المؤلفون: Craven, Claudia L.¹ (AUTHOR) claudia.craven@gmail.com, Sae-Huang, Morrakot¹ (AUTHOR), Hoskote, Chandrashekar² (AUTHOR), Watkins, Laurence D.¹ (AUTHOR), Reddy, Ugan³ (AUTHOR), Toma, Ahmed K.¹ (AUTHOR)

المصدر: World Neurosurgery. May2021, Vol. 149, pe942-e946. 5p.

مصطلحات موضوعية: *TRANSCRANIAL Doppler ultrasonography, *INTERNAL carotid artery, *RECEIVER operating characteristic curves, *CEREBRAL anoxia, *SUBARACHNOID hemorrhage

مستخلص: Multimodal monitoring of intracranial pressure and brain tissue oxygen tension (PbtO 2) have been increasingly used to detect delayed cerebral ischemia (DCI) after subarachnoid hemorrhage. At our center, patients who cannot be easily assessed clinically will undergo intracranial pressure and PbtO 2 monitoring via a NEUROVENT-PTO bolt. We aimed to determine whether the Lindegaard ratios (LRs) computed from transcranial Doppler ultrasonography (TCDU) would correlate with, or can predict, the simultaneously recorded PbtO 2 value. Patients with aneurysmal subarachnoid hemorrhage, PbtO 2 recordings from the middle cerebral artery territory, and simultaneous TCDU scans available from the ipsilateral middle cerebral artery and internal carotid artery from August 2018 to 2019 were included in the present study. The index test result was vasospasm (LR of ≥3) found on TCDU. The reference standard was the presence of regional hypoxia (PbtO 2 <20 mm Hg). The PbtO 2 results were compared with those from computed tomography angiography as a radiological standard. The predictive values were calculated using a contingency table and receiver operating characteristic curve. A total of 28 patients (6 men and 22 women; age, 59.04 ± 13.75 years) were identified with simultaneous brain tissue oxygen and TCDU recordings available. Of the 28 patients, 7 had cerebral hypoxia (PbtO 2 <20 mm Hg). We found no correlation between the PbtO 2 measurements and simultaneously recorded LRs (r 2 = 0.048; P = 0.26). A LR of ≥3 had high specificity (95.24%) for hypoxia but relatively low sensitivity (42.86%; P = 0.037). We find TCDU to be specific for predicting cerebral hypoxia (measured via an intraparenchymal probe). Therefore, it could be a useful and noninvasive tool in the context of preventative DCI monitoring. However, given the low sensitivity, the lack of vasospasm on TCDU should not preclude the possibility of the presence of evolving DCI. [ABSTRACT FROM AUTHOR]

المؤلفون: Craven, Claudia L., Asif, Hasan, Curtis, Carmel, Thompson, Simon D., D'Antona, Linda, Ramos, Joana, Thorne, Lewis, Watkins, Laurence D., Toma, Ahmed K.

المصدر: Journal of Clinical Neuroscience; Jun2020, Vol. 76, p15-19, 5p

مستخلص: • Leukocytosis in lumbar cerebrospinal fluid (CSF) can occur after cranial surgery. • The relevance of ascetic meningitis to remains unclear. • Immediately after minor intracranial surgery lumbar CSF white cell count raised. • This increase in CSF white cell count was not associated with organism growth. Raised white cell count (WCC) in lumbar CSF is a commonly used marker of meningitis. The effect of cranial neurosurgery per se on lumbar WCC is not established. At this single centre, many patients undergo ICPM followed by lumboperitoneal shunt (LPS), with lumbar CSF WCC samples taken during insertion. We aimed to determine the effect of ICP bolt insertion on lumbar CSF WCC. We undertook a retrospective analysis of lumbar CSF samples in patients who had recently undergone 24-h ICPM. Thirty-three patients (16F:7M) aged 43.31 ± 12.1 years (mean ± SD) had lumbar CSF samples after ICPM. Fourteen had CSF sampled within 6 weeks and 19 after 6 weeks of ICPM. Twenty-five samples were taken during LPS insertion, 5 during lumbar drainage/puncture and 3 during LPS revision. All 33 patients were afebrile at the point of CSF sampling. The mean lumbar WCC within 6 weeks of ICPM was significantly higher than the mean lumbar WCC after 6 weeks, being 15.4 ± 18.0 and 2.32 ± 1.79 cells/microlitre respectively respectively. There was no significant increase in RBC. In patients with raised CSF WCC, 60% of raised WCC were predominantly lymphoctyes and 40% predominantly neutrophils. Only one patient grew an organism (S. aureus). We conclude that lumbar CSF WCC can be raised following minor intracranial surgery, despite no clinical sign of infection. We caution against using lumbar CSF WCC values independently as the only marker of infection following neurosurgery. [ABSTRACT FROM AUTHOR]

: Copyright of Journal of Clinical Neuroscience is the property of Churchill Livingstone, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Pradini-Santos, Laura¹ (AUTHOR), Craven, Claudia L.¹ (AUTHOR) claudia.craven@gmail.com, Watkins, Laurence D.¹ (AUTHOR), Toma, Ahmed K.¹ (AUTHOR)

المصدر: World Neurosurgery. Apr2020, Vol. 136, p83-89. 7p.

مصطلحات موضوعية: *CATHETERS, *LITERATURE reviews, *ARRHYTHMIA, *TRICUSPID valve, *HEART atrium, *TRICUSPID valve insufficiency, *TRICUSPID valve diseases

مستخلص: Given recent positive safety evidence, ventriculoatrial (VA) shunt placement may increase in popularity once more. We describe a rare case of Tricuspid regurgitation due to VA shunt catheter tip traversing the valve. A woman aged 42 years with a preexisting VA shunt was referred to this center with 3 months of orthostatic headache, nausea, and palpitations that occurred while sleeping on her right side. An echocardiogram demonstrates a VA shunt catheter in the right atrium during cardiac diastole, which traversed the tricuspid annular plane during cardiac systole. The echocardiogram revealed mild to moderate tricuspid regurgitation. She had no clinical evidence of cardiac failure or arrhythmia and had normal electrocardiogram findings. The catheter tip appeared to be adhered to the underside of the leaflets or to the chordae tendineae. Pulling the catheter tip back could therefore cause irreversible damage to the tricuspid valve. For this reason, the catheter was not removed, and the patient was referred for close follow-up with cardiologists. A literature review was performed to determine where this rare complication fits into the spectrum of VA shunt distal catheter complications, and what techniques can be done to avoid similar occurrences. This report reiterates the importance of ensuring the tip is carefully placed within the atrium, under fluoroscopic guidance. Although rare, the described complication is difficult to manage once it has occurred. [ABSTRACT FROM AUTHOR]

المؤلفون: Craven, Claudia L.¹ (AUTHOR) claudia.craven@gmail.com, Pradini-Santos, Laura¹ (AUTHOR), Goel, Aimee¹ (AUTHOR), Thorne, Lewis¹ (AUTHOR), Watkins, Laurence D.¹ (AUTHOR), Toma, Ahmed K.¹ (AUTHOR)

المصدر: World Neurosurgery. Mar2020, Vol. 135, pe447-e451. 5p.

مصطلحات موضوعية: *INTRACRANIAL hypertension, *CATHETERS, *STANDARD deviations

مستخلص: Slit ventricles can be a challenging target during shunt catheter insertion. Traditionally, the frontal approach has been considered optimal for small ventricles. At this center, routine use of electromagnetic (EM) stereotactic guidance (Stealth, Medtronic, Dublin, Ireland) has enabled a parietooccipital (P-O) burr hole approach to the frontal horns. We compare shunt placement and revisions required for patients with slit ventricles who had shunts inserted via a P-O approach versus frontal shunt. We studied a retrospective cohort of patients with slit ventricles and a ventricular shunt inserted using EM guidance between 2012 and 2018. Slitlike ventricles were defined as the widest point of the lateral ventricle <3 mm. Outcome measures included placement accuracy and survival using the Kaplan-Meier curve. Optimal final catheter tip location was considered to be the frontal horn of the ipsilateral lateral ventricle. Eighty-two patients (77 female, 5 male) aged 34.9 ± 10.8 years (mean ± standard deviation) had ventricular shunts inserted for idiopathic intracranial hypertension (n = 63), chiari/syrinx (n = 8), congenital (n = 10), and pseudomeningocele (n = 1). Of those identified, 35 had primary P-O shunts and 46 had frontal shunts. Overall, 94% of cases had the catheter tip sitting in the frontal horn. The P-O approach was just as accurate as the frontal approach. Eight P-O shunts and 9 frontal shunts required revision over a 60-month period. There was no significant different in shunt survival between the 2 approaches (P = 0.37). EM-guided placement has enabled the P-O approach to be as safe and with equivalent survival to frontal approach. The accuracy of shunt placement between the 2 approaches was similar. [ABSTRACT FROM AUTHOR]

المؤلفون: Craven, Claudia L., Toma, Ahmed K., Watkins, Laurence D.

المصدر: Journal of Clinical Neuroscience; Mar2017, Vol. 37, p91-95, 5p

مستخلص: The ever present need to balance over drainage with under drainage in hydrocephalus has required innovations including adjustable valves with antigravity devices. These are activated in the vertical position to prevent siphoning. We describe a group of bedridden patients who presented with unexplained under drainage caused by activation of antigravity shunt components produced by peculiar head/body position. Retrospective single centre case series of hydrocephalus patients, treated with ventriculo-peritoneal (VP) shunt insertion between April 2014 – February 2016. These patients presented with clinical and radiological under drainage syndrome. Medical notes were reviewed for clinical picture and outcome. Radiological studies were reviewed assessing shunt placement and ventricular size. Seven patients presented with clinical and radiological under drainage syndrome. A consistent posturing of long term hyper-flexion of the neck whilst lying supine was observed. All patients had similar shunt construct (adjustable Miethke ProGAV valve and shunt assistant anti-gravity component). In each of those patients a hypothesis was formulated that neck flexion was activating the shunt assistance anti-gravity component in supine position. Five patients underwent shunt revision surgery removing the shunt assistant device from the cranium and adding an anti-gravity component to the shunt system at the chest. One had the shunt assistant completely removed and one patient was managed conservatively with mobilisation. All patients had clinical and radiological improvement. Antigravity shunt components implanted cranially in bedridden hydrocephalus patients will produce underdrainage due to head flexion induced anti-gravity device activation. In these patients, anti-gravity devices should be placed at the chest. Alternatively, special nursing attention should be paid to head-trunk angle. [ABSTRACT FROM AUTHOR]

: Copyright of Journal of Clinical Neuroscience is the property of Churchill Livingstone, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Craven, Claudia L., Toma, Ahmed K., Mostafa, Tarek, Patel, Neekhil, Watkins, Laurence D.

المصدر: Journal of Clinical Neuroscience; Dec2016, Vol. 34, p294-298, 5p

مستخلص: Objective Selecting probable idiopathic normal pressure hydrocephalus (INPH) patients for shunt insertion presents a challenge because of coexisting comorbidities and other conditions that could mimic NPH. The characteristic appearance of DESH (Disproportionately Enlarged Subarachnoid Space Hydrocephalus) on brain imaging has been shown to have a high positive predictive value in identifying shunt responsive INPH patients (SINPHONI trial). However, the negative predictive value of this radiological sign was not clearly demonstrated. The aim of the present study was to calculate the negative predictive value of the DESH sign. Methods A single centre study of probable INPH patients, who underwent ventriculoperitoneal (VP) shunt insertion. Shunt responsive INPH patients were identified as those having improvement in their walking speed, neuropsychological assessment and continence one year post operatively. Preoperative images were reviewed for DESH sign. Negative and Positive Predictive Values (NPV and PPV) of DESH sign were determined post analysis. Results A total of 103 probable INPH patients were included (31 were DESH positive (30%) and 72 were DESH negative (70%)). A total of 78 patients showed measurable improvement one year post shunt insertion (76%); 24 (31%) of these patients were DESH positive and 54 (69%) were DESH negative ( p = <0.001). Therefore, the DESH sign had an estimated PPV of 77% and NPV of 25%. Conclusion DESH sign demonstrates a low negative predictive value. We conclude that DESH negative patients should still undergo prognostic tests for iNPH, such as an extended lumbar drainage protocol, and should not be excluded from shunt insertion. [ABSTRACT FROM AUTHOR]

: Copyright of Journal of Clinical Neuroscience is the property of Churchill Livingstone, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Craven, Claudia, Reddy, Ugan

المصدر: Anaesthesia & Intensive Care Medicine; Dec2016, Vol. 17 Issue 12, p630-634, 5p

مستخلص: The brain uses large amounts of glucose for its basal energy requirements, and these are further increased during cerebral activation. In order that glucose can provide this energy, a plentiful and uninterrupted supply of oxygen is necessary. Cerebral blood flow is therefore critical for normal cerebral function. Its control is dictated by local intrinsic metabolic needs as well as extraneous factors such as arterial blood pressure, arterial carbon dioxide and oxygen tension, temperature and neural factors. This article reviews cerebral metabolism and cerebral blood flow and techniques by which both can be monitored. [ABSTRACT FROM AUTHOR]

: Copyright of Anaesthesia & Intensive Care Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Pradini-Santos, Laura¹ (AUTHOR), Craven, Claudia L.¹ (AUTHOR) claudia.craven@gmail.com, Sayal, Parag P.¹ (AUTHOR)

المصدر: World Neurosurgery. Dec2019, Vol. 132, p67-68. 2p.

مصطلحات موضوعية: *EHLERS-Danlos syndrome, *CEREBROSPINAL fluid, *INTRACRANIAL pressure, *ARNOLD-Chiari deformity, *NERVE block

مستخلص: Ehlers-Danlos syndrome can be associated with cerebrospinal fluid (CSF) disturbances including recurrent CSF leak and Chiari I malformations. Persistent pseudomeningoceles are known to be associated with raised intracranial pressure. We present an unusual case of a compressive epidural CSF collection occurring after a computed tomography−guided L5 nerve root block and describe an effective management strategy. [ABSTRACT FROM AUTHOR]

المؤلفون: Goel, Aimee¹ (AUTHOR) aimee.goel@hotmail.com, Asif, Hasan¹ (AUTHOR), Craven, Claudia¹ (AUTHOR), D'Antona, Linda¹ (AUTHOR), Das, Pranoy¹ (AUTHOR), Thorne, Lewis¹ (AUTHOR), Toma, Ahmed¹ (AUTHOR)

المصدر: World Neurosurgery. Jun2022, Vol. 162, p43-46. 4p.

مصطلحات موضوعية: *NERVE block, *SCALP, *CONDUCTION anesthesia, *PATIENT satisfaction, *INTRACRANIAL pressure, *FLUID dynamics

مستخلص: Elective insertion of intracranial pressure (ICP) monitoring bolts is useful for the diagnosis and treatment of disorders of cerebrospinal fluid dynamics. Patients typically report severe discomfort on bolt removal, which negatively impacts overall patient satisfaction of ICP monitoring. We assessed the efficacy and safety of using supratrochlear and supraorbital nerve block—a commonly used form of scalp anesthesia—alongside oral analgesia before bolt removal. We compared the efficacy and safety of regional scalp block anesthesia alongside oral analgesia versus oral analgesia alone in a cohort of 85 patients undergoing removal of diagnostic ICP bolts between June 2017 and April 2019 using retrospective patient questionnaires, as well as electronic admission documentation. We found that scalp block alongside oral analgesia improved bolt removal experience (4/5 vs. 3/5 on a 1−5 point Likert scale) and that a majority (70.6%) of patients would have preferred local anesthetic before removal in the oral analgesia−only group. Only 2 patients experienced mild and localized side effects: mild bruising and temporary facial and eyelid swelling following regional scalp block. We conclude that regional supraorbital and supratrochlear nerve block is a simple, safe, and effective adjunct to minimizing discomfort during bolt removal and improving overall patient satisfaction of ICP monitoring. [ABSTRACT FROM AUTHOR]

المؤلفون: Craven, Claudia L.¹ claudia.craven@gmail.com, Baudracco, Irene¹, Thompson, Simon D.¹, Thorne, Lewis¹, Watkins, Laurence D.¹, Toma, Ahmed K.¹

المصدر: World Neurosurgery. Feb2018, Vol. 110, pe514-e519. 1p.

مصطلحات موضوعية: *HYDROCEPHALUS, *TRAUMATIC tentorial herniation, *BRAIN injuries, *BRAIN diseases, *CEREBRAL ventricles, *THERAPEUTICS

مستخلص: Background Complex hydrocephalus affecting lateral and fourth ventricles separately is occasionally managed with cerebrospinal fluid diversion via supratentorial and infratentorial ventricular catheters. The optimal configuration to reduce complications is currently unknown in adults. We describe a consistently similar clinical presentation of patients with complex hydrocephalus and a fourth ventricle separately drained by infratentorial shunt insertion. Methods This was a retrospective single-center case series. Medical notes were reviewed for clinical presentation, brain imaging, and neurophysiologic tests results. All patients underwent intracranial pressure monitoring (ICPM). Outcomes were determined by ventricular appearance on brain imaging computed tomography and symptomatic improvements postoperatively. Results Five adult patients referred to the hydrocephalus service had separate infratentorial and supratentorial shunt systems. A common clinical presentation was observed, including lower motor neuron facial palsy (confirmed with electrophysiology), ophthalmoplegia, dysarthria, impaired gait headache, and nausea. We refer to this as transtentorial distortion syndrome. Twenty-four-hour ICPM demonstrated clear low pressures. All patients underwent shunt revision connecting the transtentorial shunts via a Y-connector and the addition of a distal valve. All subjects had improved ventricular appearance on computed tomography scans post revision, and normalization of ICPM was observed. In the follow-up period of 6 months, no patient required further shunt revision. Conclusion To prevent transtentorial distortion syndrome, supratentorial and infratentorial shunt constructs in adults with encysted fourth ventricles should be similar to the shunt systems widely known in the pediatric population with Dandy-Walker syndrome (i.e., joint output to a single valve distal to the connection of the 2 proximal drainage catheters). [ABSTRACT FROM AUTHOR]