Management of shunt dysfunction using noninvasive intracranial pressure waveform monitoring: illustrative case.

BACKGROUND: Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial. OBSERVATIONS: A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement. LESSONS: In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

The Craniosynostosis Puzzle: New Simulation Model for Neurosurgical Training.

BACKGROUND: Neurosurgical training usually requires long hours for hands-on procedures, making it difficult for inexperienced surgeons to quickly learn in an error-proof environment. The objective of this study was to propose a puzzle-like new model for neurosurgical education that simulates craniosynostosis correction (scaphocephaly type) using Renier's H technique. A model of a 3-dimensional (3D) anatomic simulator for craniosynostosis training is presented and evaluated. METHODS: The cranial model was created using 1-mm computed tomography scan images from patients with scaphocephaly in the Digital Imaging and Communications in Medicine format. This information was processed using an algorithm to generate a 3D biomodel in resin. The puzzle model and its variable training models were assessed qualitatively by a team of expert neurosurgeons. Next, the model was applied in trainees and was evaluated using specific questionnaires. RESULTS: Experts and trainees evaluated the model. The mean number of attempts without errors was 2.3 ± 0.675, for 1 error was 2.2 ± 0.918, and for 2 errors was 1.3 ± 0.707. The mean score of the simulator was 9.2 ± 0.421. Twelve residents (second evaluation) answered the questionnaire with a positive assessment of diagnosis capabilities, appropriateness of the model, time commitment, adequate environment, reliable 3D reconstruction, and teaching method. Three participants had used a 3D simulator previously, and the simulator was evaluated obtaining a 9.9 final average (range, 0-10). CONCLUSIONS: The puzzle may be a complementary tool for surgical training. It allows several degrees of immersion and realism, offering symbolic, geometric, and dynamic information with 3D visualization. It provides additional data to support the practice of complex surgical procedures without exposing real patients to undue risk.

Chronic Meningitis and Hydrocephalus due to Sporothrix brasiliensis in Immunocompetent Adults: A Challenging Entity.

Chronic meningitis caused by Sporothrix sp. is occasionally described in immunosuppressed patients. We report the challenges in diagnosing and managing 2 nonimmunocompromised patients with hydrocephalus and chronic meningitis caused by Sporothrix brasiliensis. This more virulent species appears to contribute more atypical and severe cases than other related species.

Interhemispheric Endoscopic Fenestration of the Lamina Terminalis through a Single Frontal Burr Hole.

Objective We evaluate the feasibility and safety of performing a novel interhemispheric endoscopic fenestration of the lamina terminalis (IEFLT) through a single frontal burr hole immediately lateral to the superior sagittal sinus. Methods Five cadaveric heads underwent IEFLT. Sequential burr holes were made beginning above the glabella and progressed cranially to caudally until the frontal sinus. An endoscope was inserted, and interhemispheric dissection of the arachnoid membranes was completed with endoscopic instruments in a straight direction from the point of entry to the lamina terminalis (LT). Angled optics (0 and 30 degrees) were used to study the neurovascular structures and surgical landmarks. Results The IEFLTs were successfully completed in all specimens and allowed for good visualization of the inferior portion of the LT. The arachnoid dissections were achieved uneventfully. The endoscope provided good surface control of the LT and excellent stereoscopic visualization of the neurovascular complexes. Improved circumferential visualization of the superior part of the anterior portion of the third ventricle was attained. Conclusion IEFLT is a potential alternative to the classic endoscopic third ventriculostomy and a simpler alternative to the subfrontal EFLT, although surgical maneuverability is still limited due to the size of the probe in relation to the narrow surgical corridor.