Post-traumatic hydrocephalus: An overview of classification, diagnosis, treatment, and post-treatment imaging evaluation

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The pathogenesis of PTH has not been fully clarified. At present, it is believed that the obstacles of cerebrospinal fluid (CSF) secretion, absorption and circulation pathways are the reasons for the development of PTH. However, recent studies have also suggested that the osmotic pressure load of CSF and the pathological changes of CSF dynamics are caused by the development of hydrocephalus. Therefore, a better understanding of the definition, classification, diagnostic criteria, treatment, and evaluation of post-treatment effects of PTH is critical for the effective prevention and treatment of PTH. In this paper, we reviewed the classification and diagnosis of PTH and focused on the treatment and the imaging evaluation of post-treatment effects of PTH. This review might provide a judgment criterion for diagnosis of PTH and a basis for the effective prevention and treatment of PTH in the future.

Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.

Choroid plexus-targeted NKCC1 overexpression to treat post-hemorrhagic hydrocephalus

Post-hemorrhagic hydrocephalus (PHH) refers to a life-threatening accumulation of cerebrospinal fluid (CSF) that occurs following intraventricular hemorrhage (IVH). An incomplete understanding of this variably progressive condition has hampered the development of new therapies beyond serial neurosurgical interventions. Here, we show a key role for the bidirectional Na-K-Cl cotransporter, NKCC1, in the choroid plexus (ChP) to mitigate PHH. Mimicking IVH with intraventricular blood led to increased CSF [K+] and triggered cytosolic calcium activity in ChP epithelial cells, which was followed by NKCC1 activation. ChP-targeted adeno-associated viral (AAV)-NKCC1 prevented blood-induced ventriculomegaly and led to persistently increased CSF clearance capacity. These data demonstrate that intraventricular blood triggered a trans-choroidal, NKCC1-dependent CSF clearance mechanism. Inactive, phosphodeficient AAV-NKCC1-NT51 failed to mitigate ventriculomegaly. Excessive CSF [K+] fluctuations correlated with permanent shunting outcome in humans following hemorrhagic stroke, suggesting targeted gene therapy as a potential treatment to mitigate intracranial fluid accumulation following hemorrhage.

The ASPECT Hydrocephalus System: a non-hierarchical descriptive system for clinical use

In patients with hydrocephalus, prognosis and intervention are based on multiple factors. This includes, but is not limited to, time of onset, patient age, treatment history, and obstruction of cerebrospinal fluid flow. Consequently, several distinct hydrocephalus classification systems exist. The International Classification of Diseases (ICD) is universally applied, but in ICD-10 and the upcoming ICD-11, hydrocephalus diagnoses incorporate only a few factors, and the hydrocephalus diagnoses of the ICD systems are based on different clinical measures. As a consequence, multiple diagnoses can be applied to individual cases. Therefore, similar patients may be described with different diagnoses, while clinically different patients may be diagnosed identically. This causes unnecessary dispersion in hydrocephalus diagnostics, rendering the ICD classification of little use for research and clinical decision-making. This paper critically reviews the ICD systems for scientific and functional limitations in the classification of hydrocephalus and presents a new descriptive system. We propose describing hydrocephalus by a system consisting of six clinical key factors of hydrocephalus: A (anatomy); S (symptomatology); P (previous interventions); E (etiology); C (complications); T (time-onset and current age). The "ASPECT Hydrocephalus System" is a systematic, nuanced, and applicable description of patients with hydrocephalus, with a potential to resolve the major issues of previous classifications, thus providing new opportunities for standardized treatment and research.

[Ommaya Reservoir and the External Ventricular Drainage]

Childhood hydrocephalus is a highly diverse disease caused by various factors, and most surgical treatments are performed during infancy. Despite the diversity of hydrocephalus pathologies, treatment options are limited. It is difficult for pediatric neurosurgeons to select and perform appropriate surgical procedures for neonates and infants. Treatment options for hydrocephalus are broadly divided into permanent and temporary. Permanent treatments include cerebrospinal fluid shunt and endoscopic third ventriculostomy; temporary treatment entails cerebrospinal fluid drainage using lumbar puncture and intermittent cerebrospinal fluid drainage with an Ommaya reservoir, ventricular drainage, and ventriculosubgaleal shunt. This article describes in detail Ommaya reservoir placement and ventricular drainage as representative procedures for temporarily treating hydrocephalus.

Metastases in the Pineal Region: A Systematic Review of Clinical Features, Management Strategies, and Survival Outcomes

BACKGROUND

Pineal region metastases are rare but often cause severe neurologic deficits. Surgical resection and chemoradiotherapy can provide therapeutic benefit. We investigated the literature to analyze clinical characteristics, management strategies, and survival of adult patients with pineal region metastases.

METHODS

PubMed, Embase, Scopus, and Cochrane were searched following the PRISMA guidelines, including studies reporting clinical outcomes of patients with pineal region metastases. Clinical presentation, management, and survival were reviewed.

RESULTS

We included 31 studies comprising 47 patients. Lung cancer (29.8%) and carcinomas of unknown origin (14.9%) were the most frequent primary tumors. In 48.9% of patients, symptomatic pineal metastases preceded primary tumor diagnosis. Headache (67.4%) and confusion (46.5%) were the most common symptoms. Parinaud syndrome (46.5%) and hydrocephalus (87.2%) were noted. Biopsy (65.9%) was preferred over resection (34.1%), and shunting strategies used were endoscopic third ventriculostomy (43.9%) and ventriculoperitoneal (26.8%). Eleven patients (32.3%) received adjuvant chemotherapy and 32 (68%) received radiotherapy. Posttreatment improvement in symptoms (56.6%) and hydrocephalus (80.5%) were noted. In patients who received adjuvant chemotherapy/radiotherapy, significant improvement in posttreatment performance status occurred with both biopsy (P < 0.001) and resection (P = 0.007). No survival differences were reported between surgery and biopsy (P = 0.912) or between complete and partial resection (P = 0.220). Overall survival was neither influenced by surgical approach (P = 0.157) nor by shunting strategy (P = 0.822). Mean follow-up was 8 months and median overall survival 3 months. Only 2 cases (4.8%) of pineal metastasis showed recurrence.

CONCLUSIONS

Pineal region metastases carry significant morbidity. Biopsy or surgical resection, combined with adjuvant chemotherapy/radiotherapy and/or shunting, may significantly improve performance status.

The Pathogenesis of Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage

Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and reportedly contributes to poor neurological outcomes. In this review, we summarize the molecular and cellular mechanisms involved in the pathogenesis of hydrocephalus following aSAH and summarize its treatment strategies. Various mechanisms have been implicated for the development of chronic hydrocephalus following aSAH, including alterations in cerebral spinal fluid (CSF) dynamics, obstruction of the arachnoid granulations by blood products, and adhesions within the ventricular system. Regarding molecular mechanisms that cause chronic hydrocephalus following aSAH, we carried out an extensive review of animal studies and clinical trials about the transforming growth factor-β/SMAD signaling pathway, upregulation of tenascin-C, inflammation-dependent hypersecretion of CSF, systemic inflammatory response syndrome, and immune dysregulation. To identify the ideal treatment strategy, we discuss the predictive factors of shunt-dependent hydrocephalus between surgical clipping and endovascular coiling groups. The efficacy and safety of other surgical interventions including the endoscopic removal of an intraventricular hemorrhage, placement of an external ventricular drain, the use of intraventricular or cisternal fibrinolysis, and an endoscopic third ventriculostomy on shunt dependency following aSAH were also assessed. However, the optimal treatment is still controversial, and it necessitates further investigations. A better understanding of the pathogenesis of acute and chronic hydrocephalus following aSAH would facilitate the development of treatments and improve the outcome.

Octopus Watch Fosters Family Resilience by Enhancing Occupational Engagement for Children with Spina Bifida and/or Hydrocephalus: Pilot Study

BACKGROUND

Children with spina bifida and/or hydrocephalus (SB&/H) often experience difficulties with activities of daily living (ADLs) due to impaired executive functioning, increasing sedentary behaviours. The HeyJoy Octopus watch, a child-friendly icon-based smartwatch could be used as an enabler to promote purposeful ADLs (i.e., goal-orientated ADLs).

OBJECTIVE

to investigate the effectiveness of the Octopus watch in promoting purposeful ADLs for children living with SB&/H (<8 years).

METHODS

Mixed-methods engaging parents and children in four phases: (1) Administered demographic questionnaire, semi-structured interview, childhood executive functioning inventory (CHEXI) and the Canadian occupational performance measure (COPM); focus group one introducing the study, information pack using smartwatch and photovoice data collection methods. (2) Measured baseline movement for four days with smartwatch without using functions. (3) Measured activity for 16-days while using the smartwatch. (4) Re-administered assessments and conducted a second focus group based on photovoice narratives.

RESULTS

movement data recorded for four participants, three of four showed mean activity increase (36%). N-of-1 analyses found one participant showed clear improvement (p = 0.021, r² = 0.28). Mean inhibition decreased by 16.4%, and mean change in COPM performance and satisfaction scores were 2.1 and 2.4, respectively. The photovoice narrative focus group supports findings evidenced with improved daily routines.

CONCLUSIONS

The Octopus watch is an innovative early intervention that can promote purposeful ADLs, fostering family resilience by enhancing occupational engagement. Further research is required.

Preoperative evaluation using external lumbar drainage for patients with posthemorrhagic hydrocephalus: A prospective, monocentric, randomized controlled trial

BACKGROUND

External lumbar drainage (ELD) remains the most common used methods with a higher sensitivity before lumboperitoneal shunt (LPS) implantation to predict the shunt outcomes in the treatment of idiopathic normal pressure hydrocephalus. However, the benefits of such supplemental test have not been tested in the treatment of post-hemorrhagic hydrocephalus (PHH).

METHODS AND DESIGN

In the current trial, 100 eligible patients with PHH will be recruited and randomly assigned to the ELD group (study group) and non-ELD group (control group). Lumbar puncture (LP) will be performed for participants in non-ELD group. LP plus ELD will be performed for participants in ELD group, those who will then be investigated the suitability of potential LPS 4 days after ELD. Two independent and practiced assessors will collect the baseline data and evaluate each participant 4 days after ELD or LP, 1 day after LPS, at the time of discharge and 1 month after LPS. The primary outcome is the shunting outcomes 1 month after surgery. The secondary outcomes include the complications related to ELD, complications related to LPS, and Evens index at each evaluation point. Meanwhile, serious adverse events occurring at any time is recorded to determine the safety of this trial.

DISCUSSION

The results of this trial will demonstrate whether preoperative evaluation using temporary ELD for patients with PHH could attenuate the risk of LPS failure.

TRIAL REGISTRATION NUMBER

ChiCTR2000034094; Pre-results.

Unilateral Hearing Loss in Children with Shunt-Treated Hydrocephalus

This study investigated the characteristics of hearing loss in children with ventriculoperitoneal (VP) shunted hydrocephalus. Twelve hydrocephalic children with patent VP shunts participated. The etiology of the hydrocephalus was either intraventricular hemorrhage or spina bifida. Audiometric examination included pure-tone air conduction thresholds, tympanometry, contralateral and ipsilateral acoustic reflex thresholds (ARTs), and distortion product otoacoustic emissions (DPOAEs). A unilateral, high-frequency, cochlear hearing loss was found in the ear ipsilateral to the shunt placement in 10 (83%) of the 12 shunt-treated hydrocephalic children. No hearing loss was observed in the ear contralateral to shunt placement. Based on the pure-tone audiometric findings, coupled with the decrease in DPOAE amplitude in the shunt ear, the hearing loss appears to be cochlear in nature. We suggest that cochlear hydrodynamics are disrupted as the result of reduced perilymph pressure, a consequence of cerebrospinal fluid (CSF) reduction due to the combined effects of a patent shunt and a patent cochlear aqueduct. In addition, a concomitant brain stem involvement is evidenced in the ART pattern, possibly produced by the patent shunt draining the CSF from the subdural space, resulting in cranial base hypoplasia.

Comparison of ventriculoperitoneal shunt to lumboperitoneal shunt in the treatment of posthemorrhagic hydrocephalus: A prospective, monocentric, non-randomized controlled trial

BACKGROUND

Ventriculoperitoneal shunt (VPS) surgery remains the most widely accepted and used option method to treat post-hemorrhagic hydrocephalus (PHH) worldwide while lumboperitoneal shunt (LPS) serves as an effectively alternative treatment. However, the outcomes of VPS and LPS in the treatment of PHH have not been compared in a prospective trial.

METHODS AND DESIGN

In this monocentric, assessor-blinded, non-randomized controlled trial, 75 eligible patients with PHH for each group will be recruited to compare the outcomes of VPS cohort with that of LPS cohort. Each participant is evaluated before surgery, at the time of discharge, 3, and 6 months after surgery by experienced and practiced assessors. The primary outcome is the rate of shunt failure 6 months after shunt surgery. The secondary measure of efficacy is National Institute of Health stroke scale, together along with Glasgow coma scale, modified Rankin Scale, and Evans index at the evaluation point. A favorable outcome is defined as shunt success with an improvement of more than 1 point in the National Institute of Health stroke scale. Complication events occurring within 6 months after surgery are investigated. A serious adverse events throughout the study are recorded regarding the safety of shunts.

DISCUSSION

The results of this trial will provide evidence for the treatment options for patients with PHH.

Hydrocephalus in Guillain barre syndrome: A case report and review of the literature

RATIONALE

Guillian-Barré syndrome (GBS) is a devastating autoimmune disorder characterized by progressive ascending weakness, areflexia with or without autonomic and sensory disturbances. Hydrocephalus is a rare but well-documented complication in patients with GBS. However, due to the rarity of this condition, no treatment guideline for GBS with hydrocephalus is currently available.

PATIENT CONCERNS

We describe a 23-year old woman with a history of bilateral limbs pain followed by dysarthria, dysphagia, severe quadriplegia 0/5, areflexia, loss of consciousness and dysautonomia. Neuroimaging studies revealed enlarged lateral ventricles; while Electromyography demonstrated demyelination and nerve injury. Lumbar puncture results showed elevated protein level 2.6 g/L; normal glucose and cell count.

DIAGNOSIS

GBS with hydrocephalus.

INTERVENTIONS

The patient was started on intravenous immunoglobulin for 5 consecutive days followed by endotracheal intubation and supportive therapy including osmotherapy and CSF drainage.

OUTCOMES

At 2 months after admission, the patient stopped choking and had a significant improvement in muscles' strength (grade 4) and pain; then was discharged. On 1 year post-discharge follow-up, CT has revealed a significant improvement of hydrocephalus, and the patient has completely returned to the normal baseline.

LESSONS

Respiratory failure is the strongest predictor of concurrent hydrocephalus in patients with GBS. The prognosis of hydrocephalus in patients with GBS is usually good, and it can be medically treated; thereby shunt surgery is rarely required.

Home telemonitoring of intracranial pressure

BACKGROUND

As technical progress advances, telemonitoring has become an important part of patient care in many areas of medical treatment. However, distanced surveillance of intracranial pressure (ICP) could not be established so far. With the recent introduction of a telemetric ICP measurement probe, new possibilities arise. Here, we report on a new home setup enabling home telemonitoring of intracranial pressure.

METHODS

Twenty patients suffering from disturbances of cerebrospinal fluid circulation, who underwent insertion of a telemetric ICP measurement probe, were provided with medical equipment to read ICP at home and save the data on an internet-enabled computer. Training in handling the equipment was performed during in-patient stay; recorded and uploaded ICP data was then analyzed online. Therefore, the treating medical team was able to access the ICP data via a secure internet connection while telephone conferencing with the patient.

RESULTS

Almost 7400 h of ICP data were recorded at home and evaluated via an internet connection according to the telemonitoring setup. This corresponds to an average record time of about 370 h per patient. ICP profiles were observed following endoscopic treatment, shunting procedures, or valve adjustments. The mean distance between the patients' residence and the consulting hospital was 172 km (range, 16-649 km).

CONCLUSIONS

ICP measurements have become accessible for telemonitoring purposes. This new management of hydrocephalus reflects an alternative method in patient care, especially for those who live far away from specialized centers.

Obstructive hydrocephalus associated with spontaneous dural arteriovenous fistula: A case report

RATIONALE

Dural arteriovenous fistulae (DAVF) are vascular disorders depicted with direct interconnection between dural arteries and cerebral venous sinuses and/or cortical veins. Only a hand full of cases have been reported in literature. DAVF obstructing the 3rd ventricle and quadrigeminal cistern resulting in hydrocephalus is very rare.

PATIENT CONCERNS

We present a 55-year-old female with 2 years history of headaches and blurring of vision. Cranial nerves examinations were unremarkable.

DIAGNOSES

Magnetic Resonance Imaging (MRI) and digital subtraction angiography showed multiple tortuous vascular malformation in the 3rd ventricle and quadrigeminal cistern resulting in obstructive hydrocephalus (OHC).

INTERVENTIONS

We utilized endovascular embolization treatment option to obliterate the lesion. We used Onyx embolization agent (ev3 Neurovascular, Irvine, CA) to embolize the lesion via the transarterial route.

OUTCOMES

The OHC resolved spontaneously after the endovascular embolization of the DAVF. The patient recovered with no further neurologic complication. Two years follow-up reveal no recurrence of the DAVF as well as hydrocephalus.

LESSONS

Adequate knowledge on the vascular anatomy is very crucial in managing DAVF.

Intracranial endodermal cyst presenting with nonobstructive hydrocephalus: A case report

RATIONALE

Endodermal cysts are rare benign lesions in the central nervous system. Their common symptoms include headache and neck pain caused by mass effect or inflammatory reaction. We report the case of an elderly woman with intracranial endodermal cyst who presented with nonobstructive hydrocephalus.

PATIENT CONCERNS

A 78-year-old woman presented with acute deterioration of consciousness caused by acute hydrocephalus. She subsequently underwent ventriculoperitoneal shunt placement. Eighteen months after this operation, she developed numbness of extremities and gait and progressive cognitive disturbances.

DIAGNOSIS

Initially, the endodermal cyst could not be recognized, but it became clinically evident in the craniocervical junction after ventriculoperitoneal shunt placement. MRI revealed multiple cystic lesions in the pontomedullary cistern. Postoperative pathology confirmed the diagnosis of endodermal cyst.

INTERVENTIONS

Subtotal resection of the cystic lesion was performed. Intra-operatively, multiple cysts containing a milky white fluid were noted and the medullary surface including the median and lateral apertures of the fourth ventricle were covered by thick, cloudy arachnoid membrane.

OUTCOMES

Although the numbness of extremities improved after the surgery, she remained bedridden due to deterioration in cognitive function and generalized muscle weakness. The patient developed recurrence 2 months after the surgery; however, no additional surgery was performed owing to her poor general condition.

LESSONS

Endodermal cysts rarely present with nonobstructive hydrocephalus caused by recurrent meningitis. In such cases, the lesions are often invisible on initial diagnostic imaging, and complete resection of the lesions is typically difficult because of strong adhesion between the cyst walls and contiguous vital structures.

Intracranial Pressure Sensor and Valve to Control Hydrocephalus

Hydrocephalus is a neurological condition that can result from trauma, hemorrhage, cancer, and infection. To control the intracranial pressure (ICP) a shunt is implanted to drain the cerebro-spinal fluid (CSF). We are working to develop an implantable pressure sensor. When the ICP is too high it will open a valve to relieve the ICP. When the ICP is too low, it will close the valve.

A Pial Arteriovenous Fistula in Infancy as the Presenting Manifestation of Hereditary Hemorrhagic Telangiectasia

BACKGROUND

Pial arteriovenous fistulas (PAVFs) are rare, accounting for 1.6%-4.7% of all intracranial vascular malformations. Often diagnosed in childhood, about 30% are associated with hereditary hemorrhagic telangiectasia. A case of PAVF diagnosed soon after birth and given cerebrovascular therapy 4 months after birth is reported.

CASE DESCRIPTION

The patient presented with heart failure immediately after birth. Ultrasonography of the head showed abnormal blood flow in the brain. On digital subtraction angiography performed 4 months after birth, a PAVF with a dural feeder shunt and a giant varix at the posterior temporal part was confirmed. After transarterial embolization (TAE), shunt blood flow disappeared. New shunt flow from the right posterior cerebral artery into the varix was confirmed by magnetic resonance imaging 3 months after the operation. A second TAE procedure using a liquid embolic material was performed and confirmed the complete disappearance of the shunt.

CONCLUSIONS

This report describes a case of infant PAVF with heart failure, a giant varix, hydrocephalus, and intraventricular hemorrhage treated by TAE using platinum coils and liquid embolic material.

Neurocutaneous melanosis presenting with hydrocephalus and malignant transformation: case-based update

INTRODUCTION

Neurocutaneous melanosis (NCM) is a sporadic condition characterised by congenital melanocytic nevi and melanocytic thickening of the leptomeninges. It is believed to result from congenital dysplasia of melanin-producing cells within the skin and leptomeninges. The management of cutaneous manifestations remains controversial; for neurological manifestations, outcome remains poor even with the use of radiotherapy and chemotherapy.

PATIENTS AND METHODS

We describe the case of a 5-month-old boy who presented with giant congenital melanocytic nevus and hydrocephalus. MR imaging and CSF immunohistochemistry confirmed leptomeningeal melanosis. We discuss the diagnosis, treatment and prognosis of this rare disorder in the light of recent published literature.

RESULTS

Patient required placement of right-sided ventriculoperitoneal shunt to control hydrocephalus. The patient tolerated the procedure well and was discharged home with normal neurological function. A presumptive diagnosis of NCM was made based on the MR characteristics, CSF cytology and clinical presentation. He received trametinib, a MAPK/Erk kinase inhibitor for 7 months. At 30 months of age, he developed left-sided weakness and status epilepticus requiring paediatric intensive care unit admission and ventilator support. The patient eventually succumbed to malignant transformation of leptomeningeal disease.

CONCLUSION

Cutaneous manifestations of NCM are usually congenital, and neurological manifestations develop early in life. Patients with large or multiple congenital nevi should therefore be investigated early to facilitate treatment. MR imaging is the investigation of choice which can further assist in performing biopsy. Symptomatic NCM is refractory to radiotherapy and chemotherapy and has a poor prognosis. A multidisciplinary approach is necessary in the management of NCM patients.

Management of hydrocephalus in patients with leptomeningeal metastases: an ethical approach to decision-making

PURPOSE

Leptomeningeal metastases (LM) are a rare, but often debilitating complication of advanced cancer that can severely impact a patient's quality-of-life. LM can result in hydrocephalus (HC) and lead to a range of neurologic sequelae, including weakness, headaches, and altered mental status. Given that patients with LM generally have quite poor prognoses, the decision of how to manage this HC remains unclear and is not only a medical, but also an ethical one.

METHODS

We first provide a brief overview of management options for hydrocephalus secondary to LM. We then apply general ethical principles to decision making in LM-associated hydrocephalus that can help guide physicians and patients.

RESULTS

Management options for LM-associated hydrocephalus include shunt placement, repeated lumbar punctures, intraventricular reservoir placement, endoscopic third ventriculostomy, or pain management alone without intervention. While these options may offer symptomatic relief in the short-term, each is also associated with risks to the patient. Moreover, data on survival and quality-of-life following intervention is sparse. We propose that the pros and cons of each option should be evaluated not only from a clinical standpoint, but also within a larger framework that incorporates ethical principles and individual patient values.

CONCLUSIONS

The decision of how to manage LM-associated hydrocephalus is complex and requires close collaboration amongst the physician, patient, and/or patient's family/friends/community leaders. Ultimately, the decision should be rooted in the patients' values and should aim to optimize a patient's quality-of-life.

[Macrocephaly in childhood]

In a wide spectrum of cases in childhood, macrocephaly does not carry a neurological risk, although a range of possibilities will have an impact on both the evolutionary and cognitive aspects of children. The previous happens in pathologies with progressive components, such as tumors or hydrocephalus, and in those cases in which the factor of the growth of the cephalic perimeter is given by structural components of the nervous system as it happens in megalocephaly. As in all other medical acts, the careful taking of the anamnesis, the appropriate neurological examination and the valuations of the neurodevelopment items can give a thorough orientation about the etiology and importance of the problem. The help of diagnostic aids as well as images will provide the other data to define the diagnosis and propose a treatment.

Posttraumatic hydrocephalus

Posttraumatic hydrocephalus (PH) is a common complication of craniocerebral trauma. It is necessary to bear this entity in mind, especially when managing craniocerebral trauma patients, because if not detected in time, it can significantly affect morbidity and mortality. It needs to be distinguished from brain atrophy with axonal degeneration, a condition requiring an entirely different treatment approach. Key words: hydrocephalus - posttraumatic - VP shunt - brain CT - progression of neurological status.

Long-Term Neurodevelopmental and Growth Outcomes of Premature Infants Born at <29 week Gestational Age with Post-Hemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt

OBJECTIVE

To compare long-term neurodevelopmental and growth (NDG) outcomes at 3 y corrected gestational age (GA) in premature infants with grade ≥ III intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus who were treated with ventriculo-peritoneal shunt with those who were not treated with shunt.

METHODS

In a retrospective cohort study, NDG outcomes were compared between preterm infants of <29 wk GA with IVH treated with shunt (IVHS) and IVH with no shunt (IVHNS). This was a single centre study. The primary outcome was moderate to severe cerebral palsy (CP).

RESULTS

Of 1762 preterm infants who survived to discharge, 90 had grade ≥ III IVH. Infants in IVHS group had more grade IV IVH than IVHNS (p < 0.05). Seventy percent of the patients in IVHNS groups had no hydrocephalus. IVHS group had increased CP (76% vs. 30%; p 0.003), and higher odds of CP after controlling for GA and IVH grade [odds ratio (OR); 4.23 (1.38 to 13.00)]. Growth delay was not different between groups.

CONCLUSIONS

Infants with IVHS are at increased risk of CP but not growth delay.

[Hydrocephalus due to hyperplasia of the choroid plexuses in a patient with trisomy 9 mosaicism. A real diagnostic and therapeutic challenge]

INTRODUCTION

Trisomy 9 is an unusual chromosome abnormality in live-born patients, which is frequently accompanied by functional and structural anomalies of the central nervous system. Among many other alterations, several studies have been published in the English-speaking literature that show an association between chromosome 9 abnormality and pathologies affecting the choroid plexuses.

CASE REPORT

We report the case of a 4-month-old male with trisomy 9 mosaicism associated to hydrocephalus secondary to choroid plexus hyperplasia, who was referred due to a clinical picture of intracranial hypertension. The cerebrospinal fluid (CSF) drainage procedure that was initially chosen caused massive ascites due to an excessive production of CSF, and led to a cascade of multiple surgical interventions, which included endoscopic and drainage procedures.

CONCLUSIONS

This is another example of an association between choroid plexus pathologies and chromosome 9 abnormality. Due to its scarce incidence, diagnosis of hydrocephalus secondary to plexus hyperplasia is difficult, as is selecting its most suitable treatment. In this type of hydrocephalus there is a double pathophysiological mechanism, which involves an increase in CSF production and a decrease in its reabsorption. Despite taking these considerations into account, the treatment of hydrocephalus secondary to plexus hyperplasia is a real challenge that usually leads to multiple surgical interventions ranging from plexectomy or coagulation of the choroid plexuses to the implantation of CSF drainage devices.

Neurosarcoidosis: unusual presentations and considerations for diagnosis and management

BACKGROUND

Sarcoidosis is a chronic, multisystem disease characterised by non-necrotising granulomatous inflammation of unknown aetiology. Most commonly, the lungs, lymph nodes, skin and eyes are affected in sarcoidosis; however, nervous system involvement occurs in approximately 5%-15% of cases. Any part of the nervous system can be affected by sarcoidosis.

CASES

Herein we describe three unusual patient presentations of neurosarcoidosis, one with optic neuritis, a second with hydrocephalus and a third with cervical myelopathy.

CONCLUSIONS

We include pertinent details about their presentations, imaging findings, pathology, management and clinical course.

Pulsatile flow in ventricular catheters for hydrocephalus

The obstruction of ventricular catheters (VCs) is a major problem in the standard treatment of hydrocephalus, the flow pattern of the cerebrospinal fluid (CSF) being one important factor thereof. As a first approach to this problem, some of the authors studied previously the CSF flow through VCs under time-independent boundary conditions by means of computational fluid dynamics in three-dimensional models. This allowed us to derive a few basic principles which led to designs with improved flow patterns regarding the obstruction problem. However, the flow of the CSF has actually a pulsatile nature because of the heart beating and blood flow. To address this fact, here we extend our previous computational study to models with oscillatory boundary conditions. The new results will be compared with the results for constant flows and discussed. It turns out that the corrections due to the pulsatility of the CSF are quantitatively small, which reinforces our previous findings and conclusions.This article is part of the themed issue 'Mathematical methods in medicine: neuroscience, cardiology and pathology'.

Thulium fiber laser recanalization of occluded ventricular catheters in an ex vivo tissue model

Hydrocephalus is a chronic medical condition that occurs in individuals who are unable to reabsorb cerebrospinal fluid (CSF) created within the ventricles of the brain. Treatment requires excess CSF to be diverted from the ventricles to another part of the body, where it can be returned to the vascular system via a shunt system beginning with a catheter within the ventricle. Catheter failures due to occlusion by brain tissues commonly occur and require surgical replacement of the catheter. In this preliminary study, minimally invasive clearance of occlusions is explored using an experimental thulium fiber laser (TFL), with comparison to a conventional holmium: yttrium aluminium garnet (YAG) laser. The TFL utilizes smaller optical fibers ( < 200 - ? m OD) compared with holmium laser ( > 450 - ? m OD), providing critical extra cross-sectional space within the 1.2-mm-inner-diameter ventricular catheter for simultaneous application of an endoscope for image guidance and a saline irrigation tube for visibility and safety. TFL ablation rates using 100 - ? m core fiber, 33-mJ pulse energy, 500 - ? s pulse duration, and 20- to 200-Hz pulse rates were compared to holmium laser using a 270 - ? m core fiber, 325-mJ, 300 - ? s , and 10 Hz. A tissue occluded catheter model was prepared using coagulated egg white within clear silicone tubing. An optimal TFL pulse rate of 50 Hz was determined, with an ablation rate of 150 ?? ? m / s and temperature rise outside the catheter of ? 10 ° C . High-speed camera images were used to explore the

Current Care and Investigational Therapies in Achondroplasia

PURPOSE OF REVIEW

The goal of this review is to evaluate the management options for achondroplasia, the most common non-lethal skeletal dysplasia. This disease is characterized by short stature and a variety of complications, some of which can be quite severe.

RECENT FINDINGS

Despite several attempts to standardize care, there is still no widely accepted consensus. This is in part due to absence of concrete data on the incidence of sudden unexplained death in infants with achondroplasia and the best investigation for ascertaining which individuals could benefit from foramen magnum decompression surgery. In this review, we identify the different options of care and management for the various orthopedic, neurologic, and respiratory complications. In parallel, several innovative or drug repositioning therapies are being investigated that would restore bone growth but may also prevent complications. Achondroplasia is the most common non-lethal skeletal dysplasia. It is characterized by short stature and a variety of complications, some of which can be quite severe. Despite several attempts to standardize care, there is still no widely accepted consensus. This is in part due to absence of concrete data on the incidence of sudden unexplained death in infants with achondroplasia and the best investigation for ascertaining which individuals could benefit from foramen magnum decompression surgery. In this review, we identify the different options of care and management for the various orthopedic, neurologic, and respiratory complications. In parallel, several innovative or drug repositioning therapies are being investigated that would restore bone growth but may also prevent complications.

Clinical value of radionuclide shuntography by qualitative methods in hydrocephalic adult patients with suspected ventriculoperitoneal shunt malfunction

To determine the clinical value of radionuclide shuntography in the evaluation of adult hydrocephalic patients with suspected ventriculoperitoneal (V-P) shunt malfunction. All adult patients who underwent Tc-99m diethylenetriamine pentaacetic acid shuntographic scans at Far Eastern Memorial Hospital between August 2005 and December 2015 were included. Shuntographic results were visually evaluated in a simple qualitative manner: prompt flow that reached the peritoneum on 30-minute early images and diffuse peritoneal tracer distribution on 2-hour delayed images were interpreted as nonobstructive shunt flow. Partial dysfunction was diagnosed as scintigraphic findings between no obstruction and complete obstruction (where complete malfunction indicated no peritoneal distribution on delayed images). The results were correlated with the clinical outcomes and surgical results within 30 days. Diagnostic sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were also calculated. A total of 93 scans in 69 patients with suspected V-P shunt malfunction were analyzed. Sixty-two scans were interpreted as abnormal, including complete (n = 26, 41.9) distal obstruction, partial (n = 35, 56.5) distal dysfunction, and miscellaneous (n = 1, 1.6, cerebrospinal fluid leak). The Se and Sp were 83.0% and 55.0%, respectively, and PPV, NPV, and accuracy were all 71.0%. Twenty-five patients (28 scans) underwent surgical revision, and the results were highly concordant with the imaging findings (Se, 92.0%; Sp, 100.0%; PPV, 100.0%; NPV, 60.0%; and accuracy, 92.9%). Radionuclide shuntography provides useful information in adult patients with V-P shunt malfunction and could be used to guide further surgical intervention.

Cerebrospinal Fluid Shunting Complications in Children

Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.

Paediatric External Ventricular Drains: Experience from a tertiary care hospital of a Developing Country

The aim of the study was to describe indications and complications of external ventricular drain (EVD) placement in children aged between 1 month and 16 years. This retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, and comprised all children who underwent EVD placement from January 2007 to December 2014. Of the 177 patients identified, 117(66%) were males 60(34%) were girls. The overall mean age was 5.4±5.2 years. The median Glasgow Coma Scale score on presentation and discharge was 13 (interquartile range [IQR]: 7) and 15 (IQR: 4), respectively. Major diagnosis included intracranial tumour 60(34%), bacterial meningitis 34(19%), tuberculous meningitis 33(18.6%), and haemorrhage 23(13%). Clinical indications for EVD insertion were acute hydrocephalus secondary to infection 64(36.2%), tumour 54(30.5%), and haemorrhage 23(13%) ventriculoperitoneal shunt malfunction or infection 25(14.1%) and traumatic brain injury 11(6.2%). Complications were observed in 47(26%) patients including infections 25(14.1%), malfunction 11(6.2%), haemorrhage 6(3.4%), misplacement 3(1.7%) and obstruction 2(1.1%). Staphylococcus was the main organism isolated. Moreover, 25(14%) patients expired. Acute hydrocephalus was the major indication and EVD infection was the major complication.

Transient Obstructive Hydrocephalus in Patients with Intracerebral Hemorrhage: Report of Two Cases

Obstructive hydrocephalus is a relatively common complication of intraventricular hemorrhage resulting in high morbidity and mortality. We report two cases of transient obstructive hydrocephalus caused by obstruction of mesencephalic duct in patients that presented with altered consciousness which resolved spontaneously in a few hours. In very rare cases, obstructive hydrocephalus due to intraventricular hemorrhage may be transient and does not need neurosurgical or invasive procedures for lowering raised intracranial pressure, which otherwise are currently preferred treatment options.

Blazing a trail

These are challenging times in the NHS,' says RCN north west regional director Estephanie Dunn. 'We are endeavouring to safeguard already diminishing budgets and services while there are increasing pressures on staff.

Small bowel perforation: a rare complication of ventriculoperitoneal shunt placement

Small bowel perforation is a rare complication of ventriculoperitoneal (VP) shunt placement. When seen, it most commonly affects the stomach or colon. We describe a case and image findings of an 8-year-old female who presented with sepsis and erosion of the VP shunt into the small bowel. The imaging findings were confirmed surgically. We also provide an overview of the current literature discussing previously reported cases, clinical features, and treatment.

Hydrocephalus in children

Hydrocephalus is a common disorder of cerebral spinal fluid (CSF) physiology resulting in abnormal expansion of the cerebral ventricles. Infants commonly present with progressive macrocephaly whereas children older than 2 years generally present with signs and symptoms of intracranial hypertension. The classic understanding of hydrocephalus as the result of obstruction to bulk flow of CSF is evolving to models that incorporate dysfunctional cerebral pulsations, brain compliance, and newly characterised water-transport mechanisms. Hydrocephalus has many causes. Congenital hydrocephalus, most commonly involving aqueduct stenosis, has been linked to genes that regulate brain growth and development. Hydrocephalus can also be acquired, mostly from pathological processes that affect ventricular outflow, subarachnoid space function, or cerebral venous compliance. Treatment options include shunt and endoscopic approaches, which should be individualised to the child. The long-term outcome for children that have received treatment for hydrocephalus varies. Advances in brain imaging, technology, and understanding of the pathophysiology should ultimately lead to improved treatment of the disorder.

Intractable Neurosarcoidosis Effectively Treated with Infliximab

We herein describe the case of an 18-year-old girl who presented with dizziness and headache in 2012. In 2013, brain magnetic resonance imaging revealed multiple intracerebral small lesions and intracerebral hydrocephalus. She was diagnosed with neurosarcoidosis following a brain biopsy. Although prednisolone, methotrexate, and azathioprine were administered, her hydrocephalus worsened and her granulomatous lesions were observed to increase in number on MRI. The patient's hydrocephalus showed no improvement despite her undergoing one ventriculoperitoneal shunt procedure, one septum pellucidum fenestration, and three ventriculoatrial shunt procedures. Infliximab therapy was then initiated, which resulted in a reduction in the size of the granulomatous lesions and the improvement of the patient's clinical symptoms. Infliximab may be a viable therapeutic option for treating intractable neurosarcoidosis.

Longitudinal Changes in the Brain Following Third Ventriculostomy in a Child With Hydrocephalus: A Case Report

The goal of this study was to detect the long-term effect of shunting on the integrity of white matter in young children with hydrocephalus.The authors reported the case of a 6-month-old boy with hydrocephalus who was evaluated by diffusion tensor imaging (DTI) before and after a shunt operation.When compared with normal children, the structures of the corpus callosum, internal capsule, and corona radiata in the patient showed a decrease in fractional anisotropy and an increase in radial diffusivity values before the shunt operation. Following successful cerebrospinal fluid shunting, long-term follow-up DTI demonstrated a trend toward normalization of the fractional anisotropy and radial diffusivity values.Shunt treatment can prevent further damage to the brain and grossly reconstitute the distorted anatomy. DTI could be a useful tool in detecting longitudinal changes after a shunt operation. Further studies involving larger case numbers are needed to detect the long-term effect of shunting on the brains of children with hydrocephalus.

Management of posterior fossa tumors and hydrocephalus in children: a review

OBJECT

Most pediatric patients that present with a posterior fossa tumor have concurrent hydrocephalus. There is significant debate over the best management strategy of hydrocephalus in this situation. The objectives of this paper were to review the pathophysiology model of posterior fossa tumor hydrocephalus, describe the individual risks factors of persistent hydrocephalus, and discuss the current management options. Specifically, the debate over preresection cerebrospinal fluid diversion is discussed.

RESULTS

Only 10-40 % demonstrate persistent hydrocephalus after posterior fossa tumor resection. It appears that young age, moderate to severe hydrocephalus, transependymal edema, the presence of cerebral metastases, and tumor pathology (medulloblastoma and ependymoma) on presentation predict postresection or persistent hydrocephalus. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH), a validated prediction model, can be used to stratify patients at point of first contact into high and low risk for persistent hydrocephalus.

CONCLUSIONS

A protocol is proposed for managing hydrocephalus that utilizes the CPPRH. Low-risk patients can be monitored conservatively with or without an intraoperative extraventricular drain, while high-risk patients require the use of an intraoperative extraventricular drain, higher postoperative hydrocephalus surveillance, and even consideration for a preoperative endoscopic third ventriculostomy.

Are parents and professionals making shared decisions about a child's care on presentation of a suspected shunt malfunction: a mixed method study?

BACKGROUND

Shunts, the main treatment for hydrocephalus, are problematic as they frequently malfunction. Identifying shunt malfunction requires parents to recognize its symptoms and health professionals to integrate parents' information about the child's symptoms within the clinical assessment to reach a diagnosis.

AIM

To investigate parent-professional shared decision making during the diagnosis of suspected shunt malfunction in acute hospital admissions.

DESIGN AND METHODS

A mixed method study involving audio recordings of admission consultations, a shared decision making questionnaire and interviews 1-week post-consultation, was undertaken. Twenty-eight family members and fourteen health professionals participated. The interactions were analysed using conversational analysis, framework approach for the interview data and descriptive statistics for questionnaire responses.

FINDINGS

Both parents and professionals focussed on establishing a diagnosis and ruling out shunt malfunction when a child with hydrocephalus was ill. Participants' perceived effective collaboration as central to this task: parents wanted to contribute to the process of diagnosis by providing information about the likely cause of symptoms. Professionals were satisfied with the level of involvement by parents, although parent satisfaction was more variable. The challenge for professionals was to integrate parents' expertise of their child's presenting symptoms within clinical decision making processes.

CONCLUSION

In this context, both parents' and professionals' perceived their interactions to be about problem-solving, rather than making decisions about treatments. Although the shared decision-making model can help patients to make better decisions between treatment options, it is unclear how best to support collaboration between professionals and parents to ensure a good problem-solving process.

An investigation into the vancomycin concentration in the cerebrospinal fluid due to vancomycin intraventricular administration in newborns: a study of 13 cases

Treatment against shunt infection by transvenous antimicrobial treatment is difficult, with a high risk of relapse. Consequently, to maintain a sufficient cerebrospinal fluid (CSF) concentration, intraventricular administration is utilized in combination with the transvenous administration of vancomycin (VCM). Few studies have so far investigated the optimum administration dose for newborns and the concentration in the CSF. Therefore, we chronologically measured the VCM concentration in the CSF after VCM intraventricular administration in newborns and attempted to elucidate the optimum administration method.The participants consisted of newborns admitted to Juntendo University Neonatal intensive care unit from March 2007 to June 2011 who underwent interventricular shunting placement. VCM was intraventricularly administered to 10 patients for a total of 13 cases. The CSF concentration of VCM was chronologically measured at 12 to 120  hours following the intraventricular administration of VCM.The intraventricular administration groups with VCM of 20 (n = 6) and 10  mg (n = 2) had a high concentration in the CSF at 24  hours following administration (95-168  mg/L), with the concentration remaining high at 72  hours (13.2-72  mg/L). At the same time, in the 5  mg group (n = 5), the concentration in the CSF 24  hours following VCM administration was sufficiently maintained (33.2-62.9  mg/L), with a sufficient trough concentration still maintained at 72  hours (11.7-16.5  mg/L).The concentration in the CSF is prolonged in newborns, thus allowing a sufficient therapeutic range to be maintained even at an intraventricular administration of 5  mg. It is therefore believed that the monitoring of the CSF is very important regarding the administration interval because the VCM concentration in the CSF differs depending on the case.

[Progress in diagnosis and treatment of intracranial hypertension and hydrocephalus in children with intracranial infections]

Intracranial infections are one of the most common neurological diseases in children and are associated with high mortality and morbidity. Intracranial hypertension and hydrocephalus are the common, fatal complications of intracranial infections, so early diagnosis and timely treatment are the keys to saving patients' lives and reducing neurological sequelae. This paper introduces the progress in the etiology, diagnosis, and treatment of intracranial hypertension and hydrocephalus in children with intracranial infections.

Cerebellar strokes: a clinical outcome review of 79 cases

INTRODUCTION

Cerebellar infarcts and haemorrhages are relatively uncommon, accounting for less than 10% of all strokes. The objective of the present study was to quantify and compare the outcomes of patients with cerebellar infarct and those of patients with cerebellar haemorrhage, as well as to identify the risk factors that predict poor outcome in patients with cerebellar stroke.

METHODS

We retrospectively reviewed the medical records of consecutive patients admitted to National University Hospital, Singapore, between 2004 and 2006, within one week of cerebellar stroke onset. Baseline data included demographics, concomitant comorbidities, and the presence or absence of brainstem compression and hydrocephalus (on computed tomography or magnetic resonance imaging). The Glasgow Outcome Scale and modified Rankin Score were used to assess outcome at discharge and at six months after discharge.

RESULTS

A total of 79 patients with cerebellar stroke were admitted during the study period. Of these 79 patients, 17.7% died and 31.6% had poor outcomes at six months after discharge. Patients with cerebellar haemorrhage were found to be more likely to have poor outcomes as compared to patients with cerebellar infarct, both at discharge (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.3-14.1) and at six months after discharge (OR 5.2, 95% CI 1.6-17.2). When compared to small lesions (< 5 cm(3)), lesions > 20 cm(3) were significantly associated with poorer outcomes and the development of hydrocephalus and brainstem compression.

CONCLUSION

Cerebellar strokes are a significant cause of morbidity and mortality. The outcomes of patients with cerebellar haemorrhage are more likely to be worse than those of patients with cerebellar infarct.

Post-hemorrhagic hydrocephalus and diabetes insipidus in preterm infants

We present two cases of transient central diabetes insipidus in preterm neonates with post-hemorrhagic hydrocephalus. Although the association between intraventricular hemorrhage and diabetes insipidus has been described in preterm infants, the association between diabetes insipidus and hydrocephalus, and the fact that such central diabetes insipidus could be reversible with the reduction of ventricular size, either because of spontaneous resolution or the placement of ventriculo-peritoneal shunt is first described here in neonates.