensitivity. The lumbar infusion study (LIS) appears to be a better option, offering additional information on brain dynamics without increasing morbidity. However, this technique remains underused. In this narrative review, supported by the extensive experience of several European expert centers, we detail the physiological basis, indications, and CSF dynamics parameters that can be measured. We also discuss technical modalities and variations, including one versus 2 needles, patient positioning, and the site of CSF measurement, as well as in vivo shunt testing. Finally, we discuss the limitations and morbidity associated with the LIS. This review aims to assist teams wishing to incorporate LIS into their screening tools for chronic hydrocephalus and other CSF disorders.

Incidence of hydrocephalus following decompressive craniectomy for ischaemic stroke: A systematic review and meta-analysis

OBJECTIVE

Decompressive craniectomy (DC) following malignant ischaemic stroke is a potentially life-saving procedure. Event rates of ventriculomegaly following DC performed in this setting remain poorly defined. Accordingly, we performed a systematic review to determine the incidence of hydrocephalus and the need for cerebrospinal fluid (CSF) diversion following DC for malignant stroke.

METHODS

MEDLINE, EMBASE and Cochrane libraries were searched from database inception to 17 July 2021. Our search strategy consisted of "Decompressive Craniectomy", AND "Ischaemic stroke", AND "Hydrocephalus", along with synonyms. Through screening abstracts and then full texts, studies reporting on rates of ventriculomegaly following DC to treat ischaemic stroke were included for analysis. Event rates were calculated for both of these outcomes. A risk of bias assessment was performed to determine the quality of the included studies.

RESULTS

From an initial 1117 articles, 12 were included following full-text screening. All were of retrospective design. The 12 included studies reported on 677 patients, with the proportion experiencing hydrocephalus/ventriculomegaly being 0.38 (95% CI: 0.24, 0.53). Ten studies incorporating 523 patients provided data on the need for permanent CSF diversion, with 0.10 (95% CI: 0.07, 0.13) requiring a shunt. The included studies were overall of high methodological quality and rigour.

CONCLUSION

Though hydrocephalus is relatively common following DC in this clinical setting, only a minority of patients are deemed to require permanent CSF diversion. Clinicians should be aware of the incidence of this complication and counsel patients and families appropriately.

A New Clinical Protocol for a Timely Diagnosis and Treatment of Hydrocephalus in Patients with Severe Acquired Brain Injury

BACKGROUND

Secondary hydrocephalus is a well-known complication of severe acquired brain injuries (sABIs) often diagnosed during inpatient rehabilitation. Currently, there is no gold standard for its detection. Therefore, we designed a novel clinical diagnostic protocol that integrates clinical, functional, biochemical and neuroradiological assessments to improve the accuracy of its diagnosis in patients with sABIs.

METHODS

This prospective cohort study will be conducted in a tertiary referral rehabilitation center in Italy. A historical cohort of patients will be compared with a prospective cohort undergoing the new clinical diagnostic protocol.

EXPECTED RESULTS

The expected results include an increase in the proportion of diagnosed cases, a reduced incidence of clinical complications, an increase in the rehabilitative outcomes at discharge, a significant reduction in the length of hospital stay, and useful information about the diagnostic and prognostic value of the neuroradiological characteristics.

CONCLUSION

We expect that this clinical diagnostic protocol will result in a more appropriate assessment and timely treatment of secondary hydrocephalus in patients with sABIs, with the ultimate goal of improving their prognosis. In addition, it could be adopted by other rehabilitation centers to improve hydrocephalus diagnosis and treatment, thereby reducing the length of hospital stay and accelerating recovery with benefits for both patients and hospitals.

Changes in computed tomography perfusion parameters and maximum contrast enhancement in patients having hydrocephalus with a ventriculoperitoneal shunt: a pilot study

BACKGROUND

Acute hydrocephalus may decrease cerebral perfusion by increasing intracranial pressure. Computed tomography perfusion (CTP) has become a significant adjunct in evaluating regional and global cerebral blood flow (CBF).

PURPOSE

To investigate the changes in cerebral perfusion parameters and maximum contrast enhancement (MCE) in patients with hydrocephalus with ventriculoperitoneal shunt (VPS).

MATERIAL AND METHODS

We performed brain CTP in 45 patients, including those with subarachnoid hemorrhage (SAH)-induced hydrocephalus with VPS (n = 14, G1), hydrocephalus (not related to SAH) with VPS (n = 11, G2), SAH-induced hydrocephalus without VPS (n = 10, G3), and hydrocephalus (not related to SAH) without VPS (n = 10, G4). We measured the cerebral perfusion in the frontal white matter (FWM), centrum semiovale, basal ganglia (BG), and eight cortical lesions of interest and compared the differences in CTP parameters among the groups.

RESULTS

Between the four groups, cerebral blood volume and MCE in the left FWM and CBF in the right FWM increased significantly in G1 and G2 who underwent VP shunt compared to G3 and G4, whereas perfusion significantly reduced in G3 and G4 who did not undergo VP shunt compared to G1 and G2. MCE in the left BG significantly increased in G2 and decreased in G3 and G4. SAH-induced hydrocephalus showed a lower perfusion than hydrocephalus (not related to SAH) in FWM.

CONCLUSIONS

Perfusion changes in patients with hydrocephalus after VP shunt were seen in the FWM and BG, which appears to be the result of the hydrocephalus reducing brain perfusion in the deep part of the brain. We concluded that SAH slows brain perfusion recovery.

Incidence of surgically treated post-traumatic hydrocephalus 6 months following head injury in patients undergoing acute head computed tomography

BACKGROUND

Post-traumatic hydrocephalus (PTH) is a well-known complication of head injury. The percentage of patients experiencing PTH in trauma cohorts (0.7-51.4%) varies greatly in the prior literature depending on the study population and applied diagnostic criteria. The objective was to determine the incidence of surgically treated PTH in a consecutive series of patients undergoing acute head computed tomography (CT) following injury.

METHODS

All patients (N = 2908) with head injuries who underwent head CT and were treated at the Tampere University Hospital's Emergency Department (August 2010-July 2012) were retrospectively evaluated from patient medical records. This study focused on adults (18 years or older) who were residents of the Pirkanmaa region at the time of injury and were clinically evaluated and scanned with head CT at the Tampere University Hospital's emergency department within 48 h after injury (n = 1941). A thorough review of records for neurological signs and symptoms of hydrocephalus was conducted for all patients having a radiological suspicion of hydrocephalus. The diagnosis of PTH was based on clinical and radiological signs of the condition within 6 months following injury. The main outcome was surgical treatment for PTH. Clinical evidence of shunt responsiveness was required to confirm the diagnosis of PTH.

RESULTS

The incidence of surgically treated PTH was 0.15% (n = 3). Incidence was 0.08% among patients with mild traumatic brain injury (TBI) and 1.1% among those with moderate to severe TBI. All the patients who developed PTH underwent neurosurgery during the initial hospitalization due to the head injury. The incidence of PTH among patients who underwent neurosurgery for acute traumatic intracranial lesions was 2.7%.

CONCLUSION

The overall incidence of surgically treated PTH was extremely low (0.15%) in our cohort. Analyses of risk factors and the evaluation of temporal profiles could not be undertaken due to the extremely small number of cases.

The Value of the Correlation Coefficient Between the ICP Wave Amplitude and the Mean ICP Level (RAP) Combined With the Resistance to CSF Outflow (Rout) for Early Prediction of the Outcome Before Shunting in Posttraumatic Hydrocephalus

Objective

To evaluate the value of the correlation coefficient between the ICP wave amplitude and the mean ICP level (RAP) and the resistance to CSF outflow (Rout) in predicting the outcome of patients with post-traumatic hydrocephalus (PTH) selected for shunting.

Materials and Methods

As a training set, a total of 191 patients with PTH treated with VP shunting were retrospectively analyzed to evaluate the potential predictive value of Rout, collected from pre-therapeutic CSF infusion test, for a desirable recovery level (dRL), standing for the modified rankin scale (mRS) of 0–2. Eventually, there were 70 patients with PTH prospectively included as a validation set to evaluate the value of Rout-combined RAP as a predictor of dRL. We calculated Rout from a CSF infusion test and collected RAP during continuous external lumbar drainage (ELD). Maximum RAP (RAPmax) and its changes relative to the baseline (ΔRAPmax%) served as specific parameters of evaluation.

Results

In the training set, Rout was proved to be a significant predictor of dRL to shunting, with the area under the curve (AUC) of 0.686 (p < 0.001) in receiver-operating characteristic (ROC) analysis. In the validation set, Rout alone did not present a significant value in the prediction of desirable recovery level (dRL). ΔRAPmax% after 1st or 2nd day of ELD both showed significance in predicting of dRL to shunting with the AUC of 0.773 (p < 0.001) and 0.786 (p < 0.001), respectively. Significantly, Rout increased the value of ΔRAPmax% in the prediction of dRL with the AUC of 0.879 (p < 0.001), combining with ΔRAPmax% after the 1st and 2nd days of ELD. RAPmax after the 1st and 2nd days of ELD showed a remarkable predictive value for non-dRL (Levels 3-6 in Modified Rankin Scale) with the AUC of 0.891 (p < 0.001) and 0.746 (p < 0.001).

Conclusion

Both RAP and Rout can predict desirable recovery level (dRL) to shunting in patients with PTH in the early phases of treatment. A RAP-combined Rout is a better dRL predictor for a good outcome to shunting. These findings help the neurosurgeon predict the probability of dRL and facilitate the optimization of the individual treatment plan in the event of ineffective or unessential shunting.

From Shunt to Recovery: A Multidisciplinary Approach to Hydrocephalus Treatment in Severe Acquired Brain Injury Rehabilitation

Background: Hydrocephalus among Severe Acquired Brain Injury (SABI) patients remains overlooked during rehabilitation. Methods: A retrospective cohort study was carried out of traumatic and non-traumatic SABI patients with hydrocephalus, consecutively admitted over 9 years in a tertiary referral specialized rehabilitation hospital. Patients were treated with ventriculoperitoneal shunt before or during inpatient rehabilitation and assessed using the Level of Cognitive Functioning Scale and Disability Rating Scale. Logistic regression models were used to identify predictors of post-surgical complications. Linear regression models were used to investigate predictors of hospital length of stay (LOS), disability, and cognitive function. Results: Of the 82 patients, 15 had post-surgical complications and 16 underwent cranioplasty. Shunt placement complication risk was higher when fixed vs. when programmable pressure valves were used. A total of 56.3% achieved functional improvement at discharge and 88.7% improved in cognitive function; of the 82 patients, 56% were discharged home. In multiple regression analyses, higher disability at discharge was related to cranioplasty and longer LOS, while poorer cognitive function was associated with cranioplasty. Increase in LOS was associated with increasing time to shunt and decreasing age. Conclusions: A significant improvement in cognitive and functional outcomes can be achieved. Cranioplasty increased LOS, and fixed pressure valves were related to poorer outcomes.

Post-traumatic hydrocephalus - incidence, risk factors, treatment, and clinical outcome

OBJECTIVES

Post-traumatic hydrocephalus (PTH) is well-known after traumatic brain injury (TBI), but there is limited evidence regarding patient selection for ventriculo-peritoneal (VP)-shunt treatment. In this study, we investigated the incidence and risk factors for PTH and the indication for and outcome after shunt treatment.

MATERIALS AND METHODS

In this retrospective study, 836 TBI patients, treated at our neurointensive care (NIC) unit at Uppsala university hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiology, treatments, and outcome variables were evaluated.

RESULTS

Post-traumatic ventriculomegaly occurred in 46% of all patients at NIC discharge. Twenty-nine (3.5%) patients received a VP-shunt. Lower GCS M at admission, greater amount of subarachnoid hemorrhage, meningitis, decompressive craniectomy (DC), and ventriculomegaly at NIC discharge were risk factors for receiving a VP-shunt. Fourteen of the PTH patients showed impeded recovery or low-pressure hydrocephalus symptoms, of whom 13 experienced subjective clinical improvement after shunt treatment. Five PTH patients showed deterioration in consciousness, of whom four improved following shunt treatment. Five DC patients received a shunt due to subdural hygromas (n =2) or external brain herniation (n = 3), of whom two patients improved following treatment. Five patients were vegetative with concurrent ventriculomegaly and these patients did not have any positive shunt response. Altogether, 19 (66%) PTH patients improved after shunt surgery.

CONCLUSION

Post-traumatic ventriculomegaly was common, but few developed symptomatic PTH and received a VP-shunt. Patients with low-pressure hydrocephalus symptoms had the best shunt response, whereas patients with suspected vegetative state exhibited a minimal shunt response.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers

OBJECT

Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI).

METHODS

A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05.

RESULTS

A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate.

CONCLUSIONS

The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

MR Elastography demonstrates reduced white matter shear stiffness in early-onset hydrocephalus

INTRODUCTION

Hydrocephalus that develops early in life is often accompanied by developmental delays, headaches and other neurological deficits, which may be associated with changes in brain shear stiffness. However, noninvasive approaches to measuring stiffness are limited. Magnetic Resonance Elastography (MRE) of the brain is a relatively new noninvasive imaging method that provides quantitative measures of brain tissue stiffness. Herein, we aimed to use MRE to assess brain stiffness in hydrocephalus patients compared to healthy controls, and to assess its associations with ventricular size, as well as demographic, shunt-related and clinical outcome measures.

METHODS

MRE was collected at two imaging sites in 39 hydrocephalus patients and 33 healthy controls, along with demographic, shunt-related, and clinical outcome measures including headache and quality of life indices. Brain stiffness was quantified for whole brain, global white matter (WM), and lobar WM stiffness. Group differences in brain stiffness between patients and controls were compared using two-sample t-tests and multivariable linear regression to adjust for age, sex, and ventricular volume. Among patients, multivariable linear or logistic regression was used to assess which factors (age, sex, ventricular volume, age at first shunt, number of shunt revisions) were associated with brain stiffness and whether brain stiffness predicts clinical outcomes (quality of life, headache and depression).

RESULTS

Brain stiffness was significantly reduced in patients compared to controls, both unadjusted (p ≤ 0.002) and adjusted (p ≤ 0.03) for covariates. Among hydrocephalic patients, lower stiffness was associated with older age in temporal and parietal WM and whole brain (WB) (beta (SE): -7.6 (2.5), p = 0.004; -9.5 (2.2), p = 0.0002; -3.7 (1.8), p = 0.046), being female in global and frontal WM and WB (beta (SE): -75.6 (25.5), p = 0.01; -66.0 (32.4), p = 0.05; -73.2 (25.3), p = 0.01), larger ventricular volume in global, and occipital WM (beta (SE): -11.5 (3.4), p = 0.002; -18.9 (5.4), p = 0.0014). Lower brain stiffness also predicted worse quality of life and a higher likelihood of depression, controlling for all other factors.

CONCLUSIONS

Brain stiffness is reduced in hydrocephalus patients compared to healthy controls, and is associated with clinically-relevant functional outcome measures. MRE may emerge as a clinically-relevant biomarker to assess the neuropathological effects of hydrocephalus and shunting, and may be useful in evaluating the effects of therapeutic alternatives, or as a supplement, of shunting.

JEDI (jugular entrapment, dilated ventricles, intracranial hypertension) syndrome: a new clinical entity? A case report

Patients with idiopathic intracranial hypertension are frequently obese women with normal/slit ventricles. Patients with high-pressure hydrocephalus, instead, present enlarged ventricles. We describe a 63-year-old woman with signs and symptoms of intracranial hypertension. Brain MRI revealed hydrocephalus. Venous Doppler ultrasound showed external compression of the omohyoid muscles on the internal jugular veins. During jugular vein decompression, intracranial pressure dropped from 18 to 6 mmHg. Patient is asymptomatic at 2-year follow-up, with decreased brain ventricles. These findings could represent a novel form of high-pressure hydrocephalus that can be successfully treated without a CSF shunt. We called this syndrome JEDI (jugular entrapment dilated ventricles intracranial hypertension).

Impact of timing of ventriculoperitoneal shunt placement on outcome in posttraumatic hydrocephalus

OBJECTIVE

Posttraumatic hydrocephalus (PTH) is a frequent sequela of traumatic brain injury (TBI) and complication of related cranial surgery. The roles of PTH and the timing of cerebrospinal fluid (CSF) shunt placement in TBI outcome have not been well described. The goal of this study was to assess the impact of hydrocephalus and timing of ventriculoperitoneal (VP) shunt placement on outcome during inpatient rehabilitation after TBI.

METHODS

In this cohort study, all TBI patients admitted to Craig Hospital between 2009 and 2013 were evaluated for PTH, defined as ventriculomegaly, and hydrocephalus symptoms, delayed or deteriorating recovery, or elevated opening pressure on lumbar puncture. Extent of ventriculomegaly was quantified by the Evans index from CT scans. Outcome measures were emergence from and duration of posttraumatic amnesia (PTA) and functional status as assessed by means of the Functional Independence Measure (FIM). Findings in this group were compared to findings in a group of TBI patients without PTH (controls) who were admitted for inpatient rehabilitation during the same study period and met specific criteria for inclusion.

RESULTS

A total of 701 patients were admitted with TBI during the study period. Of these patients, 59 (8%) were diagnosed with PTH and were included in this study as the PTH group, and 204 who were admitted for rehabilitation and met the criteria for inclusion as controls constituted the comparison group (no-PTH group). PTH was associated with initial postinjury failure to follow commands, midline shift or cistern compression, subcortical contusion, and craniotomy or craniectomy. In multivariable analyses, independent predictors of longer PTA duration and lower FIM score at rehabilitation discharge were PTH, emergency department Glasgow Coma Scale motor score < 6, and longer time from injury to rehabilitation admission. PTH accounted for a 51-day increase in PTA duration and a 29-point reduction in discharge FIM score. In 40% of PTH patients with preshunt CT brain imaging analyzed, ventriculomegaly (Evans index > 0.3) was observed 3 or more days before VP shunt placement (median 10 days, range 3-102 days). Among PTH patients who received a VP shunt, earlier placement was associated with better outcome by all measures assessed and independently predicted better FIM total score and shorter PTA duration.

CONCLUSIONS

Posttraumatic hydrocephalus predicts worse outcome during inpatient rehabilitation, with poorer functional outcomes and longer duration of PTA. In shunt-treated PTH patients, earlier CSF shunting predicted improved recovery. These results suggest that clinical vigilance for PTH onset and additional studies on timing of CSF diversion are warranted.

Posttraumatic Hydrocephalus as a Confounding Influence on Brain Injury Rehabilitation: Incidence, Clinical Characteristics, and Outcomes

OBJECTIVE

To describe incidence, clinical characteristics, complications, and outcomes in posttraumatic hydrocephalus (PTH) after traumatic brain injury (TBI) for patients treated in an inpatient rehabilitation program.

DESIGN

Cohort study with retrospective comparative analysis.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

All patients admitted for TBI from 2009 to 2013 diagnosed with PTH (N=59), defined as ventriculomegaly, delayed clinical recovery discordant with injury severity, hydrocephalus symptoms, or positive lumbar puncture results.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Primary measures were incidence of PTH and patient and injury characteristics. Secondary measures included frequency and timing of ventriculoperitoneal (VP) shunt, related complications, emergence from and duration of posttraumatic amnesia (PTA), Rancho Los Amigos Scale (RLAS) score, and FIM score at rehabilitation admission and discharge.

RESULTS

Of 701 patients with TBI admitted, 59 (8%) were diagnosed with PTH. Of these, the median age was 25 years, with 73% being men. At initial presentation, 52 (88%) did not follow commands. Fifty-two (90%) patients with PTH had a VP shunt placed. Median time from injury to shunt placement was 69 (range, 9-366) days. Seven (12%) patients with PTH experienced postsurgical seizure, 3 (6%) had shunt infection, and 7 (12%) had shunt malfunction. Thirty-six (61%) patients with PTH emerged from PTA during rehabilitation. Median total FIM score at rehabilitation admission was 20 (range, 18-76), and at discharge it was 43 (range, 18-118). Injury severity predicted outcome at rehabilitation admission, whereas shunt timing predicted outcome at rehabilitation discharge.

CONCLUSIONS

Incidence of PTH was observed in 8% of patients with TBI in inpatient rehabilitation. Earlier shunting predicted improved outcome during rehabilitation. Future studies should prospectively examine clinical decision rules, type, and timing of intervention and the coeffectiveness of rehabilitation treatment on outcomes.