Thoracic abscess due to unusual migration of a ventriculoperitoneal shunt and literature review

Background: Thoracic complications of ventriculoperitoneal (VP) cerebrospinal fluid shunting are rare and the diagnosis is difficult without neurological impairment. Case Description: We report a case of a 36-year-old woman who had a VP shunt in the right side when she was 13 years for a posterior fossa ependymoma and hydrocephalus. 23 years after surgery, she developed acute yellowfish cough and sputum, and the computed tomography scan found an intrathoracic cyst. She had a thoracotomy for the cyst and during surgery, we found the peritoneal catheter of the VP shunt, with a collected abscess in the left side. The patient was treated for the abscess and the VP shunt was removed. We also review the literature cases of thoracic complications after VP shunts. Conclusion: Thoracic abscess due to VP shunt migration is extremely rare and could happen after a long time delay VP shunt surgery.

Normal Pressure Hydrocephalus: Revisiting the Hydrodynamics of the Brain

Normal pressure hydrocephalus syndrome is the most common form of hydrocephalus in the elderly and produces a dementia which can be reversible surgically. It is characterized by ventriculomegaly and the classic triad of symmetric gait disturbance, cognitive decline and urinary incontinence, also known as Hakim’s triad. To date, the exact etiology of the disease has not been elucidated and the only effective treatment is a cerebrospinal fluid shunting procedure which can be a ventriculoatrial, ventriculoperitoneal or lumboperitoneal shunt. The most important problem is the high rate of underdiagnosis or misdiagnosis due to similarities in symptoms with other neurodegenerative disorders, and in some cases, coexistence. Hence, increasing awareness amongst the community and medical professionals in order to increase clinical suspicion, timely diagnosis and treatment are paramount. The best way to achieve this is by having a structured protocol with patient-centered tests that evaluates the entire myriad of alterations a clinician might encounter whenever treating patients with this disorder. Recent advances in imaging technology as well as cerebrospinal fluid biomarkers have given interesting insight into the pathophysiology of the disease and will certainly contribute greatly in diagnostic advancements. We finally present an institutional protocol which has been accredited by international peers with promising results in diagnostic and outcome rates.

Serial Tap Test of Patients With Idiopathic Normal Pressure Hydrocephalus - Impact on Cognitive Function and Its Meaning

BackgroundIdiopathic normal pressure hydrocephalus (INPH) is characterized by gait disturbance, urinary incontinence and cognitive decline. Symptoms are potentially reversible and treatment is based on cerebrospinal fluid shunting. The tap test (TT) is used to identify patients that will benefit from surgery. This procedure consists on the withdrawal of 20 to 50 mL of cerebrospinal fluid (CSF) through a lumbar puncture (LP) after which the symptoms of the triad are tested. Improvement in the quality and speed of gait are already recognized but cognitive improvement depends on several factors such as tests used, time elapsed after LP for re-testing, and number of punctures. Serial punctures may trigger similar conditions as external lumbar drainage (ELD) to the organism. ObjectiveThis study aimed to identify how serial punctures affect cognition in order to increase the sensitivity of the test and consequently the accuracy of surgical indication. MethodsSixty-one patients with INPH underwent baseline memory and executive tests repeatedly following the 2-Step Tap Test protocol (2-STT – two procedures of 30 mL lumbar CSF drainage separated by a 24-hour interval). The baseline scores of INPH patients were compared with those of 55 healthy controls, and with intragroup post-puncture scores of the 2-STT. ResultsThe group with INPH had lower performance than the control group in all cognitive tests (RAVLT, Stroop, CFT, FAR-COWA, FAB, MMSE, orientation, mental control), except for the forward digit span test (p = 0.707). After conducting LP procedures, the Stroop test (words, colors and errors), RAVLT (stage A1, A6 and B1), and CFT (immediate and delayed R) scores were equal to those of the control group (p > 0.05). The INPH group presented significant improvement after the first puncture in MMSE (p = 0.031) and in the Stroop Test (points) (p < 0.001). After the second puncture, subjects improved in orientation, MMSE, RAVLT (B1), Stroop (points, words, errors) and CFT (IR). ConclusionProgressive cognitive improvement occurred over the 2-STT and changes were more significant after the second LP in all cognitive domains except for RAVLT (A7). Encephalic alert system ‘arousal’ seems to participate in early improvements observed during 2-STT. The second LP increased the sensitivity of the drainage test to detect changes in cognitive variables, and consequently improved the quality of the method.

Adult idiopathic hydrocephalus: current state of the problem

The term "idiopathic hydrocephalus" in adults is a broader concept that includes larger spectrum of patients compared to "idiopathic normotensive hydrocephalus". It includes both young and elderly patients with various forms of the disease, patients with various levels of obstruction. Th ere is no general classification and general approach to treat patients with such a pathology. Endoscopic triventriculostomy in idiopathic aqueductal stenosis and cerebrospinal fluid shunting after a positive test of cerebrospinal fluid (tap test) evacuation in idiopathic normotensive hydrocephalus are proved to be effective. In patients with other forms of cerebrospinal fluid pathway obstruction, treatment approach is represented by the opinions of some surgeons. At the same time, most surgeons consider the use of cerebrospinal fluid shunting operations to be effective and justified, and they use endoscopic techniques as an option for examining ventricular system and for performing auxiliary manipulations. The high frequency of various complications of bypass surgery and slightly lower efficiency of endoscopic operations indicates the need to systematize patients; to improve selection criteria and to expand the indications for the use of endoscopic surgical techniques.

Quality of life, need for retreatment, and the re-equilibration phenomenon after venous sinus stenting for idiopathic intracranial hypertension

BackgroundLong term failure rates after venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) are poorly understood.MethodsRetrospective analysis was performed on a prospectively-maintained single center database to identify patients with medically refractory IIH who underwent VSS. Patients with persistent or severe recurrent symptoms after VSS undergo lumbar puncture (LP), therefore LP serves as a marker for treatment failure.Results81 patients underwent VSS with a mean follow-up of 10 months; 44 (54.3%) patients underwent LP after VSS due to persistent or recurrent symptoms at a mean of 12 months (median 7, range 2–43). There was a mean decrease in opening pressure (OP) on LP from pre- to post-VSS of 9.1 cm H2O (median 9.5). Overall, a total of 21 (25.9%) patients underwent further surgical intervention following VSS, including five who underwent repeat VSS (6.2% of total) and 18 who underwent cerebrospinal fluid shunting (22.2% of total). There was a non-significant (p=0.18) but overall increase in quality of life scores from pre-stenting (61.2) to last follow-up (71.2), and a significant decrease in Headache Impact Test-6 (HIT-6) scores (p=0.03) with mean pre-stenting and last follow-up scores of 62.7 and 55.8, respectively.ConclusionsVSS is an effective treatment for venous sinus stenosis in IIH; however, this study found higher rates of symptomatic recurrence and need for further surgical intervention (26%) than previously reported in the literature. Recurrence of symptoms occurred at a median of 7 months, even though OP remained lower at follow-up LP, suggestive of a re-equilibration phenomenon.