Attitudes and Practices of Lumbar Puncture among Students, Interns, and Residents of the Pediatric Department of the Mohammed VI University Hospital Center of Oujda, Morocco

Introduction: Even though lumbar puncture (LP) represents an important tool in the diagnosis of certain neurological diseases, this procedure is little practiced by our students. We aimed to evaluate the attitudes and practices of students, interns, and residents about LP, and to assess their feelings about how this procedure is taught. Materials and Methods: We conducted a cross-sectional study of 160 participants, using an anonymous questionnaire, to evaluate the attitudes and practices of students, interns and residents in the pediatrics department concerning lumbar puncture. Results: Half of the participants had never performed LP, usually because of the risk involved or lack of confidence, while 20% had performed it more than 4 times. None of the participants had learned to perform the procedure through simulation sessions, while (42%) had learned it under the supervision of a senior physician and had not been able to perform it successfully the first time. Most participants inform the patient about the procedure before performing it. Only 44% of participants acknowledged that LP can be performed under local anesthetic. The sitting position (60%) was by far the most commonly used. Most LPs were performed for diagnostic purposes. Most participants stated that the pediatric ward and the pediatric emergency department are among the departments that perform LP most frequently, and that they would be interested in taking part in simulated lumbar puncture sessions in children in the future. Conclusion: The results of our study show that LP is perceived by students as a risky procedure that is difficult to perform. Teachers should reconsider how this technical procedure is taught, by integrating simulation on mannequins into student training.

Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling

The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture（LP） and lumbar cerebrospinal fluid（CSF） drainage（LD） of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management.In this retrospective study,41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group,respectively.Clinical outcomes,including CSF infection,intracerebral hemorrhage,vasospasm,hydrocephalus,death,length of stay,duration of drainage and the Glasgow Outcome Scale score were compared between the two groups.By comparing with the LP group,the LD group showed a significantly higher rate of CSF infection（P= 0.029） and shorter duration of drainage（P〈 0.001）.Both groups displayed similar rates of vasospasm,hydrocephalus,intracerebral hemorrhage,the Glasgow Outcome Scale score one month after endovascular coiling and length of stay（P〉 0.05,respectively）.In conclusion,both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides,serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.

Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture

BACKGROUND: The objective of this study is to determine if point-of-care ultrasound(POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture(LP).METHODS: This was a prospective, randomized controlled trial comparing POCUS preprocedure identifi cation of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit.RESULTS: A total of 158 patients were enrolled. No signifi cant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation.CONCLUSION: Consistent with fi ndings of previous studies, our data indicate that there was no observed benefi t of using POCUS to identify pre-procedure landmarks when performing an LP.

Role of lumbar puncture in clinical outcome of suspected acute bacterial meningitis

BACKGROUND Meningitis remains a significant source of mortality and morbidity,with an incidence of 1 per 100000 persons in the United States.Guidelines recommend obtaining blood cultures and cerebrospinal fluid(CSF)studies in patients presenting with acute meningitis syndrome,and beginning treatment with broad spectrum antibiotics based on the age and certain predisposing conditions.In some patients however,the diagnostic lumbar puncture(LP)is not performed due to a multitude of reasons,ranging from increased intracranial pressure to failed attempt.In such situations,appropriate therapy is initiated empirically and often continued without establishment of a definitive diagnosis.AIM To determine whether a diagnostic LP in acute meningitis syndrome was associated with a better outcome and less duration of antibiotic therapy,along with potential causes for deferral of procedure.METHODS A retrospective study was conducted amongst the patients presenting to a 360 bedded community hospital in central Massachusetts with a diagnosis of acute meningitis syndrome between January 2010-September 2022.The electronic health records were accessed to collect necessary demographic and clinical data,including etiology of meningitis,lumbar puncture results,reason for procedure deferral,duration of antibiotic therapy and clinical outcome.The patients were subsequently divided into two groups based on whether they received a LP or not,and data was analyzed.RESULTS A total of 169 patients admitted with acute meningitis syndrome between September 2010-2022 were included in the study.The mean age of the participants was 54.3 years(SD+/-19.2 years).LP was performed for 130(76.9%)participants,out of which,28(21.5%)showed some growth in CSF culture.The most commonly identified organism was streptococcus pneumoniae.Amongst the 39 patients in whom LP was deferred,the major reasons recorded were:Body habitus(n=6,15.4%),and unsuccessful attempt(n=4,10.3%).While 93(71.5%)patients with LP received antibiotic therapy,only 19(48.7%)patients without LP received the antibiotics,with the principal reason being spontaneous improvement in sensorium without any diagnosed source of infection.The mean duration of antibiotic use was 12.3 days(SD+/-5.6)in the LP group and 11.5 days(SD+/-7.0)in the non-LP group(P=0.56;statistically not significant).We observed higher long term sequalae in the non-LP group(n=6,15.4%)compared to the LP group(n=9,6.9%).Similarly,the death rate was higher in the non-LP group(n=7,18.0%)compared to the LP group(n=9,6.9%).CONCLUSION LP remains the cornerstone for diagnosing meningitis,but often CSF results are unavailable,leading to empiric treatment.Our study identified that body habitus and unsuccessful attempts were the most common reasons for LP not being performed,leading to empiric antibiotic coverage.There was no difference between the duration of antibiotics received by the two groups,but a lower proportion of patients without LP received antibiotics,attributed to a spontaneous improvement in sensorium.However,the residual neurological sequelae and death rates were higher in patients without LP,signifying a potential under-treatment.A LP remains crucial to diagnose meningitis,and a lack of CSF analysis predisposes to under-treatment,leading to higher neurological sequelae and increased chances of death.

Safety and feasibility of ultra-early lumbar puncture in patients with aneurysmal subarachnoid hemorrhage

Objective:to evaluate the clinical efficacy and safety of ultra-early lumbar puncture drainage of cerebrospinal fluid(CSF)in patients with aneurysmal subarachnoid hemorrhage(SAH).Methods:patients(n=140)with aneurysmal SAH were randomly divided into observation group(n=70)and control group(n=70).After admission,CSF was drained by ultra-early lumbar puncture in the observation group and intermittent lumbar puncture after aneurysm operation in the control group.The incidences of early aneurysm rupture,acute hydrocephalus and delayed hydrocephalus were compared between the two groups.Results:there was no significant diflerence in the incidence of early-ruptured aneurysm and acute hydrocephalus between the two groups,but the incidence of delayed hydrocephalus in the observation group was significantly lower than that in the control group.Conclusion:ultra-early lumbar puncture drainage of CSF in anexirysmal SAH can effectively reduce the incidence of long-term delayed hydrocephalus and it is a safe and effective treatment.

Post Dural Puncture Headache—Review and Suggested New Treatment

Objectives: After reading this article, readers should be able to recognize Post Dural Puncture Headache, understand its mechanism and diagnostic criteria, evaluate the different treatment options available, and be familiar with a novel treatment option. Background: Post-dural puncture headache is the most common serious complication resulting from lumbar puncture and epidural or spinal anesthetics. The syndrome is characterized by severe headache that occurs within 48 hours following the puncture, located in the frontal and/or occipital region, worsened in the upright position and refractory to routine analgesia. The syndrome incidence was reported to be approximately 1% with typical obstetric anesthesiology practice which reflects more than 20,000 cases per 2014 in the US. Two possible mechanisms are hypothesized as responsible for this syndrome;cerebrospinal fluid leakage and pneumocephalus. Multiple methods of treatment have been applied with wide-ranging results. Design or Methods: Review article with introduction of a novel treatment option. Results: We postulate that Hyperbaric Oxygen Therapy can be used to treat post-dural puncture headache. The rationale for treatment is dual: enhancement of fibroblast proliferation at the site of dural puncture to facilitate faster closure of the tear and compression of air bubbles in case of pneumocephalus according to Boyle’s law. We also claim that hyperbaric oxygen therapy should be considered a prophylactic treatment, if a dural tear is suspected.

The clinical analysis of three methods in the treatment of intracranial bacterial infection

Objective To analyze the effect of three therapeutic methods to find an optimal approach to the treatment of intracranial bacterial infection by retrospectively reviewing 33 intracranial bacterial infection patients who were admitted from 1995 to 2008 in our hospital.Methods The treatments by intermittent lumbar puncture,continuous lumbar subarachnoid space drainage,and embedment of Ommaya cyst for continuous drainage from the ventricles were performed in 15 cases,12 cases,and 6 cases respectively along with intravenous application of full dose of antibiotics.Results Nineteen cases were cured and the best prognosis was from the group of Ommaya cyst embedment and continuous drainage from the ventricles.Conclusion Management goals are prompt recognition of the central nervous system(CNS)infection,rapid identification of causative organisms and initiation of treatment with the optimal management methods for complications.Embedment of Ommaya cyst for continuous drainage from the ventricle is a safe and effective treatment for intracranial bacterial infection.

Idiopathic Intracranial Hypertension without Papilloedema “Case Report”

Purpose: The purpose of this case report is to share and spread the awareness of diagnosing and managing idiopathic intracranial hypertension in atypical scenarios as in this case, who presented with multiple other medical conditions, and had no papilloedema. The presenting signs and symptoms of mere headache were misleading. The other medical conditions could have explained the patient’s headache. These included cervical spine osteoporosis, and middle ear otolith disease. This case is unique because she was found to have IIH without papilloedema, and despite having multiple cancers in the uterus, breasts, and recently the thyroid, she had no malignant cells in the CSF. The patient was treated for IIH, and her malignancies were treated separately by the corresponding physicians. Method: The patient was assessed in 2019, and was followed up closely till 2021, in collaboration with her neurologist, oncologist, and orthopedist. Result: The patient had IIH after her neurologist attempted a lumbar puncture, which showed high CSF pressure. Conclusion: Headache is a common symptom presented by patients of different ages and backgrounds. The absence of papilloedema does not exclude the diagnosis of IIH. When possible etiologies for headache are ruled out (e.g. middle and inner ear infections, anemia, intracranial tumors, glaucoma, etc.), chronic headaches that do not respond to medications, and present with visual field changes may require a lumbar puncture.

Management of Idiopathic Chronic Hydrocephalus of the Adult in Guinea: A Prospective Study in 16 Patients

Object: Incidence of Idiopathic chronic hydrocephalus of the adult (ICHA) is increasing in Guinea due to the aging of the population. The goal of this study was to describe its epidemiology, clinical presentation, and surgical outcome in a low-resource medical environment. Method: Sixteen patients operated for a probable ICHA were prospectively studied according to a uniform protocol from June 2019 to December 2020. On computerized tomography, all operated patients had a clinical triad of gait disturbance, incontinence, dementia associated with ventriculomegaly, and transependymal edema. In addition, all patients underwent a single lumbar tap, improved clinically, and were subsequently offered a shunt consisting of a simple catheter in 37.5% and a non-adjustable high-pressure valve in 62.5%. Result: The mean age was 68.31 ± 10.4 (range 49 - 89). The sex ratio H/F was 1.67/1. Clinically, the most frequent comorbidity was a combination of hypertension and diabetes in 56.5% of cases. The mean time to diagnosis was 8.31 ± 2.75 months (range 3 - 14). The immediate postoperative mortality was 12.5% from a status epilepticus and pulmonary sepsis. In addition, we observed 2 cases of chronic subdural hematoma (12.5%) and 2 cases of shunt dysfunction (12.5%) in the first three months. The functional outcome was good in 23% of patients at one month (N = 13), 50% at three months (N = 10), and 87.5% at six months (N = 8). Conclusion: In carefully selected cases, the surgical outcome of ICHA in Guinea is comparable to high-income countries. Efforts need to be put in helping patients get covered with universal insurance and generally promote Neurosurgery in the country to improve the quality of care.

Intervention at an early threshold for post-hemorrhagic ventricular dilatation in preterm infants: a systematic review and meta-analysis

Background Very few adequately powered studies exploring early thresholds for intervention in the management of post-hemorrhagic ventricular dilatation(PHVD)in preterm infants have identified consistent neurodevelopmental advantages at 12–30 months.We aimed to conduct a meta-analysis on the efficacy and safety of early versus conservative thresholds for intervention,primarily aimed at normalizing cerebrospinal fluid(CSF)pressure,in the management of PHVD in preterm infants.Methods Multiple databases were searched for eligible papers,and prospective randomized trials involving preterm infants were selected.The results are expressed as relative risks(RRs)with 95%confidence intervals(CIs).The main outcome was survival without moderate-to-severe neurodevelopmental impairment at 12–30 months.Results Ten articles representing seven randomized trials comparing early versus conservative thresholds for interventions were included.Five trials(n=545 infants)reported no difference in the main outcome between early and conservative groups[RR 0.99(0.71,1.37)].Sensitivity analysis excluding data from a medication trial did not alter the main outcome[RR 1.15(0.95,1.39)].Infants in the early threshold group received significantly more interventions[RR 1.48(1.05,2.09)].Deaths before discharge/during the initial study period[RR 1.04(0.70,1.54)]or a composite of death or shunt insertion[RR 1.04(0.86,1.27)]were comparable between the two groups.Conclusions Early intervention for PHVD,before a clinical or ultrasound threshold is met,leads to additional clinical procedures but does not improve survival without moderate–severe neurodevelopmental impairment at 12–30 months.Caution should be exercised in interpreting these results due to significant variation between the studies.

Micro packaged MEMS pressure sensor for intracranial pressure measurement

This paper presents a micro packaged MEMS pressure sensor for intracranial pressure measurement which belongs to BioMEMS. It can be used in lumbar puncture surgery to measure intracranial pressure. Minia- turization is key for lumbar puncture surgery because the sensor must be small enough to allow it be placed in the reagent chamber of the lumbar puncture needle. The size of the sensor is decided by the size of the sensor chip and package. Our sensor chip is based on silicon piezoresistive effect and the size is 400 × 400 μm2. It is much smaller than the reported polymer intracranial pressure sensors such as liquid crystal polymer sensors. In terms of package, the traditional dual in-line package obviously could not match the size need, the minimal size of recently reported MEMS-based intracranial pressure sensors after packaging is 10 × 10 mm2. In this work, we are the first to introduce a quad flat no-lead package as the package form of piezoresistive intracranial pressure sensors, the whole size of the sensor is minimized to only 3 × 3 mm2. Considering the liquid measurement environment, the sensor is gummed and waterproof performance is tested; the sensitivity of the sensor is 0.9 × 10-2 mV/kPa.