Neurosurgery Blog

J Neurosurg 113:1326–1330, 2010. (DOI: 10.3171/2010.8.JNS1067)

Managing symptomatic ventriculoperitoneal shunts with no clear evidence of shunt malfunction either clinically or radiologically can be a difficult task. The aim of this study was to assess intracranial pressure (ICP) monitoring as a method of investigating shunt function.

Methods. The authors performed a retrospective analysis of 38 continuous ICP monitoring procedures done in patients with ventriculoperitoneal shunts and suspected shunt malfunction.

Results. Thirty-eight procedures were performed in 31 patients between January 2005 and October 2008. Sixteen recordings were normal, 6 revealed overdrainage or low pressure, 11 indicated underdrainage or high pressure, and 5 showed variable shunt function. Based on the findings after 20 procedures (53%), patients were treated conservatively: 4 by readjusting the valve setting and 16 by referral to the headache neurologist for medical treatment. Forty-five percent of the conservatively treated patients improved. Surgical exploration was undertaken following 18 procedures (47%); 72% of the surgically treated patients improved.

Conclusions. Continuous ICP monitoring using an intraparenchymal probe is a safe and effective method of investigating adult hydrocephalus.

Stroke. 2010;41:2108-2129. DOI: 10.1161/STR.0b013e3181ec611b

Purpose—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

Methods—A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time.

Results—Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

Conclusions—Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

J Neurosurg 112: 399–409, 2010. (DOI: 10.3171/2009.4.JNS081664)

Object. The test-retest method is commonly used in the management of patients with normal-pressure hydrocephalus (NPH). One of the most widely used techniques in the diagnosis of this condition is evaluation of the
patient’s response to CSF evacuation by lumbar puncture (a so-called tap test or spinal tap). However, interpretation of improved results in subsequent evaluations is controversial because higher scores could reflect a real change in specific abilities or could be simply the result of a learning effect.
Methods. To determine the effect of testing-retesting in patients with NPH, the authors analyzed changes documented on 5 neuropsychological tests (the Toulouse-Pieron, Trail Making Test A, Grooved Pegboard, Word Fluency, and Bingley Memory tests) and several motor ability scales (motor performance test, length of step, and walking speed tests) in a series of 32 patients with NPH who underwent the same battery on 4 consecutive days. The same tests were also applied in 30 healthy volunteers. In both groups, the authors used the generalized least-squares regression method with random effects to test for learning effects. To evaluate possible differences in response depending on the degree of cognitive impairment at baseline, the results were adjusted by using the Mini-Mental State Examination scores of patients and controls when these scores were significant in the model.
Results. In patients with NPH there were no statistically significant differences in any of the neuropsychological
or motor tests performed over the 4 consecutive days, except in the results of the Toulouse-Pieron test, which
were significantly improved on Day 3. In contrast, healthy volunteers had statistically significant improvement in the results of the Toulouse-Pieron test, Trail Making Test A, and Grooved Pegboard test but not in the remaining neuropsychological tests. Patients in the healthy volunteer group also exhibited statistically significant improvement in the motor performance test but not in step length or walking speed.
Conclusions. No learning effect was found in patients with NPH on any of the neuropsychological or motor tests. Clinical improvement after retesting in these patients reflects real changes, and this strategy can therefore be used in both the diagnosis and evaluation of surgical outcomes.