Fluid Diversion Research Articles

Neurocutaneous Melanocytosis-Associated Hydrocephalus: The Memorial Sloan Kettering Experience from 2001 to 2022.

We report two neurocutaneous melanocytosis (NCM) patients who required ventriculoperitoneal shunt placement and subsequently developed intraperitoneal melanoma. These patients with NCM are at an increased risk for developing NRAS-associated melanomas in the central nervous system, which in turn may lead to symptomatic hydrocephalus requiring cerebrospinal fluid diversion. Due to the rarity of NCM, current knowledge on disease progression and appropriate management is limited. Ongoing studies aiming to better understand this condition and inform its clinical management may help to identify risk factors for developing more severe complications.

The effectiveness of various CSF diversion surgeries in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Idiopathic normal pressure hydrocephalus (iNPH) is commonly treated using cerebrospinal fluid (CSF) diversion procedures, most commonly ventriculoperitoneal (VP) but also lumboperitoneal (LP), ventriculoatrial (VA) shunting, and endoscopic third-ventriculostomy (ETV). Despite the prevalence of these interventions and recent advancements in iNPH diagnostic processes, there is limited up-to-date evidence regarding surgical outcomes. A systematic review and meta-analysis were conducted to analyse the effects of CSF diversion surgeries among iNPH patients. The primary outcome was efficacy of the CSF diversion procedure, defined as symptomatic improvement, and secondary outcomes included surgical complications. Several major databases were searched for original studies from inception up to June 4, 2024, which were evaluated using random-effects meta-analyses, meta-regression, and influence analyses. This study was registered with PROSPERO: CRD42023458526. Out of the 1963 studies screened, 54 were included in this review, and 4811 patients were pooled. Overall, more than 74% of patients experienced improvement after surgical treatment (95% CI: 70-78%). VP shunting demonstrated an efficacy of 75% (95% CI 70-79%), VA shunting at 75% (95% CI: 70-80%), and LP shunting at 70% (95% CI: 52-83%). ETV had a success rate of 69% (95% CI: 58-78%). Gait improvement was high at 72% (95% CI: 67-77%), while urinary and cognitive dysfunction each improved in approximately 50% of patients. The efficacy of surgery did not increase between 2005 and 2024 (p=0.54). Complications occurred in 20.6% of cases, with a surgery revision rate of 15.1%. This meta-analysis found that the overall efficacy of CSF diversion procedures for iNPH remained unchanged from 2005 to 2024, with 74% of cases showing improvement. No procedure was found to be clearly superior, and only half of the patients saw improvements in urinary and cognitive dysfunction. The stagnant efficacy over time and frequent complications highlight the need for improved patient selection criteria to best identify those most likely to benefit from CSF shunting. None for this study.

Hair-sparing approach versus traditional hair clipping for cerebral spinal fluid shunt procedures: a retrospective comparative study.

Cerebral spinal fluid (CSF) diversion methods, including ventriculoperitoneal (VP) shunts, are the standard treatment for hydrocephalus. Hair clipping (HC) has been a routine neurosurgical practice of the great majority of neurosurgeons, due to the perception that this will either decrease the risk of shunt infection or allow for a faster, unimpeded opening and closing of the skin. The benefits of not cutting or clipping hair in terms of normalizing appearance and self-esteem are obvious. The purpose of this study was to assess whether the rate of shunt infection would differ between pediatric patients receiving operation via the hair-sparing (HS) approach versus HC. A retrospective single-institution study comparing HS versus HC was conducted on pediatric patients undergoing long-term CSF shunt procedures at the Montreal Children's Hospital between August 2014 and April 2021. The primary outcome measure was shunt infection at 90 days and at long-term follow-up. Inclusion criteria were having at least 18 months of follow-up after long-term CSF shunt procedures, including insertions or revisions of VP shunts, ventriculoatrial shunts, cystoperitoneal shunts, subdural-peritoneal shunts, ventriculosubgaleal shunts, and ventriculosubgaleal reservoirs. Excluded procedures were those involving external ventricular drains, externalized shunts, Omaya reservoirs, endoscopic third ventriculostomies, and lumbar shunts. There were 434 CSF shunt procedures performed in 226 unique patients; 155 (35.71%) procedures were done using the HS approach versus 279 (64.29%) procedures via HC. At 90 days postoperatively, the infection rate was 1.29% in the HS group and 2.87% in the HC group, with an absolute risk difference of 1.58% (95% CI -1.07% to 4.23%, p = 0.24). At long-term follow-up (mean follow-up: 752 days and 716 days for the HS and HC groups, respectively), the rate of shunt infection remained at 1.29% for the HS group (no new infections) but rose to 4.66% for the HC group, with an absolute risk difference of 3.37% (95% CI 0.33%-6.41%, p = 0.03). Performing CSF shunt procedures without cutting or clipping any hair has a very low risk of shunt infection, and certainly does not appear to increase the risk of infection (or malfunction) versus the hair removal approach. It is a safe alternative and should be considered due to its esthetic and psychological benefits regarding normalization of appearance and ease of resuming a normal life following shunt surgery.

A systematic review of surgical and interventional radiology procedures for pediatric idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH) is defined as elevated intracranial pressure and consequent symptoms (mainly headache and visual deterioration) occurring in the absence of secondary causes. Surgical and interventional radiology procedures should be considered for refractory IIH and mainly include cerebrospinal fluid (CSF) diversion techniques, optic nerve sheath fenestration (ONSF), and venous sinus stenting (VSS). Our study aims to review the current literature on the application of these techniques in clinical practice. A systematic literature review on the surgical and interventional radiology treatment of IIH was conducted, focusing on ONSF, VSS, and CSF diversion techniques. According to PRISMA guidelines, all reports published in PubMed in the last 30 years (1993-2023) were considered, and among 722 papers, 48 were included in the present study, resulting in a total study population of 454 children or adolescents (11 months-17 years old). Among 454 patients, 193 underwent an invasive approach, divided into CSF diversion (115/193), ONSF (65/193), VSS (11/193), cranial subtemporal decompression (8/193), and internal cranial expansion (9/193). Sixteen of the 193 patients (8%) required reintervention due to relapsing symptoms or surgical complications, particularly those who underwent CSF diversion. Furthermore, 9/115 required shunt revision due to shunt obstruction or malfunction. We extracted data on the outcome of each procedure: of the 193 patients, 71 experienced a positive outcome with symptom resolution or improvement, while 27 demonstrated a negative outcome. Severe and refractory cases of IIH are eligible for invasive treatments. CSF diversion is the most frequently used technique, despite its high failure risk and need for reintervention. ONSF has shown good results in terms of outcome and safety, particularly in children with visual symptoms. VSS is the most recent approach, indicated in children with stenosis of the venous sinus. In our study population, VSS demonstrated good results in terms of symptom resolution and need for reintervention, but its use remains limited to a few centers. https://www.crd.york.ac.uk/, PROSPERO (CRD42024504244).

Ependymal cell lineage reprogramming as a potential therapeutic intervention for hydrocephalus.

Hydrocephalus is a common neurological condition, characterized by the excessive accumulation of cerebrospinal fluid in the cerebral ventricles. Primary treatments for hydrocephalus mainly involve neurosurgical cerebrospinal fluid diversion, which hold high morbidity and failure rates, highlighting the necessity for the discovery of novel therapeutic approaches. Although the pathophysiology of hydrocephalus is highly multifactorial, impaired function of the brain ependymal cells plays a fundamental role in hydrocephalus. Here we show that GemC1 and McIdas, key regulators of multiciliated ependymal cell fate determination, induce direct cellular reprogramming towards ependyma. Our study reveals that ectopic expression of GemC1 and McIdas reprograms cortical astrocytes and programs mouse embryonic stem cells into ependyma. McIdas is sufficient to establish functional activity in the reprogrammed astrocytes. Furthermore, we show that McIdas' expression promotes ependymal cell regeneration in two different postnatal hydrocephalus mouse models: an intracranial hemorrhage and a genetic form of hydrocephalus and ameliorates the cytoarchitecture of the neurogenic niche. Our study provides evidence on the restoration of ependyma in animal models mimicking hydrocephalus that could be exploited towards future therapeutic interventions.

The economic burden of ventriculoperitoneal shunt insertion and its complications: findings from a cohort in the Philippines.

Ventriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost. We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015 and 2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost. A total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8months (range: 7days-8years). Over a median follow-up of 222days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5425) than uncomplicated patients (PHP 40,587.20 or USD 779; p < 0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1671; p < 0.001). The study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost.

Single Institution Experience with Lumbar Drainage and Subarachnoid Hemorrhage

In our paper, we evaluate the effect of lumbar drainage on delayed cerebral ischemia and requirements for permanent cerebrospinal fluid diversion in patients with aneurysmal subarachnoid hemorrhage. We performed a retrospective cohort study from 2014-2023 at the University of Arkansas for Medical Sciences (UAMS) examining factors associated with patients (n=150) who had aneurysmal subarachnoid hemorrhage and a lumbar drain placed. Main outcomes examined were incidence of delayed cerebral ischemia, need for permanent cerebrospinal fluid diversion, and neurologic outcomes at discharge that were compared to currently published standards. We failed to appreciate a reduced occurrence of delayed cerebral ischemia (37.3% with the current literature supporting rates of 20-30%); however, we did find a low rate of requiring permanent cerebrospinal fluid diversion (12% compared to 10-20% in the current literature) with overall good neurologic outcomes at discharge (~69% of patients had a Glasgow Outcome Scale (GOS) of 4-5 at discharge). Patients with GOS≥4 at discharge were noted to be more likely to have more days or lumbar drainage and less likely to be older than 65, have had an external ventricular drain placed, and have experienced delayed cerebral ischemia. Lumbar drainage is a potentially useful adjunct in the management of secondary neurologic injury in subarachnoid hemorrhage.

The utility of MRI radiological biomarkers in determining intracranial pressure

Intracranial pressure (ICP) is a physiological parameter that conventionally requires invasive monitoring for accurate measurement. Utilising multivariate predictive models, we sought to evaluate the utility of non-invasive, widely accessible MRI biomarkers in predicting ICP and their reversibility following cerebrospinal fluid (CSF) diversion. The retrospective study included 325 adult patients with suspected CSF dynamic disorders who underwent brain MRI scans within three months of elective 24-h ICP monitoring. Five MRI biomarkers were assessed: Yuh sella grade, optic nerve vertical tortuosity (VT), optic nerve sheath distension, posterior globe flattening and optic disc protrusion (ODP). The association between individual biomarkers and 24-h ICP was examined and reversibility of each following CSF diversion was assessed. Multivariate models incorporating these radiological biomarkers were utilised to predict 24-h median intracranial pressure. All five biomarkers were significantly associated with median 24-h ICP (p < 0.0001). Using a pair-wise approach, the presence of each abnormal biomarker was significantly associated with higher median 24-h ICP (p < 0.0001). On multivariate analysis, ICP was significantly and positively associated with Yuh sella grade (p < 0.0001), VT (p < 0.0001) and ODP (p = 0.003), after accounting for age and suspected diagnosis. The Bayesian multiple linear regression model predicted 24-h median ICP with a mean absolute error of 2.71 mmHg. Following CSF diversion, we found pituitary sella grade to show significant pairwise reversibility (p < 0.001). ICP was predicted with clinically useful precision utilising a compact Bayesian model, offering an easily interpretable tool using non-invasive MRI data. Brain MRI biomarkers are anticipated to play a more significant role in the screening, triaging, and referral of patients with suspected CSF dynamic disorders.

The Ratio of Baseline Ventricle Volume to Total Brain Volume Predicts Postoperative Ventriculo-Peritoneal Shunt Dependency after Sporadic Vestibular Schwannoma Surgery.

Background/Objectives: Obstructive hydrocephalus associated with vestibular schwannoma (VS) is the most common in giant VS. Despite tumor removal, some patients may require ongoing ventriculo-peritoneal (VP) surgery. This investigation explores the factors contributing to the requirement for VP surgery following VS surgery in instances of persistent hydrocephalus (HCP). Methods: Volumetric MRI analyses of pre- and postoperative tumor volumes, cerebellum, cerebrum, ventricle system, fourth ventricle, brainstem, and peritumoral edema were conducted using Brainlab Smartbrush and 3D Slicer. The total brain volume was defined as the sum of the cerebrum, cerebellum, and brainstem. ROC analyses were performed to identify the optimum cut-off values of the volumetric data. Results: Permanent cerebrospinal fluid (CSF) diversion after surgery was indicated in 12 patients (12/71; 16.9%). The ratio of baseline volume fraction of brain ventricles to total brain ventricle volume (VTB ratio) was found to predict postoperative VP shunt dependency. The AUC was 0.71 (95% CI: 0.51-0.91), and the optimum threshold value (</≥0.449) yielded a sensitivity and specificity of 67% and 81%, respectively. Multivariable logistic regression analyses of imaging data (pre- and postoperative VS volume, VTB ratio, and extent of resection (%) (EoR)) and patient-specific factors revealed that an increased VTB ratio (≥0.049, OR: 6.2, 95% CI: 1.0-38.0, p = 0.047) and an EoR < 96.4% (OR: 9.1, 95% CI: 1.2-69.3, p = 0.032) were independently associated with postoperative VP shunt dependency. Conclusions: Primary tumor removal remains the best treatment to reduce the risk of postoperative persistent hydrocephalus. However, patients with an increased preoperative VTB ratio are prone to needing postoperative VP shunt surgery and may benefit from perioperative EVD placement.

Enhancing geothermal efficiency: Experimental evaluation of a high-temperature preformed particle gel for controlling preferential fluid flow

Enhanced Geothermal System (EGS) reservoirs represent a vital frontier in clean energy production. However, short-circulation flow within these reservoirs can significantly affect their immediate efficiency and long-term viability. Injected cold fluids moving through wide fractures or direct channels between injection and production wells reduce thermal production temperatures, disrupting energy output. Preformed Particle Gels (PPGs) have proven effective in controlling preferential fluid flow in oil and gas reservoirs, effectively regulating fluid movement. This work explores the potential of a novel High-Temperature Preformed Particle Gel (HT-PPG), designed for geothermal applications, to plug fractures in a simulated geothermal reservoir. Core flooding experiments in coated and uncoated sandstone models were conducted under varying HT-PPG sizes, swelling ratios, and fracture widths to determine gel plugging efficiency. Variations in the HT-PPG injection pressure, breakthrough pressure, and residual resistance factor (Frr) were evaluated. Water breakthrough pressures can reach 464.10 psi/ft. While the stable injection pressure of HT-PPG decreased with increasing swelling ratio and fracture width, it was higher in uncoated cores. The HT-PPG significantly sealed the fractures, drastically reducing conductivities to millidarcy levels. This work validates HT-PPG a robust solution to mitigate fluid diversion challenges in sandstone EGS reservoirs, enhancing performance and advancing sustainable geothermal energy production.

Clinical, Histologic, and Therapeutic Pattern of Posterior Fossa Tumors in Children in Cameroon: A Cross-sectional Study.

Posterior fossa tumors are significant in pediatric neurooncological populations due to their frequency and morbimortality. We convey a 10-year experience managing pediatric posterior fossa tumors at two reference centers in Cameroon. We conducted a cross-sectional study with data collected retrospectively in the Neurosurgery Department of the Central and General Hospitals of Yaounde from January 2010 to December 2019. Included in the study were all patients aged 0-15 years who underwent surgery for posterior fossa tumors. We retained 43 pediatric posterior fossa tumor files, representing 47.89% of pediatric brain tumors. The male/female sex ratio was 0.86, with a mean age of 6.93 ± 4.345 years. The predominant clinical presentations were headaches + vomiting (97.7%), visual impairment (67.4%), and altered consciousness (14%). The vermis was the most frequent site affected (46.5%). Hydrocephalus was found to be associated with the tumor in 30 patients (69.8%). Tumor excision was total in 90.7% of cases, with cerebrospinal fluid diversion performed within the surgery in 83% of cases. Pilocytic astrocytomas represented 37.2%, medulloblastomas 30.25%, ependymomas 6.9%, and brainstem gliomas 4.6%. The postoperatory mortality rate was 20.9%. The survival rate at 5 years for medulloblastomas was 43%. Pediatric posterior fossa tumors are frequent. Pilocytic astrocytomas are the most common histologic type, followed by medulloblastomas. Radical surgery is the leading standard of care. Adjuvant treatment remains limited.

The conformance control and enhanced oil recovery performance of CO2 foam reinforced by regenerated cellulose

CO2 foam flooding is one of the most promising technologies for conformance control and enhanced oil recovery (EOR) in heterogenous tight oil reservoirs. However, it is challenging to maintain foam stability at in-situ high temperature and high salinity reservoir conditions, thus seriously limiting the flooding efficiency. Herein, a new approach of CO2 foam reinforced by regenerated cellulose (RC) was proposed and evaluated by multiple light scattering method and microscopic detection; afterwards, the conformance control and EOR performances were evaluated via flooding experiments at representative reservoir conditions of 85 °C and 59737.6 mg/L, using artificial micro-models and heterogenous core test. Results have demonstrated that: Compared with CO2 foam without RC, the foam with 1 % RC could elongate the foam half-life by ∼30 times (i.e., from 18 to 543 mins) and the drainage half-time by ∼4 times (i.e., from 2.5 to 9.5 mins), respectively; For the conformance control, the CO2 foam flooding with RC improved the sweep efficiency from the respective 42.4 % and 15.8 % to 95.4 % compared with water flooding and CO2 flooding in the micromodel experiments; the CO2 foam with RC increased the injection pressure from 0.20 to 3.1 MPa in the core flooding experiments, suggesting the diversion of fluid from high permeable to low permeable zone. In terms of the EOR, the CO2 foam flooding with RC improved the oil recovery from the respective 29.7 % and 12.9 % to 92.3 % in contrast with water flooding and CO2 flooding in micro-flooding experiments and from 35.5 % to 56.4 % by core-flooding experiments; the underlying mechanisms are attributed to oil emulsification, rock wettability alteration and foam deformation. These insights provide new approaches to maintain foam stability, improve conformance control and EOR performances in heterogenous tight oil reservoirs under harsh conditions.

Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence.

The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.

Comparison of safety of lumbar drain versus external ventricular drain in symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage.

Cerebrospinal fluid (CSF) diversion is typically performed with an external ventricular drain (EVD) for symptomatic hydrocephalus (HCP) following subarachnoid hemorrhage (SAH). Lumbar drain (LD) has also been studied to reduce the incidence of vasospasm after SAH but not HCP. We performed a single center retrospective analysis to evaluate the safety of LD versus EVD for symptomatic HCP following aneurysmal SAH in a naturally randomized patient population. Patients admitted for aneurysmal SAH who developed symptomatic HCP were treated with EVD or LD depending on neurosurgeon on call. Of the 10 neurosurgeons on call, five would place EVD in all patients while the other five would request LD be placed by interventional neuroradiology; however, the distribution on call was not evenly distributed. We retrospectively compared these two groups for drain complications and outcomes with Modified Rankin Scale (mRS). From 2018 to 2021, there were a total of 77 patients with aneurysmal SAH requiring CSF diversion for HCP. There were 56 cases of EVD placement and 21 cases of LD placement. Overall drain complications were 32.0% of cases with EVD and 9.5% with LD, p = .0773. EVD versus LD complications consisted of hemorrhage (1.8% vs 0%, p = 1.0000), infection (7.1 vs 0%, p = .5698), clogged (25% vs 0%, p = .008), dislodgement (1.8% vs 4.6%, p = .4737) and replacement (16% vs 4.8%, p = .2698). No case of cerebellar tonsillar herniation occurred. mRS between EVD versus LD obtained at baseline (0.3 vs 0.3, p = .3943), discharge (3.8 vs 2.7, p = .047), 90 days (2.9 vs 2.0, p = .060), and 1 year (2.6 vs 1.6, p = .081). One year mortality rates between EVD versus LD (26.8% vs 19.0%, p = .483). Symptomatic HCP after aneurysmal SAH can be effectively and safely treated with LD. LD had lower overall complications than EVD with no hemorrhage, infection or malfunction. Further prospective randomized control study may be helpful in elucidating optimal CSF diversion for patients with symptomatic HCP.

Hydrolysis kinetics of self-degradable diverters for well stimulation

Self-degradable diverters have gained increased popularity in well stimulation as an environmentally friendly and robust fluid diversion technology. As of now, limited data and conflicting information exist in the literature regarding the hydrolytic degradation rates of diverters under field-representative conditions, and knowing these rates is crucial for optimizing well stimulation designs. In this work, we systematically measured the degradation rates of commercial self-degradable diverters in aqueous solutions spanning a wide solution pH range of 0.3–13.6 and a wide temperature range of 60–110 °C. We first demonstrated that existing bottle degradation test protocols might return misleading results due to the alteration of solution pH by degradation products, and we developed a more reliable experimental protocol using buffer solutions instead. Using this procedure, we found that as the solution pH increased, the hydrolysis rate of diverters first decreased and then increased, with a minimal degradation rate at around pH = 4. Elevated temperatures yielded faster hydrolysis. The collected kinetic data fit reasonably well to a published kinetic model that was originally developed for pure polylactic acid in deionized water, with an R2 value over 0.98 for all pH and temperature conditions. This comparison suggests that the model can be more widely applied to describe the degradation kinetics of commercial diverters over broad temperature and pH ranges. The test protocol, experimental data, and kinetic analysis in this work provide important guidance on improving the efficiency of fluid diversion and well stimulation operations.

Predictors of Hydrocephalus Risk After Stereotactic Radiosurgery for Vestibular Schwannomas: Utility of the Evans Index.

Hydrocephalus after Gamma Knife® stereotactic radiosurgery (SRS) for vestibular schwannomas is a rare but manageable occurrence. Most series report post-SRS communicating hydrocephalus in about 1% of patients, thought to be related to a release of proteinaceous substances into the cerebrospinal fluid. While larger tumor size and older patient age have been associated with post-SRS hydrocephalus, the influence of baseline ventricular anatomy on hydrocephalus risk remains poorly defined. A single-institution retrospective cohort study examining patients who developed symptomatic communicating hydrocephalus after undergoing Gamma Knife® SRS for unilateral vestibular schwannomas from 2011 to 2021 was performed. Patients with prior hydrocephalus and cerebrospinal fluid diversion or prior surgical resection were excluded. Baseline tumor volume, third ventricle width, and Evans Index (EI)-maximum width of the frontal horns of the lateral ventricles/maximum internal diameter of the skull-were measured on axial postcontrast T1-weighted magnetic resonance imaging. A total of 378 patients met the inclusion criteria; 14 patients (3.7%) developed symptomatic communicating hydrocephalus and 10 patients (2.6%) underwent shunt placement and 4 patients (1.1%) were observed with milder symptoms. The median age of patients who developed hydrocephalus was 69 years (IQR, 67-72) and for patients younger than age 65 years, the risk was 1%. For tumor volumes <1 cm3, the risk of requiring shunting was 1.2%. The odds of developing symptomatic hydrocephalus were 5.0 and 7.7 times higher in association with a baseline EI > 0.28 (P = .024) and tumor volume >3 cm3 (P = .007), respectively, in multivariate analysis. Fourth ventricle distortion on pre-SRS imaging was significantly associated with hydrocephalus incidence (P < .001). Patients with vestibular schwannoma with higher baseline EI, larger tumor volumes, and fourth ventricle deformation are at increased odds of developing post-SRS hydrocephalus. These patients should be counseled regarding risk of hydrocephalus and carefully monitored after SRS.

Calvarial Tuberculosis: Shifting Paradigm from Surgical to Conservative Approach

Abstract Background Tuberculosis (TB) is an endemic disease in developing countries like India. However, incidence of calvarial TB is very low and it presents in varied forms posing a diagnostic dilemma and delay in management. Objectives This article reports a case series of 15 patients with varied presentations of calvarial TB from a tertiary care superspeciality center of Haryana state in India. Material and Methods Study is a retrospective analysis of 15 patients with calvarial TB treated between 2018 and 2021 in a tertiary care hospital. Clinical features, radiological findings, surgical and medical management, and outcomes were reviewed. Results Of the 15 patients, 9 were males and age ranged between 12 and 45 years. Mean duration of symptoms was 2.9 months (range 1–5 months). The most common presenting symptoms were scalp swelling, discharging sinus, and pain. Four patients were treatment defaulters of pulmonary TB and two patients were found human immunodeficiency virus positive. Brain imaging showed peripherally enhancing extradural collection with bone erosions in most cases. Eleven patients were managed conservatively with fine-needle aspiration cytology (FNAC) or local debridement/sinus excision. Four patients were managed surgically with drainage of collection, excision of necrotic bone, followed by antitubercular therapy. One patient needed cerebrospinal fluid diversion for associated hydrocephalous with tubercular meningitis which could not recover and succumbed. Conclusion Calvarial TB is a rare occurrence of common prevalent diseases. Conservative management with FNAC and sinus excision followed by antitubercular treatment are the mainstay of treatment. Surgery should be reserved for extensive lesion or lesion with mass effect.

AB085. Trans-cortical trans-ventricular approach to pineal tumors: a case series.

Attributing to its deep-seated location, surrounded by significant vessels, surgical management of pineal gland lesions is still considered a challenge. Various surgical approaches are employed to access these lesions, based on patient-specific risks and benefits. Each approach has its merits and demerits. In this study, we aim to narrate our experience with trans-cortical trans-ventricular (TT) approach for pineal tumor resection. We aim to outline the procedure details, safety, efficacy, and treatment outcome of TT. This is a single-center, consecutive case series. All patients with pineal gland tumors who underwent surgical intervention, namely biopsy or resection using TT approach from 2000 to 2023 were included. Data for the patient characteristics, intraoperative details and complications were collected from the hospital's database. Mean [standard deviation (SD)] and frequency (proportions) were calculated for continuous and discrete variables, respectively. We identified 13 patients, mean age 24 (SD: 13) years in our case series. Of them, 8 (61.5%) were male. Most common presenting complains were headaches (69%), nausea/vomiting (38.5%), seizure (23%), and visual deficit (23%). Most patients, 60%, had high grade tumor and average size of tumors were 43.5 mm (SD: 18.45 mm). Pilocytic astrocyotma (23%) and pineal parenchymal tumor of intermediate differentiation (23%) were the most common diagnoses. In total, nine patients had pineal gland lesion biopsy done using TT approach along with the cerebrospinal fluid (CSF) diversion. Of them, four had tumor resection done using the same approach. Whereas four patients had primary excision done using TT approach. There were no intra-operative complications. Two patients had post-operative seizures which were treated with anti-epileptics. We did not identify any long-term sequalae attributed to this approach. We presented our data regarding the safety, efficacy, and outcomes of trans-cortical trans-ventricular approach for pineal tumor surgical management. Utilizing this novel approach for pineal lesion resection can be a great addition to surgeons' armamentarium. This unique approach allows to access the tumor for biopsy/resection and perform CSF diversion procedure, simultaneously. Moreover, the same incision can be used for the second/redo surgery.

MRI analysis of neurodevelopmental anatomy in myelomeningocele: prenatal vs postnatal repair.

Compared with postnatal repair, prenatal myelomeningocele (MMC) repair is associated with improved motor function and decreased need for cerebrospinal fluid (CSF) diversion. It is unknown how prenatal surgery alters neuroanatomical structures identifiable on magnetic resonance imaging (MRI). The purpose of this study was to use MRI to compare neurodevelopmental anatomy in patients undergoing fetal MMC repair compared with those undergoing postnatal repair. This was a retrospective review of neonates who underwent prenatal or postnatal MMC repair at our institution between 2016 and 2021. Imaging data, including prenatal ultrasound and pre- and postnatal MRI examinations, if available, were retrieved. We analyzed anatomical findings characteristically seen on MRI of the neuroaxis in patients with MMC and compared imaging findings between patients with prenatal vs postnatal MMC repair. The study population included 61 patients who underwent surgical repair for MMC during the 6-year study period, of whom 25 underwent prenatal repair and 36 postnatal repair. CSF diversion was required in 24% of the prenatally repaired cohort vs 67% of the postnatally repaired cohort (P = 0.001). On postnatal MRI, a syrinx was present in 13% of the prenatally repaired cohort vs 42% in the postnatally repaired cohort (P = 0.02). Postnatal corpus callosal (CC) morphology was abnormal in 54% of the prenatally repaired cohort vs 53% of the postnatally repaired cohort (P = 0.92), while falx morphology was normal in 92% of the prenatally repaired cohort vs 34% of the postnatally repaired cohort (P < 0.001). On postnatal MRI, patients in the prenatally repaired cohort had a shorter tentorium-to-foramen-magnum distance compared with those in the postnatally repaired cohort (mean, 18.43 mm vs 22.42 mm; P = 0.01), a larger foramen magnum diameter (mean, 22.87 mm vs 18.94 mm; P < 0.001) and a smaller degree of hindbrain herniation (mean, 1.53 mm vs 8.72 mm; P < 0.001). The cerebral aqueduct was patent in 79% of the prenatally repaired cohort vs 100% of the postnatally repaired cohort on postnatal MRI (P = 0.008). Between the two cohorts, at postnatal MRI there was no significant difference in the presence of gray-matter heterotopia, presence of the septum pellucidum or size of the massa intermedia. We report variations in developmental neuroanatomy in patients with MMC, including rates of CC dysgenesis, gray-matter heterotopia and additional cranial and spinal MRI findings. Compared to postnatal surgery, prenatal surgery is associated with changes to infratentorial anatomy, with minimal effect on supratentorial brain development. This information will be useful in counseling parents affected by fetal MMC and in understanding how prenatal repair of MMC affects brain development. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Neurosurgical management of Myelomeningocele in premature infants: a case series

IntroductionMyelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 h of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC.MethodsWe performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995–2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death.ResultsEight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1—80.8). Five patients were taken for surgery within the recommended 48 h of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient’s defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria). In both cases of sepsis, patients developed signs and symptoms more than 72 h after birth. Notably, both instances of sepsis occurred unrelated to operative intervention as they occurred before permanent MMC closure. Two patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 h of MMC closure.ConclusionsIn our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.