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Radiographics : a Review Publication of... May 2023Macrocephaly, defined as a head circumference greater than 2 standard deviations above the mean, is a relatively common presenting symptom in the pediatric population at...
Macrocephaly, defined as a head circumference greater than 2 standard deviations above the mean, is a relatively common presenting symptom in the pediatric population at routine well-child examinations and a common indication for neuroimaging. Multiple imaging modalities are complementary in evaluating macrocephaly, including US, CT, and MRI. The differential diagnosis for macrocephaly is broad, and many disease processes lead to macrocephaly only when the sutures are open. In patients with closed sutures, these entities instead lead to increased intracranial pressure, according to the Monroe-Kellie hypothesis, which states that there is an equilibrium between intracranial constituents due to the fixed intracranial volume. The authors describe a useful paradigm for classifying macrocephaly by identifying which of the four components of the cranium (ie, cerebrospinal fluid, blood and vasculature, brain parenchyma, or calvarium) has an increased volume. Patient age, additional imaging findings, and clinical symptoms are also useful features. Most cases in the pediatric population are due to increased cerebrospinal fluid spaces, such as benign enlargement of the subarachnoid space, which must be carefully distinguished from subdural fluid collections in patients with accidental or nonaccidental trauma. Other common causes of macrocephaly are discussed, including hydrocephalus secondary to an aqueductal web, hemorrhage, or a neoplasm. The authors also provide information on some of the rarer diseases for which imaging may provide the impetus for genetic testing (eg, overgrowth syndromes and metabolic disorders). RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
Topics: Child; Humans; Infant; Megalencephaly; Head; Brain; Subarachnoid Space; Magnetic Resonance Imaging
PubMed: 37104125
DOI: 10.1148/rg.220159 -
Neurosurgical Review Aug 2022Despite advances in cerebrospinal fluid shunting technology, complications remain a significant concern. There are some contradictions about the effectiveness of... (Review)
Review
Despite advances in cerebrospinal fluid shunting technology, complications remain a significant concern. There are some contradictions about the effectiveness of proximal catheter entry sites that decrease shunt failures. We aim to compare efficiency of shunts with ventricular frontal, ventricular occipital, and cisterna magna entry sites. The systemic search was conducted in the database from conception to February 16, 2022 following guidelines of PRISMA. Between 2860 identified articles, 24 articles including 6094 patients were used for data synthesis. The aggregated results of all patients showed that "overall shunt failure rate per year" in mixed hydrocephalus with ventricular frontal and occipital shunts, and cisterna magna shunt (CMS) were 9.0%, 12.6%, and 30.7%, respectively. The corresponding values for "shunt failure rate" due to obstruction were 15.3%, 31.5%, and 10.2%, respectively. The similar results for "shunt failure rate" due to infection were 11.3%, 9.1%, and 27.2%, respectively. The related values for "shunt failure rate" due to overdrainage were 2.9%, 3.9%, and 13.6%, respectively. CMS was successful in the immediate resolution of clinical symptoms. Shunting through an occipital entry site had a greater likelihood of inaccurate catheter placement and location. Contrary to possible shunt failure due to overdrainage, the failure likelihood due to obstruction and infection in pediatric patients was higher than that of mixed hydrocephalus patients. In both mixed and pediatric hydrocephalus, obstruction and overdrainage were the most and least common complications of ventricular frontal and occipital shunts, respectively. The most and least common complications of mixed CMS were infection and obstruction, respectively.
Topics: Cerebrospinal Fluid Shunts; Child; Cisterna Magna; Equipment Failure; Humans; Hydrocephalus; Neurosurgical Procedures
PubMed: 35513737
DOI: 10.1007/s10143-022-01798-0 -
Seminars in Cell & Developmental Biology Jun 2020The central nervous system develops around a fluid filled space which persists in the adult within the ventricles, spinal canal and around the outside of the brain and... (Review)
Review
The central nervous system develops around a fluid filled space which persists in the adult within the ventricles, spinal canal and around the outside of the brain and spinal cord. Ventricular fluid is known to act as a growth medium and stimulator of proliferation and differentiation to neural stem cells but the role of CSF in the subarachnoid space has not been fully investigated except for its role in the recently described "glymphatic" system. Fundamental changes occur in the control and coordination of CNS development upon completion of brain stem and spinal cord development and initiation of cortical development. These include changes in gene expression, changes in fluid and fluid source from neural tube fluid to cerebrospinal fluid (CSF), changes in fluid volume, composition and fluid flow pathway, with exit of high volume CSF into the subarachnoid space and the critical need for fluid drainage. We used a number of experimental approaches to test a predicted critical role for CSF in development of the cerebral cortex in rodents and humans. Data from fetuses affected by spina bifida and/or hydrocephalus are correlated with experimental evidence on proliferation and migration of cortical cells from the germinal epithelium in rodent neural tube defects, as well as embryonic brain slice experiments demonstrating a requirement for CSF to contact both ventricular and pial surfaces of the developing cortex for normal proliferation and migration. We discuss the possibility that complications with the fluid system are likely to underlie developmental disorders affecting the cerebral cortex as well as function and integrity of the cortex throughout life.
Topics: Animals; Cerebral Cortex; Cerebrospinal Fluid; Humans; Subarachnoid Space
PubMed: 31786096
DOI: 10.1016/j.semcdb.2019.11.011 -
BMC Neurology Apr 2021The physiological and pathological significance of the arachnoid membrane (AM) is still unknown. In this study, we investigated various characteristics of the AM,... (Observational Study)
Observational Study
BACKGROUND
The physiological and pathological significance of the arachnoid membrane (AM) is still unknown. In this study, we investigated various characteristics of the AM, focusing on the influence of inflammation and fibrosis.
METHODS
Small pieces of AM sample were obtained during neurosurgical procedures from 74 cases. The clinical and pathological characteristics of the hyperplastic AM group (≥ 50 μm) and the non-hyperplastic AM group (< 50 μm) were compared. Then, potential correlations between AM thickness and clinical characteristics were analyzed. Moreover, VEGFα, TGFβ, and TGFα levels were quantitated by real time PCR. Then, the potential correlations between AM thickness and these inflammatory or anti-inflammatory markers, and the influence of the original disease were calculated.
RESULTS
The median age of the patients in hyperplastic AM group was significantly older than that of the non-hyperplastic AM group. Moreover, the number of fibroblasts, CD68 cells, CD86 cells, and CD206 cells in the hyperplastic AM group was significantly higher than that in the non-hyperplastic AM group. The AM thickness was significantly correlated to age and number of fibroblasts, CD68 cells, CD86 cells, and CD206 cells. The thickness of the AM was significantly correlated to the messenger RNA expression levels of VEGFα (ρ = 0.337), and the VEGFα expression levels were significantly correlated with TGFβ and TNFα.
CONCLUSIONS
The AM hyperplasia was influenced by aging and could be a result of inflammation and fibrosis through cytokine secretion from the inflammatory cells and fibroblasts in the AM.
Topics: Adult; Aged; Aging; Arachnoid; Female; Fibrosis; Humans; Inflammation; Male; Middle Aged
PubMed: 33882882
DOI: 10.1186/s12883-021-02202-y -
World Neurosurgery May 2021We present a case of a progressive symptomatic intramedullary cyst, diagnosed decades after Lipiodol injection. Lipiodol was originally administered intrathecally for...
We present a case of a progressive symptomatic intramedullary cyst, diagnosed decades after Lipiodol injection. Lipiodol was originally administered intrathecally for the radiologic diagnosis of spinal masses. A link between the lesion and the history of Lipiodol injection was never suspected. Surgical exploration revealed a membrane above the lesion, separating the intradural space in a cranial and caudal compartment. On the level of the cyst, we identified glassy pearls containing a fatty liquid, compatible with Lipiodol deposits. We hypothesize that the syrinx is secondary to the impact of cerebrospinal fluid pulsations on the reactive membrane and that this membrane originated from an arachnoiditis caused by Lipiodol deposits. Lipiodol was indeed abandoned after it was found to cause arachnoiditis and neurologic sequelae. Despite the cessation of its usage, the causal role of Lipiodol in arachnoiditis and spinal cyst formation should still be considered, as symptoms may arise many years after Lipiodol administration.
Topics: Arachnoiditis; Contrast Media; Cysts; Ethiodized Oil; Female; Humans; Injections, Spinal; Middle Aged; Syringomyelia
PubMed: 33601077
DOI: 10.1016/j.wneu.2021.02.022 -
Arquivos de Neuro-psiquiatria Mar 2020At the beginning of the 20th century, cerebrospinal fluid (CSF) collection and analysis emerged as a promising aid in the diagnosis of diseases of the central nervous...
At the beginning of the 20th century, cerebrospinal fluid (CSF) collection and analysis emerged as a promising aid in the diagnosis of diseases of the central nervous system. It was obtained through the established procedure of lumbar puncture, described by Heinrich Quinke in 1891. The search for an alternative way to gather the CSF emerged in animal research, highlighting the cisterna magna as a promising source, with relative safety when performed by someone trained. Described initially and in detail by James Ayer in 1920, the procedure was widely adopted by neurologists and psychiatrists at the time, featuring its multiple advantages and clinical applications. After a period of great procedure use and exponential data collection, its complications and risks relegated the puncture of the cisterna magna as an alternative route that causes fear and fascination in modern Neurology.
Topics: Animals; Cerebrospinal Fluid; Cisterna Magna; History, 19th Century; History, 20th Century; Punctures; Spinal Puncture
PubMed: 32215456
DOI: 10.1590/0004-282X20190142 -
Clinical Imaging Mar 2020Diagnosis of extramedullary spinal diseases is often complex, firstly requiring a good anatomic knowledge for a precise localization of pathologies. The spinal canal, a... (Review)
Review
Diagnosis of extramedullary spinal diseases is often complex, firstly requiring a good anatomic knowledge for a precise localization of pathologies. The spinal canal, a tubular space delimited by vertebral bodies and neural arches, contains the spinal cord, nerve roots and cauda equina. Neural structures are surrounded and supported, from outer to inner, by meninges: dura, arachnoid and pia mater; meningeal layers divide extramedullary spaces in epidural, subdural and subarachnoid. Extramedullary diseases may be broadly classified in degenerative, neoplastic, traumatic, infective or miscellaneous. Imaging (MRI, CT) plays a fundamental role in the identification of pathologies, providing elements of differential diagnosis and accurate informations (location, extension, tissue characteristics) to guide further management. MRI is the best imaging modality technique to investigate extramedullary spaces and their diseases; however, CT may be useful in cases of bone involvement. The purposes of this article are to depict extramedullary anatomy, describe the most important extramedullary diseases following physiopathological and space-to-space criteria, illustrate imaging features of extramedullary pathologies, and underline imaging clues for differential diagnosis.
Topics: Arachnoid; Dura Mater; Humans; Magnetic Resonance Imaging; Meninges; Spinal Canal; Spinal Cord; Spinal Diseases; Spine; Subdural Space
PubMed: 31865214
DOI: 10.1016/j.clinimag.2019.12.004 -
Surgical Neurology International 2022Spinal arachnoid cysts (SAC) are typically congenital, spontaneous, traumatic (i.e., including iatrogenic/surgical), or inflammatory in origin. In descending order, they... (Review)
Review
BACKGROUND
Spinal arachnoid cysts (SAC) are typically congenital, spontaneous, traumatic (i.e., including iatrogenic/surgical), or inflammatory in origin. In descending order, they occur in the thoracic, lumbar, and cervical spine, and originate from focal entrapment of the arachnoid membrane. Arachnoid cysts represent 1-2% of all cystic spinal masses/tumors. The majority are extradural arachnoid cysts (EDAC) while 10% of all arachnoid cysts are intradural (IDAC) including subarachnoid, or extra-arachnoidal/subdural. Only rarely are they intramedullary in location. The clinical symptoms/signs of IDAC/EDAC include; intracranial hypotension (i.e., due to continued cerebrospinal fluid drainage), radiculopathy, and/or myelopathy.
METHODS
Magnetic Resonance Images (MR) and Myelo-Computed Tomography (Myelo-CT) studies classically document the predominant dorsal location of IDAC/EDAC. They also show their extent and severity contributing to root, cord, and/or cauda equina compression. In the cervical/thoracic spine, MR/Myelo-CT studies classically show the "double cord" or "windsock" signs, while the "fake arachnoiditis sign" may be seen in the lumbar spine. The latter sign signals the presence of a circumferential extra-arachnoidal-subdural cyst that centrally "traps" the cauda equina. Note, that this resembles and is often misinterpreted as adhesive archnoiditis.
RESULTS
Patients with significant SAC-related neurological deficits typically warrant early surgery. That surgery includes; partial/total resection/fenestration of cyst walls, and occlusion of communicating fistulas with or without accompanying shunts.
CONCLUSION
It is critical to recognize the clinical (i.e., intracranial hypotension, radiculopathy, and/or myelopathy) and radiographic MR/Myelo-CT signs (i.e., "double cord," "windsock signs", or "fake arachnoiditis sign") of IDAC, EDAC, or intramedullary spinal arachnoid cysts to appropriately offer treatment. For those with significant neurological deficits, early surgery (i.e. optimally 0-< 24 hours after the onset of symptoms/signs consisting of laminectomies, partial/total cyst resection/fenestration, and ligation/occlusion of the subarachnoid-cyst fistula with or without shunt placement), is essential to avoid significant permanent neurological sequelae.
PubMed: 35399888
DOI: 10.25259/SNI_153_2022 -
No Shinkei Geka. Neurological Surgery Mar 2022In aging societies, idiopathic normal-pressure hydrocephalus(iNPH)has emerged as an important disease that can negatively affect the activities of daily living among the...
In aging societies, idiopathic normal-pressure hydrocephalus(iNPH)has emerged as an important disease that can negatively affect the activities of daily living among the elderly. Evidence supporting diagnosis and treatment has accumulated and, in Japan, the third edition of the iNPH treatment guideline was published in 2020. Through the promotion of multi-facility research efforts in Japan, diagnosis of iNPH has been based on characteristic phenomena including gait disturbance, overactive bladder, cognitive impairment, and disproportionately enlarged subarachnoid space hydrocephalus(DESH). In supplementary examinations, brain transformations associated with iNPH have been evaluated using modified magnetic resonance imaging methods. Moreover, studies aimed at elucidating the disease state in combination with biological information obtained from cerebrospinal fluid findings are in progress. However, the outcome prediction of shunt treatment for atypical iNPH(i.e., non-DESH iNPH)and coexisting nervous system abnormalities is also important. In these cases, determining indications for surgery is a particular challenge.
Topics: Activities of Daily Living; Aged; Humans; Hydrocephalus, Normal Pressure; Magnetic Resonance Imaging; Prognosis; Subarachnoid Space
PubMed: 35400648
DOI: 10.11477/mf.1436204558 -
World Neurosurgery Apr 2022Central nervous system infection after neurosurgical procedures is a severe complication with high morbidity rates and sometimes mortality. Our experimental study aimed...
BACKGROUND
Central nervous system infection after neurosurgical procedures is a severe complication with high morbidity rates and sometimes mortality. Our experimental study aimed to investigate the biochemical and histopathologic effects of vancomycin on neural tissues when applied to the cisterna magna.
METHODS
Wistar albino rats were randomly divided into 4 groups: Control (Group 1) and different vancomycin dose groups (Groups 2, 3, and 4). In Group 1, 0.1 mL cerebrospinal fluid was drained from the cisterna magna and 0.1 mL 0.9% NaCI (normal saline) was administered into the subarachnoid space. In the study groups, 0.1 mL cerebrospinal fluid was drained from the cisterna magna and 0.1 mg/200g rat per day (Group 2), 0.2 mg/200g rat per day (Group 3), and 0.4 mg/200g rat per day (Group 4) vancomycin were administered into the subarachnoid space for 7 days. All rats were sacrificed on the eighth day. Serum superoxide dismutase and catalase levels were measured. Histopathologic and immunohistochemical analyses were conducted.
RESULTS
The findings showed that the administration of 0.2 and 0.4 mg/kg doses had significant differences in superoxide dismutase and catalase activity compared with the controls (P < 0.05). These vancomycin doses also induced the apoptotic process, and the enzyme activity results correlated with immunohistochemical results.
CONCLUSIONS
Dose-related neurotoxicity of intrathecal vancomycin was shown at the cellular level. The importance of dose regulation of intrathecal vancomycin has come into view. To our knowledge, this is the first study in the literature that has investigated the neurotoxic effects of vancomycin.
Topics: Animals; Cisterna Magna; Humans; Rats; Rats, Wistar; Subarachnoid Space; Superoxide Dismutase; Vancomycin
PubMed: 34971834
DOI: 10.1016/j.wneu.2021.12.082