Risk factors for shunt-dependent hydrocephalus after spontaneous subarachnoid hemorrhage.

INTRODUCTION: Subarachnoid haemorrhage (SAH) is one of the most frequent neurosurgical emergencies, most of them due to intracranial aneurysm rupture. Hydrocephalus is a prevalent complication with a high rate of complications. The aims of this study are to identify predictors of shunt-dependent hydrocephalus following aneurysmal SAH and to quantify the complications arising from ventriculoperitoneal shunts. METHODS: This study is about an observational retrospective analytic study of the patients with spontaneous SAH admitted to Miguel Servet Universitary Hospital between 2017 and 2022. Patients' clinical and radiological characteristics, type of treatment, diagnoses and treatment of hydrocephalus, complications of ventriculoperitoneal shunts and mortality are some of the data achieved in this study. A descriptive study of these variables has been done and, subsequently, the most relevant variables have been statistically analysed to identify patients with increasing risk of shunting for hydrocephalus. This study was authorized by the Ethics Committee prior to its elaboration. RESULTS: A total of 359 patients with spontaneous SAH were admitted to Miguel Servet Universitary Hospital between 2017 and 2022, with an intrahospitalary death rate of 25.3%. 66.3% of the total of patients with SAH were due to intracranial aneurysm rupture (n = 238). 45.3% of the patients with aneurysmal SAH required an external ventricular drain (EVD) to treat acute hydrocephalus. 11.7% (n = 28) developed a shunt-dependent hydrocephalus. Statistical significance was found between shunt-dependent hydrocephalus and the following: high score in modified Fisher scale and placement of EVD. The mean interval from EVD to ventriculoperitoneal shunt placement was 26.1 days. The mean rate of reoperation of patients after shunt was 17.7%, mostly due to infection. CONCLUSIONS: The most significant risk factor for shunt-dependent hydrocephalus after aneurysmal SAH was high Fisher grade and previous need of EVD. Shunt infections is the main cause of shunt reoperation. Early shunt placement in selected patients might reduce the rate of infectious complications.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study.

OBJECTIVES: The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery. DESIGN: This was an observational retrospective study. SETTINGS: A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020. PARTICIPANTS: A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection. RESULTS: More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic. CONCLUSIONS: Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy.

INTRODUCTION: Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option. METHODS: We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified. RESULTS: We identified five patients with diagnosis of acute negative-pressure hydrcephalus. In four of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in two patients (50%); the other two required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome. CONCLUSIONS: The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.

Myelopexy: A novel technique in posttraumatic syringomyelia.

Posttraumatic syringomyelia (PTS) is a well-reported phenomenon that usually takes place in the long-term course of patients following spinal cord injury. Different surgical procedures have been described: spinal cordectomy is usually a last option technique, but might be an excellent choice in patients with severe spinal cord injuries. We present a young patient with complete spinal cord injury after spine trauma, who developed posttraumatic syringomyelia with progressive motor deterioration twelve years after fixation. We performed a novel surgical technique (myelopexy) with excellent resolution of syringomyelia, sparing the negative implications of complete cord transection. Some artistic illustrations made by one of the corresponding authors are included, to better understanding of operative details.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain.

OBJECTIVE: To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. SETTINGS: The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. PARTICIPANTS: This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. INTERVENTIONS: An exploratory factorial analysis was performed to select the most relevant variables of the sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. RESULTS: Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/105 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/105 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. CONCLUSIONS: Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/105 people/week) was a statistically independent predictor of mortality. TRIAL REGISTRATION NUMBER: CEIM 20/217.

Supracerebellar transtentorial approach for left parahippocampal cavernous malformation.

BACKGROUND: Lesions in the temporomesial region can be reached by various approaches: subtemporal, transsylvian, transcortical, interhemispheric parieto-occipital, or supracerebellar transtentorial (SCTT). The choice varies according to the characteristics of the lesion and neighboring structures. CASE DESCRIPTION: In this clinical case, it is presented a 56-year-old man with long-term evolution of drug-resistant epilepsy secondary to a cavernoma in the left parahippocampal gyrus. After assessing the lesion, it was decided a SCTT approach for its resection in a semi-sitting position, to avoid language disorders or visual damage. The surgery was uneventful and the patient did not present epileptic seizures during 6-month follow-up. CONCLUSION: Performing a SCTT is safe and feasible option for resection of lesions located in the basal temporomesial region without causing damage to neighboring structures, especially those located in the middle and posterior two-thirds of temporal region.

Quadrigeminal Cistern Epidermoid Cyst: Neuroendoscopy and Endoscope-Assisted Supracerebellar Infratentorial Approach.

The pineal region is a complex anatomical location with multiple surrounding important neurovascular structures.1,2 Several approaches to this region have been described, including posterior interhemispheric, transchoroidal, infratentorial supracerebellar, supracerebellar and infracerebellar trans-sinus, and their modifications. Neuroendoscopy and endoscope-assisted surgery have been widely applied to aid resection of pineal region lesions.3-5 A 40-year-old man presented with tonic-clonic seizures and bilateral papillary edema on fundus examination. Computed tomography showed a midline lesion at the level of the quadrigeminal cistern with mass effect on the aqueduct of Sylvius and posterior wall of the third ventricle, triggering obstructive triventricular hydrocephalus. As a first intervention, a third ventriculostomy was attempted unsuccessfully owing to unfavorable third ventricle floor anatomy. This approach was used to obtain a biopsy specimen, which showed an epidermoid cyst. Ventriculoscopy showed a communication of the pineal recess and quadrigeminal cistern owing to tumor invasion. An external ventricular drain was placed to control the hydrocephalus until complete resection was performed (Video 1). Several days later, tumor resection was carried out via the median supracerebellar infratentorial approach with the patient in semisitting position. After near-total resection under microscope, the third ventricle and both lateral recesses were explored with the endoscope. A small tumor remnant (visible only with endoscope) was identified and removed. This step was essential to achieve complete resection, confirmed by magnetic resonance imaging. The patient was discharged 6 days later without complications. During follow-up, the patient remains asymptomatic. The combination of microneurosurgery, neuroendoscopy, and endoscope-assisted surgery improves management of pineal region lesions and facilitates complete resection.

Repair of internal carotid artery injury with aneurysm clip during endoscopic endonasal surgery: illustrative case.

BACKGROUND: One of the most feared and dangerous scenarios that can appear during an endoscopic endonasal surgery (EES) is the iatrogenic injury of the internal carotid artery (ICA). Several methods, along with a variety of outcomes, have been described to deal with this complication. To the authors' knowledge, this is the first report on the use of a Yasargil-type aneurysm clip to solve an ICA injury, preserving the artery's patency and having a long-term follow-up. The authors discuss the advantages and disadvantages of other vessel preservation techniques compared with clipping. OBSERVATIONS: A visually impaired 56-year-old woman was diagnosed with a giant nonfunctional pituitary tumor that invaded the sphenoidal sinus, anterior and posterior ethmoidal cells, and both cavernous sinuses, with suprasellar extension and optochiasmatic compression. The patient underwent EES, and during the final resection phase her left ICA was injured, with massive hemorrhage. LESSONS: ICA injury during endoscopic skull base surgery carries high mortality and morbidity; it is essential to maintain carotid flow when possible to avoid short-term and long-term consequences. There are several techniques depicted in the literature to deal with this situation. The authors report the use of a Yasargil mini-clip to deal with the injury for a positive outcome: primary hemostasis, vessel preservation, and no postoperative complications.

Usefulness of ipsilateral translaminar C2 screws insertion for cervical fixation in children with a low laminar profile: a technical note.

PURPOSE: The fusion of the upper cervical spine in children is demanding due to its reduced size, its anatomical complexity, or a severe pathology of the cranio-cervical junction. In some pediatric patients with today's more popular C1-C2 or, occipito-C2 techniques, it is impossible, or very risky to perform a short upper cervical fixation. METHODS: We present the utility and good results of ipsilateral laminar C2 screws insertion technique in two pediatric cases with low C2 laminar profile. Case 1: a 5-year-old child with a C1-C2 unstable subluxation, and a condylar assimilation of C1, where we performed an occipito-C2 fixation using an occipital plate and this modified translaminar C2 screw technique. Case 2: a 8-year-old Down syndrome boy who suffered an unstable subluxation of C1-C2 upon whom we performed a C1-C2 screw fixation using the same technique. RESULTS: Both cases have been followed up over a period of 7 and 2 years respectively, with good clinical results. CONCLUSIONS: We describe the technique and the feasibility of the ipsilateral insertion of translaminar C2 screws in children with low laminar profiles, as a good alternative to other techniques when the anatomy of the C2 does not permit its use or make them very risky.

Myelopexy: A novel technique in posttraumatic syringomyelia.

Posttraumatic syringomyelia (PTS) is a well-reported phenomenon that usually takes place in the long-term course of patients following spinal cord injury. Different surgical procedures have been described: spinal cordectomy is usually a last option technique, but might be an excellent choice in patients with severe spinal cord injuries. We present a young patient with complete spinal cord injury after spine trauma, who developed posttraumatic syringomyelia with progressive motor deterioration twelve years after fixation. We performed a novel surgical technique (myelopexy) with excellent resolution of syringomyelia, sparing the negative implications of complete cord transection. Some artistic illustrations made by one of the corresponding authors are included, to better understanding of operative details.

Acute negative-pressure hydrocephalus: Management algorithm and value of early endoscopic ventriculostomy. / Hidrocefalia aguda a presión negativa: propuesta de manejo y valor de la ventriculostomía temprana.

INTRODUCTION: Acute negative-pressure hydrocephalus is an uncommon, underrecognized patology with a high morbidity and mortality. We propose an algorithm to facilitate the management of these patients, promoting the early diagnosis and the use of endoscopic third ventriculostomy as initial therapeutic option. MATERIAL AND METHODS: We performed an observational retrospective study in which patients diagnosed with acute negative-pressure hydrocephalus were included. Patient age and symptoms, primary etiology of hydrocephalus, previous shunt, infection and surgical procedures, time from clinical deterioration to endoscopic procedure, definitive treatment and patient outcomes were recorded. Our management algortihm is exposed and justified. RESULTS: We identified 5patients with diagnosis of acute negative-pressure hydrcephalus. In 4 of them the management algorithm was applied and early diagnosis and endoscopic ventriculostomy were performed. We observed complete succes of the endoscopic procedure in 2 patients (50%); the other 2required permanent shunt, nevertheless resolution of the low-pressure state was achieved. One patient died after systemic infection (20%), 80% of the patients experienced good outcome. CONCLUSIONS: The early identification of a negative-pressure hydrocephalic state is essential to reduce complications. Application of a specific management algortihm and early endoscopic third ventriculostomy could be advantageous to achieve better outcomes.

Hipertensión intracraneal idiopática: experiencia en 25 años y protocolo de actuación / Idiopathic intracranial hypertension: Experience over 25 years and a management protocol

Introducción y objetivos: Se presenta nuestra experiencia en hipertensión intracraneal idiopática (HII) preimplantación y postimplantación de un protocolo específico de actuación. Material y métodos: Estudio descriptivo retrospectivo de los pacientes con diagnóstico de HII en 25 años (1990-2015), comparando los últimos 7 años (tras implantar protocolo) con los 18 previos. Resultados: De 18.865 pacientes valorados en 25 años, hay 54 casos de HII (29 lactantes y 25 niños mayores). Se comparan ambos periodos: 32 casos de 1990-2008 -publicados en An Pediatr (Barc). 2009;71:400-6- y 23 de 2008-2015. En el periodo posprotocolo, hubo 13 pacientes entre 3 y 10 meses (62% varones) con abombamiento transitorio de fontanela y 10 entre 2 y 14 años (50% varones) con papiledema. El 54% de los lactantes habían finalizado recientemente tratamiento corticoideo por bronquitis. En los mayores, un caso asoció trombosis de senos venosos por otomastoiditis, otro tratamiento corticoideo por angioma y otro tratamiento con hormona de crecimiento. Se hizo ecografía transfontanelar a todos los lactantes; TAC, RM y angioRM a todos los mayores, y punción lumbar a 2 lactantes (por sospecha de meningitis) y a todos los mayores. Todos los pacientes evolucionaron favorablemente; solo en 3 se instauró tratamiento. Una paciente recidivó. Discusión: Las características y la evolución de los pacientes son superponibles en todos los años. La HII suele tener un curso favorable, aunque puede tardar en resolverse en niños mayores y presentar graves repercusiones visuales, por lo que precisa estrecho control oftalmológico. Destacamos la utilidad del protocolo para facilitar la toma de decisiones diagnósticas, de seguimiento y tratamiento (AU)

Introduction: We present our experience on idiopathic intracranial hypertension (IIH), before and after the introduction of a specific diagnosis and management protocol. Method: A descriptive retrospective study was conducted on patients with IIH over a 25 year period (1990-2015), comparing the last 7 years (after introduction of the protocol) with the previous 18 years. Results: Among the 18,865 patients evaluated, there were 54 cases of IIH (29 infants and 25 children). A comparison was made between the two time periods: 32 cases in 1990-2008 -published in An Pediatr (Barc). 2009;71:400-6-, and 23 cases in 2008-2015. In post-protocol period, there were 13 patients aged between 3-10 months (62% males) with transient bulging fontanelle, and 10 aged between 2-14 years (50% males), with papilloedema. A total of 54% of infants had recently finished corticosteroid treatment for bronchitis. In the older children, there was one case associated with venous thrombosis caused by otomastoiditis, one case on corticosteroid treatment for angioma, and another case treated with growth hormone. Transfontanelle ultrasound was performed on all infants, and CT, MRI and angio-MRI was performed on every child. Lumbar puncture was performed on 2 infants in whom meningitis was suspected, and in all children. All patients progressed favourably, with treatment being started in 3 of them. One patient relapsed. Discussion: Characteristics and outcomes of patients overlap every year. IIH usually has a favourable outcome, although it may be longer in children than in infants. It can cause serious visual disturbances, so close ophthalmological control is necessary. The protocol is useful to ease diagnostic decisions, monitoring, and treatment (AU)

[Idiopathic intracranial hypertension: Experience over 25 years and a management protocol]. / Hipertensión intracraneal idiopática: experiencia en 25 años y protocolo de actuación.

INTRODUCTION: We present our experience on idiopathic intracranial hypertension (IIH), before and after the introduction of a specific diagnosis and management protocol. METHOD: A descriptive retrospective study was conducted on patients with IIH over a 25year period (1990-2015), comparing the last 7years (after introduction of the protocol) with the previous 18years. RESULTS: Among the 18,865 patients evaluated, there were 54 cases of IIH (29 infants and 25 children). A comparison was made between the two time periods: 32 cases in 1990-2008 -published in An Pediatr (Barc). 2009;71:400-6-, and 23 cases in 2008-2015. In post-protocol period, there were 13 patients aged between 3-10months (62% males) with transient bulging fontanelle, and 10 aged between 2-14years (50% males), with papilloedema. A total of 54% of infants had recently finished corticosteroid treatment for bronchitis. In the older children, there was one case associated with venous thrombosis caused by otomastoiditis, one case on corticosteroid treatment for angioma, and another case treated with growth hormone. Transfontanelle ultrasound was performed on all infants, and CT, MRI and angio-MRI was performed on every child. Lumbar puncture was performed on 2 infants in whom meningitis was suspected, and in all children. All patients progressed favourably, with treatment being started in 3 of them. One patient relapsed. DISCUSSION: Characteristics and outcomes of patients overlap every year. IIH usually has a favourable outcome, although it may be longer in children than in infants. It can cause serious visual disturbances, so close ophthalmological control is necessary. The protocol is useful to ease diagnostic decisions, monitoring, and treatment.

Pons herniation into skull base after cabergoline therapy of giant prolactinoma.

INTRODUCTION: Pons herniation after cabergoline therapy for giant prolactinoma is a complication not documented in literature. CASE REPORT: We report a medium aged patient who developed secondary hemiparesis after 18 months of medical treatment. MRI revealed pons herniation into the clivus. There was improvement with conservative treatment. Secuencial MRIs are presented showing the tumor at the moment of the diagnosis, tumor shrinkage and pons herniation. DISCUSSION: Some studies have shown that a significant and rapid tumor shrinkage resulting from treatment with cabergoline can occur and it is thought that some complications are related with this tumor regression, as in the presented case.