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Vandenbulcke A, Messerer M, Daniel RT, Cossu G. The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review. Brain Sci 2023; 13:1580. [PMID: 38002540 PMCID: PMC10670052 DOI: 10.3390/brainsci13111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, 1015 Lausanne, Switzerland
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Ben-Shoshan SD, Lolansen SD, Mathiesen TI, MacAulay N. CSF hypersecretion versus impaired CSF absorption in posthemorrhagic hydrocephalus: a systematic review. Acta Neurochir (Wien) 2023; 165:3271-3287. [PMID: 37642688 DOI: 10.1007/s00701-023-05746-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The molecular mechanisms underlying development of posthemorrhagic hydrocephalus (PHH) remain elusive. The aim of this systematic review was to evaluate existing literature on increased CSF secretion and impaired CSF absorption as pathogenic contributors to CSF accumulation in neonatal and adult PHH. METHODS The systematic review was conducted in accordance with the PRISMA guidelines. Relevant studies published before March 11th, 2023, were identified from PubMed and reference lists. Studies were screened for eligibility using predefined inclusion and exclusion criteria. Data from eligible studies were extracted and potential sources of bias were evaluated. RESULTS Nineteen studies quantified CSF production rates and/or CSF absorption capacity in human patients with PHH or animals with experimentally induced PHH. Increased CSF production was reported as early as 24 h and as late as 28 days post ictus in six out of eight studies quantifying CSF production rates in animals with experimentally induced PHH. Impaired CSF absorption was reported in all four studies quantifying CSF absorption capacity in human patients with PHH and in seven out of nine studies quantifying CSF absorption capacity in animals with experimentally induced PHH. Impaired CSF absorption was reported as early as 30 min and as late as 10 months post ictus. CONCLUSIONS The pathological CSF accumulation in PHH likely arises from a combination of increased CSF secretion and impaired CSF absorption, which may manifest at different time scales following a hemorrhagic event. Emergent evidence on increased CSF secretion by the choroid plexus may herald a paradigm shift in our understanding of PHH.
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Affiliation(s)
- Shai David Ben-Shoshan
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen, Denmark
| | - Sara Diana Lolansen
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen, Denmark
- Department of Neurosurgery, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark
| | - Tiit Illimar Mathiesen
- Department of Neurosurgery, University Hospital of Copenhagen - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen, Denmark.
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Luciano MG, Dombrowski SM, El-Khoury S, Yang J, Thyagaraj S, Qvarlander S, Khalid S, Suk I, Manbachi A, Loth F. Epidural Oscillating Cardiac-Gated Intracranial Implant Modulates Cerebral Blood Flow. Neurosurgery 2020; 87:1299-1310. [PMID: 32533835 PMCID: PMC7666905 DOI: 10.1093/neuros/nyaa188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 03/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We have previously reported a method and device capable of manipulating ICP pulsatility while minimally effecting mean ICP. OBJECTIVE To test the hypothesis that different modulations of the intracranial pressure (ICP) pulse waveform will have a differential effect on cerebral blood flow (CBF). METHODS Using an epidural balloon catheter attached to a cardiac-gated oscillating pump, 13 canine subjects underwent ICP waveform manipulation comparing different sequences of oscillation in successive animals. The epidural balloon was implanted unilaterally superior to the Sylvian sulcus. Subjects underwent ICP pulse augmentation, reduction and inversion protocols, directly comparing time segments of system activation and deactivation. ICP and CBF were measured bilaterally along with systemic pressure and heart rate. CBF was measured using both thermal diffusion, and laser doppler probes. RESULTS The activation of the cardiac-gate balloon implant resulted in an ipsilateral/contralateral ICP pulse amplitude increase with augmentation (217%/202% respectively, P < .0005) and inversion (139%/120%, P < .0005). The observed changes associated with the ICP mean values were smaller, increasing with augmentation (23%/31%, P < .0001) while decreasing with inversion (7%/11%, P = .006/.0003) and reduction (4%/5%, P < .0005). CBF increase was observed for both inversion and reduction protocols (28%/7.4%, P < .0001/P = .006 and 2.4%/1.3%, P < .0001/P = .003), but not the augmentation protocol. The change in CBF was correlated with ICP pulse amplitude and systolic peak changes and not with change in mean ICP or systemic variables (heart rate, arterial blood pressure). CONCLUSION Cardiac-gated manipulation of ICP pulsatility allows the study of intracranial pulsatile dynamics and provides a potential means of altering CBF.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Amir Manbachi
- Correspondence: Mark G. Luciano, MD, PhD, Departments of Neurosurgery and Biomedical Engineering, Johns Hopkins University, 600 North Wolfe Street, Phipps 126, Baltimore, MD 20287, USA.
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Martinez-Tejada I, Arum A, Wilhjelm JE, Juhler M, Andresen M. B waves: a systematic review of terminology, characteristics, and analysis methods. Fluids Barriers CNS 2019; 16:33. [PMID: 31610775 PMCID: PMC6792201 DOI: 10.1186/s12987-019-0153-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although B waves were introduced as a concept in the analysis of intracranial pressure (ICP) recordings nearly 60 years ago, there is still a lack consensus on precise definitions, terminology, amplitude, frequency or origin. Several competing terms exist, addressing either their probable physiological origin or their physical characteristics. To better understand B wave characteristics and ease their detection, a literature review was carried out. Methods A systematic review protocol including search strategy and eligibility criteria was prepared in advance. A literature search was carried out using PubMed/MEDLINE, with the following search terms: B waves + review filter, slow waves + review filter, ICP B waves, slow ICP waves, slow vasogenic waves, Lundberg B waves, MOCAIP. Results In total, 19 different terms were found, B waves being the most common. These terminologies appear to be interchangeable and seem to be used indiscriminately, with some papers using more than five different terms. Definitions and etiologies are still unclear, which makes systematic and standardized detection difficult. Conclusions Two future lines of action are available for automating macro-pattern identification in ICP signals: achieving strict agreement on morphological characteristics of “traditional” B waveforms, or starting a new with a fresh computerized approach for recognition of new clinically relevant patterns.
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Affiliation(s)
- Isabel Martinez-Tejada
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. .,Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark.
| | - Alexander Arum
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Marianne Juhler
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Andresen
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Lu X, Ji C, Wu J, You W, Wang W, Wang Z, Chen G. Intrathecal Fibrinolysis for Aneurysmal Subarachnoid Hemorrhage: Evidence From Randomized Controlled Trials and Cohort Studies. Front Neurol 2019; 10:885. [PMID: 31481923 PMCID: PMC6709660 DOI: 10.3389/fneur.2019.00885] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/30/2019] [Indexed: 01/09/2023] Open
Abstract
Background: The role of intrathecal fibrinolysis for the treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH) has been widely investigated; however, the results have been contradictory. In our study, we conducted a meta-analysis to evaluate the safety and efficacy of intrathecal (intracisternal or intraventricular) fibrinolysis for aSAH. Methods: PubMed, Web of Science, Embase, Medline, and the Cochrane library databases were searched up to February 1, 2019. The outcomes analyzed were neurologic recovery, delayed ischemic neurologic deficit (DIND), mortality, and the incidence of chronic hydrocephalus and hemorrhage. Results: A total of 21 studies comprising 1,373 patients were analyzed, including nine randomized controlled trials (RCTs) and 12 non-RCTs. The results showed that intracisternal fibrinolysis significantly decreased poor neurologic outcomes (RR = 0.62, 95% CI = 0.50–0.76, P < 0.001) and reduced the incidence of DIND (RR = 0.52, 95% CI = 0.41–0.65, P <0.001), chronic hydrocephalus (RR = 0.59, 95% CI = 0.42–0.82, P = 0.002) and mortality (RR = 0.58, 95% CI = 0.37, 0.93, P = 0.02). There was no significant difference in the occurrence of hemorrhage. Moreover, the results of the Egger test and Begg's funnel plot showed no evidence of publication bias. Conclusions: Current evidence suggests that intracisternal fibrinolysis has beneficial effects on the clinical outcomes of patients with aSAH. However, further well-designed randomized trials are needed to confirm the efficacy and safety of intracisternal fibrinolysis for the treatment of aSAH.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengyuan Ji
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiang Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wanchun You
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
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Balédent O, Czosnyka Z, Czosnyka M. "Bucket" cerebrospinal fluid bulk flow-is it a fact or a fiction? Acta Neurochir (Wien) 2019; 161:257-258. [PMID: 30421028 DOI: 10.1007/s00701-018-3731-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Olivier Balédent
- University of Picardie Jules Verne, Chimère EA 7516, CHU, 80054, Amiens, France
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University, Box 167, Addenbrookes Hospital, Cambridge, CB20QQ, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University, Box 167, Addenbrookes Hospital, Cambridge, CB20QQ, UK.
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Williamson MR, Wilkinson CM, Dietrich K, Colbourne F. Acetazolamide Mitigates Intracranial Pressure Spikes Without Affecting Functional Outcome After Experimental Hemorrhagic Stroke. Transl Stroke Res 2018; 10:428-439. [PMID: 30225552 PMCID: PMC6647499 DOI: 10.1007/s12975-018-0663-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/04/2018] [Indexed: 01/31/2023]
Abstract
Increased intracranial pressure (ICP) after stroke can lead to poor outcome and death. Novel treatments to combat ICP rises are needed. The carbonic anhydrase inhibitor acetazolamide diminishes cerebrospinal fluid (CSF) production, reduces ICP in healthy animals, and is beneficial for idiopathic intracranial hypertension patients. We tested whether acetazolamide mitigates ICP elevations by presumably decreasing CSF volume after collagenase-induced striatal hemorrhage in rats. We confirmed that acetazolamide did not adversely affect hematoma formation in this model or physiological variables, such as temperature. Then, we assessed the effects of acetazolamide on ICP. Lastly, we tested the effects of acetazolamide on behavioral and histological outcome. Acetazolamide reduced the magnitude and occurrence of short-timescale ICP spikes, assessed as disproportionate increases in ICP (sudden ICP increases > 10 mmHg), 1-min peak ICP, and the magnitude of spikes > 20 mmHg. However, mean ICP was unaffected. In addition, acetazolamide reduced ICP variability, reflecting improved intracranial compliance. Compliance measures were strongly correlated with high peak and mean ICP, whereas ipsilateral hemisphere water content was not correlated with ICP. Despite effects on ICP, acetazolamide did not improve behavioral function or affect lesion size. In summary, we show that intracerebral hemorrhage creates an impaired compliance state within the cranial space that can result in large, transient ICP spikes. Acetazolamide ameliorates intracranial compliance and mitigates ICP spikes, but does not improve functional outcome, at least for moderate-severity ICH in rats.
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Affiliation(s)
- Michael R Williamson
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Cassandra M Wilkinson
- P217 Biological Sciences Building, Department of Psychology, University of Alberta, Edmonton, AB, T6G 2E9, Canada
| | - Kristen Dietrich
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Frederick Colbourne
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
- P217 Biological Sciences Building, Department of Psychology, University of Alberta, Edmonton, AB, T6G 2E9, Canada.
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Daou B, Klinge P, Tjoumakaris S, Rosenwasser RH, Jabbour P. Revisiting secondary normal pressure hydrocephalus: does it exist? A review. Neurosurg Focus 2017; 41:E6. [PMID: 27581318 DOI: 10.3171/2016.6.focus16189] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are several etiologies that can lead to the development of secondary normal pressure hydrocephalus (sNPH). The aim of this study was to evaluate the etiology, diagnosis, treatment, and outcome in patients with sNPH and to highlight important differences between the separate etiologies. METHODS A comprehensive review of the literature was performed to identify studies conducted between 1965 and 2015 that included data regarding the etiology, treatment, diagnosis, and outcome in patients with sNPH. Sixty-four studies with a total of 1309 patients were included. The inclusion criteria of this study were articles that were written in English, included more than 2 patients with the diagnosis of sNPH, and contained data regarding the etiology, diagnosis, treatment, or outcome of NPH. The most common assessment of clinical improvement was based on the Stein and Langfitt grading scale or equivalent improvement on other alternative ordinal grading scales. RESULTS The main etiologies of sNPH were subarachnoid hemorrhage (SAH) in 46.5%, head trauma in 29%, intracranial malignancies in 6.2%, meningoencephalitis in 5%, and cerebrovascular disease in 4.5% of patients. In 71.9% of patients the sNPH was treated with ventriculoperitoneal shunt placement, and 24.4% had placement of a ventriculoatrial shunt. Clinical improvement after shunt placement was reported in 74.4% and excellent clinical improvement in 58% of patients with sNPH. The mean follow-up period after shunt placement was 13 months. Improvement was seen in 84.2% of patients with SAH, 83% of patients with head trauma, 86.4% of patients with brain tumors, 75% of patients with meningoencephalitis, and 64.7% of patients with NPH secondary to stroke. CONCLUSIONS Secondary NPH encompasses a diverse group of clinical manifestations associated with a subset of patients with acquired hydrocephalus. The most common etiologies of sNPH include SAH and traumatic brain injury. Secondary NPH does indeed exist, and should be differentiated from idiopathic NPH based on outcome and on clinical, pathophysiological, and epidemiological characteristics, but should not be considered as a separate entity.
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Affiliation(s)
- Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Petra Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
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Johansson I, Bolander HG, Kourtopoulos H. CT Showing Early Ventricular Dilatation after Subarachnoidal Hemorrhage. Acta Radiol 2016. [DOI: 10.1177/028418519203300409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We performed a retrospective analysis of 398 patients with subarachnoidal hemorrhage (SAH) confirmed by CT. On the first CT examination the temporal horns were enlarged in 84%, the frontal horns in 32%, and the third ventricle in 21% of the patients. The amount of blood in the basal cisterns was highly correlated to dilatation of the temporal horns. The temporal horns were enlarged even when small amounts of blood were found in the cisterns. The frontal and temporal horns were dilated only when moderate or large amounts of blood were present in the cisterns. In 24 patients no blood was seen in the basal cisterns on CT performed within 5 days of the hemorrhage; none of the 3 patients with aneurysms showed normal temporal horns while 18 without demonstrable aneurysms had normal, and 3 had moderately dilated, temporal horns. Because the temporal horns cannot usually be seen at CT of healthy individuals, dilatation could be a useful sign in the diagnosis of SAH.
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Czepko R, Cieslicki K. Repeated assessment of suspected normal pressure hydrocephalus in non-shunted cases. A prospective study based on the constant rate lumbar infusion test. Acta Neurochir (Wien) 2016; 158:855-63; discussion 863. [PMID: 26923798 DOI: 10.1007/s00701-016-2732-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 02/02/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Only a few reports have been published on the natural history of non-shunted patients suspected of having NPH. The aim of this study is to follow up a group of such cases. METHODS It was possible to follow up 27 patients who had not been qualified for shunting after the primary diagnosis. An assessment of Hakim's triad was performed, together with an analysis of radiological parameters and the results of lumbar infusion tests (LITs), both on admission and at the later date (on average, after 5.6 months). All parameters were analyzed with respect to periventricular lucency (PVL), atrophy, type of NPH, and the age of the patients. RESULTS There were no deteriorations and six patients improved. Those who were over 50 and who had no PVL or secondary NPH tended to improve more frequently. Significant improvement of dementia was noted (p = 0.042) in all cases, and in the group of patients without PVL (p = 0.04). The size of the ventricles did not change significantly. The values of the resistance to outflow (R), elastance (E), and ICP remained stable. CONCLUSIONS Analysis of our series revealed that the patients suspected of having NPH who had not been qualified for shunting did not deteriorate, while some of them even improved significantly as far as the level of dementia was concerned. As the CT and LIT parameters remained stable, there were no indications for repeating these examinations, at least within the period of nearly 6 months, which followed the primary diagnosis.
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Affiliation(s)
- Ryszard Czepko
- Department of Neurosurgery, St. Raphael's Hospital, 12 Bochenka str, 30-001, Krakow, Poland.
| | - Krzysztof Cieslicki
- Laboratory of Bioflows, Institute of Automatic Control and Robotics, Warsaw University of Technology, Warsaw, Poland
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García M, Poza J, Santamarta D, Abásolo D, Barrio P, Hornero R. Spectral analysis of intracranial pressure signals recorded during infusion studies in patients with hydrocephalus. Med Eng Phys 2013; 35:1490-8. [PMID: 23664413 DOI: 10.1016/j.medengphy.2013.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 02/26/2013] [Accepted: 04/11/2013] [Indexed: 10/26/2022]
Abstract
Hydrocephalus includes a number of disorders characterised by clinical symptoms, enlarged ventricles (observable using neuroimaging techniques) and altered cerebrospinal fluid (CSF) dynamics. Infusion tests are one of the available procedures to study CSF circulation in patients with clinical and radiological features of hydrocephalus. In them, intracranial pressure (ICP) is deliberately raised and CSF circulation disorders evaluated through measurements of the resulting ICP. In this study, we analysed seventy-seven ICP signals recorded during infusion tests using four spectral-based parameters: median frequency (MF) and relative power (RP) in three frequency bands. These measures provide a novel perspective for the analysis of ICP signals in the frequency domain. Each signal was divided into four artefact-free epochs (corresponding to the basal, early infusion, plateau and recovery phases of the infusion study). The four spectral parameters were calculated for each epoch. We analysed differences between epochs of the infusion test and correlations between these epochs and patient data. Statistically significant differences (p < 1.7 × 10(-3), Bonferroni-corrected Wilcoxon signed-rank tests) were found between epochs of the infusion test using MF and RP. Furthermore, some spectral parameters (MF in the basal phase, RP for the first frequency band and in the early infusion phase, RP for the second frequency band and in all phases of the infusion study and RP in the third frequency band and in the basal phase) revealed significant correlations (p < 0.01) between epochs of the infusion test and signal amplitude in the basal and plateau phases. Our results suggest that spectral analysis of ICP signals could be useful for understanding CSF dynamics in hydrocephalus.
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Affiliation(s)
- María García
- Biomedical Engineering Group, Department T.S.C.I.T., E.T.S. Ingenieros de Telecomunicación, University of Valladolid, Valladolid, Spain.
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12
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Aquilina K, Chakkarapani E, Thoresen M. Early deterioration of cerebrospinal fluid dynamics in a neonatal piglet model of intraventricular hemorrhage and posthemorrhagic ventricular dilation. J Neurosurg Pediatr 2012; 10:529-37. [PMID: 23020227 DOI: 10.3171/2012.8.peds11386] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The optimal management of neonatal intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilation is challenging. The importance of early treatment has been demonstrated in a recent randomized study, involving early ventricular irrigation and drainage, which showed significant cognitive improvement at 2 years. The objective of this study was to define the changes in CSF absorption capacity over time in a neonatal piglet model of IVH. METHODS Ten piglets (postnatal age 9-22 hours) underwent intraventricular injection of homologous blood. A ventricular access device was inserted 7-10 days later. Ventricular dilation was measured by ultrasonography. Serial constant flow infusion studies were performed through the access device from Week 2 to Week 8. RESULTS Seven piglets survived long term, 43-60 days, and developed ventricular dilation; this reached a maximum by Week 6. There was no significant difference in baseline intracranial pressure throughout this period. The resistance to CSF outflow, R(out), increased from 63.5 mm Hg/ml/min in Week 2 to 118 mm Hg/ml/min in Week 4. Although R(out) decreased after Week 5, the ventriculomegaly persisted. CONCLUSIONS In this neonatal piglet model, reduction in CSF absorptive capacity occurs early after IVH and accompanies progressive and irreversible ventriculomegaly. This suggests that early treatment of premature neonates with IVH is desirable.
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Affiliation(s)
- Kristian Aquilina
- University of Bristol School of Clinical Sciences, Frenchay Hospital, Bristol, England.
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13
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Kim SH, Chung PW, Won YS, Kwon YJ, Shin HC, Choi CS. Effect of cisternal drainage on the shunt dependency following aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2012; 52:441-6. [PMID: 23323163 PMCID: PMC3539077 DOI: 10.3340/jkns.2012.52.5.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 07/12/2012] [Accepted: 11/22/2012] [Indexed: 11/27/2022] Open
Abstract
Objective Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH. Methods Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age). Results Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus. Conclusion In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.
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Affiliation(s)
- Sung Hun Kim
- Department of Neurology, College of Medicine, Kangwon National University, Chuncheon, Korea
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Komotar RJ, Hahn DK, Kim GH, Starke RM, Garrett MC, Merkow MB, Otten ML, Sciacca RR, Connolly ES. Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. J Neurosurg 2009; 111:147-54. [DOI: 10.3171/2009.1.jns0821] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Chronic hydrocephalus requiring shunt placement is a common complication following aneurysmal subarachnoid hemorrhage (SAH). Controversy exists over whether microsurgical fenestration of the lamina terminalis during aneurysm surgery affords a reduction in the development of shunt-dependent hydrocephalus. To resolve this debate, the authors performed a systematic review and quantitative analysis of the literature to determine the efficacy of lamina terminalis fenestration in reducing aneurysmal SAH–associated shunt-dependent hydrocephalus.
Methods
A MEDLINE (1950–2007) database search was performed using the following keywords, singly and in combination: “ventriculoperitoneal shunt,” “hydrocephalus,” “subarachnoid hemorrhage,” “aneurysm,” “fenestration,” and “lamina terminalis.” Additional studies were manually singled out by scrutinizing references from identified manuscripts, major neurosurgical journals and texts, and personal files. A recent study from the authors' institution was also incorporated into the review. Data from included studies were analyzed using the chi-square analysis and Student t-test. The Cochran-Mantel-Haenszel test was used to compare overall incidence of shunt-dependent hydrocephalus.
Results
The literature search revealed 19 studies, but only 11 were included in this review, involving 1973 patients. The fenestrated and nonfenestrated cohorts (combined from the various studies) differed significantly with regard to patient sex, age, and clinical grade as well as aneurysm location (p = 0.0065, 0.0028, 0.0003, and 0.017, respectively). The overall incidence of shunt-dependent hydrocephalus in the fenestrated cohort was 10%, as compared with 14% in the nonfenestrated cohort (p = 0.089). The relative risk of shunt-dependent hydrocephalus in the fenestrated cohort was 0.88 (95% CI 0.62–1.24).
Conclusions
This systematic review revealed no significant association between lamina terminalis fenestration and a reduced incidence of shunt-dependent hydrocephalus. The interpretation of these results, however, is restricted by unmatched cohort differences as well as other inherent study limitations. Although the overall literature supports lamina terminalis fenestration, a number of authors have questioned the technique's benefits, thus rendering its efficacy in reducing shunt-dependent hydrocephalus unclear. A well-designed, multicenter, randomized controlled trial is needed to definitively address the efficacy of this microsurgical technique.
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White PM, Lewis SC, Nahser H, Sellar RJ, Goddard T, Gholkar A. HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS trial): procedural safety and operator-assessed efficacy results. AJNR Am J Neuroradiol 2008; 29:217-23. [PMID: 18184832 DOI: 10.3174/ajnr.a0936] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Coated coils have been in clinical use for several years without robust evidence to determine their safety/efficacy. The HydroCoil Endovascular Aneurysm Occlusion and Packing Study (HELPS) addresses this deficiency for the HydroCoil embolic system. This article reports periprocedural safety/operator-assessed angiographic results from HELPS. MATERIALS AND METHODS Patients were randomized to the hydrogel coil or control arms by using concealed allocation with minimization matching groups. Any bare platinum coils were allowed in the control arm, and assist devices could be used as clinically required. Both recently ruptured and not recently ruptured/unruptured aneurysms were included. Analysis was on an intention-to-treat basis. RESULTS Four hundred ninety-nine patients were recruited. Coiling was successful in 98.6%. Mean aneurysm size was 6.5 mm (26% were > or =10 mm), 53% were recently ruptured aneurysms, and an assist device was used in 46%. Seventy procedural adverse events were reported in hydrogel coils and 86 in control arms. The 3-month mortality rate was 3.6% in hydrogel coils and 2.0% in control arms; the difference was not significant (P = .6). There was a lower 2-month mortality rate in the HELPS subarachnoid hemorrhage cohort (4.1%) than would be anticipated from the International Subarachnoid Aneurysm Trial (7%). There was a trend toward increased adverse events when assist devices were used, which was substantial for stents deployed in recently ruptured aneurysms. Ninety-six percent of patients discharged were World Federation of Neurosurgeons grade 0-2 at discharge. No difference was found between arms in the operator assessment of angiographic occlusions (P = .3). CONCLUSION These HELPS results reinforce coiling as an effective treatment for aneurysms, with an excellent technical success rate. Hydrogel coils can be used in a wide spectrum of aneurysms with a risk profile equivalent to that of bare platinum.
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Affiliation(s)
- P M White
- Department of Neuroradiology, Western General Hospital, Edinburgh, UK.
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Komotar RJ, Hahn DK, Kim GH, Khandji J, Mocco J, Mayer SA, Connolly ES. THE IMPACT OF MICROSURGICAL FENESTRATION OF THE LAMINA TERMINALIS ON SHUNT-DEPENDENT HYDROCEPHALUS AND VASOSPASM AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE. Neurosurgery 2008; 62:123-32; discussion 132-4. [DOI: 10.1227/01.neu.0000311069.48862.c8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
Chronic hydrocephalus requiring shunt placement and cerebral vasospasm are common complications after aneurysmal subarachnoid hemorrhage. Recent publications have investigated the possibility that microsurgical fenestration of the lamina terminalis during aneurysm surgery may reduce the incidence of shunt-dependent hydrocephalus and cerebral vasospasm. We reviewed a single-surgeon series to compare postsurgical outcomes of patients who underwent fenestration of the lamina terminalis against those who did not.
METHODS
This study is a retrospective review of the medical records of 369 consecutive patients with aneurysmal subarachnoid hemorrhage admitted to Columbia University Medical Center between January 2000 and July 2006. All patients underwent craniotomy and clipping of at least one ruptured cerebral aneurysm by a single neurosurgeon (ESC). The incidences of shunt-dependent hydrocephalus, conversion from acute hydrocephalus on admission to chronic hydrocephalus, and clinical cerebral vasospasm were compared in patients who underwent fenestration of the lamina terminalis with those who did not. The patient cohort was thus divided into three subgroups: 1) patients whose operative records clearly indicated that they underwent fenestration of the lamina terminalis, 2) patients whose operative records clearly indicated that they did not undergo fenestration of the lamina terminalis, and 3) patients whose operative records did not indicate one way or another whether they received fenestration of the lamina terminalis. We performed two separate analyses by comparing the postsurgical outcomes in those patients who were fenestrated versus those who were definitively not fenestrated and comparing the postsurgical outcomes in those patients who were fenestrated versus those who were not plus those whose records did not document fenestration. To further control for any cohort differences, we performed a comparison between patients who were fenestrated and those who were not after matching 1:1 for presenting radiographic and clinical characteristics predictive of hydrocephalus and vasospasm. Outcomes were compared using logistic regression and multivariable analysis.
RESULTS
In the first model, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 25, 50, and 23%, respectively, versus 20, 27, and 27% in nonfenestrated patients, respectively (P = 0.28, 0.21, and 0.32, respectively). In the second model, the nonfenestrated patients plus nondocumented patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 16, 40, and 20%, respectively (P = 0.19, 0.33, and 0.60, respectively). In the matched cohort, fenestrated patients had a shunt rate, conversion rate, and rate of clinical vasospasm of 29, 67, and 20%, respectively, versus 20, 25, and 25% in nonfenestrated patients, respectively (P = 0.30, 0.24, and 0.20, respectively).
CONCLUSION
In contrast to other retrospective multisurgeon series, our retrospective single-surgeon series suggests that microsurgical fenestration of the lamina terminalis may not reduce the incidence of shunt-dependent hydrocephalus or cerebral vasospasm after aneurysmal subarachnoid hemorrhage. A prospective multicenter trial is needed to definitively address the use of this maneuver.
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Affiliation(s)
- Ricardo J. Komotar
- Department of Neurological Surgery, Columbia University, New York, New York
| | - David K. Hahn
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Grace H. Kim
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Joyce Khandji
- Department of Neurological Surgery, Columbia University, New York, New York
| | - J Mocco
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Stephan A. Mayer
- Department of Neurological Surgery, Columbia University, New York, New York
| | - E. Sander Connolly
- Department of Neurological Surgery, Columbia University, New York, New York
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Kim JM, Jeon JY, Kim JH, Cheong JH, Bak KH, Kim CH, Yi HJ, Kim KM. Influence of lamina terminalis fenestration on the occurrence of the shunt-dependent hydrocephalus in anterior communicating artery aneurysmal subarachnoid hemorrhage. J Korean Med Sci 2006; 21:113-8. [PMID: 16479076 PMCID: PMC2733958 DOI: 10.3346/jkms.2006.21.1.113] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recently, it was reported that fenestration of the lamina terminalis (LT) may reduce the incidence of shunt-dependent hydrocephalus in aneurysmal subarachnoid hemorrhage (SAH). The authors investigated the efficacy of the LT opening on the incidence of shunt-dependent hydrocephalus in the ruptured anterior communicating artery (ACoA) aneurysms. The data of 71-ruptured ACoA aneurysm patients who underwent aneurysmal clipping in acute stage were reviewed retrospectively. Group I (n=36) included the patients with microsurgical fenestration of LT during surgery, Group II (n=35) consisted of patients in whom fenestration of LT was not feasible. The rate of shunt-dependent hydrocephalus was compared between two groups by logistic regression to control for confounding factors. Ventriculo-peritoneal shunts were performed after aneurysmal obliteration in 18 patients (25.4%). The conversion rates from acute hydrocephalus on admission to chronic hydrocephalus in each group were 29.6% (Group I) and 58.8% (Group II), respectively. However, there was no significant correlation between the microsurgical fenestration and the rate of occurrence of shunt-dependent hydrocephalus (p>0.05). Surgeons should carefully decide the concomitant use of LT fenestration during surgery for the ruptured ACoA aneurysms because of the microsurgical fenestration of LT can play a negative role in reducing the incidence of chronic hydrocephalus.
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Affiliation(s)
- Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea.
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18
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Hamlat A, Adn M, Sid-ahmed S, Askar B, Pasqualini E. Theoretical considerations on the pathophysiology of normal pressure hydrocephalus (NPH) and NPH-related dementia. Med Hypotheses 2006; 67:115-23. [PMID: 16530979 DOI: 10.1016/j.mehy.2006.01.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 01/18/2006] [Indexed: 10/24/2022]
Abstract
Normal pressure hydrocephalus (NPH) is considered to be an example of reversible dementia although clinical improvement after shunting varies from subject to subject, and recent studies have pointed to a possible link with other dementia. The authors consider that the craniospinal compartment is a partially closed sphere with control device systems represented by the spinal axis and the sagittal sinus-arachnoid villi complex which interact with each other in the clinical patient setting. We hypothesise that changing spinal compliance by altering the flow process and CSF dynamics lead to hydrocephalus. Therefore four NPH types have been distinguished according to the alterations in spinal compliance, decrease in CSF absorption at the sagittal sinus or both occurrences. The authors consider that NPH and NPH-related diseases (NPH-RD) are initiated by the same common final pathway and demonstrate that NPH could represent an initial stage of NPH-RD. Progression of clinical signs can be explained as damage to the cerebral tissue by both intermittent increased intracranial pressure and pulse pressure waves leading to periventricular ischaemia. In addition, they believe that both volume equilibrium and spinal compliance are restored in patients who improve after CSF shunt, whereas in patients whose condition does not improve, only volume equilibrium is restored and not spinal compliance, which was the underlying cause of hydrocephalus in such cases. They therefore wonder whether cervical decompression should not be indicated in patients who show no improvement. Although attractive, this analysis warrants confirmation from clinical, radiological, and hydrodynamic studies.
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Affiliation(s)
- Abderrahmane Hamlat
- Department of Neurosurgery, Service de neurochirurgie, CHRU Pontchaillou, Rue Henri Le Guilloux, 35000 Rennes Cedex 2, France.
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19
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Bech-Azeddine R, Gjerris F, Waldemar G, Czosnyka M, Juhler M. Intraventricular or lumbar infusion test in adult communicating hydrocephalus? Practical consequences and clinical outcome of shunt operation. Acta Neurochir (Wien) 2005; 147:1027-35; discussion 1035-6. [PMID: 16044359 DOI: 10.1007/s00701-005-0589-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 06/08/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate the therapeutic consequences of restricting the CSF dynamic evaluation to a lumbar infusion test (LIT), as opposed to our formerly applied intraventricular assessment (VIT), in patients with communicating hydrocephalus (CH). METHOD All patients over 18 years of age referred with clinical and radiological indication of treatment-requiring secondary CH (n = 50) or idiopathic normal-pressure hydrocephalus (INPH, n = 33) were subjected to a LIT. Subsequently, a combination of the results of the LIT (mainly the resistance to CSF outflow) and the clinical presentation determined whether to proceed with (a) VIT before a decision about shunt surgery, (b) shunt surgery or (c) no further diagnostic investigation or surgery. FINDINGS In 88 percent of the patients with secondary CH and 80 percent of the patients with INPH the decision on shunt surgery was made after performing exclusively a LIT. The shunting success rate was 90 percent in patients with secondary CH and 82 percent in patients with INPH, which however in the latter group decreased to 76 percent, when including the patients undergoing an additional VIT. The achieved shunt success rates are equal or better, compared to the results from previous studies using intraventricular assessment. CONCLUSIONS LIT and VIT are equally reliable for selecting shunt responsive patients with CH, using clinical improvement rate as the main criterion for comparison. The practical and economic consequences are substantial: the LIT can be performed in an outpatient setting, whereas VIT necessitates hospitalisation for 1-2 days including occupation of the neurosurgical theatre and postoperative neuro-intensive monitoring.
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Affiliation(s)
- R Bech-Azeddine
- University Clinic of Neurosurgery, The Neuroscience Center, Rigshospitalet, H:S, Copenhagen, Denmark.
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20
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Stephensen H, Andersson N, Eklund A, Malm J, Tisell M, Wikkelsö C. Objective B wave analysis in 55 patients with non-communicating and communicating hydrocephalus. J Neurol Neurosurg Psychiatry 2005; 76:965-70. [PMID: 15965203 PMCID: PMC1739729 DOI: 10.1136/jnnp.2004.039834] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND B waves, slow and rhythmic oscillations in intracranial pressure (ICP), are claimed to be one of the best predictors of outcome after surgery for normal pressure hydrocephalus (NPH). OBJECT To determine the relation between the percentage of B waves and outcome in patients with hydrocephalus, and also the diurnal variation of B waves. METHODS ICP and patient behaviour were recorded overnight (17 to 26 hours) in 29 patients with non-communicating hydrocephalus and 26 with NPH. The B wave activity, measured with an amplitude threshold of 0.5, 0.75, 1.0, 1.5, 2.0, 3.0, and 5.0 mm Hg, was estimated as the percentage of total monitoring time (% B waves) using a computer algorithm, and correlated with postoperative outcome, defined as changes in 12 standardised symptoms and signs. RESULTS There was no linear correlation between improvement after surgery in the 55 patients and total % B waves, but a correlation was found between improvement and % B waves during sleep (r = 0.39, p = 0.04). The percentage of B waves was the same during sleep and wakefulness, and patients with NPH had the same proportion of B waves as the non-communicating patients. CONCLUSIONS B waves are commonly observed in patients with both communicating and non-communicating hydrocephalus, but are only weakly related to the degree of postsurgical improvement.
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Affiliation(s)
- H Stephensen
- Hydrocephalus Research Unit, Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Göteborg University, 413 45 Göteborg, Sweden
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21
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Ter Minassian A, Proust F, Berré J, Hans P, Bonafé A, Puybasset L, Audibert G, de Kersaint-Gilly A, Beydon L, Bruder N, Boulard G, Ravussin P, Dufour H, Lejeune JP, Gabrillargues J. [Severity criteria for subarachnoid haemorrhage: intracranial hypertension, hydrocephalus]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:723-8. [PMID: 15922542 DOI: 10.1016/j.annfar.2005.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- A Ter Minassian
- Département d'anesthésie-réanimation chirurgicale I, CHU, 4, rue Larrey, 49033 Angers cedex 1, France.
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22
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Andaluz N, Zuccarello M. Fenestration of the Lamina Terminalis as a Valuable Adjunct in Aneurysm Surgery. Neurosurgery 2004; 55:1050-9. [PMID: 15509311 DOI: 10.1227/01.neu.0000140837.63105.78] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Accepted: 05/06/2004] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE:
Hydrocephalus, vasospasm, and frontobasal injury are common complications after aneurysmal subarachnoid hemorrhage (SAH) from anterior communicating artery aneurysms. Previous studies have suggested that fenestration of the lamina terminalis (FLT) during surgery may be associated with reduced rates of shunt-dependent hydrocephalus and vasospasm. We report 106 patients affected by anterior communicating artery aneurysms and Fisher Grade 3 aneurysmal SAH and the affect of FLT on shunt-dependent hydrocephalus, vasospasm, and frontobasal injury.
METHODS:
During a 3-year period, 53 patients underwent FLT and 53 did not. We prospectively evaluated admission and discharge clinical grades, hydrocephalus at admission, occurrence of clinical vasospasm, need for interventional vasospasm therapy, frontobasal hypodensity incidence, and permanent ventriculoperitoneal shunting requirement. Follow-up ranged from 3 to 35 months (mean, 17.9 mo).
RESULTS:
Shunting incidence after aneurysmal SAH with hydrocephalus was 4.25% in patients who underwent FLT and 13.9% in patients who did not (P< 0.001). Clinical cerebral vasospasm occurred in 29.6% of patients who underwent FLT and in 54.7% of patients who did not (P< 0.001). Frontobasal hypodensity was identified postoperatively in 0% of patients who underwent FLT and in 5% of patients who did not. Good outcome was reported in 69.81% of patients who underwent FLT and in 33.96% of patients who did not (P< 0.001). Poor outcome was associated with higher Hunt and Hess grades, need for ventricular drainage, elevated intracranial pressure, and multiple interventional vasospasm therapies. No complications were linked to FLT.
CONCLUSION:
FLT was associated with statistically significant decreases in shunting rates, incidence of vasospasm, and better outcomes. We recommend its routine use in patients with Fisher Grade 3 anterior communicating artery aneurysmal SAH.
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Affiliation(s)
- Norberto Andaluz
- Neuroscience Institute, Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0515, USA
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23
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Ohwaki K, Yano E, Nakagomi T, Tamura A. Relationship between shunt-dependent hydrocephalus after subarachnoid haemorrhage and duration of cerebrospinal fluid drainage. Br J Neurosurg 2004; 18:130-4. [PMID: 15176553 DOI: 10.1080/02688690410001680975] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Subarachnoid haemorrhage (SAH) patients in Fisher group 3 have a high risk of vasospasm and chronic hydrocephalus. We have provided cisternal irrigation combined with a head-shaking method for preventing vasospasm in SAH patients. We investigated 76 SAH patients in Fisher group 3 who received cisternal irrigation with head-shaking to evaluate the relationship between the occurrence of hydrocephalus and various clinical factors, including duration of cerebrospinal fluid (CSF) drainage. Chronic hydrocephalus occurred in 25 patients (33%). The occurrence of hydrocephalus was associated with longer duration of CSF drainage (median, 13 days versus 9 days). By logistic regression analysis using significant factors, including age, preoperative neurological grade and Glasgow Outcome Scale, only the duration of drainage was independently associated with the occurrence of hydrocephalus (Odds ratio = 1.18 per day; 95% confidence interval, 1.02- 1.36). These results indicate that long duration of CSF drainage for preventing vasospasm may increase the occurrence of hydrocephalus.
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Affiliation(s)
- K Ohwaki
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Itabashi, Tokyo, Japan.
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24
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Komotar RJ, Olivi A, Rigamonti D, Tamargo RJ. Microsurgical Fenestration of the Lamina Terminalis Reduces the Incidence of Shunt-dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2002. [DOI: 10.1227/01.neu.0000309116.09463.a6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ricardo J. Komotar
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alessandro Olivi
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J. Tamargo
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Microsurgical Fenestration of the Lamina Terminalis Reduces the Incidence of Shunt-dependent Hydrocephalus after Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2002. [DOI: 10.1097/00006123-200212000-00010] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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26
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Watling CJ, Cairncross JG. Acetazolamide therapy for symptomatic plateau waves in patients with brain tumors. Report of three cases. J Neurosurg 2002; 97:224-6. [PMID: 12134920 DOI: 10.3171/jns.2002.97.1.0224] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this report, the authors describe three patients with malignant gliomas who experienced paroxysmal neurological symptoms triggered by standing. The symptoms were attributed to acute elevations of intracranial pressure, an uncommon phenomenon called "plateau waves." In each instance, the attacks occurred despite the fact that the patient was receiving dexamethasone therapy and stopped promptly with the addition of acetazolamide. Acetazolamide, an orally administered carbonic anhydrase inhibitor, appears to be a specific and effective therapy for this uncommon neurological disorder.
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Affiliation(s)
- Christopher J Watling
- Department of Clinical Neurological Sciences, University of Western Ontario, London, Canada.
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27
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Sheehan JP, Polin RS, Sheehan JM, Baskaya MK, Kassell NF. Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 1999; 45:1120-7; discussion 1127-8. [PMID: 10549928 DOI: 10.1097/00006123-199911000-00021] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Associations among various factors and the occurrence of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) were evaluated retrospectively in 897 patients enrolled in the North American study of tirilazad mesylate. METHODS Patients were assessed for hydrocephalus in a blinded fashion. Assessment of hydrocephalus was made on the basis of 3-month follow-up computed tomographic studies or, for those without a 3-month follow-up scan, on the basis of the latest computed tomographic studies obtained at least 10 days after SAH. Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or prior placement of a ventricular shunt. Univariate analysis was performed to assess relationships among various factors and hydrocephalus. Factors statistically associated with the occurrence of hydrocephalus were analyzed further using logistic regression analysis. RESULTS Overall, 25.9% of the 897 patients developed hydrocephalus. Statistically significant associations among the following factors and hydrocephalus were observed (P value; risk coefficient): 1) severity of 3-month post-SAH Glasgow Outcome Scale (0.0001; 2.00); 2) increased ventricular size at admission (0.0001; 2.78); 3) neurological grade severity at admission (0.0274; 1.26); 4) preexisting hypertension (0.0284; 1.66); 5) alcoholism (0.0066; 2.30); 6) female sex (0.0056; 0.49); 7) increased aneurysm size (0.0239; 0.56); 8) pneumonia (0.0299; 1.78); 9) meningitis (0.0290; 5.86); and 10) intraventricular hemorrhage at admission (0.0414; 1.64). CONCLUSION Hydrocephalus seems to have a multifactorial etiology. Knowledge of risk factors related to the occurrence of hydrocephalus may help guide neurosurgeons in the long-term care of patients who have experienced aneurysmal SAH.
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Affiliation(s)
- J P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
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28
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Albeck MJ, Skak C, Nielsen PR, Olsen KS, Børgesen SE, Gjerris F. Age dependency of resistance to cerebrospinal fluid outflow. J Neurosurg 1998; 89:275-8. [PMID: 9688123 DOI: 10.3171/jns.1998.89.2.0275] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resistance to cerebrospinal fluid (CSF) outflow (Rout)is an important parameter in assessing the need for CSF shunt placement in patients with hydrocephalus. The normal lower limit of Rout has been estimated on the basis of the clinical effect of shunt placement in patients with varying values of Rout and in young healthy volunteers. The lack of clinical effect from CSF shunts in some elderly patients, despite elevated Rout,suggests that the normal value of Rout increases with age and may be higher in elderly persons. The aim of the present study was to examine the relationship between Rout and age in patients without known CSF dynamic disturbances. METHOD Fifty-two patients ranging from 20 to 88 years of age and with no known CSF dynamic disorders were examined. The Rout was measured using a lumbar computerized infusion test. The correlation between Rout and age was analyzed by performing linear regression. The Rout increased significantly with patient age. The Rout in a patient in the eighth decade will be approximately 5 mm Hg/ml/minute higher than in a young patient. CONCLUSIONS The present study shows a small but critical increase in Rout with increased patient age. A notable residual variation was present and borderline values of Rout should be regarded and used with caution.
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Affiliation(s)
- M J Albeck
- University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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29
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Lodi CA, Ter Minassian A, Beydon L, Ursino M. Modeling cerebral autoregulation and CO2 reactivity in patients with severe head injury. THE AMERICAN JOURNAL OF PHYSIOLOGY 1998; 274:H1729-41. [PMID: 9612385 DOI: 10.1152/ajpheart.1998.274.5.h1729] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The mathematical model presented in a previous work is used to simulate the time pattern of intracranial pressure (ICP) and of blood velocity in the middle cerebral artery (VMCA) in response to maneuvers simultaneously affecting mean systemic arterial pressure (SAP) and end-tidal CO2 pressure. In the first stage of this study, a sensitivity analysis was performed to clarify the role of some important model parameters [cerebrospinal fluid (CSF) outflow resistance, intracranial elastance coefficient, autoregulation gain, and the position of the regulation curve] during CO2 alteration maneuvers performed at different SAP levels. The results suggest that the dynamic "ICP-VMCA" relationship obtained during changes in CO2 pressure may contain important information on the main factors affecting intracranial dynamics. In the second stage, the model was applied to the reproduction of real ICP and velocity tracings in neurosurgical patients. Ten distinct tracings, taken from six patients during CO2 changes at different mean SAP levels, were reproduced. Best fitting between model and clinical curves was achieved by minimizing a least-squares criterion function and adjusting certain parameters that characterize CSF circulation, intracranial compliance, and the strength of the regulation mechanisms. A satisfactory reproduction was achieved in all cases, with parameter numerical values in the ranges reported in clinical literature. It is concluded that the model may be used to give reliable estimations of the main factors affecting intracranial dynamics in individual patients, starting from routine measurements performed in neurosurgical intensive care units.
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Affiliation(s)
- C A Lodi
- Department of Electronics, Computer Science and Systems, University of Bologna, Italy
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Ursino M, Lodi CA, Rossi S, Stocchetti N. Intracranial pressure dynamics in patients with acute brain damage. J Appl Physiol (1985) 1997; 82:1270-82. [PMID: 9104865 DOI: 10.1152/jappl.1997.82.4.1270] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The time pattern of intracranial pressure (ICP) during pressure-volume index (PVI) tests was analyzed in 20 patients with severe acute brain damage by means of a simple mathematical model. In most cases, a satisfactory fitting between model response and patient data was achieved by adjusting only four parameters: the cerebrospinal fluid (CSF) outflow resistance, the intracranial elastance coefficient, and the gain and time constant of cerebral autoregulation. The correlation between the parameter estimates was also analyzed to elucidate the main mechanisms responsible for ICP changes in each patient. Starting from information on the estimated parameter values and their correlation, the patients were classified into two main classes: those with weak autoregulation (8 of 20 patients) and those with strong autoregulation (12 of 20 patients). In the first group of patients, ICP mainly reflects CSF circulation and passive cerebral blood volume changes. In the second group, ICP exhibits paradoxical responses attributable to active changes in cerebral blood volume. Moreover, in two patients of the second group, the time constant of autoregulation is significantly increased (>40 s). The correlation between the parameter estimates was significantly different in the two groups of patients, suggesting the existence of different mechanisms responsible for ICP changes. Moreover, analysis of the correlation between the parameter estimates might give information on the directions of parameter changes that have a greater impact on ICP.
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Affiliation(s)
- M Ursino
- Department of Electronics, Computer Science, and Systems, University of Bologna, Italy
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Mayfrank L, Kissler J, Raoofi R, Delsing P, Weis J, Küker W, Gilsbach JM. Ventricular dilatation in experimental intraventricular hemorrhage in pigs. Characterization of cerebrospinal fluid dynamics and the effects of fibrinolytic treatment. Stroke 1997; 28:141-8. [PMID: 8996503 DOI: 10.1161/01.str.28.1.141] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic ventricular dilatation (HVD) is a prominent feature of human intraventricular hemorrhage (IVH) and a strong indicator for poor outcome. We developed an IVH model to define the mechanisms responsible for HVD and to test the efficacy of intraventricular administration of tissue plasminogen activator (TPA) in the treatment of HVD. METHODS Isolated IVH was produced in pigs by injecting 10 mL of blood simultaneously with thrombin into the right lateral ventricle. The treatment group received 1.5 mg of TPA after induction of IVH. Intraventricular blood volume and the volume of the lateral ventricles were assessed by CT after 90 minutes, 7 days, and 42 days. Intracranial pressure, the pressure-volume index, and the resistance to outflow of cerebrospinal fluid (R(out)) were measured 30 minutes and 7 days after IVH. RESULTS After IVH, the volume of the lateral ventricles increased from 1.98 +/- 0.69 to 6.43 +/- 1.23 mL (P < .001). There was a linear relationship between ventricular and clot volume (P = .014). Initially, R(out) increased from 24.34 +/- 7.13 to 63.56 +/- 64.91 mm Hg/mL per minute (P < .001). After 7 days, restoration of normal cerebrospinal fluid circulation occurred, but the ventricles were still significantly enlarged (5.24 +/- 1.76 mL, P < .001) and filled with blood. Within 6 weeks, ventricular volume had returned to normal values, paralleled by complete clot resolution. Intraventricular administration of TPA significantly accelerated clot clearance and restoration of normal ventricle volume. CONCLUSIONS These results suggest that intraventricular bleeding may cause impairment of cerebrospinal fluid circulation but that the mass effect of clots distending the ventricle walls is the most important mechanism responsible for HVD. This model closely imitates several prominent features of human IVH and may therefore be a useful tool for preclinical assessment of the efficacy and safety of treatment with TPA.
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Affiliation(s)
- L Mayfrank
- Department of Neurosurgery, Medical Faculty of the University of Technology (RWTH), Aachen, Germany
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Czosnyka M, Whitehouse H, Smielewski P, Simac S, Pickard JD. Testing of cerebrospinal compensatory reserve in shunted and non-shunted patients: a guide to interpretation based on an observational study. J Neurol Neurosurg Psychiatry 1996; 60:549-58. [PMID: 8778261 PMCID: PMC486369 DOI: 10.1136/jnnp.60.5.549] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To design a computerised infusion test to compensate for the disadvantages of Katzman's lumbar infusion method: inadequate accuracy of estimation of the resistance to cerebrospinal fluid outflow and poor predictive value in normal pressure hydrocephalus. METHODS Accuracy was improved by intracranial pressure signal processing and model analysis for measurement of cerebrospinal compensatory variable. These include the CSF outflow resistance, brain compliance, pressure-volume index, estimated sagittal sinus pressure, CSF formation rate, and other variables. Infusion may be made into the lumbar space, ventricles, or, when assessing shunt function in vivo, the shunt chamber. RESULTS AND CONCLUSIONS The computerised test has been used for five years in a multicentre study in 350 hydrocephalic patients of various ages, aetiologies, and states of cerebrospinal compensation. The principles of using the test to characterise different types of CSF circulatory disorders in patients presenting with ventricular dilatation, including brain atrophy and normal and high pressure hydrocephalus, are presented and illustrated. Previous studies showed a positive correlation between cerebrospinal compensatory variables and the results of shunting, but such a prediction remains difficult in idiopathic normal pressure hydrocephalus, particularly in elderly patients. The technique is helpful in the assessment of shunt malfunction, including posture-related overdrainage, over-drainage related to the nocturnal B wave activity, and proximal or distal shunt obstruction. The appendix presents an introduction of the mathematical modelling of CSF pressure volume-compensation included in computerised infusion test software.
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Affiliation(s)
- M Czosnyka
- MRC Cambridge Centre for Brain Repair and Academic Neurosurgical Unit, University of Cambridge, UK
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Ursino M, Iezzi M, Stocchetti N. Intracranial pressure dynamics in patients with acute brain damage: a critical analysis with the aid of a mathematical model. IEEE Trans Biomed Eng 1995; 42:529-40. [PMID: 7790009 DOI: 10.1109/10.387192] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The time pattern of intracranial pressure (ICP) in response to typical clinical tests (i.e., bolus injection and bolus withdrawal of 1 to 4 mL of saline in the craniospinal space) was studied in 18 patients with acute brain damage by means of a mathematical model. The model includes the main biomechanical factors assumed to affect intracranial pressure, particularly cerebrospinal fluid (CSF) dynamics, intracranial compliance, and cerebral hemodynamics. Best fitting between model simulation curves and clinical tracings was achieved using the Powell minimization algorithm and a least-square criterion function. The simulation results demonstrate that, in most patients, the ICP time pattern cannot be explained merely on the basis of CSF dynamics but also requires consideration of the contribution of cerebral hemodynamics and blood volume alterations. In particular, only in a few patients (about 40% of total) the ICP monotonically returns toward baseline following the clinical maneuver. In most of the examined cases (about 60%), ICP exhibits an anomalous response to the same maneuver, characterized by a delayed increase after bolus injection and a delayed decrease after withdrawal. The model is able to explain these responses, imputing them to active intracranial blood volume changes induced by mechanisms controlling cerebral blood flow. Finally, the role of the main intracranial biomechanical parameters in the genesis of the ICP time pattern is discussed and a comparison with previous theoretical studies performed.
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Affiliation(s)
- M Ursino
- Department of Electronics and Automatics, University of Ancona, Italy
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Gideon P, Ståhlberg F, Thomsen C, Gjerris F, Sørensen PS, Henriksen O. Cerebrospinal fluid flow and production in patients with normal pressure hydrocephalus studied by MRI. Neuroradiology 1994; 36:210-5. [PMID: 8041442 DOI: 10.1007/bf00588133] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An interleaved velocity-sensitised fast low-angle shot pulse sequence was used to study cerebrospinal fluid (CSF) flow in the cerebral aqueduct, and supratentorial CSF production in 9 patients with normal pressure hydrocephalus (NPH) and 9 healthy volunteers. The peak aqueduct CSF flow, both caudal and rostral, was significantly increased in patients with NPH. No significant difference in the supratentorial CSF production rate was found between patients (mean 0.60 +/- 0.59 ml/min) and healthy volunteers (mean 0.68 +/- 0.31 ml/min). Our method may be useful for investigation and monitoring of patients with NPH before and after ventriculoperitoneal shunt operations.
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Affiliation(s)
- P Gideon
- Danish Research Center of Magnetic Resonance, Hvidovre Hospital, University of Copenhagen, Denmark
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Gjerris F, Snorrason E. The history of hydrocephalus. JOURNAL OF THE HISTORY OF THE NEUROSCIENCES 1992; 1:285-312. [PMID: 11618437 DOI: 10.1080/09647049209525541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- F Gjerris
- The University Clinics of Neurosurgery and Rheumatology, Rigshospitalet, Copenhagen, Denmark
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Brinker T, Seifert V, Dietz H. Subacute hydrocephalus after experimental subarachnoid hemorrhage: its prevention by intrathecal fibrinolysis with recombinant tissue plasminogen activator. Neurosurgery 1992; 31:306-11; discussion 311-2. [PMID: 1513435 DOI: 10.1227/00006123-199208000-00016] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
It is investigated whether intrathecal fibrinolysis may prevent subacute hydrocephalus after subarachnoid hemorrhage (SAH). In 19 cats, SAH was induced by the intracisternal infusion of 1 ml/kg body weight of fresh autologous blood at a rate of 0.6 ml/min. Eleven of those animals were treated by intrathecal fibrinolysis performed 24 hours after experimental SAH by intracisternal infusion of 3 mg of recombinant tissue plasminogen activator. Included were eight animals suffering from experimental SAH and four healthy animals retained for control. A computed tomographic scan performed 24 hours after the SAH displayed an acute hydrocephalus from the experimental procedure. Cerebrospinal fluid outflow resistance was 71 +/- 5.0 mm Hg/ml/min in the healthy animals, 265 +/- 19.8 mm Hg/ml/min in the nontreated animals 7 days after SAH, and 151 +/- 6.4 mm Hg/ml/min in the recombinant tissue plasminogen activator-treated animals 7 days after SAH (mean +/- standard deviation; changes significant with P less than 0.01). Postmortem planimetry of both lateral ventricles gives a mean of 3.7 +/- 2.7 mm2 in the healthy animals, 11.1 +/- 3.9 mm2 in the nontreated group after SAH (P less than 0.01), and 3.5 +/- 1.1 mm2 in the animals treated with recombinant tissue plasminogen activator. Intracranial pressure monitoring demonstrated marked intracranial pressure waves only in the nontreated animals after SAH. It is concluded that intrathecal fibrinolysis may prevent subacute hydrocephalus after experimental SAH.
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Affiliation(s)
- T Brinker
- Neurosurgical Department, Medical School, Hannover, Germany
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Børgesen SE, Albeck MJ, Gjerris F, Czosnyka M, Laniewski P. Computerized infusion test compared to steady pressure constant infusion test in measurement of resistance to CSF outflow. Acta Neurochir (Wien) 1992; 119:12-6. [PMID: 1481738 DOI: 10.1007/bf01541775] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Resistance to cerebro-spinal fluid outflow is together with intracranial pressure the most important parameter in the investigation of patients with disturbances of CSF dynamics. The methods for determination of resistance are either unreliable or too time-consuming for routine clinical use, which has limited the popularity of this kind of measurement. In this paper a method for computerized acquisition and processing of an infusion test is described. A good correlation to a standard technique is documented.
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Affiliation(s)
- S E Børgesen
- University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Tychmanowicz K, Czernicki Z, Pawłowski G, Stepińska G. ICP dependent changes of CSF outflow resistance. Acta Neurochir (Wien) 1992; 117:44-7. [PMID: 1514427 DOI: 10.1007/bf01400634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
CSF outflow resistance was studied in cats using the lumbar infusion tests. Different infusion rates were applied from 0.012 to 1.8 ml/min. ICP level obtained during infusions varied from 8.9 +/- 3.0 to 144.0 +/- 25.7 mmHg. The calculated resistance (R) values were within 75.2 +/- 14.4 to 255.6 +/- 71.2. mm Hg/ml/min. The relation between ICP and R are characterized by a curve which can be divided into three parts. First R rises until an ICP level of about 20 mmHg is reached, then R decreases fast until the ICP value is about 50 mmHg, a further drop is much slower and the ICP/R curve becomes almost parallel to the ICP axis. The possible reasons for the ICP dependent changes of R as well as the clinical importance of the results obtained are discussed.
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Affiliation(s)
- K Tychmanowicz
- Neurosurgical Clinic, Polish Academy of Sciences, Medical Research Centre, Warsaw
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Gjerris F, Børgesen SE. Current concepts of measurement of cerebrospinal fluid absorption and biomechanics of hydrocephalus. Adv Tech Stand Neurosurg 1992; 19:145-77. [PMID: 1418120 DOI: 10.1007/978-3-7091-6672-7_5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- F Gjerris
- University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Brinker T, Seifert V, Stolke D. Effect of intrathecal fibrinolysis on cerebrospinal fluid absorption after experimental subarachnoid hemorrhage. J Neurosurg 1991; 74:789-93. [PMID: 1901600 DOI: 10.3171/jns.1991.74.5.0789] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The effect of intrathecal fibrinolysis on cerebrospinal fluid (CSF) absorption was investigated after experimental subarachnoid hemorrhage (SAH). In 11 cats, SAH was induced by intracisternal application of 1 to 4 ml of fresh autologous blood. Thirty minutes after the experimental SAH, the CSF outflow resistance was found to be elevated from a median of 77 mm Hg/ml/min (range 41.3 to 109 mm Hg/ml/min) to a median of 580 mm Hg/ml/min (range 104 to 7000 mm Hg/ml/min). A logarithmic relationship could be demonstrated between the volume of subarachnoid blood and the elevation of the CSF outflow resistance. The intrathecal application of 2 mg of recombinant tissue plasminogen activator (rt-PA), which is a fibrinolytic substance suitable for lysis of subarachnoid blood clots in man, resulted in an almost total restoration of CSF absorption after experimental SAH. The CSF outflow resistance after SAH was lowered by application of rt-PA from a median of 1028.05 mm Hg/ml/min (range 394 to 7000 mm Hg/ml/min) to 79 mm Hg/ml/min (range 56.7 to 223 mm Hg/ml/min). It is concluded that the impairment of CSF absorption after SAH may play an important role in the pathogenesis of post-hemorrhagic vasospasm.
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Affiliation(s)
- T Brinker
- Neurosurgical Department, Medical School Hannover, Germany
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Albeck MJ, Børgesen SE, Gjerris F, Schmidt JF, Sørensen PS. Intracranial pressure and cerebrospinal fluid outflow conductance in healthy subjects. J Neurosurg 1991; 74:597-600. [PMID: 2002373 DOI: 10.3171/jns.1991.74.4.0597] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Conductance of cerebrospinal fluid (CSF) outflow (Cout) is an important parameter to be considered in patients with CSF circulation abnormalities. In patients with normal-pressure hydrocephalus it is the single most important parameter in determining if the patient needs CSF shunting. The lower normal limit for Cout has been estimated from the effect of shunting in patients with normal-pressure hydrocephalus, from patients retrospectively reevaluated after recovering from illness, and from patients with known abnormalities in the brain or the CSF system. The true value of Cout in normal individuals, however, has hitherto not been reported. In the present study, Cout has been measured by a lumbar infusion test in eight young volunteers with no suspicion of disease. The mean intracranial pressure (ICP) was 11 mm Hg and a linear relationship was found between CSF absorption and ICP. The mean Cout was 0.11 ml/min/mm Hg and the lower 95% confidence level was 0.10 ml/min/mm Hg. These values are in accordance with those obtained from previous studies.
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Affiliation(s)
- M J Albeck
- University Clinics of Neurosurgery and Neurology, Rigshospitalet, Copenhagen, Denmark
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Abstract
Eight patients with subarachnoid and/or intraventricular haemorrhage underwent continuous extraventricular drainage and cerebrospinal fluid production was estimated by modified open drainage. The patients were in Hunt & Hess grades 2-5 on admission. Drainage was instituted within 24 h after the last bleeding episode in seven patients and the duration of drainage was 3-37 days. The median amount of CSF that was drained in 24 h was 210 ml. CSF production rate was 0.10-0.55 ml/min (median 0.28 ml/min) and there was a great variation within as well as between patients. Thus there was a trend towards a reduction in CSF production compared to reported normal values for CSF production. Three of six surviving patients required a shunt. The possible role of reduction in CSF production rate in the modification of intracranial hypertension and hydrocephalus after subarachnoid haemorrhage is discussed.
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