Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Associated with Primary Hypertensive Hemorrhages Using IRRAflow Self-Irrigating Catheter: A Report of Three Cases and Prior Historical Controls.

BACKGROUND: Spontaneous primary intracerebral hemorrhage (ICH) accounts for 10%-15% of strokes and is accompanied by ventricular involvement in 10%-30% of cases. Intraventricular hemorrhage (IVH) is a poor prognostic factor and the current treatment paradigm of external ventricular drainage requires frequent flushing and replacement. Given the documented high rate of failure standard EVD catheters, we sought to determine if the use of the IRRAflow system with the addition of alteplase would be beneficial in this patient population for the treatment of IVH associated with primary hypertensive ganglionic hemorrhages. METHODS: Three patients with ganglionic hemorrhages and IVH underwent treatment with the IRRAflow system at our institution from December 2022 to January 2023. A retrospective review was then performed of patients with primary hypertensive ganglionic hemorrhages and EVD placement at our institution from January 2021 to present day. RESULTS: Three patients underwent treatment with the IRRAflow system and continuous lavage of Tissue Plasminogen Activator (tPA). The IVH was efficiently cleared in all cases and the drains were removed within 8 days in all cases. No patients required replacement of the drain and there were no hemorrhagic complications noted. In our retrospective review, 28 patients were identified who underwent placement of a standard EVD for the treatment of primary hypertensive ganglionic hemorrhages. When patients who had early withdrawal of care were excluded, the average length of EVD treatment was 11.3 days and the EVD replacement rate was 24%. CONCLUSIONS: We demonstrate here that the use of the IRRAflow system for the treatment of primary hypertensive hemorrhages with IVH results in rapid clearance of the IVH without safety concerns. Compared to historical controls there was a decrease in EVD duration, EVD replacement and, ICU LOS.

Rapidly progressive diffuse leptomeningeal glioneuronal tumor in an adult female: illustrative case.

BACKGROUND: Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare brain tumor only recently classified by the World Health Organization in 2016 and has few reports on its incidence in adults. OBSERVATIONS: The authors describe a case of DLGNT presenting in a 47-year-old female with seizures, cranial neuropathies, and communicating hydrocephalus with rapid clinical progression. Workup demonstrated progressive leptomeningeal enhancement of the skull base, cranial nerves, and spine, and communicating hydrocephalus. Elevated serum rheumatological markers and early response to systemic corticosteroids and immunosuppressant therapy complicated the diagnosis. Multiple biopsy attempts were required to obtain diagnostic tissue. Pathology demonstrated hypercellularity surrounding leptomeningeal vessels with nuclear atypia, staining positive for GFAP, Olig2, S100, and synaptophysin. Molecular pathology demonstrated loss of chromosome 1p, BRAF overexpression but no rearrangement, and H3K27 mutation. Repeat cerebrospinal fluid (CSF) diversion procedures were required for hydrocephalus management due to high CSF protein content. LESSONS: This report describes a rare, aggressive, adult presentation of DLGNT. Leptomeningeal enhancement and communicating hydrocephalus should raise suspicion for this disease process. Biopsy at early stages of disease progression is essential for early diagnosis and prompt treatment. Further study into the variable clinical presentation, histological and molecular pathology, and optimal means of diagnosis and management is needed.

Comparison of sodium fluorescein and intraoperative ultrasonography in brain tumor resection.

Various intraoperative neuroimaging modalities are available to the neurosurgeon during brain tumor surgery. There remains no consensus on which modalities are superior. This retrospective, single-center cohort study directly compares sodium fluorescein (SF) and intraoperative ultrasonography (IOUS) as intraoperative imaging modalities in a sample of patients with glioblastoma isocitrate dehydrogenase 1 wildtype (GBM). Adult patients with GBM who underwent surgical resection using SF or IOUS guidance between 2010 and 2020 were included. Primary outcomes included extent of resection (EOR), post-operative residual tumor volume, gross total resection (GTR) rate, false negative assessments, and the incidence of new post-operative neurologic deficits. Additionally, pre-and post-test probabilities were calculated to assess each modality's ability to identify residual tumor. 98 patients met inclusion criteria (34 SF and 64 IOUS). Mean EOR was significantly higher for SF (94 ± 11 %) when compared to IOUS (87 ± 20 %; p = 0.032). Mean post-operative residual tumor was significantly higher for IOUS (197 ± 358 mm2) when compared to SF (81 ± 161mm2; p = 0.038). GTR was more frequent with SF (62 % vs 46 %, p = 0.12). False negative assessments for residual tumor were more common with IOUS (22 % vs 15 %, p = 0.53). One patient in each group suffered a new neurologic deficit post-operatively (p = 0.58). Sensitivity, specificity, positive predictive value, and negative predictive value were 62 %, 100 %, 100 %, and 81 % for SF and 59 %, 100 %, 100 %, and 67 % for IOUS, respectively. Taken together, SF may be superior to IOUS in maximizing EOR in patients with GBM, however, both modalities appear to have good efficacy.

Efficacy of intraoperative ultrasonography in neurosurgical tumor resection.

OBJECTIVE Intraoperative ultrasonography (IOUS) is a widely accessible imaging modality that provides real-time surgical guidance with minimal identified risk or additional operative time. A recent study by the authors found a strong correlation between IOUS and postoperative MRI findings when evaluating the extent of tumor resection, suggesting that IOUS might have significant clinical implications. The objective of this study was to expand on results from the previous study in order to provide more evidence on the usage of IOUS in the determination of gross-total resection (GTR) in both adult and pediatric patients with brain tumors. METHODS This study consisted of a retrospective review of adult and pediatric neurosurgical patients who were treated at Albany Medical Center between August 2009 and March 2016 for a tumor of the brain. All patients were treated with IOUS and then underwent postoperative MRI (with and without contrast) within 1 week of surgery. RESULTS A total of 260 patients (55% of whom were males) met inclusion criteria for the study (age range 3 months to 84 years). IOUS results showed a strong association with postoperative MRI results (φ = 0.693, p < 0.001) and an 81% intended GTR rate. In cases in which GTR was pursued, 19% had false-negative results. IOUS was able to accurately identify residual tumor in 100% of subtotal resection cases where resection was stopped due to invasion of tumor into eloquent locations. Cases involving gliomas had a 75% intended GTR rate and a 25% false-negative rate. Cases involving metastatic tumors had an 87% intended GTR rate and a 13% false-negative rate. The sensitivity, specificity, negative predictive value, and positive predictive value are reported for IOUS in all included tumor pathologies, glioma cases, and metastatic tumor cases, respectively. CONCLUSIONS The use of IOUS may allow for a reliable imaging modality to achieve a more successful GTR of brain tumors in both adult and pediatric neurosurgical patients. When attempting GTR, the authors demonstrated an 81% GTR rate. The authors also report false-negative IOUS results in 19% of attempted GTR cases. The authors support the use of IOUS in both adult and pediatric CNS tumor surgery to improve surgical outcomes. However, further studies are warranted to address existing limitations with its use to further improve its efficacy and better define its role as an intraoperative imaging tool.