Need For Cerebrospinal Fluid Diversion Research Articles

Antithrombotic States and Outcomes in Patients With Angiographically Negative Subarachnoid Hemorrhage

Antithrombotic states are encountered frequently, either because of medical therapy or by preexistent pathological states, and may affect the severity of hemorrhagic strokes such as angiographically negative subarachnoid hemorrhages. To determine the effects of antithrombotic states on the outcomes of patients with angiographically negative subarachnoid hemorrhage by examining data pooled from 2 institutions. This is a retrospective review of patients who experienced angiographically negative subarachnoid hemorrhage at 2 institutions over the past 5 years. The patients were grouped into those with and those without an antithrombotic state at time of hemorrhage and were stratified according to presentation, clinical grades, outcomes, need for cerebrospinal fluid diversion, and development of vasospasm. Computed tomography of the head was assessed for bleed pattern and modified Fisher grade. Patients were excluded if a causative lesion was subsequently discovered. There is a statistically significant association between antithrombotic states and poorer presentation, higher Hunt and Hess score, increased amount of subarachnoid hemorrhage, higher modified Fisher grade, increased incidence of vasospasm, hydrocephalus, and poor outcomes as assessed by modified Rankin scale (P < .001). Patients with an antithrombotic state experience worse outcomes even with adjustment for the amount of hemorrhage as assessed by modified Fisher grade (P < .001). Patients in an antithrombotic state presenting with angiographically negative subarachnoid hemorrhage present with inferior clinical scores, diffuse hemorrhage patterns, and worse modified Fisher grades and have worse outcomes.

Is the routine placement of a CSF reservoir following endoscopic third ventriculostomy justified?

Endoscopic third ventriculostomy (ETV) is a well established treatment for selected cases of obstructive hydrocephalus. However, it does carry a significant rate of failure, which can be abrupt and life threatening. The present study analyses the benefits versus the risks of routine CSF reservoir insertion during ETV. Clinical data obtained from the medical records of patients from a single neurosurgical centre who underwent ETV between August 2002 and February 2007 were analysed retrospectively. A total of 34 records were available with follow-up ranging from 3–56 months (Median 26 months) and with patient age range between 6 months – 75 yrs (median 19 years). During this period, one neurosurgeon routinely placed reservoirs in all patients undergoing ETV (n = 34). In all instances of reservoir insertion, Ommaya reservoirs were used. The number of patients in which the reservoir was tapped for diagnostic and/or therapeutic reasons was quantified, and all complications resulting from reservoir placement recorded. ETV success was defined by a lack of subsequent need for cerebrospinal fluid diversion. In total 13 of 34 (38%) reservoirs inserted were tapped at a later date and there were no complications associated with their insertion. Tapping of reservoirs helped determine which patients required subsequent ventriculoperitoneal (VP) shunting. In at least one case reservoir tapping was carried out as an emergency and was a crucial intermediate intervention prior to further surgery. The overall success rate of ETV was 65% (95% CI, 49–81%) with four complications associated with ETV: short-term memory loss, psychosis, and two cases of post-operative seizures. These complications were not attributed to CSF reservoir insertion but the ETV procedure itself. The routine placement of CSF reservoir following ETV thus seems justified with respect to the observed benefits and lack of complications associated with its placement.

Spontaneous third ventriculocisternostomy in an infant with obstructive hydrocephalus

Spontaneous ventriculocisternostomy, the spontaneous communication between the ventricular system and the subarachnoid space, is rare. The authors report a case of an infant with obstructive hydrocephalus who developed a spontaneous third ventriculocisternostomy. The infant was initially evaluated for progressive ventriculomegaly and increasing head circumference (HC). During follow-up, the patient's HC began to follow percentile lines and magnetic resonance (MR) imaging demonstrated a reduction of the hydrocephalus. Flow-sensitive phase-contrast cine MR images revealed cerebrospinal fluid (CSF) flow through the floor of the third ventricle between the tuber cinereum and the mammillary bodies connecting the ventricular system with the prepontine cistern. Although rare, clinicians should be cognizant of this phenomenon as it may eliminate the need for CSF diversion.

Complications of interhemispheric transcallosal approach in children: Review of 15 years experience

Objective The interhemispheric transcallosal approach to deep-seated lesions in and around the ventricular system avoids cortical manipulation and injury. Few case series discuss the morbidity associated with this approach. This study describes the 15-year experience of the senior author in Southern California. Methods All pediatric patients who have undergone interhemispheric, transcallosal resections of mass lesions over a 15-year period were identified. The surgical approach was uniform with respect to positioning of the patient. Intra-operative and post-operative data were collected retrospectively from the medical records. The need for bridging vein ligation as well as the incidence of hemiparesis, seizures, memory disturbances, and the need for subsequent cerebrospinal fluid (CSF) diversion were identified. Results Sixty-five patients were identified. The incidence of transient post-operative hemiparesis appeared to be higher in those patients who required ligation of one or two parasagittal veins (44.6% versus 18.5%) with no difference in long-term outcome. Nineteen percent (18.5%) of patients had post-operative seizures; however, no long-term seizure disorder was identified. Nine percent (9.2%) had reports of transient short-term memory deficits. Thirty-four percent (33.8%) of patients required secondary operative intervention for CSF diversion. The total complication rate, including need for CSF diversion, transient hemiparesis, infection, post-operative seizures, and memory disturbance was 36.9%. By 1 year, the total number of patients with persistent hemiparesis, memory disturbance, or seizures refractory to medication was 4 (6.2%). Conclusion This series demonstrates that the interhemispheric transcallosal corridor is a versatile and safe approach in childhood, resulting in low post-operative permanent morbidity.

Arachnoid cyst with associated arachnoiditis developing after subarachnoid hemorrhage

The authors report the case of a 53-year-old woman in whom a T1-T2 spinal arachnoid cyst with associated arachnoiditis developed, compressing the thoracic spinal cord 1 year after the patient had suffered a Hunt and Hess Grade IV subarachnoid hemorrhage (SAH). Development of spinal arachnoiditis with or without an arachnoid cyst is a rare complication of aneurysmal SAH. Risk factors may include posterior circulation aneurysms, the extent and severity of the hemorrhage, and the need for cerebrospinal fluid diversion. Surgical drainage, shunt placement, or cyst excision, when possible, is the mainstay of treatment.