Cisternal Puncture Research Articles

Cisternal puncture and cervical puncture: current uses and historical review

Cisternal puncture and cervical puncture: current uses and historical review

Examination of the Cerebellomedullary Cistern Using Postmortem Computed Tomography in Various Types of Intracranial Hemorrhage

Intracranial hemorrhage is a major cause of sudden unexpected death and its identification is important for death investigations. Cisternal puncture of the cerebellomedullary cistern (CMC) can be used to identify intracranial hemorrhage during postmortem examination. Intracranial hemorrhage comprises various types of hemorrhage, and the possibility of hemorrhage identification by cisternal puncture can differ according to the type of intracranial hemorrhage. Postmortem computed tomography (PMCT) is non-invasive and can be performed before autopsy. In this study, we aimed to identify the hemorrhage in the CMC using PMCT in cases of various intracranial hemorrhage. PMCT was performed before the autopsy. Autopsy reports and PMCT were retrospectively reviewed for 108 cases of intracranial hemorrhage confirmed by conventional autopsy. Hemorrhagic regions showed ≥60 Hounsfield units on PMCT. Hemorrhage in the CMC was identified in 42.6% (46/108) by PMCT and was frequently identified in the cases of basal subarachnoid hemorrhage (SAH) (19/21). Hemorrhage in the CMC was identified in approximately 50% of patients with non-basal SAH and intracerebral hemorrhage. Detection of hemorrhage in the CMC by PMCT is hindered by several factors, such as dental artifacts. This study does not guarantee the usefulness of postmortem cisternal puncture. However, this study verified hemorrhage in the CMC according to the various types of intracranial hemorrhages using PMCT and showed its possibilities and limitations.

Craniotopographic Characteristics of Sinuous-Liquor Relationships in Mature People

The purpose of the study was to determine the craniotopographic (craniometric) indicators of sinuous-liquor relationships in the horizontal plane in people of the first and second periods of mature age, based on the maximum permissible depth of its introduction. Materials and methods. The object of the study was the dura mater of the brain with its sinuses, the ventricles of the brain and the vault of the skull of mature people. The study was performed on 100 corpses of people of different ages and gender with the manufacturing of native preparations of the brain with membranes and liquor structures. Of the indicated number of morphological objects, 70 preparations of veins and sinuses of the dura mater of the brain and 30 preparations of the cerebrospinal fluid system of the brain of mature people were made. The study used such research methods as: macro- and micropreparation of anatomical objects of the brain; cranio- and morphometry of veins, sinuses of the dura mater of the brain and liquor structures of the brain; manufacturing of corrosive (acrylic) casts – preparations of veins, sinuses of the dura mater of the brain and liquor formations of the brain; injection technique; variational-statistical analysis of morphometric data; computer-graphic analysis. Results and discussion. As a result of the study, it was found that the puncture of the central part of the lateral ventricle is better to be performed at the level of the bregma point, or between this point and the vertex (v). The puncture needle penetrates to a depth of 6.0–7.0 cm through the milling hole, which is displaced by 3.0–4.0 cm from the arrow line at an angle of 70–75°. The obtained data make it possible to determine the most optimal craniometric puncture points of the cerebrospinal fluid system of the brain. To penetrate into the cavity of the anterior horn of the lateral ventricle, the metopion point is proposed, which is located at the intersection of the median plane of the head with the line connecting the most convex areas of the frontal humps. The upper puncture of the lateral ventricle is better to be performed by puncturing at the bregma point (the point of connection of the sagittal and coronal sutures) 2.0 cm from the midline (sagittal plane); the needle is directed down and backwards and at a depth of 5–6 cm (taking into account that it is enlarged and stretched) it enters the ventricular cavity. The suboccipital puncture or a puncture of the cerebellar-cerebral cistern must be performed between the opisthocranion and lambda points. The puncture needle is inserted to a depth of 6.0–7.5 cm, and the end of the needle is gradually lowered to the base of the skull. Conclusion. The most optimal puncture points of the constituent parts of the cerebrospinal fluid system of the brain – the cavity of the anterior horn and the central part of the lateral ventricle, the cavity of the cerebellar-cerebral cistern – were determined using craniometric analysis

1106. Evaluation of Penetration of Cefiderocol into Cerebrospinal Fluid Using a Rat Meningitis Model

BackgroundCentral nervous system (CNS) infections caused by Gram-negative bacteria (GNB) are sometimes hard to treat due to antibiotic resistance and difficulty with penetration into cerebrospinal fluid (CSF). Cefiderocol (CFDC) which was approved by the FDA and the EMA in 2019 to 2020 is a siderophore cephalosporin with potent activity against various GNB including carbapenem-resistant strains. In this study, we evaluated the penetration of CFDC into CSF using a rat meningitis model. MethodsTo induce meningitis, the anesthetized immunocompetent rats were infected by intracisternal inoculation of a bacterial suspension of 8.7×101 CFU of E. coli SR200138. 200 mg/kg or 50 mg/kg of CFDC was administered via tail vein bolus injection to uninfected rats (n=4/sampling point) and rats with meningitis (n=4/sampling point) 24 hours after infection. CSF was collected by cisternal puncture and blood was collected from heart. The samplings were performed 0.25, 0.5, 1, 3, and 5 hours after dosing. The concentrations of CFDC in plasma and CSF for individuals were determined by LC/MS/MS. PK parameters for the average values in plasma and CSF were calculated. ResultsCFDC concentration and the PK parameters are shown in Figure and Table, respectively. The penetration of CFDC from plasma to CSF was observed in both uninfected and meningitis groups, and the penetration rates increased in the rats withs meningitis (AUCCSF/AUCplasma: 0.149-0.183) compared with the uninfected rats (AUCCSF/AUCplasma: 0.0508-0.0588). The penetration rates of CFDC in the meningitis were comparable to those of piperacillin, cefepime, and meropenem in human (0.32, 0.103, and 0.39 in strongly inflamed meninges, respectively) [1]. In both groups, elimination of CFDC from CSF was slower compared with that from plasma as seen with other β-lactam antibiotics such as meropenem, suggesting that T> MIC, an indicator that correlates with the efficacy of β-lactams, may be higher in CSF [2].Table. PK Parameters of Cefiderocol after Intravenous Bolus Administration in Uninfected Rats and Rats with Meningitis Figure. Concentrations of Cefiderocol after Intravenous Bolus Administration in Uninfected Rats and Rats with Meningitis ConclusionIt was confirmed that CFDC penetrates into CSF from plasma in a rat model and the penetration rate was increased 3-fold in meningitis.

Myelin basic protein and neurofilament H in postmortem cerebrospinal fluid as surrogate markers of fatal traumatic brain injury

The aim of this study was to investigate if the biomarkers myelin basic protein (MBP) and neurofilament-H (NF-H) yielded informative value in forensic diagnostics when examining cadaveric cerebrospinal fluid (CSF) biochemically via an enzyme-linked immunosorbent assay (ELISA) and comparing the corresponding brain tissue in fatal traumatic brain injury (TBI) autopsy cases by immunocytochemistry versus immunohistochemistry. In 21 trauma and 19 control cases, CSF was collected semi-sterile after suboccipital puncture and brain specimens after preparation. The CSF MBP (p = 0.006) and NF-H (p = 0.0002) levels after TBI were significantly higher than those in cardiovascular controls. Immunohistochemical staining against MBP and against NF-H was performed on cortical and subcortical samples from also biochemically investigated cases (5 TBI cases/5 controls). Compared to the controls, the TBI cases showed a visually reduced staining reaction against MBP or repeatedly ruptured neurofilaments against NF-H. Immunocytochemical tests showed MBP-positive phagocytizing macrophages in CSF with a survival time of > 24 h. In addition, numerous TMEM119-positive microglia could be detected with different degrees of staining intensity in the CSF of trauma cases. As a result, we were able to document that elevated levels of MBP and NF-H in the CSF should be considered as useful neuroinjury biomarkers of traumatic brain injury.

Cerebrospinal fluid analysis in 58 ruminants showing neurological disorders

ABSTRACT: Ruminants may be affected by a wide variety of central nervous system (CNS) diseases. Cerebrospinal fluid (CSF) analysis forms the basis for ante mortem diagnostic evaluation of ruminants with clinical signs involving the CNS. Despite its importance as a tool to aid diagnosis, data regarding CSF examinations in spontaneous cases of CNS diseases in ruminants from Brazil are limited, and most reports involve experimental studies. Therefore, this study aimed to report the results of CSF analysis in 58 ruminants showing signs of neurological disorders. CSF samples for analysis were obtained from 32 cattle, 20 sheep, and 6 goats by cerebello-medullary cistern (n=54) or lumbosacral space (n=4) puncture. These ruminants showed neurological signs related to viral (n=13), mycotic (n=3), or bacterial (n=15) infections, and toxic (n=21), traumatic (n=4), or congenital disorders (n=2). CSF analysis from ruminants with viral infections presented lymphocytic pleocytosis, even though CSF showed no changes in several cases of rabies. Neutrophilic pleocytosis, cloudiness, presence of fibrin clots, and abnormal coloration were evident in the CSF of most cases of CNS bacterial infection, such as meningoencephalitis, meningitis, abscesses, myelitis, and a case of conidiobolomycosis. On the other hand, CSF was unchanged in most cases of toxic disorders, as botulism and hepatic encephalopathy. Elevated CSF density was observed in 60% of ruminants diagnosed with polioencephalomalacia. Our findings show that evaluation of CSF is a valuable diagnostic tool when used in association with epidemiological, clinical and pathological findings for diagnosis of CNS diseases in ruminants.

Transforaminal lumbar puncture for intrathecal access: Case series with literature review and comparison to other techniques

Fluoroscopic-guided lumbar puncture (LP) is a procedure commonly performed by radiologists, which in some circumstances may be difficult or impossible using a traditional posterior interspinous or interlaminar approach. Alternatives to LP include cervical and cisternal punctures, placement of an Ommaya reservoir, and lumbar laminectomy. More recently, however, there has been a move toward access of the thecal sac through a transforaminal approach in patients with challenging anatomy. This report outlines our approach and experience using transforaminal LP (TFLP) in patients with spinal muscular atrophy (SMA) with a 100% success rate. We discuss its utility in other patients with difficult access and compare TFLP with other techniques to access the intrathecal space.

Estimation of postmortem interval by evaluation of cells in cerebro spinal fluid

Postmortem interval is of interest to the forensic pathologist from time immemorial. Due to the number of variables affecting the range of physical, biochemical and molecular changes in the postmortem, the postmortem interval could be determined only as a range. The aim of this study is to analyse the number of cells in CSF in postmortem and their morphological changes, to determine the postmortem interval. 39 cases were studied in which 27 cases were male and 12 cases were female of age ranging from 6 – 65 years. The cerebrospinal fluid sample was collected by cisternal puncture. The cases are with known postmortem interval and are grouped into 5 intervals – 0-6 hours, 6 -12 hours, 12 – 18 hours, 18 – 24 hours and more than 24 hours. There is a raise in cell count in CSF up to 12 hours while there are no degenerative changes detected in the first 6 hours. In the first 6 hours, lymphocyte count is higher than the neutrophil count. In the next six hours, the cell count increases while the lymphocytes remain higher than the neutrophil count. After 20 hours, the cell morphology is unreliable. The changes in the CSF cell count and cytology can be used along with other parameters to estimate the range of postmortem interval.

Study on the causes, prevention and treatment of complications after transsphenoidal pituitary tumor resection under neuroendoscope

Objective: To analyze the causes of complications after endoscopic transsphenoidal pituitary adenoma resection and summarize the corresponding prevention and treatment measures. Methods: The pathological data of 120 patients with pituitary adenoma in hospital were analyzed retrospectively. All patients were treated surgically, five kinds of common complications were collected, the risk factors of complications were statistically analyzed, the causes of postoperative complications were determined, and then the specific prevention and treatment strategies were summarized. Results: Long operation time (P<0.05), hypopituitarism before operation (P<0.01) and large tumor (P<0.01) were the main inducing factors of CSF rhinorrhea after operation; long operation time (OR=1.394, P<0.01), lumbar cistern puncture (OR=1.531, P<0.01) and CSF rhinorrhea after operation (OR=3.861, P<0.01) were the independent risk factors of infection; Age, large tumor and preoperative hypophysis are the main factors of postoperative hypophysis; Postoperative hypophysis and intraoperative cerebrospinal fluid rhinorrhea are the main factors of postoperative diabetes insipidus; Postoperative hypophysis and giant adenoma are the main factors of postoperative hyponatremia. Conclusion: Endoscopic transnasal transsphenoidal resection of pituitary adenoma is the most minimally invasive method at present. There are still risk factors for postoperative complications. Targeted prevention of risk factors for complications and corresponding interventions can effectively reduce the incidence of postoperative complications of pituitary adenoma.

A Safe and Reliable Technique for CNS Delivery of AAV Vectors in the Cisterna Magna.

Global gene delivery to the CNS has therapeutic importance for the treatment of neurological disorders that affect the entire CNS. Due to direct contact with the CNS, cerebrospinal fluid (CSF) is an attractive route for CNS gene delivery. A safe and effective route to achieve global gene distribution in the CNS is needed, and administration of genes through the cisterna magna (CM) via a suboccipital puncture results in broad distribution in the brain and spinal cord. However, translation of this technique to clinical practice is challenging due to the risk of serious and potentially fatal complications in patients. Herein, we report development of a gene therapy delivery method to the CM through adaptation of an intravascular microcatheter, which can be safely navigated intrathecally under fluoroscopic guidance. We examined the safety, reproducibility, and distribution/transduction of this method in sheep using a self-complementary adeno-associated virus 9 (scAAV9)-GFP vector. This technique was used to treat two Tay-Sachs disease patients (30months old and 7months old) with AAV gene therapy. No adverse effects were observed during infusion or post-treatment. This delivery technique is a safe and minimally invasive alternative to direct infusion into the CM, achieving broad distribution of AAV gene transfer to the CNS.

Cerebrospinal fluid collection in laboratory mice: Literature review and modified cisternal puncture method

BackgroundThe composition of cerebrospinal fluid (CSF) is an invaluable parameter in better understanding of cellular and molecular processes within the mammalian brain. However, the collection of significant volumes of clean CSF can be technically challenging in studies with laboratory mice. Over the past five decades, several approaches have been developed to maximize the quantity and quality of CSF samples, either from live or euthanized animals. Due to the small amounts collected, samples from single mice were often pooled or diluted to meet volume requirements of automated counters and multiple assays. New methodThis paper reviews previous work on CSF collection in mice, thus providing methodological background for the current post-mortem procedure. This modified cisternal puncture method involves the use of a peristaltic pump for consistent and slow intracardiac perfusion, as well as a loupe headset with a custom-made glass pipette for piercing a single hole in the atlanto-occipital membrane during repeated CSF draws. Sample cleanness is verified by comparing the colour of the glass pipette and the bottom of centrifuged PCR vial against a white background. ResultsWith three trained experimenters, the entire procedure (including anesthesia) takes ∼11–13 min and often results in the collection of up to 40 μl of clean CSF from males of different murine strains. Properly staggered collections allow processing of relatively large cohorts of mice per day. ConclusionsThis modification of previously employed methods can be used in studies that require tightly-timed collections of larger volumes of undiluted, tissue-free CSF and/or individual data records.

Standardized Method for Intra-Cisterna Magna Delivery Under Fluoroscopic Guidance in Nonhuman Primates

Intrathecal delivery of adeno-associated virus vectors and other therapeutics are currently being evaluated for the treatment of central nervous system sequelae of lysosomal storage diseases, motor neuron diseases, and neurodegenerative diseases. As products transition from preclinical to clinical studies, a standardized and clinically relevant method of intrathecal delivery is increasingly germane. Here, we describe a method of intrathecal delivery via suboccipital puncture into the cisterna magna under fluoroscopic guidance in nonhuman primates. This procedure is suitable for use in good laboratory practice compliant studies, has an excellent safety profile, and is highly similar to the procedure currently being explored for use in humans.

Toxicology Study of Intra-Cisterna Magna Adeno-Associated Virus 9 Expressing Human Alpha-L-Iduronidase in Rhesus Macaques

Mucopolysaccharidosis type I is a recessive genetic disease caused by deficiency of the lysosomal enzyme α-L-iduronidase, which leads to a neurodegenerative and systemic disease called Hurler syndrome in its most severe form. Several clinical trials are evaluating adeno-associated virus serotype 9 (AAV9) for the treatment of neurodegenerative diseases. Although these trials focus on systemic or lumbar administration, intrathecal administration via suboccipital puncture into the cisterna magna has demonstrated remarkable efficacy in large animals. We, therefore, conducted a good laboratory practice-compliant non-clinical study to investigate the safety of suboccipital AAV9 gene transfer of human α-L-iduronidase into nonhuman primates. We dosed 22 rhesus macaques, including three immunosuppressed animals, with vehicle or one of two doses of vector. We assessed in-life safety and immune responses. Animals were euthanized 14, 90, or 180 days post-vector administration and evaluated for histopathology and biodistribution. No procedure-related lesions or adverse events occurred. All vector-treated animals showed a dose-dependent mononuclear pleocytosis in the cerebrospinal fluid and minimal to moderate asymptomatic degeneration of dorsal root ganglia neurons and associated axons. These studies support the clinical development of suboccipital AAV delivery for Hurler syndrome and highlight a potential sensory neuron toxicity that warrants careful monitoring in first-in-human studies.

Toxicology Study of Intra-Cisterna Magna Adeno-Associated Virus 9 Expressing Iduronate-2-Sulfatase in Rhesus Macaques

Hunter syndrome is an X-linked recessive disease caused by deficiency of the lysosomal enzyme iduronate-2-sulfatase. The severe form of this progressive, systemic, and neurodegenerative disease results in loss of cognitive skills and early death. Several clinical trials are evaluating adeno-associated virus 9 for the treatment of neurodegenerative diseases using systemic or intrathecal lumbar administration. In large animals, administration via suboccipital puncture gives better brain transduction than lumbar administration. Here, we conducted a good laboratory practice-compliant investigational new drug-enabling study to determine the safety of suboccipital adeno-associated virus 9 gene transfer of human iduronate-2-sulfatase into nonhuman primates. Thirteen rhesus macaques received vehicle or one of two doses of vector with or without immunosuppression. We assessed in-life safety and immune responses. Animals were euthanized 90 days post-administration and sampled for histopathology and biodistribution. The procedure was well tolerated in all animals. Minimal mononuclear cerebrospinal fluid pleocytosis occurred in some animals. Asymptomatic minimal-to-moderate toxicity to some dorsal root ganglia sensory neurons and their associated axons occurred in all vector-treated animals. This study supports the clinical development of suboccipital adeno-associated virus 9 delivery for severe Hunter syndrome and highlights a potential toxicity that warrants monitoring in first-in-human studies.

A Case Report of Atlanto-occipital Assimilation

Background: Congenital fusion of atlas to the basiocciput is defined as atlanto-occipital assimilation/occipitalization of atlas.Case report: During the norma basalis demonstration session of skull, we have noticed an assimilation/occipitalization of atlas vertebra. Atlas fusion may be complete or partial; assimilation of atlas is associated with neurovascular and skeletal anomalies.Conclusion: Atlanto-occipital fusion may reduce the dimensions of foramen magnum thereby leads to brain stem compression causing the consequent neurological complications. Present case may pose difficulty in performing cisternal puncture. This anomaly has high clinical significance as it mimics the Arnold Chiari malformation.Bangladesh Journal of Medical Science Vol.17(1) 2018 p.169-171

Brain-originated peptides as possible biochemical markers of traumatic brain injury in cerebrospinal fluid post-mortem examination.

The release of brain-originated peptides such as tau protein (MAPT), S-100β, neurofilament light chain (NFL), and glial fibrillary acidic protein (GFAP) into the cerebrospinal fluid (CSF) has been positively correlated with head injuries in clinical and basic research. In this study, we wanted to examine if selected CSF biomarkers (GFAP, NFL, and myelin basic protein - MBP) of head injury may be useful in post-mortem examination and diagnosis of forensic cases. The study was carried out using cases of head injury and cases of sudden death (cardiopulmonary failure, no injuries of the head as control group) provided by forensic pathologists at the Department of Forensic Medicine, Medical University of Warsaw. Cerebrospinal fluid was collected within 24 h after death using suboccipital puncture. The concentration of these peptides was compared using an enzyme-linked immunosorbent assay (ELISA). Brain specimens (frontal cortex) were collected during forensic autopsies. Sections were stained immunohistochemically against GFAP, MBP, NF, and amyloid-β precursor protein (APP). As aresult we documented that elevated levels of CSF, GFAP, MBP, and NFL should be considered amarker for severe and moderate traumatic brain injury. Elevated levels of those peptides combined with anegative APP staining point to their role as markers of head trauma with ashorter time span than APP (manner of minutes).

Puncture of Cerebellar Horizontal Fissure for Retrosigmoid Approach: A Prospective and Quantitative Analysis.

Cerebrospinal fluid (CSF) drainage is important in retrosigmoid approached surgery; however, in some cases, it is not feasible due to cerebellar swelling. To introduce a method, puncture of the horizontal fissure of the cerebellum, which can reduce the cerebellum to easily obtain a good operative corridor and slowly drain CSF. Between January and December 2014, we estimated the precise location of the horizontal fissure in 56 patients who underwent surgery via a retrosigmoid approach. Then, we collected and analyzed CSF drained by puncturing the horizontal fissure. We investigated whether a good operative corridor was obtained with this method. The location of the precise horizontal fissure was a mean of 3.97 mm caudal to transverse sinus and the mean amount of CSF drained in 56 patients was 50.4 mL. A good corridor was obtained in 46 (82.1%) of 56 patients without additional cistern puncture. The puncture of the horizontal fissure can be useful in retrosigmoid approach surgery. Moreover, inexperienced surgeons can use this method to effectively avoid injury of the cerebellum.

Tau protein (MAPT) as a possible biochemical marker of traumatic brain injury in postmortem examination

MAPT is a neuronal protein that plays an important role in axonal stabilization, neuronal development, and neuronal polarity. MAPT release into the CSF and blood has been interpreted as indicative of axonal injury as its elevated levels were observed in olympic boxers even after a mild head trauma suggesting minor CNS injuries. In our study we wanted to check the potential relevance of MAPT examination for forensic purposes. The study was carried out using cases of head injury group and cases of sudden death (cardiopulmonary failure, no injuries of the head — control group) provided by forensic pathologists at the Department of Forensic Medicine, Medical University of Warsaw. CSF and blood were collected within 24h after death using suboccipital puncture and femoral vein puncture. Serum and cerebrospinal fluid Tau protein concentrations were compared using an enzyme-linked immunosorbent assay (elisa). Brain specimens (frontal cortex) were collected during forensic autopsies. Sections were stained histologically (hematoxylin-eosin) and immunohistochemically with anti human Tau antibody, anti glial fibrillary acid protein (GFAP), anti human macrosialin (CD68) or anti human endothelial cells (CD34). In our study we documented that elevated levels of serum and CSF MAPT may also be considered a marker for mild traumatic brain injury and traumatic brain injury (mTBI and TBI). An increase in CSF and serum levels of MAPT in the absence of visible macroscopic traumatic CNS changes indicates that even minor head injuries may result in changes at the neuronal level that could remain undiagnosed during regular forensic autopsy and routine histopathological examination.

P14.24 Are lateral cervical punctures under-utilized?

OBJECTIVE: To investigate the safety and utility of fluoroscopy guided lateral cervical punctures in current neuro-oncologic practice. BACKGROUND: CSF examination is indicated in various neurological disorders including infection, inflammation, and malignancy. Suspicion of leptomeningeal metastases may require multiple lumbar punctures before a definitive diagnosis is reached. Despite multiple lumbar punctures, a diagnosis oftentimes remains elusive. Although the classic cisternal puncture is associated with morbid risks of medullary hemorrhage, fluoroscopy guided lateral cervical puncture has been noted to be safe alternative in obtaining CSF from a high cervical level. Evidence for the utility of cervical puncture after non-diagnostic lumbar punctures remains lacking. METHODS: Single institution retrospective review of fluoroscopy guided lateral cervical punctures performed at Memorial Sloan Kettering Cancer Center from 12/2009 to 1/2016. Results: CSF samples were obtained from 3193 patients between 12/2009 and 1/2016. Fluoroscopy guided lateral cervical puncture was used to obtain CSF from 52 of these patients. Previous lumbar puncture was non-diagnostic in 37 patients. In 15 patients, no prior lumbar puncture was done. Fluoroscopy guided lateral cervical punctures were performed for both therapeutic (n=2) and diagnostic (n=50) indications. Diagnostic lateral cervical punctures were undertaken in 50 patients to evaluate suspected leptomeningeal metastases (n=47) and CNS infection (n=3). Analysis of CSF from these cervical punctures altered clinical management in 15 patients (32%): 10 began chemotherapy, 1 received IVIG for confirmed paraneoplastic syndrome, CNS infection was ruled out in 2 patients; 2 others were treated for confirmed CNS infections. In 5 out of 37 patients with prior non-diagnostic lumbar punctures, leptomeningeal metastasis was diagnosed by subsequent cervical punctures. There were no immediate or delayed complications related to the fluoroscopy guided lateral cervical puncture procedures. Conclusions: Fluoroscopy guided lateral cervical puncture is both diagnostically and therapeutically useful in both malignant and non-malignant CNS disease. The procedure is well-tolerated and can alter clinical management. Fluoroscopy guided lateral cervical puncture should be considered in patients for whom LP is contraindicated or non-diagnostic.

Cerebellomedullary Cistern Delivery for AAV-Based Gene Therapy: A Technical Note for Nonhuman Primates.

Accessing cerebrospinal fluid (CSF) from the craniocervical junction through the posterior atlanto-occipital membrane via cerebellomedullary injection (also known as cisternal puncture or cisterna magna injection) has become a standard procedure in preclinical studies. Such delivery provides broader coverage to the central and peripheral nervous system unlike local parenchymal delivery alone. As a clinical application, this approach offers a more reliable method for neurological gene replacement delivery in infants, where skull-mounted devices are not indicated. Here we describe a consistent, precise, and safe method for CSF injection with minimal equipment and technical skills.