To Shunt or Not to Shunt Patients with Idiopathic Normal Pressure Hydrocephalus? A Reappraisal of an Old Question

The possibility that the cerebral ventricles can dilate without any increase in the pressure of the cerebrospinal fluid (CSF) was recognized in 1935 by Penfield who reported a patient in whom "…the cerebrospinal fluid spaces are closed and the ventricles progressively enlarge without the measured intraventricular pressure rising above 150 to 200 mm of water"

Efectes del tractament de la hidrocefàlia crònica de l'adult

La hidrocefàlia crònica de l'adult (HCA) és una causa de demència potencialment reversible. Per això, és molt important diferenciar-la d'altres causes de demència, com l'Alzheimer o el Parkinson, que poden presentar símptomes semblants. Investigadors de l'Hospital Universitari Vall Hebron-UAB, han estudiat la cognició i comportament d'un grup de pacients per analitzar els canvis que es produeixen després del tractament i descriure les variables que infueixien en la millora dels pacients per així poder diferenciar els pacients que presenten aquest síndrome dels altres.La hidrocefalia crónica del adulto (HCA) es una causa de demencia potencialmente reversible. Por ello, es muy importante diferenciarla de otras causas de demencia, como el Alzheimer o el Parkinson, que pueden presentar síntomas similares. Investigadores del Hospital Universitario Vall Hebron-UAB, han estudiado la cognición y comportamiento de un grupo de pacientes para analizar los cambios que se producen después del tratamiento y describir las variables que influyen en la mejora de los pacientes para así poder diferenciar los pacientes que presentan este síndrome de los demás

Estudio prospectivo, longitudinal y observacional, sobre el grado de resección quirúrgica y la calidad de vida en pacientes con gliomas. Resultados de un estudio piloto

En este estudio prospectivo observacional se evaluaron 60 pacientes diagnosticados de glioma cerebral y sometidos a algún tipo de intervención quirúrgica como parte de su tratamiento. En ellos se analizaron las variables demográficas, clínicas, la localización de las lesiones, el volumen tumoral basal, así como, escalas de calidad de vida y el efecto del grado de resección tumoral (biopsia, resección parcial y resección total/subtotal) sobre las mismas. Los hallazgos de nuestro estudio confirmaron el beneficio de las resecciones tumorales amplias en la calidad de vida de los pacientes. Se discuten las dificultades técnicas de este tipo de estudio y su importancia de la incorporación de estas escalas en futuros estudios neuro-oncológicos.En aquest estudi prospectiu observacional es van avaluar 60 pacients diagnosticats de glioma cerebral i sotmesos a algun tipus d'intervenció quirúrgica com a part del seu tractament. En ells es van analitzar les variables demogràfiques, clíniques, la localització de les lesions, el volum tumoral basal, així com, escales de qualitat de vida i l'efecte del grau de resecció tumoral (biòpsia, resecció parcial i resecció total / subtotal) sobre les mateixes. Les troballes del nostre estudi van confirmar el benefici de les reseccions tumorals àmplies en la qualitat de vida dels pacients. Es discuteixen les dificultats tècniques d'aquest tipus d'estudi i la seva importància de la incorporació d'aquestes escales en futurs estudis neuro-oncològics

Mecanismes de recuperació de la comprensió del llenguatge després d'una lesió massiva de l'hemisferi dominant

Els pacients que sobreviuen a un infart hemisfèric maligne presenten greus seqüeles motores, a les quals cal afegir una afàsia global (impossibilitat d'emetre i comprendre llenguatge oral i escrit) si l'hemisferi afectat és el dominant. El tractament més eficaç per a aquests pacients és l'extracció temporal d'una part de la volta cranial per tal de permetre l'expansió del cervell inflamat. Tanmateix, aquest tractament és controvertit quan l'hemisferi infartat és el dominant, per les seqüeles esperables. L'estudi d'una pacient de 20 anys amb un infart massiu esquerre a la qual se li va aplicar aquest tractament mostra resultats inesperadament favorables.Los pacientes que sobreviven a un infarto hemisférico maligno presentan graves secuelas motoras, a las que hay que añadir una afasia global (imposibilidad de emitir y comprender lenguaje oral y escrito) si el hemisferio afectado es el dominante. El tratamiento más eficaz para estos pacientes es la extracción temporal de una parte de la bóveda craneal para permitir la expansión del cerebro inflamado. Sin embargo, este tratamiento es controvertido cuando el hemisferio infartado es el dominante por las secuelas esperables. El estudio de una paciente de 20 años con un infarto masivo izquierdo a la que se le aplicó este tratamiento muestra resultados inesperadamente favorables

Sulfonylurea Receptor 1, Transient Receptor Potential Cation Channel Subfamily M Member 4, and KIR6.2:Role in Hemorrhagic Progression of Contusion

Altres ajuts: J.M.S is supported by grants from the Department of Veterans Affairs (I01BX002889), the Department of Defense (SCI170199), the National Heart, Lung and Blood Institute (R01HL082517) and the National Institute of Neurological Disorders and Stroke (NINDS) (R01NS060801; R01NS102589; R01NS105633); V.G. is supported by a grant from NINDS (NS061934).In severe traumatic brain injury (TBI), contusions often are worsened by contusion expansion or hemorrhagic progression of contusion (HPC), which may double the original contusion volume and worsen outcome. In humans and rodents with contusion-TBI, sulfonylurea receptor 1 (SUR1) is upregulated in microvessels and astrocytes, and in rodent models, blockade of SUR1 with glibenclamide reduces HPC. SUR1 does not function by itself, but must co-assemble with either KIR6.2 or transient receptor potential cation channel subfamily M member 4 (TRPM4) to form K (SUR1-KIR6.2) or SUR1-TRPM4 channels, with the two having opposite effects on membrane potential. Both KIR6.2 and TRPM4 are reportedly upregulated in TBI, especially in astrocytes, but the identity and function of SUR1-regulated channels post-TBI is unknown. Here, we analyzed human and rat brain tissues after contusion-TBI to characterize SUR1, TRPM4, and KIR6.2 expression, and in the rat model, to examine the effects on HPC of inhibiting expression of the three subunits using intravenous antisense oligodeoxynucleotides (AS-ODN). Glial fibrillary acidic protein (GFAP) immunoreactivity was used to operationally define core versus penumbral tissues. In humans and rats, GFAP-negative core tissues contained microvessels that expressed SUR1 and TRPM4, whereas GFAP-positive penumbral tissues contained astrocytes that expressed all three subunits. Förster resonance energy transfer imaging demonstrated SUR1-TRPM4 heteromers in endothelium, and SUR1-TRPM4 and SUR1-KIR6.2 heteromers in astrocytes. In rats, glibenclamide as well as AS-ODN targeting SUR1 and TRPM4, but not KIR6.2, reduced HPC at 24 h post-TBI. Our findings demonstrate upregulation of SUR1-TRPM4 and K after contusion-TBI, identify SUR1-TRPM4 as the primary molecular mechanism that accounts for HPC, and indicate that SUR1-TRPM4 is a crucial target of glibenclamide

Malignant infarction of the middle cerebral artery in a porcine model. A pilot study

Animal models; Central nervous system; InfarctionModels animals; Sistema nerviós central; InfartModelos animales; Sistema nervioso central; InfartoBackground and purpose Interspecies variability and poor clinical translation from rodent studies indicate that large gyrencephalic animal stroke models are urgently needed. We present a proof-of-principle study describing an alternative animal model of malignant infarction of the middle cerebral artery (MCA) in the common pig and illustrate some of its potential applications. We report on metabolic patterns, ionic profile, brain partial pressure of oxygen (PtiO2), expression of sulfonylurea receptor 1 (SUR1), and the transient receptor potential melastatin 4 (TRPM4). Methods A 5-hour ischemic infarct of the MCA territory was performed in 5 2.5-to-3-month-old female hybrid pigs (Large White x Landrace) using a frontotemporal approach. The core and penumbra areas were intraoperatively monitored to determine the metabolic and ionic profiles. To determine the infarct volume, 2,3,5-triphenyltetrazolium chloride staining and immunohistochemistry analysis was performed to determine SUR1 and TRPM4 expression. Results PtiO2 monitoring showed an abrupt reduction in values close to 0 mmHg after MCA occlusion in the core area. Hourly cerebral microdialysis showed that the infarcted tissue was characterized by reduced concentrations of glucose (0.03 mM) and pyruvate (0.003 mM) and increases in lactate levels (8.87mM), lactate-pyruvate ratio (4202), glycerol levels (588 μM), and potassium concentration (27.9 mmol/L). Immunohistochemical analysis showed increased expression of SUR1-TRPM4 channels. Conclusions The aim of the present proof-of-principle study was to document the feasibility of a large animal model of malignant MCA infarction by performing transcranial occlusion of the MCA in the common pig, as an alternative to lisencephalic animals. This model may be useful for detailed studies of cerebral ischemia mechanisms and the development of neuroprotective strategies.The Neurotraumatology and Neurosurgery Research Unit is supported by a grant from the Departament d'Universitats, Recerca i Societat de la Informació de la Generalitat de Catalunya (SGR 2014-844). This work has been supported in part by the Fondo de Investigación Sanitaria (Instituto de Salud Carlos III) with grant FIS PI11/00700, which was co-financed by the European Regional Development Fund (ERDF) and awarded to Dr. J. Sahuquillo. A. Sánchez-Guerrero is the recipient of a personal pre-doctoral grant from the Instituto de Salud Carlos III (grant number grant number FI12/00074)

Immune cell profiling of the cerebrospinal fluid enables the characterization of the brain metastasis microenvironment

Brain metastases are the most common tumor of the brain with a dismal prognosis. A fraction of patients with brain metastasis benefit from treatment with immune checkpoint inhibitors (ICI) and the degree and phenotype of the immune cell infiltration has been used to predict response to ICI. However, the anatomical location of brain lesions limits access to tumor material to characterize the immune phenotype. Here, we characterize immune cells present in brain lesions and matched cerebrospinal fluid (CSF) using single-cell RNA sequencing combined with T cell receptor genotyping. Tumor immune infiltration and specifically CD8 + T cell infiltration can be discerned through the analysis of the CSF. Consistently, identical T cell receptor clonotypes are detected in brain lesions and CSF, confirming cell exchange between these compartments. The analysis of immune cells of the CSF can provide a non-invasive alternative to predict the response to ICI, as well as identify the T cell receptor clonotypes present in brain metastasis. The use of CSF for diagnosis of metastatic brain tumors could be of clinical and patient benefit. Here the authors undertake a single-cell RNA analysis of CSF and brain to determine whether the phenotype in the CSF is reflective of the phenotype in the tumo

The Sport Concussion Assessment Tool (SCAT2) for evaluating civilian mild traumatic brain injury. A pilot normative study

Self-report measures, particularly symptom inventories, are critical tools for identifying patients with persistent post-concussion symptoms and their follow-up. Unlike in military or sports-related assessment, in general civilian settings pre-injury levels of concussion-like symptoms are lacking. Normative data are available in adolescent and college populations, but no reference data exist to guide clinical adult explorations. The purpose of this study was to use the second edition of the Sport Concussion Assessment Tool (SCAT2) to profile a cohort of 60 healthy community volunteers who had not sustained a head injury. Participating volunteers underwent MRI scanning and were evaluated with the Hospital Anxiety and Depression Scale (HADS). Participants reported a median of 3 concussion-like symptoms and the 97.5 percentile score was found at 10.5 symptoms, out of a total of 22. The median severity score was 4.9 points, and 28.9 was the upper limit of the reference interval. Only 10 participants (16.7%) did not endorse any symptom. The most frequently endorsed symptom was feeling difficulty in concentrating, with 41.7% of the sample reporting it. Age, sex and general distress, anxiety and depressive symptoms were not associated with concussion-like symptoms. Our data yielded elevated cut-offs scores for both the number of symptoms and the symptom severity. In conclusion, postconcussive-like symptoms are frequent in the general non-concussed adult population and it should be taken into account in any future models developed for screening patients at risk of developing physical, cognitive, and psychological complaints following mild traumatic injury

Considerations in the Use of Gravitational Valves in the Management of Hydrocephalus. Some Lessons Learned with the Dual-Switch Valve

In the past decade, there has been a clear trend towards better outcomes in patients with hydrocephalus, especially those with normal pressure hydrocephalus (NPH). This is partly due to the availability of more sophisticated hardware and a better understanding of implants. However, there is little evidence to show the superiority of a specific type of valve over another. The most commonly reported consequence of hydrodynamic mismatch is shunt over-drainage. Simple differential pressure valves, with a fixed opening pressure or even adjustable valves, lead to non-physiologic intraventricular pressure (IVP) as soon as the patient moves into an upright posture. These valves fail to maintain IVP within physiological limits due to the changes in hydrostatic pressure in the drainage system. To solve this problem more complex third-generation hydrostatic valves have been designed. These gravitational devices aim to reduce flow through a shunt system when the patient is upright but there are important technical differences between them. Here we review the main characteristics of the Miethke ® Dual-Switch valve, which includes two valve chambers arranged in parallel: a low-opening pressure valve, designed for working in the supine position, and a second high-opening pressure valve, which starts working when the patient assumes the upright position. This paper specifies the main advantages and drawbacks of this device and provide a series of recommendations for its use. The discussion of this specific gravitational valve allows us to emphasize the importance of using gravitational control in implanted shunts and some the caveats neurosurgeons should take into consideration when using gravitational devices in patients with hydrocephalus. The correct function of any gravitational device depends on adequate device implantation along the vertical body axis. Misalignment from the vertical axis equal to or more than 45° might eliminate the beneficial effect of these device