Idiopathic normal pressure hydrocephalus: Validation of the DESH score as a prognostic tool for shunt surgery response.

OBJECTIVE: Several radiological markers have been linked to clinical improvement after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). However, iNPH has no pathognomonic feature, and patients are still diagnosed as probable, possible, or unlikely cases based on clinical symptoms, imaging findings, and invasive supplementary tests. The predictive value of the disproportionately enlarged subarachnoid space hydrocephalus (DESH) score is not yet conclusively determined, but it might offer a more accurate diagnostic method. The aim of the present retrospective cohort study was to validate the predictive power of the DESH score for clinical improvement after shunt surgery in iNPH patients. METHODS: We retrospectively obtained presurgical MRI and/or CT scans from 71 patients with iNPH who underwent ventriculoperitoneal shunt surgery. Radiological images were evaluated for Evans index (EI), corpus callosal angle (CA), tight high convexity (THC), Sylvian fissure dilation, and focal sulci dilation. These markers were aggregated to determine the DESH score. Patient journal entries were used to subjectively determine the extent of improvement in gait function, urinary incontinence, and/or cognition as a measure of shunt surgery response. RESULTS: Multiple logistic regression analysis, controlling for age and sex (α = 0.05), showed that DESH score was significantly correlated (OR 1.77) with subjective shunt-surgery response at a minimum of 1-month follow-up. Patients with higher DESH scores were more likely to have a favorable response to shunt surgery. CONCLUSION: Aggregating radiological markers into the DESH score is useful for predicting shunt responders among iNPH patients and can aid the selection of patients for surgery. These findings provide further support for the DESH score as a diagnostic tool for iNPH.

Perfusion Computed Tomography as a Screening Tool for Pending Delayed Cerebral Ischemia in Comatose Patients After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by delayed cerebral ischemia (DCI), leading to poor outcomes. Early diagnosis of DCI is crucial for improving survival and outcomes but remains challenging in comatose patients. In this study, we aimed to evaluate computed tomography with angiography and perfusion (P-CT) as a screening modality on postictal days four and eight for impending DCI after aSAH in comatose patients using vasospasm with hypoperfusion (hVS) as a surrogate and DCI-related infarction as an outcome measure. Two objectives were set: (1) to evaluate the screening's ability to accurately risk stratify patients and (2) to assess the validity of P-CT screening. METHODS: We conducted a retrospective review of the records of comatose patients with aSAH from January 2019 to December 2021 who were monitored with P-CT scans on days four and eight. The event rates of DCI-related infarction, hVS, and endovascular rescue therapy (ERT) were analyzed, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for DCI were calculated. DCI-related infarction was defined as new secondary cerebral infarction > 48 h < 6 weeks post aSAH not attributable to other causes, and hVS was defined as arterial narrowing with corresponding hypoperfusion on P-CT. RESULTS: Fifty-six comatose patients were included, and 98 P-CT scans were performed. The incidence of DCI-related infarction was 40%. Screening P-CT on days four and eight found vasospasm in 23% of all patients, including 11% with hVS. A positive hVS on day four or eight revealed a relative risk of 2.4 [95% confidence interval (CI) 1.13-5.11, p = 0.03], sensitivity of 23% (95% CI 8-45, p = 0.03), specificity of 95% (95% CI 36-100, p = 0.03), PPV of 0.83 (95% CI 0.36-1.00, p = 0.03), and NPV of 0.65 (95% CI 0.50-0.78). Six positive P-CT scans led to digital subtraction angiography in five patients, three of whom received ERT. All ERT-intervened patients developed DCI-related infarction. CONCLUSIONS: P-CT resulted in few interventions and often resulted in late detection of DCI at an irreversible stage. Although a positive P-CT result accurately predicts impending DCI-related infarction, screening on days four and eight alone in comatose patients with aSAH often fails to timely detect impending DCI. Based on our analysis, we cannot recommend P-CT as a screening modality. P-CT is likely best used as a confirmatory test prior to invasive interventions when guided by continuous multimodal monitoring; however, prospective studies with comparison groups are warranted. The need for a reliable continuous screening modality is evident because of the high rate of deterioration and narrow treatment window.

Early spontaneous cessation of subdural drainage after burr hole evacuation of chronic subdural hematoma and risk of recurrence.

OBJECTIVE: Subdural drainage reduces recurrence after evacuation of chronic subdural hematoma (CSDH). In the present study, the authors investigated the dynamics of drain production and potentially contributing factors for recurrence. METHOD: Patients treated with a single burr hole evacuation of CSDH between April 2019 and July 2020 were included. Patients were also participants in a randomized controlled trial. All patients included, had a passive subdural drain for exactly 24 hours. Drain production, Glasgow Coma Scale score, and degree of mobilization was recorded every hour for 24 hours. A CSDH successfully drained for 24 hours is referred to as a "case". Patients were followed for 90 days. Primary outcome was symptomatic recurrent CSDH requiring surgery. RESULTS: A total of 118 cases from 99 patients were included in the study. Of the 118 cases, 34 (29%) had spontaneous drain cessation within the first 0-8 hours after surgery (Group A), 32 (27%) within 9-16 hours (Group B), and 52 (44%) within 17-24 hours (Group C). Hours of production (P < 0.000) and total drain volume (P = 0.001) were significantly different between groups. The recurrence rate was 26.5% in group A, 15.6% in group B, and 9.6% in group C (P = 0.037). Multivariable logistic regression analysis show that cases in group C (OR: 0.13, P = 0.005) are significantly less likely to recur compared to group A. Only in 8 of the 118 cases (6.8%), the drain started draining again after an interval of three consecutive hours. CONCLUSIONS: Early spontaneous cessation of subdural drain production seems to be associated with increased risk of recurrent hematoma. Patients with early cessation of drainage did not benefit from further drain time. Observations of the present study indicate personalized drainage discontinuation strategy as a potentially alternative to a specific discontinuation time for all CSDH patients.

Small ruptured intracranial aneurysms are overrepresented at the anterior and posterior communicating artery: Results of a multiple regression analysis.

Background: Anterior communicating artery (AcomA) represents the most common location for ruptured intracranial aneurysms (rIAs). Approximately 50% of all rIAs are smaller than 7 mm, but factors that lead to rupture are multifactorial. The study investigates whether AcomA location represents an independent risk factor for small size at time of rupture (<7 mm) in a cohort of aneurysmal subarachnoid hemorrhage (aSAH) when controlling for known risk factors. Methods: The aSAH cohort was retrospectively searched from our institution charts. The cohort was dichotomized into small aneurysms (<7 mm) or large aneurysms (≥7 mm). Risk factors for rupture were identified according to the unruptured intracranial aneurysm treatment score (UIATS). These were sex, age, location, smoking, hypertension, alcohol abuse, aneurysm morphology, multiplicity, previous SAH, and family history. With size as independent variable, a multiple regression analysis was performed including UIATS risk factors. Results: One-hundred and seventy-six patients were included in the study. About 49.4% of the aneurysms were <7 mm. Multiple regression analysis demonstrated that aneurysms located at AcomA and posterior communicating artery (PcomA) was significantly more frequent smaller than 7 mm, compared to middle cerebral artery (P = 0.006), internal carotid artery (other than PcomA) (P = 0.013), and posterior circulation (P = 0.017), when controlling for risk factors. Conclusion: Ruptured AcomA and PcomA aneurysms are more frequent smaller than 7 mm compared to other locations. Patients with unruptured UIA at either AcomA or PcomA may be at increased risk of rupture even if the size of the aneurysm is small. Further studies are needed to confirm this finding.

Idiopathic normal pressure hydrocephalus; treatment and outcome in the Region of Southern Denmark.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) is a prevalent and cost-effective disease to treat. However, no gold standard exists to confidently select patients for shunt surgery. The aim of this study was to investigate how patients with suspected iNPH at our center responded to shunt surgery and to compare pre-surgical variables between shunt responders and non-responders. METHODS: Preoperative baseline characteristics, MRI and/or CT scans were retrospectively obtained in 55 shunt-operated iNPH patients. Evan's index, third ventricle diameter, dilation of Sylvian fissures, tight high convexity, focal sulci, callosal angle, Rout value, MMSE score, CSF phosphorylated tau, CSF tau, and a combination of radiologic findings (DESH score) were compared according to whether or not patients expressed satisfactory response to shunt treatment at 1-month follow-up. RESULTS: Multiple logistic regression controlling for age and gender (α = 0.05) showed that tight high convexity, dilated Sylvian fissures, focal sulci, CSF tau, CSF phosphorylated tau, and DESH score correlated significantly with subjective shunt response at 1-month follow-up. CONCLUSION: In line with current literature, Shunt responders had lower levels of CSF tau and CSF phosphorylated tau compared to non-responders. While commonly used radiologic markers are of value, they can be aggregated into a score for better selection of shunt candidates.

Magnetic resonance elastography in normal pressure hydrocephalus-a scoping review.

BACKGROUND: Magnetic resonance elastography (MRE) of the brain allows quantitative measurement of tissue mechanics. Multiple studies are exploring possible applications in normal pressure hydrocephalus (NPH) in clinical and paraclinical contexts. This is of great interest in neurological surgery due to challenges related to diagnosis and prediction of treatment effects. In this scoping review, we present a topical overview and discuss the current literature, with particular attention to clinical implications and current challenges. METHODS: The protocol was based on the PRISMA extension for scoping reviews. After a systematic database search (PubMed, Embase, and Web of Science), the articles were screened for relevance. Thirty articles were subject to detailed screening, and key technical and clinical data items were extracted. The inclusion criteria included the use of MRE on human subjects with NPH. RESULTS: Seven articles were included in the final study. These studies had various objectives including the role of MRE in the assessment of regional elastic changes in NPH, shunt effect, and evaluation of NPH symptoms. MRE revealed patterns of mechanical changes in NPH that differed from other dementias. Regional MRE changes were associated with specific NPH signs and symptoms. Neurosurgical shunting caused partial normalization in tissue scaffold parameters. The studies were highly heterogeneous in technical aspects and design. CONCLUSION: MRE studies in NPH are still limited by few participants, variable cohorts, inconsistent methodologies, and technical challenges, but the approach shows great potential for future clinical application.

The risk of developing seizures before and after surgery for brain metastases.

OBJECTIVE: Several risk factors have been shown to be associated with pre- and postoperative seizures in patients undergoing neurosurgical intervention for meningiomas and other primary brain tumors. This study aimed to identify risk factors associated with pre- and postoperative seizures in patients undergoing surgery for brain metastases (BM). PATIENTS AND METHODS: 286 patients who had undergone neurosurgical resection for brain metastases between 2007 and 2015 were included in this single-center retrospective cohort. Seizure incidence and patient characteristics were recorded. Univariate and multivariate logistic regression was performed for both pre- and postoperative seizures. RESULTS: 16.8 % of patients presented with seizures before surgical intervention, and a further 7.7 % of patients developed seizures within 3 months of surgical resection of BM. Patient age, cerebellar location, large tumor size, and headache were negatively correlated with pre-operative seizures, whereas parietal location was positively correlated. Surgery for recurrent tumor was positively correlated with newly developed seizures after surgery. CONCLUSION: Age, cerebellar location, large tumor size, and headache were negatively correlated with development of seizures while parietal location was found to be a risk factor. Lower age and resection of recurrent tumors was correlated with an increased risk of developing postoperative seizures. There was no correlation between type of primary tumor and development of seizures.