Ventricular Drainage Research Articles

Commentary: An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

Commentary: An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

Are variations in ventricular catheter placement related to design of the catheter? A single-center cohort study

Background: The use of intracranial catheters is a common procedure used for neurosurgical patients with a variety of pathologies. Despite its frequency of use, shunt failure and revision have been reported to be a common problem. Given that depth of insertion can significantly affect the catheter tip position, a single institution retrospective chart review was performed to examine the accuracy of shunt and external ventricular drain (EVD) placement. Methods: Computed tomography (CT) images of the head following shunt or ventriculostomy insertion were analyzed to determine the delta between the final length of the intracranial catheter and the intended depth described in the operative notes. Results: We found that there was a statistically significant difference in the accuracy of placement when comparing EVDs to shunts. The most used EVDs at our institution are marked with a solid black line in increments spaced 2 cm apart. The most used ventricular shunt catheter has a marking at 5 cm and 10 cm from the tip of the catheter. We believe that the visual confirmation that is afforded by metric unit markings on the EVD allows for better final placement of the catheter at the outer table of the calvarium. Conclusion: The addition of regular millimeter metric unit markings by the manufacturer is imperative in decreasing the chances of error in the insertion of ventricular catheters and preventing potential neurovascular injury to the surrounding structures.

Non-invasive assessment of intracranial pressure through the eyes: current developments, limitations, and future directions

Detecting and monitoring elevated intracranial pressure (ICP) is crucial in managing various neurologic and neuro-ophthalmic conditions, where early detection is essential to prevent complications such as seizures and stroke. Although traditional methods such as lumbar puncture, intraparenchymal and intraventricular cannulation, and external ventricular drainage are effective, they are invasive and carry risks of infection and brain hemorrhage. This has prompted the development of non-invasive techniques. Given that direct, non-invasive access to the brain is limited, a significant portion of research has focused on utilizing the eyes, which uniquely provide direct access to their internal structure and offer a cost-effective tool for non-invasive ICP assessment. This review explores the existing non-invasive ocular techniques for assessing chronically elevated ICP. Additionally, to provide a comprehensive perspective on the current landscape, invasive techniques are also examined. The discussion extends to the limitations inherent to each technique and the prospective pathways for future advancements in the field.

Unveiling Therapeutic Challenges: A Unique Case of Intracranial Myroides odoratimimus Infection Following Hemorrhagic Stroke.

Intracranial infections post-neurosurgical procedure pose substantial morbidity and mortality risks. Myroides odoratimimus, an opportunistic gram-negative pathogen, represents a real challenge because of limited clinical experience. This article details the second reported case of intracranial M. odoratimimus infection associated with external ventricular drains in an immunocompetent adult. Treatment involved a 21-day course of intravenous antibiotherapy using meropenem and vancomycin. This case underscores the complexity of managing rare complications, providing insights into therapeutic strategies for this challenging condition.

Neurosurgical Procedures in Patients Requiring Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is often withheld in patients with significant neurologic injury or recent neurosurgical intervention due to perceived futility. Studies of neurosurgical interventions before or during ECMO are limited to case reports or single-center series, limiting generalizability, and outcomes in this population are unknown. We therefore sought to report the outcomes of ECMO patients with acute neurosurgical interventions at four high-volume ECMO and comprehensive stroke centers. Retrospective case series. Four academic tertiary referral hospitals in the United States. Adults (n = 24) having undergone neurosurgical procedures before or during ECMO. None. We retrospectively reviewed adults at four institutions who had undergone neurosurgical procedures immediately before or during ECMO from 2015 to 2023. The primary outcome was survival to hospital discharge. Secondary outcomes included favorable neurologic outcome (Cerebral Performance Category 1 or 2) and neurosurgical complications. Twenty-four of 2957 ECMO patients (0.8%) were included. Primary indications for neurosurgical intervention included traumatic brain (n = 8) or spinal (n = 3) injury, spontaneous intracranial hemorrhage (n = 6), and acute ischemic stroke (n = 5). Procedures included extraventricular drain (EVD) and/or intracranial pressure monitor placement (n = 10), craniectomy/craniotomy (n = 5), endovascular thrombectomy (n = 4), and spinal surgery (n = 3). Fifteen patients (63%) survived to hospital discharge, of whom 12 (80%) were discharged with favorable neurologic outcomes. Survival to discharge was similar for venoarterial and venovenous ECMO patients (8/12 vs. 7/12; p = 0.67) and those who had neurosurgery before vs. during ECMO (8/13 vs. 7/11; p = 0.92). One patient (4%) experienced a neurosurgical complication, a nonlethal tract hemorrhage from EVD placement. Survival to discharge was similar for neurosurgical and nonneurosurgical ECMO patients at participating institutions (63% vs. 57%; p = 0.58). Patients with acute neurologic injury can feasibly undergo neurosurgery during ECMO or can undergo ECMO after recent neurosurgery. Larger studies are needed to fully understand risks for bleeding and other procedure-related complications.

Utility of cell index in the diagnosis of healthcare-associated ventriculitis and meningitis: an analytical cross-sectional study

BackgroundThe diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter.MethodsAn analytic, observational, cross-sectional study was conducted at the University of the Philippines – Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed.ResultsA total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to < 19 years old. There were no patients < 12 months old as they fulfilled at least one exclusion criteria. Forty-nine of them were later confirmed to have HCAVM based on the CDC/NHSN criteria. A CI cut-off of ≥ 1.21 gave a maximum sensitivity of 30.6% and specificity of 86.4%. Receiver operating characteristic area under the curve (AUC-ROC) analysis was 0.585. Subgroup analysis by age showed sensitivity of 52.9% in the pediatric age group and 3.13% in adults. Subgroup analysis by neurologic indication showed sensitivity of 27.6% for ICH and 35.0% for neoplasms. Subsequent AUC-ROC analyses, however, showed that CI failed to adequately diagnose HCAVM in these subgroups.ConclusionsIn our population of neurologic patients who underwent EVD insertion, the cell index is not a reliable parameter in the diagnosis of HCAVM.

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.

6791 Pituitary Apoplexy as Presentation of Atypical Teratoid/Rhabdoid Tumor

Abstract Disclosure: S.I. Babli: None. H. Alkubedan: None. N.M. Ali: None. R. Alqawahmed: None. M.M. Elhassan: None. Introduction: Pituitary apoplexy occurs in a pituitary adenoma; it migh occur in other less common types of tumors. The atypical teratoid/rhabdoid tumor (ATRT) is a very aggressive malignant tumor of the central nervous system and has a poor prognosis. It is rare to occur in adult and in the sellar region. Clinical Case: 32 years old male presented to ER with 4 days history of fever, headache and vomiting. He was conscious but confused. Vital signs Temperature 39 C, BP 120/80, HR 110 beats/min and Saturation of 95 %, Possibility of meningoencephalitis was raised, patient Brain CT showed Sellar and suprasellar mass with compression over the optic chiasma and invasion to the left cavernous sinus. Patient suddenly developed Generalize tonic-clonic convulsion and hypotension. He received IV midazolam, intubated and was started on noradrenaline and hydrocortisone, he was admitted to ICU as a case of meningoencephalitis and started on Ceftriaxone, Vancomycin and Acyclovir. Cerebrospinal fluid analysis showed RBC 175/cumm, WBC 20/cumm with 20% polymorph and 80% mononuclear cells, Protein 1.38 g/l (0.24-0.49) glucose 7.9 mmol/l with plasma glucose of 10 mmol/l. Repeated Brain CT showed Sellar and suprasellar mass with compression over the optic chiasma and invasion to the left cavernous sinus and with minimal heterogenicity and increased density suggestive of hemorrhagic components. Endocrine history revealed weight gain but no history to suggest acromegaly, Cushing’s syndrome or hypogonadism . Examinations: Patient was intubated and sedated BP 90/60 on Maximum inotropic support. Left oculomotor nerve palsy, Bilateral papilledema, he was having acanthosis nigricans with no signs of acromegaly, CS or hypogonadism. Laboratory finding: WBC17 with neutrophilia, Hgb 14.7 g/dl plt 360 Na 140 mmol/l, creatnin 180 mmol/, FT4 6.2 pmol/l, TSH 0.015, PROLACTINE 22, IGF1 29 ng/ml (41-246) Free testosterone index 2.13 (33-106), LH 0.5, FSH 0.3 .Patient had TTS and histopathology showed: SMARCB1 deficient malignant neoplasm, consistent with sellar atypical teratoid rhabdoid tumor. Post OP, patient had Ventilator associated pneumonia and recurrent attacks of seizures despite multiple antiepileptic medications. Patient was evaluated by medical and radiation oncologists but due to his general condition the treatment was postpone. One month after TSS, he developed intractable seizure new Brain CT showed interventricular haemorrhage with hydrocephalus and marked enlargement of hyperdense pituitary lesion which suggests haemorrhage. External ventricular drain was inserted but patient arrested and died. Conclusions: ATRT of the CNS usually affects young children. In the literature review performed in adults, only nine cases have occurred in the sellar or suprasellar region. Survival is variable in the different cases reported in the literature, with a mean of 26 months. Presentation: 6/2/2024

8594 Pasireotide and Pasireotide Combined Treatment in Aggressive, Giant Pituitary Neuroendocrine Tumours

Abstract Disclosure: K. Ciszek: None. A. Bogusławska: None. M. Komisarz-Calik: None. J. Kunicki: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. Pasireotide is a second-generation somatostatin analogue that gained recognition as a treatment option for acromegaly and Cushing disease. Recently, there are single reports of pasireotide treatment in other subtype of pituitary neuroendocrine tumours (PitNETs).We present a case series of aggressive, giant PitNETs which were treated with pasireotide alone or as combined multimodal treatment. Case 1: A 59-year-old male presented in our Unit due to severe headaches and visual field deficits. The patient underwent transsphenoidal surgery (TSS) ten years ago. Histopathology results showed partially acidophilic adenoma (FSH- LH- GH- ACTH- PRL-). Control MRI showed tumour regrowth - 56x56x89mm and invasion of local structures. The patient was qualified for radiotherapy, to which he did not consent. Due to the progression of symptoms, temozolomide and pasireotide were introduced. After 5 months, significant improvement in headaches and vision was observed. In MRI stable pituitary mass was noted. Case 2: A 17-year-old male presented in our clinic due to daily severe headaches and peripheral vision loss who underwent two non-radical surgeries for dopamine-resistant giant prolactinoma. In control MRIs progressing mass 38x34x33mm invading local structures was observed. Due to resistance to dopamine agonists and worsening of the symptoms, pasireotide was introduced resulting in a decrease of headaches and improvement in vision. The tumour size remained stationary. Case 3: A 59-year-old male presented with severe headaches and life threatening tumour mass effect.In MRI a 48x48x33mm mass was observed. The patient underwent two non-radical TSS, 4 cycles of pasireotide, and cyberknife treatment. Histopathology showed gonadotroph PitNET. MRI showed tumour shrinkage to 45x46x29mm, with persistent severe headaches. The patient was re-qualified for pasireotide treatment. Case 4: A 33-year-old male reported to the Clinic due to severe headaches and vomiting. In MRI pituitary mass 33x39x55mm and a cerebral oedema were revealed. TSS with external ventricular drainage was performed -histopathology results showed densely granulated silent corticotroph adenoma subtype 1, Ki67&amp;lt;1%. After 3 months, MRI showed tumour progression to 39x40x30mm. Two emergency TSS followed by stereotactic radiotherapy were performed. Combined therapy with pasireotide, cabergoline and temozolomide was introduced. After 18 months, stabilization of the disease was observed with the complete disappearance of headaches. Conclusions: Our study demonstrates the clinical potential of pasireotide treatment in aggressive, giant PitNETs. The therapy alone, or in combination has a potential role in reducing the tumour size, and allows the stabilization of the disease. The analgesic and anti-inflammatory effect of pasireotide could potentially alleviate headaches in this subset of patients. Presentation: 6/2/2024

Comparative Efficacy and Safety of External Ventricular Drains and Intraparenchymal Pressure Monitors for Intracranial Pressure Monitoring in Traumatic Brain Injury: A Systematic Review and Meta-analysis.

In the management of traumatic brain injury (TBI), intracranial pressure monitoring (ICPm) is crucial for the timely management of severe cases that show rapid neurological deterioration. External ventricular drains (EVDs) and intraparenchymal pressure monitors (IPMs) are the primary methods used in this setting; however, the debate over their comparative efficacy persists, primarily because of reliance on observational study data. This underscores the need for a meta-analysis to guide clinical decision-making. This study-level meta-analysis aims to assess and compare the efficacy and safety of EVDs versus IPMs in the management of TBI. A database search was conducted until February 13, 2024, to identify studies reporting clinical outcomes of patients with TBI who underwent ICPm with either EVD or IPM. Primary outcomes included mortality, ICPm duration, length of stay, and complications. From an initial pool of 537 articles, eight studies (six retrospective cohort studies and two prospective cohort studies), encompassing 7080 patients, met our inclusion criteria. Mortality rates showed no significant difference between groups (risk ratio 1.11 [95% confidence interval (CI) 0.86to 1.42], p = 0.42). Patients monitored with IPM had shorter intensive care unit length of stay (mean difference 0.90 [95% CI 0.21to1.59], p = 0.01) and ICPm duration (mean difference 0.79 [95% CI 0.33to1.24], p = 0.0007), with a higher risk of requiring surgical decompression. Monitoring-related complications were similar across the two groups. Our findings suggest that EVD and IPM provide similar outcomes in terms of mortality. However, IPM may offer significant advantages in reducing the duration of ICPm and intensive care unit length of stay. EVD may be preferable for certain mid-term to long-term monitoring. The predominance of observational studies in the current literature highlights the need for further clinical trials to compare these interventions.

Management of External Ventricular Drains for Neuromonitoring and Traumatic Brain Injury Treatment in Pediatric Patients Outside of Intensive Care Units: A Single-Institution Retrospective Study

BackgroundMost pediatric hospitals manage patients who require external ventricular drains (EVDs) exclusively within pediatric intensive care units (PICUs) because of institutional protocols. Our institution commonly manages patients with EVDs on the neurotrauma floor (NTF). We evaluated whether this practice results in more EVD-associated complications. MethodsA retrospective cohort study at our Level 1 pediatric trauma center identified all trauma patients ≤18 years old who received an EVD in 2018-2023. Demographics, presenting characteristics, in-hospital management, and EVD management details were recorded. The primary outcome was EVD-related complication events. ResultsOf the 81 patients who had EVDs placed after neurotrauma, 45 had their EVD managed exclusively in the PICU (PICU-EVD) and 36 had their EVD for some time while on the NTF (NTF-EVD). The groups were similar in sex (p=0.87) and age (p=0.054). PICU-EVD patients underwent fewer neurosurgeries (55.6% vs. 77.8%, p=0.04) but spent more time on ventilators (10.6±8.7 days vs. 6.4±4.8, p=0.02) and in the PICU (11.8±9.0 days vs. 8.4±5.9, p=0.02). Total hospital stay was similar between groups (p=0.44). NTF-EVD patients were on the drain longer (9.0±7.4 days vs. 13.1±9.1, p=0.03), including 5.9 days on the NTF. Four EVD-related complications occurred overall: 2 accidental dislodgements and 2 cerebrospinal fluid leaks. EVD complication rates were similar on the NTF and PICU (2.2% vs. 8.3%, p=0.21). All complications occurred late in the hospital course and were minor. A Poisson regression model comparing complication rates between PICU-only and NTF management (433 vs. 441 catheter days, respectively) found a complication rate of 6.8 per 1,000 catheter days in the NTF group versus 2.3 per 1,000 catheter days in the PICU-only group, yielding a rate ratio of 2.95 (95% confidence interval 0.29–30.4, p=0.35). However, this difference was not statistically significant. ConclusionOur center routinely discharges patients from the PICU to the NTF with EVDs in place. This practice may be associated with no increased risk or rate of EVD-related complications compared to PICU-only management. Level of EvidenceIV

An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

An external ventricular drain (EVD) placement is a commonly performed life-saving procedure. Its accidental pullout can occur in complex environments, patient care, and positioning, which leads to significant morbidity. The method of EVD fixation and pullout rates is sparsely described in the literature, and there exists a wide variation among the techniques practiced for fixation. However, some techniques require additional tools, which are expensive and unavailable in low-resource settings. We describe an improvised method of securely fixing the EVD to the scalp applicable in low-resources and describe the EVD pullout rate with the use of this technique. A retrospective review of pullout-related complications in 107 consecutive patients was performed. The EVD was fixed to the scalp using an improvised technique to loop the catheter around a soft flange and secure it with sutures. Pullout occurred in 1 patient (0.93%), who was in an alcohol withdrawal state and deliberately pulled out the catheter. There were zero nondeliberate pullouts. EVD fixation by coiling the catheter around a soft flange has a low pullout rate. Because it is secure and requires only a flange, it is suitable for low-resource settings.

Improving Successful Cannulation of External Ventricular Drain: 3D-Printed Surgical Guide for Inexperienced Neurosurgeons

ObjectiveExternal Ventricular Drain (EVD) is a fundamental neurosurgical procedure that is commonly performed by junior neurosurgeons. Expedient, successful cannulation of the ventricles can be lifesaving. Yet, the free-hand technique of EVD insertion is associated with significant mal-positioning rates. This study aims to improve EVD placement by junior neurosurgeons with the aid of a customized 3D printed surgical guide. MethodsA 3D printed surgical guide was developed and customized to our institution’s EVD insertion procedure. First year neurosurgical residents were taught how to perform pre-operative trajectory planning based on coronal brain images and how to use the surgical guide during standard EVD insertion procedure. Number of passes, accuracy of EVD placement, operative complications, need for revision, and surgeon’s experience with the guide were recorded. Results14 patients underwent guide-assisted EVD insertion by first year neurosurgical residents. Significantly, 6 (43%) patients had ventricular anatomy distorted by midline shift. All surgeons achieved successful ventricular cannulation using the EVD guide on first pass (100%). 13 out of 14 (93%) of the guide-assisted EVDs were optimally placed (Karkarla Grade 1). 1 (7%) guide-assisted EVD was suboptimally placed (Karkarla Grade 2). There was no intra or post-operative complication and there was no EVD revision. ConclusionsFor inexperienced surgeons, the 3D printed EVD guide can improve ventricular cannulation even in cases of altered ventricular anatomy. The benefit of 3D printing would also allow the guide to be widely adopted by other institutions worldwide.

Safe external ventricular drain management for infection prevention and control: a narrative review

Introduction: External ventricular drain (EVD) placement is a common neurosurgical procedure. Nurses play a crucial role in care, troubleshooting, and monitoring of EVD-related complications, making their education and training in this area of paramount importance. A well-trained nurse possesses the necessary knowledge and skills to recognize and respond promptly to EVD-related complications, such as infections, bleeding, and blockages. External ventricular drainage is associated with a high rate of nosocomial meningitis. The introduction of a well- implemented EVD care bundle can significantly decrease EVD infection rates. The support of the multi-item bundle for EVD is considered very important to reduce EVD-related infections.Aim: To summarize the most recent available evidence for the prevention and control of EVD infections. Methods: Comprehensive literature search had been done using the PubMed (Medline), Embase, CINAHL, and Cochrane databases. The narrative review was performed according to the PRISMA Extension for Scoping Review checklist (PRISMA-ScR).Results: The query identified 4266 studies; after duplicate removal and exclusion of papers due to non-pertinent criteria, 26 studies were included. Only three papers were related to pediatric patients and all were about EVD anchoring. Regarding the risk of infection, bundles and protocols are important for the reduction of the occurrence rate; however, staff adherence to these is fundamental.Conclusion: Multidisciplinary staff and training are fundamental to improve EVD management. Avoiding routine or daily sampling reduces the EVD infection rate. When the procedure is requested, it is important to follow a strict protocol and to use sterile techniques. Hydrocolloid dressings, SecurAcath, gauze, and film dressings were used to anchor the cover EVD in the studies.

Unusual presentation of fetal ventriculomegaly: a case report

Fetal ventriculomegaly (VM) is a relatively common finding during prenatal examinations and occurs in approximately 0.2% of live births. Although there are various causes, obstructive VM due to cerebellar hemorrhage is exceedingly rare. A 33-year-old primigravida presented at 32 weeks of gestation with VM. At 36 weeks of age, a male infant was delivered via cesarean section. Postnatal imaging revealed severe bilateral hydrocephalus and space-occupying lesions in the cerebellum. Initial concerns about a potential germ cell tumor were raised due to elevated alpha-fetoprotein levels in both serum and cerebrospinal fluid. An external ventricular drain was placed to manage obstructive hydrocephalus. When the baby was 1 month old, surgical exploration revealed an old blood clot without any evidence of a tumor. Histopathological examination confirmed an old hemorrhage with no malignant cells. This case underscores the diagnostic challenges in distinguishing between hemorrhages and tumors in the context of fetal VM. Despite elevated alpha-fetoprotein levels, no tumors were identified. The underlying cause of cerebellar hemorrhage remains unclear despite extensive workups. Nevertheless, this case report details multifaceted diagnostic efforts to address the rare occurrence of cerebellar hemorrhage related to fetal VM, leading to a comprehensive case presentation.

A Patient With Cryptococcal Meningitis Accompanied With Acute Intracranial Hypertension Treated by Ventricular Abdominal-wall Drainage.

Intracranial hypertension is considered a common and severe complication of cryptococcal meningitis (CM), contributing to early mortality and neurological sequelae. Timely and effective control of elevated intracranial pressure is crucial for the management of CM. Herein, the authors present a case of ventricular abdominal wall drainage for CM accompanied with acute intracranial hypertension. Notably, the patient has a history of taking immunosuppressants for thoracic and abdominal diffuse lymphangiomatosis. After continuous drainage of cerebrospinal fluid combined with standardized antifungal treatment, the patient recovered well.

A Single-Centre Analysis of Surgical Techniques for Myelomeningocele Closure: Methods, Outcomes, and Complications.

(1) Background: Neural tube defects are a prevalent cause of congenital malformations, myelomeningocele (MMC) being the most severe form. This study evaluates the clinical outcome and postoperative-associated complications following MMC surgical closures, focusing on the following three techniques: direct suture (DS); VY advancement flap (VYF); and Limberg flap (LF). (2) Methods: A retrospective observational study was conducted from March 2015 to February 2023, and the inclusion criteria were newborns who underwent lumbosacral MMC within 24 h of birth. (3) Results: Out of 20 cases, 45% underwent DS closure; 25% underwent VY-F closure; 15% underwent LF closure, and 15% (n = 3) underwent combined flap closure. A significant statistical correlation was observed between intracranial hypertension (IH), the need for external ventricular drainage (EVD), and DS closure type. In the DS group, 60% of patients required EVD (p = 0.041), and 90% had IH (p = 0.027). CSF fistula was present in 40% of LF cases and 30% of DS cases, while wound dehiscence was observed in 60% of LF cases and 30% of DS cases. (4) Conclusions: Our study demonstrated that DS was linked to higher rates of complications. The VY-F is the safest method for closing MMC defects.

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study

BackgroundThe aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH.MethodsThe clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients’ surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared.ResultsThere was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant.ConclusionsETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient’s clinical features and hematoma location.

Primary ventriculitis caused by Streptococcus intermedius - a rare case and challenge with uncertain clinical outcome. Case report.

To present a case of primary ventriculitis in a 53-year-old patient caused by Streptococcus intermedius, emphasizing the rarity of the condition and the challenges in achieving clinical improvement despite targeted therapy. The patient underwent clinical evaluation, including CT and MRI imaging, as well as CSF analysis. Empirical antibiotic therapy was initiated with cefotaxime and metronidazole, followed by targeted therapy based on CSF culture results. External ventricular drainage was performed surgically. No predisposing factors were identified in the patient. Initial imaging showed no acute changes, but follow-up imaging revealed significant ventricular inflammation. CSF analysis confirmed the presence of Streptococcus intermedius. Despite early and targeted antibiotic therapy, and surgical intervention, the patient's clinical condition did not improve. This case highlights the rarity of primary ventriculitis caused by Streptococcus intermedius and the challenges in managing it. The lack of clinical improvement despite prompt and targeted treatment underscores the need for further research to develop more effective therapeutic strategies for such infections.

Noninvasive Method Using Mechanical Extensometer for the Estimation of Intracranial Compliance by Repeated Measures Agreement Analysis.

Intracranial compliance refers to the relationship between changes in volume and the resultant changes in intracranial pressure (ICP). This study aimed to assess the agreement of a noninvasive ICP waveform device for the estimation of compliance compared with invasive ICP monitoring employing three distinct methods. We conducted a retrospective analysis of ICP waveform morphology recorded through both invasive (external ventricular drain) and noninvasive (mechanical extensometer) methods in adult patients with acute brain injury admitted to a neurointensive care unit between August 2021 and August 2022. Compliance was calculated as the amplitude of the fundamental component of cerebral arterial blood volume (estimated with concurrent Transcranial Doppler [TCD] recordings), divided by the amplitude of the fundamental component of the invasive and noninvasive ICP waveforms. Subsequently, we assessed the agreement between invasive and noninvasive intracranial compliance by repeated measures correlation coefficient analysis using three methods: TCD-derived, P2/P1 ratio, and time-to-peak (TTP). A linear mixed-effects model was used to compute the concordance correlation coefficient, total deviation index, and coefficient of individual agreement. Coverage probability plot was calculated to estimate the percent of observations within different cut points for each of the three methods. A total of 21 patients were identified for this study. Repeated measures correlation analysis showed a strong correlation (R = 0.982, 95% confidence interval [0.980-0.984], p < 0.0001) between log-transformed noninvasive and invasive compliance. Agreement statistics for TCD, P2/P1 ratio, and TTP indicated that although the concordance correlation coefficient was highest for log(TCD) values, TTP and P2:P1 ratio measures had better agreement with total deviation index and coverage probability plot analyses. Repeated measures correlations suggest that ICP waveform analyses may offer a more accurate estimate of compliance than TCD-derived methods for noninvasive ICP monitoring. Further validations studies are warranted to confidently establish this method as an indicator of intracranial compliance.