Cranial Cerebrospinal Fluid Research Articles

Impairment of spinal CSF flow precedes immune cell infiltration in an active EAE model

Accumulation of immune cells and proteins in the subarachnoid space (SAS) is found during multiple sclerosis and in the animal model experimental autoimmune encephalomyelitis (EAE). Whether the flow of cerebrospinal fluid (CSF) along the SAS of the spinal cord is impacted is yet unknown. Combining intravital near-infrared (NIR) imaging with histopathological analyses, we observed a significantly impaired bulk flow of CSF tracers within the SAS of the spinal cord prior to EAE onset, which persisted until peak stage and was only partially recovered during chronic disease. The impairment of spinal CSF flow coincided with the appearance of fibrin aggregates in the SAS, however, it preceded immune cell infiltration and breakdown of the glia limitans superficialis. Conversely, cranial CSF efflux to cervical lymph nodes was not altered during the disease course. Our study highlights an early and persistent impairment of spinal CSF flow and suggests it as a sensitive imaging biomarker for pathological changes within the leptomeninges.

The influence of spinal venous blood pressure on cerebrospinal fluid pressure

In Alligator mississippiensis the spinal dura is surrounded by a venous sinus; pressure waves can propagate in the spinal venous blood, and these spinal venous pressures can be transmitted to the spinal cerebrospinal fluid (CSF). This study was designed to explore pressure transfer between the spinal venous blood and the spinal CSF. At rest the cardiac-related CSF pulsations are attenuated and delayed, while the ventilatory-related pulsations are amplified as they move from the spinal venous blood to the spinal CSF. Orthostatic gradients resulted in significant alterations of both cardiac- and ventilatory-related CSF pulsations. Manual lateral oscillations of the alligator’s tail created pressure waves in the spinal CSF that propagated, with slight attenuation but no delay, to the cranial CSF. Oscillatory pressure pulsations in the spinal CSF and venous blood had little influence on the underlying ventilatory pulsations, though the same oscillatory pulsations reduced the ventilatory- and increased the cardiac-related pulsations in the cranial CSF. In Alligator the spinal venous anatomy creates a more complex pressure relationship between the venous and CSF systems than has been described in humans.

Etiologies and clinical characteristics of acute ataxia in a single national children's medical center

ObjectiveTo analyze etiologic factors of pediatric acute ataxia and to identify the severity of its underlying causes for urgent medical intervention. MethodsClinical data of children diagnosed with acute ataxia between December 2015 and December 2021 from one national medical center were analyzed retrospectively. ResultsA total of 99 children (59 boys, 40 girls), median age at disease onset 55 (range: 12–168) months, were enrolled. The median follow period was 46 (range 6–78) months. Eighty-six (86.9 %) children were diagnosed with immune-associated acute ataxia, among which acute post-infectious cerebellar ataxia (APCA) was the most common diagnosis (50.5 %), followed by demyelinating diseases of the central nervous system (18.2 %) and Guillain-Barré syndrome (9.1 %). On cerebrospinal fluid (CSF) examination, 35/73 (47.9 %) patients had pleocytosis (>5 cells/mm3), and 18/73 (24.7 %) had elevated protein levels. Thirty-one patients (31.3 %) had an abnormal cerebral MRI. Children with other immune-associated acute cerebellar ataxia had more extracerebellar symptoms, intracranial MRI lesions, abnormal CSF results, longer hospital stay, higher recurrence rates and incidence of neurological sequelae than children with APCA. ConclusionImmune-associated acute ataxia is the main cause of pediatric acute ataxia, among which APCA is the most common phenotype. However, some immune-associated diseases, especially autoantibody-mediated disease, which has a higher recurrence rate and neurological sequelae account for an increasing proportion of pediatric acute ataxia. When children present with extracerebellar symptoms, abnormal cranial MRI or CSF results, and without prodromal infection, prudent differential diagnosis is recommended.

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case.

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

Cerebrospinal Fluid Flow in Patients with Huntington's Disease.

Investigations of cerebrospinal fluid (CSF) flow aberrations in Huntington's disease (HD) are of growing interest, as impaired CSF flow may contribute to mutant Huntington retention and observed heterogeneous responsiveness to intrathecally administered therapies. We assessed net cerebral aqueduct CSF flow and velocity in 29 HD participants (17 premanifest and 12 manifest) and 51 age- and sex matched non-HD control participants using 3-Tesla magnetic resonance imaging methods. Regression models were applied to test hypotheses regarding: (i) net CSF flow and cohort, (ii) net CSF flow and disease severity (CAP-score), and (iii) CSF volume after correcting for age and sex. Group-wise analyses support a decrease in net CSF flow in HD (mean 0.14 ± 0.27 mL/min) relative to control (mean 0.32 ± 0.20 mL/min) participants (p = 0.02), with lowest flow in the manifest HD cohort (mean 0.04 ± 0.25 mL/min). This finding was explained by hyperdynamic CSF movement, manifesting as higher caudal systolic CSF flow velocity and higher diastolic cranial CSF flow velocity across the cardiac cycle, in HD (caudal flow: 0.17 ± 0.07 mL/s, cranial flow: 0.14 ± 0.08 mL/s) compared to control (caudal flow: 0.13 ± 0.06 mL/s, cranial flow: 0.11 ± 0.04 mL/s) participants. A positive correlation between cranial diastolic flow and disease severity was observed (p = 0.02). Findings support aqueductal CSF flow dynamics changing with disease severity in HD. These accelerated changes are consistent with changes observed over the typical adult lifespan, and may have relevance to mutant Huntington retention and intrathecally administered therapeutics responsiveness. ANN NEUROL 2023;94:885-894.

Spontaneous CSF fistula as a manifestation of idiopathic intracranial hypertension

IntroductionSpontaneous cerebrospinal fluid (CSF) fistula, of unknown origin, is a rare condition whose aetiology is increasingly related to idiopathic intracranial hypertension (IIH). This study tries to raise awareness that they should not be considered as two different processes, but that fistulas can be a form of debut, requiring a study and subsequent treatment. Repair techniques are described, as well as the study of HII. ResultsWe treated 8 patients, 5 women and three men, aged between 46 and 72 years, with a diagnosis of spontaneous CSF fistula, four nasal and four otics who underwent surgical treatment. After repair, a diagnostic study was performed for IIH by MRI and Angio-MRI, presenting in all cases a transverse venous sinus stenosis. The intracranial pressure values obtained by lumbar puncture showed values of 20mm Hg or higher. All patients were diagnosed with HII. The one-year follow-up did not reveal any recurrence of the fistulas, maintaining a control of the HII. ConclusionDespite their low frequency of both cranial CSF fistula and IIH, an association of both conditions should be considered by continuing the study and surveillance of these patients after fistula closure.

Physiologically-Based Pharmacokinetic Modelling to Predict the Pharmacokinetics and Pharmacodynamics of Linezolid in Adults and Children with Tuberculous Meningitis.

Linezolid is used off-label for treatment of central nervous system infections. However, its pharmacokinetics and target attainment in cranial cerebrospinal fluid (CSF) in tuberculous meningitis patients is unknown. This study aimed to predict linezolid cranial CSF concentrations and assess attainment of pharmacodynamic (PD) thresholds (AUC:MIC of >119) in plasma and cranial CSF of adults and children with tuberculous meningitis. A physiologically based pharmacokinetic (PBPK) model was developed to predict linezolid cranial CSF profiles based on reported plasma concentrations. Simulated steady-state PK curves in plasma and cranial CSF after linezolid doses of 300 mg BID, 600 mg BID, and 1200 mg QD in adults resulted in geometric mean AUC:MIC ratios in plasma of 118, 281, and 262 and mean cranial CSF AUC:MIC ratios of 74, 181, and 166, respectively. In children using ~10 mg/kg BID linezolid, AUC:MIC values at steady-state in plasma and cranial CSF were 202 and 135, respectively. Our model predicts that 1200 mg per day in adults, either 600 mg BID or 1200 mg QD, results in reasonable (87%) target attainment in cranial CSF. Target attainment in our simulated paediatric population was moderate (56% in cranial CSF). Our PBPK model can support linezolid dose optimization efforts by simulating target attainment close to the site of TBM disease.

Fistula espontánea de LCR como manifestación de la hipertensión intracraneal idiopática

IntroductionSpontaneous cerebrospinal fluid (CSF) fistula, of unknown origin, is a rare condition whose etiology is increasingly related to idiopathic intracranial hypertension (IIH). This study tries to raise awareness that they should not be considered as two different processes, but that fistulas can be a form of debut, requiring a study and subsequent treatment. Repair techniques are described, as well as the study of IIH. ResultsWe treated eight patients, five women and three men, aged between 46 and 72 years, with a diagnosis of spontaneous CSF fistula, four nasal and four otics who underwent surgical treatment. After repair, a diagnostic study was performed for IIH by MRI and angio-MRI, presenting in all cases a transverse venous sinus stenosis. The intracranial pressure values obtained by lumbar puncture showed values of 20mmHg or higher. All patients were diagnosed with IIH. The one-year follow-up did not reveal any recurrence of the fistulas, maintaining a control of the IIH. ConclusionDespite their low frequency of both cranial CSF fistula and IIH, an association of both conditions should be considered by continuing the study and surveillance of these patients after fistula closure.

Patterns of acute ischemic stroke and intracranial hemorrhage in patients with COVID-19

BackgroundCoronavirus disease 2019 (COVID-19) is an infection which can affect the central nervous system. In this study, we sought to investigate associations between neuroimaging findings with clinical, demographic, blood and cerebrospinal fluid (CSF) parameters, pre-existing conditions and the severity of acute COVID-19.Materials and methodsRetrospective multicenter data retrieval from 10 university medical centers in Germany, Switzerland and Austria between February 2020 and September 2021. We included patients with COVID-19, acute neurological symptoms and cranial imaging. We collected demographics, neurological symptoms, COVID-19 severity, results of cranial imaging, blood and CSF parameters during the hospital stay.Results442 patients could be included. COVID-19 severity was mild in 124 (28.1%) patients (moderate n = 134/30.3%, severe n = 43/9.7%, critical n = 141/31.9%). 220 patients (49.8%) presented with respiratory symptoms, 167 (37.8%) presented with neurological symptoms first. Acute ischemic stroke (AIS) was detected in 70 (15.8%), intracranial hemorrhage (IH) in 48 (10.9%) patients. Typical risk factors were associated with AIS; extracorporeal membrane oxygenation therapy and invasive ventilation with IH. No association was found between the severity of COVID-19 or blood/CSF parameters and the occurrence of AIS or IH.DiscussionAIS was the most common finding on cranial imaging. IH was more prevalent than expected but a less common finding than AIS. Patients with IH had a distinct clinical profile compared to patients with AIS. There was no association between AIS or IH and the severity of COVID-19. A considerable proportion of patients presented with neurological symptoms first. Laboratory parameters have limited value as a screening tool.

Postoperative Complications of Microscopic Fenestration for Middle Fossa Arachnoid Cysts: A Retrospective Study of 38 Cases and Literature Review

Introduction: Middle fossa arachnoid cyst (MFAC) is one of the most common cranial cysts in children, and the various postoperative complications following cyst fenestration represent a major concern. We conducted a retrospective study in our department and performed a systematic review of the literature to identify the risk factors for complications. Methods: A retrospective survey was conducted in 38 patients with MFAC (<14 years) who underwent microscopic fenestration from January 2019 to December 2020. Postoperative complications, including postoperative hemorrhage/hematoma, subdural hygroma (SH), cranial nerve palsy, postoperative central nervous system infection, and cerebrospinal fluid (CSF) leak, were collected. A systematic PubMed search for cohort studies on surgically treated MFAC published after 1980 was performed. The postoperative complications in the included studies were illustrated. Results: The overall complication rate in our series was 7.9%, among whom, 9 patients (23.7%) developed postoperative SH, one of which required cyst-peritoneal shunting. Patients who developed SH were significantly younger (4.0 ± 1.8 vs. 6.3 ± 3.4 years, p = 0.012). Binary logistic analysis showed that a lower age could be a risk factor for developing SH (odds ratio: 0.738, p = 0.067). One patient developed a subdural hematoma. No cranial nerve palsy or CSF leak was observed. Eighteen studies were included in the systematic review, comprising 649 cases of MFAC. The most common complication was SH (4.9%), and the postoperative complication rates were similar between the microscopic and endoscopic techniques. Conclusion: The complication rate of MFAC fenestration is considerable. SH is the most common postoperative complication, and it mostly occurs in young children. Strict surgical indications should be applied for young children.

Not Just Blood: Brain Fluid Systems and Their Relevance to Cerebrovascular Diseases.

Not Just Blood: Brain Fluid Systems and Their Relevance to Cerebrovascular Diseases.

Clinical outcomes of coblation-assisted pediatric endoscopic endonasal skull base surgery

BackgroundPediatric skull base surgeries are confined by developmental and anatomical issues. Radiofrequency coblation integrates the functions of ablation, suction, and coagulation with the ability to dissolve tissues with limited thermal injury, making it an ideal instrument for pediatric skull base surgery. We sought to evaluated the clinical outcomes of coblation-assisted pediatric endoscopic skull base surgery. MethodsMedical records of patients under 15 years of age undergoing endoscopic skull base surgery were retrospectively reviewed. The estimated blood loss (EBL)/operating time (OT) and Wormald grade were used for intraoperative blood loss grading. ResultsGenerally, 28 patients (17 males, 11 females) with an average age of 8.4 ± 4.2 years, (range, 11 months to 15 years old) were included. Coblation was applied in 20 patients for mucosa coagulation and handling, cartilage removal, tumor separation and excision. The primary diagnoses included juvenile nasopharyngeal angiofibroma (n = 5), traumatic cerebrospinal fluid (CSF) leak (n = 6), congenital meningoencephalocele (n = 6) and miscellaneous sinonasal and skull base neoplasm (n = 11). The application of coblation was related with a significant decrease in EBL/OT (34.1 ± 17.5 vs 56.3 ± 22.6 ml/h, p = 0.048) and Wormald grade (5.7 ± 1.5 vs 6.9 ± 2.0, p = 0.038), compared with the traditional techniques. All surgical procedures were uneventful. No significant difference in postoperative complications, including cranial nerve dysfunction and CSF rhinorrhea were documented during the follow-up period (average, 34.7 ± 4.4 months). ConclusionWe suggested the coblation be a safe and effective instrument for pediatric skull base surgery.

CT Image under Improved Fuzzy C-Means Clustering Algorithm for Evaluation of the Relationship between Cerebrospinal Fluid Change and Communicating Hydrocephalus after Decompressive Craniectomy in Patients with Traumatic Brain Injury

This study was aimed to realize the automatic segmentation of communicating hydrocephalus lesions in brain CT after decompressive craniotomy (DC) in patients with traumatic brain injury (TBI) and discover correlation between cerebrospinal fluid changes and communicating hydrocephalus. Based on the traditional fuzzy C-means (FCM) algorithm, a new segmentation method filter-based FCM (FBFCM) algorithm was proposed. With 56 TBI patients as the research objects, the hydrocephalus lesions in CT images of patients after DC were segmented. The segmentation success rate (SSR), the segmentation coefficient Epc, the segmentation entropy Epe, and the number of iterations were indicators reflecting segmentation performance of FBFCM. The region of interest (ROI) on the segmented image was used to study the patient’s cerebral aqueduct, foramen magnum, and C2 level of the cerebrospinal fluid velocity and flow, to analyze the characteristics of the occurrence of communicative hydrocephalus. It was indicated that average Epc of FBFCM algorithm was 0.9321 ± 0.0144, Epe was 0.1126 ± 0.0081, the average number of iterations was 14.42 ± 3.79, and the segmentation success rate was 96%. Moreover, the above four indicators had statistically considerable differences compared with those of the FCM algorithm and the hard clustering algorithm (HCM) ( P &lt; 0.05). Analysis of the cerebrospinal fluid flow rate in patients with communicative hydrocephalus found that the cerebrospinal fluid flow rate at the midbrain aqueduct of the patient increased greatly. The net flow was 0.000 ± 0.004 mL/s in the aqueduct of the midbrain, 0.001 ± 0.006 mL/s in the foramen magnum, and 0.002 ± 0.004 mL/s in the C2 layer. In summary, the FBFCM algorithm is effective in the segmentation and processing of CT images, which can further improve the effect of this diagnosis. After examination, it is concluded that the cranial cerebrospinal fluid flow rate and flow of TBI patients are improved after DC treatment, so that the patient’s condition can be effectively relieved. It has promotion value with clinical application.

Evaluation of the safety and effectiveness of a sealant hemostatic patch for preventing cerebrospinal fluid leaks in cranial surgery

ABSTRACT Background Cerebrospinal fluid (CSF) leak remains a significant source of morbidity after neurosurgical procedures. The objective is to evaluate the effectiveness and safety of a polyethylene glycol-coated collagen patch (PCC) in different neurosurgical procedures. Methods A retrospective, single-center cohort study in patients who underwent a cranial neurosurgical procedure. After collecting multiple data variables, patients were divided into two groups depending on the use of PCC as sealant on dural closure following procedures. Results Data from 230 patients were collected (PCC, 128; control group, 102). Incidence of CSF leakage was significantly lower in the PCC group (p < .001). Complications that were significantly lower in PCC than the control group included surgical infection (p = .022), and hydrocephalus (p = .017), as well as reduced rates of reintervention (p < .001) and shorter hospital stays (p = .028). Factors associated with a higher incidence of CSF leakage included posterior fossa procedures, reinterventions, and the need for CSF drainage placement. PCC reduced the risk of suffering CSF leakage by more than 75% (p = .002) once adjusted for age, surgical approach, type of cranial opening, reintervention, CSF drainage, dural substitute, and dural defect coverage. Conclusions Our findings confirm PCC as an effective means of preventing CSF leakage following cranial neurosurgery with fewer associated complications.

Altered Cerebrospinal Fluid Clearance and Increased Intracranial Pressure in Rats 18 h After Experimental Cortical Ischaemia.

Oedema-independent intracranial pressure (ICP) rise peaks 20–22-h post-stroke in rats and may explain early neurological deterioration. Cerebrospinal fluid (CSF) volume changes may be involved. Cranial CSF clearance primarily occurs via the cervical lymphatics and movement into the spinal portion of the cranio-spinal compartment. We explored whether impaired CSF clearance at these sites could explain ICP rise after stroke. We recorded ICP at baseline and 18-h post-stroke, when we expect changes contributing to peak ICP to be present. CSF clearance was assessed in rats receiving photothrombotic stroke or sham surgery by intraventricular tracer infusion. Tracer concentration was quantified in the deep cervical lymph nodes ex vivo and tracer transit to the spinal subarachnoid space was imaged in vivo. ICP rose significantly from baseline to 18-h post-stroke in stroke vs. sham rats [median = 5 mmHg, interquartile range (IQR) = 0.1–9.43, n = 12, vs. −0.3 mmHg, IQR = −1.9–1.7, n = 10], p = 0.03. There was a bimodal distribution of rats with and without ICP rise. Tracer in the deep cervical lymph nodes was significantly lower in stroke with ICP rise (0 μg/mL, IQR = 0–0.11) and without ICP rise (0 μg/mL, IQR = 0–4.47) compared with sham rats (4.17 μg/mL, IQR = 0.74–8.51), p = 0.02. ICP rise was inversely correlated with faster CSF transit to the spinal subarachnoid space (R = −0.59, p = 0.006, Spearman’s correlation). These data suggest that reduced cranial clearance of CSF via cervical lymphatics may contribute to post-stroke ICP rise, partially compensated via increased spinal CSF outflow.

Cerebrospinal Fluid Flow Dynamics during Handgrip Exercise in Young Healthy Adults: An MRI Study

Cerebral blood flow (CBF) increases during exercise, but its impact on cerebrospinal fluid (CSF) flow remains unknown. This study investigated CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Twenty-six participants (12 women) underwent the RHG and resting control conditions in random order. Participants performed 3 sets of RHG, during which CINE phase-contrast magnetic resonance imaging (PC-MRI) was performed to measure blood stroke volume (SV) and flow rate in the internal carotid (ICA) and vertebral (VA) arteries, the internal jugular vein (IJV), the superior sagittal (SSS) and straight sinuses (SRS), and CSF SV and flow rate in the cerebral aqueduct of Sylvius. Blood pressure, end-tidal CO2 (EtCO2), heart rate (HR), and respiratory rate were simultaneously measured during CINE PC-MRI scans. Compared with control conditions, RHG showed significant elevations of HR, mean arterial pressure, and respiratory rate with a mild reduction of EtCO2 (all P<0.05). RHG decreased blood SV in the measured arteries, veins, and sinuses and CSF SV in the aqueduct (all P<0.05). Conversely, RHG increased blood flow in the ICA, VA, and IJV (all P<0.05). At the aqueduct, RHG decreased the absolute CSF flow rate (P=0.031), which was calculated as a sum of the caudal and cranial CSF flow rates. Change in the ICA SV was positively correlated with changes in the IJV, SSS, SRS, and aqueductal SV during RHG (all P<0.05). These findings demonstrate a close coupling between the CBF and CSF flow dynamics during moderate-intensity RHG exercise in young healthy adults.

Brain blood and cerebrospinal fluid flow dynamics during rhythmic handgrip exercise in young healthy men and women.

The cerebral fluid response to exercise, including the arterial and venous cerebral blood flow (CBF) and cerebrospinal fluid (CSF), currently remains unknown. We used time-resolved phase-contrast magnetic resonance imaging to assess changes in CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Our data demonstrated that RHG increases the cerebral arterial inflow and venous outflow while decreasing the pulsatile CSF flow during RHG. Furthermore, changes in blood stroke volume at the measured arteries, veins, and sinuses and CSF stroke volume at the cerebral aqueduct were positively correlated with each other during RHG. Male and female participants exhibited distinct blood pressure responses to RHG, but their cerebral fluid responses were similar. These results collectively suggest that RHG influences both CBF and CSF flow dynamics in a way that is consistent with the Monro-Kellie hypothesis to maintain intracranial volume-pressure homeostasis in young healthy adults. Cerebral blood flow (CBF) increases during exercise, but its impact on cerebrospinal fluid (CSF) flow remains unknown. This study investigated CBF and CSF flow dynamics during moderate-intensity rhythmic handgrip (RHG) exercise in young healthy men and women. Twenty-six participants (12 women) underwent the RHG and resting control conditions in random order. Participants performed 3 sets of RHG, during which cine phase-contrast magnetic resonance imaging (PC-MRI) was performed to measure blood stroke volume (SV) and flow rate in the internal carotid (ICA) and vertebral (VA) arteries, the internal jugular vein (IJV), the superior sagittal (SSS) and straight sinuses (SRS), and CSF SV and flow rate in the cerebral aqueduct of Sylvius. Blood pressure, end-tidal CO2 (EtCO2 ), heart rate (HR), and respiratory rate were simultaneously measured during cine PC-MRI scans. Compared with control conditions, RHG showed significant elevations of HR, mean arterial pressure, and respiratory rate with a mild reduction of EtCO2 (all P < 0.05). RHG decreased blood SV in the measured arteries, veins, and sinuses and CSF SV in the aqueduct (all P < 0.05). Conversely, RHG increased blood flow in the ICA, VA, and IJV (all P < 0.05). At the aqueduct, RHG decreased the absolute CSF flow rate (P = 0.0307), which was calculated as a sum of the caudal and cranial CSF flow rates. Change in the ICA SV was positively correlated with changes in the IJV, SSS, SRS, and aqueductal SV during RHG (all P < 0.05). These findings demonstrate a close coupling between the CBF and CSF flow dynamics during RHG in young healthy adults.

Neuronavigation-assisted bedside placement of bolt external ventricular drains in the intensive care setting: a technical note.

The insertion of bolt external ventricular drains (EVD) on the intensive care unit (ICU) has enabled rapid cranial cerebrospinal fluid (CSF) diversion. However, bolt EVDs tend to be perceived as a more challenging technique, particularly when dealing with small ventricles or when there is midline shift distorting the ventricular morphology. Furthermore, if neuronavigation guidance is felt to be necessary, this usually assumes a transfer to an operating theatre. In this technical note, we describe the use of electromagnetic neuronavigation for bolt EVD insertion on the ICU and assess the protocol's feasibility and accuracy. Case series of neuronavigation-assisted bolt EVD insertion in ICU setting, using Medtronic Flat Emitter for StealthStation EM. Neuronavigation-guided bolt EVDs were placed at the bedside in n = 5 patients on ICU. Their widest frontal ventricular horn diameter in the coronal plane ranged from 11 to 20 mm. No procedural complications were encountered. Post-procedural CT confirmed the optimal placement of the EVDs. Electromagnetic neuronavigation is feasible at the ICU bedside and can assist the insertion of bolt EVDs in this setting. The preference for a bolt EVD to be inserted in ICU-as is standard practice at this unit-should not prohibit patients from benefitting from image guidance if required.

Comparison of Ventricular and Lumbar Cerebrospinal Fluid Composition.

ObjectiveCerebrospinal fluid (CSF) analysis is a common diagnostic tool used to evaluate diseases of the central nervous system (CNS). We sought to determine whether there is a difference between the composition of CSF sampled from an external ventricular drain (EVD) and lumbar drain (LD) and whether this made a difference in guiding therapeutic decisions.Patients and MethodsThis study was a retrospective analysis from a single neurosurgery service between the dates of January 2011 and April 2019. A total of 12,134 patients were screened. Inclusion criteria were ages 18-80 and the presence of both an EVD and LD. Exclusion criteria were not having both routes of CSF sampling and the inability to determine which samples originated from which compartment.ResultsSix patients underwent simultaneous spinal and ventricular routine CSF sampling <24 hours apart and were analyzed for their compositions. There were 42 samples, but only 20 paired EVD-LD samples that could be analyzed. When comparing the EVD and LD sample compositions, there were statistically significant differences in white blood cells (WBCs; p = 0.040), total protein (p = 0.042), and glucose (p = 0.043). Red blood cells (RBCs; p = 0.104) and polymorphonuclear leukocytes (PMN; p = 0.544) were not statistically significant. We found a statistically significant correlation between cranial and spinal CSF WBC (r = 0.944, p < 0.001), protein (r = 0.679, p = 0.001), and glucose (r = 0.805, p < 0.001). We also found that there was a significant correlation between CSF and serum glucose (r = 0.502, p = 0.040). There was no statistically significant correlation between RBCs (r = 0.276, p = 0.252).ConclusionOur results demonstrate a correlation between the cranial and spinal CSF samples, except for RBCs, with statistically significant differences in WBC, glucose, and protein values between the two sites. This confirms that sampling CSF via lumbar puncture, which carries less risk than a ventriculostomy and provides accurate data to help establish a diagnosis for intracranial pathologies.

Post-Traumatic Meningitis Is a Diagnostic Challenging Time: A Systematic Review Focusing on Clinical and Pathological Features.

Post-traumatic meningitis is a dreadful condition that presents additional challenges, in terms of both diagnosis and management, when compared with community-acquired cases. Post-traumatic meningitis refers to a meningeal infection causally related to a cranio-cerebral trauma, regardless of temporal proximity. The PICO (participants, intervention, control, and outcomes) question was as follows: “Is there an association between traumatic brain injury and post-traumatic meningitis?” The present systematic review was carried out according to the Preferred Reporting Items for Systematic Review (PRISMA) standards. Studies examining post-traumatic meningitis, paying particular attention to victims of traumatic brain injury, were included. Post-traumatic meningitis represents a high mortality disease. Diagnosis may be difficult both because clinical signs are nonspecific and blurred and because of the lack of pathognomonic laboratory markers. Moreover, these markers increase with a rather long latency, thus not allowing a prompt diagnosis, which could improve patients’ outcome. Among all the detectable clinical signs, the appearance of cranial cerebrospinal fluid (CSF) leakage (manifesting as rhinorrhea or otorrhea) should always arouse suspicion of meningitis. On one hand, microbiological exams on cerebrospinal fluid (CSF), which represent the gold standard for the diagnosis, require days to get reliable results. On the other hand, radiological exams, especially CT of the brain, could represent an alternative for early diagnosis. An update on these issues is certainly of interest to focus on possible predictors of survival and useful tools for prompt diagnosis.