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Objective: Several techniques have been described to improve the accuracy of the freehand procedure for frontal ventriculostomy and reduce complications due to suboptimal placement or misplacement of the catheter tip. To date, none of the available studies have found a reliable, low cost and consistent technique. We aimed to provide a standardized protocol for freehand frontal ventriculostomy., Methods: In the first part of the radiological study, 125 CT scans were used to measure the length of the catheter using 2 right-sided entry points. In the second part, a grid of 24 entry points on the frontal bone was used in 50 CT scans to record the distance from the cranial surface to the Foramen of Monro (FM). Ventriculostomy was performed on six cadaveric heads using a grid of 9 entry points, comparing a 5 ml syringe with the freehand technique to reach the target., Results: The first part of the radiological study showed a length from the cranial surface to the FM was overall 67,38 ± 1,03 mm. For the second part, the mean length of the 24 selected points was 68,54 ± 2,73 mm without statistical difference. In the anatomical study, the FM was reached 8 times (14.8%) with the syringe vs 31 times (57.4%) with the freehand technique, and the ventricles 43 (79.6%) vs 37 (68.5%). The mean lengths from the skull to the FM were 71.33 ± 4.21 mm., Conclusions: In this study, we showed the optimal length of a frontal ventricular catheter. We have also demonstrated that the portion of the frontal bone above the superior temporal lines matches a sphere in which the center is the FM., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Patients with idiopathic intracranial hypertension are frequently obese women with normal/slit ventricles. Patients with high-pressure hydrocephalus, instead, present enlarged ventricles. We describe a 63-year-old woman with signs and symptoms of intracranial hypertension. Brain MRI revealed hydrocephalus. Venous Doppler ultrasound showed external compression of the omohyoid muscles on the internal jugular veins. During jugular vein decompression, intracranial pressure dropped from 18 to 6 mmHg. Patient is asymptomatic at 2-year follow-up, with decreased brain ventricles. These findings could represent a novel form of high-pressure hydrocephalus that can be successfully treated without a CSF shunt. We called this syndrome JEDI (jugular entrapment dilated ventricles intracranial hypertension).

Decompressive craniectomy (DC) may be necessary to save the lives of patients suffering from intracranial hypertension. However, this procedure is not complication-free. Its two main complications are hydrocephalus and the sinking skin-flap syndrome (SSFS). The radiological findings and the clinical evaluation may be not enough to decide when and/or how to treat hydrocephalus in a decompressed patient. SSFS and hydrocephalus may be not unrelated. In fact, a patient affected by hydrocephalus, after the ventriculo-peritoneal shunt, can develop SSFS; on the other hand, SSFS per se can cause hydrocephalus. Treating hydrocephalus in decompressed patients can be challenging. Radiological findings and clinical evaluation may not be enough to define the most appropriate therapeutic strategy. Cerebrospinal fluid (CSF) dynamics and metabolic evaluations can represent important diagnostic tools for assessing the need of a CSF shunt in patients with a poor baseline neurologic status. Based on our experience, we propose a flow chart for treating decompressed patients affected by ventriculomegaly.

Background: Decompressive craniectomy (DC) is a known risk factor for the development of post-traumatic hydrocephalus. The occurrence of subdural hygroma (SH) was also reported in 23-56% of patients after DC and it seemed to precede hydrocephalus in more than 80% of cases. We analyzed the relationship among DC, SH and hydrocephalus., Methods: From 2007 to 2011, 64 patients underwent DC after head trauma. Variables we analyzed were: intaventricular hemorrhage, age, GCS, distance of craniectomy from the midline, evacuation of a hemorrhagic contusion (HC) and infection. Logistic regression was used to assess the independent contribution of the predictive factors to the development of hydrocephalus., Results: Nineteen patients (29.7%) developed hydrocephalus. Interhemispheric SH was present in 8/19 patients with hydrocephalus and temporally preceded the occurrence of ventricular enlargement. Moreover, most patients who developed a interhemispheric SH had been undergone DC whose superior margin was close to the midline. Logistic regression analysis showed that craniectomy closer than 25 mm to the midline was the only factor independently associated with the development of hydrocephalus., Conclusion: Craniectomy close to the midline can predispose patients to the development of hydrocephalus. SH could be generated with the same mechanism, and these three events could be correlated on a timeline., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objectives: Post-traumatic hydrocephalus (PTH) is commonly considered as a relative contraindication for endoscopic third-ventriculostomy (ETV). However, few studies are available on this topic., Methods: An analysis of the papers published in the last ten years has been performed, in order to assess the level of evidence on which the current indication for ETV for PTH is based. References were identified by PubMed searches of clinical articles relating to both PTH and ETV. Laboratory investigations were excluded., Results: Only 5 articles were selected, for a total of 15 patients with PTH treated with ETV. All these patients were described by the authors to have a communicating hydrocephalus. No complications of surgery were reported. Outcome data were not available for one patient. Thirteen out of the remaining 14 patients had a clinical improvement after the surgical procedure (93%). Direct or indirect information on pre-operative ICP was available for 11 cases. Eight of them had an elevated ICP and presented a clinical improvement after ETV., Conclusions: There is no current evidence to support that PTH is a contraindication for ETV. Our data suggest that we could reconsider ETV for the treatment of PTH, especially for patients with elevated ICP. Prospective clinical trials (involving several centers, due to the difficulty of recruiting patients with PTH) are needed., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The incidence of post-traumatic hydrocephalus (PTH) has been reported to be 0.7-51.4%, and we have frequently observed the development of PTH in patients undergoing decompressive craniectomy (DC). For this reason we performed a retrospective review of a consecutive series of patients undergoing DC after traumatic brain injury (TBI). From January 2006 to December 2009, 41 patients underwent DC after closed head injury. Study outcomes focused specifically on the development of hydrocephalus after DC. Variables described by other authors to be associated with PTH were studied, including advanced age, the timing of cranioplasty, higher score on the Fisher grading system, low post-resuscitation Glasgow Coma Scale (GCS) score, and cerebrospinal fluid (CSF) infection. We also analyzed the influence of the area of craniotomy and the distance of craniotomy from the midline. Logistic regression was used with hydrocephalus as the primary outcome measure. Of the nine patients who developed hydrocephalus, eight patients (89%) had undergone craniotomy with the superior limit <25 mm from the midline. This association was statistically significant (p = 0.01 - Fisher's exact test). Logistic regression analysis showed that the only factor independently associated with the development of hydrocephalus was the distance from the midline. Patients with craniotomy whose superior limit was <25 mm from the midline had a markedly increased risk of developing hydrocephalus (OR = 17). Craniectomy with a superior limit too close to the midline can predispose patients undergoing DC to the development of hydrocephalus. We therefore suggest performing wide DCs with the superior limit >25 mm from the midline.

Background and Purpose: The bilateral foramina of Monro occlusion is an extremely rare event in adults. To date, only six cases of adult hydrocephalus due to idiopatic obstruction of the bilateral foramina of Monro (including our patient) have been reported., Methods: The authors describe the case of a 41-year-old man with a recent onset of motor hindrance which occurred specially while jumping or playing basketball, together with recent memory impairment, deceleration of thought, and asthenia. The patient was studied with fast spin echo (FSE) and steady-state free precession high-resolution 3D sequences (SSFP) together with a ventricular infusion test, and subsequently treated with endoscopic foraminoplasty., Results: The presenting symptoms completely resolved. Follow-up magnetic resonance imaging (MRI) showed the patency of right Monro foramen, with gradually decreasing ventricular size and increase of subarachnoid spaces., Conclusions: These patients should be accurately studied before treatment. In fact, MRI has made it possible to know what a surgeon will exactly find on the operative field. In that way a correct surgical planning can be achieved.

Objective: The management of post-traumatic ventriculomegaly (PTV) is controversial. This is due to the difficulty to determine whether PTV is related to an atrophic process or to a true "active" hydrocephalus. The purpose of this study is to analyze the CSF-dynamics in patients with PTV and, possibly, to identify parameters that correlate with prognosis. Methods: 15 patients with PTV were treated following this protocol: 1-frontal ventriculostomy (with Rickham reservoir); 2-CSF-dynamics evaluation; 3-ventriculo-peritoneal shunt. CSF dynamics evaluation was based on an intraventricular infusion test (performed three to five days after ventriculostomy). Outflow Resistance (R-out) and Intracranial Elastance Index (EI, i.e. the reciprocal of intracranial compliance) were calculated. Patients were classified according to response to shunt into: 1-fast responders: rapid clinical improvement, i.e. within days/one month from surgery; 2-slow responders: patients presenting little clinical improvement occurring after months (despite neurorehabilitation); 3-non responders: no clinical improvement. Results: Seven patients (46.7%) were classified as fast-responders, three patients were classified as slow-responders (20%) and five patients were classified as non-responders (33.3%). Opening CSF pressure was less than 15 mmHg for all patients. R-out (cut-off >10 mmHg/ml/min) had 100% sensitivity, 50% specificity, 100% negative predictive value and 63.6% positive predictive value. EI (cut-off value >0.3) had 100% specificity, 42.4% sensitivity, 100% positive predictive value and 66.7% negative predictive value. Conclusions: Based on these considerations, we can suggest that, for patients with normal pressure PTV, analysis of CSF dynamics could be of help in selecting patients for CSF-shunt. A combination of Intracranial Elastance and of R-out could help predicting shunt responsiveness. [ABSTRACT FROM AUTHOR]