OBJECTIVEDifferent CSF diversion procedures (ventriculoperitoneal, ventriculoatrial, and lumboperitoneal shunting) have been utilized for the treatment of idiopathic normal pressure hydrocephalus. More recently, endoscopic third ventriculostomy has been suggested as a reasonable alternative in some studies. The purpose of this study was to perform a systematic review and meta-analysis to assess overall rates of favorable outcomes and adverse events for each of these treatments. An additional objective was to determine the outcomes and complication rates in relation to the type of valve utilized (fixed vs programmable).METHODSMultiple databases (PubMed, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) were searched for studies involving patients with idiopathic ventriculomegaly, no secondary cause of hydrocephalus, opening pressure < 25 mm Hg on high-volume tap or drainage trial, and age > 60 years. Outcomes included the proportion of patients who showed improvement in gait, cognition, and bladder function. Adverse events considered in the analysis included postoperative ischemic/hemorrhagic complications, subdural fluid collections, seizures, need for revision surgery, and infection.RESULTSA total of 33 studies, encompassing 2461 patients, were identified. More than 75% of patients experienced improvement after shunting, without significant differences among the different techniques utilized. Overall, gait improvement was observed in 75% of patients, cognitive function improvement in more than 60%, and improvement of incontinence in 55%. Adjustable valves were associated with a reduction in revisions (12% vs 32%) and subdural collections (9% vs 22%) as compared to fixed valves.CONCLUSIONSOutcomes did not differ significantly among different CSF diversion techniques, and overall improvement was reported in more than 75% of patients. The use of programmable valves decreased the incidence of revision surgery and of subdural collections after surgery, potentially justifying the higher initial cost associated with these valves.

Filum terminale arteriovenous fistulae are a rare type of arteriovenous shunt generally characterized by a single direct communication between the artery of the filum terminale and a single draining vein. These intradural arteriovenous shunts are three times more common in men than women (mean age 55 years). Symptoms are related to venous congestion, vascular hypertension, and a putative chronic steal phenomenon which result in spinal cord ischemia and myelopathy. Interestingly, hemorrhage has never been reported as a mode of presentation. MRI demonstrates increased flow voids and T2 changes involving the conus and the lower spinal cord, and these findings are not dissimilar from those seen with the more common type 1 spinal dural arteriovenous fistulae. Thus conventional spinal angiography is necessary for a definitive diagnosis and to localize exactly the site of the fistula. Both surgical interruption of the fistula and endovascular embolization are safe and effective therapeutic modalities. However, because of the very small caliber of the feeding artery, endovascular therapy is often not feasible; and thus, surgery remains the method more commonly utilized for their treatment. Definitive treatment consists of obliteration of the direct arteriovenous shunt. In this review, we describe the anatomy, pathophysiology, clinical presentation, imaging, and treatment options of these less common intradural arteriovenous shunts.

Glioblastoma is the most lethal brain tumor. The poor prognosis results from lack of defined tumor margins, critical location of the tumor mass and presence of chemo- and radio-resistant tumor stem cells. The current treatment for glioblastoma consists of neurosurgery, followed by radiotherapy and temozolomide chemotherapy. A better understanding of the role of molecular and genetic heterogeneity in glioblastoma pathogenesis allowed the design of novel targeted therapies. New targets include different key-role signaling molecules and specifically altered pathways. The new approaches include interference through small molecules or monoclonal antibodies and RNA-based strategies mediated by siRNA, antisense oligonucleotides and ribozymes. Most of these treatments are still being tested yet they stay as solid promises for a clinically relevant success.

No abstract

No abstract