Change in Balance and Neuropsychological Measures Post-Lumbar Drain Trial in Patients with Suspected Normal Pressure Hydrocephalus

<b><i>Objective:</i></b> Ventriculoperitoneal (VP) shunting is commonly used to treat normal pressure hydrocephalus (NPH). Assessment of cognition and balance pre- and post-lumbar drain (LD) can be used to provide objective metrics which may help determine the potential benefit of VP shunting. The aim of this investigation was to determine which measures identify clinical change as a result of a LD trial and to develop recommendations for standard NPH clinical assessment procedures. <b><i>Methods:</i></b> The Berg Balance Scale (BBS) and a brief battery of commonly used neuropsychological tests pre- and post-LD (MMSE, trail making test, animal fluency, Hopkins Verbal Learning Test – Revised, and digit span) were administered to 86 patients with a diagnosis of NPH. Subjects were divided into groups based on whether or not clinical change was present, and thus, VP shunting was recommended post-LD, and predictors of group membership were examined. <b><i>Results:</i></b> Significant improvements (<i>p</i> &#x3c; 0.05) were seen on the BBS and Trail Making Part B in the VP shunt-recommended group, with no other significant changes over time in either group. Regression analyses found that VP shunt recommendation was accurately predicted for 80% of the sample using the BBS score alone, with accuracy increasing to 85% when Trails B was added. <b><i>Conclusions:</i></b> Scores from the BBS and Trails B were most likely to change in those chosen to undergo VP shunting post-LD. Given that the typical clinical presentation of NPH includes gait disturbance and cognitive impairment, it is recommended that a standard pre-/post-LD evaluation include the BBS and trail making test.

The neurosurgical management of sinonasal malignancies involving the anterior skull base: a 28-year experience at The MD Anderson Cancer Center

OBJECTIVE Sinonasal malignancies that extend to the anterior skull base frequently require neurosurgical intervention. The development of techniques for craniofacial resection revolutionized the management of these neoplasms, but modern and long-term data are lacking, particularly those related to the incorporation of endoscopic techniques and novel adjuvant chemotherapeutics into management schema. The present study was performed to better define the utility of surgical management and to determine factors related to outcome. METHODS Patients who underwent surgery between 1993 and 2020 were included in this retrospective cohort study. Only patients with greater than 6 months of clinical and radiological follow-up were included. Outcome measures included progression, survival, and treatment-related complications. RESULTS Two hundred twenty-five patients were included. The mean clinical follow-up was 6.5 years. The most common histological diagnosis was olfactory neuroblastoma (33%). Overall, metastatic disease and brain invasion were present in 8% and 19% of patients, respectively, at the time of surgery. A lumbar drain was used in 54% of patients. When stratified by decade, higher-stage disease at surgery became more frequent over time (15% of patients had metastatic disease in the 3rd decade of the study period vs 4% in the 1st decade). Despite the inclusion of patients with progressively higher-stage disease, median overall survival (OS) remained stable in each decade at approximately 10 years (p = 0.16). OS was significantly worse in patients with brain invasion (p = 0.006) or metastasis at the time of surgery (p = 0.014). Complications occurred after 28% of operations, but typically resulted in no long-term negative sequelae. Use of a lumbar drain was a significant predictor of complications (p = 0.02). Permanent ophthalmological disabilities were observed after 4% of surgical procedures. One patient died during the perioperative period. Finally, major complications (Clavien-Dindo grade ≥ IIIb) decreased from 27% of patients in the 1st decade to 10% in the 3rd decade (p = 0.007). CONCLUSIONS The surgical management of sinonasal malignancies with anterior skull base involvement is effective and generally safe. Surgical management, however, is only one facet of the overall multimodal management paradigms created to optimize patient outcomes. Survival outcomes have remained stable despite more extensive disease at surgery in patients who have presented in recent decades. The safety of such surgery has improved over time owing to the incorporation of endoscopic surgical techniques and the avoidance of lumbar spinal drainage with open resection.

Ruptured Suprasellar Dermoid Cyst Treated With Lumbar Drain to Prevent Postoperative Hydrocephalus: Case Report and Focused Review of Literature

Background: Ruptured intracranial dermoid cysts are extremely rare. Standard treatment consists of endonasal decompression or craniotomy with evacuation and copious irrigation of subarachnoid spaces to remove any disseminated cystic contents. Disseminated fat particles in the subarachnoid space may be the cause of further sequalae, including the subsequent development of chemical meningitis and hydrocephalus. Here, we present a case of ruptured suprasellar dermoid cyst treated with craniotomy for emergent optic nerve decompression, followed by postoperative hydrocephalus successfully treated with lumbar drain.Case description: We describe a 30-year-old man with a history of migraines who presented with acute onset of headache, photophobia, nausea, vomiting, and vision loss in the left eye. Head CT and brain MRI demonstrated a ruptured suprasellar dermoid cyst with associated mass effect on the optic nerves and frontal lobes as well as fat attenuation material within the subarachnoid spaces. The patient underwent left frontotemporal craniotomy for cyst resection and developed non-obstructive hydrocephalus on postoperative day 1, refractory to external ventricular drainage. Placement of a lumbar drain cleared the subarachnoid space of debris derived from the ruptured dermoid cyst, and the hydrocephalus resolved. The patient did not require permanent CSF diversion.Conclusions: Intracranial dermoid cysts are uncommon, and rupture is a rare event. Standard surgical treatment with craniotomy for evacuation may leave disseminated dermoid contents and fat particles throughout the subarachnoid spaces. We highlight a case of ruptured suprasellar dermoid cyst with postoperative communicating hydrocephalus treated with lumbar drain when external ventricular drain (EVD) was ineffective. Review of the current literature reveals inconsistent findings on the effects of remaining fat particles. In cases with clinical evidence of increased intracranial pressure due to non-obstructive hydrocephalus attributable to chemical meningitis, temporary lumbar drainage is an option to be considered before committing the patient to permanent shunting.

Lumbar drain for CSF leakage: a word of caution

A continuous lumbar drain is a frequently practiced procedure to prevent cerebrospinal fluid (CSF) infection in post-operative neurosurgical cases. However, the level of CSF drained must correspond to the intracranial pressures, where any accidental increase in lumboventricular gradient by slipping of the drainage bag below the level of the iliac crest can lead to over drainage and catastrophe. The learning point is to use automated or manual measures to monitor Intra-Cranial Pressure (ICP) and sound alarm in such an event to prevent sagging of the brain.

Case Series of Rapid Surgical Interventions in Fulminant Intracranial Hypertension

Aims: Examine ophthalmologic outcomes and complications of lumbar drain and cerebrospinal fluid shunts in pediatric fulminant intracranial hypertension. Methods: Patients under 21 years of age with a diagnosis of fulminant intracranial hypertension with temporary lumbar drain only, shunt after lumbar drain, and shunt only were included. Parameters investigated include lumbar drain data, medication freedom, time to resolution of papilledema, improvement in cranial nerve palsy, afferent pupillary defects, visual fields, visual acuity, and complications of each intervention. Results: Four patients had temporary lumbar drain, 2 temporary lumbar drain and cerebrospinal fluid shunt, and 3 shunt only. All achieved medication freedom and resolution of papilledema and cranial nerve palsies (if present). Most had resolution of preprocedure afferent pupillary defects. Minor residual visual field deficits occurred in 67%, and all had visual acuity improvement. One patient’s lumbar drain dislodged, and one patient had 2 cerebrospinal fluid shunt revisions. Conclusion: Temporary lumbar drain with medical therapy may be a viable first approach to fulminant intracranial hypertension.

Quantitative Evaluation of Gait Changes Using APDM Inertial Sensors After the External Lumbar Drain in Patients With Idiopathic Normal Pressure Hydrocephalus

Objectives: Gait and balance disturbances are common symptoms of idiopathic normal pressure hydrocephalus (iNPH). This study aimed to quantitatively evaluate gait and balance parameters after external lumbar drainage (ELD) using APDM inertial sensors.Methods: Two-minute walkway tests were performed in 36 patients with suspected iNPH and 20 healthy controls. A total of 36 patients underwent ELD. According to clinical outcomes, 20 patients were defined as responders, and the other 16 as non-responders. The gait parameters were documented, and the corresponding differences between responders and non-responders were calculated.Results: When compared with healthy controls, patients with suspected iNPH exhibited decreased cadence, reduced gait speed, a higher percentage of double support, decreased elevation at mid-swing, reduced foot strike angle, shorter stride length, difficulty in turning, and impaired balance functions. After the ELD, all these manifestations, except elevation at mid-swing and balance functions, were significantly improved in responders. The change of Z-score absolute value in the six parameters, except for foot strike angle, was &gt;1. No significant improvement was observed in non-responders.Conclusion: APDM inertial sensors are useful for the quantitative assessment of gait impairment in patients with iNPH, which may be a valuable tool for identifying candidates that are suitable for shunting operations.