Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study

BACKGROUND

There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications.

OBJECTIVES

To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber.

DESIGN AND SETTING

A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil.

METHODS

Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups.

RESULTS

Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively.

CONCLUSIONS

Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe.

REGISTRATION

RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Ventriculoatrial Shunt Versus Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Ventriculoperitoneal shunt (VPS) is usually the primary choice for cerebrospinal fluid shunting for most neurosurgeons, while ventriculoatrial shunt (VAS) is a second-line procedure because of historical complications. Remarkably, there is no robust evidence claiming the superiority of VPS over VAS. Thus, we aimed to compare both procedures through a meta-analysis.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, the authors systematically searched the literature for articles comparing VAS with VPS. The included articles had to detail one of the following outcomes: revisions, infections, shunt-related mortality, or complications. In addition, the cohort for each shunt model had to encompass more than 4 patients.

RESULTS

Of 1872 articles, 16 met our criteria, involving 4304 patients, with 1619 undergoing VAS and 2685 receiving VPS placement. Analysis of revision surgeries showed no significant difference between VAS and VPS (risk ratio [RR] = 1.10, 95% CI: 0.9-1.34; I2 = 84%, random effects). Regarding infections, the analysis also found no significant difference between the groups (RR = 0.67, 95% CI: 0.36-1.25; I2 = 74%, random effects). There was no statistically significant disparity between both methods concerning shunt-related deaths (RR = 2.11, 95% CI: 0.68-6.60; I2 = 56%, random effects). Included studies after 2000 showed no VAS led to cardiopulmonary complications, and only 1 shunt-related death could be identified.

CONCLUSION

Both methods show no significant differences in procedure revisions, infections, and shunt-related mortality. The literature is outdated, research in adults is lacking, and future randomized studies are crucial to understand the profile of VAS when comparing it with VPS. The final decision on which distal site for cerebrospinal shunting to use should be based on the patient's characteristics and the surgeon's expertise.

Treatment of Idiopathic Normal Pressure Hydrocephalus with a Novel Programmable Valve: Prospective Evaluation of Costs, Efficacy, and Safety

Objective  Programmable valves provide an equal or superior neurological outcome when compared with fixed pressure ones, with fewer complications, in treating idiopathic normal pressure hydrocephalus (iNPH) patients. Long-term costs of these treatments have not been properly compared in literature. We sought to compare costs, efficacy, and safety of 1-year treatment of iNPH patients with programmable valve Sphera Pro and a fixed pressure valve. Materials and Methods  A prospective cohort of iNPH patients treated with programmable valve was compared with a historical cohort of iNPH patients treated with fixed pressure valve. Our primary outcome was mean direct cost of treating iNPH up to 1 year. Efficacy in treating iNPH and safety were assessed as secondary outcomes. Statistical Analysis  Proportions were compared using chi-square or Fisher's exact tests. Normally distributed variables were compared using the Student's t -test or the Mann-Whitney's U test. Differences in the evolution of the variables over time were assessed using generalized estimating equations. All tests were two-sided, with an α of 0.05. Results  A total of 19 patients were analyzed in each group (mean age 75 years, the majority male). Comorbidities and clinical presentation were similar between groups. Both fixed pressure and programmable valve patients had neurological improvement over time ( p  < 0.001), but no difference was seen between groups ( p  = 0.104). The fixed pressure valve group had more complications than the programmable valve group (52.6% vs. 10.5%, respectively, p  = 0.013). Annual treatment cost per patient was US$ 3,820 ± 2,231 in the fixed pressure valve group and US$ 3,108 ± 553 in the programmable valve group. Mean difference was US$712 (95% confidence interval, 393-1,805) in favor of the programmable valve group. Conclusion  The Sphera Pro valve with gravitational unit had 1 year treatment cost not higher than that of fixed pressure valve, and resulted in similar efficacy and fewer complications.

Comparison of Noninvasive Measurements of Intracranial with Tap Test Results in Patients with Idiopathic Normal Pressure Hydrocephalus

Background

Normal pressure hydrocephalus is a disease directly related to the change in intracranial compliance and consequent repercussions in the brain parenchyma. Invasive monitoring of such parameters proves to be reliable especially for prognosis in neurocritical patients; however, it is not applicable in an outpatient service setting. The present study describes the comparison between the tap test results and the parameters obtained with a non-invasive sensor for monitoring intracranial compliance in patients with suspected NPH.

Methods

Twenty-eight patients were evaluated before and after lumbar puncture of 50mL of CSF (the tap test), comprising clinical assessment, magnetic resonance imaging, physical therapy assessment using the Timed Up and Go test, Dynamic Gait Index, BERG test, neuropsychological assessment, and recording of non-invasive intracranial compliance data using the Brain4care^® device in three different positions (lying, sitting, and standing) for 5 min each. The tap test results were compared to the Time to Peak and P2/P1 ratio parameters obtained by the device.

Results

The group that had a positive Tap test result presented a median P2/P1 ratio greater than 1.0, suggesting a change in intracranial compliance. In addition, there was also a significant difference between patients with positive, negative, and inconclusive results, especially in the lying position.

Conclusion

A non-invasive intracranial compliance device when used with the patient lying down and standing up obtained parameters that suggest correspondence with the result of the tap test.

Alcohol use, abuse and dependence among elderly in outpatient treatment through the application of AUDIT

OBJECTIVE

To identify or use alcohol abuse and abuse in the IAMSPE elderly, through the application of AUDIT, socioeconomic characterization of the elderly, and problems associated with drinking and weight, if there is a relationship between depression and alcohol abuse.

METHODS

This is a cross-sectional, exploratory, and descriptive study with a quantitative approach. One hundred elderly patients were interviewed to apply a socioeconomic form and to assess alcohol consumption from AUDIT.

RESULTS

correlation between alcohol consumption and female gender (p = 0.021). Most of the participants were between 60 and 79 years old, were female, had a partner, had completed elementary school, had income and selected house, were retired and unemployed.

CONCLUSION

In the present study, we found no correlation between alcohol abuse and depression; Only one correlation was found between male gender and higher alcohol abuse. However, a significant prevalence of moderate use of high alcohol was found (3.9% in women and 21.7% in men), i.e., it poses a risk to the health of the elderly.

Home physical exercise program: analysis of the impact on the clinical evolution of patients with normal pressure hydrocephalus

OBJECTIVE

To present a program of home physical exercises for patients with normal pressure hydrocephalus (NPH) and to evaluate adherence, acceptance and applicability; to verify possible changes in patients with NPH in the home physical exercise program, comparing patients with, and without, a ventriculoperitoneal shunt, regarding gait, quality of life, activities of daily living, static and dynamic balance and its impact on the risks of falling.

METHODS

This was a controlled clinical trial, with assessments in three moments (0, 10 and 18 weeks) at the home, from October 2015 to November 2017. Fifty-two patients (30 women and 22 men) participated in the study.

RESULTS

There was a statistically significant improvement with 10 weeks of home physical exercises for the groups with and without ventriculoperitoneal shunt, respectively, in the sub-items: activities of daily living p = 0.032*, p = 0.003*; static balance p < 0.001*, p < 0.001*; functional capacity p < 0.001*, p = 0.027*; and dynamic balance and gait p = 0.009*, p < 0.001*. There was no statistically significant difference for the subitems: quality of life p = 0.695, p = 1.000; and NPH grading scale p = 0.695, p = 1.000, respectively.

CONCLUSION

The developed program of home physical exercise was easily applied and there was good acceptance by most patients with NPH included in the research. There was a statistically significant improvement with the 10 weeks of home physical exercises in the sub-items: activities of daily living, static balance and functional capacity, for both groups. In the sub-item dynamic balance and gait, there was a statistically significant improvement for both groups, but with a higher score for the group with a ventriculoperitoneal shunt. There was no statistically significant difference for the sub-items: quality of life, NPH grading scale and risk of falls, based on the Berg scale.

Clinical performance of fixed-pressure Sphera Duo® hydrocephalus shunt

INTRODUCTION

Cerebral hydrodynamics complications in shunted patients are due to the malfunction of the system. The objective of this retrospective, single-center, single-arm cohort study is to confirm the safety and performance of Sphera® Duo when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cysts.

METHODS

Data were generated by reviewing 112 adult patient's charts, who were submitted to a ventriculoperitoneal shunt surgery and followed for one year after surgery.

RESULTS

The results show us that 76% of patients had their neurological symptoms improved and that the reoperation rate was 15% in the first year following surgery.

DISCUSSION

Sphera Duo® shunt system is an applicable shunt option in routine neurosurgical management of hydrocephalus by several causes. It has presented good results while mitigating effects of overdrainage. Overdrainage is especially important in adults with non-hypertensive hydrocephalus and can cause functional shunt failure, which causes subnormal ICP (particularly in the upright position) and is associated with characteristic neurological symptoms, such as postural headache and nausea.

CONCLUSION

Sphera Duo® shunt system is safe when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cyst.

Development of the Brazilian Portuguese version of the "Grading scale for idiopathic normal pressure hydrocephalus": cross-cultural adaptation, reliability and validity

OBJECTIVE

The current study translated to Portuguese and validated the normal pressure hydrocephalus (NPH) scale originally developed in English as the Grading Scale for Idiopathic Normal Pressure Hydrocephalus.

METHODS

Following Guillemin's validation protocol, the last version of the Portuguese NPH scale was applied to 121 consecutive patients with a diagnosis of normal pressure hydrocephalus (73 men and 48 women) from the Group of Cerebral Hydrodynamics from July 2010 to March 2012.

RESULTS

The mean age was 71.09 years old, ranging from 35 to 92 years. The rate of agreement and reproducibility was high, as confirmed by Cohen's Kappa coefficient, with excellent intraobserver correlation for the NPH scale items individually evaluated: gait (0.80), dementia (0.90) and incontinence (0.87).

CONCLUSIONS

The Portuguese version of the Grading Scale for Idiopathic Normal Pressure Hydrocephalus was successfully translated and validated for use in Brazilian patients.

Smartphone-assisted minimally invasive neurosurgery

OBJECTIVE

Advances in video and fiber optics since the 1990s have led to the development of several commercially available high-definition neuroendoscopes. This technological improvement, however, has been surpassed by the smartphone revolution. With the increasing integration of smartphone technology into medical care, the introduction of these high-quality computerized communication devices with built-in digital cameras offers new possibilities in neuroendoscopy. The aim of this study was to investigate the usefulness of smartphone-endoscope integration in performing different types of minimally invasive neurosurgery.

METHODS

The authors present a new surgical tool that integrates a smartphone with an endoscope by use of a specially designed adapter, thus eliminating the need for the video system customarily used for endoscopy. The authors used this novel combined system to perform minimally invasive surgery on patients with various neuropathological disorders, including cavernomas, cerebral aneurysms, hydrocephalus, subdural hematomas, contusional hematomas, and spontaneous intracerebral hematomas.

RESULTS

The new endoscopic system featuring smartphone-endoscope integration was used by the authors in the minimally invasive surgical treatment of 42 patients. All procedures were successfully performed, and no complications related to the use of the new method were observed. The quality of the images obtained with the smartphone was high enough to provide adequate information to the neurosurgeons, as smartphone cameras can record images in high definition or 4K resolution. Moreover, because the smartphone screen moves along with the endoscope, surgical mobility was enhanced with the use of this method, facilitating more intuitive use. In fact, this increased mobility was identified as the greatest benefit of the use of the smartphone-endoscope system compared with the use of the neuroendoscope with the standard video set.

CONCLUSIONS

Minimally invasive approaches are the new frontier in neurosurgery, and technological innovation and integration are crucial to ongoing progress in the application of these techniques. The use of smartphones with endoscopes is a safe and efficient new method of performing endoscope-assisted neurosurgery that may increase surgeon mobility and reduce equipment costs.

Endoscopic view of an internal carotid artery aneurysm presenting with hydrocephalus

Giant aneurysms (>25 mm) represent approximately 5-10% of all intracranial aneurysms. In this paper it's reported a giant calcified aneurysm presenting with hydrocephalus. It's highlighted the pre-operative images and intra-operative endoscopic findings.

Failed Ventriculoperitoneal Shunt: Is Retrograde Ventriculosinus Shunt a Reliable Option?

BACKGROUND

Currently, the treatment of hydrocephalus is mainly carried out through a ventriculoperitoneal shunt (VPS) insertion. However, in some cases, there may be surgical revisions and requirement of an alternative distal site for shunting. There are several described distal sites, and secondary options after VPS include ventriculopleural and ventriculoatrial shunt, which have technical difficulties and harmful complications.

OBJECTIVES

In this preliminary report we describe our initial experience with retrograde ventriculosinus shunt (RVSS) after failed VPS.

RESULTS

In 3 consecutive cases we applied RVSS to treat hydrocephalus in shunt-dependent patients who had previously undergone VPS revision and in which peritoneal space was full of adhesions and fibrosis. RVSS was performed as described by Shafei et al., with some modifications to each case. All 3 patients kept the same clinical profile after RVSS, with no perioperative or postoperative complications. However, revision surgery was performed in the first operative day in 1 out of 3 patients, in which the catheter was not positioned in the superior sagittal sinus.

CONCLUSIONS

We propose that in cases where VPS is not feasible, RVSS may be a safe and applicable second option. Nevertheless, the long-term follow-up of patients and further learning curve must bring stronger evidence.

Effect of volume replacement during combined experimental hemorrhagic shock and traumatic brain injury in prostanoids, brain pathology and pupil status

Traumatic brain injury (TBI) is the main cause of trauma-related deaths. Systemic hypotension and intracranial hypertension causes cerebral ischemia by altering metabolism of prostanoids. We describe prostanoid, pupilar and pathological response during resuscitation with hypertonic saline solution (HSS) in TBI. Method Fifteen dogs were randomized in three groups according to resuscitation after TBI (control group; lactated Ringer's (LR) group and HSS group), with measurement of thromboxane, prostaglandin, macroscopic and microscopic pathological evaluation and pupil evaluation.Result Concentration of prostaglandin is greater in the cerebral venous blood than in plasma and the opposite happens with concentration of thromboxane. Pathology revealed edema in groups with the exception of group treated with HSS.Discussion and conclusion There is a balance between the concentrations of prostaglandin and thromboxane. HSS prevented the formation of cerebral edema macroscopically detectable. Pupillary reversal occurred earlier in HSS group than in LR group.

The Retrograde Ventriculosinusal Shunt in an Animal Experimental Model of Hydrocephalus

Currently, hydrocephalus treatment is performed mainly with ventriculoperitoneal shunting. This experimental study aims at assessing whether the experimental model of hydrocephalus in dogs is applicable to the laboratory study of the retrograde ventriculosinusal shunt (RVSS). Four mongrel dogs were assessed. After randomization, the animals were divided into two groups: an experimental group that underwent the induction of hydrocephalus/RVSS and a control group, for the measurement of the mean arterial pressure, intracranial pressure and pressure in the superior sagittal sinus (SSS). The controls presented a mean arterial pressure of 68 mm Hg (71 and 65), an intracranial pressure of 163 mm H2O (149.6 and 176.8) and a pressure at the SSS of 40 mm H2O (40 and 40). The kaolin injection into the cisterna magna at a concentration of 0.3 mg/ml was capable of inducing the clinical and radiological mechanism of hydrocephalus (intracranial pressure = 250 mm H2O, pressure at the SSS = 50 mm H2O). The caliber of the SSS was 2.5 ± 1.0 mm. The fact that the SSS caliber of the dog was the same size as the external diameter of the catheter used resulted in the complete obstruction of the SSS when the catheter was inserted. We believe we could design and perform an experimental model to test the RVSS. It is applicable and feasible. The model of hydrocephalus, the surgical apparatus and the scenario were adequate, but the shunt system needs to be proportionally made to the canine anatomy.

Surgical technique of retrograde ventricle-sinus shunt is an option for the treatment of hydrocephalus in infants after surgical repair of myelomeningocele

ABSTRACT Introduction Treatment of hydrocephalus is accomplished primarily through a ventricular-peritoneal shunt (VPS). This study aims to describe the application of retrograde ventricle-sinus shunt (RVSS) in patients with hydrocephalus after surgical treatment of myelomeningocele. Method A prospective, randomized and controlled pilot study. We consecutively enrolled 9 patients with hydrocephalus after surgical repair of myelomeningocele from January 2010 to January 2012. These patients underwent elective RVSS or VPS. Five underwent RVSS and 4 underwent VPS. Patients were followed for one year with quarterly evaluations and application of transcranial Doppler. Results RVSS group showed outcomes similar to those of VPS group. Doppler revealed significant improvement when comparing preoperative to postoperative period. RVSS group had significantly higher cephalic perimeter than VPS group. Neuropsychomotor development, complications and subjective outcomes did not differ between groups. Conclusion RVSS shunt is viable; it is an alternative option for the treatment of hydrocephalus.

Performance of the fixed pressure valve with antisiphon device SPHERA® in the treatment of normal pressure hydrocephalus and prevention of overdrainage

Normal pressure hydrocephalus (NPH) is characterized by the triad of gait apraxia, dementia and urinary incontinence associated with ventriculomegaly and normal pressure of cerebrospinal fluid. Treatment is accomplished through the implantation of a ventricular shunt (VPS), however some complications are still frequent, like overdrainage due to siphon effect. This study analyses the performance of a valve with anti-siphon device (SPHERA®) in the treatment of patients with NPH and compares it with another group of patients with NPH who underwent the same procedure without anti-siphon mechanism (PS Medical® valve). 30 patients were consecutively enrolled in two groups with 15 patients each and followed clinically and radiologically for 1 year. Patients submitted to VPS with SPHERA® valve had the same clinical improvement as patients submitted to VPS with PS Medical®. However, complications and symptomatology due to overdrainage were significantly lower in SPHERA® group, suggesting it as a safe tool to treat NPH.

Evidences in the treatment of idiopathic normal pressure hydrocephalus

INTRODUCTION

idiopathic normal pressure hydrocephalus (INPH) is characterized by gait apraxia, cognitive dysfunction and urinary incontinence. There are two main treatment options: ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV). However, there are doubts about which modality is superior and what type of valve should be applied. We are summarizing the current evidence in INPH treatment.

METHODS

an electronic search of the literature was conducted on the Medline, Embase, Scielo and Lilacs databases from 1966 to the present to obtain data published about INPH treatment.

RESULTS

the treatment is based on three pillars: conservative, ETV and VPS. The conservative option has fallen into disuse after various studies showing good results after surgical intervention. ETV is an acceptable mode of treatment, but the superiority of VPS has made the latter the gold standard.

CONCLUSION

well-designed studies with a high level of appropriate evidence are still scarce, but the current gold standard for treatment of INPH is conducted using VPS.

Application of a 980-nanometer diode laser in neuroendoscopy: a case series

OBJECTIVE

Ventricular neuroendoscopy represents an important advance in the treatment of hydrocephalus. High-power (surgical) Nd:YAG laser and low-level laser therapy (using 685-nm-wavelength diode laser) have been used in conjunction with neuroendoscopy with favorable results. This study evaluated the use of surgical 980-nm-wavelength diode laser for the neuroendoscopic treatment of ventricular diseases.

METHODS

Nine patients underwent a neuroendoscopic procedure with 980-nm diode laser. Complications and follow-up were recorded.

RESULTS

Three in-hospital postoperative complications were recorded (1 intraventricular hemorrhage and 2 meningitis cases). The remaining 6 patients had symptom improvement after endoscopic surgery and were discharged from the hospital within 24-48 hours after surgery. Patients were followed for an average of 14 months: 1 patient developed meningitis and another died suddenly at home. The other patients did well and were asymptomatic until the last follow-up consultation.

CONCLUSIONS

The 980-nm diode laser is considered an important therapeutic tool for endoscopic neurological surgeries. This study showed its application in different ventricular diseases.

Laparoscopy for ventriculoperitoneal shunt implantation and revision surgery

Ventriculoperitoneal shunting (VPS) is a widely accepted technique for the treatment of hydrocephalus. The probability of shunt dysfunction is pretty high throughout life. Laparoscopy has become a valuable tool to perform VPS and treat abdominal complications. An electronic literature search was performed to reveal the published data relating laparoscopy and ventriculoperitoneal shunt in Medline, Embase, Scielo and Lilacs databases. The keywords employed were “laparoscopy” OR “laparoscopic surgery” AND “ventriculoperitoneal shunt” OR “shunt” AND “surgery” OR “implantation” OR “revision” OR “complication”. No high quality trials were developed comparing conventional laparotomic incision vs laparoscopic approach. Both approaches have evolved and currently there are less invasive options for laparotomy, like periumbilical small incisions; and for laparoscopy, like smaller and less incisions. Operating room time, blood loss and hospital stay may be potentially smaller in laparoscopic surgery and complications are probably the same as laparotomy. In revision surgery for abdominal complications after VPS, visualization of whole abdominal cavity is fundamental to address properly the problem and laparoscopic approach is valuable once it is safe, fast and much less invasive than laparotomy. Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. Laparoscopy assisted shunt surgery in selected cases might be a less invasive and more effective option for intrabdominal manipulation. The laparoscopic approach allows a better catheter positioning, lysis of fibrotic bundles and peritoneal inspection as well, without any additional complication.

Comparison of functional electrical stimulation associated with kinesiotherapy and kinesiotherapy alone in patients with hemiparesis during the subacute phase of ischemic cerebrovascular accident

OBJECTIVE

To compare the functional electrical stimulation associated with functional kinesiotherapy alone in patients after ischemic cerebrovascular accident.

METHODS

The study included 20 patients who were divided into two groups: Group I (GI): functional electrical stimulation plus functional kinesiotherapy and Group II (GII): functional kinesiotherapy. We evaluated active and passive range of motion, in knee flexion and extension muscle strength, activities of daily living and quality of life. The evaluations were conducted in the pretreatment period, after 10 sessions and after 20 physical therapy sessions.

RESULTS

There was a significant improvement in all variables studied for both groups. However, significant improvements for the sub-items functional capacity and social aspects were seen only in the patients treated with associated functional electrical stimulation and kinesiotherapy.

CONCLUSION

Although both groups of patients improved with the treatment, the association of functional electrical stimulation and kinesiotherapy showed superiority in two quality of life items, in the sub-items functional capacity and social aspects.

Programmable valve represents an efficient and safe tool in the treatment of idiopathic normal-pressure hydrocephalus patients

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by gait disturbance, dementia and /or urinary incontinence, dilation of the ventricular system and normal opening cerebrospinal fluid pressure. Shunt surgery is the standard treatment of iNHP. Diversions with programmable valves are recommended, once drainage pressure can be changed. However, well-defined protocols still lack guiding the steps to attain proper pressure for each patient. Methods: In our study, we reported the experience of shunting 24 patients with iNPH using Strata® (Medtronic) valve, following a protocol based on a positive Tap Test. Results: We observed clinical improvement in 20 patients and stability/worsening in 4 patients. Complications occurred in five patients, including one death. The results display improvement, and complications occurred at a lower rate than reported in other studies. Conclusions: The Strata® valve used in the proposed protocol represents an efficient and safe tool in the treatment of iNPH.

Role of Endoscopic Third Ventriculostomy and Ventriculoperitoneal Shunt in Idiopathic Normal Pressure Hydrocephalus

BACKGROUND:

Currently, the most common treatment for idiopathic normal pressure hydrocephalus (INPH) is a ventriculoperitoneal shunt (VPS), generally with programmable valve implantation. Endoscopic third ventriculostomy (ETV) is another treatment option, and it does not require prosthesis implantation.

OBJECTIVE:

To compare the functional neurological outcome in patients after 12 months of treatment with INPH by using 2 different techniques: ETV or VPS.

METHODS:

Randomized, parallel, open-label trial involving the study of 42 patients with INPH and a positive response to the tap test, from January 2009 to January 2012. ETV was performed with a rigid endoscope with a 30° lens (Minop, Aesculap), and VPS was performed with a fixed-pressure valve (PS Medical, Medtronic). The outcome was assessed 12 months after surgery. The neurological function outcomes were based on the results of 6 clinical scales: mini-mental, Berg balance, dynamic gait index, functional independence measure, timed up and go, and normal pressure hydrocephalus.

RESULTS:

There was a statistically significant difference between the 2 groups after 12 months of follow-ups, and the VPS group showed better improvement results (ETV = 50%, VPS = 76.9%).

CONCLUSION:

Compared with ETV, VPS is a superior method because it had better functional neurological outcomes 12 months after surgery.

Performance of fixed-pressure valve with antisiphon device SPHERA(®) in hydrocephalus treatment and overdrainage prevention

Patients with hydrocephalus and risk factors for overdrainage may be submitted to ventricular shunt (VS) implant with antisiphon device. The objective of this study was to prospectively evaluate for two years the clinical and tomographic results of the implant of fixed-pressure valves with antisiphon device SPHERA(®) in 35 adult patients, with hydrocephalus and risk factors for overdrainage. Of these, 3 had congenital hydrocephalus in adult patients with very dilated ventricles (Evans index >50%), 3 had symptomatic overdrainage after previous VS implant (subdural hematoma, hygroma or slit ventricle syndrome), 1 had previous chronic subdural hematoma, 15 had normal pressure hydrocephalus with final lumbar pressure <5 cm H(2)O after tap test (40 mL), 6 had pseudotumor cerebri, and 7 had hydrocephalus due to other causes. Clinical improvement was observed and sustained in 94.3% of the patients during the two-year period with no computed tomography (CT) evidence of hypo or overdrainage, and no immediate early or late significant complications.

Revisiting hydrocephalus as a model to study brain resilience

Hydrocephalus is an entity which embraces a variety of diseases whose final result is the enlarged size of cerebral ventricular system, partially or completely. The physiopathology of hydrocephalus lies in the dynamics of circulation of cerebrospinal fluid (CSF). The consequent CSF stasis in hydrocephalus interferes with cerebral and ventricular system development. Children and adults who sustain congenital or acquired brain injury typically experience a diffuse insult that impacts many areas of the brain. Development and recovery after such injuries reflects both restoration and reorganization of cognitive functions. Classic examples were already reported in literature. This suggests the presence of biological mechanisms associated with resilient adaptation of brain networks. We will settle a link between the notable modifications to neurophysiology secondary to hydrocephalus and the ability of neuronal tissue to reassume and reorganize its functions.

Could craniometric measurements explain the growth of the superior sagittal sinus?

OBJECTIVE

The objective of this study was to relate demographic variables and craniometric measures with measurements of the superior sagittal sinus (SSS) at different points along the path of the SSS. The findings were then discussed with regards to theories of skull growth.

METHODS

We studied 33 skulls with known demographic characteristics and measured various craniometric parameters and distances related to the specific dimensions of the SSS. These data were statistically analyzed, and the results are presented.

RESULTS

Of the 33 cadaver samples, 16 were female and 17 were male, aged between 28 and 87 years at the time of death. The cross-sectional area of the SSS measured at the coronary suture was positively correlated with the biauricular length. In addition, when measured 1.5 cm above the torcula, the cross-sectional area of the SSS was negatively correlated with the distance between the medial epicanthi.

CONCLUSIONS

The relationships found may indicate that the growth of the SSS is proportional to the activity of each segment of the SSS that occurs along its path.

Hypopituitarism due to hydrocephalus: case report and review of the literature

INTRODUCTION

Although rare, chronic hydrocephalus may cause amenorrhea and delayed puberty associated with obesity as the main endocrine manifestations. Since the first operation carried out in 1950 on a patient with amenorrhea and hydrocephalus, fewer than 30 patients with these features have been reported.

CASE REPORT

Our patient represents a teenage case of primary amenorrhea, partial adrenal insufficiency and adult growth hormone deficiency caused by hydrocephalus due to aqueductal stenosis. Our English-language literature search for similar well-documented cases yielded less than 30 cases. Our management consisted of endoscopic third ventriculostomy, which resulted in regular menstrual cycles and normalization of somato- and adrenocorticotropic axes.

DISCUSSION

This is a rare case of a 20-year-old woman with primary amenorrhea caused by hydrocephalus due to aqueductal stenosis. Neurosurgical treatment produced relief in hypothalamic hydrodynamics tension, allowing recovery of hormonal function and restoring normal menstrual cycles.

Determining ICH Score: can we go beyond?

Spontaneous intracerebral hemorrhage (SICH) still presents a great heterogeneity in its clinical evaluation, demonstrating differences in the enrollment criteria used for the study of intracerebral hemorrhage (ICH) treatment. The aim of the current study was to assess the ICH Score, a simple and reliable scale, determining the 30-day mortality and the one-year functional outcome. Consecutive patients admitted with acute SICH were prospectively included in the study. ICH Scores ranged from 0 to 4, and each increase in the ICH Score was associated with an increase in the 30-day mortality and with a progressive decrease in good functional outcome rates. However, the occurrence of a pyramidal pathway injury was better related to worse functional outcome than the ICH Score. The ICH Score is a good predictor of 30-day mortality and functional outcome, confirming its validity in a different socioeconomic populations. The association of the pyramidal pathway injury as an auxiliary variable provides more accurate information about the prognostic evolution.

Pilot study in neonates using low-level laser therapy in the immediate postoperative period of myelomeningocele

ABSTRACT Objective: To analyze the tissue repair behavior after corrective surgical incision in neonates submitted to low-level laser therapy, in an attempt to diminish the incidence of postoperative dehiscence following the surgery for myelomeningocele performed immediately after birth. Methods: It is a prospective pilot study with 13 myelomeningocele patients submitted to surgery at birth who received adjuvant treatment with low-level laser therapy (Group A). Diode laser C.W., λ = 685t nm, p = 21 mW, E = 0.19 J was punctually applied along the surgical incision, summing up 4 to 10 J energy delivered per patient, according to the surgical wound area and, then, compared with the previous results, which were obtained from 23 patients undergoing surgery without laser therapy (Group B). Results: This pilot study showed a significant decline in dehiscence of surgical wounds in neonates submitted to low-level laser therapy as compared to controls (7.69 versus 17.39%, respectively), demonstrating this is an effective, safe and noninvasive treatment method. conclusion: This new adjuvant therapeutic proposal with low-level laser therapy aided healing of surgical wounds, preventing morbidities, as well as decreasing hospital stay, which implies cost of reduction for patients and for the institution.

Treatment of colloid cysts of the third ventricle through neuroendoscopic Nd: YAG laser stereotaxis

OBJECTIVE: Colloid cysts (IIIVT CC) are benign neuroepithelial cysts located in the anterior third ventricle. The authors propose the use of Nd:YAG laser stereotactic neuroendoscopic for guided resection of the third ventricle colloid cysts. METHOD: Eleven patients presented third ventricle colloid cysts and were treated by Nd:YAG laser guided with stereotactic endoscopy (n=7) , stereotactic endoscopy (n=3) or stereotactly guided puncture (n=1). The patients were followed prospectively (average 33 months, range 19-64 months). The clinical data, neuroimaging findings, hospitalization stay, outcomes and complications of the method were evaluated. RESULTS: All patients presented headache; six had papilledema, one had gait disturbance and one had third-nerve palsy. Neuroimaging showed hydrocephalus and a IIIVT CC with 14.4-mm mean diameter. After surgery all patients presented clinical and image improvement. Only two patients presented transient morbidities that were easily treated: One had diabetes insipidus that lasted for two days and was treated with a single dose of DDAVP, and another had chemical aseptic meningitis, probably due to the contact of the cyst content with the CSF. This patient was treated with antibiotics and corticosteroids with complete resolution of the problem without sequels. The other patients were discharged from the hospital 48 h after surgery. CONCLUSION: The stereotactic neuroendoscopy-guided procedure with Nd:YAG laser allowed the complete removal of the third ventricle colloid cysts, without definitive morbidities, sequels or recurrence of the lesion.

Surgical treatment of myelomeningocele carried out at 'time zero' immediately after birth

BACKGROUND/AIMS

To present a protocol of immediate surgical repair of myelomeningocele (MMC) after birth ('time zero') and compare this surgical outcome with the surgery performed after the newborn's admission to the nursery before the operation.

METHODS

Data from the medical files of 31 patients with MMC that underwent surgery after birth and after admission at the nursery (group I) were compared with a group of 23 patients with MMC admitted and prospectively followed, who underwent surgery immediately after birth--'at time zero' (group II).

RESULTS

The preoperative rupture of the MMC occurred more frequently in group I (67 vs. 39%, p < 0.05). The need for ventriculoperitoneal shunt was 84% in group I and 65% in group II and 4 of them were performed during the same anesthetic time as the immediate MMC repair, with no statistically significant difference. Group I had a higher incidence of small dehiscences when compared to group II (29 vs. 13%, p < 0.05); however, there was no statistically significant difference regarding infections. After 1 year of follow-up, 61% of group I showed neurodevelopmental delay, whereas only 35% of group II showed it.

CONCLUSIONS

The surgical intervention carried out immediately after the birth showed benefits regarding a lower incidence of preoperative rupture of the MMC, postoperative dehiscences and lower incidence of neurodevelopmental delay 1 year after birth.

Intracranial arterial aneurysms in childhood: case report

A case of an intracranial arterial aneurysm at internal carotid bifurcation in a 10-year-old girl is described with the special features of cerebral aneurysm which occur in children, comparing with the adults. We alert for the necessity of carefully operative technique in order to avoid damage and intraoperative rupture of the aneurysm due to the very thin vessel wall that this population can develop. Our recommendation is early surgery in these patients.

Volume replacement with lactated Ringer's or 3% hypertonic saline solution during combined experimental hemorrhagic shock and traumatic brain injury

BACKGROUND

The devastating effects of hypotension on head-trauma-related mortality are well known. This study evaluates the systemic and cerebral hemodynamic responses to volume replacement with 3% hypertonic saline (HSS) or lactated Ringer's solution (LR), during the acute phase of hemorrhagic shock (HS) associated with traumatic brain injury (TBI).

METHODS

Fifteen dogs were assigned to one of three groups (n = 5, each) according to the volume replacement protocol, infused after TBI (brain fluid percussion, 4 atm) and epidural balloon to an intracranial pressure (ICP) higher than 20 mm Hg and HS, induced by blood removal to a mean arterial pressure (MAP) of 40 mm Hg in 5 minutes: Group HS+TBI+HSS (8 mL/kg of 3% HSS), HS+TBI+LR (16 mL/kg LR), and Group HS+TBI (controls, no fluids). We simulated treatment during prehospital and early hospital admission. Groups HS+ TBI and HS+TBI+LR received shed blood infusion to a target hematocrit of 30%. Measurements included shed blood volume, fluid volume infused to restore MAP, MAP, cardiac output, cerebral perfusion pressure, cerebral and systemic lactate, and oxygen extraction ratios.

RESULTS

Fluid replacement with HSS 3% or LR promoted major hemodynamic benefits over control animals without luids. Cerebral perfusion pressure was higher than controls and similar between treated groups; however, HSS 3% infusion was associated with lower ICP during the "early hospital phase" and a higher serum sodium and osmolarity.

CONCLUSION

In the event of severe head trauma and hemorrhagic shock, the use of HSS 3% and larger volumes of LR promote similar systemic and cerebral hemodynamic benefits. However, a lower ICP was observed after HSS 3% than after LR.

Hemophilia and child abuse as possible causes of epidural hematoma: case report

INTRODUCTION

Head trauma is an important consequence of child abuse. Specific pathophysiological mechanisms in child abuse are responsible for the "whiplash shaken-baby syndrome", which would favour the occurrence of intracranial hemorrhages.

CASE REPORT

We report the case of a child who developed epidural hematoma following minor-intensity head trauma. Initial diagnosis of child abuse was made, but subsequent investigation led to the diagnosis of hemophilia A.

CONCLUSION

Even though epidural hematoma is not closely associated with child abuse, this etiology must always be considered when the reported trauma mechanism is out of proportion to the magnitude of the encountered lesions.

Intraventricular pressure monitoring in patients with thalamic and ganglionic hemorrhages

In the present study, we have evaluated the use of intraventricular pressure catheters in thalamic and ganglionic hemorrhages. Ten patients admitted in our Emergency Department in Glasgow Coma Scale (GCS) equal or below 13 enrolled the study (at least one point should have been lost in the eye opening score to exclude purely aphasic patients that were fully alert). After a complete clinical and neurological evaluation, computed tomography scans were obtained and the volume of the hematomas, as well as presence or absence of hydrocephalus, were considered. Intraventricular pressure catheters connected in parallel to external derivation systems were implanted and patients were thereafter sent to the ICU. Patients that presented mass effect lesions with sustained increased ICP levels or clinical and neurological deterioration were submitted in addition, to the surgical evacuation of the hematomas. Clinical evolution, complications and the rehabilitation of the patients were recorded. Clinical outcome was assessed with the Glasgow Outcome Score. In all but three patients the initial intracranial pressure levels were bellow 20 mmHg (mean for all patients was 14.1 +/- 6.5 mmHg). Notwithstanding, these three patients were extremely difficult to treat. For this group of patients mortality was 100%. Among the patients that presented ICP levels bellow 20 mmHg, 04 developed hydrocephalus and 03 did not display ventricular dilation. As expected, the major benefits concerning the intraventricular pressure catheters connected in parallel with external derivation systems were observed in the group of patients that presented ICP levels bellow 20 mmHg and had hydrocephalus. Mild non-statistically significant correlations for all the three groups were achieved either when the initial GCS and ICP levels (r=-0.28, p=0.43) or when ICP levels and the volumes of the hematomas were compared (r=0.38, p=0.28). In addition, no significant correlations were observed concerning the final outcome of the patients and the variables previously evaluated.

Anatomic study of the filum terminale and its correlations with the tethered cord syndrome

OBJECTIVE

To evaluate the intradural anatomic features of the filum terminale (FT) in fresh human cadavers, analyzing morphological parameters relevant for the diagnosis of the tethered cord syndrome.

METHODS

Forty-one fresh cadavers were dissected, and the following parameters were evaluated: cadaver height, weight, and age, FT length, FT diameters at the initial point and midpoint, and topographic relationships of the initial and fusion points of the FT to the adjacent vertebrae.

RESULTS

The mean FT length was 156.44 mm (range, 112.8-211.1 mm), the mean initial diameter was 1.38 mm (range, 0.4-2.5 mm), and the mean midpoint diameter was 0.76 mm (range, 0.1-1.55 mm). Four specimens (9.76%) exhibited FT thicknesses of more than 2 mm at their initial points. The FT most frequently started at the middle L1 level (19.51%) and fused with the dura mater at the upper S2 level (31.71%). Two fila (4.88%) started below the L2 level. Statistically significant correlations were observed (Pearson correlation, P < 0.05) between specimen weight and height (P = 0.019), initial point and midpoint diameters of the FT (P < 0.001), initial vertebral level and specimen height (P = 0.012), and initial and fusion vertebral levels (P = 0.004).

CONCLUSION

Variation ranges were large for almost all anatomic parameters of the FT. Six cadavers (14.63%) in our study fulfilled one of the anatomic diagnostic criteria for tethered cord syndrome. Neurosurgeons must remember the normal variations in the anatomic features of this region when establishing the diagnosis of tethered cord syndrome or performing surgical procedures involving the caudal part of the dural sac.

Lumbar disc herniation associated with scoliosis in a 15-year-old girl: case report

Intervertebral disc herniation is a rare condition in childhood and adolescence, although some cases have already been reported in the literature. We present the case of a 15 year-old-girl with low back pain and scoliosis. She had no previous history of trauma or collagen diseases. MRI showed L4-L5 and L5-S1 disc herniations and no further bone and structural changes. After two level discectomy, pain ceased and scoliosis improved, without further treatment. Based on her evolution and on what has already been reported in literature, we consider that scoliosis associated with disc herniation in young patients is most likely to be only an anthalgic position, not indicative of further structural changes.