A case report of hydrocephalus due to diffuse villous hyperplasia of the choroid plexus: surgical treatment by combination a flexible videoscope with a rigid endoscope.

PURPOSE: Diffuse villous hyperplasia of the choroid plexus (DVHCP) and choroid plexus papilloma (CPP) are rare benign tumors usually diagnosed as a result of progressive hydrocephalus, especially in childhood. We present the case of a Japanese boy diagnosed with progressive hydrocephalus due to DVHCP. METHODS: Case: A 2-year and 3-month-old Japanese boy was found to have delayed motor development (equivalent to 1 year and 2 months old), an enlarged head circumference of 51 cm within + 1.5 standard deviation (S.D.), and incomplete closure of the anterior fontanel. The magnetic resonance imaging (MRI) showed lobular enlargement of the bilateral choroid plexuses extending from the trigone to the body and inferior horn of the lateral ventricle. The endoscopic choroid plexus coagulation surgery was performed to reduce the CSF formation rate. RESULTS: DVHCP was diagnosed both pathologically and clinically. Postoperatively, the patient progressed without complications, such as cerebrospinal fluid leakage. Although ventricular enlargement persisted, the anterior fontanel recessed, and the expansion of the head circumference stopped. CONCLUSION: Few cases of bilateral DVHCP and CPP have been reported in the literature. We encountered a case in which effective choroid plexus coagulation was performed for hydrocephalus due to DVHCP using less invasive endoscopic technique. It also represented an association between DVHCP and the gain of chromosome 9p.

A Case of Neonate with Split Cord Malformation Presenting with Hypoplasia of the Left Lower Extremity.

The frequency of split cord malformation (SCM) is approximately 1 in 5000 births; however, patients are rarely diagnosed with SCM in the neonatal period. Moreover, there have been no reports of SCM with hypoplasia of the lower extremities at birth. A 3-day-old girl was transferred to our hospital for a thorough examination of hypoplasia of the left lower extremity and lumbosacral abnormalities detected after birth. The spinal magnetic resonance imaging (MRI) revealed a split spinal cord in a single dural tube. Based on the MRI findings, the patient was diagnosed with SCM type II. Following discussions with the parents, pediatricians, neurosurgeons, psychologists, and social workers, we decided to perform untethering to prevent further neurological impairment after achieving a sufficient body weight. The patient was discharged on day 25 of life. Early diagnosis and intervention may improve the neurological prognosis in terms of motor function, bladder and bowel function, and superficial sensation; thus, clinicians should report infrequent findings that may lead to SCM diagnosis. SCM should be differentiated in patients with left-right differences in the appearance of the lower extremity, particularly in those with lumbosacral abnormalities.

Abusive head trauma in Japan.

PURPOSE: Abusive head trauma (AHT) is a serious cause of morbidity and mortality in the pediatric population, especially in young infants. This review of the literature aimed to understand the characteristics of AHT in Japan. METHODS: PubMed and the Japanese database Ichuushi were searched to understand the differences in AHT between Japan and other countries. RESULTS: Shaking was identified as an uncommon cause of injury, while mothers were the most common perpetrator of pediatric AHT in Japan. Although uncommon in other countries, infantile subdural hematoma caused by an accidental slight head injury was reported in Japan. CONCLUSION: As in other countries, AHT is a major condition which pediatric neurosurgeons face in Japan. The mechanisms of injury and perpetrators of AHT seemed to differ slightly between western countries and Japan. Additionally, non-accidental infantile acute subdural hematoma was reported mainly in Japan. Therefore, further care and fair judgment is necessary when investigating child abuse in Japan.

[Neuroendoscopic Third Ventriculostomy].

Endoscopy is essential in less invasive surgery and its use has widely expanded in almost all surgical specialties. This procedure has also been adopted for neurosurgery. It is now introduced in skull base surgery, expanded from endoscopic transsphenoidal surgery, to remove pituitary tumors, assisting tumor removal or removing a tumor only with the endoscope; spine surgery; and endoscopic third ventriculostomy(ETV). ETV is now accepted as a standard technique for treating noncommunicating hydrocephalus. Currently, 1067 neurosurgeons are certified by the Japan Society for Neuroendoscopy, and endoscopic surgery is recognized as a typical treatment option. This article describes the surgical procedure for ETV, a basic procedure for pediatric hydrocephalus. It is important to master intraventricular manipulation using the endoscope. Also, certain tips must be implemented before and after the endoscopic procedure to avoid complications. It is also necessary to emphasize the difference between adult cases, such as high risk of cerebrospinal fluid leakage in child cases. So that every single effort must be done to avoid this leak.

Robinow syndrome in a newborn presenting with hydrocephalus and craniosynostosis.

INTRODUCTION: Robinow syndrome is a rare entity with a characteristic appearance, such as hypertelorism, short stature, mesomelic shortening of the limbs, hypoplastic genitalia, and rib as well as vertebral anomalies. We had treated a patient with Robinow syndrome who developed hydrocephalus and craniosynostosis which is not usually associated. CASE PRESENTATION: The ventricle enlargement was detected during pregnancy in a female infant. She did not develop hydrocephalus just after birth. Her facial appearance was fetus-like, so the pediatricians had suspected Robinow syndrome. During follow-up examinations, a rapidly enlarging head circumference was detected when she was 3 months old. Her conscious level was not disturbed, but she had a tight fontanel and sunset phenomenon was recognized. Hydrocephalus was diagnosed by radiographic imaging so that she underwent ventriculo-peritoneal shunting (VPS). Her irregular head enlargement seized. Six months after surgery, her parents noticed the brachycephalic shape of her head. A computed tomography (CT) and magnetic resonance (MR) scan were conducted and showed that her bilateral coronal, bilateral lambdoid, and the sagittal suture were fused in addition with a tonsillar herniation. Since the sutures were not remaining, we diagnosed that this was a primary pan synostosis rather than secondary craniosynostosis due to VPS. Posterior cranial vault distraction with foramen magnum decompression (FMD) was conducted. The distractor was extended by 1 mm per day up to 30 mm. After a consolidation period of 2 months, the distractors were removed. Through this intervention, a 15.4% increase (+196cc) of the intracranial space with an improvement of the chronic tonsillar herniation was achieved. CONCLUSION: To confirm the diagnosis of Robinow syndrome, a genetic test was conducted. The analysis showed ROR2 Exon3 (c233 c>t p. Thr 78 Met), which is found in the recessive type of Robinow syndrome. We report this patient as, to our best knowledge, the first case documented case of Robinow disease presenting with hydrocephalus and craniosynostosis. Posterior cranial vault distraction with FMD is a useful way to treat this condition.

Differentiating comorbidities and predicting prognosis in idiopathic normal pressure hydrocephalus using cerebrospinal fluid biomarkers: a review.

Idiopathic normal pressure hydrocephalus (iNPH) is a condition resulting from impaired cerebrospinal fluid (CSF) absorption and excretion characterized by a triad of symptoms comprising dementia, gait disturbance (impaired trunk balance), and urinary incontinence. CSF biomarkers not only assist in diagnosis but are also important for analyzing the pathology and understanding appropriate treatment indications. As the neuropathological findings characteristic of iNPH have yet to be defined, there remains no method to diagnose iNPH with 100% sensitivity and specificity. Neurotoxic proteins are assumed to be involved in the neurological symptoms of iNPH, particularly the appearance of cognitive impairment. The symptoms of iNPH can be reversed by improving CSF turnover through shunting. However, early diagnosis is essential as once neurodegeneration has progressed, pathological changes become irreversible and symptom improvement is minimal, even after shunting. Combining a variety of diagnostic methods may lead to a more definitive diagnosis and accurate prediction of the prognosis following shunt treatment. Identifying comorbidities in iNPH using CSF biomarkers does not contraindicate shunting-based intervention, but does limit the improvement in symptoms it yields, and provides vital information for predicting post-treatment prognosis.

Controversies related to pediatric Chiari I malformation.

PURPOSE: Foramen magnum decompression is a common surgical treatment for Chiari type 1 malformation (CM-1). There are several methods for the intervention to the dura matter such as dural plasty sectioning the dura, also removing the outer membrane of the dura without intradural manipulation. We compared retrospectively our cases with a presentation of illustrative cases. Finally, we add our comments to the worldwide questionnaire which was offered. METHODS: Twenty-six patients (9 males and 17 females) who underwent surgery from 2010 to 2019 were included. The age distribution was 1 to 55 years old (mean: 16.4 ± 11.3).They were divided into two groups, group A which underwent outer membranectomy and group B which underwent dural plasty. RESULTS: There were 15 cases in group A and 11 cases in group B, and tonsillectomy was performed in 5 cases out of the 11. Symptoms improved in 7 cases (47%) and 5 cases (45%), respectively. Improvement of the syrinx was seen in 14 cases (93%) and 10 cases (90.9%), respectively. No complications were seen in group A; however, one CSF leak and 2 pseudomeningoceles were seen in group B. CONCLUSION: The number of our cohort is not large enough to analyze statistics, but it seems that outer membranectomy is similar to dural plasty in terms of the results of surgery with a lower risk of complications for the treatment in non-complicated CM-1.

Quantitative Analysis of Change in Intracranial Volume After Posterior Cranial Vault Distraction and Frontal Orbital Advancement/Remodeling.

INTRODUCTION: Patients with craniosynostosis with shortened occipitofrontal diameter are mainly treated with posterior cranial vault distraction osteogenesis (PVDO) in our institution. If further intracranial volume (ICV) expansion is needed, additional treatment with frontal orbital advancement (FOA) is done. On the contrary, frontal orbital remodeling (FOR) is done for better aesthetic results. In this study, post-treatment ICV changes in patients with craniosynostosis treated with these methods have been investigated. METHODS: Patients who underwent FOA or FOR in addition to PVDO at Juntendo University Hospital between 2011 and 2017 were reviewed for patient characteristics and pre/postoperative ICV measurements using 3-dimensional computed tomography scans. RESULTS: Nine patients aged from 5 months to 6 years 8 months at the time of PVDO were included. For PVDO, the ICV change was 113 to 328 mL, and the enlargement ratio of ICV was 109% to 152%. Two patients were further operated with FOA while the remaining 7 with FOR. With FOA, ICV change was 73 to 138 mL, while enlargement ratio of ICV was 107% to 114%. With FOR, ICV change was 3 to 45 mL (mean 20 mL), while enlargement ratio of ICV was 100% to 103%. CONCLUSION: The PVDO is our first line of treatment for ICV expansion and posterior cranial fossa decompression in patients with severe craniosynostosis. The FOA is performed if extra ICV increase is necessary. This approach seems to enable larger ICV expansions compared with other conventional methods. The FOR should be reserved for patients in whom adequate ICV levels are achieved with PVDO yet additional frontal reshaping is necessary.

The metopic-sagittal craniosynostosis-report of 35 operative cases.

PURPOSE: We have diagnosed 35 cases of the supposedly rare condition metopic-sagittal synostosis in the past 20 years. Here, we introduce their clinical symptoms, neuroradiological findings, and surgical treatment methods, as well as discuss the relevant literature. METHODS: Subjects included 35 patients (33 boys and 2 girls; mean age 4.2 years; range 1-8 years). Magnetic resonance imaging (MRI) confirmed that there were no abnormal findings in the brain. Thirty patients presented with symptoms including speech delay, hyperactivity, autistic tendency, motor impairment, self-mutilation, and panic/temper tantrum behaviors. No other congenital malformation was observed, and all cases were considered to be the non-syndromic type. The final diagnosis was made using three-dimensional computed tomography (3D-CT) scans. The surgery was done the fronto-orbital advancement in addition to remove the large parts of sphenoid bones including sphenoid ridges at the skull base and trimmed the calvarium as necessary to reduce pressure. RESULTS: Surgical intervention improved clinical symptoms in nearly all 35 patients; cosmetic problems in patients with scaphocephaly were also corrected. CONCLUSIONS: In the cases of child patients with metopic-sagittal synostosis who had clinical symptoms, surgical intervention improved such symptoms, suggesting its potential utility for metopic-sagittal synostosis with clinical symptoms. A surgical procedure focusing on the skull base was important for our successes. Based on the fact that metopic-sagittal synostosis was diagnosed in 35 patients at one institution over a relatively short period of time, this pathological condition may not be as rare as is currently believed.

Conservative Treatment of Large Aplasia Cutis Congenita of the Scalp With Bone Defect With Basic Fibroblast Growth Factor Application.

The object of this report is to share our experience of conservative management of giant aplasia cutis congenita (ACC) of the scalp with the topical application of basic fibroblast growth factor (bFGF). Complete epithelialization of the 9 × 8 cm sized defect was achieved in 33 weeks. Careful conservative management could eliminate the requirement of surgery for giant ACC defects of the scalp with bone defects and should be tried if surgery is thought to be risky or has consecutive morbidity. Topical bFGF application seems to accelerate healing, also providing a better epithelium for later reconstructive treatments and its usage could be standardized in the future.

In vitro performance of the fixed and adjustable gravity-assisted unit with and without motion-evidence of motion-induced flow.

BACKGROUND: Anti-siphon devices and gravitational-assisted valves have been introduced to counteract the effects of overdrainage after implantation of a shunt system. The study examined the flow performance of two gravitational-assisted valves (shunt assistant - SA and programmable shunt assistant - proSA, Miethke & Co. KG, Potsdam, Germany) in an in vitro shunt laboratory with and without motion. METHODS: An in vitro laboratory setup was used to model the cerebrospinal fluid (CSF) drainage conditions similar to a ventriculo-peritoneal shunt and to test the SA (resistance of +20 cmH2O in 90°) and proSA (adjustable resistance of 0 to +40 cmH2O in 90°). The differential pressure (DP) through the simulated shunt and tested valve was adjusted between 0 and 60 cmH2O by combinations of different inflow pressures (40, 30, 20, 10, and 0 cmH2O) and the hydrostatic negative outflow pressure (0, -20, and -40 cmH2O) in several differing device positions (0°, 30°, 60°, and 90°). In addition, the two devices were tested under vertical motion with movement frequencies of 2, 3, and 4 Hz. RESULTS: Both gravity-assisted units effectively counteract the hydrostatic effect in relation to the chosen differential pressure. The setting the proSA resulted in flow reductions in the 90° position according to the chosen resistance of the device. Angulation-related flow changes were similar in the two devices in 30-90° position, however, in the 0-30° position, a higher flow is seen in the proSA. Repeated vertical movement significantly increased flow through both devices. While with the proSA a 2-Hz motion was not able to induce additional flow (0.006 ± 0.05 ml/min), 3- and 4-Hz motion significantly induced higher flow values (3 Hz: +0.56 ± 0.12 ml/min, 4 Hz: +0.54 ± 0.04 ml/min). The flow through the SA was not induced by vertical movements at a low DP of 10 cmH2O at all frequencies, but at DPs of 30 cmH2O and higher, all frequencies significantly induced higher flow values (2 Hz: +0.36 ± 0.14 ml/min, 3 Hz: +0.32 ± 0.08 ml/min, 4 Hz: +0.28 ± 0.09 ml/min). CONCLUSIONS: In a static setup, both tested valves effectively counteracted the hydrostatic effect according to their adjusted or predefined resistance in vertical position. Motion-induced increased flow was demonstrated for both devices with different patterns of flow depending on applied DP and setting of the respective valve. The documented increased drainage should be considered when selecting appropriate valves and settings in very active patients.

Quantitative Analysis of Change in Intracranial Volume After Posterior Cranial Vault Distraction.

Posterior cranial vault distraction is considered to be more effective for increasing intracranial volume than fronto-orbital advancement or anterior cranial vault expansion, but the changes in intracranial volumes after posterior cranial vault distraction remain unclear. The changes in intracranial volume were investigated in patients of premature craniosynostosis treated by this technique. Seven patients, 3 boys and 4 girls aged from 5 months to 3 years 3 months (mean 23 months) at operation, with craniosynostosis underwent posterior cranial vault distraction at Juntendo University Hospital from 2011 to 2014. Patient characteristics, length of distraction, and pre- and postoperative computed tomography findings were reviewed. Total intracranial volume, including the supratentorial space and posterior cranial fossa, was measured using the workstation functions on three-dimensional computed tomography scans. Posterior distraction was performed without severe complications except in 2 patients requiring additional surgeries. The distraction length was 22.3 to 39 mm (mean 31 mm), the intracranial volume change was 144 to 281 mL (mean 192 mL), and the enlargement ratio of intracranial volume was 113% to 134% (mean 121%). The present quantitative analysis of intracranial volume change after posterior distraction showed greater increases in intracranial volume compared with previous reports. Furthermore, intracranial volumes in our patients became nearly normal and were maintained for the follow-up period (maximum 13 months). Posterior cranial vault distraction is very effective to increase cranial volume, so may be the first choice of treatment in patients of craniosynostosis.

Analysis of pre- and post-operative symptoms of patients with mild trigonocephaly using several developmental and psychological tests.

PURPOSE: Over the past decade, we collected the cases where patients underwent decompressive cranioplasty for the treatment of mild metopic suture synostosis (mild trigonocephaly) with developmental delays. To evaluate the effectiveness of this surgery, we administered several developmental and psychological examinations to children with this condition who underwent decompressive cranioplasty. METHODS: Thirty-four children (32 boys and 2 girls) who had developmental disorders with mild trigonocephaly underwent four different tests at three different time points (pre-operation, 3 and 6 months after surgery) including the: (a) Kyoto form developmental test (2001) to calculate the developmental quotient (DQ), (b) National Rehabilitation Center Sign-Significance Test (NRC S-S test) to evaluate the patients' language use and acquisition, (c) Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS) to identify autistic tendencies, and (d) Japanese Child Behavior Checklist (J-CBCL) to evaluate behavioral problems. The scores were initially analyzed using analyses of variance. When significant results were observed, Tukey-Kramer multiple comparison tests were applied for further statistical evaluation. RESULTS: Significant DQ improvements were observed, as assessed by the Kyoto form developmental test. Additionally, significant improvement in the expression of words (measured with the NRC S-S test), the scores on PARS, and some behavioral factors (measured with the J-CBCL) were observed. CONCLUSIONS: The results in this cohort suggest that decompressive cranioplasty may play an important role in supporting the improvement of developmental delays in these patients.

Reversible Cerebral Vasoconstriction Syndrome without Headache.

A 49-year-old woman with a family history of Moyamoya disease presented with sudden onset of right hemiparesis without headache. Magnetic resonance imaging (MRI) of the head revealed a cerebral infarct in the left corona radiata, and magnetic resonance angiography (MRA) revealed severe stenosis of the bilateral internal carotid, middle, anterior, and posterior cerebral arteries. Antithrombotic therapy improved her symptoms. After 2 weeks, MRA revealed changes in cerebral arterial vasodilation, indicating reversible cerebral vasoconstriction syndrome (RCVS). Five months later, she presented with transient dysarthria without headache ; MRA revealed multiple cerebral artery stenosis, and 2 days later, it revealed changes in cerebral arterial vasodilation. RCVS presents with reversible multifocal narrowing of the cerebral arteries with thunderclap headache, commonly observed in middle-aged women. RCVS without headache is rare. RCVS should be a differential diagnosis in patients with multiple cerebral artery stenoses without headache, and serial MRI is important for its diagnosis. J. Med. Invest. 71 : 323-326, August, 2024.

Delayed Diagnosis of Spinal Dural Arteriovenous Fistula: A Case Report and Scoping Review.

Spinal dural arteriovenous fistula (SDAVF) is among the most common arterial shunt diseases typically found in middle aged or older men. Herein, we aimed to clarify the reasons for misdiagnoses and delayed diagnoses of SDAVF, determine how these affect prognoses, and establish how they can be prevented. We conducted a PubMed/MEDLINE literature search using "spinal dural arteriovenous fistula", "delayed diagnosis", "late diagnosis", and "misdiagnosis" terms. We identified 18 articles, including 965 SDAVF cases. Patients were predominantly males (71.8-100.0%) (mean age: 53.5-71.0 years). Misdiagnoses rates varied (17.5-100.0%) and encompassed many conditions. The mean time between early manifestations and confirmed diagnosis was approximately 10-15 months and from the first radiologic image revealing dural arteriovenous fistula (DAVF) features to diagnosis was 9.2-20.7 months. Posttreatment outcomes showed a significant improvement in motor functions, gait, and micturition, particularly in patients exhibiting preoperative symptoms over a short period. SDAVF is frequently misdiagnosed or subject to delayed diagnosis, causing poor clinical outcomes. SDAVF symptoms including progressive lower-limb weakness, paresthesia, and vesicorectal dysfunction are indications for spinal magnetic resonance imaging with subsequent spinal angiography, wherein DAVF is evidenced by extensive T2 hyperintensity and flow-void abnormalities. We reported a representative case with delayed diagnosis.

Spinal magnetic resonance imaging artifacts in lumboperitoneal shunt surgery using adjustable valve implantation on the paravertebral spinal muscles.

BACKGROUND: Adjustable shunt valves that have been developed for managing hydrocephalus rely on intrinsically magnetic components ; thus, artifacts with these valves on magnetic resonance imaging (MRI) are inevitable. No studies on valve-induced artifacts in lumboperitoneal shunt (LPS) surgery have been published. Therefore, this study aimed to evaluate valve-induced artifacts in LPS. METHODS: We retrospectively reviewed all MRIs obtained between January 2023 and June 2023 in patients with an implanted Codman CERTAS Plus adjustable shunt valve (Integra Life Sciences, Princeton, New Jersey, USA). The valve was placed <1 cm subcutaneously on the paravertebral spinal muscle of the back, with its long axis perpendicular to the body axis. The scans were performed using a Toshiba Medical Systems 1.5 Tesla scanner. The in-plane artifact sizes were assessed as the maximum distance of the artifact from the expected region of the back. RESULTS: All spinal structures or spinal cords can be recognized, even with valve-induced artifacts. The median maximum valve-induced artifact distance on T1-weighted axial imaging was 25.63 mm (mean, 25.98 mm ; range, 22.24-30.94 mm). The median maximum valve-induced artifact distance on T2-weighted axial imaging was 25.56 mm (mean, 26.27 mm ; range, 21.83-29.53 mm). CONCLUSION: LPS surgery with adjustable valve implantation on paravertebral muscles did not cause valve-induced artifacts in the spine and spinal cord. We considered that LPS could simplify the postoperative care of these patients. J. Med. Invest. 71 : 154-157, February, 2024.

Distinguishing Cerebral Infarction With Neck Pain and Hemiparesis From Cervical Spinal Epidural Hematoma Without MRI: A Case Report.

In patients presenting neck pain and hemiparesis, differentiation between cerebral infarction and cervical spinal epidural hematoma is vital yet challenging, particularly when magnetic resonance imaging (MRI) is not feasible. A 59-year-old woman presented with a sudden onset of left-sided hemiparesis and neck pain. MRI was contraindicated because the patient underwent embolization in childhood. Head computed tomography (CT) revealed no evidence of hemorrhage or early ischemic signs. Cervical CT revealed no evidence of hematoma within the spinal canal. Myelography and CT myelography revealed no significant cervical spine abnormalities. The diagnosis was cerebral infarction. Cervical spine MRI is the gold standard examination for diagnosing cervical spinal epidural hematoma, but cervical spine CT, myelography, and CT myelography may be useful when MRI is contraindicated.

Genetic studies of myelomeningocele.

INTRODUCTION: Myelomeningocele is one of the major congenital malformations involving the central nervous system. It is caused by a disruption of the neural tube closure, which is completed at 3-4 weeks of gestation. DISCUSSION: Multidisciplinary approach is necessary to treat and support this malformation which is a huge burden to the patient, family, and the society. This is a characteristic anomaly that it is known that taking folic acid during the periconceptional period, it is possible to reduce the risk of having a neural tube defect (NTD). Although folate fortification had dramatically reduced the incidence, it was not possible to diminish the risk. To date, many studies have been conducted focusing on candidate genes related to folate and glucose metabolism. We will describe a brief review of genetic etiology of candidate genes of metabolic pathways of folate and glucose, animal models of NTDs, and finally recent studies of microRNA.

Hands-on neuroendovascular practice for nonselective undergraduate medical students increases interest and aspirations in pursuing neurosurgery as a specialization.

Background: The number of medical students aspiring to become neurosurgeons has decreased worldwide, mainly due to poor work-life balance among neurosurgeons; therefore, recruiting students for neurosurgery is essential to ensure the availability and appropriate quality of neurosurgical treatment. This study aimed to evaluate the efficacy of hands-on neuroendovascular practice for nonselective undergraduate medical students to determine whether this increases their interest in neurosurgery and contributes to their aspirations of becoming neurosurgeons. Methods: Hands-on neuroendovascular practice for mechanical thrombectomy was performed by undergraduate 5th-year medical students during their 2-week clinical rotation in the Department of neurosurgery at our university hospital between April 2021 and March 2023. After the neurosurgery practice, a questionnaire about their understanding of neurosurgery and aspirations for this specialization before and after the practice was anonymously completed by all students. Results: Overall, 153 students completed the questionnaire. Of these, 140 (91.5 %) showed increased interest in neurosurgery after participating in the hands-on practice. Through this practice, the number of students who considered neurosurgery as their first choice or one of their specialty choices increased from 8 (5.2%) to 12 (7.8%) (P = 0.3534) and from 19 (12.4%) to 52 (34.0%) (P < 0.0001), respectively. Furthermore, the number of students with no aspiration to become neurosurgeons decreased from 95 (62.1%) to 43 (28.1%) (P < 0.0001). Conclusion: Hands-on neuroendovascular practice for nonselective undergraduate medical students effectively increased their interest in neurosurgery specialization and their desire to become neurosurgeons. Therefore, this practice can help recruit medical students for neurosurgery specialization.

Surgical Treatment of Vertebral Compression Fracture in a Patient with Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) with gait disturbance can be effectively treated with a cerebrospinal fluid shunt. Furthermore, balloon kyphoplasty (BKP) is a successful minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). This case report presents the surgical management of an elderly patient with iNPH who presented after a VCF due to a fall. A 77-year-old woman who had been experiencing progressive gait disturbance for five years reported experiencing back pain one month after a fall. Imaging revealed a recent L1 VCF that did not compromise the spinal canal. Furthermore, the Mini-Mental State Examination results and the timed up-and-go test were 20 points and 17.96 seconds, respectively. Magnetic resonance imaging revealed ventriculomegaly with an Evans' index of 0.35. Her symptoms improved temporarily after a tap test, and she was diagnosed with probable iNPH. BKP was performed for VCFs, followed by the lumboperitoneal (LP) shunt placement for iNPH one month later. Following the operation, her symptoms improved without complications. After one month of performing BKP, an LP shunt would be placed to prevent shunt complications, such as infection and catheter-related neurological symptoms. Screening for iNPH in the elderly who present after VCFs due to a fall may identify iNPH patients who may benefit more from surgical treatments.