Third Ventricle Research Articles

P.128 Recurrent subarachnoid hemorrhage secondary to Chiari 1 malformation

Background: We describe a patient with recurrent subarachnoid hemorrhage (SAH) secondary to Chiari 1 malformation. Methods: A retrospective review of the clinical chart was performed. Results: A previously healthy female in her 70’s presented with worst headache of life. CT demonstrated 4th ventricular hemorrhage with SAH extending into the bilateral cerebellomedullary fissures. CTA did not show a vascular etiology and patient was discharged home. Incidental note was made of a right persistent trigeminal artery. The patient then represented 2 weeks later with worst headache of life and decreased level of consciousness. CT demonstrated extensive SAH extending into the 3rd and 4th ventricles. CTA and diagnostic cerebral angiogram did not show a vascular etiology. MRI brain/C-spine revealed Chiari 1 malformation. An external ventricular drain was placed but could not be weaned. She underwent suboccipital craniectomy with C1 laminectomy. Intraoperatively, there was a prominent dorsal spinal vein that appeared under tension as it pierced the arachnoid membrane and subsequently entering the dura as a rudimentary occipital sinus. This vein was coagulated and divided. The patient recovered well and was at neurological baseline at 6 month follow-up. Conclusions: This is the first reported case of recurrent SAH secondary to Chiari 1 malformation.

Management of Peri-mesencephalic Hemorrhage leading to acute hydrocephalus in an infant following Mild Trauma (P12-5.030)

<h3>Objective:</h3> To characterize etiology, risk factors, and management of peri-mesencephalic hemorrhage and severity of clinical presentation in pediatric populations <h3>Background:</h3> Peri-mesencephalic hemorrhage (PMH) is a form of mild subarachnoid hemorrhage (SAH) where the bleed is localized near the midbrain or just anterior to the pons without intraparenchymal or ventricular extension. It is typically a non-aneurysmal SAH (NASAH) with no clear source of bleeding after extensive vessel imaging including angiogram. Many hypotheses have been proposed such as spontaneous rupture of a perforating artery or an entirely venous source. Traumatic causes are rarely described. Outcomes are typically much better than aneurysmal SAH and other forms of NASAH with very low risk of rebleed, hydrocephalus, and little to no long-term neurologic deficits. <h3>Design/Methods:</h3> case study <h3>Results:</h3> An 8-month-old developmentally appropriate girl with no prior history of trauma who presented with three episodes of vomiting and lethargy 3–4 hours after a fall from standing position due to loss of balance while she was holding on to a folding chair. She fell backwards onto a tile floor and chair fell on top of her. CTH was obtained which showed prepontine and pontocerebellar hemorrhage spreading to ambient cisterns, IVH of the lateral and 3rd ventricles with acute noncommunicating hydrocephalus and no fracture. CTA with contrast and later MRI brain, MRA, and angiogram did not show any aneurysm or AVM per neurosurgery. EVD was placed with improvement in mental status. Repeat MRI brain was stable with very slight interval increase ventricle, and patient discharged home after 3rd ventriculostomy with no deficits. <h3>Conclusions:</h3> Though rare, trauma is a potential cause of PMH in pediatric populations and can present with acute hydrocephalus due to obstruction of ventricular system successfully treated with EVD placement and 3rd ventriculostomy with positive outcome. Hemorrhage may potentially be due to rupture of small perforating arteries through a sheering force. <b>Disclosure:</b> Dr. Johnson has nothing to disclose. Dr. Ming has nothing to disclose. Dr. Heshmati has nothing to disclose.

An Unusual Case of Posterior Fossa Predominant Posterior Reversible Encephalopathy Syndrome (PRES) Leading to Acute Hydrocephalus (P10-7.002)

<h3>Objective:</h3> To discuss acute hydrocephalus as an unusual complication of Posterior Reversible Encephalopathy Syndrome. <h3>Background:</h3> Posterior Reversible Encephalopathy Syndrome (PRES) is a well-recognized clinical and radiologic syndrome typically characterized by parieto-occipital vasogenic edema along with neurological symptoms, that improves after management or withdrawal of offending factor, in most cases being acute uncontrolled hypertension. However, clinical presentation and radiological findings are variable and may encompass different cerebral structures. Although pathophysiology is not well established, failure of sympathetic autoregulation in the vertebrobasilar system is thought to be related. This failure leads to breakdown of the blood-brain barrier, hence the vasogenic-type edema appreciated on imaging. Acute obstructive hydrocephalus is a rare and potentially fatal complication of PRES. <h3>Design/Methods:</h3> A 56-year-old Caucasian female who presented due to encephalopathy, headache and falls in the setting of hypertensive emergency. CT (Computed Tomography) head showed hypodense pons, midbrain, cerebellum, and bilateral thalami with effacement of the fourth ventricle, ventriculomegaly in the lateral and 3rd ventricles with associated trans-ependymal edema. Due to initial concern of posterior fossa mass leading to acute hydrocephalus, neurosurgery was consulted, and extra ventricular drain (EVD) was placed for emergent CSF diversion. <h3>Results:</h3> MRI Brain with and without contrast showed no evidence of acute ischemia or enhancing lesions. Severe edema was redemonstrated within the pons, midbrain, bilateral thalami, and cerebellum. Susceptibility weighted imaging showed microhemorrhages confined to the brainstem. The patient’s clinical exam improved after blood pressure management and EVD placement. Repeat head CT showed decreased cerebral edema and improvement of fourth ventricle obstruction. Based on presentation of hypertensive encephalopathy with posterior circulation vasogenic edema that improved with blood pressure management, PRES diagnosis was made. <h3>Conclusions:</h3> Posterior fossa predominant PRES is an uncommon presentation that if overlooked may lead to life threatening complications. Early recognition of clinical manifestations and radiological findings may lead to favorable outcomes. <b>Disclosure:</b> Dr. Morales-Nunez has nothing to disclose. Dr. Baez-Lugo has nothing to disclose. Dr. Yalcin has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Garcia has nothing to disclose. Dr. Nichols has nothing to disclose.

Galen's Ampulla Aneurysm: A Case Report

Introduction: Galen's vein aneurysm is a rare complex intracranial arteriovenous malformation, associating pseudo-aneurysmal dilation of Galen's ampulla with one or more arteriovenous fistulas. The prognosis is often poor, with high mortality and a risk of neurological sequelae. Objective: To support the role of imaging in the diagnosis, with illustration by two observations collected within our Radiopediatrics department of the CHU Mohammed VI of Marrakech, having benefited from a cerebral angio-scanner. Case Report: 1st case:is an 18-month-old infant with no particular history presenting macrocrania with generalized seizures.2nd case:is also a 2-year-old infant, with the appearance of a vein in the suborbital groove for 6 months, with no other associated signs.3rd patientis a 1-year-old infant with macrocrania with signs of HTIC. 4th case6-month-old boy, presents with HTIC syndrome. Objective cerebral CT in the first three patients: a rounded median mass, in the pineal region behind the 3rd ventricle, slightly hyperdense in spontaneous contrast; CT angiography proves the vascular nature of the lesion by showing intense and homogeneous enhancement after injection of PDC, associated with dilation of the venous sinuses, and moderate passive triventricular hydrocephalus by compression of the aqueduct of Sylvius. The fourth patient benefited from a transfontanellar ultrasound which objectified an anechoic interhemispheric fusiform structure presenting a vascular flow to the color Doppler. Conclusion: The aneurysmal malformation of the Vein of Galen (AVGM) is a rare vascular malformation, specific to children, discovered ante or post natally, in fact only corresponds to a venous dilation draining an arterio-venous malformation, whose system afferent arterial comes from the carotid system or the vertebro-basilar axis; it results from the absence of differentiation in the mature arterio-venous system, between 7 and 12 SA, of a primitive, median embryonic vein which ......

768 The Device for Intraventricular Entry (DIVE) Guide: A Novel Solution to a Perpetual Problem

INTRODUCTION: Safe and reliable access to the ventricular system is a necessary skill in the neurosurgical armamentarium. The freehand technique for catheter placement remains an accepted method, yet the inaccuracy rate can be as high as 40%, with as many as 3 passes per procedure, and complication rates between 10-40%. A number of devices have been developed to assist with catheter placement, however, these devices inhibit ergonomics or require larger incisions and expensive navigation technology. METHODS: A novel device for ventricular entry, the DIVE guide, was designed by the first and senior author. 50 patients undergoing extra ventricular drain (EVD) or shunt placement were prospectively enrolled for DIVE assisted catheter placement under an IRB approved study with a non-significant risk (NSR) device designation. The primary outcome is catheter location on CT. Secondary outcomes include number of catheter passes, clinically significant hemorrhages and procedure-related infections. RESULTS: 50 patients were enrolled at a single academic center for ventricular access with DIVE assistance. Indications included subarachnoid or intraventricular hemorrhage, TBI, hydrocephalus, pseudotumor and post-surgical wound drainage. 76% (38/50) underwent right sided placement and 24% (12/20) underwent left. 100% (50/50) had successful cannulation in an average of 1.06 passes. Post procedure head CT confirmed ipsilateral frontal horn or 3rd ventricle placement (Kakarla Grade 1) in 92% (46/50) and 8% (4/50) in the contralateral lateral ventricle (Grade 2). There were no significant tract hemorrhages or procedural infections. CONCLUSIONS: This a prospective study to investigate the safety and efficacy of DIVE-assisted ventricular access. 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla Grade 1, in an average of 1.06 passes.

Usefulness of intravoxel incoherent motion MRI for visualizing slow cerebrospinal fluid motion

BackgroundIn the cerebrospinal fluid (CSF) dynamics, the pulsations of cerebral arteries and brain is considered the main driving force for the reciprocating bidirectional CSF movements. However, measuring these complex CSF movements on conventional flow-related MRI methods is difficult. We tried to visualize and quantify the CSF motion by using intravoxel incoherent motion (IVIM) MRI with low multi-b diffusion-weighted imaging.MethodsDiffusion-weighted sequence with six b values (0, 50, 100, 250, 500, and 1000 s/mm2) was performed on 132 healthy volunteers aged ≥ 20 years and 36 patients with idiopathic normal pressure hydrocephalus (iNPH). The healthy volunteers were divided into three age groups (< 40, 40 to < 60, and ≥ 60 years). In the IVIM analysis, the bi-exponential IVIM fitting method using the Levenberg–Marquardt algorithm was adapted. The average, maximum, and minimum values of ADC, D, D*, and fraction of incoherent perfusion (f) calculated by IVIM were quantitatively measured in 45 regions of interests in the whole ventricles and subarachnoid spaces.ResultsCompared with healthy controls aged ≥ 60 years, the iNPH group had significantly lower mean f values in all the parts of the lateral and 3rd ventricles, whereas significantly higher mean f value in the bilateral foramina of Luschka. In the bilateral Sylvian fossa, which contain the middle cerebral bifurcation, the mean f values increased gradually with increasing age, whereas those were significantly lower in the iNPH group. In the 45 regions of interests, the f values in the bilateral foramina of Luschka were the most positively correlated with the ventricular size and indices specific to iNPH, whereas that in the anterior part of the 3rd ventricle was the most negatively correlated with the ventricular size and indices specific to iNPH. Other parameters of ADC, D, and D* were not significantly different between the two groups in any locations.ConclusionsThe f value on IVIM MRI is useful for evaluating small pulsatile complex motion of CSF throughout the intracranial CSF spaces. Patients with iNPH had significantly lower mean f values in the whole lateral ventricles and 3rd ventricles and significantly higher mean f value in the bilateral foramina of Luschka, compared with healthy controls aged ≥ 60 years.

Brain Biometry Reveals Impaired Brain Growth in Preterm Neonates with Intraventricular Hemorrhage

Introduction: Preterm birth and cerebral hemorrhage have adverse effects on brain development. Alterations in regional brain size on magnetic resonance imaging (MRI) can be assessed using 2D biometrical analysis, an easily applicable technique showing good correlation with 3D brain volumes. Methods: This retrospective study included 74 preterm neonates with intraventricular hemorrhage (IVH) born <32+0 weeks of gestation between 2011 and 2019. Cerebral MRI was performed at term-equivalent age, and 2D measurement techniques were used for biometrical analysis and compared to normative data of two control groups. Finally, the correlation and association of brain parameters and patterns of impaired brain growth and outcome at 2 and 3 years of age were evaluated. Results: Interhemispheric distance (IHD), the 3rd ventricle, and lateral ventricles presented larger, in contrast, cerebral biparietal width (cBPW), fronto-occipital diameter (FOD), and the length of the corpus callosum were smaller in IVH patients compared to respective controls. The strongest correlations with outcome were observed for the parameters FOD, anteroposterior diameter of the vermis, transverse cerebellar diameter (tCD), corpus callosum, 3rd ventricle, and left ventricular index. Patients with the small FOD, small BPW, and increased IHD pattern reached overall lower outcome scores at follow-up. Discussion: Preterm neonates with IVH showed reduced total brain sizes and enlarged pericerebral spaces compared to neurologically healthy controls. Biometric analysis revealed that several 2D brain parameters as well as different patterns of impaired brain growth were associated with neurodevelopmental impairment in early childhood. These findings may support prediction of long-term outcome and parental counseling in patients with IVH.

Anatomy of hypothalamic and diencephalic nuclei involved in seasonal fertility regulation in ewes.

In this study, we describe in detail the anatomy of nuclei involved in seasonal fertility regulation (SFR) in ewes. For this purpose, the intergeniculate leaflet of the visual thalamus, the caudal hypothalamic arcuate nucleus, and suprachiasmatic, paraventricular and supraoptic nuclei of the rostral hypothalamus were morphometrically and qualitatively analyzed in Nissl-stained serial sections, in the three anatomical planes. In addition, data were collected on calcium-binding proteins and cell phenotypes after immunostaining alternate serial sections for calretinin, parvalbumin and calbindin. For a complete neuroanatomical study, glial architecture was assessed by immunostaining and analyzing alternate sections for glial fibrillary acidic protein (GFAP) and ionized calcium-binding adapter molecule 1 (IBA1). The results showed a strong microglial and astroglia reaction around the hypothalamic nuclei of interest and around the whole 3rd ventricle of the ewe brain. Moreover, we correlated cytoarchitectonic coordinates of panoramic serial sections with their macroscopic localization and extension in midline sagittal-sectioned whole brain to provide guidelines for microdissecting nuclei involved in SFR.

The hypothalamic neuropeptide, QRFP, regulates high fat diet intake in female Long-Evans rats following ovariectomy

Obesity rates in women continue to increase throughout the lifespan and obesity-related comorbidities are prevalent in women in estrogen deficiency. The hypothalamic neuropeptide, QRFP, is an orexigenic peptide that increases the intake of high fat diet (HFD) in female rats and is overexpressed following ovariectomy (OVX). Therefore, the goal of the current series of experiments was to elucidate the effect of QRFP on HFD intake following OVX and determine if QRFP-26 administration in ovariectomized females altered expression of prepro-neuropeptide Y (NPY), agouti-related peptide (AgRP) and proopiomelanocortin (POMC) mRNA in the mediobasal hypothalamus (MBH) and prepro-orexin in the lateral hypothalamus (LH). The intake of HFD was measured following acute administration of QRFP-26 prior to or following estradiol benzoate (EB) treatment in ovariectomized females. When administered prior to EB treatment, QRFP-26 increased HFD intake. EB treatment attenuated the effects of QRFP-26 on HFD intake. Sub-chronic, continuous administration of QRFP-26 increased HFD intake and weight gain following OVX. Subchronic, continuous administration of QRFP siRNA into the 3rd ventricle via osmotic pump decreased prepro-QRFP mRNA levels in the MBH by ∼75%, decreased HFD intake and decreased weight gain following OVX. QRFP-26administration did not alter the expression of prepro-NPY, AgRP or POMC mRNA in the MBH, but decreased prepro-orexin mRNA in the LH of ovariectomized females. Overall, results from these studies support the orexigenic neuropeptide, QRFP, as an important mediator of the ingestion of highly palatable foods and subsequent weight gain in females during estrogen deficiency.

Sudden unexpected death caused by a colloid cyst in the third ventricle: case report

BackgroundColloid cysts arise from congenital abnormalities of the endodermis and are characteristically comprised of an external fibrous layer, with a lining of cuboidal and columnar epithelial cells and endodermal ciliated cells. They contain a gelatinous matrix, produced by mucus-producing epithelial cells.Case presentationAn 8-year-old Saudi girl died in Dammam Central Hospital, to which she was admitted by her parents following her complaints of intense headaches. When the body was examined externally, it was noted that she had bilateral eye congestion, evidence of needle marks on all four limbs and in the region of the femoral triangle and bruising in the central chest and left shoulder areas. No other evidence of injury was noted. A cyst in the third ventricle of the brain was identified at post mortem. Investigations for alcohol, toxins and illicit substances were negative.ConclusionIt was surmised that the child had died as a result of a cerebral colloid cyst and its clinical sequelae.

Effects of central FGF21 infusion on the glucose homeostasis in rats (brain–pancreas axis)

Introduction Glucose homeostasis is a physiological process mediated by a variety of hormones. Fibroblast growth factor (FGF) 21 is a protein expressed in the liver, adipose tissue, muscle and pancreas and exerts actions in multiple targets including adipose, liver, pancreas and hypothalamus. The aim of this study was to examine the possible involvement of FGF21 in pancreatic and central control of glucose by measuring reflective changes in the release of insulin and glucagon. Methods Thirty adult male Wistar Albino rats were divided; Control, PD + aCSF, PD + FGF21 groups (n = 10). Effects of intracerebroventricular (icv) FGF21 administration to pancreatic denervated (PD) rats. Agouti-related protein (AgRP), Pro-opiomelanocortin (POMC) levels and blood glucose homeostasis were investigated. Results Administration of FGF21 to 3rd ventricle increased food consumption but body weight didn’t change significantly. AgRP level increased, pancreatic insulin levels increased, and glucagon level decreased. Conclusion Central FGF21 administration is effective in regulating blood glucose homeostasis by increasing the amount and efficiency of insulin and changing glucose use.

Discriminative MRI Findings of Pituitary Adenomas from Craniopharyngiomas

Purpose: The aim of this study is to determine and define differential magnetic resonance imaging (MRI) findings of pituitary adenomas and craniopharyngiomas. Materials and methods: This retrospective analysis was performed on MR imaging findings of 45 pituitary adenomas and 41 craniopharyngiomas with solid and cystic mixed appearance. MRI findings including shape ovoid, snowman, lobulation, chiasma compression, cavernous sinus invasion, 3rd ventricle compression, calcification, predominant type – cystic vs solid, contrast enhancement patterns – homogenous, reticular and extension were assessed. Results: Among MRI findings superiorly lobulated shape, third ventricle compression and reticular enhancement of solid parts were common in craniopharyngiomas while snowman shape, predominantly solid content, homogenous enhancement of solid parts were compatible with adenomas significantly at p &lt;0.05 for all. Conclusion: Tumor shape and contrast enhancement patterns of solid parts seem discriminative MRI features for pituitary adenoma and craniopharyngiomas.

Relationship between cognitive profile and neuroradiographic parameters in patients with idiopathic normal pressure hydrocephalus.

Background: Normal pressure hydrocephalus (NPH) is a reversible type of dementia, which affects 0.2 to 5.9 percent of elders. It manifests with triad of gait disturbances, urinary incontinence, and cognitive decline. In this study, association between cognitive and neuroradiographic parameters of idiopathic NPH (iNPH) was appraised to find out possible biomarkers for preventive intervention. Methods: In a cross-sectional study, 16 patients with iNPH were evaluated for third and fourth ventricle diameter, diameter of temporal horn of lateral ventricle, Evans index (EI), callosal angle (CA), callosal bowing, and ballooning of frontal horn. The Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG) was used to take cognitive profile. Relation between brain magnetic resonance imaging (MRI) indices and cognitive domains was extracted, using generalized linear model (GLM). Results: Patients with mild callosal bowing had better function in memory (P = 0.050) and language (P = 0.001) than those with moderate to severe callosal bowing. Negative or mild ballooning of frontal horn was also associated with higher scores in memory (P = 0.010), executive function (EF) (P = 0.029), and language (P = 0.036) than moderate to severe ballooning of frontal horn. Increased 3rd ventricle diameter was associated with decline in total cognition (P = 0.008), memory (P = 0.019), EF (P = 0.012), and language (P = 0.001). Relation between other radiographic indices and cognitive function was not significant. Conclusion: Third ventricular diameter, rounding of frontal horn of lateral ventricle, and callosal bowing are more accurate neuroradiographic parameters to predict cognitive decline in iNPH.

ODP301 Corticotroph Macroadenomas with Extensions to Third Ventricle: Four Case Reports

Abstract Background Pathophysiology of corticotroph macroadenomas has not been elucidated. In this study, we present four cases of adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas with extensions to the third ventricle (TV) and investigate their clinical and pathological characteristics. Case 1 A male in his seventies went to a hospital because of a fall. Upon performing computed tomography, a tumor was incidentally noted. Pituitary MRI revealed a macroadenoma with extension to TV. He presented with Cushingoid features (CF). His basal ACTH level was 112 pg/mL, and urinary free cortisol (UFC) was 129.1 μg/day. Cortisol was not suppressed in the 0.5 mg dexamethasone suppression test (0.5 mg DST). ACTH level increased in the corticotropin-releasing hormone (CRH) stimulation test and the desmopressin (DDAVP) stimulation test. He was diagnosed with Cushing's disease (CD), and endoscopic transsphenoidal surgery (ETSS) was performed. Pathological findings showed densely granulated corticotroph adenoma (DGCA). Somatostatin receptor type 5 (SSTR5) was negative, and ubiquitin-specific protease 8 (USP8) was not mutated. Case 2 A female in her fifties had a visual field defect and pigmentation of the face. MRI revealed a macroadenoma with extension to TV. She presented with CF. Her basal ACTH level was 57.9 pg/mL, and UFC was 259.7 μg/day. Cortisol was not suppressed in the 0.5 mg DST. ACTH level increased in the CRH test and the DDAVP test. She was diagnosed with CD. Pathological findings showed DGCA. SSTR5 was moderate positive, and USP8 was suspected to be mutated. Case 3 A female in her fifties had a throbbing headache. MRI showed a macroadenoma with extension to TV. She did not present with CF. Her basal ACTH level was 71.8 pg/mL, and UFC was 134.3 μg/day. Cortisol was not suppressed in the 0.5 mg DST. ACTH showed response to the CRH test and the DDAVP test. She was diagnosed with subclinical Cushing's disease (SCD) and sparsely granulated corticotroph adenoma (SGCA). SSTR5 was slightly positive, and USP8 was not mutated. Case 4 A male in his fifties had general malaise and polyuria. MRI showed a macroadenoma with extension to TV. He did not present with CF. His basal ACTH level was 179 pg/mL, and UFC was 187.4 μg/day. Cortisol was not suppressed in the 0.5 mg DST. ACTH did not show response to the CRH test and the DDAVP test. He was diagnosed with SCD, and the tumor had oncocytic changes. SSTR5 was negative, and USP8 was not mutated. Conclusion The findings from these case reports suggest that phenotypes of CD and SCD are associated with the differences between SGCA and DGCA. Moreover, it is also suggested that USP8 mutations correlate with SSTR5 expression in macroadenomas that extend to the TV. Presentation: No date and time listed

Single cell and spatial transcriptomic analyses reveal microglia-plasma cell crosstalk in the brain during Trypanosoma brucei infection

Human African trypanosomiasis, or sleeping sickness, is caused by the protozoan parasite Trypanosoma brucei and induces profound reactivity of glial cells and neuroinflammation when the parasites colonise the central nervous system. However, the transcriptional and functional responses of the brain to chronic T. brucei infection remain poorly understood. By integrating single cell and spatial transcriptomics of the mouse brain, we identify that glial responses triggered by infection are readily detected in the proximity to the circumventricular organs, including the lateral and 3rd ventricle. This coincides with the spatial localisation of both slender and stumpy forms of T. brucei. Furthermore, in silico predictions and functional validations led us to identify a previously unknown crosstalk between homeostatic microglia and Cd138+ plasma cells mediated by IL-10 and B cell activating factor (BAFF) signalling. This study provides important insights and resources to improve understanding of the molecular and cellular responses in the brain during infection with African trypanosomes.

Sinking skin syndrome in a decompressive craniectomy series: Clinical and radiological features.

The sinking skin syndrome (SSS) is a particular complication after a decompressive craniectomy (DC). It still remains a poorly understood and underestimated entity. Retrospective case series of craniectomized patients with and without SSS. Clinical and radiological features (DC diameter, shape of craniectomy flap, and midline deviation) were described and relative volumes of intracranial loss were quantified. Twenty-seven patients (63% with SSS). The most common indication for DC was traumatic brain injury: 48.15%. The p50 diameter of DC was 12.8 cm for patients with SSS and 11.1 cm for patients without (Z score = 0.32). DC area was 81.5 cm2 for patients with SSS and 71.43 cm2 for patients without the syndrome (Z score = 0.61). According to the shape of the craniectomy flap, we classified our patients as: «same level» (51.8%), «sunken» (25.9%), and «extracranial herniation» (14.8%). Two patients (7.4%) had paradoxical herniation. Midline deviation was present in 12 (70.6%) patients with SSS. The 3rd ventricle volume average was 1.2 cc for patients with SSS versus 2.35 cc for patients without (Z score = 0.04). About 94.11% of patients (16 out of 17) clearly improved after replacement of the cranial defect. In our series, low 3rd ventricle volumes had a good relation with SSS. The presence of a sunken flap does not guarantee SSS per se and we propose the following radiologic description: A = sunken, B = same level, C = extracranial herniation, and D = paradoxical. Replacement of the skull defect is the main treatment.

Pituitary Stalk Hemangioblastoma: Complete Resection through Orbitozygomatic Approach with Extradural Anterior Clinoidectomy.

Background Pituitary stalk hemangioblastomas (PSHBLs) are rare vascular tumors and their surgical removal is challenging due to the proximity with several fundamental anatomic structures including the pituitary stalk, third ventricle, hypothalamus, and optic pathways. To date, only few descriptions of transcranial and transsphenoidal approaches for PSHBLs have been reported in the literature and none in video, with suboptimal outcomes in terms of pituitary function preservation. Here, we describe the use of orbitozygomatic (OZ) craniotomy with extradural anterior clinoidectomy (EAC) for the removal of a PSHBL with preservation of the pituitary stalk. Case Description A 60-year-old woman with a sporadic symptomatic HBL of the pituitary stalk, with the typical features of avid contrast enhancement on T1- and flow voids on T2-weighted magnetic resonance imaging (MRI) images, underwent a right OZ craniotomy with EAC. The choice of the approach was guided by the necessity of exposing the floor of the 3rd ventricle and infundibulum, where the origin of the pituitary stalk is better appreciated and preserved, without brain retraction. EAC was deemed important due to the necessity of widening the right carotico-oculomotor and opticocarotid triangles and gaining access to the ophthalmic segment of the internal carotid artery, origin of the superior hypophyseal artery, and the tumor supply. The postoperative MRI confirmed gross tumor removal with preservation of the pituitary stalk and no tumor recurrence after 2 years of follow-up. Conclusion OZ craniotomy coupled with EAC facilitates surgical removal of PSHBLs thus augmenting the chances of pituitary function preservation. The link to the video can be found at https://youtu.be/hH65W937RGY .

Bedside Ultrasound for Ventricular Size Monitoring in Patients with PEEK Cranioplasty: A Preliminary Experience of Technical Feasibility in Neurotrauma Setting

BackgroundPosttraumatic hydrocephalus is a known complication after traumatic brain injury, particularly affecting patients undergoing decompressive craniectomy. Posttraumatic hydrocephalus monitoring in these patients represents a common issue in neurosurgical practice. Patients require periodical assessments by means of computed tomography (CT) scans. This study presents a preliminary institutional series in which ultrasound was used as a bedside imaging technique to monitor ventricular size in patients harboring a polyetheretherketone (PEEK) cranioplasty. Exploiting the PEEK cranioplasty permeability to echoes, we evaluated the feasibility of this bedside imaging method in monitoring hydrocephalus evolution, determining effects of ventriculo-peritoneal shunt, and excluding complications.MethodsEight patients with traumatic brain injury harboring PEEK cranioplasty following decompressive craniectomy were prospectively evaluated. Ultrasound measurements were compared with CT scan data taken the same day, and ventricular morphometry parameters were compared.ResultsUltrasound images through the PEEK cranioplasty were of high quality and intracranial anatomy was distinctly evaluated. A strong correlation was observed between ultrasound and CT measurements. Concerning distance between lateral ventricles frontal horns (IFH) and the diameter of the third ventricle (TV), we found a strong correlation between transcranial sonography and CT measurements in preventriculoperitoneal shunt (rho = 0.92 and p = 0.01 for IFH; rho = 0.99 and p = 0.008 for TV) and in postventriculoperitoneal shunt examinations (rho = 0.95 and p = 0.03 for IFH; rho = 0.97 and p = 0.03 for TV). The mean error rate between transcranial sonography and CT scan was 1.77 ± 0.91 mm for preoperative IFH, 0.65 ± 0.27 mm for preoperative TV, 2.18 ± 0.82 mm for postoperative IFH, and 0.48 ± 0.21 mm for postoperative TV.ConclusionsTranscranial ultrasound could represent a simplification of the follow-up and management of ventricular size of patients undergoing PEEK cranioplasty. Even if this is a small series, our preliminary results could widen the potential benefits of PEEK, not only as effective material for cranial reconstruction but also, in selected clinical conditions, as a reliable window to explore intracranial content and to monitor ventricular sizes and shunt functioning.

The Periventricular Nucleus as a Brain Center Containing Dopaminergic Neurons and Neurons Expressing Individual Enzymes of Dopamine Synthesis

Since the 1980s, the concept of dopamine-rich brain centers as clusters of only dopaminergic neurons has been fundamentally revised. It has been shown that, in addition to dopaminergic neurons, most of these centers contain neurons expressing one of the enzymes of dopamine synthesis: tyrosine hydroxylase (TH) or aromatic L-amino acid decarboxylase (AADC). We have obtained convincing evidence that in rats, the hypothalamic periventricular nucleus (PeVN) is one of the largest dopamine-rich centers, containing dopaminergic and monoenzymatic neurons. Indeed, using double immunostaining for TH and AADC, the PeVN was shown to contain almost three thousand dopaminergic and monoenzymatic neurons. According to high-performance liquid chromatography, PeVN contains L-DOPA and dopamine, which, apparently, are synthesized in monoenzymatic TH neurons and bienzymatic neurons, respectively. According to confocal microscopy, neurons (cell bodies, fibers), which were immunopositive only to TH, only to AADC, or both, are in close topographic relationships with each other and with the 3rd ventricle. These data suggest the mutual regulation of the neurons, as well as the delivery of dopamine and L-DOPA to the third ventricle, which is confirmed by their detection in the cerebrospinal fluid. Thus, evidence has been obtained that PeVN is one of the largest dopamine-rich centers of the brain, containing dopaminergic and monoenzymatic neurons.

Comparative Expression Profile of RFRP-3 in Hypothalamus and Testis of Adult Rats

Background: The present study focused on the localization and comparative expression analysis of RFRP-3 gene in the hypothalamus and testis of adult male rats. Methods: Brain and testis tissue samples were collected from adult Wister rats and used for immunohistochemistry for identification and localization RFRP-3 producing neurons. The expression level of the RFRP-3 gene was assessed by Real-time PCR and compared with muscle tissue. Result: The results confirmed the presence of RFRP-3 secreting neurons in the hypothalamus and in the testes. Scattered RFRP-3 in cell bodies was identified primarily in the VMH, DMH and surrounding the third ventricle of the brain. In testis, RFRP-3 was detected in Leydig cells, Sertoli cells and germ cells. The expression level of RFRP-3 gene in the hypothalamus was observed to be significantly higher in hypothalamus than in testicular tissue (p less than 0.01) of adult rats.