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Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case

Dominic Chau, Zachary R Barnard, , Thomas J Muelleman, Adam M Olszewski, Anna K D’Agostino, Marcel M Maya, Peyton Nissen, Kevin A Peng, Wouter I Schievink, Gregory P Lekovic, and

BACKGROUND

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory.

OBSERVATIONS

A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula.

LESSONS

Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever “otogenic” pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 11 (Sep 2023)

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Does earlier vestibular therapy after sport-related concussion lead to faster recovery?

Michael Zargari, Kristen Williams, Jacob Jo, Trevor J. Anesi, Olivia L. Prosak, Amad Amedy, Anthony E. Bishay, Scott L. Zuckerman, and Douglas P. Terry

OBJECTIVE

Many patients experience vestibular dysfunction following a sport-related concussion (SRC). Vestibular rehabilitation therapy has recently become more well established. In a cohort of athletes with SRC, the authors sought to 1) assess the relationship between symptoms at the initial clinic visit and time to referral for vestibular therapy, and 2) evaluate whether earlier referral to vestibular therapy was associated with faster recovery, as defined as days to return to learn (RTL), symptom resolution (SR), and return to play (RTP).

METHODS

A retrospective cohort study was conducted using a regional multidisciplinary concussion center’s database. Patients aged 12–23 years diagnosed with SRC who received vestibular rehabilitation therapy between October 2017 and October 2021 were included. Demographics and Post-Concussion Symptom Scale (PCSS) scores were extracted. The independent variable of interest was time to vestibular therapy referral. The three outcome variables were RTL, SR, and RTP. Spearman’s rho correlation (rho) was used to evaluate the relationship between total PCSS score and individual symptoms (balance problems, blurred vision, and dizziness) and time to referral for vestibular therapy. Multivariable linear regression was performed to determine the impact of time to vestibular therapy on the three outcomes of RTL, SR, and RTP. Covariates included initial symptom burden, age, and prior concussions.

RESULTS

Forty-two concussed athletes were referred for vestibular therapy (mean age 16.8 ± 2.7 years; 54.8% female). The mean time from concussion to the initial clinic visit was 22.4 ± 20.2 days, and the mean time from the initial clinic visit to vestibular therapy referral was 4.9 ± 11.3 days. Initial total PCSS scores (rho[37] = 0.05, p = 0.78) and individual symptoms, including balance problems (rho[33] = −0.004, p = 0.98), blurred vision (rho[34] = −0.17, p = 0.33), and dizziness (rho[33] = 0.07, p = 0.67), were not correlated with time to referral for vestibular therapy. Multivariable linear regression analysis found that earlier vestibular therapy referral was predictive of shorter days to SR (p = 0.002) and RTP (p = 0.02) but not RTL (p = 0.59).

CONCLUSIONS

In athletes with SRC referred for vestibular therapy, earlier vestibular therapy referral was significantly associated with faster time to RTP and SR. Future investigations should focus on identifying common postconcussive signs and symptoms that serve as indications for referral to vestibular therapy.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Editorial. The glymphatic system imagined and now imaged: what is it, and why is it important?

Mark G. Hamilton

In Journal of Neurosurgery Publish Before Print

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Establishment and multicenter external validation of a risk prediction model for de novo intracranial aneurysms based on a systematic review and meta-analysis of 19 cohorts

Jiahe Tan, Rui Song, Jun Su, Hongyu Wu, Wenqiao Fu, Yinrui Ma, and Zhaohui He

OBJECTIVE

A de novo intracranial aneurysm (IA) is a second, new IA that develops in patients with IAs distant from where the initial IA was detected. This study aimed to identify risk factors for de novo IA formation and establish and externally validate a multicenter risk prediction model for de novo IAs.

METHODS

A systematic review and meta-analysis of existing de novo IA cohorts was conducted to form the derivation cohort. The risk ratios and 95% CIs of each risk factor were calculated. In addition, risk scores included in the model were calculated based on the statistically significant risk factors with their weightings. Then the model was validated in a multicenter external cohort of Chinese patients, and receiver operating characteristic and calibration curves, decision curve analysis, and Kaplan-Meier curves were used to evaluate the model.

RESULTS

Nineteen studies with 9351 patients, of whom 304 patients (3.25%) developed de novo IAs, were included in the derivation cohort. These patients developed de novo IAs at 2.5–18.5 years during a total follow-up of 3.3–18.8 years. The statistically significant risk factors were age < 60 years, female sex, smoking history, family history of IAs, multiple IAs at initial diagnosis, and initial IAs in the middle cerebral artery, with risk scores of 4, 5, 2, 6, 3, and 3, respectively. Then, a multicenter external cohort comprising 776 patients, of whom 45 patients (5.80%) developed de novo IAs, was included in the validation cohort. De novo IAs formed in these patients at a mean of 5.25 years during a mean follow-up of 6.19 years. The area under the curve of the model was 0.804, with a sensitivity of 0.667 and specificity of 0.900, at a cutoff value of 13. The calibration curve, decision curve analysis, and Kaplan-Meier curves also indicated good performance of the model.

CONCLUSIONS

This prediction model is a convenient and intuitive tool for identifying high-risk patients with de novo IAs. Reasonable use of the model can not only aid in clinical decision-making but also play a positive role in the prevention of aneurysmal subarachnoid hemorrhage to a certain extent.

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. An opportunity to reflect on our textbook content for pediatric functional neurosurgery

Maryam N. Shahin, Melissa A. LoPresti, and Jeffrey S. Raskin

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Letter to the Editor. Potential confounding variables when assessing racial disparities in outcomes after MVD for TN

Travis S. CreveCoeur, Raviteja Bethamcharla, Michael S. Gold, Wolfgang B. Liedtke, and Raymond F. Sekula Jr.

In Journal of Neurosurgery Publish Before Print

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The life and legacy of John Robert Cobb: the man behind the angle

Kathleen S. Botterbush, Justin K. Zhang, Pranav S. Chimakurty, Philippe Mercier, and Tobias A. Mattei

In 1934, Dr. John Robert Cobb moved to New York to serve as the Gibney Orthopedic Fellow at the Hospital for the Ruptured and Crippled, now known as the Hospital for Special Surgery. In this role, Cobb was faced with a unique task that would shape not only his personal career but also the fields of scoliosis and spine care: to design the first scoliosis specialty clinic. He critically reviewed the treatment methods for scoliosis outlined by prior pioneers in spine surgery and kept his own meticulous records of diagnoses, treatments, and radiographs. Cobb’s work culminated in major contributions to spine surgery that are highly relevant to this day, including the Cobb angle and the Cobb elevator. In this detailed analysis of the career and academic legacy of Dr. John R. Cobb, the authors examine in detail the historical events surrounding Cobb’s great contributions to spine surgery and their lasting impact on our specialty, as well as unique aspects of his personal life. This historical vignette constitutes the first comprehensive analysis of the life, career, and academic legacy of Dr. John R. Cobb, the man behind the angle.

In Journal of Neurosurgery: Spine Publish Before Print

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Long-term outcomes after conservative and EDAS treatment for 111 elderly patients with moyamoya disease: longitudinal and cross-sectional study

Jing-Jie Li, Xiao-Peng Wang, Qian-Nan Wang, Xiang-Yang Bao, Qing-Bao Guo, Zi-Qing Kong, Gan Gao, Min-Jie Wang, Si-Meng Liu, He-Guan Fu, Qian Zhang, and Lian Duan

OBJECTIVE

This study aimed to explore the clinical features of moyamoya disease (MMD) and the efficacy of encephaloduroarteriosynangiosis (EDAS) in elderly patients with MMD and to identify the risk factors for long-term stroke events.

METHODS

Clinical data were retrospectively collected on elderly patients with MMD (age ≥ 60 years) who had been treated at the authors’ center from May 2007 to December 2017. Clinical features, angiographic findings, and long-term outcomes (> 5-year follow-up) were analyzed. Cox regression analysis was performed to determine the risk factors for postoperative stroke events. Long-term stroke events were analyzed using Kaplan-Meier curves.

RESULTS

The mean age at symptom onset was 62.9 ± 3.0 years among 111 elderly patients with MMD. Vascular comorbidities were present in 80 (72.1%) patients. The ratio of female to male patients was 1:1.2. Familial MMD was found in 7 (6.3%) patients. Cerebral ischemia was the most common clinical manifestation observed in 82 (73.9%) patients. Most patients (59.5%) presented with Suzuki stages 5 and 6 MMD, and 29 (26.1%) patients presented with stenosis or occlusion of the posterior circulation. Unilateral MMD was present in 17 (15.3%) patients. Among the 58 (52.3%) patients who underwent EDAS, 28 (48.3%) and 30 (51.7%) underwent bilateral and unilateral surgeries, respectively. Overall, 53 (47.7%) patients were treated conservatively using internal medicine. After a median follow-up duration of 8.2 years, stroke incidence in the EDAS and conservative treatment groups was respectively 17.2% (7 and 3 cases of cerebral infarction and hemorrhage, respectively) and 49.1% (22 and 4 cases of cerebral infarction and hemorrhage, respectively). The stroke incidence rate was higher in the conservative group than in the EDAS group, with a statistically significant difference (p = 0.001) according to results of the Kaplan-Meier analysis. The identified predictor of postoperative stroke events was initial hemorrhage in the EDAS group and advanced age, aneurysm, and initial ischemia in the conservative treatment group.

CONCLUSIONS

The postoperative long-term stroke rate among elderly patients with MMD was lower in the EDAS group than in the conservative treatment group. Long-term stroke events were associated with advanced age, aneurysm, and initial ischemia after conservative treatment and only initial hemorrhage after EDAS.

In Journal of Neurosurgery Publish Before Print

Open access

Noninvasive assessment of glymphatic dysfunction in idiopathic normal pressure hydrocephalus with diffusion tensor imaging

Charalampos Georgiopoulos, Anders Tisell, Rafael T. Holmgren, Andreas Eleftheriou, Johanna Rydja, Fredrik Lundin, and Lovisa Tobieson

OBJECTIVE

Diffusion tensor imaging (DTI) along the perivascular space (ALPS) (DTI-ALPS)—by calculating the ALPS index, a ratio accentuating water diffusion in the perivascular space—has been proposed as a noninvasive, indirect MRI method for assessing glymphatic function. The main aim of this study was to investigate whether DTI-ALPS would reveal glymphatic dysfunction in idiopathic normal pressure hydrocephalus (iNPH) and whether the ALPS index was associated with disease severity.

METHODS

Thirty iNPH patients (13 men; median age 77 years) and 27 healthy controls (10 men; median age 73 years) underwent MRI and clinical assessment with the Timed Up and Go test (TUG) and Mini-Mental State Examination (MMSE); only the patients were evaluated with the Hellström iNPH scale. MRI data were analyzed with the DTI-ALPS method and Radscale screening tool.

RESULTS

iNPH patients showed significantly lower mean ALPS index scores compared with healthy controls (median [interquartile range] 1.09 [1.00–1.15] vs 1.49 [1.36–1.59], p < 0.001). Female healthy controls showed significantly higher ALPS index scores than males in both hemispheres (e.g., right hemisphere 1.62 [1.47–1.67] vs 1.33 [1.14–1.41], p = 0.001). This sex difference was not seen in iNPH patients. The authors found a moderate exponential correlation between mean ALPS index score and motor function as measured with time required to complete TUG (r = −0.644, p < 0.001), number of steps to complete TUG (r = −0.571, p < 0.001), 10-m walk time (r = −0.637, p < 0.001), and 10-m walk steps (r = −0.588, p < 0.001). The authors also found a positive linear correlation between mean ALPS index score and MMSE score (r = 0.416, p = 0.001). Simple linear regression showed a significant effect of diagnosis (B = −0.39, p < 0.001, R2 = 0.459), female sex (B = 0.232, p = 0.002, R2 = 0.157), and Evans index (B = −4.151, p < 0.001, R2 = 0.559) on ALPS index. Multiple linear regression, including diagnosis, sex, and Evans index score, showed a higher predictive value (R2 = 0.626) than analysis of each of these factors alone.

CONCLUSIONS

The ALPS index, which was significantly decreased in iNPH patients, could serve as a marker of disease severity, both clinically and in terms of neuroimaging. However, it is important to consider the significant influence of biological sex and ventriculomegaly on the ALPS index, which raises the question of whether the ALPS index solely reflects glymphatic function or if it also encompasses other types of injury. Future studies are needed to address potential confounding factors and further validate the ALPS method.

In Journal of Neurosurgery Publish Before Print

Open access

Normal growth curve of choroid plexus in children: implications for assessing hydrocephalus due to choroid plexus hyperplasia

Hiroaki Hashimoto, Osamu Takemoto, Keisuke Nishimoto, Gento Moriguchi, Motoki Nakamura, and Yasuyoshi Chiba

OBJECTIVE

Pediatric hydrocephalus requires evaluation while accounting for growth of the intracranial structures, but information on choroid plexus growth in children is lacking. This study aimed to create normal growth curves for intracranial volume, choroid plexus volume, and lateral ventricles volume. Additionally, the authors aimed to objectively assess the degree of hydrocephalus caused by choroid plexus hyperplasia (CPH) and to examine the impact of surgical procedures.

METHODS

This retrospective study analyzed the head CT scans of pediatric patients with minor head trauma treated at Osaka Women’s and Children’s Hospital between March 2006 and May 2023. The study segmented and calculated intracranial, choroid plexus, and lateral ventricles volumes. The study also calculated the correlation coefficients among these 3 parameters. Patients aged 0 to 10 years were divided into 15 age-related clusters, and mean ± SD values were calculated for each cluster. Growth curves were created by plotting mean values sequentially. Volume obtained from patients with CPH were z-normalized using mean and SD values and compared.

RESULTS

A total of 229 CT scans (94 from females) were analyzed, and positive correlations were observed among intracranial volume, choroid plexus volume, and lateral ventricles volume, with the strongest correlation between the choroid plexus and lateral ventricles volumes. The growth rate of intracranial volume was rapid until approximately 20 months of age, while those of choroid plexus volume and lateral ventricles volume increased rapidly until approximately 1 year of age. Subsequently, choroid plexus volume and lateral ventricles volume plateaued at 1.5 ml and 10 ml, respectively. Three patients with CPH were enrolled and quantitatively evaluated on the basis of the z-normalized volume. Notable abnormal volumes of the choroid plexus (range z-normalized values 24.11–51.17) and lateral ventricles (46.78–122.36) were observed. In 2 patients, improvements in the z-normalized values of intracranial volume and lateral ventricles volume were observed after surgical interventions. Additionally, in 1 patient, choroid plexus volume was reduced by approximately 24% (range z-normalized values 51.17–38.93) after bilateral endoscopic plexus coagulation.

CONCLUSIONS

This study provides normal growth curves for intracranial volume, choroid plexus volume, and lateral ventricles volume. Knowledge of these normal values holds the potential for objective assessment of abnormal values associated with hydrocephalus and choroid plexus diseases such as CPH.

In Journal of Neurosurgery: Pediatrics Publish Before Print