Cerebrospinal fluid diversion in patients with enlarged Virchow-Robin spaces without ventriculomegaly

Abstract

Objective -Enlarged Virchow-Robin spaces (eVRS) are an MRI biomarker in several neurological diseases of inflammatory, neurodegenerative, vascular, metabolic, or genetic origin. We report on a further condition in which eVRS were observed in patients with an ongoing chronic hydrocephalus-like clinical picture without ventriculomegaly who improved after CSF diversion, and we discuss the possible mechanisms underlying this finding. Materials and methods -A retrospective study of seven patients presenting progressive gait, cognitive, and urinary disturbances in association with eVRS was undertaken. Results -All patients presented an Evans ratio <0.30 and >20 eVRS at the level of basal ganglia and periventricular parenchyma as assessed by T2-weighted MRI. All patients underwent prolonged external lumbar drainage (PELD) with good response. Six patients received ventriculoperitoneal shunt with improvement of their clinical status compared to that before PELD (follow-up: 8-58 months, mean 24.6). The seventh patient did not undergo ventriculoperitoneal shunt and received a second PELD with persistent improvement (follow-up: 14 months). Conclusions -Our results indicate that a mechanism involving CSF accumulation and stasis in the subarachnoid space was at least a concurrent factor of this clinical picture. This study should stimulate new perspectives on the role of CSF disturbances in the pathogenesis of diseases associated with VRS enlargement.

Influence of general anaesthesia on slow waves of intracranial pressure

“…Propofol has a predictable pharmacokinetic profile and advantageous pharmacodynamic characteristics including profound suppression of cerebral metabolic rate and preserved cerebral autoregulation. 25,26 The safety of fentanyl and remifentanil as adjuvants in neuroanaesthesia and neurointensive care is also supported by a large body of evidence. [18][19][20][21] The impact of neuromuscular blockers on CSF dynamics is negligible.…”

“…Coherent changes in CO2, CBF and ventilation have been described in situations such as central sleep apnoea. 25,26 Whether such ventilation changes could account for the observed differences is unknown. GA-induced alterations in slow wave ABP power could account for changes in slow wave ICP power.…”

Case report: A multiple sclerosis patient with imaging features of glymphatic failure benefitted from CSF flow shunting

“…This report does not suggest a new therapy for MS. It represents an exploratory approach to neurodegenerative diseases (Scollato et al, 2016 ), in which CSF flow disturbances play a possible role in the failure of G-Ls (Nedergaard and Goldman, 2020 ; Gallina et al, 2021 ), leading to inadequate brain clearance of toxic molecules and immune cells (Iliff et al, 2012 ).…”

Comparison of ventricular drain location and infusion test in hydrocephalus

“…Increasingly in clinical practice, infusion tests are being undertaken as a means to objectively measure the flow dynamics of fluid within shunts in vivo , especially when the diagnosis of shunt dysfunction is not clearly evident from the clinical presentation and changes in ventricular size on CT alone, which may never happen in normal pressure hydrocephalus (NPH). Although infusion test technique may be seen as little bit outdated, and new theories for development of hydrocephalus are proposed , use of infusion test to scrutinize shunt performance in vivo seems to be clinically well funded .…”