Results of Surgical Treatment of Aneurysmal Subarachnoid Hemorrhage in a Single Institution Over 12 Years.

OBJECTIVE: For patients with aneurysmal subarachnoid hemorrhage (aSAH) in whom endovascular treatment is not the optimal treatment strategy, microsurgical clipping remains a viable option. We examined changes in morbidity and outcome over time in patients treated surgically and in relation to surgeon volume and experience. METHODS: All patients who underwent microsurgery for aSAH from 2007 to 2019 at our institution were included. We compared technical complication rates and surgical outcomes between experienced (≥50 independent cases) and inexperienced (<50 independent cases) surgeons and between high-volume (≥20 cases/year) and low-volume (<20 cases/year) surgeons. RESULTS: Most of the 1,003 aneurysms (970 patients, median age 56 years) were in the middle cerebral (41.4%), anterior communicating (27.6%), and posterior communicating (17.5%) arteries; 46.5% were <7 mm. The technical complication rate was 7%, resulting in postoperative infarct in 4.9% of patients. Nineteen patients (2%) died within 30 days of admission. There were no significant changes in rates of technical complication, postoperative infarct, or mortality over the study period. There were no differences in postoperative infarction and technical complication rates between experienced and inexperienced surgeons (P = 0.28 and P = 0.05, respectively), but there were differences when comparing high-volume and low-volume surgeons (P = 0.03 and P < 0.001, respectively). The independent predictors of postoperative infarctions were aneurysm size (P = 0.001), intraoperative large-vessel injury (P < 0.001), and low surgeon volume (P = 0.03). CONCLUSIONS: We present real-world data on surgical morbidity and outcomes after aSAH. We demonstrated a relationship between surgeon volume and outcome for surgical treatment of aSAH, which supports the benefit of subspecialization in cerebrovascular surgery.

Differences in Cerebrospinal Fluid Dynamics in Posttraumatic Hydrocephalus Versus Atrophy, Including Effect of Decompression and Cranioplasty.

INTRODUCTION: Challenges in diagnosing post-traumatic hydrocephalus (PTH) have created a need for an accurate diagnostic tool. We aim to report CSF dynamics in PTH and atrophy, along with differences before and after cranioplasty. METHODS: We retrospectively analyzed traumatic brain injury patients with ventriculomegaly who had infusion studies. We divided patients depending on CSF dynamics into two groups: 'likely PTH' (A) and 'likely atrophy' (B). A group of idiopathic normal pressure hydrocephalus shunt-responsive patients was used for comparison (C). RESULTS: Group A consisted of 36 patients who were non-decompressed or had a cranioplasty in situ for over 1 month. Group B included 16 patients with low Rout, AMP, and dAMP, 9 of whom were decompressed. Rout and dAMP were significantly higher in Group A than B, but significantly lower than Group C (45 iNPH patients). RAP change during infusion in group A indicated depleted compensatory reserve compared to ample reserve in group B. Repeat studies in five decompressed patients post-cranioplasty showed all parameters increased. CONCLUSIONS: Infusion tests are not useful in decompressed patients, whilst cranioplasty allowed differentiation between possible PTH and atrophy. Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus reported on imaging.

Comparison of Assessment for Shunting with Infusion Studies Versus Extended Lumbar Drainage in Suspected Normal Pressure Hydrocephalus.

INTRODUCTION: Tools available for diagnosis of normal pressure hydrocephalus (NPH) and prediction of shunt-response are overnight ICP monitoring, infusion studies, and extended lumbar drainage (ELD). We investigated the shunt-response predictive value by infusion tests versus ELD. MATERIAL AND METHODS: We retrospectively recruited 83 patients who had undergone both infusion study and ELD assessments and compared infusion study hydrodynamics with improvement at clinic follow-up after ELD and after shunting. RESULTS: 62 patients had Rout >11 mmHg/mL/min. 28 Showed physiotherapy-documented improvement following ELD, and were selected for shunting, of which 21 were shunted. Of these, 19 showed improvement. Eight patients with Rout >20 mmHg/mL/min showed no response to ELD and were not shunted.There were 21 patients with Rout <11 mmHg/mL/min: five were shunted, showed improvement at follow-up, and had Rout >6 mmHg/mL/min. ICP amplitude did not differ at baseline or plateau between responders and non-responders. CONCLUSIONS: ELD response and CSF dynamics differed remarkably. All patients with Rout <6 mmHg/mL/min showed no improvement with ELD, indicating that ELD and shunting might be contraindicated in these subjects. High Rout patients with no response to ELD could merit further consideration.

Shunt Testing In Vivo: Illustration of Partially Obstructed Ventricular Catheter by In-Growing Choroid Plexus.

Assessing shunt function in vivo presents a diagnostic challenge. Infusion studies can be a cost-effective and minimally invasive aid in the assessment of shunt function in vivo. We describe a case of a patient who after a foramen magnum decompression for type I Chiari malformation developed bilateral posterior fossa subdural hygromas and mild hydrocephalus, eventually necessitating insertion of a ventriculoperitoneal shunt. The patient returned with symptoms that were concerning for infection of the shunt. A bedside infusion study helped confirm that the ventricular catheter was partially obstructed by in-growing choroid plexus, but also that the shunt was no longer necessary. Partial blockage due to in-growing choroid plexus was confirmed during surgery to remove the shunt. We discuss the behaviour of in-growing choroid plexus and how partial obstruction can be detected with the use of an infusion study, as well as how this compares to the pattern observed in complete shunt obstruction. The benefits of using infusion studies in the assessment of shunt function are also explored.

Cerebrospinal fluid dynamics in non-acute post-traumatic ventriculomegaly.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is potentially under-diagnosed and under-treated, generating the need for a more efficient diagnostic tool. We aim to report CSF dynamics of patients with post-traumatic ventriculomegaly. MATERIALS AND METHODS: We retrospectively analysed post-traumatic brain injury (TBI) patients with ventriculomegaly who had undergone a CSF infusion test. We calculated the resistance to CSF outflow (Rout), AMP (pulse amplitude of intracranial pressure, ICP), dAMP (AMPplateau-AMPbaseline) and compensatory reserve index correlation coefficient between ICP and AMP (RAP). To avoid confounding factors, included patients had to be non-decompressed or with cranioplasty > 1 month previously and Rout > 6 mmHg/min/ml. Compliance was assessed using the elasticity coefficient. We also compared infusion-tested TBI patients selected for shunting versus those not selected for shunting (consultant decision based on clinical and radiological assessment and the infusion results). Finally, we used data from a group of shunted idiopathic Normal Pressure Hydrocephalus (iNPH) patients for comparison. RESULTS: Group A consisted of 36 patients with post-traumatic ventriculomegaly and Group B of 45 iNPH shunt responders. AMP and dAMP were significantly lower in Group A than B (0.55 ± 0.39 vs 1.02 ± 0.72; p < 0.01 and 1.58 ± 1.21 vs 2.76 ± 1.5; p < 0.01. RAP baseline was not significantly different between the two. Elasticity was higher than the normal limit in all groups (average 0.18 1/ml). Significantly higher Rout was present in those with probable PTH selected for shunting compared with unshunted. Mild/moderate hydrocephalus, ex-vacuo ventriculomegaly/encephalomalacia were inconsistently reported in PTH patients. CONCLUSIONS: Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus or atrophy reported on CT/MRI. Compliance appears reduced in PTH.

Validation of Davson's equation in patients suffering from idiopathic normal pressure hydrocephalus.

INTRODUCTION: The so-called Davson's equation relates baseline intracranial pressure (ICP) to resistance to cerebrospinal fluid outflow (Rout), formation of cerebrospinal fluid (If) and sagittal sinus pressure (PSS) There is a controversy over whether this fundamental equation is applicable in patients with normal pressure hydrocephalus (NPH). We investigated the relationship between Rout and ICP and also other compensatory, clinical and demographic parameters in NPH patients. METHOD: We carried out a retrospective study of 229 patients with primary NPH who had undergone constant-rate infusion studies in our hospital. Data was recorded and processed using ICM+ software. Relationships between variables were sought by calculating Pearson product correlation coefficients and p values. RESULTS: We found a significant, albeit weak, relationship between ICP and Rout (R = 0.17, p = 0.0049), Rout and peak-to-peak amplitude of ICP (AMP) (R = 0.27, p = 3.577e-05) and Rout and age (R = 0.16, p = 0.01306). CONCLUSIONS: The relationship found between ICP and Rout provides indirect evidence to support disturbed Cerebrospinal fluid circulation as a key factor in disturbed CSF dynamics in NPH. Weak correlation may indicate that other factors-variable PSS and formation of CSF outflow-contribute heavily to linear model expressed by Davson's equation.