Background: After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management. Methods: For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient’s shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration. Results: Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2–4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels. Conclusion: Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.

In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical pos...

Background: Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods: We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results: Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion: Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

We present the case of a 49-year-old woman with sudden onset of severe headaches and a ruptured aneurysm located inside the fenestration of the infraclinoid part of the internal carotid artery in the segments C4 and C5 distal to the origin of the ophthalmic artery. An interdisciplinary approach enabled the successful treatment of the aneurysm by wrapping and stent-assisted coiling. We discuss this rare congenital anomaly of a fenestrated internal carotid artery together with the 12 other cases published worldwide.

Background/Objectives: Magnetic resonance-guided focused ultrasound (MRgFUS) ventral intermediate nucleus (Vim) thalamotomy is an established treatment for medication-refractory tremor, but longitudinal cognitive and affective data remain limited. We described global cognition, depressive symptoms, and anxiety after unilateral MRgFUS Vim thalamotomy in essential tremor (ET) and tremor-dominant Parkinson’s disease (PD). Methods: This exploratory, descriptive analysis of a retrospective single-center cohort included 25 participants (ET n = 11; PD n = 14). Montreal Cognitive Assessment (MoCA), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scores were analyzed from baseline to the final available complete follow-up. Random-intercept mixed-effects models used all 54 complete observations. Sensitivity analyses examined first follow-up (W2), baseline-adjusted BDI comparisons, and random slopes. Holm correction addressed primary-outcome multiplicity; exploratory cognitive tests used false-discovery-rate correction. Results: Median assessment follow-up was 12.7 months (interquartile range 9.0–15.2; maximum 22.6). No significant whole-cohort change was detected in MoCA (mean change −0.12, 95% CI −1.33 to 1.09; Holm-adjusted p = 0.927), BDI (−0.36, −1.99 to 1.27; p = 0.927), or BAI (−2.60, −5.24 to 0.04; p = 0.188). The exploratory ET BDI change was −2.73 points at final follow-up (95% CI −4.51 to −0.95; Holm-adjusted p = 0.029) and −1.45 at W2 (−4.72 to 1.81; p = 0.262). The random-intercept time-by-diagnosis interaction for BDI was significant (β = 0.365 points/month, 95% CI 0.124 to 0.607; Holm-adjusted p = 0.009), whereas the four baseline-adjusted diagnostic contrasts did not survive joint Holm correction. No individual cognitive test remained significant after false-discovery-rate correction. Conclusions: These findings are descriptive and exploratory. No statistically significant cohort-level cognitive or affective change was detected. Diagnosis-related BDI findings were sensitive to endpoint definition and baseline adjustment and cannot be attributed causally to MRgFUS in this uncontrolled cohort.