Cerebrospinal Fluid Infection Research Articles

The Role of Watertight Dural Closure in Supratentorial Craniotomy: A Systematic Review and Meta-Analysis.

The idea of watertight dural closure (WTDC) seems extremely obvious to avoid complications such as cerebrospinal fluid (CSF) leak and infection, especially in spinal and posterior fossa surgeries. Nonetheless, several studies have shown that leaving the dura open is not associated with an increased risk of complications. The aim of this systematic review and meta-analysis is to compare non-WTDC and WTDC in patients undergoing supratentorial craniotomy regarding the risk of postoperative complications. We searched PubMed, Web of Science, Embase, and Cochrane for randomized control trials and observational studies comparing non-WTDC with WTDC in patients undergoing supratentorial craniotomy. Outcomes of interest were CSF leak, overall infection, meningitis, and subgaleal fluid collection (SFC). Statistical analysis was performed using RStudio 2023.12.1 + 402. Heterogeneity was assessed using I2 statistics. Of 1541 potential articles, 7 met the inclusion criteria. The review comprised 3 randomized control trials, 1 prospective study, and 3 retrospective cohort studies. Among the 1619 patients, 766 (47.3%) and 853 (52.7%) patients were in the non-WTDC and WTDC groups, respectively. There was no significant difference in CSF leak between the non-WTDC and WTDC groups (risk ratio [RR] 1.61; 95% CI 0.68-3.77; P = .276; I2 = 0%). Furthermore, we did not find significant differences in overall infection (RR 1.62; 95% CI 0.95-2.76; P = .078; I2 = 4%), meningitis (RR 1.87; 95% CI 0.64-5.46; P = .251; I2 = 0%), and SFC (RR 1.53; 95% CI 0.64-3.65; P = .342; I2 = 52%) between the non-WTDC and WTDC groups. These findings suggest that non-WTDC is a safe method and is not associated with an increased risk of CSF leak, overall infection, meningitis, and SFC compared with WTDC.

Surgical Correction of Orbital Hypertelorism With Absorbable Plate Instead of Frontal and Orbital Bar and Inverted U-Shaped Osteotomy.

The aim of the study is to investigate the effect and feasibility of using absorbable plate instead of frontal and orbital bar and inverted U-shaped osteotomy to correct the widening of orbital distance. The surgical effect and feasibility of using absorbable plate instead of frontal and orbital bridge plus inverted U-osteotomy for orbital widening syndrome in seven cases between January 2019 and February 2022 were retrospectively analyzed. First, the surgical procedure for orbital hypertelorism was inverted U-shaped orbital osteotomy, and a frontal bone flap was removed, exposing the superior orbital margin and the orbital circumference, and the orbital bone was directly cut off by inverted U-shaped osteotomy. The widened bone in the middle of the orbit was removed, and a long absorbable plate was used to replace the orbitofrontal bridge. The two sides of the orbit were fixed on the absorbable plate, and the absorbable plate was fixed on the rear skull. The clinical effect of treatment, complications (such as cerebrospinal fluid leakage and infection), safety, and feasibility of surgery were evaluated. Using absorbable plate instead of fronto-orbital bridge achieved the effect of orbitofrontal bridge, without orbital distance widening, cerebrospinal fluid leakage, and intracranial infection. Operating time was reduced. There was no metal fixation, and there was no risk of a second operation. The effect of replacing the frontal-orbital bridge with an absorbable plate and inverted U-shaped osteotomy is positive, the operation time is short, and the orbital distance is clearly improved. This approach can replace the traditional orbital-distance operation, and the incidence of postoperative cerebrospinal fluid leakage and infection is low. Long-term follow-up results are stable.

Surgical Correction of Orbital Hypertelorism With Absorbable Plate Instead of Frontal and Orbital Bar and Inverted U-Shaped Osteotomy.

The aim of the study is to investigate the effect and feasibility of using absorbable plate instead of frontal and orbital bar and inverted U-shaped osteotomy to correct the widening of orbital distance. The surgical effect and feasibility of using absorbable plate instead of frontal and orbital bridge plus inverted U-osteotomy for orbital widening syndrome in seven cases between January 2019 and February 2022 were retrospectively analyzed. First, the surgical procedure for orbital hypertelorism was inverted U-shaped orbital osteotomy, and a frontal bone flap was removed, exposing the superior orbital margin and the orbital circumference, and the orbital bone was directly cut off by inverted U-shaped osteotomy. The widened bone in the middle of the orbit was removed, and a long absorbable plate was used to replace the orbitofrontal bridge. The two sides of the orbit were fixed on the absorbable plate, and the absorbable plate was fixed on the rear skull. The clinical effect of treatment, complications (such as cerebrospinal fluid leakage and infection), safety, and feasibility of surgery were evaluated. Using absorbable plate instead of fronto-orbital bridge achieved the effect of orbitofrontal bridge, without orbital distance widening, cerebrospinal fluid leakage, and intracranial infection. Operating time was reduced. There was no metal fixation, and there was no risk of a second operation. The effect of replacing the frontal-orbital bridge with an absorbable plate and inverted U-shaped osteotomy is positive, the operation time is short, and the orbital distance is clearly improved. This approach can replace the traditional orbital-distance operation, and the incidence of postoperative cerebrospinal fluid leakage and infection is low. Long-term follow-up results are stable.

PCR-positive meningococcal CSF infection without pleocytosis but high IL-6 and IL-8.

Meningococcal meningitis is still a severe disease causing high mortality and morbidity rates. Early diagnosis is crucial to ensure prompt antibiotic therapy. However, identification of the pathogen can be challenging. A 32-year-old male patient with systemic lupus erythematosus (SLE) presented to the emergency room with fever, nausea, vomiting, headache and lower back pain as well as multiple petechial bleedings. On suspicion of meningococcal infection, the emergency doctor had already administered one dose of ceftriaxone before arrival to the clinic. Blood works showed massive inflammation due to bacterial infection. Cerebrospinal fluid (CSF) analysis showed normal cell count, protein and glucose levels but PCR was positive for Neisseria meningitis and IL-6 as well as IL-8 were elevated. On antibiotic therapy with ceftriaxone, the patient's condition improved quickly. We present a rare case of meningococcal infection of the CSF in a SLE patient without further CSF abnormalities. We discuss the involvement of early antibiotic treatment and the role of the patient's immune status in the normal CSF findings of this case. Moreover, this case demonstrates the importance of early antibiotic therapy in bacterial meningitis for the clinical outcome.

Infections Associated with Medtronic Duet External Ventricular Drains - Rhode Island Hospital, Providence, Rhode Island, January 2023-January 2024.

External ventricular drains (EVDs) are medical devices that are inserted into the ventricles of the brain to drain excess fluid, manage intracranial hypertension, monitor intracranial pressure, and administer medications. Unintentional disconnections and breaks or fractures (breaks) of EVDs or associated drainage system components can result in cerebrospinal fluid (CSF) leakage and increased risk for EVD-associated infections. After replacement of Integra Life Sciences EVD systems with Medtronic Duet EVD systems at Rhode Island Hospital in mid-September 2023, a threefold increase was observed in the prevalence of positive CSF cultures, from 2.8 per 1,000 days with an EVD in place (EVD days) during January-September 2023 to 11.4 per 1,000 EVD days during October 2023-January 2024 (rate ratio [RR] = 5.7; 95% CI = 1.5-22.0; p = 0.01) and an eightfold increase in the prevalence of infections, from 0.7 to 6.5 per 1,000 EVD days (RR = 9.8; 95% CI = 1.1-87.3; p = 0.04). An investigation by Rhode Island Hospital Infection Control during December 2023-January 2024 identified frequent reports of disconnections and breaks of the Medtronic Duet EVD system. A search of the Food and Drug Administration Manufacturer and User Facility Device Experience database identified 326 reports nationwide of disconnection and breaks of components of the Duet EVD system, including 175 during 2023. A Medical Product Safety Network report was filed. The Duet EVD product was ultimately recalled in January 2024, citing disconnections of the EVD system and reports of CSF leakage and infection. Given the widespread use of EVD systems by neurosurgery centers and the risk for EVD-associated infections, a strategy for future consideration by hospital infection prevention and control programs might be inclusion of EVD-associated infections in hospital surveillance programs to rapidly identify increases in these events and determine factors related to such infections to prevent additional infections.

Impact of Anterior and Posterior Vault Distraction Osteogenesis (A-PVDO) and 3D-Printed Positioning/Shaping Templates in Apert Syndrome: A Case Series Study.

This study seeks to examine the impact of anterior and posterior vault distraction osteogenesis (A-PVDO) in conjunction with 3D-printed positioning and shaping templates for the management of Apert syndrome. From January 2018 to February 2022, a retrospective analysis was conducted on 6 cases of Apert syndrome employing fronto-orbital 3D-printed positioning and molding templates. The cranium underwent surgical modification in accordance with the template's configuration and was affixed with absorbable plates. Subsequently, distraction devices were applied, encompassing both anterior and posterior craniotomies. The evaluation encompassed clinical outcomes, complications (including cerebrospinal fluid leakage and infection), safety, and the feasibility of the distraction osteogenesis procedure. Six patients diagnosed with Apert syndrome underwent treatment involving the integration of fronto-orbital 3D-printed positioning and shaping templates in conjunction with anterior and posterior cranial distraction osteoplasty. Follow-up durations ranged from 18 to 32 months (average: 22mo). No instances of fronto-orbital retraction, cerebrospinal fluid leakage, or intracranial infection were noted during the follow-up period. The sole reported complication entailed an infection at the extension rod site in 1 case. All patients conveyed satisfaction with the treatment outcomes. The application of 3D-printed positioning and shaping templates in tandem with anterior and posterior cranial distraction osteogenesis demonstrates efficacy in addressing Apert syndrome. Notably, significant enhancements in head shape and orbit were observed, and the incidence of postoperative complications such as cerebrospinal fluid leakage and infection remained minimal. Moreover, long-term follow-up affirmed stability.

Scalp and Dural Reconstruction With a Tensor Fascia Lata Myofascial and Anterolateral Thigh Fasciocutaneous Chimeric Flap: A Case Report

Composite scalp and cranial defects present a challenge due to the unique elements that need to be reconstructed. The goals of reconstruction are to protect intracranial contents, prevent cerebrospinal fluid leak (CSF) and infection, and to provide durable soft tissue coverage. We present a case of an immunocompromised patient with history of craniotomy who developed osteomyelitis and a cranial abscess resulting in a composite defect with dural, bony, and soft tissue loss. To achieve vascularized watertight dural repair and durable soft tissue coverage for resolution of infection and eventual staged cranioplasty, we performed a free tensor fascia lata (TFL) myofascial and anterolateral thigh (ALT) fasciocutaneous chimeric flap. The patient healed well without CSF leak or infection at 5-month follow-up and cranioplasty is planned. Use of a chimeric TFL and ALT flap is effective in the treatment of large, composite cranial defects in the setting of active infection.

Navigated bedside implantation of external ventricular drains with mobile health guidance: technical note and case series

PurposeExternal ventricular drain (EVD) implantation is one of the fundamental procedures of emergency neurosurgery usually performed freehand at bedside or in the operating room using anatomical landmarks. However, this technique is frequently associated with malpositioning leading to complications or dysfunction. Here, we describe a novel navigated bedside EVD insertion technique, which is evaluated in a clinical case series with the aim of safety, accuracy, and efficiency in neurosurgical emergency settings.MethodsFrom 2021 to 2022, a mobile health–assisted navigation instrument (Thomale Guide, Christoph Miethke, Potsdam, Germany) was used alongside a battery-powered single-use drill (Phasor Health, Houston, USA) for bedside EVD placement in representative neurosurgical pathologies in emergency situations requiring ventricular cerebrospinal fluid (CSF) relief and intracranial pressure (ICP) monitoring.ResultsIn all 12 patients (8 female and 4 male), navigated bedside EVDs were placed around the foramen of Monro at the first ventriculostomy attempt. The most frequent indication was aneurysmal subarachnoid hemorrhage. Mean operating time was 25.8 ± 15.0 min. None of the EVDs had to be revised due to malpositioning or dysfunction. Two EVDs were converted into a ventriculoperitoneal shunt. Drainage volume was 41.3 ± 37.1 ml per day in mean. Mean length of stay of an EVD was 6.25 ± 2.8 days. Complications included one postoperative subdural hematoma and cerebrospinal fluid infection, respectively.ConclusionCombining a mobile health–assisted navigation instrument with a battery-powered drill and an appropriate ventricular catheter may enable and enhance safety, accuracy, and efficiency in bedside EVD implantation in various pathologies of emergency neurosurgery without adding relevant efforts.

Duraplasty using a combination of a pedicled dural flap and collagen matrix in posterior fossa decompression for pediatric Chiari malformation type 1 with syrinx.

In posterior fossa decompression for pediatric Chiari malformation type 1 (CM-1), duraplasty methods using various dural substitutes have been reported to improve surgical outcomes and minimize postoperative complications. To obtain sufficient posterior fossa decompression without cerebrospinal fluid-related complications, we developed a novel duraplasty technique using a combination of a pedicled dural flap and collagen matrix. The objective of this study was to describe the operative nuances of duraplasty using a combination of a pedicled dural flap and collagen matrix in posterior fossa decompression for pediatric CM-1. We reviewed the clinical and radiographic records of 11 consecutive pediatric patients who underwent posterior fossa decompression with duraplasty using a combination of a pedicled dural flap and collagen matrix followed by expansile cranioplasty for CM-1. The largest area of the syrinx and the size of the posterior fossa were calculated. The maximum syrinx area was reduced by a mean of 68.5% ± 27.3% from preoperatively to postoperatively. Four patients (36.4%) had near-complete syrinx resolution (> 90%, grade III reduction), five (45.5%) had 50% to 90% reduction (grade II), and two (18.2%) had < 50% reduction (grade I). The posterior fossa area in the midsagittal section increased by 8.9% from preoperatively to postoperatively. There were no postoperative complications, including cerebrospinal fluid leakage, pseudomeningocele formation, or infection. Duraplasty using a combination of a pedicled dural flap and collagen matrix in posterior fossa decompression is a promising safe and effective surgical technique for pediatric CM-1 with syrinx.

Incidence, pathogens and antimicrobial resistance of blood and cerebrospinal fluid isolates from a tertiary neonatal unit in South Africa: A 10 year retrospective review.

To determine trends in incidence, etiology and antimicrobial susceptibility of blood and cerebrospinal fluid (CSF) culture confirmed infections in hospitalized infants in a large tertiary neonatal unit in South Africa. Single-center, retrospective review of laboratory records of bacteria and fungi, and their susceptibility profiles, isolated from blood and CSF of infants hospitalized in the neonatal unit at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 1st January 2010 to 31st December 2019. Laboratory data on isolates and their antimicrobial susceptibilities were collected. Coagulase-negative Staphylococcus, Corynebacteria and Bacillus spp. were excluded. Patient-level clinical and laboratory data were not available. There were 8,319 significant isolates, giving an infection rate of 14.3/1000 patient-days. Infection rates increased from 12.0 to 15.7/1000 patient-days (estimated average yearly change 0.6[95%CI, 0.5-0.7];p = <0.001). Gram-negative infection rates increased from 4.3 to 10.8/1000 patient-days (estimated average yearly change 0.7[95%CI,0.6-0.8];p = <0.001). The 2 most commonly isolated Gram-negative organisms were Acinetobacter baumannii (44%) and Klebsiella pneumoniae (39%). Carbapenem resistance was seen in 31% of all Gram-negatives and increased over time (estimated average yearly change 4.8%[95%CI,4.2%-5.3%];p<0.001). Gram-positive infection rates decreased (estimated average yearly change -0.1[95%CI,-0.2- -0.05];p = <0.001). Staphylococcus aureus was the most common Gram-positive isolated. Rates of methicillin-resistant Staphylococcus aureus decreased from 91% to 55%(estimated average yearly change -2.8%[95%CI,-3.5%-2%],p< 0.001). Rates of fungal isolates decreased (estimated average yearly change -0.06[95%CI,-0.1 --0.02]);p = 0.007). Candida parapsilosis (52%) and Candida albicans (35%) were the most common fungi isolated. There has been a marked overall increase in rates of blood and/or CSF infections, with an absolute increase in Gram-negative infections observed, replacing Gram-positive and fungal pathogens. Extended spectrum beta-lactamase Gram-negative isolates are being replaced by carbapenem resistance, with around one third of all significant Gram-negative isolates now carbapenem resistant. Research into hospital based novel treatment and prevention interventions for neonatal sepsis should be urgently prioritized.

Extraventricular Drain Care Bundle Decreases Cerebrospinal Fluid Infection Rates Associated With Extraventricular Drain-Related Procedures and Systemic Infection.

Infection associated with extraventricular drain (EVD)-related procedures is well known. To investigate the impact of our institution's EVD care bundle on the infection rates associated with EVD-related procedures. A retrospective study was conducted from June 2022 to June 2023 to compare the infection rate six months before and six months after the implantation of the EVD care bundle. A total of 58 patients were included in the study (n=33 patients in 2022 and n=25 patients in 2023). The infection rate was 21.2% (7/33) prior to the implementation of the EVD care bundle and 0.0% (0/25) afterward. The seven patients with cerebrospinal fluid (CSF) infection did not have a higher total number of EVD-related procedures compared to the other 26 patients without CSF infection (8.0 vs. 9.4, p=0.7364); however, the mean number of EVD replacements was higher in patients with CSF infection (1.4 vs. 3.4, p=0.0028). The total number of EVD-related procedures was not different between 2022 and 2023 (8.3 vs. 5.2, respectively, p=0.1892); however, the mean number of EVD replacements was lower in 2023 (1.8 vs. 1.0, p=0.0257). In 2022, 22/33 patients had systemic infection, among which 7/22 also had CSF infection. In 2023, 13/25 patients had a systemic infection, among which 0/13 had CSF infection. The EVD care bundle consisting of standardizations, checklists, and monitoringreduces the CSF infection rates associated with EVD-related procedures and systemic infection.

Application of Dural Suturing in Reconstruction of Sellar Floor for Cerebrospinal Fluid Leakage During Neuroendoscopic Intranasal Approach Surgery: A Meta-Analysis.

To assess the safety and efficacy of utilizing dural suturing as an adjunctive procedure for saddle floor reconstruction in patients undergoing endoscopic surgery in the sellar region. According to the PRISMA guidelines, we searched the literature on sellar floor reconstruction in endoscopic sellar surgery. Fixed- or random-effects meta-analysis was used to pool the rate of return to postoperative cerebrospinal fluid (poCSF) leakage, repair operations, postoperative hospitalization, complete resection, infection, lumbar drainage (LD), and operative duration. A total of six studies involving 723 participants were included in the current meta-analysis. The pooled results demonstrated that patients in the dural suturing group had a lower incidence of poCSF leakage [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.07 - 0.44; p=0.0002] and repair operation [OR, 0.24; 95% CI, 0.07 - 0.78; p=0.02], as well as a shorter hospitalization period [standardized mean difference (SMD), -0.45; 95% CI, -0.62 - -0.28; p < 0.00001]. There was no significant difference between the two groups in terms of the complete resection [OR, 1.06; 95% CI, 0.62 - 1.80; p=0.84], postoperative infection [OR, 0.49; 95% CI, 0.21 - 1.15; p=0.10] and lumbar drainage (LD) [OR, 0.28; 95% CI, 0.06 - 1.23; p=0.09]. Additionally, the dural suturing group may require a longer operative duration [SMD, 0.29; 95% CI, 0.02 - 0.56; p=0.03]. The results suggest that dural suturing can be advantageous in reducing postoperative complications and shortening postoperative hospitalization following neuroendoscopic surgery in the sellar region without increasing the risk of infection.

Evaluation of Biocompatibility and Healing Properties of Dural Substitutes Produced by Electrospinning Technology.

Dural reconstruction is a critical process after neurosurgical procedures. Improper dural repair leads to serious side-effects, such as cerebrospinal fluid leakage or infection. This is why it is important to properly repair the dura using a dural substitute, and research into dural substitutes is ongoing. The ideal dural substitute should be non-toxic, biocompatible, and capable of maintaining adequate tension and preventing cerebrospinal fluid leakage for extended periods in vivo. This study evaluated the biocompatibility and healing properties of Safe-Seal, poly-L-lactic acid synthetic bioabsorbable dural substitute produced by electrospinning technology. Safe-Seal, was created by electrospinning, which is a technique for nanofiberizing polymers into three-dimensional structures, and its cytotoxicity was evaluated. The animal study used 30 rats, divided into three groups assessed at two time points (4 and 12 weeks). The study groups were a negative control group with no treatment, an experimental group with Safe-Seal (TDM Co. Ltd., Gwangju, Republic of Korea) implantation, and a positive control group with a commercial product, Redura® (Medprin Biotech, Frankfurt, Germany) implantation. Safe-Seal exhibited no cytotoxic or adverse effects in the in vivo animal study. Histologically, Safe-Seal displayed less inflammatory cell infiltration, less adhesion to brain tissue, and connectivity with the surrounding dura mater as compared to the negative control group and without any significant differences from Redura® in all evaluation criteria. Safe-Seal presented adequate biocompatibility in vivo and contributed to the healing of the dura mater at a similar level to that of Redura® when applied to dural defects.

Systemic and cerebrospinal fluid biomarkers for tuberculous meningitis identification and treatment monitoring.

Tuberculous meningitis is a life-threatening infection with high mortality and disability rates. Current diagnostic methods using cerebrospinal fluid (CSF) samples have limited sensitivity and lack predictive biomarkers for evaluating prognosis. This study's findings reveal excessive activation of the immune response during tuberculous meningitis (TBM) infection. Notably, a strong negative correlation was observed between CSF levels of monokine induced by interferon-γ (MIG) and the CSF/blood glucose ratio in TBM patients. MIG also exhibited the highest area under the curve with high sensitivity and specificity. This study suggests that MIG may serve as a novel biomarker for differentiating TBM infection in CSF or serum, potentially leading to improved diagnostic accuracy and better patient outcomes.

Application of Unilateral Double-Channel Endoscopic Lamina Fenestration Decompression in Lumbar Spinal Stenosis

Objective: This paper aims to observe and explore the application effect of unilateral double-channel endoscopic lamina fenestration decompression in the clinical treatment of patients with lumbar spinal stenosis. Methods: The study period is from January 2020 to December 2022, 60 patients with lumbar spinal stenosis were recruited and divided into the control group (traditional interlaminar fenestration) and the study group (unilateral double-channel endoscopic lamina fenestration decompression) according to the method of coin tossing, with 30 cases in each group. The operation time, perioperative blood loss, incision diameter, total hospitalization time, postoperative complications, Japanese Orthopedic Association (JOA), Numerical Rating Scale (NRS) pain score, and excellent rate of lumbar recovery were compared. Results: The operation time of the study group was longer than that of the control group, the amount of perioperative blood loss was lower than that of the control group, the incision diameter was smaller than that of the control group, and the total hospitalization time was shorter than that of the control group (P &lt; 0.05). Postoperative complications such as dural tear, cerebrospinal fluid leakage, infection, and paravertebral muscle injury in the study group were less than those in the control group (P &lt; 0.05). The JOA score of the study group was higher than that of the control group, and the NRS score was lower than that of the control group 6 months after operation (P &lt; 0.05). The operation effect was evaluated according to the modified MacNab standard 6 months after operation, and the excellent rate of lumbar spine recovery in the study group was higher than that in the control group (P &lt; 0.05). Conclusion: Unilateral double-channel endoscopic fenestration decompression of the lamina has a definite application effect, it can significantly reduce postoperative complications of lumbar spinal stenosis, and promote the recovery of lumbar spine function. It has the advantages of mild pain, high safety, less bleeding, small incision, and other advantages, which can be recommended in the treatment of lumbar spinal stenosis.

Relationship between catheter related cerebrospinal fluid infections and systemic immune-inflammation index.

This study investigated the relationship between the systemic immune inflammation index (SII) and catheter-related infections and their effects on prognosis in pediatric patients. A total of 56 pediatric patients diagnosed with ventriculoperitoneal (V-P) shunt infection between January 2017 and October 2019 were included. V-P shunt infection diagnosis was made based on clinical findings. All cerebrospinal fluid (CSF) samples were subjected to direct microscopic examination and culture. Protein, glucose, and sodium levels in CSF, CSF leukocytes, and hematological and biochemical parameters were measured. Fifty-six patients with growth in CSF culture were included in this study. 55.4% of the cases were female and 44.6% male. V-P shunt was detected in 82.1% of the cases and external ventricular drainage (EVD) catheter-related infection in 17.9%. The CSF/blood glucose ratio was significantly lower (p=0.046), and SII was significantly increased (p=0.002) in non-coagulase-negative staphylococci. Early and appropriate antibiotic therapy reduces morbidity and mortality in catheter-related infections. However, it is important to start empirical antibiotherapy until culture results are expected. Therefore, further research on the estimation of possible factors is needed.

Epstein-Barr virus: To be a trigger of autoimmune glial fibrillary acidic protein astrocytopathy?

Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy is a novel autoimmune disease of central nervous system (CNS). It is unclear whether Epstein-Barr virus (EBV) is related to autoimmune GFAP astrocytopathy. To describe the clinical, laboratory, and imaging characteristics of patients with autoimmune GFAP astrocytopathy. The clinical, laboratory, and imaging findings of patients are presented. The levels of GFAP in CSF were detected by ELISA. T and B cell subsets in CSF were detected by flow cytometry. GFAP-IgG in serum and cerebrospinal fluid (CSF) were tested by cell-based assay (CBA) and tissue-based assay (TBA). All three patients had fever, cognitive dysfunction, limb weakness, and positive GFAP-IgG with EBV infection in CSF. Enteric glia cells may involve in this disease. Typical imaging findings include the gadolinium enhancement of linear perivascular radial perpendicular to the ventricle, meningeal enhancement (especially in midbrain interpeduncal fossa), longitudinally extensive lesions involving spindle cords, and more T2/Flair-hyperintense lesions in the periventricular white matter at late stage. The patients had poor response to antiviral treatment and strong response to steroid pulse therapy. EBV could induce CNS autoimmune response in autoimmune GFAP astrocytopathy. The detection of GFAP-IgG and EBV may facilitate the early diagnosis in these patients.

거대 뇌하수체 선종

A giant pituitary adenoma remains a major challenge for neurosurgeons, despite advances in en-doscopic endonasal surgery. These tumors can grow in different directions, which can affect the surrounding neurovascular structures. When the tumor grows towards the suprasellar region, it can affect important structures such as the optic nerves, anterior cerebral arteries, and hypothalamus. When it occupies the interpeduncular and prepontine cisterns, the oculomotor nerves or posterior communicating arteries may be at risk. Postoperative hemorrhage due to incomplete resection is also a concern and can lead to the need for revisional surgery or another surgical approach. Patients with giant pituitary adenomas typically have longer hospital stays due to the high rates of postoperative complications, such as cerebrospinal fluid leakage, diabetes insipidus, and infection. Gross total re-section rates are also lower for these types of tumors. This study provides a comprehensive review of the literature to date and reports various clinical outcomes associated with giant pituitary adenomas.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience

Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use. A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation. Forty-one patients were retrospectively identified (ELD= 30 and EVD= 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome. The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage (IVH) with obstructive hydrocephalus requiring extraventricular drainage (EVD) or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 SAH patients, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant(p=0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls(p=0.039). Hydrocephalus requiring EVD occurred in 10.9% of the LD group and 28.7% of the control group(p<0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group(p=0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(p=0.272). Prompt LD is a feasible option for treating selective aneurysmal SAH patients.