Search

Background and purpose Idiopathic normal-pressure hydrocephalus (iNPH) is a progressive, severe brain disorder, which mainly affects people above the age of 65 years. iNPH is characterized by the accumulation of excess cerebrospinal fluid in the brain's ventricles. In most cases, iNPH patients can be effectively treated with shunt surgery, which involves placing a tube into the brain to drain the excess fluid. As part of the European Brain Council-led Value of Treatment project, this study aimed to investigate the cost-effectiveness of delivering timely and adequate iNPH treatment in Germany. Methods The study identified treatment gaps that prevent iNPH patients from receiving adequate and timely treatment. The cost-effectiveness of delivering shunt surgery to iNPH-prevalent patients aged ≥65 years in Germany was calculated using decision-analytical modelling. The model compared two alternatives, current care (shunt surgery in 25% of iNPH cases) and target care (shunt surgery in 90% of iNPH cases), and looked at healthcare costs (diagnosis, shunt intervention and follow-up care) from the public health insurance perspective, as well as effectiveness outcomes in terms of lives saved and quality-adjusted life-years (QALYs) gained. Results Delivering timely and adequate iNPH treatment proved to be cost-effective. Cost per life saved varied between €27 921 at 5 years and €246 726 at 15 years. Cost-per-QALY estimates varied between €10 202 at 5 years and €35 128 at 15 years. Conclusions Idiopathic normal-pressure hydrocephalus is a treatable but often not-treated disease, resulting in unnecessary and avoidable disease burden for the healthcare system. Actions required to close this treatment gap are straightforward and their implementation has been modelled with successful outcomes.

Endometriosis is a disorder in women which is characterized by extrauterine manifestations. We describe a case of cerebellar endometriosis in a 39-year-old woman who underwent posterior fossa decompression multiple times without establishing a correct diagnosis. Her neurologic status progressively worsened due to chronic hydrocephalus and brainstem compression by cysts. Late in the clinical course, histology from the cyst wall was taken that revealed endometriosis with clear cells and positive immunohistology for progesterone and estrogen receptors. Treatment with gestagens was started but did not improve the patient's status. In patients with chronic recurring intracranial cysts and hydrocephalus, cerebral endometriosis should be considered.

Normal pressure hydrocephalus is a disease in elderly patients and one of the most common causes of treatable dementia. It occurs frequently with microangiopathy and Alzheimer's disease, so that differential diagnosis plays an important role. This is crucially determined by imaging findings. Therapy consists of cerebrospinal fluid drainage through a shunt, which should be performed as early as possible to improve the chances of success. This report is based on a summary of the relevant literature that has been reviewed in PubMed with reference to epidemiology, symptoms, pathophysiology, diagnostics, and therapy. The results were supplemented by the joint guidelines of the German Society of Neurology and the German Society of Neurosurgery. The understanding of the pathophysiologic changes leading to normal pressure hydrocephalus has expanded significantly in recent years to include concepts explaining relevant comorbidities. Diagnosis is based on radiological and clinical indicators, although accurate differentiation with respect to comorbidities is not always possible. A high response rate to treatment can be achieved by good patient selection. Positive prognostic markers for therapeutic success include Disproportionately Enlarged Subarachnoid Space Hydrocephalus (DESH), short disease duration, predominant gait disturbance, and few comorbidities. · Normal pressure hydrocephalus mainly affects patients older than 65 years of age with high comorbidity rate for microangiopathy and Alzheimer's disease. · Radiologic findings play an important role in the diagnosis and follow-up after shunting. · The earlier a shunt is placed, the better the outcome.· Illies T, Eckert B, Kehler U. What Radiologists Should Know About Normal Pressure Hydrocephalus. Fortschr Röntgenstr 2021; 193: 1197 - 1206. Der Normaldruckhydrozephalus ist eine Erkrankung älterer Patienten und eine der häufigsten Ursachen einer behandelbaren Demenz. Er tritt gehäuft mit einer Mikroangiopathie und einem M. Alzheimer auf, sodass die Differenzialdiagnostik eine wichtige Rolle spielt. Diese wird entscheidend von den Bildbefunden getragen. Die Therapie besteht in einer Liquorableitung durch einen Shunt, die möglichst frühzeitig erfolgen sollte, um die Erfolgsaussichten zu verbessern. Die Arbeit beruht auf einer Zusammenfassung der Literatur und wurde mittels Recherche in PubMed hinsichtlich der relevanten Arbeiten zu Epidemiologie, Klinik, Pathophysiologie, Diagnostik und Therapie durchgeführt. Ergänzt wurden die Resultate durch die gemeinsame Leitlinie der Deutschen Gesellschaft für Neurologie und der Deutschen Gesellschaft für Neurochirurgie. Das Verständnis der zu einem Normaldruckhydrozephalus führenden pathophysiologischen Veränderungen ist in den letzten Jahren deutlich erweitert worden und schließt Konzepte zur Erklärung der Komorbiditäten mit ein. Die Diagnostik erfolgt anhand radiologischer und klinischer Indikatoren, wobei eine genaue Differenzierung zu den Komorbiditäten weiterhin nicht immer möglich ist. Durch gute Patientenselektion kann eine hohe Ansprechrate auf die Therapie erreicht werden. Positive prognostische Marker für einen Therapieerfolg sind ein Disproportionally Enlarged Subarachnoid Space Hydrocephalus (DESH), eine kurze Krankheitsdauer, eine vorherrschende Gangstörung und wenige Komorbiditäten. · Der Normaldruckhydrozephalus betrifft hauptsächlich Patienten über 65 Jahre mit hoher Komorbidität einer Mikroangiopathie und eines M. Alzheimer.. · Die Bildgebung spielt eine wichtige Rolle in der Diagnostik und der Therapiekontrolle.. · Je früher eine Shuntanlage erfolgt, desto besser ist die Prognose..· Illies T, Eckert B, Kehler U. What Radiologists Should Know About Normal Pressure Hydrocephalus. Fortschr Röntgenstr 2021; 193: 1197 – 1206.

ZusammenfassungFür Diagnostik, Differenzialdiagnostik und Differenzialtherapie des Normaldruckhydrozephalus ist die Bildgebung entscheidend. Auch wenn die Therapie eines Normaldruckhydrozephalus nicht erfolgreich sein sollte, werden zahlreiche Fragen an den Radiologen gestellt. Der Artikel gibt eine Übersicht über das Krankheitsbild des Normaldruckhydrozephalus und die speziellen prä- und postchirurgischen Anforderungen an die Bildgebung.

Background We investigated the understudied anatomical variations of the superior petrosal vein (SPV) complex (SPVC), which may play some role in dictating the individual complication risk following SPVC injury. Methods Microvascular decompressions of the trigeminal nerve between September 2012 and July 2016. All operations utilized an SPVC preserving technique. Preoperative balanced fast field echo (bFFE) magnetic resonance imaging, or equivalent sequences, and operative videos were studied for individual SPVC anatomical features. Results Applied imaging and operative SPVC anatomy were described for fifty patients (mean age, 67.18 years; female sex and right-sided operations, 58% each). An SPVC component was sacrificed intentionally in 6 and unintentionally in only 7 cases. Twenty-nine different individual variations were observed; 80% of SPVCs had either 2 SPVs with 3 or 1 SPV with 2, 3, or 4 direct tributaries. Most SPVCs had 1 SPV (64%) and 2 SPVs (32%). The SPV drainage point into the superior petrosal sinus was predominantly between the internal auditory meatus and Meckel cave (85.7% of cases). The vein of the cerebellopontine fissure was the most frequent direct tributary (86%), followed by the pontotrigeminal vein in 80% of SPVCs. Petrosal-galenic anastomosis was detected in at least 38% of cases. At least 1 SPV in 54% of the cases and at least 1 direct tributary in 90% disturbed the operative field. The tributaries were more commonly sacrificed. Conclusions The extensive anatomical variation of SPVC is depicted. Most SPVCs fall into 4 common general configurations and can usually be preserved. BFFE or equivalent sequences remarkably facilitated the intraoperative understanding of the individual SPVC in most cases.

Cerebrospinal fluid (CSF) shunt revision surgery represents a huge social and economic burden. Few studies, however, have evaluated shunt revision surgeries in the context of their avoidability, and existing data are from paediatric populations. Using ratings from an expert panel, we classified avoidable and unavoidable shunt revisions in a mixed cohort of CSF-shunt patients. In a retrospective review of a prospectively maintained, single-centre database, we identified all shunt systems implanted for the first time over a 10-year period (2007–2016) and all subsequent revision surgeries with a follow-up of at least 1 year. A panel of five expert shunt surgeons classified each revision surgery as avoidable or unavoidable. Rates of each were calculated and correlated with clinical data. Of 210 revision surgeries (314 patients, mean age, 49.9 years; mean follow-up, 4.2 years), the panel judged 114 as unavoidable (54.3%) and 96 (45.7%) as avoidable. Level of surgeon education correlated with these rates, but even in the most experienced hands, 12.5% of revisions were classified as avoidable. Avoidable revisions occurred significantly earlier than unavoidable interventions (mean; 112 and 448 days, respectively) after the index surgery. Rates of avoidable shunt revision surgery are alarmingly high, even in experienced hands. Avoidable revisions occur significantly earlier, predominantly within the first 3 months after the index surgery.

Objective Cerebrospinal fluid (CSF) overdrainage is a major problem in shunt therapy for hydrocephalus. The adjustable gravitational valve proSA allows for the first time a targeted compensation for overdrainage in the upright position without interfering with the differential pressure valve. To evaluate benefit, safety and reliability, the multicenter prospective registry PROSAIKA was conducted in 10 German neurosurgical centers. Methods Between March 2009 and July 2010, 120 hydrocephalic patients undergoing first time shunt implantation or shunt revision using proSA entered the study. 93 patients completed the 12 months follow-up. Results Hydrocephalus symptoms were improved in 86%, unchanged in 9% and deteriorated in 3%. In 51%, the proSA opening pressure was readjusted one or several times to treat suspected suboptimal shunt function, this resulted in clinical improvement in 55%, no change in 25%, and deterioration in 20% of these patients. The 1 year censored proSA shunt survival rate was 89%. Device related shunt failure was seen in two cases. Conclusions This is the first clinical report on the implantation of the adjustable gravitational valve proSA with a follow-up of 12 months in a substantial number of patients. Irrespective of different hydrocephalus etiologies and indications for shunt surgery, the overall results after 12 months were very satisfying. The high frequency of valve readjustments underlines the fact that preoperative selection of the appropriate valve opening pressure is difficult. The low number of revisions and complications compared to other valves proves that proSA implantation adds no further risk; this valve is reliable, helpful and safe.

Objectives To investigate whether gravitational valves reduce the risk of overdrainage complications compared with programmable valves in ventriculoperitoneal (VP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). Background Patients with iNPH may benefit from VP shunting but are prone to overdrainage complications during posture changes. Gravitational valves with tantalum balls are considered to reduce the risk of overdrainage but their clinical effectiveness is unclear. Methods We conducted a pragmatic, randomised, multicentre trial comparing gravitational with non-gravitational programmable valves in patients with iNPH eligible for VP shunting. The primary endpoint was any clinical or radiological sign (headache, nausea, vomiting, subdural effusion or slit ventricle) of overdrainage 6 months after randomisation. We also assessed disease specific instruments (Black and Kiefer Scale) and Physical and Mental Component Scores of the Short Form 12 (SF-12) generic health questionnaire. Results We enrolled 145 patients (mean (SD) age 71.9 (6.9) years), 137 of whom were available for endpoint analysis. After 6 months, 29 patients in the standard and five patients in the gravitational shunt group developed overdrainage (risk difference −36%, 95% CI −49% to −23%; p

Primary central nervous system vasculitis (PCNSV) is an idiopathic disorder resulting in multifocal inflammation of small arteries and veins of the cortex and leptomeninges. Typically there is no evidence of vasculitis outside the central nervous system [7]. It is a rare disorder, but, nevertheless, responsible for 3–5 % of cerebrovascular accidents in patients aged \50 years [5]. The pathogenesis is poorly understood and the underlying cause is still unknown [2]. Diagnostic criteria include (1) acquired neurological deficits remaining unexplained after complete evaluation; (2) cerebral angiography with alternating segments of stenosis with normal or dilated intervening segments, and arterial occlusions; (3) no evidence of systemic vasculitis or any other condition that could mimic the angiographic findings [4]. The clinical signs and symptoms are nonspecific (e.g., nausea, headache, focal-neurological deficits, neuropsychological disturbances), reflecting the diffuse and often patchy nature of the pathologic process contributing to a high number of misleading diagnoses [7]. While magnetic resonance imaging of the brain is abnormal in more than 90 % of patients, the findings are unspecific. Multiple small or large ischemic lesions with partial hemorrhagic transformation are frequently found. Cerebrospinal fluid (CSF) analysis is usually abnormal with a modest elevation of total protein and lymphocytes. Cerebral angiography may show abnormal vessels, but has a low sensitivity and specificity [2]. Brain biopsy remains the gold standard for the diagnosis of PCNSV. After exclusion of other causes of multifocal infarctions or pleocytosis in CSF (e.g., endocarditis) brain biopsy is mandatory to confirm vasculitis before initiating a potentially toxic therapy [1]. Here we are presenting a patient with a diffuse perivascular melanoma, mimicking PCNSV. We report on a 45-year-old male who suffered from a dull holocephalic headache for three months, loss of weight (more than 10 kg over the last six months), intermittent nausea and vomiting, and progressive exhaustion during the last weeks. He also reported transient paresthesia in the right arm, gait disturbances, and blurred vision. The patient denied any fever and night sweats. His past medical history showed a naevus excised 15 years ago, which was later identified as a malignant melanoma. Frequent follow-up examinations were unremarkable. His temperature was 37.2 C; other vital signs, the general examination and routine blood studies including the erythrosedimentation rate (ESR) and acute phase M. Schneider (&) P. P. Urban Abteilung fur Neurologie, Asklepios Klinik Barmbek, Rubenkamp 220, 22291 Hamburg, Germany e-mail: mart.schneider@asklepios.com

Background: Cerebrospinal fluid (CSF) leaks are well-known and frequent complications of intracranial procedures. Numerous studies have focused on the clinical aspects of incidence, risk factors, outcome, treatment, and prevention; however, large prospective multicenter studies are missing. The aim of this study was to prospectively analyze the rate of CSF leaks and their causes. Method: A total of 545 patients with a variety of intracranial procedures (elective and trauma) were recruited in a multicenter, prospective, observational study over a 12-month period. Results: In 545 cranial surgeries, we observed a CSF leak rate of 7.7% (n=42) at the time of discharge from the hospital. Significant risk factors for CSF leaks were posterior fossa surgery, opened pneumatized spaces, patients younger than 66 years, size of craniotomies, craniectomies rather than craniotomies, remaining dura defects larger than 1 cm, and wound closure without using muscle sutures, continuous locked, or unlocked sutures. Non-significant risk factors for CSF leaks were revision craniotomies, craniotomies for different pathologies, previous radiotherapy and/or systemic chemotherapy, augmentation of dura sutures with various materials, and wound drains as well as temporary CSF drains. Conclusion: Despite the number of techniques and developments for dural closure, the problem of CSF leaks remains evident and further improvement has to be made.

Objective Shunt obstructions may partly be caused by brain debris, which intrude into the ventricular catheter during ventricle puncture. Avoiding contact between the catheter and brain tissue, by using a peel-away sheath, should reduce the number of shunt failures caused by obstruction. To test this hypothesis, we conducted a randomized, prospective multicenter study. Methods 201 patients from 6 different neurosurgical centers in Germany receiving a ventriculo-peritoneal shunt were included in this study. Of these, 177 patients completed a 1-year follow-up period. Surgery was randomized in a 1 to 1 fashion, such that out of 177 procedures, 91 were performed using a peel-away sheath and 86 were performed without. The rate of surgical re-interventions and shunt obstructions within a 12-month period was recorded. Results Within 1 year post-surgery, 17 shunt obstructions (9.6%) leading to shunt revisions were recorded. However, no difference was found between surgeries performed using a peel-away sheath (9.9%) or not (9.3%). The overall shunt infection rate was 2.8% and the shunt revision rate for overdrainage was 3.9%. Conclusions The theoretical advantages attributed to the use of a peel-away sheath to introduce a ventricular catheter could not be confirmed in this randomized study, suggesting that the proposed role of brain debris in shunt obstructions may be overestimated.

Object Ventriculoatrial (VA) shunts inserted for the treatment of hydrocephalus are known to be a risk factor for pulmonary hypertension. The aim of this study was to evaluate the incidence of pulmonary hypertension among adult patients with VA shunts. Methods All patients who had received a VA shunt at one of two institutions between 1985 and 2000 were invited for a cardiopulmonary evaluation. The investigation included a thorough history taking, clinical examination, echocardiography, and pulmonary function testing including diffusing capacity of the lung for carbon monoxide (DLCO). Pulmonary hypertension was defined as systolic pulmonary artery pressure > 35 mm Hg at rest. Results The study group consisted of 86 patients, of whom 38 (44%) could be examined. The patients' mean age was 47.1 ± 18.4 years; the median interval between shunt insertion and cardiopulmonary evaluation was 15 years (range 5–20 years). Of the 38 patients, 20 (53%) had Doppler velocity profiles of tricuspid regurgitation that were adequate for the estimation of pulmonary artery systolic pressure. Doppler-defined pulmonary hypertension was observed in 3 patients (8%), 2 of whom underwent right heart catheterization. Chronic thromboembolic pulmonary hypertension was confirmed in both patients, and medical therapy, including anticoagulation, was started. The VA shunt was removed in both cases and replaced with a different type of device. Pulmonary function tests revealed a restrictive pattern in 15% and typical obstructive findings in 9% of patients. In 30% of patients the DLCO was less than 80% of predicted, and blood gas analysis showed hypoxemia in 6% of patients. No significant differences in pulmonary function tests were noted between the patients with and without echocardiographic evidence of pulmonary hypertension. However, patients with pulmonary hypertension had significantly lower DLCO values. Conclusions The authors detected pulmonary hypertension by using Doppler echocardiography in a significant proportion of patients with VA shunts. It is therefore recommended that practitioners perform regular echocardiography and pulmonary function tests, including single-breath DLCO in these patients to screen for pulmonary hypertension to prevent hazardous late cardiopulmonary complications.

Background: The insertion of ventriculoatrial (VA) shunts for the treatment of hydrocephalus is thought to be associated with the development of pulmonary hypertension in adults. Objectives: It was the aim of this study to describe the frequency and the clinical spectrum of pulmonary hypertension in adults with VA shunts. Methods: Patients with pulmonary hypertension were retrospectively evaluated from January 1999 to December 2006. Results: Among the 575 patients with pulmonary hypertension, 6 (mean age 42.5 ± 8.3 years) were identified as having received a VA shunt. Mean pulmonary artery pressure for these patients was 53.3 ± 14.9 mm Hg. The interval between shunt placement and the diagnosis of pulmonary hypertension was 9–27 years (median 16.5). While ventilation perfusion scans showed multiple bilateral perfusion defects in all patients, chest CT or pulmonary angiography demonstrated pulmonary thromboembolism in only 2 of the 6 patients. These 2 patients subsequently underwent pulmonary endarterectomy. Another patient required heart-lung transplantation because of severe pulmonary hypertension; lung histology showed prominent eccentric medial hypertrophy and intimal proliferation without evidence of thromboembolism. Contrary to earlier reports, outcomes were generally good, with a 100% survival rate for the first 8 years following diagnosis. Conclusions: Severe pulmonary hypertension can develop in adult patients with VA shunts. Therefore, clinicians should consider pulmonary hypertension as a potential cause for respiratory symptoms in patients who have received VA shunts.

The authors present the case of a 2-year-old boy who was born with a small bulging mass in the middle frontonasal area and hypertelorism. In the neonatal period he suffered from a continuous lacrimal secretion mistaken for recurrent conjunctivitis. Cranial computerized tomography scanning and magnetic resonance imaging revealed a frontoethmoidal encephalocele associated with an ocular leakage of cerebrospinal fluid. One-stage repair of the encephalocele, along with correction of hypertelorism and bone grafting of the forehead, was performed with good result. During a 2-year follow-up period no neurological deficits appeared.

Primary central nervous system lymphomas (PCNSL's) are rare tumours which generally accounted for 1.0-1.5% of all intracranial neoplasms. However, within the last decade the frequency of cerebral lymphomas has dramatically increased. We retrospectively analysed the neuroradiological findings (computed tomography (CT), MRI, angiography) in 37 patients with PCNSL. Thirty patients with the clinically and neuroradiologically suspected diagnosis of cerebral lymphoma underwent CT- or MRI-guided stereotactic biopsy. In seven cases an open surgical intervention was performed. Preoperatively, CT with and without contrast medium was performed in all but two cases. Twenty-eight patients received MRI (axial SE T2 weighted, triplanar SE T1 weighted, triplanar SE T1+Gadolinium). Additionally, in 9 patients cerebral angiography was performed. Typical neuroradiological patterns are: (1) iso- or hyper-density (85.5%) on unenhanced CT scan with marked contrast enhancement (87.7%); (2) infiltration/contact of leptomeningeal and/or ependymal spaces (97.3%); (3) hyperintensity on T2 with moderate oedema (80.3%). Histopathological work-up included conventional and immunohistochemical stains performed on formalin fixed and paraffin embedded bioptical specimen. Despite widely used preoperative dexamethasone treatment, an accurate histopathological diagnosis of PCNSL of B cell type was established in all cases except one. The high percentage of accurate histopathological diagnosis was based on: (1) great mean sample volume per biopsy site; (2) great number of biopsies in patients suspected to have cerebral lymphomas; and (3) MR-guided stereotactic procedures if the lesion was not clearly identifiable on CT scan.

The advantages of using magnetic resonance imaging (MRI) as opposed to computed tomographic (CT) scans or ventriculography in stereotactic surgery include the increased tissue contrast of the lesion or target, direct non-reformatted multiplanar imaging and target coordinate determination as well as reduced imaging artefacts produced by the stereotactic frame. One disadvantage of MR stereotaxis, however, is the potential for anatomic inaccuracy due to equipment-induced inhomogeneities of the magnetic field. The authors present an experimental study on an in vitro model to examine the accuracy of target localization using the Leksell stereotactic frame and MR imaging. Ten formalin-fixed brains taken from patients who had died of non-neurological diseases were sealed in a properly modelled plaster-cast shell simulating the skull bone. These models were fixed in the Leksell stereotactic frame and high-field MR images were performed (Siemens Magnetom SP 1.5 Tesla, T1-weighted spin echo sequences, TR/TE 600/15 ms, slice thickness 2 mm, FOV 300 mm). Following electrocoagulation of different targets on both lentiforme nuclei, the localization and extension of the lesions were controlled by MRI. A gross-/histopathological verification was performed. This model allows a good representation of the anatomic structures without any artefacts. The postoperative MRI control and the pathological examination of the lesions matched well with the preoperatively defined targets. The correlation of coordinates and measurements obtained with the pathological studies were within a +/- 2 mm range in all cases.

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP syndrome) is a life threatening, severe complication of pre-eclampsia with typical laboratory findings. An unusual case of a 36-year-old woman with HELLP syndrome and the initial complication of intracerebral haemorrhage is presented. The diagnosis of HELLP syndrome was confirmed by elevated liver enzymes, low platelets, increased total bilirubin and increased lactate dehydrogenase. The intracranial haematoma was removed with good neurological recovery ensuing. However, this case was complicated by cerebral vasospasm on the eleventh day, confirmed by cerebral angiography and computer tomographic findings. The patient died from brain swelling. Possible vasospam should be considered during the treatment of patients with HELLP syndrome.

Objective The goal of this study was the retrospective analysis of long-term data on endoscopic ventriculocisternostomy versus ventriculoperitoneal shunt placement in the treatment of hydrocephalus. Methods A total of 159 patients were included in the study. One hundred and twenty-three patients received a ventriculoperitoneal shunt, whereas 36 patients were treated with an endoscopic procedure. Only patients with a postoperative observation period of at least 3 years were included in the analyses of the long-term data. In addition to general patient and operation data, the number and frequency of perioperative complications (infections, dysfunctions) and the frequency and type of necessary revision operations were collected. Results The average observation period was 69 months for both groups. The risk of operative revision was significantly elevated in the shunt group despite a comparable observation period. Whereas 86.11% of the endoscopy group did not require an operative revision, that only applied to 68.85% of the shunt group. The complication rate was 42.7% in the shunt group per procedure, which was clearly higher than in the endoscopy group at only 9.4%. Conclusion The risk of operative revision and/or complications is significantly lower in the endoscopic ventriculocisternostomy group compared to the ventriculoperitoneal shunt group. Given the appropriate indication, endoscopic ventriculocisternostomy is thus the treatment of choice.

BACKGROUND: Little is known about variables associated with overdrainage complications and neurofunctional and health-related quality of life outcomes in idiopathic normal-pressure hydrocephalus (iNPH) patients after shunt surgery. OBJECTIVE: To identify candidate demographic and disease-specific predictors of overdrainage and patient-related outcomes, allowing for more personalized care of patients with iNPH. METHODS: This was a secondary analysis of the dataset of the SVASONA study, a multicenter randomized trial comparing gravitational and conventional gravitational valves for treating iNPH. We evaluated the association between baseline items and the incidence of overdrainage, using different endpoint definitions. RESULTS: We identified only a few variables associated with a possible increased risk of overdrainage. Apart from using conventional rather than gravitational valves, longer duration of surgery and female sex were associated with a higher risk of clinical signs and symptoms suggestive of overdrainage (hazard ratio: 1.02, 95% confidence interval: 1.01-1.04 and 1.84, 95% confidence interval: 0.81-4.16). The occurrence of clinical symptoms of overdrainage, and the need for exchanging a programmable by a gravitational valve may adversely affect disease-specific outcomes like the Kiefer score. CONCLUSION: Few, if any, baseline and treatment characteristics may be helpful in estimating the individual risk of complications and clinical outcomes after shunt surgery for iNPH. Patients should be informed that longer surgery for any reason may increase the risk of later overdrainage. Also, women should be counseled about a sex-associated increased risk of the development of clinical symptoms of overdrainage, although the latter cannot be distinguished from a generally higher prevalence of headaches in the female population.

The supremacy of low-pressure valves (LPV) in the therapy of patients with idiopathic normal pressure hydrocephalus (iNPH) has been proven by the Dutch NPH study. The downside of LPVs is the high rate of overdrainage complications. In the meantime gravitational units have been developed with the objective of minimising overdrainage complications. Do these gravitational units allow the same favourable outcomes as in the Dutch NPH study without overdrainage complications? The goal of this prospective randomised controlled multicentre trial is to compare the rate of overdrainage complications after shunt surgery with programmable valves with or without a gravitational unit.Patients suspected with iNPH with gait ataxia and one or two other symptoms of Hakim's triad and enlarged ventricles on CT or MRI underwent a cerebrospinal fluid (CSF) infusion test, CSF tap test and/or continuous ICP measurement in seven experienced centres. If iNPH was diagnosed the patients were randomised to receive a ventriculoperitoneal shunt with a programmable valve with or without a gravitational unit. The patients were followed up for 3, 6 and 12 months after surgery. The primary hypothesis of the study was that programmable valves with gravitational units will reduce the rate of overdrainage from 25% to 10%. The outcome measured by iNPH-specific outcome scales (Kiefer score, Black grading scale) and the generic quality of life (short form 12, SF12) was defined as the secondary endpoint. To detect the hypothesised difference in the incidence of overdrainage with a type I error of 5% and a type II error of 20%, correcting for multiple testing and an anticipated drop-out rate of 10%, we planned to enrol 250 patients. To ensure safety and efficacy we performed a planned interim analysis halfway.The study design has been found to be effective with regard to the primary hypothesis.The design of the SVASONA study was developed to be able to confirm the primary hypothesis. Thus, the method of the study should solve the dilemma of the Dutch NPH study by the randomised comparison of LPVs with and without gravitational units.

Objective: The supremacy of low-pressure valves (LPV) in the therapy of patients with idiopathic normal pressure hydrocephalus (iNPH) has been proven by the Dutch NPH study. The downside of LPVs is the high rate of overdrainage complications. In the meantime gravitational units have been developed with the objective of minimising overdrainage complications. Do these gravitational units allow the same favourable outcomes as in the Dutch NPH study without overdrainage complications? The goal of this prospective randomised controlled multicentre trial is to compare the rate of overdrainage complications after shunt surgery with programmable valves with or without a gravitational unit.

A 59-year-old female patient suddenly developed vomiting and gait disturbances followed by decreasing consciousness. CT scans revealed a hemorrhage within the left basal ganglia region with rupture into the ventricles and consecutive hydrocephalus. On angiography an aneurysm in the region of the caput nuclei caudati was shown to be the source of the bleeding. On repeat-angiography 4 months later the aneurysm was no longer visualized, probably due to thrombosis. This is an extraordinary case of a basal ganglia aneurysm comparable with the aneurysms of Willis' circle, but located in a region where generally microaneurysms — mostly combined with hypertension or moyamoya disease can be found.

Overdrainage is a common complication observed after shunting patients with idiopathic normal-pressure hydrocephalus (iNPH), with an estimated incidence up to 25%. Gravitational units that counterbalance intracranial pressure changes were developed to overcome this problem. We will set out to investigate whether the combination of a programmable valve and a gravitational unit (proGAV, Aesculap/Miethke, Germany) is capable of reducing the incidence of overdrainage and improving patient-centered outcomes compared to a conventional programmable valve (Medos-Codman, Johnson & Johnson, Germany).

Acute clinical deterioration due to infarction or haemorrhage of an existing, often previously unrecognized, pituitary tumour is a rare but well-described complication. It can occur spontaneously or may be caused e.g. by mechanical ventilation, infection or surgical procedures. We report on a case of pituitary apoplexy occurring in a 64-year-old patient 3 weeks after cardiac surgery. The patient presented with deep coma and dilated pupils. Magnetic resonance imaging revealed a haemorrhagic pituitary tumour. After prompt endocrinologic replacement therapy with levothyroxine and hydrocortisone the patient regained consciousness. Neurological examination revealed right oculomotor nerve palsy and bilateral cranial nerve VI palsy. Subsequent trans-sphenoidal removal of a nonfunctional macroadenoma with large necrotic areas was performed. The patient recovered completely. To our knowledge, pituitary tumours presenting with a combination of deep coma and dilated pupils must be considered exceedingly rare. Possible pathophysiologic mechanisms are discussed. As our case illustrates, even in severe cases complete recovery is possible if the diagnosis is suspected, and diagnostic and therapeutic measures are initiated in time.

The case of a 17-year-old male with hydrocephalus caused by aqueductal obstruction is presented. A ventriculo-peritoneal shunt was implanted and later removed due to an infection. In the clinical follow-up no deterioration was observed. No further surgery was necessary. The repeat-MRI showed spontaneous resolution of the hydrocephalus with a normal aqueduct.

The authors report on the development of myelopathy in a case of hypoplastic upper cervical spine with atlanto-axial instability. Its surgical treatment with transarticular screw fixation and interlaminar fusion is outlined.

A patient with neurofibromatosis type 1 had pulsating exophthalmos of the right eye with diplopia resulting from severe dysplasia of the sphenoid bone and consecutive herniation of the right temporal lobe. The right orbital tectum was reconstructed with titanium mesh and iliac spongiosa via a lateral orbitotomy using intraoperative navigation. For intraoperative referencing a cortical fixed–reference system and a skin scanning laser device were used. Postoperatively, the diplopia was reduced, but the patient asked for further treatment and the procedure was repeated 6 months later. Intraoperatively, the previously implanted titanium mesh was deformed and most of the transplanted bone was resorbed, probably because of pressure. A more extended mesh was implanted and iliac spongiosa was placed on both sides. Intraoperative navigation was used during both procedures. The adverse effects of diplopia were minimized and follow–up computed tomography after seven months confirmed that the bone graft was in place.

In order to avoid shunt occlusions through particles of brain parenchyma a new procedure was used. Conventionally during ventricle puncture brain tissue may intrude into perforating holes of the ventricular catheter and subsequently shunt dysfunction may occur. By using a peel-away sheath the ventricular catheter can be protected during puncture. The conventional technique (n=90) was compared with the peel-away sheath technique (n=20) in a retrospective analyses in regard to shunt revisions during a 1-year period. Shunt revision was done in 18% (16/90) within 1 year using the conventional technique, respectively, 5% (1/20) using the peel-away sheath technique. Although criteria for statistical significance were not reached these data are worth to be mentioned. A randomised prospective study is initiated and the key features are presented.

A simple method to reapply the Leksell stereotactic frame using marked carbon pins is described. This method allows the reapplication in a quick and safe manner without repetition of the CT scan. The reproducibility was very high.

The management of colloid cyst remains controversial, evaluation of the competing methods seems to be necessary. We report on our experience with colloid cysts in the last decade: ten were managed solely endoscopically, 10 were resected microsurgically (9 via a transcortical/transventricular, 1 via a transcallosal approach). The outcome in the endoscopic group was excellent in 9 cases and unsatisfying in 1 case (recurrence). In the microsurgical group we achieved a good outcome in 5 of 10 cases, a fair outcome in 4 cases and 1 lethal outcome (caused by pulmonary embolism). Complications in the endoscopic group: one intraoperative bleeding, 1 stitch granuloma, 1 mispuncture of the ventricle, and 1 meningitis. Complications in the microsurgical group: 1 subdural effusion, 1 flap infection, 1 mild hemiparesis, 1 transient impairment of consciousness and 1 pulmonary embolism. Mean operative time and length of hospitalization of the endoscopic group were clearly shorter than in the microsurgical group: 91 min versus 267 min time of surgery, 5.1 days versus 18.9 days of hospitalization. Complete resection was achieved in 8 of 10 cases of microsurgery, and in 3 of 10 cases in endoscopy. Endoscopic management results in lower costs and superior patients' comfort. The reduced number of total resections in the endoscopic group may lead to a higher recurrence rate in long-term follow-up, which might be a serious disadvantage of endoscopy. However, more experience in the endoscopic techniques may result in a higher rate of total resection of colloid cysts.

The aim of this study was to develop a device which allows an intermediate, painless fixation of a stereotactic frame prior to definite pin fixation. To stabilize the stereotactic frame rubber coated metal springs were used. By testing the springs on 30 volunteers with different head diameters and circumferences the optimal shape was determined. In the clinical setting 15 patients undergoing stereotactic surgery were tested, stability and patient's convenience were measured. The procedure was well tolerated and measurements revealed symmetric distances between head and frame. Therefore these metal springs are a useful accessory to the Leksell stereotactic system.

The authors report on one case of an abscess at the pyramidal apex. The 52-year old male patient presented with pareses of the fifth and seventh cranial nerves and hypacusis on the right side. After diagnostic procedures (CT-scan, carotid angiography), a tumor at the apex of the right pyramid was expected. During surgery a large encapsulated mass was found containing pus. A bacterial agent could not be isolated. The abscess bordered on the mucosal lining of the sphenoid sinus and on the cells of mastoid bone. The starting point of an abscess at the pyramidal apex is most commonly an otitis media, most frequently caused by staphylococcus. Sterile abscesses are seen in almost 20%. Of differential diagnosis on has to keep in mind other space-occupying lesions especially epidermoid or dermoid cysts.

Acute subdural haematoma (SDH) secondary to a raptured intracranial aneurysm is a rare event. Out of a total of 292 patients with a verified aneurysm (period 1986–1992) in five cases SDH was the diagnosis on CT-evaluation. One patient was in such a bad condition that no treatment was indicated. The remaining four patients were operated on: craniotomy and haematoma evacuation in two cases, craniotomy for haematoma evacuation and aneurysm-clipping in the other two cases. Two patients died and two achieved a good outcome.

We present the data of 99 patients operated on for infratentorial pilocytic astrocytoma from 1955 to 1980 at the Neurosurgical Department of the University of Hamburg/West Germany. Twenty-two patients had died. From 56 patients long-term follow-up was obtained. A comparison was done for patients either operated on until 1969 or since 1970, the time when microscopes had been introduced into the operation theatre. The mortality rate clearly dropped with the beginning of the “microsurgical era”, certainly due to other improvements as well, e. g. neurosurgical intensive care. The drop in mortality was not accompanied by an improvement in outcome. Future perspectives of possibly further improving the therapy of pilocytic astrocytomas are outlined.

A 38 year old woman presented with a short history of headache, double vision, and rotatory vertigo. Medical history was negative except years of nicotine misuse. Cranial MRI disclosed a large infarction in the area supplied by the left posterior inferior cerebellar artery (PICA). Occlusion of the left vertebral artery was confirmed by MR angiography. Five months later, she was again admitted with headache, vomitus, and marked meningism. Cranial CT …

Third ventriculostomy for acquired non-communicating hydrocephalus is an excellent alternative to shunting procedures. Nevertheless, complications can be severe and even fatal (e.g., lesion of the basilar artery), especially if the floor of the 3rd ventricle is very tough and/or opaque. The authors describe a safe method of sharp perforation of the floor, which should be applied if blunt fenestration cannot be achieved easily.