Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage

INTRODUCTION

Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts.

METHODS

This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients' clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration.

RESULTS

A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection.

CONCLUSIONS

The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Venous congestive encephalopathy secondary to arteriovenous fistula aggravated by cerebrospinal fluid shunt

We present a unique clinical case of venous congestive encephalopathy in the context of a cerebral arteriovenous fistula with clinical worsening secondary to valvular overdrainage. ICP monitoring, the different pressure settings of the programable CSF shunt and the detailed clinical description that is carried out offer us enough data to understand that this case provides important pathophysiological knowledge to a little-known disease.

Epidemiology, Diagnostic Strategies, and Therapeutic Advances in Diffuse Midline Glioma

Object: Diffuse midline glioma (DMG) is a highly aggressive and lethal brain tumor predominantly affecting children and young adults. Previously known as diffuse intrinsic pontine glioma (DIPG) or grade IV brain stem glioma, DMG has recently been reclassified as "diffuse midline glioma" according to the WHO CNS5 nomenclature, expanding the DMG demographic. Limited therapeutic options result in a poor prognosis, despite advances in diagnosis and treatment. Radiotherapy has historically been the primary treatment modality to improve patient survival. Methods: This systematic literature review aims to comprehensively compile information on the diagnosis and treatment of DMG from 1 January 2012 to 31 July 2023. The review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and utilized databases such as PubMed, Cochrane Library, and SciELO. Results: Currently, molecular classification of DMG plays an increasingly vital role in determining prognosis and treatment options. Emerging therapeutic avenues, including immunomodulatory agents, anti-GD2 CAR T-cell and anti-GD2 CAR-NK therapies, techniques to increase blood-brain barrier permeability, isocitrate dehydrogenase inhibitors, oncolytic and peptide vaccines, are being explored based on the tumor's molecular composition. However, more clinical trials are required to establish solid guidelines for toxicity, dosage, and efficacy. Conclusions: The identification of the H3K27 genetic mutation has led to the reclassification of certain midline tumors, expanding the DMG demographic. The field of DMG research continues to evolve, with encouraging findings that underscore the importance of highly specific and tailored therapeutic strategies to achieve therapeutic success.

Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy

INTRODUCTION

Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option.

METHODS

We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified.

RESULTS

We identified five patients with diagnosis of acute negative-pressure hydrcephalus. In four of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in two patients (50%); the other two required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome.

CONCLUSIONS

The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.

Quadrigeminal Cistern Epidermoid Cyst: Neuroendoscopy and Endoscope-Assisted Supracerebellar Infratentorial Approach

The pineal region is a complex anatomical location with multiple surrounding important neurovascular structures.^1,2 Several approaches to this region have been described, including posterior interhemispheric, transchoroidal, infratentorial supracerebellar, supracerebellar and infracerebellar trans-sinus, and their modifications. Neuroendoscopy and endoscope-assisted surgery have been widely applied to aid resection of pineal region lesions.^3-5 A 40-year-old man presented with tonic-clonic seizures and bilateral papillary edema on fundus examination. Computed tomography showed a midline lesion at the level of the quadrigeminal cistern with mass effect on the aqueduct of Sylvius and posterior wall of the third ventricle, triggering obstructive triventricular hydrocephalus. As a first intervention, a third ventriculostomy was attempted unsuccessfully owing to unfavorable third ventricle floor anatomy. This approach was used to obtain a biopsy specimen, which showed an epidermoid cyst. Ventriculoscopy showed a communication of the pineal recess and quadrigeminal cistern owing to tumor invasion. An external ventricular drain was placed to control the hydrocephalus until complete resection was performed (Video 1). Several days later, tumor resection was carried out via the median supracerebellar infratentorial approach with the patient in semisitting position. After near-total resection under microscope, the third ventricle and both lateral recesses were explored with the endoscope. A small tumor remnant (visible only with endoscope) was identified and removed. This step was essential to achieve complete resection, confirmed by magnetic resonance imaging. The patient was discharged 6 days later without complications. During follow-up, the patient remains asymptomatic. The combination of microneurosurgery, neuroendoscopy, and endoscope-assisted surgery improves management of pineal region lesions and facilitates complete resection.

Supracerebellar transtentorial approach for left parahippocampal cavernous malformation

Background:

Lesions in the temporomesial region can be reached by various approaches: subtemporal, transsylvian, transcortical, interhemispheric parieto-occipital, or supracerebellar transtentorial (SCTT). The choice varies according to the characteristics of the lesion and neighboring structures.

Case Description:

In this clinical case, it is presented a 56-year-old man with long-term evolution of drug-resistant epilepsy secondary to a cavernoma in the left parahippocampal gyrus. After assessing the lesion, it was decided a SCTT approach for its resection in a semi-sitting position, to avoid language disorders or visual damage. The surgery was uneventful and the patient did not present epileptic seizures during 6-month follow-up.

Conclusion:

Performing a SCTT is safe and feasible option for resection of lesions located in the basal temporomesial region without causing damage to neighboring structures, especially those located in the middle and posterior two-thirds of temporal region.

Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy

INTRODUCTION

Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option.

MATERIAL AND METHODS

We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified.

RESULTS

We identified 5patients with diagnosis of acute negative-pressure hydrcephalus. In 4 of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in 2 patients (50%); the other 2required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome.

CONCLUSIONS

The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.