Detectability of the choroid plexus of the third ventricle with magnetic resonance ventriculography.

PURPOSE: To clarify the detectability of the choroid plexus of the third ventricle (ChPl3V) with magnetic resonance ventriculography (MRVn) employing a steady-state free precession (SSFP) sequence in comparison to surgical endoscopic movies as a golden standard, as we encountered some clinical cases of total agenesis of corpus callosum (ACC) where we could not recognize the choroid plexus of the third ventricle and found no previous article addressing this problem. MATERIALS AND METHODS: This retrospective study included consecutive patients from 2010 to 2016 for whom endoscopic evaluation of the third ventricle was conducted. The anterior portion of the right and left streaks of ChPl3V was evaluated in 8 patients on 16 sites, while the posterior portion of both streaks of ChPl3V was evaluated in 13 patients on 26 sites. Sensitivity of MRVn to visualize ChPl3V with endoscopic movies as the golden standard was calculated. RESULTS: Sensitivity of MRVn in visualizing the anterior portion of ChPl3V was 0.813, and that for the posterior portion 0.692. The anterior portion of ChPl3V was visualized in all cases where no tumor contacted the foramen of Monro. CONCLUSION: MRVn visualizes the anterior portion of ChPl3V with significant sensitivity and the posterior portion with lower one.

Quantitative Computed Tomography Ventriculography for Assessment and Monitoring of Hydrocephalus: A Pilot Study and Description of Method in Subarachnoid Hemorrhage.

BACKGROUND: There is no facile quantitative method for monitoring hydrocephalus (HCP). We propose quantitative computed tomography (CT) ventriculography (qCTV) as a novel computer vision tool for empirically assessing HCP in patients with subarachnoid hemorrhage (SAH). METHODS: Twenty patients with SAH who were evaluated for ventriculoperitoneal shunt (VPS) placement were selected for inclusion. Ten patients with normal head computed tomography (CTH) findings were analyzed as negative controls. CTH scans were segmented both manually and automatically (by qCTV) to generate measures of ventricular volume. RESULTS: The median manually calculated ventricular volume was 36.1 cm3 (interquartile range [IQR], 30-115 cm3), which was similar to the median qCTV measured volume of 37.5 cm3 (IQR, 32-118 cm3) (P = 0.796). Patients undergoing VPS placement demonstrated an increase in median ventricular volume on qCTV from 21 cm3 to 40 cm3 on day T-2 and to 51 cm3 by day 0, a change of 144%. This is in contrast to patients who did not require shunting, in whom median ventricular volume decreased from 16 cm3 to 14 cm3 on day T-2 and to 13 cm3 by day 0, with an average overall volume decrease 19% (P = 0.001). The average change in ventricular volume predicted which patients would require VPS placement, successfully identifying 7 of 10 patients (P = 0.004). Using an optimized cutoff of a change in ventricular volume of 2.5 cm3 identified all patients who went on to require VPS placement (10 of 10; P = 0.011). CONCLUSIONS: qCTV is a reliable means of quantifying ventricular volume and hydrocephalus. This technique offers a new tool for monitoring neurosurgical patients for hydrocephalus, and may be beneficial for use in future research studies, as well as in the routine care of patients with hydrocephalus.

Correlations of atrial diameter and frontooccipital horn ratio with ventricle size in fetal ventriculomegaly.

OBJECTIVE Fetal ventriculomegaly (FV), or enlarged cerebral ventricles in utero, is defined in fetal studies as an atrial diameter (AD) greater than 10 mm. In postnatal studies, the frontooccipital horn ratio (FOHR) is commonly used as a proxy for ventricle size (VS); however, its role in FV has not been assessed. Using image analysis techniques to quantify VS on fetal MR images, authors of the present study examined correlations between linear measures (AD and FOHR) and VS in patients with FV. METHODS The authors performed a cross-sectional study using fetal MR images to measure AD in the axial plane at the level of the atria of the lateral ventricles and to calculate FOHR as the average of the frontal and occipital horn diameters divided by the biparietal distance. Computer software was used to separately segment and measure the area of the ventricle and the ventricle plus the subarachnoid space in 2 dimensions. Segmentation was performed on axial slices 3 above and 3 below the slice used to measure AD, and measurements for each slice were combined to yield a volume, or 3D VS. The VS was expressed as the absolute number of voxels (non-normalized) and as the number of voxels divided by intracranial size (normalized). A Pearson correlation coefficient was used to measure the strength of the relationships between the linear measures and the size of segmented regions in 2 and 3 dimensions and over various gestational ages (GAs). Differences between correlations were compared using Steiger's z-test. RESULTS Fifty FV patients who had undergone fetal MRI between 2008 and 2014 were included in the study. The mean GA was 26.3 ± 5.4 weeks. The mean AD was 18.1 ± 8.3 mm, and the mean FOHR was 0.49 ± 0.11. When using absolute VS, the correlation between AD and 3D VS (r = 0.844, p < 0.0001) was significantly higher than that between FOHR and 3D VS (r = 0.668, p < 0.0001; p = 0.0004, Steiger's z-test). However, when VS was normalized, correlations were not significantly different between AD and 3D VS (r = 0.830, p < 0.0001) or FOHR and 3D VS (r = 0.842, p < 0.0001; p = 0.8, Steiger's z-test). For GAs of 24 weeks or earlier, AD correlated more strongly with normalized 3D VS (r = 0.902, p < 0.0001) than with FOHR (r = 0.674, p < 0.0001; p < 0.0001, Steiger's z-test). After 24 weeks, there was no difference in correlations between linear measures (AD or FOHR) and 3D VS (r > 0.9). Correlations of linear measures with VS in 2 and 3 dimensions were similar, and inclusion of the subarachnoid space did not significantly alter results. CONCLUSIONS Findings in the study support the use of AD as a measure of VS in fetal studies as it correlates highly with both absolute and relative VS, especially at early GAs, and captures the preferential dilation of the occipital horns in patients with FV. Compared with AD, FOHR similarly correlates with normalized VS and, after a GA of 24 weeks, can be reported in fetal studies to provide continuity with postnatal monitoring.

Neuroendoscopic Approach to Intracranial Ependymal Cysts.

BACKGROUND: Intraparenchymal cysts without communication to the ventricles or the subarachnoid space are named ependymal or epithelial cysts. The estimated ratio of their incidence compared with arachnoid cysts is 1:10. Neurologic deficit can occur when the cyst exerts mass effect on its surroundings. We evaluated the success rate of endoscopic fenestration of intracranial ependymal cysts. METHODS: Our prospectively maintained endoscopy database was screened for all cases of ependymal cysts. The charts were retrospectively reviewed for symptoms, surgery, postoperative course, and complications. Magnetic resonance imaging scans performed before and after surgery were analyzed. RESULTS: We identified 6 patients harboring an intracranial ependymal cyst. The cyst location was frontoparietal, parietal, occipital, or mesencephalic. Patients presented with several symptoms according to the location of the cyst (i.e., epilepsy, hemiparesis, diplopia, hemianopsia). All patients were treated by navigation-guided endoscopic fenestration of the cyst to the ventricular system. Two complications occurred: a cerebrospinal fluid leak, which was managed surgically by wound revision without the need for cerebrospinal fluid shunting, and a chronic subdural hematoma, which occurred 6 weeks after surgery and required burr hole evacuation. Follow-up period ranged from 6 months to 9 years. Magnetic resonance imaging revealed that all cysts decreased in size. Symptoms improved in all patients. CONCLUSIONS: Endoscopic fenestration of ependymal cysts to an adjacent ventricular cavity is a treatment option with excellent long-term results and minimal morbidity. It should be considered as the therapy of choice to avoid craniotomy and shunt dependence.

The Pioneering and Unknown Stereotactic Approach of Roeder and Orthner from Göttingen. Part I. Surgical Technique for Tailoring Individualized Stereotactic Lesions.

During the 1950s through the 1970s, Hans Orthner and Fritz Roeder, two German neurologists from Göttingen, developed a sophisticated technique to perform functional stereotactic surgery with outstanding accuracy. They introduced direct air ventriculography performed in the same surgical session as the ablative stereotactic procedure. For individualized surgical targeting, Orthner prepared a stereotactic atlas (>60 brains) with an ingenious brain-slicing device, the Göttinger macrotome. Brains were grouped based on similarity of six different head and ventricle measurements. A brain cluster representing the best match for a patient was selected for stereotactic targeting. Stereotactic lesions were tailored in an individual manner and shaped by stringing together multiple small coagulations following intraoperative test stimulation. This was achieved from a single probe trajectory by using well-engineered string electrodes with calibrated curving and involved laborious calculations. Only high-frequency thermocoagulation was regarded as appropriate for lesioning. With this meticulous technique, the most advanced stereotactic procedures were performed, including bilateral pallidotomy that ultimately could be restricted to the ansa lenticularis and ventromedial hypothalamotomy, the most delicate stereotactic operation performed to date. Outside Göttingen, this technique has only been used by Prof. Dieter Müller in Hamburg, Germany. This elaborate stereotactic approach is widely unknown and deserves to be discussed in a historical context.

Measuring Ventricular Width on Cranial Computed Tomography: Feasibility of Dose Reduction in a Custom-Made Adult Phantom.

PURPOSE: To estimate feasible dose reduction to reliably measure ventricular width in adults with hydrocephalus in follow-up cranial computed tomography (CCT) using a custom-made phantom. MATERIALS AND METHODS: A gelatine-filled adult calvarium with embedded central fibers of two carrots representing the lateral ventricles was used as a phantom. The phantom was scanned 11 times with two CT scanners (LightSpeed Ultra, GE and Somatom Sensation, Siemens), using tube currents of 380/400, 350, 300, 250, 200, 150 and 100 mA, and tube voltages of 140, 120, 100 and 80 kV. The width of the carrots was measured at four sites in consensus decision of two principle investigators blinded to the scan parameters. Values measured at 380/400 mA and 140 kV served as a reference for the width of the ventricles. Measurements received 1 point if they did not differ more than 0.5 mm from the reference values. A maximum score of 4 could be achieved. RESULTS: The relationship between the correct width measurement of the carrots (lateral ventricles) and the radiation dose can be described by a quadratic regression function. Pixel noise increases and accuracy of measurements decreases with a lower radiation dose. Starting from a tube current of 380/400 mA and a tube voltage of 140 kV, the dose can be reduced by 76 % for LightSpeed Ultra and by 80 % for Somatom Sensation provided that a margin of error of 37.5 % (score = 2.5) for correct width measurement of the carrots is accepted. CONCLUSION: Lowering the radiation dose by up to 48 % for LightSpeed Ultra and by 52 % for Somatom Sensation, compared to the standard protocol (120 kV and 400 mA) still allowed reliable measurements of ventricular widths in this model. KEY POINTS: • There is a quadratic relationship between correct width measurements of lateral ventricles and radiation dose in CT. • Reduction of radiation dose results in increased pixel noise and increased error for correct ventricle width measurement. • Due to a considerable attenuation difference between cerebrospinal fluid and brain parenchyma, a dose reduction for the determination of ventricular size in CT seems feasible and should be performed.

[Changes in Cerebral Blood Flow and Cognitive Function in Patients Undergoing Coronary Bypass Surgery With Cardiopulmonary Bypass].

PURPOSE: to study effect of coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) on regional cerebral blood flow and cognitive function in patients with ischemic heart disease (IHD). MATERIAL AND METHODS: We included into this study 22 patients with IHD subjected to CABG surgery with CPB. All patients underwent brain SPECT scanning and comprehensive neuropsychological testing 1 day before, 10-14 days and 6 months after surgery. RESULTS: Overall CABG with CPB was followed by reduction of regional cerebral blood flow relative to baseline in frontal and parietal cortex (p < 0.01). Substantial reduction (> 5%) of cerebral perfusion in early postoperative period was observed in 15 patients (68%) while seven patients (32%) had no significant changes of regional cerebral blood flow. Changes of cerebral perfusion correlated with dynamics of cognitive status. Mean measures of immediate verbal memory, delayed memory, and learning decreased after surgery by 25.6 (p = 0.002), 43.3 (p = 0.000003), and 23.1% (p = 0.00000), respectively. Moreover after CABG with CPB patients demonstrated slowing of psychomotor speed by 13.6% (p = 0.03). CONCLUSION: CABG with CPB was associated with reduction of cerebral perfusion leading to cognitive dysfunction. Immediate and delayed verbal and visual memory, learning and psychomotor speed were most sensitive to the negative effects of surgery.

Neuroendoscopic endonasal management of cerebrospinal fluid rhinorrhea.

Neuroendoscopic endonasal approach has gained popularity in managing traumatic, spontaneous, and especially iatrogenic cerebrospinal fluid (CSF) rhinorrhea. The authors examined 8 patients presenting with CSF rhinorrhea between December 2012 and June 2014: 5 patients had iatrogenic leak, 2 patients had traumatic leak, and 1 patient had a spontaneous onset of CSF rhinorrhea. Sites of the CSF leaks were detected through computed tomographic cisternography and magnetic resonance imaging in the patients with traumatic and spontaneous leaks. All patients received neuroendoscopic endonasal surgery for the CSF leak. The largest defect was 22 mm in maximum diameter. Endoscopic supraciliary "keyhole" approach was performed in 1 patient after confirmation of a frontal sinus leak using the endoscopic endonasal approach. The success rate was 100% in the first attempt. Follow-up period ranged from 3 to 24 months, and no recurrence was reported. Identifying the leak site and choosing the appropriate surgical technique remain the most important factor in surgical success.

Minimally invasive cone beam CT-guided evacuation of parenchymal and ventricular hemorrhage using the Apollo system: proof of concept in a cadaver model.

INTRODUCTION: The Apollo system (Penumbra Inc, Alameda, California, USA) is a low profile irrigation-aspiration system designed for the evacuation of intracranial hemorrhage. OBJECTIVE: To demonstrate the feasibility of using Apollo in combination with cone beam CT guidance. METHODS: Parenchymal (n=1) and mixed parenchymal-intraventricular hematomas (n=1) were created in cadaver heads using a transvascular (n=1) or transcranial (n=1) approach. Hematomas were then imaged with cone beam CT (CB-CT), and the long axis of the hematoma defined. The CB-CT data were then used to guide transcranial access to the hematoma-defining the location of the burr hole and the path to the leading edge of the hematoma. An 8F vascular sheath was then placed under live fluoroscopic guidance into the hematoma. A second CB-CT was performed to confirm localization of the sheath. The hematoma was then demarcated on the CB-CT and the Apollo wand was introduced through the 8F sheath and irrigation-aspiration was performed under (periodic) live fluoroscopic guidance. The operators manipulated the wand within the visible boundaries of the hematoma. After irrigation-aspiration, a control CB-CT was performed to document reduction in hematoma volume. RESULTS: Transvascular and transcranial techniques were both successful in creating intracranial hematomas. Hematomas could be defined with conspicuity sufficient for localization and volumetric measurement using CB-CT. Live fluoroscopic guidance was effective in navigating a sheath into the leading aspect of a parenchymal hematoma and guiding irrigation-aspiration with the Apollo system. Irrigation-aspiration reduced the parenchymal hemorrhage volume from 14.8 to 1.7 cc in 189 s in the first case (parenchymal hemorrhage) and from 26.4 to 4.1 cc in 300 s in the second case (parenchymal and intraventricular hemorrhage). CONCLUSIONS: The cadaver model described is a useful means of studying interventional techniques for intracranial hemorrhage. It seems feasible to use CB-CT to guide the evacuation of intraparenchymal and intraventricular hemorrhage using the Apollo system through a minimally invasive transcranial access.

Singular case of third ventricle metastasis of colorectal carcinoma--case report.

Third ventricle tumors are uncommon central nervous system lesions and unusual locations for metastatic colorectal cancer. We present a case of a 68 year old woman with a solitary 3rd ventricle lesion found on a computed tomography scan of the brain and the synchronous mass of the right colon. The aim in this case was local control of cerebral lesion with pathological diagnosis. Surgery was followed by a short-term good evolution but with sudden death.

Pilot study of radiation dose reduction for pediatric head CT in evaluation of ventricular size.

BACKGROUND AND PURPOSE: CT is a ubiquitous, efficient, and cost-effective method to evaluate pediatric ventricular size, particularly in patients with CSF shunt diversion who often need emergent imaging. We therefore sought to determine the minimum dose output or CT dose index required to produce clinically acceptable examinations. MATERIALS AND METHODS: Using a validated noise insertion method and CT projection data from 22 patients, standard pediatric head CT images were reconstructed with weighted filtered back-projection and sinogram-affirmed iterative reconstruction corresponding to routine, 25%, and 10% dose. Reconstructed images were then evaluated by 3 neuroradiologists (blinded to dose and reconstruction method) for ventricular size, diagnostic confidence, image quality, evidence of hemorrhage, and shunt tip location, and compared with the reference standard. RESULTS: There was no significant difference in the ventricular size ranking, and the sensitivity for moderate to severe hydrocephalus was 100%. There was no significant difference between the full-dose level and the ventricular size rankings at the 25% or the 10% dose level for either reconstruction kernel (P > .979). Diagnostic confidence was maintained across doses and kernel. Hemorrhage was more difficult to identify as image quality degraded as dose decreased but was still seen in a majority of cases. Shunts were identified by all readers across all doses and reconstruction methods. CONCLUSIONS: CT images having dose reductions of 90% relative to routine head CT examinations provide acceptable image quality to address the specific clinical task of evaluating ventricular size.

Characterization of intraventricular and intracerebral hematomas in non-contrast CT.

Characterization of hematomas is essential in scan reading, manual delineation, and designing automatic segmentation algorithms. Our purpose is to characterize the distribution of intraventricular (IVH) and intracerebral hematomas (ICH) in NCCT scans, study their relationship to gray matter (GM), and to introduce a new tool for quantitative hematoma delineation. We used 289 serial retrospective scans of 51 patients. Hematomas were manually delineated in a two-stage process. Hematoma contours generated in the first stage were quantified and enhanced in the second stage. Delineation was based on new quantitative rules and hematoma profiling, and assisted by a dedicated tool superimposing quantitative information on scans with 3D hematoma display. The tool provides: density maps (40-85HU), contrast maps (8/15HU), mean horizontal/vertical contrasts for hematoma contours, and hematoma contours below a specified mean contrast (8HU). White matter (WM) and GM were segmented automatically. IVH/ICH on serial NCCT is characterized by 59.0HU mean, 60.0HU median, 11.6HU standard deviation, 23.9HU mean contrast, -0.99HU/day slope, and -0.24 skewness (changing over time from negative to positive). Its 0.1(st)-99.9(th) percentile range corresponds to 25-88HU range. WM and GM are highly correlated (R (2)=0.88; p<10(-10)) whereas the GM-GS correlation is weak (R (2)=0.14; p<10(-10)). The intersection point of mean GM-hematoma density distributions is at 55.6±5.8HU with the corresponding GM/hematoma percentiles of 88(th)/40(th). Objective characterization of IVH/ICH and stating the rules quantitatively will aid raters to delineate hematomas more robustly and facilitate designing algorithms for automatic hematoma segmentation. Our two-stage process is general and potentially applicable to delineate other pathologies on various modalities more robustly and quantitatively.

Safety and feasibility of combined coiling and neuroendoscopy for better outcomes in the treatment of severe subarachnoid hemorrhage accompanied by massive intraventricular hemorrhage.

Subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) is associated with poor outcomes. The aim of this study was to evaluate the safety and feasibility of combined coiling and neuroendoscopy for treating severe SAH with massive IVH. Between April 2008 and June 2011, 49 patients with a severe SAH were treated at the Department of Neurosurgery, Fukuoka University, Japan; 10 of these patients had a massive IVH with a ruptured aneurysm. All 10 patients (three men and seven women; mean age, 63.1±8.5 years) were treated with coiling and neuroendoscopic removal of the IVH within 2 days of onset. Coiling was successfully performed at a mean volume embolization ratio of 21.8±5.5%. Neuroendoscopic removal of the IVH reduced the mean Graeb score from 10.5±2.0 to 4.8±2.5 (p=0.005). All external drains were removed on day 3. No rebleeding or acute hydrocephalus was noted. The Glasgow Outcome Scale scores at discharge indicated two patients with good recovery, three with moderate disability, four in a vegetative state, and one dead. A good modified Rankin Scale (mRS) score (0-2) at least 6 months later (mean follow-up period, 15.4±9.2 months) was observed for five patients (50%), and a poor mRS score (3-6) was observed for the remaining four patients. Neuroendoscopically removing the IVH from all of the ventricles between the lateral and the fourth ventricle and coiling the ruptured aneurysm is a safe, feasible approach for treating severe SAH with massive IVH.

Imaging findings of intraventricular and ependymal lesions.

Intraventricular and ependymal lesions comprise a wide spectrum of tumoral, cystic, vascular, infectious and inflammatory disorders. With respect to tumoral and cystic diseases, the location, age and CT and MRI patterns are the main factors for diagnosis. The MRI findings of infectious diseases are supported by the clinical history, immune status and laboratory findings. Intracranial associated lesions may be very helpful for the diagnosis of Sturge-Weber, subependymal giant cell astrocytoma and systemic diseases, such as sarcoidosis and histiocytosis. Intraventricular vascular lesions are rare but present typical features on neuroimaging. The aim of this review is to provide a detailed description of these disorders with an emphasis on the key imaging findings and to generate a narrow differential diagnosis. We present a diagnostic approach based on the solid or cystic aspect of the intraventricular focal mass, its origin from the ventricular wall or choroid plexus and its location within the ventricular system. We also propose a differential diagnosis for ependymal dissemination: the ependymal enhancement may be due to ventriculitis from adjacent parenchymal lesions, the ependymal spread of tumors or infectious or inflammatory/systemic diseases.

Usefulness of intraoperative magnetic resonance ventriculography during endoscopic third ventriculostomy.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is the preferred method for the treatment of noncommunicating hydrocephalus. The different success rates of ETV indicate the difficulties in predicting the success of this procedure. OBJECTIVE: To show the usefulness of intraoperative ventriculography performed by the low-field 0.15-T magnetic resonance imager Polestar N20 during ETV. METHODS: The study was conducted in 11 patients with noncommunicating hydrocephalus caused by tumors or cysts of the third ventricle (n = 5), nontumoral stenosis of the sylvian aqueduct (n = 3), and fourth ventricle outlet obstruction (n = 3). Intraoperative magnetic resonance (iMR) ventriculography was performed before and after the ETV. RESULTS: In each case, iMR-ventriculography was a safe procedure and determined the exact site of obstruction of cerebrospinal fluid flow. In all cases, iMR-ventriculography performed after ETV showed with the greatest accuracy the patency of the performed fenestrations, demonstrating in 9 patients good flow of the contrast from the third ventricle to the basal cisterns, restricted flow in 1 patient, and no flow in 1 patient. The results of ventriculography were consistent with the postoperative neurological status of operated-on patients. In 3 patients, the opinion of the surgeons about the patency of endoscopic fenestration, based on intraoperative observation of the third ventricle floor, was inconsistent with the results from iMR-ventriculography. CONCLUSION: Low-field iMR-ventriculography is a safe procedure that can be successfully applied during ETV to determine the site of obstruction in hydrocephalus and the patency of performed ventricle fenestration.

Role of magnetic resonance ventriculography in multiloculated hydrocephalus.

OBJECT: In this paper the authors' goal was to investigate the clinical usefulness of Gd-enhanced MR ventriculography (MRV) in pediatric patients affected by multiloculated hydrocephalus. METHODS: Eighteen patients (11 boys and 7 girls, age range 2-14 months) with a diagnosis of multiloculated hydrocephalus were included in the study. After injection of gadodiamide (0.02-0.04 mmol) into the lateral ventricle by tapping the anterior fontanel, sagittal, coronal, and axial T1-weighted MR images were acquired. The location of the septations and the sites of obstruction of CSF flow were assessed. Postoperative MRV was obtained to confirm the results of endoscopic treatment in most complex cases. RESULTS: No adverse events were observed after injection of contrast medium into the ventricular system. Preoperative MRV accurately defined the exact morphology of septae and ventricular walls in all cases. In 1 case the diagnosis of multiloculated hydrocephalus was ruled out. Sites of obstruction of CSF flow within the ventricular system were also well established. In 4 cases the multiple compartments were proven to intercommunicate. Postoperative MRV was useful in assessing the functional status of third ventriculostomy, aqueductoplasty, and other endoscopic fenestrations. CONCLUSIONS: Magnetic resonance ventriculography is a safe, effective, and reliable technique. The accurate definition of the anatomy of the ventricles and the site of obstruction in multiloculated hydrocephalus can help to plan the most appropriate treatment and minimize the number of procedures. Although MRV is also useful during postoperative follow-up to determine the results of endoscopic treatment, it should be limited to particularly complex cases, due to its invasiveness.

Extents of white matter lesions and increased intraventricular extension of intracerebral hemorrhage.

OBJECTIVES: To determine whether the extent of white matter lesions on a CT scan of acute intracerebral hemorrhage patients is associated with the prevalence and severity of intraventricular extension of hemorrhage. DESIGN AND SETTING: A post hoc analysis of Acute Brain Bleeding Analysis-IntraCerebral Hemorrhage cohort, a nationwide prospective cohort of acute intracerebral hemorrhage patients (total number of cohort subjects, 1,604). PATIENTS: Spontaneous intracerebral hemorrhage patients (n = 1,262). INTERVENTIONS: None. MEASUREMENTS: The authors analyzed CT scan images taken within 48 hours after stroke onset. Extent of white matter lesions, volume of intracerebral hemorrhage, presence of intraventricular extension of hemorrhage, and intraventricular extension of hemorrhage score (approximation of intraventricular extension of hemorrhage volume) were measured using CT scans, and demographic, laboratory, clinical, and mortality data were also gathered through review of medical records and retrieval from the governmental statistical archive. MAIN RESULTS: The frequency of intraventricular extension of hemorrhage in our population was 27.2% (343 subjects). The proportion of extensive white matter lesions in intraventricular extension of hemorrhage subjects (33.8%) was higher than that of non-intraventricular extension of hemorrhage cases (16.3%; p < 0.01). Multivariable analysis showed that mild (odds ratio, 1.48; 95% confidence interval 1.05- 0.09; p < 0.01) and extensive (odds ratio, 2.73; 95% confidence interval 1.88-3.98; p < 0.01) white matter lesions were significantly associated with the presence of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage patients. The estimated mean of the intraventricular extension of hemorrhage score from the extensive white matter lesions group (9.09 ± 0.76) was significantly higher than that of the no white matter lesions group (6.72 ± 0.78; p < 0.01 from analyses of covariances) after adjustment for relevant covariates. CONCLUSIONS: We documented that the severity of white matter lesions is related to the occurrence and amount of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage cases.

MR and CT of brain's cava.

The Cavum Septi Pellucidi (CSP), Cavum Vergae (CV) and Cavum Veli Interpositi, are anatomical variants located in the midline of the brain. It is important to identify these conditions to distinguish them from other entities that may require treatment. In this paper, our purpose is to describe MR and CT findings of CSP, CV and Cavum Veli Interpositi, explaining the differential diagnosis.

Indocyanine green angiography in endoscopic third ventriculostomy.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become a well-established method for the treatment of noncommunicating hydrocephalus with a high success rate and a relatively low morbidity rate. However, vessel injury has been repeatedly reported, often with a fatal outcome. Vessel injury is considered to be the most threatening complication. The use of indocyanine green (ICG) angiography has become an established tool in vascular microneurosurgery. OBJECTIVE: We report our initial experience with endoscopic ICG angiography in ETV for intraoperative visualization of the basilar artery and its perforators to reduce the risk of vascular injury. METHODS: Eleven patients with noncommunicating hydrocephalus underwent ETV. Before opening of the third ventricular floor, ICG angiography was performed using a prototype neuroendoscope for intraoperative visualization of ICG fluorescence. RESULTS: In 10 patients, ETV and ICG angiography were successfully performed. In 1 case, ICG angiography failed. Even in the presence of an opaque floor of the third ventricle (n = 5), ICG angiography clearly demonstrated the course of the basilar artery and its major branches and was considered useful. CONCLUSION: ICG angiography has the potential to become a useful adjunct in ETV for better visualization of vessel structures, especially in the presence of aberrant vasculature, a nontranslucent floor of the third ventricle, or in case of reoperations.