Changes in postural stability after cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus.

Introduction: In patients with idiopathic normal pressure hydrocephalus (iNPH), the characteristics of balance disturbance are not as well understood as those related to gait. This study examined changes in postural stability in quiet standing after the cerebrospinal fluid tap test (CSFTT) in these patients. Furthermore, the study explored the relationship between the amount of spontaneous body sway and both gait and executive function. Materials and methods: All patients diagnosed with iNPH underwent CSFTT. We evaluated their center of pressure (COP) measurements on a force plate during quiet standing, both pre- and post-CSFTT. Following the COP measurements, we calculated COP parameters using time and frequency domain analysis and assessed changes in these parameters after CSFTT. At pre-CSFTT, we assessed the Timed Up and Go (TUG) and the Frontal Assessment Battery (FAB). We investigated the relationship between COP parameters and the TUG and FAB scores at pre-CSFTT. Results: A total of 72 patients with iNPH were initially enrolled, and 56 patients who responded positively to CSFTT were finally included. Post-CSFTT, significant improvements were observed in COP parameters through time domain analysis. These included the velocity of COP (vCOP), root-mean-square of COP (rmsCOP), turn index, torque, and base of support (BOS), compared to the pre-CSFTT values (p < 0.05). In the frequency domain analysis of COP parameters post-CSFTT, there was a decrease in both the peak and average of power spectral density (PSD) values in both the anteroposterior (AP) and mediolateral (ML) directions below 0.5 Hz (p < 0.05). In addition, the TUG scores showed a positive correlation with vCOP, rmsCOP, turn index, torque, BOS, and both the peak and average PSD values in the AP and ML directions below 0.5 Hz (p < 0.05). The FAB scores demonstrated a negative correlation with vCOP, rmsCOP, turns index, BOS, and both peak and average PSD values in the AP direction below 0.5 Hz (p < 0.05). Conclusion: In patients with iNPH who responded to CSFTT, there was an improvement in spontaneous body sway during quiet standing after CSFTT. Increased spontaneous sway is associated with impaired gait and frontal lobe function. This may be linked to impaired cortico-cortical and cortico-subcortical circuits in patients with iNPH.

Paramedian versus midline approach of spinal anesthesia: a systematic review and meta-analysis with trial sequential analysis.

PURPOSE: Midline approach of spinal anesthesia has been widely used for patients undergoing surgical procedures. However, it might not be effective for obstetric patients and elderly with degenerative spine changes. Primary objective was to examine the success rate at the first attempt between the paramedian and midline spinal anesthesia in adults undergoing surgery. METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting date until February 2023. Randomized clinical trials (RCTs) comparing the paramedian versus midline approach of spinal anesthesia were included. The primary outcome was the success rate at the first attempt of spinal anesthesia. RESULTS: Our review included 36 RCTs (n = 5379). Compared to the midline approach, paramedian approach may increase success rate at the first attempt but the evidence is very uncertain (OR: 0.47, 95% CI 0.27-0.82, ρ = 0.007, level of evidence:very low). Our pooled data indicates that the paramedian approach likely reduced incidence of post-spinal headache (OR: 2.07, 95% CI 1.51-2.84, ρ < 0.00001, level of evidence:moderate). The evidence suggests that the paramedian approach may result in a reduction in the occurrence of paresthesia (OR: 1.61, 95% CI 1.06-2.45, ρ = 0.03, level of evidence:low). CONCLUSIONS: Our meta-analysis of 36 RCTs showed that paramedian approach may result in little to no difference in success rate at the first attempt owing to its very low level of evidence. However, given the low level of evidence and studies with small sample sizes, these findings need to be interpreted with caveat. CLINICAL TRIAL REGISTRATION NUMBER: CRD42023397781.

Factors influencing refusal of lumbar puncture in children under age 10: a cross-sectional study.

Background: This study aimed to investigate the factors associated with refusal of lumbar puncture (LP) in children aged 1-10 years who presented to a paediatric department in our hospital. Methods: A sample of parents and guardians of children who presented to the paediatric department were surveyed to gather information about their educational background and decision-making processes. Attending doctors were also interviewed using a questionnaire to gather their perspectives on the reasons for LP refusal in children. Attending doctors then tried to convince the parents or guardians to see if it changed their decision. Results: The study found that the majority of parents and guardians had a lower educational background, with over half being illiterate. Refusal of LP was seen most frequently in parents or guardians who were illiterate. The decision-making process was found to be heavily dependent on the father in a male-dominated society. Peer pressure and lack of knowledge were found to be factors that contributed to LP refusal. Conclusion: Refusal of a LP was linked to having a lower educational background and to societal influences in this cross-sectional study of children aged 1-10 years. More than half of the parents and guardians were illiterate, indicating that they had a lower level of education. Refusing LP was influenced by a number of factors, including social pressure and a lack of information. However, these obstacles were overcome thanks to the efforts of the attending doctors who dispelled myths and reassured the parents and guardians of the necessity and safety of the procedure. Possible roadblocks include a lack of financial resources and common misconceptions about LP. These results highlight the significance of addressing educational and societal factors to enhance children's healthcare.

Optimized Method of Unilateral Spinal Anesthesia: A Double-blind, Randomized Clinical Study.

Background: Unilateral spinal anesthesia is often accompanied by technical difficulties in implementation, multiple puncture attempts, unsuccessful punctures, and, as a result, insufficient anesthesia, along with various complications associated with a dural puncture. Objectives: This work compares the efficacy and safety of conventional Unilateral Spinal Anesthesia (USpA) and unilateral spinal anesthesia with electrical nerve stimulation (USpA+ENS). Methods: A total of 134 patients with an upcoming vascular surgery on one lower extremity were randomly assigned to two groups. All the patients were positioned with the operated limb below and used 7.5 mg of Bupivacaine-Spinal®. In the UsPA group, anesthesia was performed according to the standard technique. In the USpA+ENS group, electrical nerve stimulation was additionally used. Primary outcomes were the presence or absence of post-dural puncture headache (PDPH), number of puncture attempts, lateralization, and anesthesia adequacy. Secondary outcomes were intraoperative pain scores, the presence or absence of nausea and vomiting, and the need for hemodynamics correction. Results: The frequency of puncture complications was sufficiently lower in the USpA+ENS group than in the UsPA group. The local anesthetic solution distribution, pain score indicators, and secondary outcomes were comparable in both groups with a slight difference. Conclusions: We showed that USpA+ENS reduces the incidence of puncture complications and improves the quality of anesthesia and adherence of both patients and anesthesiologists to the unilateral spinal anesthesia technique.

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Accuracy Evaluation Trial of Mixed Reality-Guided Spinal Puncture Technology.

Purpose: To evaluate the accuracy of mixed reality (MR)-guided visualization technology for spinal puncture (MRsp). Methods: MRsp involved the following three steps: 1. Lumbar spine computed tomography (CT) data were obtained to reconstruct virtual 3D images, which were imported into a HoloLens (2nd gen). 2. The patented MR system quickly recognized the spatial orientation and superimposed the virtual image over the real spine in the HoloLens. 3. The operator performed the spinal puncture with structural information provided by the virtual image. A posture fixation cushion was used to keep the subjects' lateral decubitus position consistent. 12 subjects were recruited to verify the setup error and the registration error. The setup error was calculated using the first two CT scans and measuring the displacement of two location markers. The projection points of the upper edge of the L3 spinous process (L3↑), the lower edge of the L3 spinous process (L3↓), and the lower edge of the L4 spinous process (L4↓) in the virtual image were positioned and marked on the skin as the registration markers. A third CT scan was performed to determine the registration error by measuring the displacement between the three registration markers and the corresponding real spinous process edges. Results: The setup errors in the position of the cranial location marker between CT scans along the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) axes of the CT bed measured 0.09 ± 0.06 cm, 0.30 ± 0.28 cm, and 0.22 ± 0.12 cm, respectively, while those of the position of the caudal location marker measured 0.08 ± 0.06 cm, 0.29 ± 0.18 cm, and 0.18 ± 0.10 cm, respectively. The registration errors between the three registration markers and the subject's real L3↑, L3↓, and L4↓ were 0.11 ± 0.09 cm, 0.15 ± 0.13 cm, and 0.13 ± 0.10 cm, respectively, in the SI direction. Conclusion: This MR-guided visualization technology for spinal puncture can accurately and quickly superimpose the reconstructed 3D CT images over a real human spine.

Diagnostic Yield of Combined Lumbar Puncture and Brain MRI in Critically Ill Patients With Unexplained Acute Encephalopathy: A Retrospective Cohort Study.

Critically ill patients frequently experience acute encephalopathy, often colloquially termed "altered mental status" (AMS); however, there are no consensus guidelines or criteria about performing lumbar puncture (LP) and advanced neuroimaging in medical ICU patients with unexplained encephalopathy. OBJECTIVES: We sought to characterize the yield of combined LP and brain MRI (bMRI) in such patients as determined by both the frequency of abnormal results and the therapeutic efficacy of these investigations, that is, how often results changed management. DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study of medical ICU patients admitted to a tertiary academic center between 2012 and 2018 who had documented diagnoses of "AMS" and/or synonymous terms, no clear etiology of encephalopathy, and had undergone both LP and bMRI. MAIN OUTCOMES AND MEASURES: The primary outcome was the frequency of abnormal diagnostic testing results determined objectively for LP using cerebrospinal fluid (CSF) findings and subjectively for bMRI through team agreement on imaging findings deemed significant through retrospective chart review. We subjectively determined the frequency of therapeutic efficacy. Finally, we analyzed the effect of other clinical variables on the likelihood of discovering abnormal CSF and bMRI findings through chi-square tests and multivariate logistic regression. RESULTS: One hundred four patients met inclusion criteria. Fifty patients (48.1%) had an abnormal CSF profile or definitive microbiological or cytological data by LP, 44 patients (42.3%) had bMRI with significant abnormal findings, and 74 patients (71.2%) had abnormal results on at least one of these investigations. Few clinical variables were associated with the abnormal findings in either investigation. We judged 24.0% (25/104) of bMRI and 26.0% (27/104) of LPs to have therapeutic efficacy with moderate interobserver reliability. CONCLUSIONS: Determining when to perform combined LP and bMRI in ICU patients with unexplained acute encephalopathy must rely on clinical judgment. These investigations have a reasonable yield in this selected population.

An unexpected effect of traumatic and bloody lumbar puncture among patients with primary headaches in emergency department.

BACKGROUND: This study aimed to investigate the association between traumatic tap and the incidence of post-dural puncture headache (PDPH) following lumbar puncture (LP) among patients who underwent LP with a primary discharge diagnosis of primary headache in the emergency department (ED). METHODS: We retrospectively reviewed the medical records of patients who visited a single tertiary ED with the symptom of a headache and underwent LP for cerebrospinal fluid (CSF) analysis between January 2012 and January 2022. Patients who met the definition of PDPH and revisited the ED or outpatient clinic within 2 weeks of discharge were included. For comparative analysis, we divided the groups according to CSF RBC counts (group 1, CSF RBC <10 cells/µL; group 2, 10-100 cells/µL; group 3, ≥100 cells/µL). The primary outcome was the difference in CSF RBC counts between the ED or outpatient clinic revisiting patients who underwent LP within 2 weeks after discharge from the ED. The secondary outcomes were the admission rate and risk factors for PDPH; sex, age, needle size, and CSF pressure. RESULTS: Data from 112 patients were collected; PDPH was reported in 39 patients (34.8%), and 40 (35.7%) patients were admitted. The median (interquartile range) CSF RBC count was 10 [2-100.8] cells/µL. One-way analysis of variance test of the mean differences among the three groups showed no differences in age, the duration of headache before LP, PLT counts, PT, or aPTT among the groups. There were differences in the number of admitted patients (30 vs. 7 vs. 3, P < 0.001) and the incidence of PDPH (29 vs. 6 vs. 4, P < 0.003). In the comparison of the PDPH and non-PDPH groups, there were differences in age (28.7 ± 8.4 years vs. 36.9 ± 18.4 years, P = 0.01) and the admission rate (85% vs. 9%, P < 0.001). CONCLUSIONS: Notably, our results suggest that traumatic LP may be an unexpected factor in reducing the occurrence rate of PDPH. Consequently, the admission rate for PDPH was significantly reduced among patients with traumatic LP and those with primary headaches. In this study, we collected and analyzed the data from a relatively small sample size of 112 patients. Further studies are needed to evaluate the relationship between traumatic LP and PDPH.

Feasibility of percutaneous dural sac puncture via a posterior trans-sacral foraminal conduit approach: a CT morphometric analysis.

We assess the theoretical feasibility of percutaneous posterior sacral foramen (pSF) needle puncture of the sacral dural sac (DS) by studying the three-dimensional imaging anatomy of pSFs relative to the sacral canal (SC). On CT images of 40 healthy subjects, we retrospectively studied sacral alae passageways from SC to pSFs in all three planes to determine if an imaginary spinal needle could theoretically traverse S1 or S2 pSFs in a straight path toward DS. If not straight, we measured multiplane angulations and morphometrics of this route. We found no straight connections between S1 or S2 pSFs and SC. Instead, there were bilateral spatially complex dorsoventral M-shaped "foraminal conduits" (FCs; common, ventral, and dorsal) from SC to anterior SFs and pSFs that would prevent percutaneous straight needle puncture of the DS. This detailed knowledge of the sacral FCs will be useful for accurate imaging interpretation and interventional procedures on the sacrum.

Difficult Spinal-Arachnoid Puncture (DSP) Score: Development and Performance Analysis.

BACKGROUND: Difficult and traumatic neuraxial blocks and procedures are not uncommon. Although score-based prediction has been attempted, the practical application of those has remained limited for various reasons. The aim of this study was to develop a clinical scoring system from the strong predictors of failed spinal-arachnoid puncture procedures assessed previously using artificial neural network (ANN) analysis and analyze the score's performance on the index cohort. METHODS: The present study is based on the ANN model analyzing 300 spinal-arachnoid punctures (index cohort) performed in an academic institute in India. For the development of the score, i.e., Difficult Spinal-Arachnoid Puncture (DSP) Score, the coefficient estimates of the input variables, which showed a Pr(>|z|) value of <0.01, were considered. The resultant DSP Score was then applied to the index cohort for receiver operating characteristic (ROC) analysis, Youden's J point determination for best sensitivity and specificity, and diagnostic statistical analysis for the cut-off value for predicting the difficulty. RESULTS: A DSP Score incorporating spine grades, performers' experience, and positioning difficulty was developed; the minimum and maximum scores were 0 and 7, respectively. The area under the ROC curve for the DSP Score was 0.858 (95% confidence interval 0.811-0.905), Youden's J point for cut-off was at 2, which showed a specificity and sensitivity of 98.15% and 56.5%, respectively. CONCLUSION: The ANN model-based DSP Score developed for predicting the difficult spinal-arachnoid puncture procedure showed an excellent area under the ROC curve. At the cut-off value 2, the score had a sensitivity plus specificity of approximately 155%, indicating that the tool can be useful as a diagnostic (predictive) tool in clinical practice.

Feasibility of intrathecal therapeutic injections in spinal muscular atrophy patients via a percutaneous transsacral hiatus route: An initial neuroimaging morphometric study.

INTRODUCTION/AIMS: Standard fluoroscopic lumbar puncture (LP) can be impossible in patients with severe spinal deformities from spinal muscular atrophy (SMA) who require intrathecal nusinersen therapy. There usually exists a straight trajectory in the lower sacral canal (SC) that could allow image-guided percutaneous transsacral hiatus puncture of the lumbosacral dural sac. In this study we determine whether sacra are comparatively straighter in SMA patients (SMAps) vs healthy controls (HCs), which may facilitate unhindered transsacral hiatus spinal needle insertion for intrathecal nusinersen therapy. METHODS: We retrospectively analyzed lumbosacral spine computed tomograms (CTs) or CT-myelogram images of 38 SMAps and age- and sex-matched HCs. We digitally measured ventrodorsal sacral curvatures, SC surface areas, dural sac termination levels, and distances from sacral hiatus to the most caudad aspects of dural sacs ("needle distance"). RESULTS: Mean ages of HCs and SMAps were 32.7 and 31.7 years, respectively, with dural sacs terminating at similar levels. Mean values for morphometrics were: (a) midsagittal SC surface area for HCs = 701.2 mm2 , and for SMAps = 601.5 mm2 (not statistically significant [ns]); (b) using a "line method," sacral curvature for HCs = 61.9°, and SMAp = 35.7° (P = .0009), and was similar when using an "angle summation method"; (c) width of sacral hiatus for HCs = 14.9 mm, and SMAps = 15.0 mm (ns); and (d) "needle distance" for HCs = 54.7 mm, and SMAps = 49.9 mm (ns). DISCUSSION: SMAps have significantly straighter sacra compared with HCs, which theoretically renders them more amenable to percutaneous transsacral hiatus puncture of the dural sac.

Interpretation of white blood cell counts in the cerebrospinal fluid of neonates with traumatic lumbar puncture: a retrospective cohort study.

BACKGROUND: Difficulty in interpreting white blood cell (WBC) counts in cerebrospinal fluid (CSF) complicates the diagnosis of neonatal meningitis in traumatic lumbar punctures (LP). The aim of our study was to determine the correction factor for WBC counts in traumatic LP that offers the greatest diagnostic efficacy in meningitis. METHODS: We conducted a retrospective observational study of LP in neonates between January 2014 and December 2020. Traumatic LP was defined as a red blood cell (RBC) count ≥ 1,000 cells/mm3 CSF and pleocytosis as WBCs ≥ 20 cells/mm3 CSF. The CSF RBC:WBC ratio was analyzed by linear regression to determine a new correction factor. Cell count adjustments were also studied using the 500:1, the 1,000:1 ratio method, and the peripheral blood RBC:WBC ratio, using ROC curves and studies of accuracy (sensitivity and specificity). RESULTS: Overall, 41.0% of the 1,053 LPs included in the study were traumatic. The best results for effective WBC correction were the method based on the peripheral blood ratio (sensitivity = 1.0 and specificity = 0.9 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.9 for viral meningitis) and the 400:1 ratio (sensitivity = 1.0 and specificity = 0.8 for bacterial meningitis and sensitivity = 0.8 and specificity = 0.8 for viral meningitis) obtained from linear regression (95% CI 381.7-427.4; R2 = 0.7). CONCLUSION: Both the peripheral blood correction and the 400:1 correction reduce the number of neonates classified with pleocytosis who were not eventually diagnosed with meningitis. Both methods might be a useful tool to clarify the neonatal meningitis diagnosis, offering neonatologists the possibility to assess the WBC count in traumatic LP.

Normal pressure hydrocephalus: an update / Hidrocefalia de pressão normal: uma atualização

ABSTRACT Normal pressure hydrocephalus (NPH) has been a topic of debate since its introduction in publications. More frequent in the elderly population, it is characterized by gait disturbance, urinary urge incontinence and cognitive decline. Therefore, it is a clinical-radiological entity with relatively common findings for the age group, which together may have greater specificity. Therefore, its diagnosis must be careful for an adequate selection of patients for treatment with ventricular shunt, since the symptoms are potentially reversible. The tap test has a high positive predictive value as a predictor of therapeutic response, but a negative test does not exclude the possibility of treatment. Scientific efforts in recent years have been directed towards a better understanding of NPH and this narrative review aims to compile recent data from the literature in a didactic way for clinical practice.

RESUMO A hidrocefalia de pressão normal (HPN) é tema de debate desde sua introdução na literatura. Mais frequente na população idosa, caracteriza-se por distúrbio de marcha, urge-incontinência urinária e declínio cognitivo. Portanto, trata-se de uma entidade clínico-radiológica com achados relativamente comuns para a faixa etária, que em conjunto, podem ter maior especificidade. Sendo assim, seu diagnóstico deve ser criterioso para uma adequada seleção de pacientes para tratamento com a derivação ventricular, uma vez que os sintomas são potencialmente reversíveis. O tap test possui valor preditivo positivo alto preditor de resposta terapêutica, mas um teste negativo não exclui a possibilidade de tratamento. Esforços científicos nos últimos anos têm sido direcionados para melhor entendimento da HPN e essa revisão narrativa se propõe a compilar dados recentes da literatura de forma didática para a prática clínica.

Utilidad de la ecografía a pie de cama en la punción lumbar: un análisis del rendimiento diagnóstico basado en la evidencia disponible

Los avances en la tecnología de la ciencia biomédica han permitido incrementar la tasa de éxito de las intervenciones gracias a las mejoras en seguridad y eficacia. Durante la evaluación del paciente con un trastorno neurológico agudo que requiere una punción lumbar, existen algunas condiciones que pueden dificultar la realización de este procedimiento, tales como la infección en el lugar de la punción o las anomalías óseas que puedan causar una lesión medular. El uso de la ecografía a pie de cama es una buena alternativa para acompañar a la punción debido a su capacidad para explorar estructuras que no pueden ser evaluadas mediante la exploración física. En los centros hospitalarios de baja complejidad, donde pueden existir barreras de acceso a herramientas de imagen costosas, la ecografía es una opción rentable para el abordaje de patologías urgentes. Con base en lo anterior, el objetivo de este manuscrito consiste en revisar conceptos relevantes basados en la evidencia más reciente, que están relacionados con el uso de la ecografía para la realización de la punción lumbar.

Advances in biomedical technology have increased the success rate of medical procedures due to improvements in safety and efficacy. During the assessment of patients with acute neurological disorder who require a lumbar puncture, some conditions may hinder its performance, such as infection at the puncture site or bone abnormalities that may cause spinal cord injury. Bedside ultrasound is a good alternative to assist in the performance of a puncture, due to its ability to examine structures that cannot be assessed by physical examination. In primary health care centers, where there may be obstacles that prevent access to expensive imaging tools, ultrasound is a cost-effective option in the approach to urgent pathologies. In view of the foregoing, this paper aims to review important recent evidence-based concepts related to the use of ultrasound for the performance of a lumbar puncture.

Viraje linfocitario en un caso de encefalitis herpética: La importancia del análisis del líquido cefalorraquídeo. Caso clínico / Lymphocyte shift in a patient with herpetic encephalitis. Report of one case

Central nervous system infections are a medical emergency, due to their high fatality and sequelae. Timely treatment is essential, and should be initially indicated empirically by clinical guidance, without microbiological certainty. Hence the importance of cerebrospinal fluid (CSF) analysis as an etiological and therapeutic guide in the crucial initial hours of management. We report a 57-year-old woman consulting for fever and altered mental status. A brain CAT scan was normal. A lumbar puncture disclosed a CSF with predominance of neutrophils. Suspecting a bacterial meningitis, antimicrobial treatment was started but 48 hours after, the patient did not improve. A new lumbar puncture disclosed a CSF with predominance of lymphocytes. The lymphocyte shift prompted a PCR that was positive for herpes virus. The patient was treated with acyclovir with a good evolution.

Safety and Feasibility of Research Lumbar Puncture in Huntington's Disease: The HDClarity Cohort and Bioresource.

BACKGROUND: Biomarkers are needed to monitor disease progression, target engagement and efficacy in Huntington's disease (HD). Cerebrospinal fluid (CSF) is an ideal medium to research such biomarkers due to its proximity to the brain. OBJECTIVE: To investigate the safety and feasibility of research lumbar punctures (LP) in HD. METHODS: HDClarity is an ongoing international biofluid collection initiative built on the Enroll-HD platform, where clinical assessments are recorded. It aims to recruit 1,200 participants. Biosamples are collected following an overnight fast: blood via venipuncture and CSF via LP. Participants are healthy controls and HD gene expansion carriers across the disease spectrum. We report on monitored data from February 2016 to September 2019. RESULTS: Of 448 participants screened, 398 underwent at least 1 sampling visit, of which 98.24% were successful (i.e., CSF was collected), amounting to 10,610 mL of CSF and 8,200 mL of plasma. In the total 572 sampling visits, adverse events were reported in 24.13%, and headaches of any kind and post-LP headaches in 14.86% and 12.24%, respectively. Frequencies were less in manifest HD; gender, age, body mass index and disease burden score were not associated with the occurrence of the events in gene expansion carriers. Headaches and back pain were the most frequent adverse events. CONCLUSION: HDClarity is the largest CSF collection initiative to support scientific research into HD and is now stablished as a leading resource for HD research. Our data confirm that research LP in HD are feasible and acceptable to the community, and have a manageable safety profile.

Prone position: A possible method to decrease post dural puncture headache (PDPH) during surgery.

OBJECTIVES: Postdural puncture headache (PDPH) is a complication associated with spinal and epidural anesthesia, characterized by a very severe dull, non-throbbing positional headache along with nausea, vomiting and other symptoms. The aim of this study was to compare positional character of PDPH, where the effects of prone and supine positions during surgery were compared for the risk of the headache. METHODS: This cohort study, was carried out at (XXX) University of Medical Sciences from June 2019 to June 2020 after the approval from the Ethical Committee. 1416 patients participated in this study among whom either supine or prone positions were used for the surgery, based on the type of surgical requirements. All patients received spinal where, 18-gauge cannula was inserted and lactated ringer 4 mL per Kg per hour was used for the administration. Using an aseptic technique, a 26-gauge Quincke needle was inserted intrathecally via a midline approach into the L3-L4 or L4-L5 interspace with the patient in the sitting position. Patients received 10 mg 0.5% hyperbaric bupivacaine. 444 patients were operated in the prone position during surgery (P group) and the 972 patients were in the supine position (S group). RESULTS: We compared the rate of PDPH between the two groups. 3 (0.68%) patients with pilonidal sinus were operated in prone position experienced headache and 87 of those operated in supine position (8.95%) had headache (P < 0.001); and the odds ratio of developing headache when operated in supine position was 13.16. CONCLUSIONS: Prone position during surgery appears to be a reliable way to reduce PDPH following spinal or epidural anesthesia.

Sensorineural hearing loss following lumbar puncture, spinal anaesthesia or epidural anaesthesia: a case series and literature review.

BACKGROUND: Sensorineural hearing loss following spinal anaesthesia, epidural anaesthesia or lumbar puncture is a rare phenomenon that is thought to occur when reduced cerebrospinal fluid pressure is transmitted to the inner ear through an enlarged cochlear aqueduct. METHOD: This study presents two cases of sensorineural hearing loss following spinal anaesthesia for caesarean section as well as presenting results of a systemic review of the available literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. Risk factors associated with poorer outcomes and an approach to management of this rare condition are also discussed. RESULTS: Twenty-one cases were identified. The literature was systematically reviewed showing presentations, investigations performed, treatments offered and outcomes. CONCLUSION: Sensorineural hearing loss following spinal anaesthesia, epidural anaesthesia or lumbar puncture is a rare occurrence that requires a high degree of clinical suspicion and prompt investigation and treatment.

Lumbar puncture: considerations, procedure, and complications.

Lumbar puncture is an important technique used to obtain cerebrospinal fluid, administer medications, and monitor intracerebral pressure. As essential invasive approach to diagnosing and treating central nervous system disorders, clinicians should be familiar with lumbar puncture. This review includes the considerations, contraindications, procedures, and complications of lumbar puncture.