[Surgical treatment of patients with skull defects and cerebrospinal fluid flow disorders after previous decompressive craniectomy]

Decompressive craniectomy (DC) is performed for refractory intracranial hypertension following severe traumatic brain injury, vascular and oncological diseases. This fact increases the number of patients with extensive and giant skull defects. Cerebrospinal fluid (CSF) flow disorders after DC are often accompanied by ventriculomegaly. However, only some patients with ventriculomegaly have hydrocephalus and require CSF bypass procedures. Differentiation of post-traumatic hydrocephalus requiring surgical treatment and atrophic dilation of ventricular system «ex vacuo» caused by brain injury is still an important issue. Skull sealing as a way to normalize CSF circulation and eliminate hydrocephalus is also an open question. Currently, there is no unified approach to patients with extensive and giant cranial defects combined with post-traumatic hydrocephalus. There is no unified algorithm for sequence of reconstructive and CSF bypass operations in these patients. Literature data on risks of infectious complications for different surgical strategies are controversial.

Refractory psychiatric symptoms and seizure associated with Dandy-Walker syndrome: A case report and literature review

BACKGROUNDS

Dandy-Walker syndrome (DWS) is a group of brain malformations which occasionally accompanied by psychotic symptoms. The co-occurrence of DWS and epilepsy in children is quite rare.

CASE DESCRIPTION

We reported a 14-year-old male who presented with a 8-month history of inconsistent upper limb tremor and accidental seizure. The MRI showed the typical alterations of DWS: cystic dilatation of the fourth ventricle, vermian hypoplasia, enlarged posterior fossa. He received the ventriculoperitoneal shunting (VPS) placement for hydrocephalus and had a symptom-free period for 8 days. Then he experienced a recurrence of involuntary upper limb tremor and behavior disturbance after decreasing the pressure of cerebrospinal fluid (CSF) from 150 to 130 mm Hg. After being treated with Olanzapine 10 mg/d, Clonazepam 3 mg/qn and Valproate acid (VPA) 500 mg/bid for nearly a month, his mental status and psychotic symptoms fluctuated. A search of Pub Med showed little report of hydrocephalus and DWS comorbidity with seizure and psychosis. Here we presented the whole process of a rare disease from the very beginning with all his symptoms, examinations and treatments.

CONCLUSION

VPS placement surgery at an earlier stage may be an effective way to avoid inevitable brain damage so as to improve the clinical outcomes for patients with DWS. Continued treatment with regard to DWS condition may include shunt placement, but it mainly focus on developmental concerns, with occupational and physical therapy along with ongoing supportive psychotherapy to improve the coping skills and quality of life.

The Clinical Application of Robot-Assisted Ventriculoperitoneal Shunting in the Treatment of Hydrocephalus

Background

This work aims to assess the effectiveness and safety of robotic assistance in ventriculoperitoneal shunting and to compare the results with data from traditional surgery.

Methods

We retrospectively analyzed 60 patients who had undergone ventriculoperitoneal shunting, of which shunts were implanted using a robot in 20 patients and using traditional surgical methods in the other 40 patients. Data related to surgery were compared between the two groups, and the accuracy of the drainage tube in the robot-assisted group was assessed.

Results

In the robot-assisted surgery group, the operation duration was 29.75 ± 6.38 min, intraoperative blood loss was 10.0 ± 3.98 ml, the success rate of a single puncture was 100%, and the bone hole diameter was 4.0 ± 0.3 mm. On the other hand, the operation duration was 48.63 ± 6.60 min, intraoperative blood loss was 22.25 ± 4.52 ml, the success rate of a single puncture was 77.5%, and the bone hole diameter was 11.0 ± 0.2 mm in the traditional surgery group. The above are statistically different between the two groups (P < 0.05). Only one case of surgery-related complications occurred in the robot-assisted group, while 13 cases occurred in the traditional surgery group. There was no significant difference in the hospitalization time. In the robot-assisted surgery group, the average radial error was 2.4 ± 1.5 mm and the average axial error was 1.9 ± 2.1 mm.

Conclusion

In summary, robot-assisted implantation is accurate, simple to operate, and practical; the duration of surgery is short; trauma to the patient is reduced; and fewer postoperative complications related to surgery are reported.

Reappraisal of Pediatric Normal-Pressure Hydrocephalus

While normal-pressure hydrocephalus (NPH) is most commonly diagnosed in older adulthood, a significant body of literature has accumulated over half a century documenting the clinical phenomenon of an NPH-like syndrome in pediatric patients. As in adult NPH, it is likely that pediatric NPH occurs due to a heterogeneous array of developmental, structural, and neurodegenerative pathologies, ultimately resulting in aberrant cerebrospinal fluid (CSF) flow and distribution within and around the brain. In this review, we aimed to systematically survey the existing clinical evidence supporting the existence of a pediatric form of NPH, dating back to the original recognition of NPH as a clinically significant subtype of communicating hydrocephalus. Leveraging emergent trends from the old and more recent published literature, we then present a modern characterization of pediatric NPH as a disorder firmly within the same disease spectrum as adult NPH, likely with overlapping etiology and pathophysiological mechanisms. Exemplary cases consistent with the diagnosis of pediatric NPH selected from the senior author’s neurosurgical practice are then presented alongside the systematic review to aid in discussion of the typical clinical and radiographic manifestations of pediatric NPH. Common co-morbidities and modern surgical treatment options are also described.

Neurosarcoidosis with hydrocephalus as a first presenting sign: a unique case report

There is a possible relationship with cerebral ischemic events and neurosarcoidosis. It should be considered in the differential diagnosis in a case of unexplained hydrocephalus, vascular white matter lesions and vasculitis related findings.

Clinical application of ventriculoperitoneal shunting in treating traumatic brain injury

This study explored the clinical application of ventriculoperitoneal (VP) shunting in treating traumatic brain injury (TBI). A retrospective analysis was performed on 100 patients who had hydrocephalus due to TBI and were admitted to Shanxian Central Hospital from February 2012 to June 2016. Among these patients, 50 underwent VP shunting surgery and were assigned to the experimental group. The remaining 50 underwent lumboperitoneal (LP) shunting surgery and were assigned to the control group. Twenty days after surgery, all patients were evaluated for clinical outcomes, neurological deficit scores and complications. The results were compared between the two groups. Patients in the experimental group were further separated into three subgroups according to the severity of hydrocephalus, and clinical outcomes were compared among the subgroups. It was found that the effective rate in the experimental group was significantly higher than that in the control group, and the difference was statistically significant (P<0.05). The effective rate in the mild hydrocephalus subgroup was significantly higher than that in the severe hydrocephalus subgroup, with a statistically significant difference (P<0.05). The effective rate in the moderate hydrocephalus subgroup was significantly higher than that in the severe hydrocephalus subgroup, with a statistically significant difference (P<0.05). The incidence of complications in the control group was significantly higher than that in the experimental group, and the difference was statistically significant (P<0.05). The postoperative neurological deficit score in the experimental group was significantly lower than that in the control group, and the difference was statistically significant (P<0.05). In conclusion, patients with hydrocephalus due to TBI had better clinical outcome when treated with VP shunting than those treated with LP shunting. Moreover, a better outcome was observed when the patient had milder hydrocephalus. Therefore, the early diagnosis and timely treatment with VP shunting are of great importance for patients with hydrocephalus.

Disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in normal pressure hydrocephalus misinterpreted as atrophy: autopsy and radiological evidence

Disproportionately enlarged subarachnoid-space hydrocephalus (DESH), a feature of normal pressure hydrocephalus (NPH), is often misinterpreted as cortical atrophy. We report a 67-year-old man with features of NPH but not diagnosed because radiographic findings were interpreted as cortical atrophy. Autopsy showed findings consistent with NPH and no neurodegenerative disease. The second patient with DESH underwent shunt surgery. Entrapped fluid diminished after the surgery, confirming this is not atrophy, but due to a CSF dynamic process. Patients with DESH have tight sulci adjacent to the entrapped fluid pockets, distinguishing it from cortical atrophy. 18F-Fluorodeoxyglucose PET can help differentiate DESH from cortical atrophy.

The cost of hydrocephalus: a cost-effectiveness model for evaluating surgical techniques

In BriefThe authors analyzed the costs associated with the three different procedures used to treat hydrocephalus in the pediatric population. They believe this study highlights the importance of patient-specific treatment decisions that are based on etiology and previous intervention. The patient-specific medical characteristics are a driving force in the cost of care.

White Matter Changes in Corpus Callosum in a Patient with Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (INPH) is characterized by the clinical triad of gait and cognitive dysfunction and urinary incontinence. Ventriculoperitoneal (VP) shunting is often required for treatment. Review of literature shows few case reports discussing benign magnetic resonance imaging (MRI) T2 hyperintense changes in the corpus callosum of NPH patients after shunting due to mechanical compression of the middle and posterior regions of the body against falx cerebri leading to ischemic demyelination. These changes can be a delayed phenomenon and may interfere with clinical evaluation and may lead to unnecessary procedures and investigations. We present a patient with NPH who was admitted to the neurocritical care unit in coma with quetiapine and trazodone overdose. Diffuse changes in the body of the corpus callosum were seen on MRI suspicious for acute vasogenic edema due to drug overdose. However, it was later determined to be due to the VP shunting for the NPH. We report this case to raise the awareness of neuroimaging changes in patients with NPH who have VP shunting.

Role of ventriculoperitoneal shunting in patients with neoplasms of the central nervous system: An analysis of 59 cases

Approximately 1-5% of patients with cerebral metastasis and ~40% of patients with primary brain tumors suffer from hydrocephalus. These patients often exhibit a poor prognosis. The aim of the present study was to reassess the validity of ventriculoperitoneal shunting (VPS) with the assistance of the general surgeon in oncological patients. A total of 59 patients underwent first-time VPS at the Beth Israel Deaconess Medical Center (Boston, USA) between 2004 and 2012; 40 patients had hydrocephalus from brain metastasis and 19 from primary tumors. The analyzed independent variables included demographics, body mass index, past medical history, clinical presentation, indication for surgery, Karnofsky performance status (KPS) score and surgical technique; the dependent variables were postoperative symptoms and occurrence, cause and time of shunt failure. The outcomes were analyzed with the t-test and Kaplan-Meier estimates for shunt survival. The mean age of the patients was 57.2 years and the mean operative time was 50.4 min. Symptomatic palliation was achieved in 93% of the cases; patients with severe symptoms, such as debilitating headaches, nausea and vomiting, benefited significantly from VPS. The mean follow-up time was 6.3 months; complications occurred in only 7 patients (11.8%) during follow-up: 2 in the proximal shunt (1 infection and 1 obstruction), both requiring revision, 1 infection in the distal catheter requiring shunt removal, 2 cases of intracerebral bleeding that were monitored with computed tomography scans, 1 wound infection treated with antibiotics and 1 valve complication that required temporary revision. The initial and 3-month KPS scores were 65±16.4 and 75±16.0, respectively. The mean overall shunt survival was 6.4 months (range, 1.0 day-76.0 months) from the placement of the VP shunt. At 3 months after VPS, 93.5% of the patients remained alive with functioning shunts and at 1 year 87% of the shunts were still functioning. In conclusion, VPS remains a valid option for cancer patients with low KPS, as it improves the quality of life in such patients, even in the setting of previous infection, hemorrhage, or leptomeningeal disease, since shunt patency outlasts the overall survival of nearly all patients.

Ventriculoperitoneal shunting: Laparoscopically assisted versus conventional open surgical approaches

OBJECTIVES

Ventriculoperitoneal shunting (VPS) is a mainstay of hydrocephalus therapy, but carries a significant risk of device malfunctioning. This study aims to compare the outcomes of laparoscopic ventriculoperitoneal shunting versus open ventriculoperitoneal shunting (OVPS) VPS-placement and reviews our findings in the pertinent context of the literature from 1993 to 2012.

MATERIALS AND METHODS

Between 2003 and 2012, a total of 232 patients underwent first time VPS placement at Beth Israel Deaconess Medical Center. Of those, 155 were laparoscopically guided and 77 were done conventionally. We analyzed independent variables (age, gender, medical history, clinical presentation, indication for surgery and surgical technique) and dependent variables (operative time, post-operative complications, length of stay in the hospital) and occurrence of shunt failure.

RESULTS

Mean operative time was 43.7 min (18.0-102.0) in the laparoscopic group versus 63.0 min (30.0-151.0) in the open group, (P < 0.05). Length of stay was similar, 5 days in the laparoscopic and in the open group, (P = 0.945). The incidence of shunt failure during the entire follow-up period was not statistically different between the two groups, occurring in 14.1% in the laparoscopic group and 16.9% in the open group, (P = 0.601). Kaplan-Meier analysis demonstrated no difference in shunt survival between the two groups (P = 0.868), with functionality in 85% at 6-months and 78.5% at 1-year.

CONCLUSION

According to our study, LVPS-placement results compare similarly to OVPS placement in most aspects. Since laparoscopic placement is not routinely indicated, we suggest a prospective study to assess its value as an alternate technique especially suitable in obese patients and patients with previous abdominal operations.

Cerebral venous thrombosis after ventriculoperitoneal shunting: a case report

Ventriculoperitoneal shunting (VPS) is a simple procedure, but there are several potential complications. We describe the first reported case of cerebral venous thrombosis (CVT) after VPS. A 69-year-old man suffering from normal pressure hydrocephalus underwent left VPS. Two months later he developed CVT and cerebral venous hemorrhage in the left frontal lobe. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed the thrombus formation just adjacent to the shunt tube. One possible cause is compression of the cortical vein after brain shift and/or tension of the cortical vein due to intracranial hypotension. A protein C deficiency was also detected. Surgeons should be aware that cerebral venous thrombosis can occur after VPS.

An update on idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a condition of unknown etiology often encountered in neurologic practice. It produces nonlocalizing symptoms and signs of raised intracranial pressure and, when left untreated, can result in severe irreversible visual loss. It most commonly occurs in obese women of childbearing age, but it can also occur in children, men, nonobese adults, and older adults. Although it is frequently associated with obesity, it can be associated with other conditions, such as obstructive sleep apnea and transverse cerebral venous sinus stenoses. Recent identification of subgroups at high risk for irreversible visual loss, including black patients, men, and patients with fulminant forms of IIH, help guide the optimal management and follow-up. Ongoing studies of venous anatomy and physiology in IIH patients, as well as a recently begun randomized clinical treatment trial, should provide further insight into this common yet poorly understood syndrome.