Cerebrospinal Fluid Diversion Procedures Research Articles

Modified frontal horn index: a novel risk predictor for sunken flap syndrome in the patients undergoing shunt procedures for post-decompressive craniectomy hydrocephalus

BackgroundDecompressive craniectomy (DC) is a neurosurgical procedure, frequently used in lowering the refractory intracranial pressure (ICP) following traumatic brain injuries. Post-traumatic hydrocephalus (PTH), a debilitating complication in the patients with traumatic brain injuries, occurs in 11.9–36% patients undergoing DCs. Sunken flap syndrome (SFS) is a rare entity, following DCs or cerebrospinal fluid (CSF) diversion procedures for PTH after DCs and leads to neurological deterioration of the patients. Literature regarding risk factors associated with SFS in the patients undergoing ventriculoperitoneal shunt procedures for hydrocephalus following DCs is scarce. The aim of this study is to determine the incidence of SFS and to establish a relationship between several clinico-radiological features and SFS in patients undergoing shunt procedures for PTH.ResultsThis retrospective study was conducted in a tertiary care trauma centre upon 60 patients who underwent shunt procedures for PTH. Intraventricular haemorrhage (P < 0.0001), communicating-type hydrocephalus (P = 0.0006), and modified frontal horn index (P < 0.0001) were significantly associated with development of SFS. MFHI > 43 was a significant risk factor in development of SFS.ConclusionsSFS is the common complication following shunt procedures for PTH after DCs. MFHI is significant risk predictor for SFS. MFHI > 43 is associated with higher chances of developing SFS following shunt insertion in PTH. Early cranioplasty following DCs might prevent development of SFS.

Brain Stem Hemorrhage after Insertion of a Lumbar Drain: An Extremely Rare but Fatal Complication of a Routine Procedure

AbstractDecompressive craniectomy (DC) is a life-saving procedure to control refractory intracranial pressure after traumatic brain injury. Postdecompressive craniectomy hydrocephalus (PDCH) is debilitating complication following DCs. Lumbar drainage (LD) is a temporary measure that is helpful in the assessment of PDCH and its functioning can predict the risks and benefits of definitive cerebrospinal fluid (CSF) diversion procedures. LD is associated with multiple complications. Intracranial hemorrhage is a rare but devastating complication following LD. Here, the authors report a case in which LD was performed as a temporary measure to assess PDCH, resulting in brain stem hemorrhage (BSH). A 45-year-old male underwent DC for severe traumatic brain injury. Patient developed PDCH in postoperative period. LD was done as a bridging procedure for definitive CSF diversion procedure, which resulted in fatal BSH. Authors conclude that although a simple procedure, LD can be associated with fatal BSH. Since drainage of CSF after LD is unpredictable in patients of PDCH, a close monitoring of the functioning of the LD system is required to avoid overdrainage and brain herniations.

Comparative Analysis of Surgical Site Infections in Pediatric Brain Tumor Patients: Hygiene Practices, Risk Factors, and Implications for Healthcare Costs and Mortality

Surgical site infections (SSIs) significantly impact pediatric central nervous system tumor outcomes. We present our data of SSIs and their influence on outcomes of pediatric brain tumor patients treated between January 2011 till December 2022. This study utilized retrospective data from patients' medical records. Chi-squared test was used for correlational analysis. Independent sample t-test was used for equality of means. Linear and logistic regression was done to review impact of independent variables on dependent variable. Survival analysis was done using Kaplan–Meier curves. Between 2011 and 2022, 336 pediatric patients (202 males, 134 females) were diagnosed with brain tumors. Majority patients (279; 83%) underwent surgery (91% elective). Commonest tumor site was cerebellum (84/279; 30%). Tumor resection status was gross total resection (29/279; 46%), subtotal resection (59/279; 21%), near total resection (48/279; 17%), and partial resection (20/279; 7%); while 32/279 patients (11%) had a biopsy only. Hydrocephalus was present in 166/279 patients (59%); while majority (160/166; 96%) underwent a cerebrospinal fluid (CSF) diversion procedure. SSI developed in 23/279 patients (8%), leading to delayed postoperative management in majority (15/23; 65%). SSIs were significantly associated with lower age of presentation (p = 0.01), less duration between symptoms and diagnosis (p = 0.00), performance of CSF diversion procedure (p = 0.04), increase in hospital stay (p = 0.00), delay in postoperative management (15/23; 65%) (p = 0.01), decline in treatment completion (p = 0.01), and poor survival (p = 0.01). Majority (171/279) of patients (61%) completed treatment. The overall survival of our cohort was 84.9% with a median follow-up time of 11 (interquartile range [IQR]: 36, 1) months. Survival was significantly lower (56.5%) in patients with SSI (p = 0.01). Median time to death was 18 months. Progression-free survival was 77.4% with a median progression-free time of 8 (IQR: 28, 1) months. Median time to progression was 9 (IQR: 24, 4.5) months. The incidence of SSIs in our cohort closely resembled that of high-income countries. Risk factors for SSIs included younger age, a shorter time between symptom onset and surgery, undertaking of CSF diversion procedures. Adverse effects of SSIs included increased costs, delays in postoperative management, incomplete treatment, and higher mortality rates. This study emphasizes the substantial impact of SSIs on healthcare resources and patient well-being.

Gamma Knife Radiosurgery for Third Ventricular Colloid Cysts: A Retrospective Study

Introduction: Colloid cysts often occur in the third ventricle, and they are considered benign, slowly growing lesions. They commonly present with symptoms of intracranial hypertension and rarely sudden death due to acute hydrocephalus. The management options include cerebrospinal fluid diversion procedure by shunt, endoscopic or transcranial surgical excision, and stereotactic aspiration. Complications associated with excisional procedures make them undesirable to some patients. Stereotactic radiosurgery has emerged as a noninvasive less risky treatment option. To date, there is no clinical series in the literature reporting on this treatment modality. The aim of the study was to determine the efficacy and safety of gamma knife (GK) radiosurgery in the treatment of third ventricular colloid cysts. Methods: This is a retrospective study involving 13 patients with third ventricular colloid cysts who underwent GK radiosurgery. GK radiosurgery was used as a primary treatment in all the patients. The median prescription dose was 12 Gy (11–12 Gy). The cyst volumes ranged from 0.2 to 10 cc (median 1.6 cc). Results: The median follow-up was 50 months (18–108 months). Cyst control was achieved in 100% of the patients. Complete or partial response was observed in 12 patients (92%). Eight patients (62%) had hydrocephalus on imaging at the initial diagnosis. Seven of these patients had VP shunt insertion before GK. One patient required shunt insertion after GK. Conclusion: GK for third ventricular colloid cysts is a promising treatment, regarding its efficacy and safety, to be added to other treatment options. A longer follow-up is required to confirm long-term control.

Geometric variability in radiological appearance of third ventricle in congenital hydrocephalus- is it really so pliable? Or do we need to visualize it differently? A two-case study and literature review

Enlargement of third ventricle is seen due to multiple causes, usually associated with hydrocephalus. Raised intracranial pressure (ICP) is the most common indication for a cerebrospinal fluid diversion procedure. However, congenital anomalies like Dandy walker malformation (DWM) may not always manifest with raised ICP. Identifying neurological delay and neurocognitive parameters and correlating this with existing anatomical features is extremely important. We discuss this report of two cases of patients with DWM where abnormal morphology of the third ventricle was analysed and used to interpret clinical neurological delay.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population.

To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies. Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records. Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected. The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

Healthcare-Associated Ventriculitis in Children during COVID-19 Pandemic: Clinical Characteristics and Outcome of a First Infection.

During the COVID-19 pandemic, patients in need of neurosurgical care suffered. Elective procedures were postponed, and emergency care visits decreased. Healthcare-associated ventriculitis (HAV) is a serious problem in children, with poor outcomes and frequent relapses. Our objective was to describe the clinical characteristics and the factors associated with a first HAV in children during two years of the pandemic. A retrospective cross-sectional study was performed from January 2021 to December 2022. The inclusion criteria were patients who developed a first HAV after a primary cerebrospinal fluid diversion procedure. The controls included patients without a first infection. Intraoperative and clinical data were extracted from medical records. A total of 199 CSF diversion surgeries were registered. A first infection occurred in 17 patients (8.5%), including 10 with external ventricular drain (EVD) and 6 with ventricular shunts. Gram-positive cocci were identified in 70.6%. Six patients recovered uneventfully, eight had relapse or superinfections, and three eventually died. Twenty patients were included as controls. Factors associated with a first infection were a younger age (median 9 vs. 102 months, p < 0.01), malnutrition (23.5% vs. 0%, p = 0.03), and an EVD placement (58.8% vs. 10%, p = 0.03). None of the intraoperative factors showed statistically significant differences. The rate of HAV was high. Most cases presented in children <1 year and with an EVD.

Cerebrospinal Fluid Protein Concentrations in Hydrocephalus

CSF protein levels are altered in neurological disorders, such as hydrocephalus of different etiologies. In this retrospective observational study, we analyzed cerebrospinal fluid (CSF) samples in hydrocephalic diseases such as aqueductal stenosis (AQS, n = 27), normal pressure hydrocephalus (NPH, n = 24), hydrocephalus communicans (commHC, n = 25) and idiopathic intracranial hypertension (IIH)/pseudotumor cerebri (PC, n = 7) in comparison with neurological patients without hydrocephalic configuration (control, n = 95). CSF was obtained through CSF diversion procedures and lumbar punction and analyzed for protein concentrations according to the institution's laboratory standards. We found significantly decreased CSF protein levels in patients suffering from AQS (0.13 mg/dL [0.1-0.16 mg/dL] p = 2.28 × 10-8) and from PC (0.18 mg/dL [0.12-0.24 mg/dL] p = 0.01) compared with controls (0.34 mg/dL [0.33-0.35 mg/dL]). Protein levels were not altered in patients suffering from commHC and NPH compared with neurologically healthy individuals. We propose that a decrease in CSF protein levels is part of an active counterregulatory mechanism to lower CSF volume and, subsequently, intracranial pressure in specific diseases. Research regarding said mechanism and more specific proteomic research on a cellular level must still be performed to prove this hypothesis. Differences in protein levels between different diseases point to different etiologies and mechanisms in different hydrocephalic pathologies.

Spinal pseudomeningocele closure: capsulofascial interposition technique.

The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion. At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here. Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures. We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.

Rapidly progressive diffuse leptomeningeal glioneuronal tumor in an adult female: illustrative case.

Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare brain tumor only recently classified by the World Health Organization in 2016 and has few reports on its incidence in adults. The authors describe a case of DLGNT presenting in a 47-year-old female with seizures, cranial neuropathies, and communicating hydrocephalus with rapid clinical progression. Workup demonstrated progressive leptomeningeal enhancement of the skull base, cranial nerves, and spine, and communicating hydrocephalus. Elevated serum rheumatological markers and early response to systemic corticosteroids and immunosuppressant therapy complicated the diagnosis. Multiple biopsy attempts were required to obtain diagnostic tissue. Pathology demonstrated hypercellularity surrounding leptomeningeal vessels with nuclear atypia, staining positive for GFAP, Olig2, S100, and synaptophysin. Molecular pathology demonstrated loss of chromosome 1p, BRAF overexpression but no rearrangement, and H3K27 mutation. Repeat cerebrospinal fluid (CSF) diversion procedures were required for hydrocephalus management due to high CSF protein content. This report describes a rare, aggressive, adult presentation of DLGNT. Leptomeningeal enhancement and communicating hydrocephalus should raise suspicion for this disease process. Biopsy at early stages of disease progression is essential for early diagnosis and prompt treatment. Further study into the variable clinical presentation, histological and molecular pathology, and optimal means of diagnosis and management is needed.

Intracranial venous stenting for idiopathic intracranial hypertension.

There is increasing evidence in the literature to support venous sinus stenting in patients with idiopathic intracranial hypertension who fail first-line therapy. Venous sinus stenting is a safe and successful technique compared with cerebrospinal fluid diversion procedures. This study examines the clinical outcomes of patients post intracranial venous stenting for intracranial hypertension across three tertiary hospitals in Western Australia. A retrospective analysis was performed on 83 consecutive patients treated with intracranial venous stenting for IIH at three tertiary hospitals from October 2013 to March 2020. Data were collected from outpatient clinic letters, electronic discharge letters, electronic radiological imaging and procedural reports. 89.2% patients were able to cease Acetazolomide post stenting. 78.3% patients reported resolution of headaches. 84.3% patients demonstrated resolution of their papilloedema. 91.6% patients demonstrated improvement of their visual acuity. Compared with a recent meta-analysis by Satti and Chaudry in 2015, our results demonstrated a higher technical success rate and lower complication rates. Our study findings support the paradigm shift from CSF diversion procedures to venous sinus stenting in patients with IIH who fail first-line therapy. Venous sinus stenting has a high technical success rate and significantly lower complication rates than other invasive treatments.

A 20-year multicentre retrospective review of optic nerve sheath fenestration outcomes.

Optic nerve sheath fenestration (ONSF) longitudinal outcomes remain unclear and are vital in the assessment of vision failure in patients with raised intracranial pressure (ICP). Furthermore, limited observational data exists regarding its use in other causes of raised ICP. To determine the efficacy and safety of ONSF for idiopathic intracranial hypertension (IIH), cerebral venous sinus thrombosis (CVST), and other indications. Multicentre study from a tertiary hospital and specialty eye referral hospital in Melbourne, Australia, from July 2000 to December 2020. A total of 116 eyes from 70 patients undergoing ONSF were retrospectively reviewed with patient demographics, surgery indications, visual acuity (VA), visual fields, fundus photos of optic discs, retinal nerve fibre layer (RNFL) thickness, average thickness of optic discs on optical coherence tomography (OCT), and complications recorded. Parametric tests were used to compare the treatment groups pre- and post-operatively. A total of 116 eyes from 70 patients underwent ONSF, which involved 92 eyes with IIH, 9 eyes with CVST, and 15 eyes with other aetiologies ('Other'). Post ONSF, there was a best corrected visual acuity (BCVA) improvement or stabilisation in 84% of patients in all groups, with 50% achieving a BCVA of 6/6 or better at the final follow-up. RNFL, visual fields, and fundus grades all trended towards improvement, with most improvement noted by day 360. Common complications included transient diplopia (n = 29, 25%) and worsening of visual function requiring further cerebrospinal fluid (CSF) diversion procedures (n = 20, 17%). Complications were most significant in the 'Other' group with 1/3 of eyes requiring further CSF diversion procedures. Our data demonstrates effectiveness in the use of ONSF in papilloedema with visual failure due to IIH or CVST and when other CSF diversion procedures or medical therapies have failed.

Differences between myelomeningocele and myeloschisis lesions in patients undergoing open in-utero spina bifida repair

Spina bifida lesions are broadly classified as myelomeningocele (MMC: with sac) and myeloschisis (MSC: without sac) lesions, with MSC being the most severe type. Although prenatal repair methods are similar, baseline differences, surgical management, and postnatal outcomes remains largely unknown. The objective was to compare prenatal findings, closure methods, and 12-month outcomes. A prospective cohort of 111 open in-utero repair consecutive patients at a single institution were assessed (2011-2022). Lesion type was defined by ultrasound for the presence of a sac elevated from the lesion. Surgical eligibility was similar to the MOMS study, but expanded BMI inclusion criteria to ≤40 from 2018. Intraoperative management was pediatric neurosurgeon dependent. We compared preoperative differences in ventricular sizes, tonsillar herniation levels, extremity function, skin patch requirement, and neonatal outcomes including cerebrospinal fluid (CSF) leakage, wound dehiscence, and CSF diversion procedures until 12 months of age. Significance was considered at a p=0.05. Ultrasound and MRI identified 60 cases that were MMC and 51 as MSC. Maternal demographics, the gestational age (GA) at prenatal evaluation and the upper level of lesion were similar between groups (Table 1). Preoperative ventricular measurements were greater in the MMC cases. There were no differences in the upper level of lesions. MSC has severe baseline tonsillar herniation compared to MMC. There was higher talipes and loss of baseline motor function in the MMC group. The need for a skin closure patch was 21.7% in MMC vs 43.1% in MSC (p=0.002; Table 2). The length of NICU stay was 17 days longer in the MSC vs. the MMC group. There were no differences in ventricular diversion rates within a year from birth. Prenatally diagnosed MMC is associated with greater ventriculomegaly and talipes, and with less tonsillar herniation and fetal movement than those with MSC defects. Longer NICU stays in the MSC group is secondary to the higher need for skin closure with a patch and delayed healing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Comparative Outcomes and/or Complications Following Ventriculoperitoneal versus Lumboperitoneal Shunts: A Scoping Review

Cerebrospinal fluid (CSF) diversion procedure in the form of ventriculoperitoneal shunt (VPS) has been performed for over a century and is a well-established method for treating hydrocephalus. With the passage of time and the availability of better technology, several other CSF diversion modalities developed with variable risks and benefits. Lumboperitoneal shunt (LPS) is a close and safe contestant for the VP shunt procedure and is regarded as an alternative treatment modality for hydrocephalus. The present scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A literature search for the study was performed on PubMed, COCHRANE, SCOPUS and ScienceDirect (from inception to 7 July 2022). Those studies that were published in the English language with a report on comparison between VPS and LPS for the management of hydrocephalus were included in the review process. Those studies that do not have comparative outcomes, case reports, letters, reviews, preclinical studies, conference reports and non-human studies were excluded from the study. Search results showed 134 records; after removing the duplicates and excluding 12 studies with reasons, five studies were included in the present review. Several complications were described in patients who underwent either VP Shunt or LP Shunt surgery. Although communicating hydrocephalus forms one of the most significant subgroups of patients in neurosurgical practice and VP and LP shunt procedures are also widely performed, the literature review shows limited comparative efficacy. In addition, the reported studies have a broad spectrum of indications, disease conditions and complications with a heterogeneous patient population. To further develop the high level of evidence, there is a need for well-designed prospective protocols to help us develop uniform and practical guidelines. In the present review, we looked into the common complications, including shunt malfunction, shunt infection, subdural haematoma, shunt obstruction and shunt migration between two groups.

Modeling Neonatal Intraventricular Hemorrhage through Intraventricular Injection of Hemoglobin.

Neonatal intraventricular hemorrhage (IVH) is a common consequence of premature birth and leads to brain injury, posthemorrhagic hydrocephalus (PHH), and lifelong neurological deficits. While PHH can be treated by temporary and permanent cerebrospinal fluid (CSF) diversion procedures (ventricular reservoir and ventriculoperitoneal shunt, respectively), there are no pharmacological strategies to prevent or treat IVH-induced brain injury and hydrocephalus. Animal models are needed to better understand the pathophysiology of IVH and test pharmacological treatments. While there are existing models of neonatal IVH, those that reliably result in hydrocephalus are often limited by the necessity for large-volume injections, which may complicate modeling of the pathology or introduce variability in the clinical phenotype observed. Recent clinical studies have implicated hemoglobin and ferritin in causing ventricular enlargement after IVH. Here, we develop a straightforward animal model that mimics the clinical phenotype of PHH utilizing small-volume intraventricular injections of the blood breakdown product hemoglobin. In addition to reliably inducing ventricular enlargement and hydrocephalus, this model results in white matter injury, inflammation, and immune cell infiltration in periventricular and white matter regions. This paper describes this clinically relevant, simple method for modeling IVH-PHH in neonatal rats using intraventricular injection and presents methods for quantifying ventricle size post injection.

The impact of telephone consultations due to COVID-19 on paediatric neurosurgical health services.

PurposeThe aim of the study was to evaluate the role of telephone consultations due to the pandemic in the management of paediatric neurosurgical patients and, furthermore, to examine the proportion of patients who eventually needed a face-to-face appointment and assess the underline reasons for that.MethodsThis retrospective study included all the paediatric neurosurgical patients who had a telephone appointment during a 3-month lockdown period. Overall, 319 patients (186 males and 133 females) aged 8.36 ± 4.88 (mean ± SD) had a consultation via telephone. Two hundred fifty-one (78.7%) patients had a follow-up assessment and 68 (21.3%) were new appointments.ResultsPatients were divided between two main groups. Group A included 263 patients (82.4%) whose consultation was adequate via telephone, and Group B included 56 patients (17.6%) who required a complementary face-to-face appointment. Patients who were more likely to require a supplementary appointment were patients with either dysraphism or ventriculomegaly and benign enlarged subarachnoid spaces (BESS) (43.3% and 36.4%, respectively). Interestingly, most children with hydrocephalus who underwent a cerebrospinal fluid (CSF) diversion procedure and children with Chiari I malformation were appropriately assessed via telephone (85.1% and 83.3%, respectively). Finally, children aged < 2 years (55.2%) were better managed with face-to-face appointments. No difference was noticed regarding follow-up and new appointments.ConclusionAlthough telemedicine was not unknown to neurosurgical services, the actual application of telephone or video consultations remained quite limited. It was COVID-19 pandemic who reinforced the use of telemedicine, and taking into consideration its promising results, we can safely assume that it can be incorporated into neurosurgical health care even once the pandemic crisis has resolved.

COVID-19 Impact on Cerebrospinal Fluid Diversion: A Single Institution Experience.

Introduction: Several studies have demonstrated that the absolute numbers of select surgical interventions for myocardial infarction, stroke, and appendicitis decreased during the COVID-19 pandemic, possibly due to overall decreased hospital presentation. We sought to identify if this pattern was also true for children with hydrocephalus and cerebrospinal fluid (CSF) diversion procedures. We hypothesized that there would be a detectable decrease in CSF diversion procedures performed during the COVID-19 pandemic, as compared to a pre-COVID-19 baseline.Methods: A chart review of all patients that underwent a CSF diversion procedure from March 2019 to February 2021 was performed at Ann and Robert H. Lurie Children’s Hospital of Chicago. The pre-COVID-19 period was defined as March 2019 to February 2020 and the COVID-19 pandemic period was defined as March 2020 to February 2021. CSF diversion procedures included endoscopic third ventriculostomy (ETV), ETV/choroid plexus cauterization (CPC), initial shunt placement, shunt removal/replacement, shunt revision, and temporization procedures. Data included gender, race, ethnicity, insurance type, etiology of hydrocephalus, type of procedure, and whether the procedure was performed due to infection. Results: Overall, there was no significant difference in the absolute number of CSF diversion procedures performed when comparing the pre-COVID-19 and COVID-19 periods (244 and 238, respectively). Furthermore, there was no observed difference in the gender, ethnicity, or insurance status of children undergoing a CSF diversion procedure. There was, however, a significant increase in the number of procedures performed due to infection during the COVID-19 pandemic at our institution (p = 0.04).Conclusion: Unlike several other surgical conditions during the COVID-19 pandemic, a statistically significant change in CSF diversion procedures was not observed at our institution. The increased number of procedures for infection at our institution is likely multifactorial and will be investigated further.

Clinical Relevance of Transorbital Ultrasonographic Measurement of Optic Nerve Sheath Diameter (ONSD) for Estimation of Intracranial Pressure Following Cerebrospinal Fluid Diversion Surgery

Background and aimRaised intracranial pressure (ICP) can be estimated by various invasive as well as non-invasive techniques. Optic nerve sheath diameter (ONSD ) is a bedside non-invasive technique for assessment of ICP as a regular follow-up tool and has added advantage over CT scan/MRI, which require patient transfer to the suite. Cerebrospinal fluid (CSF) diversion procedures such as a ventriculoperitoneal shunt or external ventricular drainage are commonly done to relieve symptoms of patients with raised ICP. Change in ICP measured through ONSD after CSF diversion procedures may guide the proper functioning of the shunt and immediate post-operative management. The present study was conducted to compare ONSD before and after CSF diversion procedures and correlate the ONSD with ICP. Our secondary objective was to determine the ONSD cutoff for the prediction of ICP >20mm Hg.Setting, design, and methodsThis prospective, comparative, and observational study was carried out at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India. The present study was conducted on 40 adult patients undergoing CSF diversion surgery under general anaesthesia. Ultrasonographic measurement of the ONSD was performed before induction, after induction, after endotracheal intubation, after completion of shunt surgery, and then every two hours for 12 hours. The direct ICP was measured by the neurosurgeon at the time of the initial ventricular puncture.Statistical analysisThe Wilcoxon signed-rank test was used to compare pre and post variables. Qualitative variables were compared using the Chi-Square test/Fisher’s exact test as appropriate. Spearman's rho statistical measure of linear association was applied to measure the strength of linear association between parameters to show how close the points lie to a straight line. A p-value of <0.05 was considered statistically significant.ResultsThe mean value of ONSD before induction and after induction was 6.36 ± 0.61 mm and 6.29 ±0.64 mm, respectively. After endotracheal intubation, ONSD slightly increased to 6.34 ±0.62mm, followed by a consistent decrease in ONSD values. The mean direct ICP recorded was 30.93±6.22 mmHg. Comparison of mean ONSD before induction, after induction, and after intubation with ONSD after surgery was statistically significant (p <0.001). We found a strong positive correlation between direct ICP and ONSD after intubation with a correlation coefficient of 0.969 (P <0.001). Receiver operating characteristic (ROC) curve analysis showed an ONSD cutoff of >5.85, predicted ICP>20 mmHg with a sensitivity of 92.3%, and specificity of 85.7%.ConclusionMeasurement of ONSD by ultrasonography is an important and reliable tool in the assessment of normalization of ICP post CSF diversion procedure.

Role of Lumboperitoneal shunt in CSF diversion: Outcome in common indications and beyond

Dr. Sameer Aryal1, Dr. Ramchandra Shrestha1, Dr. Alok Deo1, Dr. Gopal Raman Sharma1 1Dhirghayu Guru Hospital, Chabahil, Kathmandu Introduction: A Lumboperitoneal shunt is a procedure of diverting Cerebrospinal Fluid from the lumbar thecal sac to peritoneum. Common indications are Idiopathic Intracranial Hypertension (IIH), Normal Pressure Hydrocephalus (NPH), recurrent CSF fistulas, growing skull fractures etc. It has been often used as a last resort in patients with communicating hydrocephalus who underwent multiple failed ventriculostomy procedures. We present our study of 14 cases of LP shunting done for common indications, we retrospectively analyzed the clinical data of these cases and present our outcome. Objective: Objective of this study was to evaluate the outcome of Lumboperitoneal Shunt and assess its overall role in cerebrospinal fluid diversion procedures. Materials &amp; Methods: Retrospective Study (June 2015- January 2020) Results: A total of 14 cases (6 males and 8 females) were operated from June 2015 to January 2020.Majority of the cases 64.3% (n= 9) were IIH, 21.4% (n=3) were cases of NPH and 14.3% (n=2) were cases of communicating hydrocephalus. Two cases presented with repeat of symptoms after initial improvement and underwent shunt revision. Blockage of thecal catheter due to kinking was found in both cases. Symptomatic improvement was seen in all cases. Conclusion: These results show that Lumboperitoneal Shunt is an excellent option in cerebrospinal fluid diversion whenever indicated. It carries low risk and has good outcome. Key Words: Lumboperitoneal, shunt, theco-peritoneal, idiopathic, benign, intracranial, hypertension, cerebrospinal, fluid, diversion, normal, pressure, hydrocephalus

Endoscopic third ventriculostomy for the management of hydrocephalus secondary to posterior fossa tumors: A retrospective study.

Background: Endoscopic third ventriculostomy (ETV) is an effective alternative to ventriculoperitoneal shunting as well as external ventricular drainage for the urgent management of acute hydrocephalus. We performed this study to investigate the efficacy and safety of ETV before tumor resection in managing hydrocephalus in patients with posterior fossa brain tumors (PFBT) in our neurosurgery department.Methods: We conducted this retrospective observational study between February 2018 and February 2020 on all cases diagnosed with PFBT associated with triventricular obstructive hydrocephalus. We retrospectively reviewed the demographic characteristics, operative procedures, and radiological investigations of all cases. During the follow-up period, clinical, as well as radiological success were evaluated.Results: Twenty-two ETV procedures were performed in 22 cases of PFBT (mean age = 22.1 years, SD = 11.4). Of the 22 cases, 8 cases (36.4%) had ependymoma, 7 cases (31.8%) had cerebellar astrocytoma, and 5 cases (22.7 %) had medulloblastoma, while 2 cases (9.1%) had diffuse pontine gliomas. The median follow-up duration was 9 months (range 3–13 months). The most commonly reported clinical presentation was the significant intracranial pressure increase. All operations were performed successfully in all cases. Only two ETV post-tumor resection failures were documented during the follow-up period.Conclusion: Preoperative ETV has shown to be an effective long-term cerebrospinal fluid diversion procedure to manage PFBT-associated hydrocephalus, with a relatively low rate of complications. Further prospective studies are required to assess the regular use of ETV before complete tumor resection.