Obstruction Of Aqueduct Research Articles

Changes of cerebrospinal fluid pressure gradient in different body positions under experimental impairment of cerebrospinal fluid pathway: new insight into hydrocephalus development.

It is generally accepted that hydrocephalus is a consequence of the disbalance between cerebrospinal fluid (CSF) secretion and absorption which should in turn lead to CSF pressure gradient development and ventricular enlargement. To test CSF pressure gradient role in hydrocephalus development, we experimentally caused CSF system impairment at two sites in cats. In the first group of animals, we caused Sylvian aqueduct obstruction and recorded CSF pressure changes pre and post obstruction at three measuring sites (lateral ventricle -LV, cortical-CSS and lumbar subarachnoid space -LSS) during 15 min periods and in different body positions over 360 degrees. In the second group of experiments, we caused cervical stenosis by epidural plastic semiring implantation and monitored CSF pressure changes pre and post stenosis implantation at two measuring sites (lateral ventricle and lumbar subarachnoid space) during 15 min periods in different body positions over 360 degrees. Both groups of experimental animals had similar CSF pressures before stenosis or obstruction at all measuring points in the horizontal position. During head-up verticalization, CSF pressures inside the cranium gradually became more subatmospheric with no significant difference between LV and CSS, as they are measured at the same hydrostatic level, while CSF pressure inside LSS became more positive, causing the development of a large hydrostatic gradient between the cranial and the spinal space. With cervical stenosis, CSF pressure inside the cranium is positive during head-up verticalization, while in cats with aqueductal obstruction CSF pressure inside the CSS remains negative, as it was during control period. Concomitantly, CSF pressure inside LV becomes less negative, thus creating a small hydrostatic gradient between LV and CSS. Since CSF pressure and gradient changes occur only by shifting body position from the horizontal plane, our results indicate that cervical stenosis in a head-up vertical position reduces blood perfusion of the whole brain, while aqueductal obstruction impairs only the perfusion of the local periventricular brain tissue. It seems that, for evolutionary important bipedal activity, free craniospinal communication and good spinal space compliance represent crucial biophysical parameters for adequate cerebral blood perfusion and prevention of pathophysiological changes leading to the development of hydrocephalus.

Surgical aspects of classification and neuroimaging characteristics of idiopathic hydrocephalus in adults

Background. Hydrocephalus can be developing by a traumatic brain injury, intracranial hemorrhage, tumor, meningitis of congenital malformation of the central nervous system. When the cause of the hydrocephalus is unclear it is supposed as idiopathic hydrocephalus. The most important classification features are the etiology and level of CSF obstruction. The classification was improved and developed with diagnostic and surgical methods simultaneously. Currently, the neurosurgeons have the possibility for usage of various methods and techniques of surgical treatment with their advantages and disadvantages. Systematization of radiological parameters is necessary to make a decision about the type of the surgery.Aim. To analyze and systematize the neuroimaging characteristics of various forms of idiopathic hydrocephalus in adults, to assess the possible classification of idiopathic hydrocephalus.Materials and methods. Between October 2011 and March 2021 290 patients with idiopathic adult hydrocephalus were operated at the N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of Russia: onset of symptoms in adulthood; no indications of the etiology of hydrocephalus and congenital hydrocephalus. The age of the patients was 50 ± 18.2 (18–85) years. The magnetic resonance images of patients were evaluated for the size of the ventricles, condition of convexital and basal subarachnoid spaces, obstruction of the CSF pathways, and changes in the position of the premamillary membrane, septum pellucidum, the roof of the 3rd ventricle and the tonsils of the cerebellum, the size of the sella turcica, the angle of the corpus callosum. The frequency of each of these parameters is statistically estimated for each form of idiopathic hydrocephalus.Results. Aqueduct stenosis has become the most frequent form of idiopathic hydrocephalus. Hydrocephalus in obstruction of the foramen of Monroe, aqueduct, foramen of Magendie, and cisterns of the posterior cranial fossa was significantly more characteristic of young people (p <0.05). Hydrocephalus with obstruction of convexital CSF spaces can be called hydrocephalus of the elderly (p <0.001). Hydrocephalus without verified signs of occlusion CSF pathways occurs equally in all age groups. The FOHR index was significantly more important, and only in case of cisternal obstruction. Enlargement one or both lateral ventricles and flattening of the roof of the 3rd ventricle is characterized for Monro’s foramen obstruction (p <0.001). The membrane at the outlet of the 4th ventricle and the absence of the “flow void” was typically only for patients with obstruction of the foramen of Magendie (p <0.001). Ventral dislocation of the premamillary membrane was characteristic of obstruction of the cerebral aqueduct, the foramen of Magendie, and cisterns of the posterior cranial fossa. Compression of the convexital CSF spaces occurred in case of obstruction of the aqueduct, the foramen of Magendie, but CSF spaces of the posterior cranial fossa – only with obstruction of the foramen of Magendie. Dilation of the 4th ventricle was significantly associated with obstruction of the foramen of Magendie and cisterns of the posterior cranial fossa (p <0.05). DESH symptom was significantly associated with obstruction of convexital CSF spaces (p <0.001). Additional membranes in the cisterns of the posterior fossa were found only in cases of cisternal obstruction (p <0.001). Cerebellar tonsils herniation was observed with obstruction of the foramen of Monroe, cerebral aqueduct, and foramina of Magendie.Conclusion. Because of statistical analysis, general signs found in all types of hydrocephalus, and private ones, characterizing only specific signs of the type of the disease, both were found. The classification is logical and justified, it is well applicable in neurosurgical and radiological practice. It allows rational planning of diagnostic evaluation and treatment of patients. A modern magnetic resonance imaging protocol should include T2 scans (with “flow void”) and FIESTA/CISS scans in the required planes, axial FLAIR scans.

Predicting endoscopic third ventriculostomy success in pediatric shunt dysfunction: a monocentric retrospective case series of 70 consecutive children, systematic review, and meta-analysis.

The outcome of endoscopic third ventriculostomy (ETV) in children who had previously received shunts and who were experiencing shunt dysfunction is still discussed in terms of efficacy (success rate from 40% to 80%) and safety (0%-32.5% of complications). Reported predictive factors of secondary ETV failure are age, early onset of hydrocephalus, and prematurity. The best surgical strategy in the different subgroups of patients with shunt dysfunction is still debated. Therefore, the authors aimed to identify subgroups of patients in whom shunt treatment was associated with favorable outcome of ETV, to define the role of ETV in patients with global rostral midbrain dysfunction syndrome. This study was a monocentric retrospective case series and a meta-analysis of children who had previously received shunts and who underwent secondary ETV for shunt dysfunction between 2012 and 2022. Clinical and MRI features were examined, along with surgical outcome, etiology of hydrocephalus, and preoperative ETV Success Score. Univariate and multivariate analyses were performed to find predictors of outcome of secondary ETV. Youden's J index was calculated on age distribution to find an optimal age cutoff. Systematic review of the literature and a meta-analysis were performed according to the PRISMA statement. Seventy consecutive patients were included. The overall success rate of secondary ETV was 63%. Primary obstructive hydrocephalus, age ≥ 36 months, and the presence of aqueductal obstruction were predictors of ETV success. Multivariate analysis found that age < 36 months, primary inflammatory hydrocephalus, and presence of fourth ventricular obstruction were associated with ETV failure. All patients with global rostral midbrain dysfunction syndrome experienced clinical and radiological improvement after ETV. The meta-analysis showed that postinflammatory etiology and age < 36 months were predictors of ETV failure. ETV is safe and effective for children with obstructive hydrocephalus experiencing shunt dysfunction, notably in cases of primary obstructive hydrocephalus with aqueductal stenosis, and among children whose age was ≥ 36 months who had postinflammatory hydrocephalus.

Diagnosis and Management of Pineal Germinoma: From Eye to Brain.

Pineal germinomas can be very complex in terms of presentation, diagnosis, and management. This review attempts to simplify this complexity in an organized manner, addressing the anatomic relationships that provide the basis for the uniqueness of pineal germinoma. Ocular findings and signs and symptoms of elevated intracranial pressure are the keys to suspecting the diagnosis and obtaining the necessary imaging and cerebrospinal fluid studies. Other symptoms can suggest spread beyond the pineal region. Surgery may only be needed to obtain tissue for a definitive diagnosis, as germinoma is highly responsive to chemotherapy and focused radiation therapy. Hydrocephalus, usually related to tumor obstruction of the cerebral aqueduct, may also need to be addressed. Outcome for pineal germinoma is usually excellent, but relapse can occur and may require additional intervention. These issues are detailed in this review.

195 Aberrant Brain Biomechanics Initiates Ventricular Dilation in a Genetic Subtype of Congenital Hydrocephalus

INTRODUCTION: We have previously shown using human genetics and mouse models that TRIM71 is a bona fide disease gene causing human congenital hydrocephalus. Disease-associated mutations in TRIM71 disrupt neural stem cell proliferation, however how these developmental effects physiologically lead to ventricular dilation is not clear. METHODS: We developed a number of novel methods to characterize cerebrospinal fluid (CSF) circulation, including cilia-generated currents and bulk flow. We then used these methods to comprehensively characterize CSF dynamics and intracranial physiology in hydrocephalic Trim71R595H/+ mice that harbor the same point mutation found in human hydrocephalus patients. RESULTS: We found that in hydrocephalic Trim71R595H/+ mice, impaired neurogenesis results in a hypoplastic cerebrocortical wall that exhibits loss of stiffness and elasticity. This leads to a floppy hypercompliant state wherein the brain parenchyma is unable to hold the pressure exerted by CSF, thereby facilitating passive pooling of CSF and secondary distention of the ventricles. Ventriculomegaly occurs in the absence of altered cilia-generated CSF flow or congenital aqueductal obstruction. Neuroimaging studies in patients with TRIM71 mutations also suggest cortical hypoplasia as the primary physiological factor leading to secondary ventricular dilation and passive pooling of CSF. CONCLUSIONS: We highlight the importance of precisely regulated neural stem cell fate and neurogenesis for maintaining normal brain-CSF biomechanical interactions that limit ventricular expansion. We thus demonstrate that some or potentially many forms of CH are in fact a congenital brain malformation akin to microcephaly with secondarily enlarged ventricles rather than a primary disturbance in CSF circulation.

Mesencephalic developmental venous anomaly causing obstructive hydrocephalus: illustrative case.

Developmental venous anomalies (DVAs) are congenital anatomical variants of the normal deep parenchymal veins. DVAs are occasionally found incidentally on brain imaging, and most cases are asymptomatic. However, they rarely cause central nervous disorders. Herein, a case of mesencephalic DVA that caused aqueduct stenosis and hydrocephalus and discuss its diagnosis and treatment is reported. The patient was a 48-year-old female who presented with depression. Computed tomography and magnetic resonance imaging (MRI) of the head revealed obstructive hydrocephalus. Contrast-enhanced MRI revealed an abnormally distended linear region with enhancement on the top of the cerebral aqueduct, which was confirmed as a DVA by digital subtraction angiography. An endoscopic third ventriculostomy (ETV) was performed to improve the patient's symptoms. Intraoperative endoscopic imaging showed obstruction of the cerebral aqueduct by the DVA. This report describes a rare case of obstructive hydrocephalus caused by DVA. It highlights the usefulness of contrast-enhanced MRI for diagnosing cerebral aqueduct obstructions due to DVAs and the effectiveness of ETV as a treatment option.

Magnitude of Hydrocephalus in Neonates: Its Surgical Management and Complications

Abstract: Background: To determine magnitude of congenital or acquired hydrocephalus and its possible management and complications. Materials and Methods: This Hospital based Retrospective observational study was conducted in department of pediatric surgery King Edward medical university / Mayo hospital Lahore from January 2021 to March 2022. All patients presented from neonatal life till 3 months of age with hydrocephalus due to congenital or acquired reasons were included in this study. There were 55 male and 28 female patients with male predominance. A detailed Proforma was made giving patients information, associated congenital or acquired anomaly and surgical management of hydrocephalus. All patients were operated on elective operation theatre list. Post-operative complications were noticed on admission files and addressed. Results: During the study period, 83(n=1) patients with hydrocephalus were admitted in department of pediatric surgery Mayo hospital Lahore. Among these patients, 56(67.5%) patients have hydrocephalus associated with myelomeningocele while 10(12%) patients with encephalocele. 11(13.3%) patients showed hydrocephalus due to post tuberculosis meningitis while 3(3.6%) patients with Arnold chiari 2 malformation. 1(1.2%) patients presented with hydrocephalus due to Congenital obstruction of cerebral aqueduct while 2(2.4%) with Intracranial hemorrhage ventriculoperitoneal shunting was performed in 55(66.3%) patients to treat hydrocephalus. Conservative management of hydrocephalus was done in 24(28.9%) patients while in 4(4.8%) patients ventricular taping was done. Wound infection was major post-operative complication and was noted in in 13 (15.7%) patients. Conclusion: Ventriculo peritoneal shunting is main treatment modality for obstructed hydrocephalus. Major complication of ventriculo pertoneal shunting is infection which can be prevented by proper prophylactic antibiotics as well as sterile environment of operation theatre.

Three-dimensional quantification of fibrosis and ossification after cochlear implantation via virtual re-sectioning: Potential implications for residual hearing

Hearing preservation may be achieved initially in the majority of patients after cochlear implantation, however, a significant proportion of these patients experience delayed hearing loss months or years later. A prior histological report in a case of delayed hearing loss suggested a potential cochlear mechanical origin of this hearing loss due to tissue fibrosis, and older case series highlight the frequent findings of post-implantation fibrosis and neoosteogenesis though without a focus on the impact on residual hearing.Here we present the largest series (N = 20) of 3-dimensionally reconstructed cochleae based on digitally scanned histologic sections from patients who were implanted during their lifetime. All patients were implanted with multichannel electrodes via a cochleostomy or an extended round window insertion. A quantified analysis of intracochlear tissue formation was carried out via virtual re-sectioning orthogonal to the cochlear spiral.Intracochlear tissue formation was present in every case. On average 33% (SD 14%) of the total cochlear volume was occupied by new tissue formation, consisting of 26% (SD 12%) fibrous and 7% (SD 6%) bony tissue. The round window was completely covered by fibro-osseous tissue in 85% of cases and was associated with an obstruction of the cochlear aqueduct in 100%. The basal part of the basilar membrane was at least partially abutted by the electrode or new tissue formation in every case, while the apical region, corresponding with a characteristic frequency of < 500 Hz, appeared normal in 89%.This quantitative analysis shows that after cochlear implantation via extended round window or cochleostomy, intracochlear fibrosis and neoossification are present in all cases at anatomical locations that could impact normal inner ear mechanics.

Cystoperitoneal Shunting for Patient with Hydrocephalus Associated with Aqueductal Obstruction in Dandy-Walker Malformation: A Case Report

Dandy-Walker Malformation presents as a congenital anomaly that affects the posterior fossa. Presenting hydrocephalus as secondary to Dandy-Walker Malformation is the main concern and complication. The cyst formation in the posterior fossa obstructs the cerebrospinal flow that led to the hydrocephalus. Ideal management to treat Dandy-Walker malformation are varied. Shunting, cyst excision, and endoscopy third ventriculostomy are the proposed management. Case Report Presenting a case of a 1-month-age male baby who was diagnosed with vermis agenesis and posterior fossa enlargement by antenatal ultrasound. Later on, Magnetic Resonance Imaging revealed Dandy-Walker Malformation with hydrocephalus and aqueduct obstruction. Cystoperitoneal shunt was performed for this patient. Proximal shunt trajectory measured from Magnetic Resonance Imaging. As the goal of therapy is to achieve normal development, this patient needs long-term follow-up in collaboration with pediatric and physiotherapy. After 18 months of follow-up, he was able to crawl with routine and proper physiotherapy. Conclusion Hydrocephalus in Dandy-Walker Malformation patients related to aqueduct obstruction may be treated with a single Cystoperitoneal shunt. Aqueduct obstruction in these patients may be temporary due to high pressure on the posterior fossa that pushed the vermis forward. Cystoperitoneal shunt may reduce posterior fossa pressure and then deprive the pressure that obstructs aqueduct.

Endoscopic third ventriculostomy in an infant with vein of Galen aneurysmal malformation treated by endovascular occlusion: Case report and a review of literature

IntroductionVein of Galen aneurysmal malformations (VGAMs) can, through multiple mechanisms, complicate with hydrocephalus (HCP). It is generally agreed that management strategies in this scenario should focus on endovascular embolizations. Treatment options for non-responders, however, have been only scarcely reported upon. Case presentationWe present a nine-month-old boy with a mural type VGAM complicated by HCP. Despite endovascular occlusion of the sole feeder, the child exhibited hydrocephalus progression prompting an Endoscopic Third Ventriculostomy (ETV). This procedure restored a cerebrospinal fluid (CSF) circulation otherwise impaired by aqueduct obstruction. Later, a new feeder arose and a second embolization was ultimately needed in order to achieve VGAM regression. Throughout four years of follow up, the child attained all developmental marks. Discussion/conclusionVGAMs are prone to hydrocephalus development as there is both an underlying venous congestion and a mechanical, obstructive component. Although there is a rationale for addressing both components, the underlying AV shunts and subsequent venous pressure elevations usually determine failure of traditional CSF shunting strategies. It is therefore challenging to manage HCP in patients who failed to improve following endovascular embolizations. For such cases, ETV stands as an elegant minimal invasive alternative with potential to provide a more physiologic drainage route and thus better allow for neurological development.

The role of mesencephalic aqueduct obstruction in hydrocephalus development: a case report

We report on three patients with mesencephalic aqueduct obstruction, which completely blocked the cerebrospinal fluid communication between the third and fourth cerebral ventricle, demonstrated by standard and high-resolution magnetic resonance sequences. Only one patient developed radiological and clinical presentation of hydrocephalus, without radiological signs of increased intraventricular pressure. The remaining two patients did not show clinical signs of hydrocephalus and had a normal radiological presentation of the ventricular system. These findings contradict the classical concept of cerebrospinal fluid physiology. This concept assumes a unidirectional circulation of cerebrospinal fluid through the mesencephalic aqueduct from the secretion site, predominantly in the choroid plexuses, to the resorption site, predominantly in the dural venous sinuses. Therefore, the obstruction of the mesencephalic aqueduct would inevitably lead to triventricular hypertensive hydrocephalus in all patients. The current observations, however, accord with the new concept of cerebrospinal fluid physiology, which postulates that cerebrospinal fluid does not circulate unidirectionally because it is both formed and resorbed along the entire capillary network within the central nervous system.

Endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for hydrocephalus of infancy: a technical review.

In the twenty-first century, choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) has emerged as an effective treatment for some infants with hydrocephalus, leading to the favourable condition of 'shunt independence'. Herein we provide a narrative technical review considering the indications, procedural aspects, morbidity and its avoidance, postoperative care and follow-up. The CP has been the target of hydrocephalus treatment for more than a century. Early eminent neurosurgeons including Dandy, Putnam and Scarff performed CPC achieving generally poor results, and so the procedure fell out of favour. In recent years, the addition of CPC to ETV was one of the reasons greater ETV success rates were observed in Africa, compared to developed nations, and its popularity worldwide has since increased. Initial results indicate that when ETV/CPC is performed successfully, shunt independence is more likely than when ETV is undertaken alone. CPC is commonly performed using a flexible endoscope via septostomy and aims to maximally cauterize the CP. Success is more likely in infants aged >1 month, those with hydrocephalus secondary to myelomeningocele and aqueductal obstruction and those with >90% cauterized CP. Failure is more likely in those with post-haemorrhagic hydrocephalus of prematurity (PHHP), particularly those <1 month of corrected age and those with prepontine scarring. High-quality evidence comparing the efficacy of ETV/CPC with shunting is emerging, with data from ongoing and future trials offering additional promise to enhance our understanding of the true utility of ETV/CPC.

Intracranial Hemorrhage

Intracranial Hemorrhage

Peculiar Characteristics of Arteriovenous Malformations Arising in the Galenic Region.

Arteriovenous malformations (AVM) are congenital vascular lesions fed by arterial feeders originating from branches of the internal carotid artery (ICA) or vertebrobasilar artery. We experienced unique AVMs arising in the midline Galenic region, receiving blood supply from the ICA/vertebral artery systems and the external carotid artery system. We retrospectively reviewed data on eight patients who had an AVM arising in the Galenic region and were treated in the University of Tokyo Hospital between 1990 and 2019. The median age at diagnosis was 62 years. Three cases (38%) presented with obstructive hydrocephalus due to aqueduct obstruction caused by an engorged vein of Galen. In all cases, feeders from dural arteries were present and the vein of Galen was the primary drainer. All patients underwent stereotactic radiosurgery. Five patients were followed for > two years; nidus obliteration was confirmed in one, and > 75% shrinkage was confirmed in three, while one patient died due to hemorrhage. Altogether, AVMs arising in the Galenic region are rare and exhibit several peculiar characteristics including the presence of dural feeders, an older age at presentation and presentation with obstructive hydrocephalus.

MRI evaluation of the endolymphatic space in otosclerosis and correlation with clinical findings

PurposeThe purpose of this study was to investigate the clinical features of ears with otosclerosis and their correlation with endolymphatic hydrops and blood-labyrinth barrier (BLB) impairment on 3T magnetic resonance imaging (MRI). Materials and methodsThis was a single-center retrospective imaging study. Thirty-nine ears from 29 patients (17 men, 12 women; mean age 52±12 [SD] years; range 27–74 years) with non-operated otosclerosis were included. All patients underwent three-dimensional fluid attenuated inversion recovery (FLAIR) MRI sequences performed 4hours after the intravenous administration of a single dose of gadolinium-based contrast material. MRI examinations were analyzed by two radiologists for the presence of saccular hydrops (SH) and BLB impairment. Results of MRI examinations were compared with clinical findings, hearing levels and extent of otosclerotic lesions based on high-resolution computed tomography findings. BLB impairment was evaluated using the signal intensity ratio, ratio of intensities between the basal turn of the cochlea and the medulla. ResultsSH was observed in 1/39 (3%) otosclerotic ears and BLB impairment in 8/39 (21%) while 8/29 patients with otosclerosis (28%) had vertigo. No significant associations were found between SH or BLB impairment on MRI, and the presence of vertigo or the degree of sensorineural hearing loss. ConclusionClinical manifestations of otosclerosis (sensorineural hearing loss and rotatory vertigo) were not significantly associated with MRI findings such as BLB impairment and endolymphatic hydrops. SH was only observed in one patient with obstruction of the vestibular aqueduct by an otosclerotic focus.

Acute post-traumatic hydrocephalus in children due to aqueductal obstruction by blood clot: a series of 6 patients.

Post-traumatic hydrocephalus following head injury is a well-known entity. Most cases occur in patients with severe head injuries, often following decompressive craniectomy. On the contrary, acute post-traumatic hydrocephalus, caused by aqueductal obstruction by a blood clot, following mild head injury is uncommon. Six patients aged between 6 and 15months presented hydrocephalus secondary to a blood clot in the aqueduct. Because of intracranial hypertension at presentation, 4 patients were urgently treated with external ventricular drains (EVDs). Post-operative course was uneventful. In 2 cases, EVDs were removed without further treatments. In 2 cases, hydrocephalus recurred. These patients were successfully treated with endoscopic third ventriculostomy. The remaining two patients developed symptoms a few days after the trauma. One, that presented hydrocephalus at imaging, was managed with a ventriculo-peritoneal shunt; the other, that presented subdural hygroma, was managed with subduro-peritoneal shunt that was removed later. All patients had complete recovery. Hydrocephalus secondary to clot in the aqueduct may rarely be the result of mild head injury in young children. Usually, prompt surgical management warrants a very good outcome. Most children may be treated without a permanent shunt, by using external drains and endoscopic third ventriculostomy.

Two cases of delayed obstructive hydrocephalus due to aqueductal obstruction after intraventricular hemorrhage

Two cases of delayed obstructive hydrocephalus due to aqueductal obstruction after intraventricular hemorrhage

Prenatal aqueduct stenosis: Association with rhombencephalosynapsis and neonatal outcome.

To examine prenatal MRI and postnatal imaging in fetuses with congenital aqueductal stenosis (CAS) to determine the frequency of association of rhombencephalosynapsis (RES) and how it may affect neonatal intensive care unit (NICU) course. A single center IRB-approved retrospective study of children with CAS was performed. Prenatal MRI, postnatal images, and clinical data were reviewed. Statistical analysis was performed with SAS statistical software package version 9.3. Aqueduct obstruction was confirmed for all 30 participants. Hydrocephalus required shunting in all but one (97%). Fifteen neonates had CAS with rhomboencephalosynapsis (RES) (50%). Although neonatal course between the two groups was comparable, 53% of CAS with RES neonates required feeding assistance versus 20% in CAS only (P=0.128). Shunting in the CAS with RES group occurred at average of 6days of life versus CAS group at 55days (P=0.196). Biometry measurements showed a statistically significant decrease in pons antero-posterior diameter in both groups (CAS only P=0.0049 and CAS with RES P=0.0003) when compared with norms for gestational age. CAS has a high association with RES. Feeding assistance in the NICU and earlier neurosurgical intervention may be required in patients with CAS who also have RES.

Congenital Toxoplasmosis presenting as multiple ring enhancing lesions in brain on neuroimaging

We report a case of congenital toxoplasmosis in a male child who presented at 1 month 21 days of life. He had a past history of meningitis on third day of life which resolved with intravenous antibiotics. This time, the child presented with progressive enlargement of head and CSF (Cerebrospinal fluid) showed elevated protein levels with cellular reaction and CT scan showed dilated ventricular system with aqueductal obstruction and multiple ring-enhancing lesions in bifrontal and bioccipital regions with a right porencephalic cyst. Repeat CSF after 14 days of intravenous antibiotics showed elevated protein with no cellular reaction. Fundus examination was normal. Toxoplasma blood serology (IgG and IgM) in baby and mother were positive. The child received treatment with Pyrimethamine, Clindamycin, Folinic acid and Prednisolone. CSF parameters got normalized and multiple ring-enhancing lesions disappeared on repeat CT scan. He underwent a Ventriculo-Peritoneal shunt surgery for the hydrocephalus and was discharged in a stable condition.

The many faces of prenatal imaging diagnosis of primitive aqueduct obstruction.

To describe the different prenatal imaging patterns related to primary aqueduct obstruction throughout pregnancy and their impact on prenatal counseling. Retrospective review of consecutive prenatal cases of isolated aqueduct obstruction diagnosed over a seven-year period (2010-2016). Prenatal imaging findings, postnatal imaging, pathological data and postnatal outcome, were analyzed. Twelve cases were included. In four cases, termination of pregnancy was performed, due to early severe ventriculomegaly in three cases suggestive of complete aqueduct obstruction. In eight cases in which pregnancy was continued, three different evolving imaging patterns were demonstrated. In three cases the ventriculomegaly evolved rapidly during third trimester and were subsequently associated with abnormal white matter changes on fetal MRI. Theses cases led to premature delivery in two cases and early surgical care in all, with focal cystic parenchymal damage shown on follow-up MRI in two cases. Slowly evolving ventriculomegaly in three cases diagnosed in the second and the third trimester which required delayed surgery during the first year of life. Stable ventriculomegaly in two cases which did not require any surgical procedure. The diagnosis of primary aqueduct obstruction may be based on different prenatal imaging patterns that include either severe early ventriculomegaly, stable, slowly or rapidly evolving ventriculomegaly.