Cerebrospinal Fluid Removal Research Articles

Continuous Versus Intermittent Cerebrospinal Fluid Drainage after Severe Traumatic Brain Injury in Children: Effect on Biochemical Markers

Drainage of cerebrospinal fluid (CSF) is routinely used in the treatment of severe traumatic brain injury (TBI), either continuously or intermittently in response to increases in intracranial pressure (ICP). There has been little study of the effect of CSF drainage method on the biochemistry, pathophysiology or outcome of TBI in adults or children. Having previously reported that a variety of markers of injury or repair increase in CSF after severe TBI, we chose to evaluate directly the effect of CSF drainage method on the biochemistry and volume of CSF drained as well as ICP. We hypothesized that concentrations of these markers would be similar in CSF drained continuously vs intermittently. We compared CSF levels of markers of neuronal injury (neuron specific enolase, [NSE]), glial injury (s100B), inflammation (interleukin-6 [IL-6]), and regeneration (vascular endothelial growth factor [VEGF]) (measured by ELISA) in 80 CSF samples from 19 severely injured children whose CSF was drained continuously (n = 13) versus intermittently (n = 6) as part of standard care in two institutions. Compared to continuous CSF drainage, intermittent drainage of CSF was associated with twofold greater CSF concentrations of NSE, s100B, IL-6 and VEGF (p < 0.05) and with about half the volume of CSF removal than continuous drainage (p = 0.002). The resulting elimination (concentration × volume) of these biochemicals, however, was not influenced by drainage method. Patients treated with continuous drainage had lower mean ICPs than those with intermittent drainage (13.6 ± 0.69 vs. 21.8 ± 0.95 mm Hg, p < 0.0001). We conclude that the method of CSF drainage greatly affects concentrations of CSF markers after TBI and may influence ICP. The influence of method on CSF marker concentration must be kept in mind when interpreting

Cardiac Encephalopathy.

Many patients develop confusion, lethargy, and cognitive and behavioral abnormalities during or after cardiac decompensation. Congestive heart failure and the accompanying elevation in systemic venous pressure and decrease in cardiac output can lead to changes within the cranial cavity that cause an encephalopathy. At times, excess cerebrospinal fluid accumulates within the cranium causing an apathetic state identical to that seen in patients with other causes of hydrocephalus. Awareness of the syndrome of cardiac encephalopathy and optimal management of congestive heart failure and body fluids can reverse the neurologic dysfunction. In some patients with excess cerebrospinal fluid, lumbar puncture with removal of cerebrospinal fluid can reverse the apathetic state.

Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump

Baclofen delivered by intrathecal pumps (ITB) is increasingly being utilized in the pediatric population, however, resources and education to support problems with these devices are limited. Typical management strategies for systemic baclofen overdose include removal of baclofen from the device reservoir or removal of cerebrospinal fluid from the adjacent device catheter. Appropriate care of these patients requires awareness of the clinical patterns of toxicity and mechanics of the ITB pump delivery system. This report describes the clinical presentation, unfamiliar dilemmas, and the management of a pediatric patient with intrathecal baclofen toxicity, noting problems that may arise in the care of these patients.

CSF removal in infantile posthemorrhagic hydrocephalus results in significant improvement in cerebral hemodynamics.

Rational intervention in infants with posthemorrhagic hydrocephalus (PHH) would be facilitated greatly by bedside measure of impaired cerebral perfusion, as there is substantial evidence that impaired perfusion and oxidative metabolism contribute to irreversible brain injury in hydrocephalus. Near-infrared spectroscopy (NIRS) measures changes in the cerebral concentration of oxygenated and deoxygenated hemoglobin and oxidized cytochrome oxidase at the bedside of infants continuously and noninvasively. The total hemoglobin and the hemoglobin difference signal are derived from the sum and difference, respectively, of oxygenated and deoxygenated hemoglobin. Changes in total hemoglobin reflect changes in cerebral blood volume; our previous work has shown that changes in hemoglobin difference signal reflect changes in cerebral blood flow. We hypothesized that cerebrospinal fluid (CSF) removal in infants with PHH would result in significant increases in cerebral perfusion, cerebral blood volume, and oxidative metabolism, as measured by NIRS. Continuous NIRS recordings were performed during CSF removal on 16 infants with PHH. There was a statistically significant increase in oxygenated hemoglobin (p < 0.001), total hemoglobin (p = 0.001), and hemoglobin difference signal (p = 0.006), but not oxidized cytochrome oxidase, accompanying CSF removal. There was no significant correlation between either the volume of CSF removed (in milliliters per kilogram body weight) or the opening pressure and the change in any of the measured or calculated NIRS signals. These findings demonstrate the pronounced effect of CSF removal on cerebral perfusion in infants with PHH. NIRS may be a useful technique to detect impending cerebral ischemia in such infants and thereby provide a means to guide the rational management of PHH.

Intracranial pressure changes during intermittent CSF drainage

Premature very-low-birth-weight infants with posthemorrhagic hydrocephalus are often managed with intermittent cerebrospinal fluid drainage from a ventricular reservoir. There are little data regarding intracranial pressure changes during intermittent drainage to determine the amount and frequency of cerebrospinal fluid removal or to determine the correct resistance of future programmable shunts. The objective of this study was to determine the feasibility of using a commercially available intracranial pressure transducer to measure changes in pressure associated with this procedure. Continuous intracranial pressure was measured in three infants with a transducer placed at the time of ventricular reservoir insertion. Daily reservoir taps began 48 hours after placement and intracranial pressure was monitored for 7 days. Intracranial pressure before the initial tap was comparable to levels previously reported as normal. The daily removal of 10 cc/kg of cerebrospinal fluid was sufficient to lower intracranial pressure below baseline, however it was associated with wide swings in pressure and, in one patient, sustained negative pressure. The use of direct intracranial pressure monitoring may be useful in determining the optimal amount and frequency of cerebrospinal drainage from infants with posthemorrhagic hydrocephalus managed with a ventricular reservoir, as well as determining resistance settings of subsequent programmable shunts.

Estudo das alterações neurológicas em cães submetidos à mielografia, utilizando os meios de contrastes iopamidol e iohexol

Este estudo objetivou avaliar os efeitos colaterais do emprego do iopamidol e do iohexol nosexames mielográficos com e sem retirada de líquor. Foram utilizados 24 cães, fêmeas, sadias do canil da FMVZ - UNESP - Botucatu, com peso médio de 15kg. O protocolo anestésico consistiude levopromazina como pré-anestésico e tiopental como anestésico. A punção do espaço subaracnóide foi realizada na cisterna magna com agulha 30xS e a dose de contraste utilizada foi de0,3ml/kg. Os animais foram divididos aleatoriamente em quatro grupos: G1, sem retirada de líquore emprego do iopamidol; G2, com retirada de líquor e emprego do iopamidol; G3, sem retirada do líquor e emprego do iohexol, e G4, com retirada de líquor e emprego do iohexol. Os animais foram avaliados quanto aos movimentos involuntários e repetitivos das articulações, movimentos de cabeça, movimentos tônicos-clônicos, rigidez muscular, vocalização, salivação, midríase, e convulsão. Os animais dos grupos G1 e G2 apresentaram alto índice de convulsão (66.6%) e o tempo entre a administração do contraste e o aparecimento dos sintomas neurológicos foi menor para o G2.

Comparison between the lumbar infusion and CSF tap tests to predict outcome after shunt surgery in suspected normal pressure hydrocephalus

Objective: To compare the lumbar infusion test and the cerebrospinal fluid (CSF) tap test for predicting the outcome of shunt surgery in patients with suspected normal pressure hydrocephalus. Methods: 68...

Management of Elevated Intracranial Pressure

Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.

Quantitative local cerebral blood flow change after cerebrospinal fluid removal in patients with normal pressure hydrocephalus measured by a double injection method with N-isopropyl-p-[(123)I] iodoamphetamine.

The efficacy of cerebrospinal fluid (CSF) shunting surgery for normal pressure hydrocephalus (NPH) is difficult to predict. The CSF removal test is useful but quantification of the results is difficult. A method to quantitatively measure cerebral blood flow (CBF) by single photon emission computed tomography twice within 30 min after double injection of N-isopropyl-p-[(123)I] iodoamphetamine using a background subtraction method to correct for the temporal profile was utilized in tandem with CSF removal via a lumbar spinal tube in 22 patients of NPH to produce maps of baseline CBF and quantitative CBF change after CSF removal. All 22 patients with NPH underwent ventriculoperitoneal shunting surgery and were divided into two groups according to improvement in clinical symptoms and signs (responder group, N=15; nonresponder group, N=7). Baseline clinical characteristics and baseline CBF values were not significantly different between the two groups. Regional and whole brain CBF changes in the responder group (range 98-105%, whole brain 101+/-39%) were significantly higher than those in the nonresponder group (range 41-48%, whole brain 46+/-40%) (P<0.01). Discrimination analysis showed that an increase of more than 80% in CBF after CSF removal was predictive of response to shunt surgery with 77% accuracy. This new quantitative CSF removal test could be useful for selecting good candidates for CSF shunting surgery among patients with NPH.

Vascular parkinsonism: clinical correlates predicting motor improvement after lumbar puncture.

Vascular parkinsonism (VP) is a poorly defined entity which has clinical, and perhaps pathological, overlap with other diagnoses. Although classical VP involves lesions of the basal ganglia, the majority of cases actually show diffuse subcortical white matter changes (SCWMC) on imaging. The exact pathologies of these white matter changes are debated and likely heterogeneous, but are generally thought to represent areas of chronic or recurrent partial ischemia. Cerebrospinal fluid (CSF) drainage is the treatment for NPH and has been reported to improve symptoms in some patients with idiopathic NPH and associated SCWMC. To determine whether historical, clinical, or radiographic factors predict improvement in VP patients after CSF drainage, we removed 35-40 ml of CSF via lumbar punctures (LP) from 40 patients and compared responders with nonresponders for a variety of demographics, clinical features, and blindly interpreted magnetic resonance images (MRI). Fifteen patients (37.5%) reported "significant and irrefutable" gait improvement after LP. Twelve (30.0%) reported no effect and 13 (32.5%) reported mild or very transient improvement. Timed gait in a subset of patients improved (P < 0.05) immediately after LP. Clinically, improvement after CSF removal was predicted by any positive response to levodopa (P < 0.001), the lack of vertical gaze palsies (P < 0.05), the lack of a pure freezing gait (P < 0.05), and the lack of hypotensive episodes (P < 0.05). Blinded MRI interpretation did not find features which clearly predicted response. Some patients diagnosed with VP improved after LP. Clinically, these patients tended to resemble idiopathic PD, whereas nonresponders more closely resembled progressive supranuclear palsy (PSP). These results warrant further investigation and also raise the possibility of testing CSF drainage in patients with idiopathic PD complicated by SCWMC.

A hundred years of narcolepsy research.

The emergence of a clinical syndrome: The first convincing descriptions of narcolepsy-cataplexy were reported in Germany by Westphal (1877) (100) and Fisher (1878) (25). The unique association of episodes of muscle weakness triggered by excitement and sleepiness were described in these two reports. In both cases, hereditary factors were noted, with the mother of Westphal’s patient and one sister of Fisher’s patient presenting narcolepsy symptoms. The leading hypothesis to explain narcolepsy at the time was to refer to the well publicized case of von Zastrow. Von Zastrow was a recently arrested pathological rapist widely believed to experience pathological sleepiness as a result of repressed homosexuality and excessive masturbation. Gelineau (1880) (28, 29) is widely recognized for giving narcolepsy its name and for recognizing the disorder as a specific clinical entity. Its description of a wine cask maker with narcolepsy in la Gazette des hopitaux de Paris was classical but Gelineau did not strictly differentiate muscle weakness episodes and sleep attacks triggered by emotions. Rather, Gelineau suggested a common physiology for these two symptoms. Loewenfeld (1902), was the first to give a name to muscle weakness episodes triggered by emotions or “cataplexy” (53). The 1917-1927 epidemic of encephalitis lethargica led to a renewed interest in narcolepsy and sleep research but also added much confusion to the nosological definition of narcolepsy. Encephalitis lethargica often presented initially with somnolence and the term “narcolepsy” was often used to describe any form of daytime sleepiness. The association of somnolence and occulomotor paralysis also led to the pioneer work of Von Economo (1930) and the recognition of the posterior hypothalamus as a critical region for the promotion of wakefulness (98). In fact, Von Economo should be credited as being one of the first investigators to correctly propose that a region in the posterior hypothalamus was lesioned in human narcolepsy. In 1930, he wrote: “it is very probable, though not proved, that the narcolepsy of Gelineau, Westphal and Redlich has its primary cause in an yet unknown disease of that region” (98). As narcolepsy with cataplexy was also observed in some cases of encephalitis lethargica, clinicians long debated the existence of idiopathic narcolepsy and the importance of cataplexy for defining the clinical entity. Large case series of narcolepsy-cataplexy were reported by Addie (1926) (1), Wilson (1927) (101) and Daniels (1934) (17). The review by Daniels is considered by many as one of the most insightful clinical reviews published to this date. Further work at the Mayo Clinic, by Yoss and Daly (103) and in Prague by Bedrich Roth (91), then led to the classic description of the narcolepsy tetrad. Various methods were initially proposed in the treatment of narcolepsy, including intrathecal injection of air, cerebrospinal fluid removal and X-ray irradiation of the hypothalamic region. Ephedrine treatment was generally used as the only marginally effective treatment for daytime sleepiness until Prinzmetal and Bloomberg introduced amphetamines in 1935 (87). Yoss and Daly introduced methylphenidate in the 1960s (104). Shortly after the discovery of t r icycl ic antidepressants in 1957, Akimoto, Honda and Takahashi used imipramine in the treatment of human cataplexy (2), e s t a b l i s h i n g t h e d u a l stimulant/antidepressant pharmacological treatment most commonly used in narcoleptic patients to this date.

The effect of cerebrospinal fluid drainage on cerebral perfusion in traumatic brain injured adults.

Cerebrospinal fluid drainage is a first line treatment used to manage severely elevated intracranial pressure (> or = 20 mm Hg) and improve outcomes in patients with acute head injury. There is no consensus regarding the optimal method of cerebrospinal fluid removal. The purpose of this investigation was to determine whether cerebrospinal fluid drainage decreases intracranial pressure and improves cerebral perfusion and to identify factors that impact treatment effectiveness. This study involved 31 severely head injured patients. Intracranial pressure and other indices of cerebral perfusion (cerebral perfusion pressure, cerebral blood flow velocity, and regional cerebral oximetry) were measured before, during, and after cerebrospinal fluid drainage. Arterial and jugular venous oxygen content was measured before and after cerebrospinal fluid drainage. Patients underwent three randomly ordered cerebrospinal fluid drainage protocols that varied in the volume of cerebrospinal fluid removed (1 mL, 2 mL, and 3 mL) for a total of 6 mL of cerebrospinal fluid removed. There was a significant change in the intracranial pressure from a mean at baseline of 26.1 mm Hg (SD = 4.4) to 22.1 mm Hg immediately after drainage. One third of patients experienced a decrease in the intracranial pressure below 20 mm Hg; in two patients the intracranial pressure dropped less than 1 mm Hg. The following factors predicted 61.5% of the variance in the responsiveness of intracranial pressure to drainage: vecuronium hypothermia, baseline cerebral perfusion pressure and acuity of illness. Cerebrospinal fluid drainage provides a transient decrease in intracranial pressure without a measurable improvement in other indices of cerebral perfusion.

Elucidating the pathophysiology of syringomyelia.

Syringomyelia causes progressive myelopathy. Most patients with syringomyelia have a Chiari I malformation of the cerebellar tonsils. Determination of the pathophysiological mechanisms underlying the progression of syringomyelia associated with the Chiari I malformation should improve strategies to halt progression of myelopathy. The authors prospectively studied 20 adult patients with both Chiari I malformation and symptomatic syringomyelia. Testing before surgery included the following: clinical examination; evaluation of anatomy by using T1-weighted magnetic resonance (MR) imaging; evaluation of the syrinx and cerebrospinal fluid (CSF) velocity and flow by using phase-contrast cine MR imaging; and evaluation of lumbar and cervical subarachnoid pressure at rest, during the Valsalva maneuver, during jugular compression, and following removal of CSF (CSF compliance measurement). During surgery, cardiac-gated ultrasonography and pressure measurements were obtained from the intracranial, cervical subarachnoid, and lumbar intrathecal spaces and syrinx. Six months after surgery, clinical examinations, MR imaging studies, and CSF pressure recordings were repeated. Clinical examinations and MR imaging studies were repeated annually. For comparison, 18 healthy volunteers underwent T1-weighted MR imaging, cine MR imaging, and cervical and lumbar subarachnoid pressure testing. Compared with healthy volunteers, before surgery, the patients had decreased anteroposterior diameters of the ventral and dorsal CSF spaces at the foramen magnum. In patients, CSF velocity at the foramen magnum was increased, but CSF flow was reduced. Transmission of intracranial pressure across the foramen magnum to the spinal subarachnoid space in response to jugular compression was partially obstructed. Spinal CSF compliance was reduced, whereas cervical subarachnoid pressure and pulse pressure were increased. Syrinx fluid flowed inferiorly during systole and superiorly during diastole on cine MR imaging. At surgery, the cerebellar tonsils abruptly descended during systole and ascended during diastole, and the upper pole of the syrinx contracted in a manner synchronous with tonsillar descent and with the peak systolic cervical subarachnoid pressure wave. Following surgery, the diameter of the CSF passages at the foramen magnum increased compared with preoperative values, and the maximum flow rate of CSF across the foramen magnum during systole increased. Transmission of pressure across the foramen magnum to the spinal subarachnoid space in response to jugular compression was normal and cervical subarachnoid mean pressure and pulse pressure decreased to normal. The maximum syrinx diameter decreased on MR imaging in all patients. Cine MR imaging documented reduced velocity and flow of the syrinx fluid. Clinical symptoms and signs improved or remained stable in all patients, and the tonsils resumed a normal shape. The progression of syringomyelia associated with Chiari I malformation is produced by the action of the cerebellar tonsils, which partially occlude the subarachnoid space at the foramen magnum and act as a piston on the partially enclosed spinal subarachnoid space. This creates enlarged cervical subarachnoid pressure waves that compress the spinal cord from without, not from within, and propagate syrinx fluid caudally with each heartbeat, which leads to syrinx progression. The disappearance of the abnormal shape and position of the tonsils after simple decompressive extraarachnoidal surgery suggests that the Chiari I malformation of the cerebellar tonsils is acquired, not congenital. Surgery limited to suboccipital craniectomy, C-I laminectomy, and duraplasty eliminates this mechanism and eliminates syringomyelia and its progression without the risk of more invasive procedures.

Elucidating the pathophysiology of syringomyelia

Object Syringomyelia causes progressive myelopathy. Most patients with syringomyelia have a Chiari I malformation of the cerebellar tonsils. Determination of the pathophysiological mechanisms underlying the progression of syringomyelia associated with the Chiari I malformation should improve strategies to halt progression of myelopathy. Methods The authors prospectively studied 20 adult patients with both Chiari I malformation and symptomatic syringomyelia. Testing before surgery included the following: clinical examination; evaluation of anatomy by using T1-weighted magnetic resonance (MR) imaging; evaluation of the syrinx and cerebrospinal fluid (CSF) velocity and flow by using phase-contrast cine MR imaging; and evaluation of lumbar and cervical subarachnoid pressure at rest, during the Valsalva maneuver, during jugular compression, and following removal of CSF (CSF compliance measurement). During surgery, cardiac-gated ultrasonography and pressure measurements were obtained from the intracranial, cervical subarachnoid, and lumbar intrathecal spaces and syrinx. Six months after surgery, clinical examinations, MR imaging studies, and CSF pressure recordings were repeated. Clinical examinations and MR imaging studies were repeated annually. For comparison, 18 healthy volunteers underwent T1-weighted MR imaging, cine MR imaging, and cervical and lumbar subarachnoid pressure testing. Compared with healthy volunteers, before surgery, the patients had decreased anteroposterior diameters of the ventral and dorsal CSF spaces at the foramen magnum. In patients, CSF velocity at the foramen magnum was increased, but CSF flow was reduced. Transmission of intracranial pressure across the foramen magnum to the spinal subarachnoid space in response to jugular compression was partially obstructed. Spinal CSF compliance was reduced, whereas cervical subarachnoid pressure and pulse pressure were increased. Syrinx fluid flowed inferiorly during systole and superiorly during diastole on cine MR imaging. At surgery, the cerebellar tonsils abruptly descended during systole and ascended during diastole, and the upper pole of the syrinx contracted in a manner synchronous with tonsillar descent and with the peak systolic cervical subarachnoid pressure wave. Following surgery, the diameter of the CSF passages at the foramen magnum increased compared with preoperative values, and the maximum flow rate of CSF across the foramen magnum during systole increased. Transmission of pressure across the foramen magnum to the spinal subarachnoid space in response to jugular compression was normal and cervical subarachnoid mean pressuree and pulse pressure decreased to normal. The maximum syrinx diameter decreased on MR imaging in all patients. Cine MR imaging documented reduced velocity and flow of the syrinx fluid. Clinical symptoms and signs improved or remained stable in all patients, and the tonsils resumed a normal shape. Conclusions The progression of syringomyelia associated with Chiari I malformation is produced by the action of the cerebellar tonsils, which partially occlude the subarachnoid space at the foramen magnum and act as a piston on the partially enclosed spinal subarachnoid space. This creates enlarged cervical subarachnoid pressure waves that compress the spinal cord from without, not from within, and propagate syrinx fluid caudally with each heartbeat, which leads to syrinx progression. The disappearance of the abnormal shape and position of the tonsils after simple decompressive extraarachnoidal surgery suggests that the Chiari I malformation of the cerebellar tonsils is acquired, not congenital. Surgery limited to suboccipital craniectomy, C-1 laminectomy, and duraplasty eliminates this mechanism and eliminates syringomyelia and its progression without the risk of more invasive procedures.

Controlled Continuous Spinal Drainage Using a Flow-Regulated Pump

Controlled Continuous Spinal Drainage Using a Flow-Regulated Pump

Inadvertent intraoperative myelography with hypaque: Case report and discussion

Myelography is routinely performed safely using nonionic water-soluble radiographic contrast media. However, inadvertent introduction of ionic contrast media into the thecal space can result in a syndrome of spasms and convulsions, which can lead to death if not recognized and dealt with in a timely manner. We report a case of inadvertent use of the ionic diatrizoate meglumine, an ionic contrast agent, instead of a nonionic contrast agent during intraoperative myelography. The patient developed a sterotypical syndrome of ascending myoclonic spasms, resulting in rhabdomyolysis. Treatment included elevation of the head, removal of cerebrospinal fluid, administration of anticonvulsants, diuresis and sedation, and neuromuscular blockade. The patient recovered well, and there were no long-term sequelae. Intrathecal introduction of ionic contrast media and the resultant syndrome must be recognized promptly and treated with aggressive medical management to address rhabdomyolysis and seizures. Ionic contrast media should be stored and marked in such a way as to avoid inadvertent use in myelography.

Neonatal hydrocephalus: hemodynamic response to fontanelle compression-- correlation with intracranial pressure and need for shunt placement.

To determine whether the hemodynamic response to fontanelle compression during Doppler sonography can be used to indirectly assess intracranial pressure and help determine the need for shunt placement in hydrocephalic infants. Sixty Doppler sonographic examinations were performed to obtain resistive indexes before and during fontanelle compression in 14 hydrocephalic infants. Twenty-five intracranial pressure measurements were obtained in 12 infants during cerebrospinal fluid removal and correlated with the change in resistive index during compression of the anterior fontanelle. Baseline resistive index without fontanelle compression was not correlated with intracranial pressure (r = .1, P = .63). A statistically significant correlation was found between the change in resistive index during compression and elevated intracranial pressure (r = .8, P < .0001). Maximum change in resistive index was significantly higher (P < .001) in infants who subsequently required surgical intervention (mean [+/- standard deviation], 74% +/- 9; range, 47%-132%) than in infants who did not require ventricular drainage (mean, 19% +/- 6; range, 3%-29%, P < .0003). Hemodynamic response to fontanelle compression can be used as a noninvasive predictor of progressive or persistently elevated intracranial pressure in newborns with hydrocephalus and may be helpful in predicting need for shunt placement.

Postmyelography headache: a review.

The author reviews the topic of postdural puncture headache (PDPH) so radiologists can better understand, prevent, and treat this common complication of myelography. PDPH, a postural headache relieved by lying supine, occurs after 36.0%-58.2% of myelographic procedures performed with 22-gauge Quincke needles. It begins within 3 days and lasts 3-5 days. Thin, young women are more likely to develop PDPH. Smaller gauge needles, blunt-tip needles, a paramedian approach, and parallel orientation of a bevel needle are associated with lower PDPH rates. Intravenous hydration, no removal of cerebrospinal fluid, experience of the myelographer, and inpatient status have been inconsistently associated with lower PDPH rates. Treatment is supportive with bed rest. Oral or intravenous methylxanthine agents may be given for more severe PDPH. An epidural blood patch, although rarely needed, is very effective.

Pinpoint for windows

<b>Background:</b> Since 1992, infants with progressive posthaemorrhagic ventricular dilatation (PHVD) have been treated in the Neonatal Intensive Care Unit, Wilhelmina Children’s Hospital, Utrecht, The Netherlands, with a ventricular reservoir. <b>Objective:</b> To retrospectively study the incidence of infection using this invasive procedure. <b>Methods:</b> Between January 1992 and December 2003, 76 preterm infants were treated with a ventricular reservoir. Infants admitted during two subsequent periods were analysed: group 1 included infants admitted during 1992–7 (n = 26) and group 2 those admitted during 1998–2003 (n = 50). Clinical characteristics and number of reservoir punctures were evaluated. The incidence of complications over time was assessed, with a focus on the occurrence of infection of the reservoir. <b>Results:</b> The number of punctures did not change during both periods. Infection was significantly less common during the second period (4% (2/50) <i>v</i> 19.2% (5/26), p = 0.029). <b>Conclusion:</b> The use of a ventricular reservoir is a safe treatment to ensure adequate removal of cerebrospinal fluid in preterm infants with PHVD. In experienced hands, the incidence of infection of the ventricular reservoir or major complications remains within acceptable limits.

The predictive value of cerebrospinal fluid dynamic tests in patients with th idiopathic adult hydrocephalus syndrome.

To evaluate the predictive value of the cerebrospinal fluid (CSF) tap test and CSF outflow conductance in the selection of patients with the idiopathic adult hydrocephalus syndrome, defined exclusively on a clinical basis, for shunt surgery. A prospective, consecutive case series. All patients were assessed before surgery and at 3 months after shunt placement. Preoperatively, CSF pressure, conductance, and CSF formation rate were assessed by a constant-pressure infusion method. Improvement in gait and cognitive functions after removal of CSF was noted (ie, with the CSF tap test). Postoperatively, the infusion method was used to evaluate shunt function. Tertiary, academic referral center. Thirty-five patients with idiopathic adult hydrocephalus (normal-pressure hydrocephalus) syndrome based on conservative clinical criteria. No predictive tests were used for inclusion. All patients had a typical gait disturbance and a communicating hydrocephalus. Twenty-eight patients also had dementia or incontinence, or both. The CSF diversion (Cordis, [Orbis-Sigma]) valve, six patients; Hakim's standard system (Cordis Hakim standard system), 29 patients. OUTCOMES OF SURGERY: Serial videotaping of gait, a comprehensive neuropsychologic battery, and the Bartel index of activities of daily life. Gait was improved in 25 (72%) of the 35 patients, whereas the Bartel index remained unchanged. The conditions of five of seven patients with gait disturbance as the sole symptom improved. The spatial function (37% improved) and the findings from the Fuld object memory tests (29% improved) were significantly improved. Shunt dysfunction could not explain the lack of effect of an operation in the remaining patients. It should be noted that these results obtained at 3 months postoperatively may not be applicable in a long-term perspective. The CSF outflow conductance or CSF tap test were not able to identify those patients who would or would not benefit from a CSF diversion procedure. However patients had a lower conductance and a higher CSF pressure than did control subjects. Considerable improvement in gait was seen, but cognitive function was little affected. The CSF tap test or conductance does not provide additional information that is necessary to distinguish between patients whose conditions will or will not respond to shunting, when selection for surgery is based on conservative clinical criteria.