Implications of intracochlear decomposition gas formation in non-putrefied cadavers.

Introduction: Postmortem computed tomography (pmCT) prior to forensic autopsy has become increasingly important in recent decades, especially in forensic documentation of single injuries, injury patterns, and causes of death. Postmortem decomposition gas formation can also be detected in pmCT scans, which might affect cochlear implant research in postmortem human temporal bones (TBs). Material and methods: Fifty non-putrefied hanging fatalities within a 2-year period (January 2017 to December 2019) were included with 100 TBs. Each body underwent whole-body pmCT prior to forensic autopsy. PmCT scans were analyzed with respect to the presence of intracochlear gas despite the lack of putrefaction at autopsy by an experienced fellow neurotologist. Results: PmCT revealed gas formation in two individuals despite the lack of head trauma and putrefaction at postmortem examination and autopsy. Both individuals showed enclosed gas in the vestibule and the cochlea on both sides. Discussion: Intracochlear gas formation, most likely related to decomposition, may occur despite the lack of putrefaction at postmortem examination and autopsy and can be detected by pmCT. This finding seems to be rather rare in non-traumatic death cases but might affect cochlear pressure research in postmortem human TB.

The CRECHE study: testing the urban myth that chocolate Santa Clauses are re-wrapped Easter Bunnies.

OBJECTIVE: To test the urban myth that surplus chocolate Easter Bunnies are re-packaged as Santa Clauses for the following Christmas holiday season. DESIGN: Prospective radiographic cohort study of seasonal chocolate figurines, supplemented by anonymous 5-item questionnaire survey of belief in the re-wrapping myth (Generic Risk Items Noted by Chocolate consumers in Health care settings; GRINCH). SETTING: Two tertiary referral trauma centres in Germany (Berlin and Duisburg). PARTICIPANTS: Eighteen chocolate Easter Bunnies and 15 chocolate Santa Clauses from different manufacturers purchased during 2020; 502 randomly selected people passing through the entrance halls of the two hospitals during 16 September - 12 October 2020. MAIN OUTCOME MEASURES: Whole body computed tomography (WBCT) images of chocolate Easter Bunnies and Santa Clauses assessed by four independent, board-certified radiologists using a visual contour resemblance scale (CRS); survey participants' views on statements related to the re-wrapping myth. RESULTS: Expert examiners clearly distinguished the WBCT images of chocolate Easter Bunnies and Santa Clauses; the mean difference in CRS was 84.2 points (95% CI, 78.5-90.0 points), with excellent inter-observer agreement (mean intra-class correlation coefficient, 0.99; 95% CI, 0.99-1.00). A total of 214 survey participants (43%) disagreed and 145 (29%) agreed with the proposition that seasonal chocolate figurines are re-packaged and re-sold the following season. CONCLUSION: Although about one-third of our survey respondents did not rule out the possibility of seasonal sweets being re-used, WBCT imaging found no similarity between chocolate foil-wrapped Easter and Christmas figurines, providing solid evidence against this urban myth. Chocolate Santa Clauses are unlikely to pose a significant threat to hospital food hygiene requirements. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN16847363 (prospective).

Gravitational shunt valves in hydrocephalus to challenge the sequelae of over-drainage.

INTRODUCTION: In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical position, CSF diversion is somehow non-physiological. The integration of gravitational valves in VPS was established to counteract the hydrostatic draining force and to approach a physiological condition of the cerebrospinal diverting system. Numerous clinical studies have shown that gravitational valves are able to reduce secondary complications of VPS treatment. It remains a challenge for the treating neurosurgeon to select the correct valve resistance based on individual anatomies and different etiologies of hydrocephalus as well as varying levels of activity of the patient. AREAS COVERED: This review covers the development of gravitational shunt valves from historical, theoretical and clinical aspects for pediatric and adult etiologies of hydrocephalus. We discuss the role of gravitational shunt valves in preventing over-drainage issues and present the state-of-the-art literature. Furthermore, ongoing prospective trials are presented. EXPERT OPINION: Counteracting the hydrostatic force by selecting the correct valve in a VPS system to achieve physiological balance in CSF diversion during vertical and horizontal body changes has become the current standard for hydrocephalus management. Gravitational shunt valves reliably address this need to minimize over-drainage events in the vertical position without affecting the CSF flow in the horizontal position. The results of ongoing prospective studies on the safety and efficacy of adjustable gravitational valves are still pending. Due to the complexity of the CSF flow, lifelong follow-up care for patients with VPS is critical.

Secondary deterioration in patients with normal pressure hydrocephalus after ventriculoperitoneal shunt placement: a proposed algorithm of treatment.

BACKGROUND: After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management. METHODS: For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient's shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration. RESULTS: Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2-4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels. CONCLUSION: Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.

An interdisciplinary approach to the treatment of a complex infraclinoidal internal carotid artery aneurysm.

We present the case of a 49-year-old woman with sudden onset of severe headaches and a ruptured aneurysm located inside the fenestration of the infraclinoid part of the internal carotid artery in the segments C4 and C5 distal to the origin of the ophthalmic artery. An interdisciplinary approach enabled the successful treatment of the aneurysm by wrapping and stent-assisted coiling. We discuss this rare congenital anomaly of a fenestrated internal carotid artery together with the 12 other cases published worldwide.

GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique.

BACKGROUND: Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position. OBJECTIVE: To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study). METHODS: In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications. RESULTS: The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay. CONCLUSION: The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.

Outcome of modern shunt therapy in patients with idiopathic normal pressure hydrocephalus 6 years postoperatively.

OBJECTIVE: Shunt therapy in idiopathic normal pressure hydrocephalus (iNPH) can improve symptoms in 84% of patients 1 year postoperatively. Therefore, implantation of a ventriculoperitoneal shunt (VPS) prevents or at least prolongs the time during which patients are not dependent on care from others because of gait disorder or dementia. In this study, the medium-term results of modern shunt therapy were evaluated. METHODS: The authors retrospectively studied outcome in iNPH patients in whom VPSs were implanted. At yearly follow-up examinations over at least 6 years, clinical symptoms were recorded according to the NPH recovery rate (NPH-RR): (preoperative Kiefer Scale [KS] score - postoperative KS score)/(preoperative KS score × 10). Time and cause of death over this period were also analyzed. RESULTS: Among the 147 patients treated for iNPH in the period between 1997 and 2006, 69 had died at the time of the authors' survey. Sixty-one patients reached the 6-year examination. The median age was 64 years (range 33-83 years) at the time of VPS implantation and 73 years (range 41-91 years) at the time of this study. Six years after shunt implantation, the median KS score was significantly lower than the preoperative score (4.3 vs 8.1 points). Fifty-nine percent of 61 patients had an excellent outcome, 15% had satisfactory benefit, and 26% had unsatisfactory results 6 years postoperatively. Three of the 147 patients who underwent implantation of a VPS died of cerebral diseases 4-10 years postoperatively. CONCLUSIONS: Implantation of a VPS is a safe procedure and can improve symptoms in 74% of patients with iNPH in the longer term.

Indications for valve-pressure adjustments of gravitational assisted valves in patients with idiopathic normal pressure hydrocephalus.

BACKGROUND: Modern ventriculoperitoneal shunts (VPS) are programmable, which enables clinicians to adjust valve-pressure according to their patients' individual needs. The aim of this retrospective analysis is to evaluate indications for valve-pressure adjustments in idiopathic normal pressure hydrocephalus (iNPH). METHODS: Patients operated between 2004 and 2011 diagnosed with iNPH were included. Kiefer-Scale was used to classify each patient. Follow-up exams were conducted 3, 6, and 12 months after shunt implantation and yearly thereafter. Initial valve-pressure was 100 or 70 mmH2O. Planned reductions of the valve-pressure to 70 and 50 mmH2O, respectively, were carried out and reactive adjustment of the valve-pressure to avoid over- and under-drainage were indicated. RESULTS: A total of 52 patients were provided with a Medos-Hakim valve(Codman®) with a Miethke shunt-assistant(Aesculap®) and 111 patients with a Miethke-proGAV(Aesculap®). 180 reductions of the valve-pressure took place (65% reactive, 35% planned). Most patients (89%) needed one or two adjustments of their valve-pressures for optimal results. In 41%, an improvement of the symptoms was observed. Gait disorder was improved most often after valve-pressure adjustments (32%). 18 times an elevation of valve-pressure was necessary because of headaches, vertigo, or the development of subdural hygroma. Optimal valve-pressure for most patients was around 50 mmH2O (36%). CONCLUSION: The goal of shunt therapy in iNPH should usually be valve-pressure settings between 30 and 70 mmH2O. Reactive adjustments of the valve-pressure are useful for therapy of over- and underdrainage symptoms. Planned reductions of the valve opening pressure are effective even if postoperative results are already satisfactory.