Hydrocephalus in patients with vestibular schwannoma

BACKGROUND

Hydrocephalus (HC) is common in patients with vestibular schwannoma (VS). This can be managed with a cerebrospinal fluid (CSF) diversion procedure prior to VS resection or with VS resection, keeping CSF diversion in reserve unless required postoperatively. No clear consensus exists as to which approach is superior. This study identifies factors predictive of the development of HC, and analyses outcomes for those managed with primary CSF resection versus tumour resection.

METHODS

Single-centre retrospective cohort study of 204 consecutive adult patients with a unilateral VS from May 2009 to June 2021. Data was collected on patient and tumour demographics, management, and outcome.

RESULTS

204 patients, with a mean age at presentation of 59.5 (21-83), with 50% female, and a mean follow-up of 7.5 years (1.8-13.9) were included. 119 were managed conservatively, 36 with stereotactic radiosurgery only, and 49 with surgery. 30 (15%) patients had radiological HC, of which 23 (77%) were obstructive, and 7 (23%) were communicating. Maximum intracranial tumour diameter and Koos grade were higher in patients with HC. Of the patients with HC the majority (20, 67%) were managed initially with CSF diversion, with 12 patients undergoing subsequent tumour resection, and three patients avoiding primary resection. Nine (30%) were managed with primary surgical resection, of whom three required subsequent CSF diversion. Complication rates and Modified Rankin Scale (MRS) were comparable or lower in the CSF diversion group (8%, MRS ≤2 = 83%), versus the primary resection group (67%, MRS ≤2 = 67%), and the primary surgical resection without HC group (25%, MRS ≤2 = 86%).

CONCLUSIONS

CSF diversion prior to tumour resection is a safe and acceptable strategy compared to primary VS resection, with improved outcomes and reduced surgical complications. Randomized studies and national databases are needed to determine the long-term outcomes of patients treated with CSF diversion versus primary resection.

Analysis of Evolution of Hydrocephalus in Posterior Fossa Tumors and Validation Study of the Modified Canadian Preoperative Prediction Rule for Hydrocephalus in Children and Frankfurt Grading System for Prediction of Cerebrospinal Fluid Diversion in Adults with Posterior Fossa Tumors

OBJECTIVE

We sought to analyze the evolution of hydrocephalus and enumerate its predictive factors in posterior fossa tumors in children and adults. We also validated the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) and Frankfurt grading systems as tools to predict cerebrospinal fluid (CSF) diversion in children and adults, respectively.

METHODS

A retrospective review of patients with posterior fossa tumors operated between 2012 and 2019 was performed. Clinical, radiologic, and operative data were obtained. Validation was performed for both scores via receiver operating characteristic (ROC) curves and evaluation of the area under the curve (AUC).

RESULTS

We included 116 children and 343 adults in the study. Of the adults, 141 patients had intraaxial tumors and 172 had extraaxial tumors. The insertion of external ventricular drain (EVD), its duration, papilledema was noted to have significant influence on the need for permanent CSF diversion (P < 0.05) in children. The ROC for mCPPRH score was 0.659 (0.501-0.816), Age- 0.496 (0.334-0.658) and Evans index- 0.788 (0.654-0.922). In adults- Intraaxial tumours Age, Frankfurt score, duration of EVD, Diagnosis, Extent of resection and periventricular capping significant predictors and ROC age AUC 0.300 (0.193-0.407), Evans index 0.939 (0.888-0.990), and Frankfurt score 0.908 (0.853-0.964) (P < 0.05), whereas in extraaxial tumors Frankfurt grading, sex, duration of EVD, presence of perilesional edema and extent of resection (P < 0.05) ROC age AUC 0.439 (0.344-0.534), Evans index 0.941 (0.906-0.977), and Frankfurt score 0.847 (0.782-0.912).

CONCLUSIONS

This is the first external validation study for the 2 predictive systems in use. mCPPRH demonstrated poor predictive accuracy, and Frankfurt grading system demonstrated good accuracy. EVD insertion and its duration was significantly predictive of the need for permanent CSF diversion.

Extra-Axial Third Ventriculostomy Through Lamina Terminalis with Multiple Cisternostomies - Rescue Surgery for Patients with Failed Shunt Surgeries and Hydrocephalus

Background and Aim

Contemporary management of hydrocephalus involves various modes of cerebrospinal fluid (CSF) diversion, including shunt surgery and endoscopic ventriculostomy. However, there are times when either of these procedures have either failed or are not feasible. Highly invasive procedures aimed at internal CSF have been described previously, which, with the aid of modern microsurgical techniques, can be attempted in cases with very limited options. Our aim was to study the utility of extra-axial third ventriculostomy via lamina terminalis fenestration with multiple cisternostomies in the treatment of failed hydrocephalus.

Materials and Methods

Forty-five patients with hydrocephalus were operated for extra-axial trans-lamina terminalis third ventriculostomy with multiple cisternostomies from January 2017 to January 2019. A minimally invasive supraorbital craniotomy was performed with subfrontal fenestration of the lamina terminalis and trans-lamina terminalis fenestration of the floor of the third ventricle with multiple cisternostomies including the optico-carotid cistern and opening of the Liliequist membrane.

Results

Tuberculous meningitis was the most common etiology in the series, and multiple shunt procedures and incompatible CSF profiles were the most common reasons that necessitated this alternate rescue procedure. At a mean follow-up of 6 months, no patient required a revision shunt surgery. There was one death due to cardiac failure with anasarca, unrelated to the procedure.

Conclusions

Extra-axial trans-lamina terminalis ventriculostomy with cisternostomies can safely be performed using minimally invasive micro-neurosurgical techniques, adding to the armamentarium of neurosurgeons in the management of complex cases of hydrocephalus.

Risk factors for posttraumatic hydrocephalus after decompressive hemicraniectomy in pediatric patients with traumatic brain injury

OBJECTIVE

Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Decompressive hemicraniectomy (DHC) is a treatment option for severe pediatric TBI (pTBI) not amenable to medical management of intracranial pressure. Posttraumatic hydrocephalus (PTH) is a known sequela of DHC that may lead to further injury and decreased capacity for recovery if not identified and treated. The goal of this study was to characterize risk factors for PTH after DHC in patients with pTBI by using the Kids' Inpatient Database (KID).

METHODS

The records collected in the KID from 2016 to 2019 were queried for patients with TBI using International Classification of Diseases, 10th Revision codes. Data defining demographics, complications, procedures, and outcomes were extracted. Multivariate regression was used to identify risk factors associated with PTH. The authors also investigated length of stay and hospital charges.

RESULTS

Of 68,793 patients with pTBI, 848 (1.2%) patients underwent DHC. Prolonged mechanical ventilation (PMV) was required in 475 (56.0%) patients with pTBI undergoing DHC. Three hundred (35.4%) patients received an external ventricular drain (EVD) prior to DHC. PTH was seen in 105 (12.4%), and 50 (5.9%) received a ventriculoperitoneal shunt. DHC before hospital day 2 was negatively associated with PTH (OR 0.464, 95% CI 0.267-0.804; p = 0.006), whereas PMV (OR 2.204, 95% CI 1.344-3.615; p = 0.002) and EVD placement prior to DHC (OR 6.362, 95% CI 3.667-11.037; p < 0.001) were positively associated with PTH. PMV (OR 7.919, 95% CI 2.793-22.454; p < 0.001), TBI with subdural hematoma (OR 2.606, 95% CI 1.119-6.072; p = 0.026), and EVD placement prior to DHC (OR 4.575, 95% CI 2.253-9.291; p < 0.001) were independent predictors of ventriculoperitoneal shunt insertion. The mean length of stay and total hospital charges were significantly increased in patients with PMV and in those with PTH.

CONCLUSIONS

PMV, presence of subdural hematoma, and EVD placement prior to DHC are risk factors for PTH in patients with pTBI who underwent DHC. Higher healthcare resource utilization was seen in patients with PTH. Identifying risk factors for PTH may improve early diagnosis and efficient resource utilization.

Perioperative external ventricular drainage vs. no-EVD strategy in pediatric posterior fossa tumors-pilot study results

INTRODUCTION

Pediatric brain tumors of the posterior fossa often present with occlusive hydrocephalus. Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS) has been established for definite hydrocephalus treatment. The aim of the study was to analyze the impact and safety of perioperative temporary external ventricular CSF drainage (EVD) placement on postoperative hydrocephalus outcome compared to a no-EVD strategy.

PATIENTS AND METHODS

In a prospective database, 36 posterior fossa tumor patients of 2-18 years were included with a follow-up of 1 year. Fifty-eight percent presented with preoperative hydrocephalus. Patients were assigned to non-hydrocephalus group: group I (n = 15) and to preoperative hydrocephalus, group IIa with EVD placement (n = 9), and group IIb without EVD (n = 12).

RESULTS

Median age of patients was 8.1 years (range 3.17 to 16.58 years). One-third of 21 hydrocephalus patients required ETV or VPS (n = 7). Occurrence of de novo hydrocephalus in group I after surgery was not observed in our cohort. Age and histology were no confounding factor for EVD placement between group IIa and IIb (p = 0.34). The use of EVD did not result in better control of hydrocephalus compared to no-EVD patients considering pre- and postoperative MRI ventricular indices (p = 0.4). Perioperative placement of an EVD resulted in a threefold risk for subsequent VPS or ETV (group IIa 55.5% vs group IIb 16.6%): relative risk for EVD patients compared to no-EVD patients with hydrocephalus was 3.3 (CI = 1.06-13.43, p = 0.09).

CONCLUSION

Perioperative EVD placement appears to harbor a threefold relative risk of requiring subsequent permanent CSF diversion in children above 2 years. EVD was not more effective to control ventricular enlargement compared to tumor removal alone. The no-EVD strategy was safe and did not result in postoperative complications. Thus, to evaluate potential adverse effects on hydrocephalus outcome by EVD placement, a prospective study is warranted to falsify the results.

Direct ventriculoatrial shunt in a pediatric patient: case report and technical note

BACKGROUND /IMPORTANCE

The safety of direct cardiac shunts has been historically described in the pediatric population before the introduction of silastic catheters but are rarely utilized in modern practice. Herein, we describe several technical nuances regarding the placement of a direct ventriculoatrial catheter in a pediatric patient, including the creation of a sternal divot to accommodate for the movement of the catheter during growth.

CLINICAL PRESENTATION

We report a complex case of a 2-year-old former premature infant with multiple systemic congenital abnormalities, including tracheal atresia (type 2), complete atrioventricular septal defect status post repair, and shunted hydrocephalus. She developed multiple shunt malfunctions secondary to abdominal malabsorption and shunt infections.

CONCLUSION

Multiple options for distal shunt placement, including the atrium via open and endovascular techniques, the abdomen, gallbladder, and pleura, were considered, but the direct cardiac placement was felt to be the safest option given the patient's coexisting conditions. Placement requires a multidisciplinary team. Special consideration should be made for linear growth in children.

Criteria for Cerebrospinal Fluid Diversion in Retractorless Sphenoid Wing Meningioma Surgery: A Technical Report

Objective  Sphenoid wing meningiomas (SWMs) can present surgical challenges, in that they are often obscured by overlying brain, encase critical neurovascular structures, and obliterate cerebrospinal fluid (CSF) cisterns. While brain retraction can enable access, its use can have potentially deleterious effects. We report the benefits and outcomes of the criteria we have developed for use of cerebrospinal diversion to perform retractorless surgery for SWMs. Design  Technical report. Setting  Yale School of Medicine and Yale New Haven Hospital. Participants  Between May, 2019 and December, 2020, ten consecutive patients were included who met the presented criteria for SWM surgery with preoperative lumbar drain (LD) placement. Main Outcome Measures  Length of hospital stay, surgical complications, and extent of resection. Results  We have developed the following criteria for LD placement in patients with SWMs such that LDs are preoperatively placed in patients with tumors with one or more of the following criteria: (1) medial location along the sphenoid wing, (2) vascular encasement resulting in obliteration of the optic carotid cistern and/or proximal sylvian fissure, and/or (3) the presence of associated edema. CSF release, after craniotomy and sphenoid wing removal, allowed for optimization of exposure, leading to the maximal safe extent of tumor resection without brain retraction or any complications. Conclusions  Preoperative LD placement is effective in allowing for maximal extent of resection of SWMs and may be considered in cases where local CSF release is not possible. This technique is useful in those tumors located more medially, with encasement of the vasculature and/or associated with edema.

Trends in Utilization of Temporary and Permanent Cerebrospinal Fluid Diversion and Catheter Cerebral Angiography for Patients with Aneurysmal Subarachnoid Hemorrhage in the United States

INTRODUCTION

We sought to analyze the rate of utilization of methods of cerebrospinal fluid diversion over time in a nationally representative cohort of patients admitted with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The Nationwide Inpatient Sample was queried for patients admitted with aSAH from 2006 to 2018. Patients who received external ventricular drainage (EVD), lumbar drainage, ventriculoperitoneal shunt (VPS), and cerebral angiography were then identified. A Cochrane-Armitage test was conducted to assess the linear trend of proportions of EVD, lumbar drains, VPS, and mean cerebral angiograms per admission. Four regression analyses were conducted to infer the association of baseline variables to EVD, lumbar drain, VPS, and mean number of cerebral angiographies.

RESULTS

A total of 133,567 admissions were identified from 2006-2018 involving aSAH. Of these, 41.82% received EVD, 6.22% received lumbar drainage, 10.58% received VPS, and 75.03% had cerebral angiograms. There was an average upward trend of 1.57% in annual EVD utilization, downward trend of -0.28% in utilization of lumbar drainage, no changes in VPS utilization, and an upward trend of 0.04 angiograms per year (P < 0.001). There was a higher proportion of Black patients treated with EVD and VPS in both urban teaching hospitals and large hospitals.

CONCLUSIONS

Our results show the temporal trends in utilization of temporary and permanent methods of cerebrospinal fluid diversion and catheter cerebral angiography among patients with aSAH in the United States. The underutilization of VPS following EVD and the differences in EVD and VPS utilization depending on race and hospital size deserve further exploration.

The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery

There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by β2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.

Shunt technology for infants and a lifetime

The use of cerebrospinal fluid (CSF) shunts remains a fundamental therapeutic modality in the management of hydrocephalus. Nowadays, neurosurgeons have an arsenal of different shunt technologies on their hands, with several companies producing many different configurations of them. The greatest difficulty of treating a child with hydrocephalus is to deal with a brain that will enormously change its size and hydrodynamic conditions and a body that will multiply its height and weight in a short time. Detailed knowledge of the hydrodynamic properties of shunts is mandatory for any neurosurgeon and much more for those taking care of pediatric patients. It is necessary to know that these properties of the valve may influence the evolution of the patient after shunting and it is recognized that a patient physiology-specific valve selection may yield better outcomes and decrease complications. This article provides a summary of the most common available CSF valves and overdrainage control devices, their technology, and possible combinations. The objective is to offer a quick overview of the armamentarium to facilitate the recognition of the implanted device and improve the selection of the most suitable valve for each patient.

The role of amyloid PET in patient selection for extra-ventricular shunt insertion for the treatment of idiopathic normal pressure hydrocephalus: A pooled analysis

BACKGROUND

Idiopathic Normal Pressure Hydrocephalus (iNPH) can be effectively treated through shunt insertion. However, most shunted patients experience little or no clinical benefit, which suggests suboptimal patient selection. While contentious, multiple studies have reported poorer shunt outcomes associated with concomitant Alzheimer's disease. Prompted by this observation, multiple studies have assessed the role of amyloid PET, a specific test for Alzheimer's disease, in patient selection for shunting.

METHODS

A comprehensive literature search was performed to identify studies that assessed the association between amyloid PET result and the clinical response to shunting in patients with suspected iNPH. Pooled diagnostic statistics were calculated.

RESULTS

Across three relevant studies, a total of 38 patients with suspected iNPH underwent amyloid PET imaging and shunt insertion. Twenty-three patients had a positive clinical response to shunting. 18/28 (64.3%) of patients with a negative amyloid PET and 5/10 (50%) with a positive amyloid PET had a positive response to shunting. The pooled sensitivity, specificity and accuracy was 33.3%, 76.2% and 58.3%. None of these statistics reached statistical significance.

CONCLUSION

The results of this pooled analysis do not support the selection of patients with suspected iNPH for shunting on the basis of amyloid PET alone. However, due to small cohort sizes and weakness in study design, further high-quality studies are required to properly determine the role of amyloid PET in assessing this complex patient group.

The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement

BACKGROUND

Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts.

OBJECTIVE

To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement.

METHODS

This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection.

RESULTS

A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection.

CONCLUSION

These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.

The survival of reimplanted shunts following externalization: a single-institution cohort study

OBJECTIVE

The failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant.

METHODS

In this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure.

RESULTS

Among 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161-3449) days for VPSs and 1163 (IQR 360-2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5-11) days for VPSs and 8 (IQR 6-15) days for VASs. No rare complications occurred in the VAS group.

CONCLUSIONS

Shunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.

Gravitational shunt valves in hydrocephalus to challenge the sequelae of over-drainage

INTRODUCTION

In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical position, CSF diversion is somehow non-physiological. The integration of gravitational valves in VPS was established to counteract the hydrostatic draining force and to approach a physiological condition of the cerebrospinal diverting system. Numerous clinical studies have shown that gravitational valves are able to reduce secondary complications of VPS treatment. It remains a challenge for the treating neurosurgeon to select the correct valve resistance based on individual anatomies and different etiologies of hydrocephalus as well as varying levels of activity of the patient.

AREAS COVERED

This review covers the development of gravitational shunt valves from historical, theoretical and clinical aspects for pediatric and adult etiologies of hydrocephalus. We discuss the role of gravitational shunt valves in preventing over-drainage issues and present the state-of-the-art literature. Furthermore, ongoing prospective trials are presented.

EXPERT OPINION

Counteracting the hydrostatic force by selecting the correct valve in a VPS system to achieve physiological balance in CSF diversion during vertical and horizontal body changes has become the current standard for hydrocephalus management. Gravitational shunt valves reliably address this need to minimize over-drainage events in the vertical position without affecting the CSF flow in the horizontal position. The results of ongoing prospective studies on the safety and efficacy of adjustable gravitational valves are still pending. Due to the complexity of the CSF flow, lifelong follow-up care for patients with VPS is critical.

Posterior Reversible Encephalopathy Syndrome After Transsphenoidal Resection of Pituitary Macroadenoma

BACKGROUND

Posterior reversible encephalopathy syndrome is manifested by a reversible neurologic deficit such as vision loss, encephalopathy, and a posterior location, typically the occipital lobes. It is commonly thought to be related to acute, severe hypertension.

CASE DESCRIPTION

A 51-year-old woman presented with visual loss for several months, and a suprasellar mass was diagnosed. She underwent transsphenoidal surgery, which was complicated by cerebrospinal fluid leak, and she developed posterior reversible encephalopathy syndrome while undergoing postoperative cerebrospinal fluid drainage via lumbar catheter. Her visual acuity progressed to blindness, but blindness was reversed by discontinuation of lumbar drainage, tight blood pressure control, and high-dose steroid drip.

CONCLUSIONS

To our knowledge, this is only the second case of posterior reversible encephalopathy syndrome following transsphenoidal surgery to be reported in the neurosurgical or ophthalmic English language literature.

A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH)

Idiopathic intracranial hypertension denotes raised intracranial pressure in the absence of an identifiable cause and presents with symptoms relating to elevated ICP, namely headaches and visual deterioration. Treatment of IIH aims at reducing intracranial pressure, relieving headache and salvaging patients' vision. Surgical interventions are recommended for medically refractory IIH and include CSF diversion techniques, optic nerve sheath fenestration, bariatric surgery and venous sinus stenting. Prospective studies on the surgical options for IIH are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane Library, MEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. VSS improved papilledema, visual fields and headaches in 87.1%, 72.7% and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. CSF diversion techniques diminished papilledema, visual field deterioration and headaches in 78.9%, 66.8% and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. ONSF ameliorated papilledema, visual field defects and headaches in 90.5, 65.2% and 49.3% of patients. Severe complication rate was 2.2% and failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favourable complication profile. In light of this, VSS ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH.

Understanding the complex pathophysiology of idiopathic intracranial hypertension and the evolving role of venous sinus stenting: a comprehensive review of the literature

Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure without established etiology. Although there is now consensus on the definition of the disorder, its complex pathophysiology remains elusive. The most common clinical symptoms of IIH include headache and visual complaints. Many current theories regarding the etiology of IIH focus on increased secretion or decreased absorption of cerebrospinal fluid (CSF) and on cerebral venous outflow obstruction due to venous sinus stenosis. In addition, it has been postulated that obesity plays a role, given its prevalence in this population of patients. Several treatments, including optic nerve sheath fenestration, CSF diversion with ventriculoperitoneal or lumboperitoneal shunts, and more recently venous sinus stenting, have been described for medically refractory IIH. Despite the availability of these treatments, no guidelines or standard management algorithms exist for the treatment of this disorder. In this paper, the authors provide a review of the literature on IIH, its clinical presentation, pathophysiology, and evidence supporting treatment strategies, with a specific focus on the role of venous sinus stenting.

Peter Plus Syndrome: A Neurosurgeon's Perspective

Peter plus syndrome (PPS) is a rare, hereditary (autosomal recessive) disorder characterized by a mutation in the beta-1,3-galactosyltransferase-like gene (chromosome 13q12), which causes impaired glycosylation of several structural and functional proteins throughout the body. Clinical signs and symptoms of PPS are highly variable and include structural malformations affecting multiple organ systems including central nervous system. We aim to discuss a neurosurgeon's perspective to PPS in this report. A 2-year-old boy presented with congenital dysmorphic facies, bilateral central corneal opacities, delayed developmental milestones, short-stature (75cm), rhizomelia with brachydactyly, and history of surgery for anal atresia on the second day of life. Screening craniospinal magnetic resonance imaging revealed mild ventriculomegaly, cavum septum pellucidum, cavum velum interpositum, vermian hypoplasia, and normal spine. Cytogenetic analysis showed a mutation in the beta-1,3-galactosyltransferase-like gene on chromosome 13. Clinical picture in our patient suggested the diagnosis of PPS. Parents often seek ophthalmological consultation due to visual impairment predominantly, and this syndrome largely remains unknown among neurosurgeons. Nonetheless, babies with PPS may present with neurological symptoms such as seizures, spastic diplegia, tinnitus, or hearing loss as well as a life-threatening neurosurgical emergency arising due to raised intracranial pressure. Therefore, the role of neurosurgeon becomes crucial in managing these cases.

United Kingdom CSF Disorders Day 2018

The multi-specialty approach to managing patients with cerebrospinal fluid (CSF) disorders requires neurology, neurosurgery, neuroradiology and neuro-ophthalmology. The annual United Kingdom CSF disorders meeting presented the first guidelines for idiopathic intracranial hypertension focusing on protecting the vision, managing the underlying disease and reducing headache morbidity. The most recent scientific concepts in CSF disorders were presented, as was the applied understanding of shunt and valve technology.

First clinical experience with the new noninvasive transfontanelle ICP monitoring device in management of children with premature IVH

We previously introduced a novel noninvasive technique of intracranial pressure (ICP) monitoring in children with open fontanelles. Within this study, we describe the first clinical implementation and results of this new technique in management of children with hydrocephalus caused by intraventricular hemorrhage (IVH). In neonates with posthemorrhagic hydrocephalus (PHH), an Ommaya reservoir was implanted for initial treatment of hydrocephalus. The ICP obtained noninvasively with our new device was measured before and after CSF removal and correlated to cranial ultra-sonographies. Six children with a mean age of 27.3 weeks and mean weight of 1082.3 g suffering from PHH were included in this study. We performed an overall of 30 aspirations due to ventricular enlargement. Before CSF removal, the mean ICP was 15.3 mmHg and after removal of CSF the mean ICP measured noninvasively decreased to 3.4 mmHg, p = 0.0001. The anterior horn width (AHW), which reflects early expansion of the ventricles, was before and after CSF removal 15.1 mm and 5.5 mm, respectively, p < 0.0006. There was a strong correlation between noninvasively measured ICP values and sonographically obtained AHW, r = 0.81. Ultimately, all children underwent ventriculoperitoneal shunt procedures. This is the first study providing proof for a noninvasively ICP-based approach for management of posthemorrhagic hydrocephalus in newborn children.

Transtentorial Brain Herniation After Lumbar Drainage in Patient Planned for Cranioplastic Reconstruction: Catastrophic Play Between Atmospheric and Intracranial Pressure

BACKGROUND

The sinking skin flap syndrome, also known as the syndrome of the trephined or the trephination syndrome, occurs in patients who have undergone a decompressive craniectomy. As opposed to this, persistent brain herniation also occurs in patients after a decompressive craniectomy and a cerebrospinal fluid (CSF) drainage procedure is one of the therapies used to reduce it. A continuous lumbar CSF drainage procedure can upset the pressure dynamics of the atmosphere versus intracranial pressures to a point of fatal clinical deterioration and hence needs to be closely monitored.

CASE DESCRIPTION

Our case report speaks of persistent brain herniation in which drainage of CSF led to a trephination syndrome, which was reversed once again, by measures to increase CSF production and intracranial pressure.

CONCLUSIONS

Timely intervention eventually led to a favorable outcome and avoidance of a catastrophy.

Medulloblastoma: Distinctive Histo-Molecular Correlation with Clinical Profile, Radiologic Characteristics, and Surgical Outcome

OBJECTIVE

Medulloblastoma (MB) is a heterogenous tumor, and the prognosis is influenced by various clinical, histological, and molecular factors. The aim of the study is to determine the clinical profile and radiologic characteristics among the histo-molecular subgroups, the predictors of surgical outcome, and the pattern of relapse in pediatric and adult MB.

METHOD

An analysis of 118 patients of MB who underwent surgical treatment at National Institute of Mental Health and Neurosciences, India, over a 7-year period (2005-2011) is presented. The clinical profile, radiologic characteristics, surgical nuances, and survival patterns are discussed. The relevant statistical analysis was done using SPSS software, version 22.0.

RESULTS

The mean age of the cohort was 12 years (12.3 ± 8.7). The primary manifestation was raised intracranial tension headache in 53 patients (44.9%), which was the predominant symptom in large cell/anaplastic (LCA)- and WNT-activated subgroups. The median preoperative Karnofsky performance score was 60 (60.6 ± 12.9). Vermian and hemispheric location of tumor was most commonly observed in non-WNT/non-SHH (groups 3 and 4; 91.7%) and SHH-activated (42.9%) subgroups, respectively. Ninety-two patients (78%) underwent preoperative ventriculoperitoneal shunts (VPS) for obstructive hydrocephalus (HCP) and 14 patients (11.8%) underwent VPS in the postoperative period. The median overall survival (OS) for the whole group was 82.1 ± 5.7 months and the median recurrence-free survival was 51.0 ± 4.8 months. While radiotherapy had a significant influence on OS, progression-free survival was influenced by radiotherapy as well as chemotherapy in both pediatric and adult cohort. Desmoplastic/nodular subtype and WNT-activated subgroup had the best prognosis; LCA and non-WNT/non-SHH had the worst prognosis.

CONCLUSIONS

Majority of the patients were pediatric in the study. Age, hemispheric location of tumor, extent of resection, and adjuvant treatment status were the important clinical prognostic factors for survival. Surgery for MB is formidable, and VPS can be considered in persistent symptomatic and progressive HCP. Our study on pediatric and adult MB validates the prognostic significance of various clinical, radiologic, and histo-molecular parameters of MB.

United Kingdom CSF Disorders Day 2017

The management of patients with cerebrospinal fluid disorders requires a multi-specialty approach involving specialists in neurosurgery, neurology, neuroradiology and neuro-ophthalmology. A symposium on CSF disorders was organised by the clinical and academic teams at University Hospitals Birmingham, United Kingdom. The meeting featured a synopsis of the latest scientific research on CSF disorders. Some of the more challenging and controversial issues facing the multi-speciality team were presented and discussed. A summary of the event is provided.

From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites

Hydrocephalus represents the pathological elevation of cerebrospinal fluid (CSF) levels as a consequence of various embryological or acquired defects. Although the classic method of treatment is by means of diverting the CSF from the ventricular system towards the peritoneum, there are other sites of diversion that have proven their efficiency through time, in the context of complications related to the more common option of intraperitoneal insertion. The aim of the review is to assess and organize a database of all the types of shunt locations from the oldest shunt attempts until present, using Pubmed and Medline and to underline the particularities related to technique, indications, complications and associated epidemiological background. Current literature reveals up to 36 sites of diversion of CSF with a diverse topography varying from cephalic regions such as venous sinuses or mastoid bone, thoracic elements such as the heart or the pleura and abdominopelvic segments such as the peritoneum or the urinary bladder. Several atypical locations were studied such as the fallopian and intestinal shunts. Although ventriculoperitoneal and ventriculoatrial shunts are the most commonly used shunts today, there are some systems such as the ventriculosinusal and ventriculolymphatic shunts that prove to be equally as efficient. The successful treatment of hydrocephalus requires a complete comprehension of the indications and therapeutic options and a reliable evaluation of the risks and possible complications. The profile of cerebral ventricular shunts is highly dynamic and the spectrum of cerebrospinal fluid diversion offers multiple solutions in the benefit of the patient.

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.

Surgical decision-making in the management of childhood tumors of the CNS disseminated at presentation

OBJECTIVE It is relatively unusual for pediatric CNS tumors to be disseminated at presentation, and the literature on the clinical features, management, and outcomes of this specific group is scarce. Surgical management in this population is often challenging, particularly in the presence of hydrocephalus. The authors present their recent experience of treating pediatric CNS tumors that were disseminated at presentation, and they compare these lesions with focal tumors. METHODS The authors performed a retrospective review of prospectively collected data on children presenting to a tertiary center between 2003 and 2016 inclusive. RESULTS Of 361 children with CNS tumors, the authors identified 53 patients with disease dissemination at presentation (male/female ratio 34:19, median age 3.8 years, age range 7 days to 15.6 years) and 308 without dissemination at presentation (male/female ratio 161:147, median age 5.8 years, age range 1 day to 16.9 years). Five tumor groups were studied: medulloblastoma (disseminated n = 29, focal n = 74), other primitive neuroectodermal tumor (n = 8, n = 17), atypical teratoid rhabdoid tumor (n = 8, n = 22), pilocytic astrocytoma (n = 6, n = 138), and ependymoma (n = 2, n = 57). The median follow-up duration in survivors was not significantly different between those with disease dissemination at presentation (64.0 months, range 5.2-152.0 months) and those without it (74.5 months, range 4.7-170.1 months) (p > 0.05). When combining data from all 5 tumor groups, dissemination status at presentation was significantly associated with a higher risk of requiring CSF diversion, a higher surgical complication rate, and a reduced likelihood of achieving gross-total resection of the targeted lesion (all variables p < 0.05). Differences between the 5 tumor groups were evident. No factors that predicted the need for permanent CSF diversion following temporary external ventricular drainage were identified on multivariate analysis, and there was no clear superiority of either ventriculoperitoneal shunt surgery or endoscopic third ventriculostomy as a permanent CSF diversion procedure. CONCLUSIONS Tumor type and dissemination status at initial presentation significantly affect outcomes across a range of measures. The management of hydrocephalus in patients with CNS tumors is challenging, and further prospective studies are required to identify the optimal CSF diversion strategy in this population.

Symptomatic tension pneumocephalus following Palacos® cranioplasty in a shunted patient

Tension pneumocephalus is an exceedingly rare complication of cerebrospinal fluid diversion occurring after surgery, trauma or spontaneous fistula formation. We report a case in a patient with a ventriculoperitoneal shunt who developed symptomatic tension pneumocephalus via a skin defect within 24 hours of undergoing bone cement cranioplasty.

The cerebral venous system and the postural regulation of intracranial pressure: implications in the management of patients with cerebrospinal fluid diversion

Loss of cerebrospinal fluid (CSF) occurs commonly in daily neurosurgical practice. Understanding the altered physiology following CSF loss is important for optimization of patient care and avoidance of complications. There is overwhelming evidence now that the cerebral venous system plays a major role in intracranial pressure (ICP) dynamics especially when one takes into account the effects of postural changes, atmospheric pressure, and gravity on the craniospinal axis as a whole. The CSF and cerebral venous compartments are tightly coupled in two important ways. CSF is resorbed into the venous system, and there is also an evolved mechanism that prevents overdrainage of venous blood with upright positioning known as the Starling resistor. With loss of CSF pressure, this protective mechanism could become nonfunctional which may result in posture-related venous overdrainage through the cranial venous outflow tracts leading to pathologic states. This review article summarizes the relevant anatomic and physiologic basis of the relationship between the craniospinal venous and CSF compartments in the setting of CSF diversion. It is hoped that this article improves our understanding of ICP dynamics after CSF loss, adds a new dimension to our therapeutic methods, stimulates further research into this field, and ultimately improves our care of these patients.

Infratentorial complications following preresection CSF diversion in children with posterior fossa tumors

OBJECT

This report presents the incidence, causes, and morbidity and mortality of infratentorial complications following CSF diversion before resection in children with posterior fossa tumors.

METHODS

The medical records of 437 children admitted to Abo El-Reesh Pediatric University Hospital with a diagnosis of posterior fossa tumor between 2005 and 2012 were retrospectively reviewed. Seven children developed neurological deterioration following CSF diversion due to infratentorial complications. Computed tomography scans revealed intratumoral hemorrhage (ITH) in 5 cases, while upward transtentorial herniation (UTH), as evidenced by obliteration of the quadrigeminal and ambient cisterns, was diagnosed in 2 cases.

RESULTS

Hydrocephalus was noted in 381 patients, and 301 patients underwent CSF diversion before resection. A ventriculoperitoneal (VP) shunt was used in 214 patients, and 6 children (2.8% of shunted cases) deteriorated neurologically (4 due to ITH and 2 due to UTH). Endoscopic third ventriculostomy (ETV) was performed in 87 patients, 1 of whom developed ITH (1.1% of the patients undergoing ETV). Six patients deteriorated within 8 hours (85.7%), whereas 1 patient, the only survivor, deteriorated after 24 hours. The incidence of infratentorial complications between VP shunts and ETVs was not found to be significantly different (p = 0.659). There was a higher risk of such complications in large posterior fossa tumors (diameter ≥ 4 cm) extending close to the tentorial incisura, especially in patients with severe hydrocephalus and significant peritumoral edema.

CONCLUSIONS

Infratentorial complications (ITH and UTH) in children with posterior fossa tumors are not uncommon (2.3%) after preresection CSF diversion (VP shunt or ETV) and are associated with a very poor prognosis in most cases, even with surgical intervention.

Risk factors for failed transverse sinus stenting in pseudotumor cerebri patients

BACKGROUND

Idiopathic intracranial hypertension (IIH) when no underlying etiology is found, is a clinical syndrome characterized by elevated intracranial pressure (ICP) (>25 cm H2O), which may lead to headaches and visual symptoms. In patients with IIH who are found to have transverse sinus stenosis, placement of a venous stent across the stenosis has been shown to lower ICP and to resolve the symptoms in several case series, with generally favorable results. In this study, we examine common risk factors associated with failure of transvenous stenting for IIH. If venous sinus stenting fails, CSF diversion should be considered as the next line of treatment.

METHODS

We retrospectively reviewed the records of eighteen patients diagnosed with IIH who underwent venous sinus stenting for transverse sinus stenosis with a mean pressure gradient (MPG) of at least 4 mmHg. Fifteen of these patients did not need further treatment. We compared their pre- and post-treatment, neurological and neuro-ophthalmological evaluations to the three patients who went on to have a shunt placement as a second line treatment.

RESULTS

Shunting after stent placement patients (n=3) had a mean age of 30 years and a mean body mass index of 36.6 kg/m(2), whereas the group that underwent stent placement alone (n=15) had a mean age of 40.7 years and a mean body mass index of 33.3 kg/m(2). In the shunting after stent placement group, the mean opening pressure on the most recent lumbar puncture obtained prior to any intervention was 50 cm of H2O, whereas the group that underwent stent placement alone had an opening CSF pressure of 37 cm of H2O which was statistically significant (p<0.05). There were no other significant differences in pre- or post-intervention factors between the two groups.

CONCLUSION

In patients with IIH and documented evidence of venous sinus stenosis with a pressure gradient, venous sinus stenting should be the primary treatment of choice; however, some patients may be refractory to stenting and still require permanent CSF diversion, which can be complicated in these chronically anticoagulated patients. Patients with persistent papilledema post-stenting and highly elevated opening pressure pre-stenting should be followed closely as they are at greatest risk of requiring a shunt and failing stenting.

Neurosurgical care of pediatric brain tumor patients in a rehabilitation unit

As brain tumor patients are transferred to a rehabilitation unit in a stable condition, subsequent neurosurgical involvement is needed to address later developing complications. Problems of cerebrospinal fluid circulation are the most common and include shunt malfunction. Infection is the next in frequency, with wound and shunt infection the most likely. Bleeding rarely occurs, especially acutely, and is more apt to be seen with chronic subdural hematomas.