Comparing the Long-Term Cardiovascular Outcomes of Lumbo-Peritoneal, Ventriculo-Peritoneal, or Non-Shunting Treatment after Idiopathic Normal Pressure Hydrocephalus: A Nationwide Retrospective Cohort Study.

Purpose: With advances in medical technology, the average lifespan has increased, leading to a growing significance of idiopathic normal pressure hydrocephalus (iNPH), particularly in the elderly population. Most patients with iNPH have been treated either with ventriculo-peritoneal shunts (VPS) or conservative measures. However, lumbo-peritoneal shunts (LPS) have emerged as an alternative treatment option for iNPH in recent decades, extensive research still lacks comparing outcomes with LPS to those with VPS or non-surgical treatment. The aim of the resent study is to disclose the long-term therapeutic outcomes of LPS, VPS, and non-shunting in patients with iNPH. Methods: We used the National Health Insurance Research Database in Taiwan to assess the long-term outcomes of these treatment options. We enrolled 5,537 iNPH patients who received shunting surgery, of which 5,254 were VPS and 283 were LPS. To compare the difference between each group, matching was conducted by propensity score matching using a 1:1 ratio based on LPS patients. Primary outcomes included death and major adverse cardiovascular events (MACEs) Results: Our findings show that VPS resulted in significantly more MACEs than non-surgical treatment (Odds ratio: 1.83, 95% confidence interval: 1.16-2.90). In addition, both VPS and LPS groups had significantly lower overall mortality rates than non-shunting group. Moreover, LPS had lower overall mortality but similar MACEs rates to VPS. Conclusions: Based on these findings, we propose that the LPS is preferable to the VPS, and surgical treatment should be considered the primary choice over conservative treatment unless contraindications are present.

Machine Learning Assisting the Prediction of Clinical Outcomes following Nucleoplasty for Lumbar Degenerative Disc Disease.

BACKGROUND: Lumbar degenerative disc disease (LDDD) is a leading cause of chronic lower back pain; however, a lack of clear diagnostic criteria and solid LDDD interventional therapies have made predicting the benefits of therapeutic strategies challenging. Our goal is to develop machine learning (ML)-based radiomic models based on pre-treatment imaging for predicting the outcomes of lumbar nucleoplasty (LNP), which is one of the interventional therapies for LDDD. METHODS: The input data included general patient characteristics, perioperative medical and surgical details, and pre-operative magnetic resonance imaging (MRI) results from 181 LDDD patients receiving lumbar nucleoplasty. Post-treatment pain improvements were categorized as clinically significant (defined as a ≥80% decrease in the visual analog scale) or non-significant. To develop the ML models, T2-weighted MRI images were subjected to radiomic feature extraction, which was combined with physiological clinical parameters. After data processing, we developed five ML models: support vector machine, light gradient boosting machine, extreme gradient boosting, extreme gradient boosting random forest, and improved random forest. Model performance was measured by evaluating indicators, such as the confusion matrix, accuracy, sensitivity, specificity, F1 score, and area under the receiver operating characteristic curve (AUC), which were acquired using an 8:2 allocation of training to testing sequences. RESULTS: Among the five ML models, the improved random forest algorithm had the best performance, with an accuracy of 0.76, a sensitivity of 0.69, a specificity of 0.83, an F1 score of 0.73, and an AUC of 0.77. The most influential clinical features included in the ML models were pre-operative VAS and age. In contrast, the most influential radiomic features had the correlation coefficient and gray-scale co-occurrence matrix. CONCLUSIONS: We developed an ML-based model for predicting pain improvement after LNP for patients with LDDD. We hope this tool will provide both doctors and patients with better information for therapeutic planning and decision-making.

Continuous intrathecal saline infusion for treating refractory spontaneous intracranial hypotension: A case report.

Spontaneous intracranial hypotension (SIH) is a poorly understood condition that presents with a wide variety of symptoms, ranging from mild headaches to coma. It is typically caused by continuous spontaneous leakage of spinal cerebrospinal fluid (CSF), resulting in orthostatic headaches. However, the appropriate management of refractory SIH remains unclear. A 50-year-old man presented with orthostatic headache followed by a rapid decline in mental status. The imaging findings were consistent with the diagnosis of SIH, with bilateral cerebral subdural hematomas and abnormal fluid collection in the posterior epidural space from the T2 to T12 levels. Computed tomography myelography of the whole spine revealed multiple high-flow CSF leakages at the T6 to T8 levels. Despite treatment with bilateral burr hole drainage for subdural hematomas and repeated lumbar epidural blood patch (EBP) three times, the patient's condition worsened and he developed stupor. A lumbar intrathecal saline bolus (90 ml) was administered to restore CSF depletion. The patient's verbal function improved immediately, and continuous intrathecal saline infusion was administered at a rate of 10 ml/h for two days. The patient's stupor gradually resolved, and after his symptoms improved, the EBP injection was repeated at the T8 level. The patient recovered completely, and during the six-year follow-up, there were no signs of recurrence. SIH may cause a refractory decline in mental status, and lumbar intrathecal saline infusion may help arrest or reverse an impending central (transtentorial) herniation. This case demonstrates an appropriate bolus and continuous infusion of normal saline, and documents the resolution of SIH. This maneuver may change the CSF flow pattern and aims to seal the CSF fistula. Further studies are needed to better understand the mechanism of intrathecal saline infusion and establish effective treatment strategies for refractory cases of SIH.