Search

Purpose: Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus. Secondary stoma closure may be life threatening and is the most common reason for late ETV failure, mostly secondary to local scarring. Local stents intended to maintain patency are rarely used. In this study, we summarize our experience using stented ETV (sETV), efficacy, and safety. Material and methods: Data was retrospectively collected from all consecutive patients who underwent ETV with stenting at four centers. Collected data included indications for using sETV, hydrocephalic history, surgical technique, outcomes, and complications. Results: Sixty-seven cases were included. Forty had a primary sETV, and 27 had a secondary sETV (following a prior shunt, ETV, or both). The average age during surgery was 22 years. Main indications for sETV included an adjacent tumor (n = 15), thick or redundant tuber cinereum (n = 24), and prior ETV failure (n = 16). Fifty-nine patients (88%) had a successful sETV. Eight patients failed 11 ± 8 months following surgery. Reasons for failure included obstruction of the stent, reabsorption insufficiency, and CSF leak (n = 2 each), and massive hygroma and tumor spread (n = 1 each). Complications included subdural hygroma (n = 4), CSF leak (n = 2), and stent malposition (n = 1). There were no complications associated with two stent removals. Conclusion: Stented ETV appears to be feasible and safe. It may be indicated in selected cases such as patients with prior ETV failure, or as a primary treatment in cases with anatomical alterations caused by tumors or thickened tuber cinereum. Future investigations are needed to further elucidate its role in non-communicating hydrocephalus. [ABSTRACT FROM AUTHOR]

Systemic drug delivery is the current clinically preferred route for cancer therapy. However, challenges associated with tumor localization and off-tumor toxic effects limit the clinical effectiveness of this route. Locoregional drug delivery is an emerging viable alternative to systemic therapies. With the improvement in real-time imaging technologies and tools for direct access to tumor lesions, the clinical applicability of locoregional drug delivery is becoming more prominent. Theoretically, locoregional treatments can bypass challenges faced by systemic drug delivery. Preclinically, locoregional delivery of drugs has demonstrated enhanced therapeutic efficacy with limited off-target effects while still yielding an abscopal effect. Clinically, an array of locoregional strategies is under investigation for the delivery of drugs ranging in target and size. Locoregional tumor treatment strategies can be classified into two main categories: 1) direct drug infusion via injection or implanted port and 2) extended drug elution via injected or implanted depot. The number of studies investigating locoregional drug delivery strategies for cancer treatment is rising exponentially, in both preclinical and clinical settings, with some approaches approved for clinical use. Here, we highlight key preclinical advances and the clinical relevance of such locoregional delivery strategies in the treatment of cancer. Furthermore, we critically analyze 949 clinical trials involving locoregional drug delivery and discuss emerging trends. [Display omitted] • Locoregional delivery is an effective alternative to systemic delivery for oncotherapy. • Locoregional delivery can be achieved via direct infusion or depot-based strategies. • Preclinical studies indicate strong abscopal potential of locoregional delivery. • Clinical trials investigating locoregional delivery are increasing exponentially. • Procedure standardization and combination strategy may be fruitful in near future. [ABSTRACT FROM AUTHOR]

Tongming Zhu,1,&ast; Junyan Fu,2,&ast; Di Zang,1,3,&ast; Zhe Wang,1,4,&ast; Xiangru Ye,1 Xuehai Wu,1 Jin Hu1 1Department of Neurosurgery, Fudan University Huashan Hospital, National Center for Neurological Disorders, National Key Laboratory for Medical Neurobiology, Shanghai Key Laboratory of Brain Function and Regeneration, Institutes of Brain Science, MOE Frontiers Center for Brain Science, Shanghai Medical College-Fudan University, Shanghai, People’s Republic of China; 2Department of Radiology, Fudan University Huashan Hospital, Shanghai, People’s Republic of China; 3Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, People’s Republic of China; 4Department of Medical Imaging Technology, SJTU-Ruijin-UIH Institute for Medical Imaging Technology, Shanghai, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Xuehai Wu; Jin Hu, Department of Neurosurgery, Fudan University Huashan Hospital, No. 12, Middle Wulumuqi Road, Shanghai, People’s Republic of China, Email wuxuehai2013@163.com; hujin@fudan.edu.cnBackground: The effect of Ommaya reservoirs on the clinical outcomes of patients with intraventricular hemorrhage (IVH) remains unclear.Objective: We aimed to determine the effect of combining the Ommaya reservoir and external ventricular drainage (EVD) therapy on IVH and explore better clinical indicators for Ommaya implantation.Methods: A retrospective analysis was conducted on patients diagnosed with IVH who received EVD-Ommaya drainage between January 2013 and March 2021. The patient population was divided into two groups: the Ommaya-used group, comprising patients in whom the Ommaya drainage system was activated post-surgery, and the Ommaya-unused group, comprising patients in whom the system was not activated. The study analyzed clinical, imaging, and outcome data of the patient population.Results: A total of 123 patients with IVH were included: 75 patients in the Ommaya-used group and 48 patients in the Ommaya-unused group. The patients in the Ommaya-used group showed a lower 3-month GOS than those in the Ommaya-unused group (p< 0.0001). The modified Graeb scale (mGS) in the Ommaya-unused group was significantly lower than that in the Ommaya-used group before the operation (p< 0.01) but not after surgery (p> 0.05). The GCS in the Ommaya-unused group was significantly lower than that in the other group, and there was a close correlation between the GCS and 3-month GOS (p< 0.0001). The GCS score showed significance in predicting the use of Ommaya (p< 0.001).Conclusion: The study demonstrated that combining EVD and Ommaya drainage was a safe and feasible treatment for IVH. Additionally, preoperative GCS was found to predict the use of Ommaya drainage in subsequent treatment, providing valuable information for pre-surgery decision-making.Keywords: intraventricular hemorrhage, Ommaya, external ventricular drainage

Background: Craniopharyngiomas (CPs) are rare, low-grade tumors characterized by a range of debilitating symptoms. Most of the existing literature reports postoperative outcomes of the different treatment modalities of childhood CP. However, few studies have reported the impact of these different treatment methods on the quality of life (QoL) of survivors of childhood CP. Therefore, we aim to assess the correlation between different surgical modalities on the QoL of patients with childhood CP from a lower-middle-income country. Methods: Twenty-nine survivors who underwent treatment for CP were included in the study. The selected patients had either been managed with complete resection, debulking, or placement of an Ommaya reservoir. QoL was assessed by the pediatric quality of life (PedsQL) questionnaire. The effect of the different treatment modalities on the QoL was assessed. Results: Mean follow-up was 4.4 ± 2.19 years. The type of surgery was significantly related to the mean PedsQL scores for the total score as well as each of the individual domain scores (P < 0.001). Complete resection of the tumor resulted in the lowest mean (standard deviation) PedsQL total score of 56.6 ± 7.12 compared to the Ommaya reservoir with biopsy (83.3 ± 5.69) and debulking (93.8 ± 3.37) (P < 0.001). Conclusion: There was a significant effect of the type of surgical treatment on the QoL of the survivors of childhood CP. It is important to consider the long-term outcomes in addition to immediate postoperative outcomes when deciding on a treatment strategy while managing children with CP. [ABSTRACT FROM AUTHOR]

Ommaya reservoir insertion is an elective neurosurgical procedure to deliver repeated intraventricular therapy, but placement can be complicated by malposition of the catheter, clogging, infection or poor postoperative cosmesis. Here, we describe the technique used by the senior author for accurate placement including preassembly of the reservoir and catheter, and recessing of the reservoir so that others may consider the technique for their practice. Results in a consecutive series of 27 Ommaya placements were reviewed. Catheter tip placement accuracy, complications and surgical times were reported. Indications were leptomeningeal cancer or infection. Postoperative imaging showed the catheter tip was located in the frontal horn (96%) or body (4%) of the ipsilateral lateral ventricle. The median surgical time was 36 minutes (range 17-63 minutes). There were no parenchymal or subarachnoid hemorrhages. Infections occurred in 7% (n=2) of cases, and both infections presented greater than 60 days postoperative. In conclusion, we have found that image guidance can optimize accuracy in placement, that preassembly of the reservoir and catheter may be used with a 25-gauge spinal needle stylet to minimize risk of clogging during placement, and that recessing of the reservoir produces the best aesthetic result.

Introduction: Diffuse midline brainstem gliomas have a poor prognosis and are generally not amenable to surgical resection. Occasionally, palliative surgical procedures can be performed to improve the quality of life of these patients. We describe three patients with solid-cystic brainstem gliomas in whom an Ommaya reservoir catheter was placed to reduce mass effect. Objectives: To describe the characteristics, indications for, and operative technique of Ommaya reservoir catheter placement in patients with solid-cystic diffuse midline glioma. Materials and methods: A review was conducted of the medical records of pediatric patients with solid-cystic diffuse midline glioma H3 K27-altered, treated with an Ommaya reservoir at Hospital J.P. Garrahan between 2014 and 2021 together with a search of the literature. Results: Three cases of stereotaxic Ommaya placement in solid-cystic diffuse midline gliomas, H3 K27M-altered were identified. After the procedure, clinical improvement and reduction of the size of the tumor cyst size was achieved. No associated complications were seen. At the time of the study, one patient died, and the remaining two patients continued in follow-up at our hospital. Conclusion: We believe that the placement of an intratumoral Ommaya reservoir catheter may be considered a therapeutic option to improve symptoms and quality of life of selected patients with solid-cystic diffuse midline glioma. [ABSTRACT FROM AUTHOR]

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.

Central nervous system (CNS) tumors are the most common solid malignancy in the pediatric population. Based on adoptive cellular therapy's clinical success against childhood leukemia and the preclinical efficacy against pediatric CNS tumors, chimeric antigen receptor (CAR) T cells offer hope of improving outcomes for recurrent tumors and universally fatal diseases such as diffuse intrinsic pontine glioma (DIPG). However, a major obstacle for tumors of the brain and spine is ineffective T cell chemotaxis to disease sites. Locoregional CAR T cell delivery via infusion through an intracranial catheter is currently under study in multiple early phase clinical trials. Here, we describe the Seattle Children's single-institution experience including the multidisciplinary process for the preparation of successful, repetitive intracranial T cell infusion for children and the catheter-related safety of our 307 intracranial CAR T cell doses.

Introduction Weaning from external ventricular drainage (EVD) of cerebrospinal fluid (CSF) in hydrocephalus induced by aneurismal subarachnoid hemorrhage (SAH) had been proposed either through the rapid, gradual or intermittent approaches. There are no uniform guidelines for it. Given this, we planned to study the comparative outcome between EVD drainage with intermittent clamping versus EDV followed by Ommaya reservoir. Material and Methods The present retrograde observational study was conducted from July 2018 to March 2021 in the department of neurosurgery with 67 patients who developed hydrocephalus following SAH after aneurysm rupture. We divided the patients into two groups. Group 1 had only EVD placed for CSF drainage with intermittent clamping before the placement of the ventriculoperitoneal (VP) shunt, and, in group 2, an Ommaya reservoir was placed after EVD before the shunt. Result There were 38 patients in group 1 and 29 in group 2. They were age-matched, with a mild male predominance in group 1. Shunt dependency was significantly reduced in group 2 patients (p = 0.011), along with reduced length of stay in ICU (p = 0,001) and length of stay in Hospital (p = 0.019). We found improved Glasgow outcome score in group 2 patients (p = 0.006) together with reduced incidence of infarct (p = 0.0095). Conclusion We may infer from the present study that continuous drainage through EVD, initially, in hydrocephalus induced by SAH following aneurysm rupture, increases cerebral perfusion pressure (CPP) and decreases intracranial pressure (ICP) leading to decreased infarct rate and intermittent drainage through Ommaya following EVD reservoir, decreases shunt dependency, reduces ICU and hospital stay, with improved Glasgow outcome score on follow-up, but these findings need to be validated in a prospective randomized control trial.

An Ommaya reservoir can be used to treat posthemorrhagic hydrocephalus secondary to intraventricular hemorrhage of prematurity until an acceptable weight can be obtained to place a permanent shunt. Identifying newborns at higher risk of developing shunt conversion may improve the management of these patients. This study aimed to develop a predictive algorithm for conversion of an Ommaya reservoir to a permanent shunt using artificial intelligence techniques and classical statistics. A database of 43 preterm patients weighing ≤1500 g with posthemorrhagic hydrocephalus (Papile grades III and IV with Levene ventricular index >4 mm above the 97th percentile) managed with an Ommaya reservoir at our institution between 2002 and 2017 was used to train a k -nearest neighbor algorithm. Validation of results was done with cross-validation technique. Three scenarios were calculated: 1) considering all features regardless whether or not they are correlated with the output variable; 2) considering the features as predictors if they have a correlation >30% with the output variable; 3) considering the output of the previous analysis. When considering the outputs of a previous multivariate analysis, the algorithm reached 86% of cross-validation accuracy. The use of machine learning–based algorithms can help in early identification of patients with permanent need of a shunt. We present a predictive algorithm for a permanent shunt with an accuracy of 86%; accuracy of the algorithm can be improved with larger volume of data and previous analysis. [ABSTRACT FROM AUTHOR]

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity. [ABSTRACT FROM AUTHOR]

Background: Intraventricular chemotherapy via Ommaya reservoir is an important part of the treatment in patients with malignant central nervous system tumors. In these patients, catheter placement can be challenging due to the normal-sized ventricles. Method: Intraoperative ultrasound guidance was used for Ommaya reservoir placement in a 56-year-old patient with multiple intracranial and leptomeningeal metastases who had cavum septum pellucidum et vergae malformation. The catheter was successfully placed into the frontal horn of the lateral ventricle outside the cavum. Conclusion: Intraoperative ultrasound is a suitable image guidance system in patients with slit-like or normal-sized ventricles. It can also be used in patients with ventricular malformations. [ABSTRACT FROM AUTHOR]

Background: Craniopharyngiomas (CPs) are rare, low-grade tumors characterized by a range of debilitating symptoms. Most of the existing literature reports postoperative outcomes of the different treatment modalities of childhood CP. However, few studies have reported the impact of these different treatment methods on the quality of life (QoL) of survivors of childhood CP. Therefore, we aim to assess the correlation between different surgical modalities on the QoL of patients with childhood CP from a lower-middle-income country., Methods: Twenty-nine survivors who underwent treatment for CP were included in the study. The selected patients had either been managed with complete resection, debulking, or placement of an Ommaya reservoir. QoL was assessed by the pediatric quality of life (PedsQL) questionnaire. The effect of the different treatment modalities on the QoL was assessed., Results: Mean follow-up was 4.4 ± 2.19 years. The type of surgery was significantly related to the mean PedsQL scores for the total score as well as each of the individual domain scores ( P < 0.001). Complete resection of the tumor resulted in the lowest mean (standard deviation) PedsQL total score of 56.6 ± 7.12 compared to the Ommaya reservoir with biopsy (83.3 ± 5.69) and debulking (93.8 ± 3.37) ( P < 0.001)., Conclusion: There was a significant effect of the type of surgical treatment on the QoL of the survivors of childhood CP. It is important to consider the long-term outcomes in addition to immediate postoperative outcomes when deciding on a treatment strategy while managing children with CP., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results. Materials and Methods: Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed Results: Thirty‑two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow‑up period. Conclusions: Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality. [ABSTRACT FROM AUTHOR]

The authors report the case of a 39-year-old woman with leukemic meningitis. A right frontal Ommaya reservoir was placed for intrathecal chemotherapy. During and immediately following the first injection of chemotherapy, the patient developed an episode of nausea, emesis, frontal headache and diarrhea. These same symptoms were later elicited during a second and third administration of chemotherapy. Post-placement head computed tomography showed the tip of the catheter projecting approximately 1.5 cm inferior to the floor of the left frontal ventricle. After a revision of the Ommaya catheter due to suboptimal positioning, subsequent intrathecal chemotherapy administration was tolerated without any of the adverse symptoms previously encountered. The case documents an unusual complication arising from catheter migration in the setting of intrathecal chemotherapy and also demonstrates the value in troubleshooting Ommaya reservoir complications rather than prematurely abandoning its use in favor of lumbar puncture. [ABSTRACT FROM AUTHOR]

Placement of Ommaya reservoirs for the administration of intrathecal chemotherapy may be complicated by comorbid thrombocytopenia among patients with hematologic or leptomeningeal disease. Aggregated data on risks of Ommaya placement among thrombocytopenic patients are lacking. This study assesses complications, revision rates, and costs associated with Ommaya placement among patients with thrombocytopenia in a large population sample. Using a national administrative database, this retrospective study identifies a cohort of adult patients with cancer who underwent Ommaya placement between 2007 and 2016. Preoperative thrombocytopenia was defined as diagnosis of secondary thrombocytopenia, bleeding event, procedure to control bleeding, or platelet transfusion, within 30 days before index admission. Univariate and multivariate analyses were performed to assess costs, 30-day complications, readmissions, and revisions among patients with and without preoperative thrombocytopenia. The analytic cohort included 1652 patients, of whom 29.3% met criteria for preoperative thrombocytopenia. In-hospital mortality rates were 7.7% among patients thrombocytopenia with versus 1.2% among patients without thrombocytopenia (P < 0.001). Preoperative thrombocytopenia was associated with 14.5 times greater hazard of intracranial hemorrhage within 30 days following Ommaya placement, occurring in 25.6% versus 2.0% of patients with and without thrombocytopenia, respectively (P < 0.014). Revision rates did not differ significantly between patients with and without thrombocytopenia. Thrombocytopenia was associated with longer length of stay (7.4 vs. 13.9 days, P < 0.001) and additional $10,000 per patient in costs of index hospitalization (P < 0.001). This is the largest study to date documenting costs and complication rates of Ommaya placement in patients with and without thrombocytopenia. [ABSTRACT FROM AUTHOR]

Background Hydrocephalus in patients with neurofibromatosis (NF) type 1 is usually obstructive and may arise secondary to tumoral or nontumoral causes. Treatment of hydrocephalus in these patients is often challenging owing to combined pathologies and unique anatomic changes. The use of endoscopic third ventriculostomy (ETV) as treatment has rarely been described in this group. We aimed to characterize indications, considerations, and outcome of ETV in patients with NF 1 gathered in a multicenter international cohort. Methods Five centers participated in this retrospective study. Following institutional review board approval, data and images were collected. Patients of all ages with NF 1 who underwent ETV for treatment of obstructive hydrocephalus were included. Patients who had no postoperative radiologic or clinical follow-up were excluded. ETV failure was defined as recurrent clinical or radiologic signs of hydrocephalus. Results The study included 42 patients. Common etiologies for hydrocephalus were aqueductal/tectal tumor (31%), aqueductal web (26%), and aqueductal stenosis owing to NF-related changes (14%). Ten patients had a preoperative diagnosis of optic pathway glioma. ETV failures were identified in 6 patients within 1 month, in 3 patients within 9 months, and in 1 patient within 4 years. ETV was successful in 32 patients (76%) with a mean follow up of 59.4 months ± 50.9 (range, 4 months to 15 years). Conclusions ETV is a safe treatment for selected patients with NF 1 and obstructive hydrocephalus. Individual anatomic and pathologic aspects should be taken into consideration. [ABSTRACT FROM AUTHOR]

Ommaya reservoirs are an important surgical therapy for the chronic intrathecal administration of chemotherapy for patients with leptomeningeal carcinomatosis. Surgical accuracy is paramount in these patients with typically normal sized ventricles, and may be improved with stereotactic guidance. This paper aimed to review a large series of stereotactic Ommaya catheter placements, examining accuracy and complications. We conducted a retrospective review of 109 consecutive adult patients who underwent stereotactic Ommaya catheter placement for leptomeningeal carcinomatosis or central nervous system lymphoma at Columbia University Medical Center, USA, from 1998–2013. The rate of accurate placement in the ventricular system was 99%, with the only poor catheter position due to post-placement migration. The rate of peri-operative complications was 6.4%. Hemorrhagic complications occurred in patients with thrombocytopenia or therapeutic anti-coagulation pre-operatively or during the post-operative period. Use of stereotaxy for catheter placement of Ommaya reservoirs is safe and effective, and should be considered when placing a catheter into non-hydrocephalic ventricles. [ABSTRACT FROM AUTHOR]

Purpose: Ventricular access devices (VADs) are commonly placed in the lateral ventricle but rarely placed in other ventricular compartments. This manuscript describes technical aspects of VAD placement into the fourth ventricle for the purpose of treating malignant posterior fossa brain tumors. Methods: As part of a pilot clinical trial to treat recurrent malignant brain tumors in children, seven patients underwent posterior fossa craniotomy and placement of a ventricular catheter under direct vision into the fourth ventricle. The catheter was placed without passing through any brain parenchyma. It was then connected to a VAD placed subcutaneously at the inferior aspect of the incision. Three of the seven patients underwent simultaneous subtotal resection of recurrent tumor located in the fourth ventricle or cerebellum, and one patient underwent simultaneous tumor biopsy. The VAD was used to administer chemotherapy (methotrexate) in five of the seven patients. Results: Six patients had no new neurological deficits after surgery, and one patient had partial left-sided facial weakness that was attributed to resection of tumor close to the floor of the fourth ventricle. No new neurological deficits were caused by VAD placement or by methotrexate infusions into the fourth ventricle. Conclusions: A VAD for chemotherapy infusion can be placed safely into the fourth ventricle without damaging the brainstem or cerebellum. Attention to anatomical details specific to the fourth ventricle are important when placing a fourth ventricle VAD and when using it to administer chemotherapy. [ABSTRACT FROM AUTHOR]

Background: Accuracy in Ommaya reservoir catheter placement is critical to chemotherapy infusion. Most frameless image guidance is light emitting diode (LED) based, requiring a direct line of communication between instrument and tracker, limiting freedom of instrument movement within the surgical field. Electromagnetic neuronavigation may overcome this challenge. Objective: To compare Ommaya reservoir ventricular catheter placement using electromagnetic neuronavigation to LED-based optical navigation, with emphasis on placement accuracy, operative time and complication rate. Methods: Twenty-eight patients who underwent placement of Ommaya reservoirs at our institution between 2010 and 2014 with either electromagnetic (12 patients) or optical neuronavigation (16 patients) were retrospectively reviewed. Results: Half of the patients were male. Their mean age was 56 years (range 28-87 years). Accuracy and precision in catheter tip placement at the target site (foramen of Monro) were both higher (p = 0.038 and p = 0.043, respectively) with electromagnetic neuronavigation. Unintended placement of the distal catheter contralateral to the target site occurred more frequently with optical navigation, as did superior or inferior positioning by more than 5 mm. Mean operative times were shorter (p = 0.027) with electromagnetic neuronavigation (43.2 min) than with optical navigation (51.0 min). There were three complications (10.7%) - one case each of cytotoxic edema, post-operative wound infection, and urinary tract infection. The rate of complication did not differ between groups. Conclusion: In contrast with optical neuronavigation, frameless and pinless electromagnetic image guidance allows the ability to track instrument depth in real-time. It may increase ventricular catheter placement accuracy and precision, and decrease operative times. [ABSTRACT FROM AUTHOR]

Methods: Leptomeningeal metastases (LM) in the setting of glioma have often been thought to carry a particularly poor prognosis. We sought to better characterize this phenomenon through a review of patients with glioma seen in our institution over the preceding 10 years. We focus here on 34 cases with LM due to grade III or IV glioma. Over the period in question, we estimate a prevalence of almost 4% in those affected by grade IV tumors. Results: Leptomeningeal spread was present at the time of initial diagnosis in 4 patients. Among the others, LM occurred at the time of first progression of disease in 17. The median time to development of LM (excluding those where it was present at initial diagnosis) was 16.4 months [95% confidence interval (CI) 8.2-43.9]. The median time to further progression of disease following LMwas 4.9 months (95% CI 3.1-6.9).Twenty-five patients were known to have died at the time of writing. Thus, median overall survival (OS) was 10.2 months (95% CI 8.8-14.7) following LM. At the time of diagnosis of LM, some form of treatment (chemotherapy and/or radiation vs. no treatment) increased OS (median 11.7 vs. 3.3 months, p <0.001 by log-rank test). Use of radiation therapy (vs. no radiation) also increased OS, although the effect was more modest (7.8 vs. 16.8 months, p =0.07). Higher Karnofsky Performance Status (KPS) at the time of diagnosis of LM was associated with OS (p =0.007, median OS for KPS ⩾90 19 months vs. 7.8 for KPS <90). In a two-variable model incorporating the use any treatment (vs. none) and KPS, the latter tended to be a more significant predictor of survival (p =0.22 vs. p =0.06 by likelihood-ratio test). This was also true for radiation (vs. none) and KPS (p =0.27 vs. p =0.02). No significant benefit could be demonstrated for the use of chemotherapy considered alone, either systemic or intrathecal. It should be noted that 4 of 9 patients receiving intrathecal chemotherapy had a ventriculo-peritoneal shunt in place during these injections, which may have reduced its effectiveness. Conclusion: Overall, treatment appears to improve outcomes. We favor maximal treatment, as tolerated, particularly with a KPS of ⩾70. Such treatment would typically include radiation to the maximum tolerated dose, concurrent, and adjuvant chemotherapy (preferably with an alkyating agent), in addition to intrathecal treatment. [ABSTRACT FROM AUTHOR]

Summary: Objectives: Ommaya reservoirs (OmR) are used in the treatment of cancer yet risk factors and outcome of infection are not well characterized. We therefore examined our experience with this device. Methods: Using administrative databases, we identified all patients with OmR in situ between 1993 and 2008 at Memorial Sloan-Kettering Cancer Center. Charts were reviewed for laboratory, demographic, and clinical information. Results: During the study period, 616 patients with OmRs received care at MSKCC comprising 462,467 Ommaya-days. 34 patients with OmR infection were identified (5.5% of patients, 0.74 infections per 10,000 Ommaya-days). 32% of infections occurred within 30 days of OmR placement. Most (74%) OmR infections occurring after 30 days post-placement were associated with OmR access in the preceding 30 days. Recovered organisms included coagulase-negative staphylococci (56%) and Propionibacterium acnes (24%). 70% of patients had fever and/or headache and 69% had cerebrospinal fluid pleocytosis. 50% of patients had the reservoir removed during treatment of the infection. Conclusions: OmR infection occurs in one of every 20 persons with the device. A third of the infections appear related to OmR placement while the remainder may occur at any time and usually are associated with recent reservoir access. Treatment often includes device removal. [Copyright &y& Elsevier]

Background: Intra-cerebrospinal fluid (CSF) chemotherapy for leptomeningeal metastasis (LM) can be delivered intraventricularly via an Ommaya reservoir. However, hydrocephalus associated with LM can interfere with chemotherapeutic drug distribution, and ventriculoperitoneal shunts can prevent drug distribution to the extra-ventricular CSF space. This study examined the feasibility of combining a lumboperitoneal (LP) shunt with an Ommaya reservoir to both control intracranial pressure and allow for intraventricular chemotherapy., Methods: We identified 16 patients with LM who received both an Ommaya reservoir and an LP shunt, either concurrently or sequentially, and subsequently received intraventricular chemotherapy. The feasibility of this combination for intraventricular chemotherapy was evaluated by assessing 1) the distribution of intraventricularly injected drugs in CSF samples collected 0, 6, and 12 h post-injection and 2) adverse events associated with the procedure and drug administration., Results: Patients received a median of seven rounds (range 1-37) of intraventricular chemotherapy during a median follow-up period of 5.2 months after LP shunt insertion. Pharmacokinetic data were obtained from six patients. Baseline methotrexate (MTX) levels from Ommaya reservoirs varied from 339.9 µM to 1,523.5 µM. CSF sampled from LP shunt reservoirs revealed an elimination half-life (t 1/2 ) of 2.63 h, and the mean ratio of MTX concentration at 12 h to that at baseline was 0.05±0.05, ensuring drug distribution from the ventricle to the spinal canal. Nine patients (56%) underwent revision surgery due to catheter migration, malfunction, or infection. Among these patients, CSF infections attributable to intraventricular chemotherapy (n=3) occurred, but no infections occurred in later cases after we began to employ a complete aseptic technique., Conclusion: LP shunt combined with Ommaya reservoir insertion is a feasible option for achieving both intracranial pressure control and the continuation of intraventricular chemotherapy in patients with LM., Competing Interests: Ho-Shin Gwak, the editor-in-chief of Brain Tumor Research and Treatment, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest., (Copyright © 2022 The Korean Brain Tumor Society, The Korean Society for Neuro-Oncology, and The Korean Society for Pediatric Neuro-Oncology.)

When pain is refractory to systemic opioid and non-opioid analgesic therapy and palliative chemoradiation or ablative or stimulant neurosurgical procedures are not possible, palliative treatment becomes limited, particularly if the patient wishes to be at home at the end of life. Intracerebroventricular (ICV) infusion of morphine in the home setting might be presented as an option. The present article reviews the basic and clinical evidence of the efficacy and safety of ICV administration of opioids. Information was gathered from various bibliographic sources, including PubMed and others, and summarized and evaluated to assess the efficacy and safety of ICV opioids for pain relief. Results from ICV infusion of morphine into terminally ill patients refractory to other pain treatments have been reported since the early 1980s. Good efficacy has been achieved for the vast majority of patients, without serious development of analgesic tolerance. There have also been a low incidence of adverse effects, such as constipation and respiratory depression, and a significant retention of alertness associated with this route of administration. Intracerebroventricular infusion of opioid analgesics thus appears to be a safe and effective therapy for the palliative treatment of refractory pain. [ABSTRACT FROM AUTHOR]

Background: The majority of ventriculoperitoneal (VP) shunt malfunctions are due to proximal catheter failure. Ideal placement of Ommaya reservoirs is desired to avoid toxicity from intraparenchymal chemotherapy infusion. Objective: To determine whether stereotactic placement of ventricular catheters decreases the rate of Ommaya reservoir complications and the rate of proximal VP shunt failure. Methods: Under institutional review board approval, areview of a prospectively collected database was doneidentifying all patients who underwent stereotactic-guided placement of VP shunts and Ommaya reservoirs performed by a single surgeon between November 2007 and November 2009. Neuronavigation was used to preset a surgical plan consisting of an ideal entry point (usually frontal) and target point (ipsilateral foramen of Monro). The navigation probe was passed along this trajectory. After removal of the navigation probe, pre-sized ventricular catheters were passed without a stylet along the created path. Post-operative CT scans and clinical follow-up were assessed. Results: 70 patients (mean age 44.6 years) underwent 52 VP shunt and 18 Ommaya reservoir placement procedures. Rigid cranial fixation was used in all cases. All catheters were placed in a single pass. Mean operative time was 62 min. Mean follow-up was 16.3 months. No proximal malfunctions or Ommaya complications have been seen thus far. One patient required repositioning of an Ommaya reservoir as post-operative CT showed poor placement (1.4%). One patient with hydrocephalus due to cryptococcal meningitis developed an abdominal abscess and required removal of his entire shunt with subsequent replacement. One patient was noted to have a small amount of intraventricular hemorrhage; this did not result in any clinical change and did not require any further intervention. No other surgical complications were noted. Conclusion: In terms of results corroborating decreased proximal malfunction rates, we present the largest series of stereotactic-guided ventricular catheter placements to date. Though time in the operating room is increased due to navigation registration, actual operative time is comparable to procedures without navigation. A longer-term follow-up is needed to assess the longevity of our positive short-term results. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Intraoperative ultrasound (iUS) is an effective guidance and imaging system commonly used in neuro-oncological surgery. Despite the versatility of iUS, its utility for single burr hole puncture guidance remains fairly underappreciated., Objective: To highlight the simplicity, versatility, and effectiveness of iUS guidance in brain puncture by presenting the current case series and technical note collection., Methods: We present 4 novel uses of iUS guidance for single burr hole brain puncture: cannulation of normal-sized ventricles, endoscopic third ventriculostomy (ETV) guidance, evacuation of interhemispheric empyema, and stereotactic biopsy assistance., Results: All techniques were performed successfully in a total of 16 patients. Normal-sized ventricles were cannulated in 7 patients, among whom 5 underwent Ommaya reservoir placement and 2 underwent ventriculoperitoneal shunt placement for idiopathic intracranial hypertension. No more than 1 attempt was needed for cannulation. All ventricular tip positions were optimal as shown by postoperative imaging. iUS guidance was used in 5 ETV procedures. The working cannula was successfully introduced to the lateral ventricle, providing the optimal trajectory to the third ventricular floor in these cases. Interhemispheric subdural empyema was aspirated with iUS guidance in 1 patient. Volume reduction was clearly visible, allowing near-total evacuation of the empyema. iUS guidance was used for assistive purposes during stereotactic biopsy in 3 patients. No major perioperative complications were observed throughout this series., Conclusion: iUS is an effective and versatile guidance system that allows for real-time imaging and can be easily and safely employed for various brain puncture procedures., (© Congress of Neurological Surgeons 2021.)

Endoscopic third ventriculostomy (ETV) is a well established treatment for selected cases of obstructive hydrocephalus. However, it does carry a significant rate of failure, which can be abrupt and life threatening. The present study analyses the benefits versus the risks of routine CSF reservoir insertion during ETV. Clinical data obtained from the medical records of patients from a single neurosurgical centre who underwent ETV between August 2002 and February 2007 were analysed retrospectively. A total of 34 records were available with follow-up ranging from 3-56 months (Median 26 months) and with patient age range between 6 months - 75 yrs (median 19 years). During this period, one neurosurgeon routinely placed reservoirs in all patients undergoing ETV (n = 34). In all instances of reservoir insertion, Ommaya reservoirs were used. The number of patients in which the reservoir was tapped for diagnostic and/or therapeutic reasons was quantified, and all complications resulting from reservoir placement recorded. ETV success was defined by a lack of subsequent need for cerebrospinal fluid diversion. In total 13 of 34 (38%) reservoirs inserted were tapped at a later date and there were no complications associated with their insertion. Tapping of reservoirs helped determine which patients required subsequent ventriculoperitoneal (VP) shunting. In at least one case reservoir tapping was carried out as an emergency and was a crucial intermediate intervention prior to further surgery. The overall success rate of ETV was 65% (95% CI, 49-81%) with four complications associated with ETV: short-term memory loss, psychosis, and two cases of post-operative seizures. These complications were not attributed to CSF reservoir insertion but the ETV procedure itself. The routine placement of CSF reservoir following ETV thus seems justified with respect to the observed benefits and lack of complications associated with its placement. [ABSTRACT FROM AUTHOR]

The authors demonstrate the utility of portable intraoperative CT scans for the rapid identification of ventricular catheter tip location after Ommaya reservoir placement. The O-arm (Medtronic Sofamor Danek, Memphis, TN, USA) was utilized to confirm ventricular catheter placement intraoperatively. Conventionally, a postoperative CT scan is obtained prior to Ommaya reservoir use to ensure proper catheter placement. By obtaining these images intraoperatively, revisions may be performed without the need for an additional surgical procedure, and the reservoir may be utilized immediately postoperatively. [ABSTRACT FROM AUTHOR]

Meningitis is a common and life-threatening infection of the central nervous system (CNS) in infants with long-term and disabling sequelae like hydrocephalus. Hydrocephalus is treated by diverting cerebrospinal fluid (CSF) either to another body cavity (via CSF shunt) or externally (via CSF drain) which are prone to infection. Though rare, Candida parapsilosis ( C. parapsilosis ) is a known pathogen in device-associated CNS infections and has been reported in both, infants and adults. A six-month-old male infant was brought to the hospital with disproportionate head enlargement of three months duration. Magnetic resonance imaging (MRI) was suggestive of gross asymmetrical hydrocephalus. An external ventricular drain (EVD) was placed, and vancomycin and meropenem were started. Four weeks later, he developed a fever with a blocked EVD. Repeat MRI revealed gross asymmetric dilatation of left lateral ventricle along with pneumocephalus in the right periventricular region. A right temporoparietal craniotomy with drainage of a multiloculated abscess was done along with the removal of right EVD and placement of left EVD. CSF showed pan-susceptible C. parapsilosis and fluconazole was started. Despite treatment, CSF continued to grow C. parapsilosis through day 10. The EVD was removed, and an Ommaya reservoir along with the ventricular catheter was placed for better interventricular antibiotic administration. After day 13 CSF became sterile. Ommaya reservoir was removed, fluconazole was continued for three weeks, and a ventriculoperitoneal shunt was placed five weeks later. The device-associated CNS infections are insidious with nonspecific manifestations making diagnosis difficult. C. parapsilosis has been increasing in prevalence, especially in immunocompromised hosts, infants, and in patients with indwelling catheters. Amphotericin B or fluconazole is the usual treatment with excellent outcomes and no mortality. This case underscores the need for suspicion of C. parapsilosis as a cause of device-associated CNS infections., Competing Interests: The authors have declared that no competing interests exist.

Background: The use of Ommaya catheters or ventriculoperitoneal shunts with programmable valves (pVP-shunts) for intraventricular drug administration is increasingly more common., Procedure: We reviewed the safety and complication rate associated with ventricular access devices in patients receiving compartmental intraventricular radioimmunotherapy (cRIT)., Results: One hundred fifty one patients with recurrent primary or metastatic central nervous system (CNS) tumors (1-34 years) had a ventricular access device (143 Ommaya reservoirs, 8 VP shunts with programmable valves) placed for drug administration and cerebrospinal fluid acquisition. Patients received 2-5 serial injections (124) I- or (131) I- labeled monoclonal antibody 3F8 or 8H9. For each injection, catheters remained accessed for pharmacokinetic studies up to 48 hours or were individually accessed 3-6×/injection. Thereafter catheters were accessed for periodic routine cytology. Six patients (4%) had complications including three with catheter migration in the newly-placed setting requiring surgical revision. Two patients had pericatheter cyst formation (with cyst formation before radioimmunotherapy administration in one patient) resulting in elective removal and endoscopic cystoventriculostomy in both patients. There were no catheter-related infections, hemorrhages, seizures, focal deficits, or valve malfunctioning. Four patients later required Ommaya conversion to VP shunts because of hydrocephalus secondary to disease progression., Conclusions: We report a long-term safety profile of ventricular access devices in patients receiving cRIT. Minimal acute complications are observed despite the frequency of cerebrospinal fluid acquisition; long-term complications are rare. Programmable VP shunts appear to be a safe and effective alternative to Ommaya catheters., (© 2014 Wiley Periodicals, Inc.)