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Acute low-pressure hydrocephalus in aneurysmal subarachnoid hemorrhage

Patrick Czorlich, Nils Schweingruber, Jennifer Göttsche, Marius M. Mader, and Manfred Westphal

OBJECTIVE

Acute and chronic hydrocephalus are common pathologies after aneurysmal subarachnoid hemorrhage (SAH). Generally, the presence of acute hydrocephalus is associated with elevated intracranial pressure (ICP) treated with a ventricular drain. Subsequently, however, pronounced hydrocephalus without elevated ICP may develop in some patients with SAH in the postacute phase. This is described as acute low-pressure hydrocephalus (aLPH), and there are very limited data in the literature of this pathology. The aim of this study was to evaluate the rate of and factors associated with aLPH and describe its clinical course.

METHODS

In this retrospective single-center cohort study, the frequency and clinical characteristics of SAH-associated aLPH were investigated. Acute LPH was defined as an increase in ventricular size as measured by the Evans index, ICP within the normal range (< 5 mm Hg) at the time of ventricular enlargement, and timely neurological improvement after indwelling ventricular CSF drainage with negative pressure up to 5 cm H2O below normal level. Demographic and SAH-specific factors in patients with SAH treated using an external ventricular drain were extracted from the electronic medical chart and further analyzed.

RESULTS

From November 2010 to May 2020, 15 (3.7.%) of 406 patients with SAH fulfilled the criteria for aLPH. Acute LPH was diagnosed after an average of 13.1 ± 7.7 days. The presence of IVH and its extension were associated with the occurrence of aLPH. After undergoing the transient phase of aLPH, these patients subsequently developed a chronic, typical malresorptive hydrocephalus requiring a ventriculoperitoneal shunt more often (66.7% vs 17.4%, p < 0.001) and stayed longer in the intensive care unit (27 vs 20.5 days, p = 0.043) and in the hospital (36.4 vs 26.3 days, p = 0.004).

CONCLUSIONS

Acute LPH is a rare pathology in patients with SAH and negatively impacts the clinical course. It should be especially considered in patients with a lack of neurological improvement, an increase in ventricular width, and normal ICP values, so that forced CSF drainage is implemented.

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes

Free access

Characteristics of shunt failure in 38,095 adult shunt insertion surgeries: a systematic review and meta-analysis

Albert M. Isaacs, Runze Yang, Magalie Cadieux, David Ben-Israel, Nicholas Sader, Michael Opoku-Darko, Leonardo Frizon, Heather Yong, Zahra Premji, Sean Nagel, Mark G. Hamilton, and

OBJECTIVE

The management of excess CSF in patients with hydrocephalus typically requires using a shunt to divert CSF. Unfortunately, there is a high rate of shunt failure despite improvements in device components and insertion techniques. Reoperation is frequently necessary, which contributes to patient harm and increased healthcare costs. While factors affecting shunt failure are well defined in the pediatric population, information regarding adults is lacking. The authors undertook a systematic review and meta-analysis to determine how shunt failure in the adult population is reported and investigated the etiologies of shunt failure.

METHODS

This review is reported according to PRIMSA and utilized the MEDLINE, Embase, and Google Scholar databases. Abstracts were screened by two independent reviewers, and data were extracted in duplicate by two independent reviewers. Statistical analyses were performed using SPSS and Stata.

RESULTS

The pooled rates of shunt failure were 10% (95% CI 5%–15%) in studies with a mean follow-up time of less than 1 year, 12% (95% CI 8%–14%) with a follow-up time between 1 and 2 years, and 32% in studies with a follow-up time of 2 years or greater (95% CI 19%–43%). The pooled rate of failure was 17% across all studies. The most common cause of shunt failure was obstruction at 3.0% (95% CI 2%–4%), accounting for 23.2% of shunt failures. Infection was the second most common at 2.8% (95% CI 2%–3%), accounting for 22.5% of shunt failures. The most common location of shunt failure was the distal catheter, with a failure rate of 4.0% (95% CI 3%–5%), accounting for 33.4% of shunt failures. The definition of shunt failure was heterogeneous and varied depending on institutional practices. The combination of symptoms with either CT or MRI was the most frequently reported method for assessing shunt failure.

CONCLUSIONS

Important variation regarding how to define, investigate, and report shunt failure was identified. The overall shunt failure rate in adults is at least 32% after 2 years, which, while lower than that typically reported in the pediatric population, is significant. The most common causes of shunt failure in adults are infection and obstruction. The most common site of failure occurred at the distal catheter, highlighting the need to develop strategies to both report and mitigate distal shunt failure in adult shunt patients.

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes

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CSF dynamics in long-standing overt ventriculomegaly in adults

Alessandro Pirina, Ignacio Jusue-Torres, Virginie Desestret, Luca Albini Riccioli, Emmanuel Jouanneau, Giorgio Palandri, and Romain Manet

OBJECTIVE

Long-standing overt ventriculomegaly in adults (LOVA) is a form of chronic hydrocephalus and its pathophysiology and treatment remain debated. An analysis of CSF dynamics in this condition has rarely been reported. The aim of this study was to analyze hydrodynamic characteristics of patients with suspected LOVA to discuss its pathophysiological mechanisms and the importance of CSF dynamics analysis for diagnosis and treatment of these patients.

METHODS

This retrospective cohort study, conducted between May 2018 and October 2022, included adult patients aged > 18 years investigated in a department of neurosurgery through a lumbar infusion study for suspicion of LOVA (n = 23). These patients were then compared with a control cohort explored for suspicion of idiopathic normal pressure hydrocephalus (iNPH; n = 30). Clinical symptoms, radiological findings, and hydrodynamic parameters were analyzed. The authors specifically compared two hydrodynamic parameters: resistance to CSF outflow, or Rout, which relies on CSF resorption, and pressure-volume index (PVI), which reflect overall craniospinal compliance. The lumbar infusion study was considered pathological (confirming the diagnosis of chronic hydrocephalus) when at least one of these two parameters was altered.

RESULTS

Rout was significantly less frequently increased (cutoff ≥ 12 mm Hg/ml/min) in patients with LOVA (52%) than in those with iNPH (97%; p < 0.001). In contrast, PVI was impaired (cutoff ≤ 25 ml) in both cohorts, i.e., in 61% of patients with LOVA and in 83% of patients with iNPH. Overall, the rate of pathological lumbar infusion study in LOVA (87%) was not statistically different than in iNPH (100%). However, PVI was the only impaired parameter most frequently found in those with LOVA (35%) compared with those with iNPH (3%; p = 0.002).

CONCLUSIONS

This study suggests that there is a differential CSF dynamics pattern when comparing patients with LOVA versus those with iNPH. A higher proportion of patients with LOVA showed isolated compliance impairment. These findings highlight the utility of CSF dynamics analysis for the evaluation of patients with suspected chronic obstructive hydrocephalus such as LOVA. Future research with larger case series may help define diagnosis and treatment algorithms of chronic obstructive hydrocephalus based on CSF dynamics analysis, in addition to clinical and radiological criteria.

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes

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Editorial. Weaning external ventricular drains after aneurysmal subarachnoid hemorrhage: how should we measure success?

Mark G. Hamilton

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes

Open access

Endoscopic fenestration of an enlarging giant occipital arachnoid cyst

Rachel Blue, Jaskeerat Gujral, Hasan S. Ahmad, and Omar Choudhri

This case demonstrates an endoscopic fenestration of an enlarging giant occipital arachnoid cyst. The patient is a 42-year-old woman presenting with headache, progressive vision loss, and nausea and vomiting. MRI demonstrates a large, nonenhancing cystic lesion in the right occipital lobe measuring up to 8.3 cm, consistent with an arachnoid cyst. This surgical video illustrates the technique for an endoscopic fenestration into the native ventricular system utilizing stereotactic MRI-guided stealth navigation. Postoperatively, the patient had full recovery with improvement of headaches and vision and was discharged on postoperative day 1 without complications.

The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22129

In Neurosurgical Focus: Video Volume 8: Issue 2 (Apr 2023): Intraventricular Endoscopic Surgery

Open access

Endoscopic transventricular resection of a colloid cyst

Sebastian Lehmann and Henry W. S. Schroeder

This video demonstrates the purely endoscopic gross-total resection of a third ventricle colloid cyst that is partially covered by a large thalamostriate vein. To gain an ideal approach, the initial trajectory pointed to the interventricular septum above the cyst. After the head of the caudate nucleus is passed, it is retracted laterally by the endoscopic sheath for the ideal far lateral approach to the cyst. Using a pneumatic endoscope holder enables the surgeon to perform the procedure bimanually. After complete removal of the cyst, postoperative inspection confirms the intact fornix, veins, and caudate nucleus without signs of pressure-related damage.

The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22140

In Neurosurgical Focus: Video Volume 8: Issue 2 (Apr 2023): Intraventricular Endoscopic Surgery

Open access

Endoscopic ultrasonic resection of calcified tumor of the third ventricle

Pietro Spennato, Nicola Onorini, Francesca Vitulli, Alessia Imperato, Lucia De Martino, Claudio Ruggiero, and Giuseppe Cinalli

In this video, the authors present ultrasonic resection of calcified tumor of the third ventricle in a 12-year-old boy. He presented to the emergency department with a 1-week history of headache, drowsiness, and bilateral papilledema. Despite extensive calcification visible on a CT scan, a minimally invasive pure endoscopic approach was chosen. The use of an ultrasonic aspirator allows fast and safe removal of the tumor. The histological diagnosis was a low-grade glioneuronal tumor. In conclusion, the endoscopic ultrasonic aspirator is a useful tool to resect tumors in the ventricular system. The presence of calcifications within the tumor does not contraindicate an endoscopic approach.

The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22143

In Neurosurgical Focus: Video Volume 8: Issue 2 (Apr 2023): Intraventricular Endoscopic Surgery

Open access

Feasibility of extended transforaminal approach (medial subchoroid) for resection of a benign aqueductal tumor in a patient with type 1 neurofibromatosis

Jose M. Narro-Donate, Jose J. Guil-Ibañez, Maria José Castelló-Ruiz, Fernando García-Pérez, Gaizka Urreta-Juarez, and José Masegosa-González

The extended transforaminal endoscopic approach allows visualization and manipulation of the third ventricle posterior structures in a safe and comfortable manner. The medial subchoroidal approach has been described as a feasible alternative to the classical transchoroidal approach.

In this video, the authors present the case of a 14-year-old male with a history of neurofibromatosis type 1 who was referred to our department after presenting with headaches and diplopia for 2 weeks. Suspecting an aqueduct tumor, the authors performed an endoscopic surgical procedure through a single approach with third cisternostomy and resection of the tumor that produced the stenosis.

The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22155

In Neurosurgical Focus: Video Volume 8: Issue 2 (Apr 2023): Intraventricular Endoscopic Surgery

Free access

The impact of cerebrospinal fluid shunting on quality of life in idiopathic normal pressure hydrocephalus: a long-term analysis

Giovanni Grasso and Fabio Torregrossa

OBJECTIVE

Idiopathic normal pressure hydrocephalus (iNPH) represents an insidious type of dementia considered reversible after shunt placement. Although the clinical outcome has been widely studied, few studies have reported on quality of life (QOL) after surgery. This study evaluated the long-term clinical and QOL outcomes of iNPH patients after ventriculoperitoneal shunt (VPS) implantation. Factors influencing QOL in iNPH were also investigated.

METHODS

From 2009 to 2020, a single-institution retrospective study was conducted to compare shunted iNPH patients with a homogeneous control group. QOL was analyzed using the SF-36 questionnaire with yearly follow-up for as long as 11 years. Severity of symptoms, comorbidities, and clinical data were also recorded.

RESULTS

Among 187 treated patients, 15 had died at the time of the authors’ evaluation, and 45 did not match the inclusion criteria. The mean ± SD (range) follow-up was 118.5 ± 4.2 (18–132) months. QOL improved in 103/130 (79%) patients through 5 years after shunt surgery, although it remained lower than that of the control group (p < 0.0001). The SF-36 score reduced progressively, reaching baseline at 5–7 years of follow-up and decreased to below baseline at 7–11 years of follow-up (p < 0.0001). Predictors of improved QOL were younger age (p < 0.001), lower body mass index (BMI) (p < 0.001), and better Mini-Mental State Examination (MMSE) performance (p < 0.001) before surgery. Decreased postoperative QOL was associated with cerebrovascular disease, diabetes, and severity of symptoms (gait and cognition) at presentation (p < 0.001).

CONCLUSIONS

VPS implantation, along with a strict and comprehensive follow-up, has been shown to improve QOL in iNPH patients for as long as 5 years after surgery. Younger age, lower BMI, and better MMSE score are positive predictors of improved QOL after shunt placement.

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes

Free access

Introduction. Adult hydrocephalus: advancements in diagnosis, treatment, and patient outcomes

Mark G. Hamilton, Hanna Israelsson, Giorgio Palandri, Benjamin D. Elder, and Michael A. Williams

In Neurosurgical Focus Volume 54 (2023): Issue 4 (Apr 2023): Adult Hydrocephalus: Advancements in Diagnosis, Treatment, and Patient Outcomes