Cerebrospinal Fluid Tap Research Articles

Clinical signs, diagnostic imaging, histopathology and outcome in a dog with meningoencephalomyelitis of unknown origin and concurrent involvement of the cauda equina and left sciatic nerve

AbstractA 3‐year‐old, female, neutered toy poodle dog was presented with generalised tremors, neck pain and obtundation. Neurological examination revealed a multifocal localisation (brainstem and cervical spinal cord). Magnetic resonance imaging findings and cerebrospinal fluid tap were consistent with meningoencephalomyelitis of unknown origin. After immunosuppressive treatment, the dog improved, but while tapering experienced two relapses. During the second relapse, clinical presentation revealed multifocal clinical signs affecting the brainstem, the lumbosacral spinal cord and the left sciatic nerve. Magnetic resonance imagings of the brain, lumbosacral spinal cord and the left sciatic nerve, cerebrospinal fluid analysis and histopathology of the left sciatic nerve confirmed a recurrence of a meningoencephalomyelitis of unknown origin involving the central nervous system and the peripheral nervous system. Immunosuppressive treatment was re‐instituted, with improvement of clinical signs. At 1‐year follow‐up, the dog remains clinically stable with no treatment.

Forget About Memory: Disentangling the Amnestic Syndrome in Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) can present with both episodic amnestic syndrome and biomarkers of Alzheimer's disease (AD) pathology. To examine the associations between amnestic syndrome and cerebrospinal fluid (CSF) AD biomarkers in iNPH and the CSF tap test response in iNPH patients with amnestic syndrome. We used the Free and Cued Selective Reminding Test to divide iNPH into amnestic and non-amnestic patients. We compared their clinical, biological, and radiological characteristics and examined the reversibility of gait spatiotemporal parameters and neuropsychological performances after a CSF tap test. Univariate and multiple linear regression models examined the association between memory performance and clinical-biological characteristics. Sixty-two non-amnestic patients (mean age 77.0±7.0 years, 38.7% female) and thirty-eight amnestic patients (mean age 77.0±5.9 years, 36.8% female) presented similar levels of AD biomarkers and clinical-radiological profiles. Global cognition and education levels were lower in the amnestic iNPH group. We found no association between AD biomarkers and memory performances (total tau: β= -4.50; 95% CI [-11.96;2.96]; p = 0.236; amyloid-β (1-42): β= 8.60, 95% CI [-6.30;23.50]; p = 0.240). At baseline, amnestic iNPH patients performed worse on executive functions, attention, and gait speed but improved similarly to the non-amnestic iNPH patients after the tap test. In our clinical sample of iNPH patients, we confirm the lack of specificity of the amnestic profile for predicting AD pathology. Clinicians should not preclude amnestic iNPH patients from undergoing an invasive procedure of CSF derivation.

Patterns of Microbial Infections in Post-Infective Hydrocephalus and Treatment Methods at Bugando Medical Center

Background: Post Infective Hydrocephalus is among the complicated types of hydrocephalus and poses a challenge in management of these patients, globally. Antibiotics susceptibility patterns of common bacteria implicating in pyogenic ventriculitis complicated with hydrocephalus were not clearly known at our setting. Therefore, we determined antibiotics susceptibility patterns of common bacteria implicating in pyogenic ventriculitis complicated with hydrocephalus to recommend empirical therapy while waiting for culture and sensitivity results at Bugando Medical Centre (BMC) in Mwanza, Tanzania. Methods: Thirty-five patients with hydrocephalus who had undergone cerebrospinal fluid (CSF) tapping and analysis were selected randomly retrospectively and their bacteriological culture and sensitivity results were analyzed to determine the common microbial patterns. Patients were rationally prescribed antibiotics depending on laboratory results for 7 days and were later done control CSF cultures until negative cultures were achieved. Results: A total of 35 patients with median (interquartile range [IQR]) age was 5.5 [2-8] months were reviewed. The majority of participants were males, 62.9% (22/35). 20% (7/35) and 37.1% (13/35) had turbid CSF-shunt sample and first culture positive results, respectively, whereas one patient had culture positive with two pathogens resulting to 14 isolates. Gram positive bacteria were predominantly isolated (66.7%, 8/14), whereby S. aureus was frequently encountered (35.7%, 5/14). Overall, gram positive and negative bacteria exhibited least resistance against tetracycline (16.7% and 25%) and ciprofloxacin (16.7% and 25%) respectively. Three (8.6%) patients died from respiratory complications. Conclusion: Post infective hydrocephalus is a clinically challenging but treatable form of hydrocephalus and Staphylococcus aurous is the most common cause. This study found that the use of a seven-day regimen as cost effective and associated with a shorter hospital stay with the focus on CSF analysis with subsequent microbial targeted antibiotic therapy to achieve sterile CSF culture. Treatment strategy should be multidisciplinary approach with collaboration from microbiologists, radiologists, pediatricians and neurosurgeons.

Presumptive West Nile Virus infection in a Komodo Dragon (Varanus komodoensis)

Abstract A 3-yr-old, male Komodo dragon (Varanus komodoensis) presented acutely in early October 2021 with an abnormal posture and asymmetric tetraparesis. The subadult lizard had spent the previous 4 months either in an outdoor space or in an indoor space with open windows. Physical examination, radiographs, and complete blood count and chemistry panel failed to reveal the cause of the neurologic signs. West Nile virus (WNV) plaque reduction serum neutralization on presentation was negative (1:20), as was WNV polymerase chain reaction (PCR) testing and viral isolation on whole blood. Empirical treatment with a daily corticosteroid, course of antibiotics, and encouragement of mild exercise was initiated. Magnetic resonance imaging of the brain and spinal cord was unremarkable, and a lumbar cerebrospinal fluid (CSF) tap revealed a mononuclear pleocytosis and protein elevation. Follow-up WNV serology revealed rising titer and seroconversion 13 days after presentation (1:80) and 32 days after presentation (1:640); however, WNV PCR testing of CSF fluid was negative. Thi Komodo dragon gradually improved over six weeks before being put back on public display 74 days after presentation. The WNV titer remained high (1:640) through the winter of 2021-22, and an anamnestic response was observed following a vaccination series with a killed equine vaccine in the spring of 2022. There is a previous brief report of WNV infection in a captive crocodile monitor (Varanus salvadorii), and an unpublished case in the same species at the first author’s institution. This is the first report of neurologic disease from presumptive WNV infection in a Komodo dragon. We recommend that WNV infection be a differential diagnosis if a varanid lizard present with acute neurologic signs with a history of arthropod vector exposure, particularly in the summer or fall.

Blake's pouch cyst-like imaging abnormalities in idiopathic normal pressure hydrocephalus

ObjectiveBlake's pouch cyst is a cause of congenital non-communicating hydrocephalus. Recent study revealed that adult onset communicating normal pressure hydrocephalus sometimes accompanied by Blake's pouch cyst-like imaging abnormalities. However, relationships between two disease entities remains uncovered. The aim of this study was to investigate the prevalence of Blake's pouch cyst-like imaging abnormalities in idiopathic normal pressure hydrocephalus and their impact on the clinical features. MethodsFirst, we investigated the existence of Blake's pouch cyst-like imaging abnormalities in 46 idiopathic normal pressure hydrocephalus patients (mean age 76.8 ± 5.2 years old; 28 women) and 247 normal controls (mean age 65.2 ± 4.0 years old; 120 women). Second, the demographic, clinical and imaging characteristics were compared between idiopathic normal pressure hydrocephalus with and without Blake's pouch cyst-like imaging abnormalities. ResultsBlake's pouch cyst-like imaging abnormalities were more prevalent in idiopathic normal pressure hydrocephalus patients (17.4 %) than in the normal population (2.4 %). Idiopathic normal pressure hydrocephalus with Blake's pouch cyst-like imaging abnormalities showed a trend toward a younger onset than those without Blake's pouch cyst-like imaging abnormalities, while clinical features, including the response to cerebrospinal fluid tap test and shunt treatment, did not differ between two groups. ConclusionsIncomplete cerebrospinal fluid obstruction associated with Blake's pouch cyst-like imaging abnormalities may be a cause of idiopathic normal pressure hydrocephalus.

Changes in postural stability after cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus.

In patients with idiopathic normal pressure hydrocephalus (iNPH), the characteristics of balance disturbance are not as well understood as those related to gait. This study examined changes in postural stability in quiet standing after the cerebrospinal fluid tap test (CSFTT) in these patients. Furthermore, the study explored the relationship between the amount of spontaneous body sway and both gait and executive function. All patients diagnosed with iNPH underwent CSFTT. We evaluated their center of pressure (COP) measurements on a force plate during quiet standing, both pre- and post-CSFTT. Following the COP measurements, we calculated COP parameters using time and frequency domain analysis and assessed changes in these parameters after CSFTT. At pre-CSFTT, we assessed the Timed Up and Go (TUG) and the Frontal Assessment Battery (FAB). We investigated the relationship between COP parameters and the TUG and FAB scores at pre-CSFTT. A total of 72 patients with iNPH were initially enrolled, and 56 patients who responded positively to CSFTT were finally included. Post-CSFTT, significant improvements were observed in COP parameters through time domain analysis. These included the velocity of COP (vCOP), root-mean-square of COP (rmsCOP), turn index, torque, and base of support (BOS), compared to the pre-CSFTT values (p < 0.05). In the frequency domain analysis of COP parameters post-CSFTT, there was a decrease in both the peak and average of power spectral density (PSD) values in both the anteroposterior (AP) and mediolateral (ML) directions below 0.5 Hz (p < 0.05). In addition, the TUG scores showed a positive correlation with vCOP, rmsCOP, turn index, torque, BOS, and both the peak and average PSD values in the AP and ML directions below 0.5 Hz (p < 0.05). The FAB scores demonstrated a negative correlation with vCOP, rmsCOP, turns index, BOS, and both peak and average PSD values in the AP direction below 0.5 Hz (p < 0.05). In patients with iNPH who responded to CSFTT, there was an improvement in spontaneous body sway during quiet standing after CSFTT. Increased spontaneous sway is associated with impaired gait and frontal lobe function. This may be linked to impaired cortico-cortical and cortico-subcortical circuits in patients with iNPH.

Predicting post-surgical outcomes in idiopathic normal pressure hydrocephalus using clinically important changes from the cerebrospinal fluid tap test

ObjectivePatients diagnosed with idiopathic Normal Pressure Hydrocephalus (iNPH) typically experience symptom improvements after undergoing a cerebrospinal fluid-tap test (CSF-TT), These improvements are recognized as indicative of potential improvements following surgical intervention. As gait disturbance is the most common iNPH symptom, gait improvements are of predominant interest. The purpose of this study was to examine if clinically important changes in gait and balance from CSF-TT predict meaningful changes following surgery. MethodThe study involved analysis of data collected in a prospective observational study for 34 iNPH patients who underwent a CSF-TT and subsequent surgery. Linear regression, logistic regression and classification trees were used for predictive modelling comparing changes from CSF-TT with post-surgical changes in Tinetti, Timed Up and Go (TUG) and Berg Balance Scale (BBS) outcomes. ResultsPredictive models for minimal clinically important differences (MCIDs) from CSF-TT to surgery were significant for Tinetti (odds ratio = 1.42, p = 0.02) and BBS (odds ratio = 1.57, p < 0.01). Four items on Tinetti and two items on BBS were identified with a predictive accuracy of 79% and 76% respectively. BBS has the highest sensitivity (85%) and negative predictive value (77%). TUG had a 100% specificity and 100% positive predictive value. The predictive model using MCIDs for TUG was not significant (odds ratio = 1.13, p = 0.06). ConclusionClinically important changes from CSF-TT are useful in predicting post-surgical outcomes in iNPH patients. Tinetti and BBS, both have predictive value using MCID scores as cut off values, of which BBS is a stronger outcome measure for prediction.

Movement Disorders and Rehabilitation in Idiopathic Normal Pressure Hydrocephalus

Movement disorders, particularly gait and balance disturbances can lead to falls and reduced daily activities in patients with idiopathic normal pressure hydrocephalus (iNPH). In this study, we investigate movement disorders from both the pathophysiological and kinematic perspectives in patients with iNPH. Additionally, we discuss essential factors that should be evaluated before and after cerebrospinal fluid tap tests and shunt surgeries and considerations for assessment of fall risk in patients with iNPH. Additionally, we describe the most recent findings on rehabilitation of iNPH patients.

Upper extremity motor function before and after the cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus: A retrospective study.

Upper extremity motor function before and after the cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus: A retrospective study.

A Male Patient with Hydrocephalus via Multimodality Diagnostic Approaches: A Case Report.

Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is a kind of hydrocephalus that is easily to be misdiagnosed with brain atrophy due to the similarity of ventricular dilation and cognitive impairment. In this case, we present an old male patient who was diagnosed with iNPH by multimodality approaches. Outcomes: A 68-year-old male patient, with deteriorated gait, declined cognitive function for at least 3 years and urinary incontinence for 3 months. The doctors suspected him a patient with hydrocephalus or Alzheimer's disease based on his symptoms. We used multimodality diagnostic approaches including brain imaging, cerebrospinal fluid tap test, continuous intracranial pressure monitoring, and infusion study to make the final diagnosis of iNPH. He underwent ventriculoperitoneal shunt surgery and was well recovered. Conclusion: This case demonstrates the efficacy of using multimodality approaches for iNPH diagnosis, which saves patient time and clinical cost, worthy of further promotion.

Prevalence of idiopathic normal pressure hydrocephalus in patients with vertebral compression fractures

Background: Patients with idiopathic normal pressure hydrocephalus (iNPH) may be more prone to all fracture types due to falls. Vertebral compression fractures (VCFs) are a global burden that temporarily or permanently affects millions of elderly people. This study aimed to investigate the prevalence of iNPH in patients with VCFs. Methods: We retrospectively reviewed 128 patients aged 60–102 years who underwent balloon kyphoplasty (BKP) for VCFs between November 1, 2017, and March 31, 2020. We also assessed the presence of the iNPH triad (i.e., gait disturbance, cognitive impairment, and urinary incontinence). Patients with Evans’ index (EI) &gt;0.3 and the iNPH triad were defined as having possible iNPH, those with clinical improvement after a cerebrospinal fluid tap test were defined as having probable iNPH, and those with clinical improvement after a shunt surgery were defined as having definite iNPH. Results: Of the 128 patients, seven were excluded due to a history of intracranial disease that could cause ventricular enlargement or gait disturbance. Another 70 patients who did not undergo head computed tomography or magnetic resonance imaging one year before or after BKP were excluded from the study. Finally, 51 patients with a mean age of 78.9 years were enrolled. The mean EI value of these 51 patients was 0.28, with 18 patients showing EI &gt;0.3. Moreover, 18 had possible iNPH, one had probable iNPH, and one had definite iNPH. Conclusion: Screening for iNPH in elderly patients with VCFs can allow early diagnosis of iNPH and benefit them more from surgical treatment.

Endoscopic third ventriculostomy in post traumatic hydrocephalus

Background: Hydrocephalus is a known sequelae in traumatic brain injury patients. It may occur early or late and presents with dementia, urinary incontinence and difficulty in walking. There are two distinct types of normal pressure hydrocephalus one is idiopathic most commonly seen in the elderly age groups and the other is secondary due to a CerebroVascular Accident, trauma or surgery. The idiopathic type may not respond to the cerebrospinal fluid diversion procedure, but the secondary type responds to the cerebrospinal fluid diversion procedure. Our study aims at exploring the option of Endoscopic third ventriculostomy in these patients not making them shunt dependent. Materials and methods: The patients with traumatic brain injury admitted to the department of neurosurgery between January 2012 and January 2018 were included in the study. Congenital hydrocephalus and secondary hydrocephalus due to spontaneous Sub arachnoid haemorrhage and tumours were excluded. 14 patients were identified and if there was some improvement in their condition after cerebrospinal fluid tap tests were planned for endoscopic third ventriculostomy. Results: Out of the 14 patients 2 were females and the remaining 12 were males. 2 did not improve at all. 12 had some improvement out of which 3 had a failure and underwent a ventriculo peritoneal shunt. Hence there were 5 failures out of 14 which made 35.7%. Conclusion: Endoscopic third ventriculostomy is an option which can be offered to patients with secondary hydrocephalus. The chances of failure though present the procedure is minimally invasive and improves cerebrospinal fluid dynamics.

FC42: Evaluation of patients with cognitive impairment due to suspected idiopathic normal-pressure hydrocephalus at medical centers for dementia: a nationwide hospital-based survey in Japan

Objective:Treatment of idiopathic normal-pressure hydrocephalus (iNPH) requires collaboration between dementia specialists and neurosurgeons. The role of dementia specialists is to differentiate patients with iNPH from patients with other dementia diseases and to determine if other dementia diseases are comorbid with iNPH. We conducted a nationwide hospital-based questionnaire survey on iNPH in medical centers for dementia (MCDs).Methods:We developed a questionnaire to assess how physicians in MCDs evaluate and treat patients with cognitive impairment due to suspected iNPH and the difficulties these physicians experience in the evaluation and treatment of patients. The questionnaire was sent to all 456 MCDs in Japan.Results:Questionnaires from 279 MCDs were returned to us (response rate: 61.2%). Patients underwent cognitive tests, evaluation of the triad symptoms of iNPH, and morphological neuroimaging examinations in 96.8, 77.8, and 98.2% of the MCDs, respectively. Patients with suspected iNPH were referred to other hospitals (e.g., hospitals with neurosurgery departments) from 78.9% of MCDs, and cerebrospinal fluid (CSF) tap test was performed in 44 MCDs (15.8%). iNPH guidelines (iNPHGLs) and disproportionately enlarged subarachnoid space hydrocephalus (DESH), a specific morphological finding, were used and known in 39.4% and 38% of MCDs, respectively. Logistic regression analysis with “Refer the patient to other hospitals (e.g., hospitals with neurosurgery departments) when iNPH is suspected.” as the response variable and (a) using the iNPHGLs, (b) knowledge of DESH, (c) confidence regarding DESH, (d) difficulty with performing brain magnetic resonance imaging, (e) knowledge of the methods of CSF tap test, (f) absence of physician who can perform lumbar puncture, and (g) experience of being told by neurosurgeons that referred patients are not indicated for shunt surgery as explanatory variables revealed that the last two factors were significant predictors of patient referral from MCDs to other hospitals.Conclusion:Sufficient differential or comorbid diagnosis using CSF tap test was performed in a few MCDs. Medical care for patients with iNPH in MCDs may be improved by having dementia specialists perform CSF tap tests and share the eligibility criteria for shunt surgery with neurosurgeons.

Abnormalities of hippocampal shape in idiopathic normal‐pressure hydrocephalus patients

AbstractBackgroundWe utilized 3‐dimensional, surface‐based, morphometric analysis to investigate hippocampus shape between 2 groups: (1) idiopathic normal‐pressure hydrocephalus (INPH) patients who had a positive response to the cerebrospinal fluid tap test and (2) healthy controls. The aims were (1) to evaluate INPH‐related structural abnormalities of the hippocampi and (2) to investigate relationships between hippocampal shape changes and gait disturbance in INPH patients.MethodForty‐eight INPH patients and 25 healthy controls were imaged with MRI, including 3‐dimensional volumetric images, for vertex‐based 3‐dimensional hippocampal shape analysis.ResultVertex‐wise shape analysis revealed significant bilateral deformation in patients with INPH compared with healthy controls after FDR correction. Both the left and right hippocampi were more elongated and narrowed in INPH patients than in the healthy controls. In both hemispheres, INPH patients demonstrated an upward bending of the middle and posterior hippocampus reflecting a bilateral vertical displacement from body to tail. Significant correlations were found between local shape deformity and the timed up and go and 10 meter walking tests (to a greater degree on the right than on the left). Bilateral inward deformations at the superomedial hippocampal tail and inferior hippocampal body were consistently associated with inferior performance across tests. Inward deformations at the right medial and lateral hippocampal head and right superior hippocampal body were also consistently associated with worse performance across tests.ConclusionThese results suggest that patients with INPH have unique patterns of hippocampal shape changes. Our findings encourage future studies to elucidate the underlying mechanism of hippocampal morphometric abnormalities in INPH patients. Changes in overall shape may contribute to the distinctive gait abnormalities associated with INPH.

MODL-25. INTERNAL CAROTID INJECTION MODEL OF BRAIN METASTASIS DESCRIBES LEPTOMENINGEAL DISEASE

Abstract Leptomeningeal disease (LMD), the most aggressive form of central nervous system (CNS) metastasis in which cancer cells infiltrate leptomeninges, is universally and rapidly fatal due to poor detection and no effective treatment. Treatment of LMD is challenged by the diffuse nature of the disease, low specificity of detection, poor drug penetration into CNS and high neurotoxicity. LMD is a heterogeneous disease: co-existence of leptomeningeal spread and parenchymal brain metastases in not uncommon, and LMD tumors vary in size and may be found at various locations throughout entire neuroaxis. Radiographic detection (i.e., MRI) works well for big “bulky” metastases but may produce normal results in patients with active disease identified by cerebrospinal fluid (CSF) tap. This spatial and morphological heterogeneity of LMD may ultimately be responsible for a varied and limited therapy response. Mechanistic and translational studies of LMD are hampered by the lack of adequate in vivo models that recapitulate the consecutive steps of LMD progression separate from systemic disease. In this study, we show that the internal carotid (ICA) injection of tumor cells, which is widely used to model brain metastasis, produces leptomeningeal spread. The ICA injection of various tumor cell lines faithfully recapitulated the stages, heterogeneity, and spatial distribution of human LMD. While some cell lines demonstrated clear preference for growth in brain parenchyma, they still had a measurable population of cells within the leptomeninges. Most bulky LMD metastases formed and grew near fenestrated endothelium, where the direct access to blood might support tumor growth and survival. A population not associated with the fenestrated endothelium consisted mostly of single non-dividing non-hypoxic cells. This diffuse cancer spread limited the efficacy of standard whole-brain radiation therapy. Thus, leptomeningeal spread should be taken into account when interpreting the data from the ICA model that is widely used to study brain metastasis.

Successful intraoperative ultrasound-guided retrieval of intracranial grass seed foreign body in a 4-month-old puppy.

A 4-month-old female-entire Vizsla dog was referred for progressive seizure activity, vomiting, lethargy, inappetence, and neck pain. CT revealed focal inflammation, a calvarial osseous defect, a possible foreign body within the brain, and associated vasogenic edema. A cerebrospinal fluid tap revealed marked septic neutrophilic pleocytosis. MRI findings supported diagnosis of a 1.7cm foreign body within the brain. A right rostrotentorial craniectomy was performed, and intraparenchymal grass seed was removed in its entirety via intraoperative ultrasound guidance. The patient was discharged 2 days postoperatively, and long-term follow-up revealed no abnormal neurological signs.

Ependymal cyst in the caudal cranial fossa of a young Belgian Malinois dog with abnormal cerebrospinal fluid findings

Abstract Fluid-filled cavities within the brain are well-recognized in human and veterinary medicine. Congenital or acquired brain cystic lesions could be isolated or associated with other diseases. Clinical signs related to cysts depend on their size and the mass effect they exert on surrounding neuroanatomical structures. We present a case of a 5-month-old Belgian Malinois dog with cervical pain and right head tilt. The dog had a normal haematochemical profile and negative infectious disease tests. A contrast enhancement Computed Tomography scan revealed the presence of a thin-walled cystic lesion in the caudal cranial fossa at the level of the right pontine-cerebellar junction. A cerebrospinal fluid tap was performed by lumbar puncture, revealing a monocytic pleocytosis. After initial improvement following corticosteroid and antibiotic therapy, clinical signs worsened, and the dog underwent a second clinical evaluation and magnetic resonance imaging examination. After euthanasia a complete postmortem examination was performed. Histological and immunohistochemical findings were suggestive of an ependymal cyst.

Successful Cervical Epidural Blood Patch as a Treatment of Spontaneous Intracranial Hypotension - A Case Report

Background: Spontaneous intracranial hypotension can be a source of headache due to a continuous cerebrospinal fluid leakage. Case: A 33-year-old male patient with unremarkable history was presented with a headache, accompanying posterior neck stiffness and tinnitus lasting for 4 days. The opening pressure from cerebrospinal fluid tapping was 60mmH2O. Magnetic resonance imaging of the neck showed fluid collection at right C1-2 level, suggesting spontaneous intracranial hypotension. The headache did not respond to conservative treatments. Epidural blood patch was performed at C4-5 level. On postoperative day 1, remnant headache was only 20 percent and patient was discharged the day after. Conclusions: In spontaneous intracranial hypotension with leakage site at high cervical level, an epidural blood patch at a different cervical level can be safely performed to relieve the symptoms.

Staged or simultaneous operations for ventriculoperitoneal shunt and cranioplasty: Evidence from a meta-analysis.

To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta-analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols. A meta-analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion. Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04-5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74-4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68-3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50-5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38-4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38-6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25-2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62-7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10-14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42-4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights. Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.

Risk estimation for idiopathic normal-pressure hydrocephalus: development and validation of a brain morphometry-based nomogram.

To develop and validate a nomogram based on MRI features for predicting iNPH. Patients aged ≥ 60years (clinically diagnosed with iNPH, Parkinson's disease, or Alzheimer's disease or healthy controls) who underwent MRI including three-dimensional T1-weighted volumetric MRI were retrospectively identified from two tertiary referral hospitals (one hospital for derivation set and the other for validation set). Clinical and imaging features for iNPH were assessed. Deep learning-based brain segmentation software was used for 3D volumetry. A prediction model was developed using logistic regression and transformed into a nomogram. The performance of the nomogram was assessed with respect to discrimination and calibration abilities. The nomogram was internally and externally validated. A total of 452 patients (mean age ± SD, 73.2 ± 6.5years; 200 men) were evaluated as the derivation set. One hundred eleven and 341 patients were categorized into the iNPH and non-iNPH groups, respectively. In multivariable analysis, high-convexity tightness (odds ratio [OR], 35.1; 95% CI: 4.5, 275.5), callosal angle < 90° (OR, 12.5; 95% CI: 3.1, 50.0), and normalized lateral ventricle volume (OR, 4.2; 95% CI: 2.7, 6.7) were associated with iNPH. The nomogram combining these three variables showed an area under the curve of 0.995 (95% CI: 0.991, 0.999) in the study sample, 0.994 (95% CI: 0.990, 0.998) in the internal validation sample, and 0.969 (95% CI: 0.940, 0.997) in the external validation sample. A brain morphometry-based nomogram including high-convexity tightness, callosal angle < 90°, and normalized lateral ventricle volume can help accurately estimate the probability of iNPH. • The nomogram with MRI findings (high-convexity tightness, callosal angle, and normalized lateral ventricle volume) helped in predicting the probability of idiopathic normal-pressure hydrocephalus. • The nomogram may facilitate the prediction of idiopathic normal-pressure hydrocephalus and consequently avoid unnecessary invasive procedures such as the cerebrospinal fluid tap test, drainage test, and cerebrospinal fluid shunt surgery.