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Objective: This study compared the clinical therapeutic efficacy of syringo-subarachnoid shunt placement with direct tube and T-tube via the dorsal root entry zone (DREZ) approach for treatment of eccentric syringomyelia., Methods: A retrospective study was performed of 41 patients with idiopathic or secondary eccentric syringomyelia from November 2011 to December 2022. Syringo-subarachnoid shunt placement with direct tube or T-tube via the DREZ approach was performed. The modified Japanese Orthopaedic Association low back pain scale was used to investigate the severity of clinical symptoms. Magnetic resonance imaging was used to investigate therapeutic efficacy（reduction of the cavity volume by >10% was considered an improvement and 50% was considered a significant improvement)., Results: Incision length of the spinal cortex in the direct tube group was shorter than in the T-tube group (3.10 ± 0.28 cm vs. 5.03 ± 0.19 cm), with a significant difference between the 2 groups (t = -52.56, P < 0.001). Modified Japanese Orthopaedic Association score 3 months postoperatively was significantly better than the preoperative score in both the direct tube group（t = 40.954, P < 0.001） and the T-tube group（t = 24.769, P < 0.001）. Statistical comparison revealed there was no difference in imaging improvement between the direct tube group and T-tube group 3 months (χ 2  = 0.20, P = 0.655) and 12 months (χ 2  = 0.21, P = 0.647) postoperatively., Conclusions: Syringo-subarachnoid shunt placement with direct tube via the DREZ approach for treatment of eccentric syringomyelia is safer than with T-tube via the DREZ approach due to smaller incision length and less of a space-occupying effect with same therapeutic efficacy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Idiopatic normal pressure hydrocephalus (iNPH) is a progressive neurologic syndrome featured by the triad of gait disturbance, mental deterioration and urinary incontinence, associated with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. The clinical presentation may be atypical or incomplete, or mimicked by other diseases, so conventional neuroradiologic imaging plays an important role in defining this pathology. iNPH pathophysiologic mechanisms have not yet been fully elucidated, although several studies have demonstrated the involvement of the glymphatic system, a highly organized fluid transport system, the malfunction of which is involved in the pathogenesis of several disorders including normotensive hydrocephalus., Methods: Recent studies have shown how crucial in the diagnosis of this pathology is the definition of morphologic biomarkers, such as ventricular enlargement disproportionate to cerebral atrophy and associated ballooning of frontal horns; periventricular hyperintensities; and corpus callosum thinning and elevation, with callosal angle <90 degrees., Results: Another interesting feature that is becoming a well-recognized factor to look for and useful for the diagnosis of iNPH is disproportionately enlarged subarachnoid space hydrocephalus, which includes enlarged ventricles, tight high-convexity and medial surface subarachnoid spaces, and expanded Sylvian fissures. A correct choice of MRI sequences is important for a proper characterization identification of others diseases that may underlie this pathology. Magnetic resonance imaging allows us to evaluate CSF flow, enabling us to define qualitative and quantitative parameters necessary for the purpose of accurate iNPH diagnosis., Conclusions: iNPH can represent a real diagnostic challenge; a proper correlation among clinical features, traditional MRI, and CSF dynamics analysis can lead to a correct diagnosis., (Copyright © 2023. Published by Elsevier Inc.)

Objective: The presence of tightened sulci in the high-convexities (THC) is a key morphological feature for the diagnosis of idiopathic normal pressure hydrocephalus (iNPH), but the exact localization of THC has yet to be defined. The purpose of this study was to define THC and compare its volume, percentage, and index between iNPH patients and healthy controls., Methods: According to the THC definition, the high-convexity part of the subarachnoid space was segmented and measured the volume and percentage from the 3D T1-weighted and T2-weighted magnetic resonance images in 43 patients with iNPH and 138 healthy controls., Results: THC was defined as a decrease in the high-convexity part of the subarachnoid space located above the body of the lateral ventricles, with anterior end on the coronal plane perpendicular to the anterior commissure-posterior commissure (AC-PC) line passing through the front edge of the genu of corpus callosum, the posterior end in the bilateral posterior parts of the callosomarginal sulci, and the lateral end at 3 cm from the midline on the coronal plane perpendicular to the AC-PC line passing through the midpoint between AC and PC. Compared to the volume and volume percentage, the high-convexity part of the subarachnoid space volume per ventricular volume ratio < 0.6 was the most detectable index of THC on both 3D T1-weighted and T2-weighted magnetic resonance images., Conclusions: To improve the diagnostic accuracy of iNPH, the definition of THC was clarified, and high-convexity part of the subarachnoid space volume per ventricular volume ratio <0.6 proposed as the best index for THC detection in this study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Traumatic subarachnoid-pleural fistula is an uncommon occurrence. We present a case of a patient sustaining a subarachnoid-pleural fistula after a gunshot wound to the neck, which ultimately resulted in substantial pneumocephalus. The patient underwent successful operative repair of the fistula with notable improvement and resolution of pneumocephalus., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Benign Enlargement of the Subarachnoid Spaces in Infancy (BESSI) is a common finding during workup for progressive macrocephaly. BESSI has been associated with slightly higher prevalence of subdural (SD) spaces and a risk for developing subdural hematoma. This study utilizes fast brain magnetic resonance imaging (MRI) to investigate the prevalence of visible SD spaces in BESSI., Methods: A retrospective review was performed for all pediatric patients who underwent brain MRI for macrocephaly. Patients with a diagnosis of BESSI were included in the study. A total of 109 patients met the inclusion criteria. Patient demographics were collected, and images were reviewed for size of subarachnoid, visible SD spaces, and ventricle size. Descriptive and inferential statistics were performed., Results: The average age was 8 ± 4.6 months, 64 (59%) were male, and 55 patients had no previous medical history (50%). Sixty-seven percent of all patients were identified to have visible SD spaces. Eleven patients had confirmed SD hematomas; 1 patient was deemed to have abusive head trauma. Visible SD spaces were associated with younger age (6.9 months). Thirty-one patients with visible SD spaces had follow-up MRI, with complete resolution by 33 months., Conclusions: BESSI is a self-limiting pathology that has been associated with visible SD spaces and potential risk for SD hemorrhages. We report a high prevalence of visible SD spaces within BESSI through utilization of fast brain MRI. These spaces may contribute to the higher rate of incidental subdural hematoma in this population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Areas of contrast accumulation (CA) are commonly found on routine computed tomography (CT) performed immediately after thrombectomy. In the present study, we investigated the types of CA associated with the different outcomes, including symptomatic intracranial hemorrhage (sICH)., Methods: The present study analyzed the data from 145 patients with anterior circulation stroke who had undergone non-contrast-enhanced conventional CT immediately after thrombectomy. The following variables were investigated: collateral status, failure of recanalization, Alberta stroke program early CT score (ASPECTS) applied to CA lesions and diffusion-weighted imaging infarct lesions, and sICH., Results: Of the 145 patients, 102 (70.3%) had CA lesions. All types of CA (any CA, cortical CA, subarachnoid CA, and CA ASPECTS) were significantly associated with poor outcomes (modified Rankin scale score >2). In particular, subarachnoid CA (odds ratio, 23.994; 95% confidence interval, 4.696-122.589) and CA ASPECTS (odds ratio, 0.550; 95% confidence interval, 0.404-0.750) were independently associated with sICH. Patients with subarachnoid CA had poorer collateral status and a larger final infarct size than those without subarachnoid CA, although the initial National Institutes of Health stroke scale score and recanalization rate were comparable between the 2 groups. A CA ASPECTS of ≤5 predicted sICH with a sensitivity of 66.7% and a specificity of 92.6% (area under the curve, 0.854)., Conclusions: Our data suggest that a subarachnoid CA location and CA ASPECTS are predictors of sICH. In particular, a subarachnoid location of CA might signify damage of the subarachnoid collateral arteries, leading to a larger infarct., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cerebrovascular disease is the fifth cause of mortality in Puerto Rico. There is no descriptive study for the presentation of spontaneous subarachnoid hemorrhage (SAH) in our institution. Therefore, our primary aim was to perform a retrospective analysis of adult patients with spontaneous SAH and assess the need for digital subtraction angiography (DSA) after initially aneurysm-negative computed tomography angiography (CTA) in nonaneurysmal SAH, specifically perimesencephalic SAH (PM-SAH)., Methods: Medical records of 324 adult patients with aneurysmal and nonaneurysmal SAH treated at the Puerto Rico Medical Center from 2015 to 2018 were retrospectively analyzed. Demographics, past medical history, clinical characteristics, and imaging information were extracted., Results: Acute hydrocephalus, mortality at 30 days, prevalence of diffuse SAH pattern, and Fisher and World Federation of Neurosurgical Societies grades >2 on initial examination were higher in the aneurysmal SAH subgroup. Patients with nonaneurysmal SAH had a significantly higher prevalence of chronic kidney disease and diabetes mellitus. Of the patients with nonaneurysmal PM-SAH with initial aneurysm-negative CTA, 100% were subsequently confirmed by DSA., Conclusions: Patients in the aneurysmal SAH subgroup correlated with an increased disease burden. Furthermore, this study shows that in our population, patients with nonaneurysmal PM-SAH with a low Fisher and World Federation of Neurosurgical Societies grade and with comorbid diabetes mellitus and chronic kidney disease may not need DSA after a negative initial CTA result., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Rupture of the spinal dermoid is rare. There may be intracranial deposition of fat secondary to it. We report a case of an adult male who presented with features of obstructive hydrocephalus secondary to ruptured lumbar dermoid. A 42-year-male presented with acute-onset headache and vomiting for 2 days. There was grade 3 papilledema on fundus examination. Magnetic resonance imaging showed ventriculomegaly with aqueductal obstruction. Multiple T1 and T2 hyperintense deposits were also noted along the ventricular wall. Magnetic resonance imaging of the spine showed a T1, T2 hyperintense intramedullary lesion at the lumbar region with multiple fat deposits along the spinal axis. He underwent endoscopic third ventriculostomy and is doing well at the 6-month follow-up. He is asymptomatic for the spinal lesion. Silent rupture of the spinal dermoid causing obstructive hydrocephalus is rare. These patients may remain asymptomatic for the spinal lesion and improves with cerebrospinal fluid diversion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Diagnosis of idiopathic normal pressure hydrocephalus is based in clinical data, radiologic variables, and invasive cerebrospinal fluid (CSF) testing, such as the lumbar infusion test. Several neuroimaging findings are inconclusively related to improvement after CSF shunt surgery. CSF tests are invasive and have complications. The aim of this study was to select radiologic variables related to a positive lumbar infusion test so as to avoid this test in patients., Methods: Patients with possible idiopathic normal pressure hydrocephalus were reviewed. The collected radiologic data were cingulate sulcus sign, disproportionately enlarged subarachnoid space, callosal angle, and width of temporal horns. Two groups were established: group 1, comprising patients with resistance to CSF outflow <12 mm Hg/mL/minute, and group 2, comprising patients with resistance to CSF outflow >12 mm Hg/mL/minute. Negative and positive predictive values were determined., Results: The study included 43 patients in group 1 and 64 patients in group 2. Group 2 significantly showed more acute callosal angle with higher accuracy cutoff value of 90.6°, lower width of temporal horns with higher accuracy cutoff value of 8 mm, and higher percentage of cingulate sulcus sign and disproportionately enlarged subarachnoid space. Matching the radiologic variables, positive predictive values were >80%; however, negative predictive values were low., Conclusions: Owing to high positive predictive values of matched radiological variables, the lumbar infusion test could be avoided in the diagnosis of idiopathic normal pressure hydrocephalus. However, when 1 or 2 of the variables are negative, this invasive test should be performed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A 34-year-old right-handed female presented to the emergency department with a worsening headache, neck stiffness, intermittent abnormal sensation, and right arm weakness. Shortly after arrival, she had a generalized tonic-clonic seizure. A noncontrast head computed tomography scan revealed a right-sided, low-attenuating, lobulated mass ipsilateral to her arm symptoms. Magnetic resonance imaging revealed an abnormal signal throughout the subarachnoid space and increased fluid-attenuated inversion recovery sequence signal contralateral to the mass. This presentation suggested a false localization sign of sensory and motor disturbance ipsilateral to the mass likely caused by cyst rupture and sebum spread contralateral, causing cortical irritation (evidenced by increased fluid-attenuated inversion recovery sequence signal). During mass resection, sebum was visible throughout the subarachnoid space. The patient had an uneventful recovery from surgery and has been seizure free since the resection with steady improvement of symptoms. This case highlights the importance of avoiding cyst rupture of dermoid cysts., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Perivascular spaces (PVS), also known as Virchow-Robin spaces, are pial-lined, interstitial fluid-filled structures in the brain that accompany cerebral vessels as they penetrate the cerebral substance. In healthy individuals, a PVS diameter of <2 mm is considered normal and can typically be seen within the white matter on magnetic resonance imaging (MRI). When PVS dilate, they are considered benign lesions and are associated with aging and other risk factors. These dilated PVS can cause neurologic symptoms, depending on their size and location. Symptomatic, massive enlargement of PVS are referred to as "giant" or "tumefactive" PVS; these are extremely rare and require neurosurgical intervention., Case Description: We present a rare case of giant tumefactive PVS (GTPVS) associated with hydrocephalus in a female patient who presented with progressive headache for 6 months. The patient was found to have giant tumefactive dilatation of PVS involving the right midbrain, with extension to the pons and thalamus, and with supratentorial moderate hydrocephalus. She was treated with cerebrospinal fluid diversion alone., Conclusions: PVS are found on MRI in healthy people; rarely, they may dilate and cause neurologic symptoms. GTPVS are rare and can be misdiagnosed as central nervous system tumors; however, their imaging characteristics facilitate diagnosis. It has been postulated that these expanding PVS are due to defects in the drainage of interstitial fluid, where it enters into the ventricular system, and they are not the result of increased intraventricular pressure. We hypothesize that this may have been the case for the patient in our study, as the GTPVS collapsed following the insertion of a ventriculoperitoneal shunt. However, more recent literature provides evidence to support the idea that hydrocephalus is the consequence, and not the cause, of aqueduct compression by the lesion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Surgery for syringomyelia generally aims to treat the underlying cause, if it is known. Optimal management is unclear for idiopathic syringomyelia, or when treatment of the putative cause has failed or is high risk. Syrinx to subarachnoid shunting is an option for these cases; a series is reported to assess the outcomes of this approach., Methods: We retrospectively analyzed the clinical and radiologic features of a consecutive series of patients with syringomyelia treated with syrinx to subarachnoid shunting., Results: Forty-one patients (19 male, 4-79 years old) were treated from 2000 to 2016, including 15 patients with idiopathic syringomyelia, 13 with spinal trauma, 5 with Chiari malformation, 4 with arachnoiditis, 3 with tethered cord, and 1 with arachnoid bands. The patients were treated with a syrinx to subarachnoid shunt, and a subset also underwent expansile duraplasty. At follow-up (3-108 months, mean 36 months) syrinx size was reduced in 37 patients, and there was improvement or stabilization of symptoms in all but 1 patient. Three patients had temporary lower limb sensory symptoms after surgery. Other complications were 2 transient cerebrospinal fluid leaks, a pseudomeningocoele, and 1 postoperative myocardial infarction. Two cases of shunt dislodgement required reoperation, and a third case required early reoperation for an enlarging syrinx. There were no cases of shunt blockage or infection., Conclusions: Syrinx to subarachnoid shunting is a safe and effective treatment for idiopathic syringomyelia and for patients who are not suitable for, or have not responded to, other treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Intradural epidermoid tumors of the spinal cord are commonly associated with spinal cord dysraphism or invasive procedures. We report the particular relationships between spinal subarachnoid compartments and thoracic intradural-extramedullary epidermoid tumor, highlighting the relevant anatomic changes that may influence microsurgery., Methods: A 40-year-old woman from compressive myelopathy owing to a thoracic epidermoid tumor extending from T3 to T4 and not associated with spina bifida, trauma, previous surgery, or lumbar spinal puncture underwent microsurgical excision. Accurate tumor membrane dissection, respecting spinal arachnoidal compartments, was performed. Reposition of a laminoplasty plateau helped in restoring thoracic spine anatomic integrity., Results: Safe gross total tumor resection was achieved. Complete neurologic recovery as well as absence of recurrent tumor was documented at 4-year follow-up. A literature review revealed only 2 other cases of "isolated" thoracic spine epidermoid tumor. However, description of the relationship between tumor membranes and spinal subarachnoid compartments was not available in either case., Conclusions: A thorough knowledge of spinal subarachnoid space anatomy is helpful to distinguish between tumor membranes and arachnoidal planes and to achieve a safe and complete resection to avoid recurrences., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score., Methods: Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome., Results: Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels., Conclusions: The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Colloid cysts (CCs) are rarely found in the sellar-suprasellar region. Differential diagnosis of CCs is more challenging in this region because many other cystic lesions may locate or invade sellar or suprasellar structures. We present a large and unusual case of sellar-suprasellar CC with extension into the suprasellar, interpeduncular, and prepontine cisterns. This is the first case of sellar-suprasellar CC treated with an endoscopic transsphenoidal approach., Case Description: A 33-year-old woman presented with a 1-year history of recurrent headaches. Her headaches had been unresponsive to medical treatment for the last 2 weeks. She had normal neurologic and ophthalmologic examinations. Neuroradiologic studies showed a large cystic sellar lesion with extension into the suprasellar, interpeduncular, and prepontine cisterns. The lesion did not show any enhancement, not even in the cyst wall. Her hormonal status was also normal. The cystic lesion was totally resected via a purely endoscopic endonasal approach. There were no complications, and the patient was recovered completely with improvement of her headache. Pathology was consistent with a CC. At 6-month follow-up, magnetic resonance imaging did not show any evidence of the residual or recurrent lesion., Conclusions: Although rarely found in this location, CC should be considered in the differential diagnosis in patients who present with a sellar-suprasellar cystic lesion. Additionally, sellar-suprasellar CC would be a good candidate for the endoscopic endonasal approach., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: A Rathke cleft cyst (RCC) with nonhemorrhagic rupture mimicking pituitary apoplexy has been reported rarely., Case Description: A 52-year-old woman, previously diagnosed with asymptomatic RCC, came to us with a severe headache, along with visual dysfunction and symptoms of pituitary insufficiency. Fluid-attenuated inversion recovery magnetic resonance imaging demonstrated diffuse hyperintensity in the cerebral cisterns, whereas watery clear cerebrospinal fluid was obtained by lumbar puncture. Surgery performed 1 month after onset revealed a nonhemorrhagic lesion, with a final diagnosis of nonhemorrhagic RCC rupture., Conclusions: We conclude that nonhemorrhagic RCC rupture and subsequent leakage of the contents into subarachnoid space were the underlying pathogenesis in the present case of RCC resembling apoplexy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Many studies have shown that cerebrospinal fluid (CSF) behaves irregularly, rather than with laminar flow, in the various CSF spaces. We adapted a modified previously known magnetic resonance imaging technique to visualize irregular CSF motion. Subsequently, we assessed the usefulness and clinical significance of the present method., Materials and Methods: Normal CSF motion in 10 healthy volunteers was visualized with the dynamic improved, motion-sensitized, driven-equilibrium steady-state free precession technique. Subsequently, CSF motion visualization with a modified sequence was applied to 3 patients., Results: In healthy volunteers, we achieved visualization of the irregularity of CSF flow in the ventricles and spinal canal, whereas CSF motion was diminished in the peripheral part of the intracranial subarachnoid space. In one case, we confirmed the patency of the patient's third ventriculostomy fenestration site. In the other, we verified the usefulness of the proposed sequence for determining the communication between the ventricle or subarachnoid space and the cyst., Conclusions: Using the present sequence, we obtained images that accentuated CSF motion, which is largely composed of irregular motion. This method does not require pulse triggering or complex post-processing of images and allows visualization of CSF motion in a short period of time in selected whole imaging planes. It can therefore be applied clinically to diagnose various diseases that cause abnormalities in the CSF space., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Traumatic brain injury (TBI) is one of the major challenges in health care, representing the third most frequent cause of death. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies. Here we describe cisternostomy, an emerging surgical treatment for the treatment of TBI., Methods: Cisternostomy is a novel technique that incorporates knowledge of skull base and microvascular surgery. By opening the brain cisterns to atmospheric pressure, the technique could decrease the intracranial pressure due to a backshift of the cerebrospinal fluid (CSF) from the swollen brain to the cisterns through the Virchow-Robin spaces., Results: An increasing number of evidence has demonstrated a paravascular pathway that facilitates CSF flow from the subarachnoid space through the brain parenchyma. This network of paravascular channels, termed as the "glymphatic" pathway, reduces considerably its activity after TBI, thus participating in the development of brain edema formation. Cisternostomy, by opening the brain cisterns to atmospheric pressure, could decrease the intracerebral pressure due to a backshift of CSF through the Virchow-Robin spaces., Conclusions: In the current common practice, the surgical measures for TBI include external ventricular drainage insertion and decompressive craniectomy. There is evidence that both of these measures reduce intracranial pressure but the effect on the outcome, particularly in the long term, is equivocal. A new line of evidence supports cisternostomy as an emerging surgical treatment for TBI., (Copyright © 2016 Elsevier Inc. All rights reserved.)