Pseudotumor cerebri syndrome in children: Clinical characteristic and re-classification

AimTo describe the clinical characteristics of children with pseudotumor cerebri syndrome (PTCS) who were diagnosed according to the modified Dandy criteria and to reclassify them according to the newly proposed diagnostic criteria by Freidman.MethodologyThis retrospective study included the period from January 2016-to July 2021.Results50 patients were included; 34 males and 16 females with a male to female ratio of 2.1:1. The average age at onset of symptoms was 8 years. Obesity was noticed in 6 (12%) patients; 34 (68%) had symptoms upon presentation. The most common presenting symptom was headache (28 patients; 56%), papilledema was present in 33 (66%) patients. Most patients (37; 74%) had an initial cerebrospinal fluid (CSF) pressure ≥280 mmH₂O. At last follow-up, papilledema resolved in 11/32 (34.3%) patients, and headache resolved in 17/23 (74%) patients. 22/50 (44%) patients fulfilled the definite criteria proposed by Freidman, 11/50 (22%) fulfilled the probable, 10/50 (20%) were categorized as possible, and 7 (14%) patients were categorized as unmet.ConclusionPTCS is a chronic condition. Managing patients who do not have papilledema or who do not meet the newly proposed higher CSF pressure is challenging. Although, applying the newly proposed criteria captured most of our patients, however, around one quarter were managed based on clinical experience. This study indicates a strong need for future guidelines tailored specifically for children, taking into consideration that the cut-off point of CSF pressure might not be similar for all populations.     

Applied cerebral physiology

The brain is an exquisitely sensitive organ, requiring a constant supply of blood, oxygen, and glucose to function. Cerebral blood flow is autoregulated to provide a near constant blood supply despite fluctuations in whole body physiology. The blood–brain barrier acts to ensure that the brain microenvironment remains tightly regulated. The pressure within the cranium must also be tightly controlled to maintain optimal cerebral perfusion and ultimately prevent herniation of brain parenchyma. Several physiological parameters can be monitored including intracranial pressure, cerebral oxygenation and metabolic stress and clinical use is increasing including in traumatic brain injury and subarachnoid haemorrhage patients.     

Therapeutic hypothermia and acute brain injury

Secondary brain injury has devastating effects on morbidity, mortality and good functional outcomes. Neuroprotection is multimodal, with decades of preclinical and small clinical studies showing the benefits of therapeutic hypothermia. The basic scientific principles have merit, yet large randomized controlled trials fail to show a clear benefit. This article will review the basic science – the practical aspects of delivering targeted temperature management and evaluate the evidence behind its use for acute brain injuries. With a lack of high-quality evidence for hypothermia, recent consensus statements are shifting the paradigm away from hypothermia to the maintenance of normothermia and prevention of pyrexia.     

颅内动脉瘤患者介入栓塞术后脑供血不足发生的影响因素分析

目的分析颅内动脉瘤(IA)患者介入栓塞术后脑供血不足发生的影响因素。方法回顾性分析接受介入栓塞术治疗的90例IA患者病例资料、相关检查资料;统计患者术后3周脑供血不足发生情况,设计基线资料填写表,阅读并记录患者相关基线资料,将可能的影响因素纳入,经Logistic回归分析找出可能导致IA患者介入栓塞术后脑供血不足发生的影响因素。结果90例IA患者术后有13例发生脑供血不足,发生率为14.44%;IA患者脑供血不足发生者动脉瘤最大径、吸烟史、合并高血压、Hunt-Hess分级、甘油三酯(TG)水平、总胆固醇(TC)水平与未发生脑供血不足者比较,差异有显著性(P＜0.05);经Logistic回归分析,动脉瘤最大径＞10 mm、合并高血压、TG和TC水平升高可能是IA患者介入栓塞术后脑供血不足发生的危险因素(P＜0.05)。结论IA患者介入栓塞术后脑供血不足可能与动脉瘤最大径＞10 mm、合并高血压、TG和TC水平升高有关。     

The dynamic fetal brain

PURPOSE: To evaluate fetuses with normal intracranial anatomy in the second trimester that became abnormal in the third trimester. METHODS: We sonographically examined 6 fetuses with a normal second-trimester head sonogram that presented later in pregnancy with an abnormal head sonogram. RESULTS: Four categories of intracranial pathology were depicted: obstructive hydrocephalus, intraventricular intracranial hemorrhage, non-intraventricular intracranial hemorrhage, and porencephaly. CONCLUSIONS: Despite a normal midtrimester intracranial examination, evaluation of the fetal intracranial contents should be undertaken in subsequent sonographic examinations, because significant pathology can develop spontaneously.     

Intracranial pressure and cerebral haemodynamics

Intracranial pressure (ICP) refers to the pressure within the skull, which is determined by the volumes of the intracranial contents; blood, brain and cerebrospinal fluid. Monro–Kellie homeostasis stipulates that a change in the total intracranial volume is accompanied by a change in the ICP, which is more precisely described by the intracranial pressure–volume relationship. Maintenance of a relatively constant ICP is essential for maintenance of the cerebral perfusion pressure, which in turn determines global cerebral blood flow. Although the physiological process of autoregulation ensures that cerebral blood flow is tightly maintained over a range of cerebral perfusion pressures, large increases in the ICP can result in severely impaired autoregulation, meaning that cerebral blood flow may be compromised. In this review article we provide an overview of the physiological determinants of the ICP and cerebral blood flow. We go on to illustrate how pathological states can compromise physiological compensatory mechanisms in order to potentially dangerous disturbances of the ICP and cerebral blood flow.     

The risk of intracranial infection in adults with hydrocephalus after ventriculoperitoneal shunt surgery: A retrospective study

Infection remains the most significant complication of ventriculoperitoneal shunt (VPS) surgery. The objective of this study was to investigate intracranial infections complicating VPS surgery in adults with hydrocephalus. Patients who underwent VPS surgery for hydrocephalus between 2000 and 2016 were included. Clinical data and follow‐up evaluations were examined and analysed retrospectively. A total of 502 patients with hydrocephalus who underwent VPS surgery were included. They were followed up for at least 2 years. Twelve patients with incomplete data were excluded. Four hundred and ninety patients were included in the final analysis. Twenty‐five cases of intracranial infection occurred, accounting for 5.1% of patients with VPS surgery. The mean age of the patients was 57.1 ± 10.1 years (range, 39–72 years). The incidence of intracranial infection in patients over 60 years of age was higher than that in patients under 60 years of age (P = .007). Age (P = .007), diabetes (P = .026), skin infection (P = .028), bed‐ridden (P = .007), and modified operation (P = .011) were highly correlated with the incidence of intracranial infection. The findings of this retrospective study show that age, diabetes, skin infection, bed‐ridden, and modified operation of hydrocephalus significantly and independently correlated with the incidence of infection. Prospective studies are needed to assess the relationship between the incidence of infection and risk factors in patients with hydrocephalus after VPS.