Management of shunt dysfunction using noninvasive intracranial pressure waveform monitoring: illustrative case.

BACKGROUND: Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial. OBSERVATIONS: A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement. LESSONS: In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

Natural history and neuro-oncological approach in spinal gangliogliomas: a systematic review.

To describe the natural history of spinal gangliogliomas (GG) in order to determine the most appropriate neuro-oncological management. A Medline search for relevant publications up to July 2023 using the key phrase "ganglioglioma spinal" and "ganglioglioma posterior fossa" led to the retrieval of 178 studies. This corpus provided the basis for the present review. As an initial selection step, the following inclusion criteria were adopted: (i) series and case reports on spinal GG; (ii) clinical outcomes were reported specifically for GG; (iii) GG was the only pathological diagnosis for the evaluation of the tumor; (iv) papers written only in English was evaluated; and (v) papers describing each case in the series were included. The World Health Organization (WHO) 2021 grading criteria for gangliogliomas were applied. A total of 107 tumors were evaluated (63 from male patients and 44 from female patients; 1.43 male/1.0 female ratio, mean age 18.34 ± 15.84 years). The most common site was the cervical spine, accounting for 43 cases (40.18%); GTR was performed in 35 cases (32.71%) and STR in 71 cases (66.35%), while this information was not reported in 1 case (0.94%). 8 deaths were reported (7.47%) involving 2 males (25%) and 6 females (75%) aged 4-78 years (mean 34.27 ± 18.22) years. GGs located on the spine displayed the same gender ratio as these tumors in general. The most frequent symptom was pain and motor impairment, while the most prevalent location was the cervical spinal cord. GTR of the tumor posed a challenge for neurosurgeons, due to the difficulty of resecting the lesion without damaging the spinal eloquent area, explaining the lower rate of cure for this tumor type.

The Relationship between Injury Characteristics and Post-Traumatic Recovery after Diffuse Axonal Injury.

BACKGROUND: The diagnosis and prognosis of diffuse axonal injury (DAI) remain challenging. This research aimed to analyze the impact on activities of daily living (ADL), functional outcomes, quality of life (QoL), and the association between lesion severity and DAI location identified through imaging exams. METHODS: This prospective cohort study included 95 patients diagnosed with DAI. Data were collected at admission, three, six, and twelve months post-injury. The associations between variables were evaluated using a mixed-effects model. RESULTS: Functional recovery and QoL improved between three and twelve months after DAI. An interaction was observed between independence in performing ADL and subarachnoid hemorrhage (p = 0.043) and intraventricular hemorrhage (p = 0.012). Additionally, an interaction over time was observed between the Glasgow Outcome Scale (GOS) and DAI severity (p < 0.001), brain lesions (p = 0.014), and the Disability Rating Scale (DRS) with injury in brain hemispheres (p = 0.026) and Adams classification (p = 0.013). Interaction effects over time were observed with the general health perceptions and energy/vitality domains with intraventricular hemorrhage, and the social functioning domain with the obliteration of basal cisterns and Gentry's classification. CONCLUSION: The use of CT in the acute phase of DAI is important for predicting outcomes. The severity and location of DAI are associated with functional outcomes, ADL, and QoL.

Unruptured Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis of Mortality and Morbidity in Aruba-Eligible Studies.

BACKGROUND: Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies. METHODS: Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities. RESULTS: Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%. CONCLUSIONS: The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.

New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment.

Background: Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods: This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results: There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion: Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series.

Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.

Severe traumatic brain injury and acute kidney injury patients: factors associated with in-hospital mortality and unfavorable outcomes.

OBJECTIVE: The purpose of this study was to identify the occurrence of AKI, and factors associated with in-hospital mortality and unfavorable outcomes in patients with severe traumatic brain injury (TBI) and acute kidney injury (AKI) severity. METHOD: A retrospective cohort study which analyzed data with severe TBI between 2013 and 2017. We examined demographic and clinical information, and outcome by in-hospital mortality, and the Glasgow Outcome Scale six months after TBI. We associated factors to in-hospital mortality and unfavorable outcome in severe TBI and AKI with an association test. RESULTS: A total of 219 patients were selected, 39.3% had an AKI, and several factors associated with AKI occurrence after severe TBI. Stage 2 or 3 of AKI (OR 12.489; 95% CI = 4.45-37.94) were independent risk for both outcomes in multivariable models, severity injury by the New Trauma Injury Severity Score (OR 0.97; 95% CI = 0.96-0.99) for mortality, and the New Injury Severity Score (OR1.07; 95% CI = 1.04-1.10) and Trauma and Injury Severity Score (OR = 0.98; 95% CI = 0.965-0.997) for unfavorable outcome. CONCLUSION: The findings of our study confirmed that AKI severity and severity of injury was also related to increased mortality and unfavorable outcome after severe TBI.

Non-invasive Intracranial Pressure Waveform Analysis in Chiari Malformation Type 1: A Pilot Trial.

OBJECTIVE: This pilot study aimed to investigate the role of Posterior Fossa Decompression (PFD) on the intracranial pressure (ICP) waveform in patients with Chiari Malformation type 1 (CM1). It also sought to explore the relationship between symptom improvement and ICP waveform behavior. METHODS: This exploratory cohort study evaluated adult patients diagnosed with CM1. The patients underwent PFD using a standard technique at our institution, which involved a 3 × 3 cm posterior craniectomy and excision of the posterior arch of C1. The ICP waveform was measured using an external strain-gauge device connected to a pin attached to the skull. Measurements were collected pre- and post-PFD, and the P2/P1 ratio was calculated pre- and postoperatively. RESULTS: The pilot study comprised 6 participants, 3 men and 3 women, with ages ranging from 39 to 68 years. The primary symptoms were cerebellar ataxia and typical headaches. The study found that most patients who showed clinical improvement, as judged by the Gestalt method, had a postoperative decrease in the P2/P1 ratio. However, 1 patient did not show an improvement in the P2/P1 ratio despite a good clinical outcome. CONCLUSIONS: This study suggests that the P2/P1 ratio may decrease after PFD. However, we highlight the need for further research with a larger sample size to confirm these preliminary results.

A Systematic Review and Meta-Analysis on the Management and Outcome of Isolated Skull Fractures in Pediatric Patients.

BACKGROUND: The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF). MATERIALS AND METHODS: This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered. RESULTS: A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0-0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66-89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0-15%). No deaths were reported in any of the 25 studies. CONCLUSIONS: Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.

Postoperative Seizure Prophylaxis in Meningioma Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Seizures in the early postoperative period may impair patient recovery and increase the risk of complications. The aim of this study is to determine whether there is any advantage in postoperative seizure prophylaxis following meningioma resection. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. PUBMED, Web of Science, Embase, Science Direct, and Cochrane were searched for papers until April 2023. RESULTS: Among nine studies, a total of 3249 patients were evaluated, of which 984 patients received antiepileptic drugs (AEDs). No significant difference was observed in the frequency of seizure events between patients who were treated with antiepileptic drugs (AEDs) and those who were not. (RR 1.22, 95% CI 0.66 to 2.40; I2 = 57%). Postoperative seizures occurred in 5% (95% CI: 1% to 9%) within the early time period (<7 days), and 9% (95% CI: 1% to 17%) in the late time period (>7 days), with significant heterogeneity between the studies (I2 = 91% and 97%, respectively). In seizure-naive patients, the rate of postoperative seizures was 2% (95% CI: 0% to 6%) in the early period and increased to 6% (95% CI: 0% to 15%) in the late period. High heterogeneity led to the use of random-effects models in all analyses. CONCLUSIONS: The current evidence does not provide sufficient support for the effectiveness of prophylactic AED medications in preventing postoperative seizures in patients undergoing meningioma resection. This underscores the importance of considering diagnostic criteria and conducting individual patient analysis to guide clinical decision-making in this context.

Is transcranial direct current stimulation (tDCS) effective to improve cognition and functionality after severe traumatic brain injury? A perspective article and hypothesis.

Severe traumatic brain injury (sTBI) is an important cause of disability and mortality and affects people of all ages. Current scientific evidence indicates that motor dysfunction and cognitive impairment are the main limiting factors in patients with sTBI. Transcranial direct current stimulation (tDCS) seems to be a good therapeutic option, but when it comes to patients with sTBI, the results are inconclusive, and some protocols have not yet been tested. In addition, there is still a lack of information on tDCS-related physiological mechanisms, especially during the acute phase. In the present study, based on current evidence on tDCS mechanisms of action, we hypothesized that performing tDCS sessions in individuals with sTBI, especially in the acute and subacute phases, together with conventional therapy sessions, could improve cognition and motor function in this population. This hypothesis presents a new possibility for treating sTBI, seeking to elucidate the extent to which early tDCS may affect long-term clinical outcomes.

The current state of global contribution to open access publishing in neurosurgery: A bibliometric analysis.

•The top three countries made up 56.7% of the total open-access (OA) contributions.•Low and lower-middle-income countries are less than 8% of the total OA publications.•There is a disparity in academic voice in the neurosurgical literature.•Disparities potentially affect neurosurgery practice and knowledge dissemination.

Quantification of tumor induced motor cortical plasticity using navigated transcranial magnetic stimulation in patients with adult-type diffuse gliomas.

Introduction: The evaluation of brain plasticity can provide relevant information for the surgical planning of patients with brain tumors, especially when it comes to intrinsic lesions such as gliomas. Neuronavigated transcranial magnetic stimulation (nTMS) is a non-invasive tool capable of providing information about the functional map of the cerebral cortex. Although nTMS presents a good correlation with invasive intraoperative techniques, the measurement of plasticity still needs standardization. The present study evaluated objective and graphic parameters in the quantification and qualification of brain plasticity in adult patients with gliomas in the vicinity of the motor area. Methods: This is a prospective observational study that included 35 patients with a radiological diagnosis of glioma who underwent standard surgical treatment. nTMS was performed with a focus on the motor area of the upper limbs in both the affected and healthy cerebral hemispheres in all patients to obtain data on motor thresholds (MT) and graphical evaluation by three-dimensional reconstruction and mathematical analysis of parameters related to the location and displacement of the motor centers of gravity (ΔL), dispersion (SDpc) and variability (VCpc) of the points where there was a positive motor response. Data were compared according to the ratios between the hemispheres of each patient and stratified according to the final pathology diagnosis. Results: The final sample consisted of 14 patients with a radiological diagnosis of low-grade glioma (LGG), of which 11 were consistent with the final pathology diagnosis. The normalized interhemispheric ratios of ΔL, SDpc, VCpc, and MT were significantly relevant for the quantification of plasticity (p < 0.001). The graphic reconstruction allows the qualitative evaluation of this plasticity. Conclusion: The nTMS was able to quantitatively and qualitatively demonstrate the occurrence of brain plasticity induced by an intrinsic brain tumor. The graphic evaluation allowed the observation of useful characteristics for the operative planning, while the mathematical analysis made it possible to quantify the magnitude of the plasticity.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis.

OBJECTIVES: We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted. REVIEW METHODS: Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS. RESULTS: The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference. CONCLUSION: Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Animal models for the study of intracranial hematomas (Review).

Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.

Noninvasive intracranial pressure waveforms for estimation of intracranial hypertension and outcome prediction in acute brain-injured patients.

Analysis of intracranial pressure waveforms (ICPW) provides information on intracranial compliance. We aimed to assess the correlation between noninvasive ICPW (NICPW) and invasively measured intracranial pressure (ICP) and to assess the NICPW prognostic value in this population. In this cohort, acute brain-injured (ABI) patients were included within 5 days from admission in six Intensive Care Units. Mean ICP (mICP) values and the P2/P1 ratio derived from NICPW were analyzed and correlated with outcome, which was defined as: (a) early death (ED); survivors on spontaneous breathing (SB) or survivors on mechanical ventilation (MV) at 7 days from inclusion. Intracranial hypertension (IHT) was defined by ICP > 20 mmHg. A total of 72 patients were included (mean age 39, 68% TBI). mICP and P2/P1 values were significantly correlated (r = 0.49, p < 0.001). P2/P1 ratio was significantly higher in patients with IHT and had an area under the receiving operator curve (AUROC) to predict IHT of 0.88 (95% CI 0.78-0.98). mICP and P2/P1 ratio was also significantly higher for ED group (n = 10) than the other groups. The AUROC of P2/P1 to predict ED was 0.71 [95% CI 0.53-0.87], and the threshold P2/P1 > 1.2 showed a sensitivity of 60% [95% CI 31-83%] and a specificity of 69% [95% CI 57-79%]. Similar results were observed when decompressive craniectomy patients were excluded. In this study, P2/P1 derived from noninvasive ICPW assessment was well correlated with IHT. This information seems to be as associated with ABI patients outcomes as ICP.Trial registration: NCT03144219, Registered 01 May 2017 Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03144219 .