CORRESPONDENCE

Long-term Follow-up of a Previously Reported Case of

Cerebellar Aspergillosis With the Implication of the
Potential Therapeutic Effect of Intracavitary
Amphotericin B Application
To the Editor:
We presented a completely uneventful clinical course of a 45-
year-old woman with breast cancer (Stage IIIA, T2,N2,M0) who
previously underwent surgical removal of cerebellar aspergillosis
and peroperative intracavitary amphotericin B (AmB) application
as explained in detail in our previous report dated 2002 in
Neurosurgery1 (Figure 1). Clinical course of the patient after 2
consecutive abscess removal surgery and peroperative intracavitary
antifungal therapy was uneventful and she is still alive with a sat-
isfying degree of primary cancer control. We had administered
intracavitary AmB locally into the surgical bed after the repeat-
surgical removal of recurrent abscess material and the abscess wall.
Patient was also administered AmB and itraconazole for 3 months FIGURE 2. Postoperative (late follow-up) T1-weighted
and 1 year respectively. She was then regularly examined and she is axial magnetic resonance imaging shows postoperative
well with no clinical or radiological signs of abscess recurrence changes with no abscess recurrence.
(Figure 2). Aspergillosis involving central nervous system (CNS)
are generally manifested by abscess formation in the anterior cir-
culation and ischemic strokes in the posterior circulation.2,3 CNS
aspergillosis is generally encountered in immunocompromised successfully treated a renal transplant patient with an aspergillus
patients with a high mortality rate.4,5 Antifungal agents have poor brain abscess by applying AmB locally into the abscess site using
penetration into the brain and cerebrospinal fluid regardless of the a closed reservoir system after radical surgical debridement resulting
mode of application; systemic or intrathecal; thus aspergillus brain in a cure with a follow-up of 6 years.6 Likewise, recently, Ozc xelik
abscess often appears to be a fatal disease. Camarata et al et al reported the successful treatment of neuroaspergillosis in
a leukemic patient using systemic new generation antifungal agents
(voriconazole and caspofungin) combined with the intracavitary
instillation of AmB (0.3 mg/day for 15 days) into the operative
field.7 However, this patient died due to leukemic relapse. We had
applied topical intracavitary AmB in our patient in repeat surgery
for the recurrent abscess and we did not observe any abscess re-
currence in a 7-year follow up with no neurological sequelae or
untoward side effects. In this context, we aimed to highlight the
potential long-term therapeutic effect of topical AmB in preventing
abscess recurrence caused by aspergillus species. However, it is our
belief that we need further patient reports in order to optimize the
use of intracavitary AmB with regards to mode of application
(continuous vs single), dosing and the drug-exposure time.

Baki S. Albayrak
Sait Sxirin
Fikret Arpac
Ersin Erdogan
Ankara, Turkey

FIGURE 1. T1-weighted axial magnetic resonance imag-

ing with gadolinium enhancement reveals right cerebellar 1. Erdogan E, Beyzadeoglu M, Arpaci F, Celasun B. Cerebellar aspergillosis:
lesion with rim pattern enhancement and mass effect. case report and literature review. Neurosurgery. 2002;50(4):874-876; discussion
876-877.

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CORRESPONDENCE

2. Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of the brain and paranasal sinuses
in immunocompromised patients: CT and MRI imaging findings. AJNR Am J
Roentgenol. 1992;162(1):155-159. TABLE. Crude and Adjusted Odds Ratios for the Incidence of
3. Beal MF, OCarroll P, Kleinman GM, Grossman RI. Aspergillosis of the nervous ENM in a Population of Patients With Tumors of the Central
system. Neurology. 1982;32:473-479. Nervous Systema
4. Cohen J. Clinical manifestations and management of aspergillosis in the Characteristics Unadjusted Odds Adjusted
compromised patient. In: Warnock DW, Richardson MD, eds. Fungal Infection
Ratio Odds
in the Compromised Patient. Chichester, UK: John Wiley & Sons; 1991:
117-151. (95% CI) Ratio (95% CI)
5. Bjorkholm B, Elgefors B. Cerebellar aspergilloma. Scand J Infect Dis. 1986;18(4): Age, y
375378. 0 to 14 1.00
6. Camarata PJ, Dunn DL, Farney AC, Parker RG, Seljeskog EL. Continual intra-
15 to 44 0.22 (0.15-0.31)
cavitary administration of amphotericin B as an adjunct in the treatment of as-
pergillus brain abscess: case report and review of the literature. Neurosurgery. 45 to 64 0.16 (0.11-0.23)
1992;31(3):575-579. 65 and older 0.31 (0.23-0.42)
7. Ozcxelik T, Ozkalemka[cedil]s F, Kocaeli H, et al. [Successful treatment of neuro- Sex
aspergillosis in a patient with acute lymphoblastic leukemia: role of surgery, systemic Male 1.00
antifungal therapy and intracavitary therapy]. Mikrobiyol Bul. 2009;43(3):499-506. Female 1.01 (0.80-1.29)
Grade
I 1.00 1.00
10.1227/NEU.0b013e3181f3d2b3
II 0.42 (0.12-1.45) 0.59 (0.12-2.95)
III 1.72 (0.62-4.80) 2.71 (0.66-11.12)
IV 1.50 (0.60-3.76) 4.07 (1.20-13.80)
Years of Diagnosis
1988-1993 1.00
The Epidemiology of Extraneural Metastases From 1994-1999 0.95 (0.70-1.29)
Primary Brain, Spinal Cord, and Meningeal Tumors 2000-2006 0.84 (0.63-1.12)
To the Editor: Primary Site
Extraneural metastasis (ENM) is a rare complication of tumors Cerebrum 1.00 1.00
Cerebellum 8.17 (5.71-11.68) 13.48 (6.27-28.96)
of the nervous system. Almost 85 years ago, Bailey and Cushing
Brainstem and 3.45 (2.26-5.27) 7.57 (3.44-16.64)
found that certain brain tumors never metastasize outside of the Spinal Cord
nervous system,1 a claim disproved 2 years later when the first Meninges 9.36 (5.90-14.85) 14.35 (4.19-49.17)
case of ENM from a primary brain tumor was published.2 In this
a
report we characterize the demographic and clinical determinants ENM, extraneural metastasis; CI, confidence interval.
of ENM, and its impacts on survival.
To do so, we used data from the National Cancer Institutes
Surveillance, Epidemiology, and End-Results database. We extracted
data on patients diagnosed with tumors of the central nervous system
from 1988 to 2006. We estimated incidence proportions and con-
structed multivariate logistic regression models to evaluate socio-
demographic and clinical determinants of the presence of ENM at
diagnosis. In addition, we estimated the effect of the presence of
ENM at diagnosis on overall survival using Cox proportional hazards
models. From 1988 to 2006 we identified 273 cases of ENM at
diagnosis in 28 441 cancers of the central nervous system giving an
overall incidence proportion of 0.96% (95% confidence interval
[CI], 0.85-1.08).
We found that tumor grade and primary site was associated
with ENM at diagnosis. In adjusted models, the effects of Grades
II and III tumors on ENM at diagnosis were not statistically
significantly different from Grade I tumors. However, patients
with Grade IV tumors were about 300% more likely to have
ENM at diagnosis compared to those with Grade I tumors
(Table). Moreover, patients with tumors of the cerebellum,
brainstem and spinal cord, and meninges were all more likely to
present with ENM at diagnosis compared to those with cerebral
tumors, although confidence intervals were rather wide.
FIGURE. Kaplan-Meier plot of survival for patients with patients with and
Previously, it has been thought that ENM was on the rise without extraneural metastasis at diagnosis.
due to patients having longer life expectancies.3 Between 1988

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and 2006 the changes in incidence proportions were highly vari-
able. SEER data do not suggest that the incidence of ENM is
increasing.
The presence of ENM appeared to have a significant impact on
the survival of patients. The median survival of patients with
ENM was three months shorter than those without ENMs at
diagnosis (11 months vs 14 months). ENM at diagnosis was
associated with an adjusted hazard ratio of mortality of 1.53 (95%
CI, 1.16-2.02; P = .002) compared to no ENM at diagnosis, after
controlling for age, grade, and primary site. However, the sur-
vivor functions of patients with and without ENM at diagnosis
were not statistically significantly different from each other
(P = .5032; Figure).
This study found that the incidence of ENM at diagnosis remains
small, the grade and site of the tumor is associated with the presence
of ENM, and ENMs are associated with reduced survival.
Nicolas R. Smoll
Elmer V. Villanueva
Churchill, Victoria, Australia
1. Bailey P, Cushing P. A Classification of the Tumors of the Glioma Group on a His-
togenetic Basis with a Correlated Study of Prognosis. Philadelphia, PA: J.B. Lippincott;
1926.
2. Davis L. Spongioblastoma Multiforme of the Brain. Ann Surg. 1928;87(1):
8-14.
3. Giordana MT, Ghimenti C, Leonardo E, Balteri I, Iudicello M, Duo D.
Molecular genetic study of a metastatic oligodendroglioma. J Neurooncol. 2004;
66(3):265-271.
10.1227/NEU.0b013e3181f3d3dd
Spinal Intradural Extramedullary Hydatidosis: Report of
3 Cases
To the Editor:
We have read with interest the paper by Lakhdar et al1 in
which the authors report 3 patients who presented with pro-
gressive paraparesis attributed to a histologically proven intradural
hydatid cyst and wish to congratulate our colleagues on this
contribution to the literature on spinal echinococcosis. The au-
thors have documented their case nicely. Nevertheless, we think
several aspects of this article seem to deserve further comment and
clarification.
We completely agree with the authors that the worldwide
distribution of hydatid infection is limited to rural and low-
developed areas, particularly in Mediterranean countries. At
present, it is not a subject often dealt with in the international
neurosurgical literature because it is virtually unknown in
Western countries and North America. Despite all the advances
in imaging techniques and therapeutic methods, however, spinal
hydatidosis is serious disease and can cause high rate of
recurrence, neurological impairment or death because total
NEUROSURGERY
Copyright Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
CORRESPONDENCE
removal of the most cysts are impossible without injuring
the roots.2,3
As mentioned by the authors, this entity is extremely rare
and the exact mechanism for intradural involvement is not yet
clear. In the article, excluding the three new cases presented, the
authors claim that only 26 cases with spinal intradural extra-
medullary hydatid cyst have been published in the literature. In
1967, however, Acquaviva et al4 reported 8 cases of intradural
extramedullary hydatid cysts. In 1970, Ley and Marti5 also
reported a case with intramedullary hydatid cyst, and then
c et al6 documented a new case with cervical intradural
Goxer
extramedullary hydatid cyst. Afterwards, Isxlekel et al7 reported
described a case of spinal intradural hydatid cyst, which had
also been reported in another international journal as a dupli-
cative publication. Recently, Shukla et al8 and Gunesx et al9
added one case each. Recently, we carefully reviewed intradural
extramedullary hydatid cysts and found further 13 detailed
reports of spinal intradural hydatid cysts in the world litera-
ture,2-16 in addition to those cited by Lakhdar et al1 Thus, the
total number of cases with spinal intradural intra/extra-
medullary hydatid cysts was 45, not 26, although the papers
reported in 2009 and 2010 by Arif and Zaheer,2 Gunesx et al,9
Kaen et al,2 Midyat et al13 and Limaiem et al3 could not be
included in the authors literature review. Interestingly, only 2
out of the 45 cases reported in the literature had been called as
intramedullary hydatid cyst.5,14
In clinical practice, the presenting symptoms are mostly
atypical and, based on their features, spinal hydatidosis may often
be confused with spinal tumor and tuberculoma in some
countries where tuberculosis is common.16 In some cases, spinal
intradural cysts may develop secondary to rupture and/or dis-
semination from an intracranial or extradural spinal cyst, if the
dura mater had been opened during the previous surgical
interventions.7,16
Nowadays, radiologists and spinal surgeons can use MR im-
aging to differentiate alive and fertile cysts from the inactive forms
of hydatidosis. Furthermore, it is widely accepted that in vivo
MRS may be used as an adjunct to imaging in both diagnosis of
intraspinal hydatid cysts and monitoring of drug therapy, al-
though the cysts of the cases presented in the article seem alive
and active on T2-weighted MR images. Consequently, we
strongly suggest that the hydatid disease should be considered in
the differential diagnosis when radiological findings suggest spinal
infections or tumors, and that surgical decompression in asso-
ciation with chemotherapy is the treatment of choice.
Mehmet Turgut
Aydn, Turkey
Ahmet Tuncay Turgut
Ankara, Turkey
1. Lakhadar F, Arkha Y, Rifi L, Derraz S, El Ouahabi A, El Khamlichi A. Spinal
intradural extramedullary hydatidosis: report of three cases. Neurosurgery. 2009;
65(2):372-377.
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CORRESPONDENCE
2. Kaen A, Lagares A, Perez-Nunez A, Rivas JJ, Ramos A, Lobato RD. Intradural
extramedullary spinal hydatidosis: case report. Neurochirurgia (Astur). 2009;20(3):
282-287.
3. Limaiem F, Bellil S, Bellil K, et al. Primary hydatidosis of the central nervous
system: a retrospective study of 39 Tunisian cases. Clin Neurol Neurosurg. 2010;
112(1):23-28.
4. Acquaviva R, Tamio PM. Lechinococcose vertebromedullaire. A propos de 14
observations [in French]. Neurochirurgie. 1964;10:649-650.
5. Ley A, Marti A. Intramedullary hydatid cyst. J Neurosurg. 1970;33(4):257-259.
6. Goxcer AI, Tuna M, Ildan F, Bagdatoglu H, Hacyakupoglu S. Cervical intradural
extramedullary hydatid cyst. Turk Neurosurg. 1994;4:169-171.
7. Isxlekel S, Ersxahin Y, Zileli M, et al. Spinal hydatid disease. Spinal Cord.
1998;36(3):166-170.
8. Shukla S, Trivedi A, Singh K, Sharma V. Craniospinal hydatidosis: report of three
cases. J Pediatr Neurosci. 2008;3:146-149.
9. Gunesx M, Akdemir H, Tugcu B, Gunald O , Gumuxs E, Akpnar A. Multiple
intradural spinal hydatid disease. Spine. 2009;34:E346-E350.
10. Arif SH, Zaheer S. Intradural extramedullary primary hydatid cyst of the
spine in a child: a very rare presentation. Eur Spine J. 2009;18(Suppl 2):
179-182.
11. Hilmani S, El Malki M, Bertal A, et al. Lumbar intradural hydatid cyst. Case report
(in French). Neurochirurgie. 2004;50(1):57-60.
12. Mathuriya SN, Arora OP, Khosla VK, Prabhakar SK, Chopra JS, Kak VK. In-
fected intradural hydatid cyst at foramen magnum. A case report. Clin Neurol
Neurosurg. 1985;87(4):283-286.
13. Midyat L, Gokcxe S, Onder A, Ozdemir Y, Mursalov G, Mir S. A very rare cause of
childhood paraparesis: primary intradural extramedullary spinal hydatid cyst.
Pediatr Infect Dis J. 2009;28(8):754-755.
14. Rumana M, Mahadevari A, Nayil Khurshid M, et al. Cestode parasitic infestation:
intracranial and spinal hydatid disease - a clinicopathological study of 29 cases from
South India. Clin Neuropathol. 2006;25(2):98-104.
15. Toplaloglu A. Report of two cases with hydatidosis- one subdural extramedullary
and other vertebral-paravertebral in location [in Turkish]. Turk Tp Cem Mec.
1958;24:327-332.
16. Turgut M. Hydatid disease of the spine: a survey study from Turkey. Infection.
1997;25(4):221-226.
10.1227/NEU.0b013e3181f35f1b
Hydranencephaly Vs Hydrocephalus
I read with interest the article titled Endoscopic Choroid
Plexus Cauterization vs Ventriculoperitoneal Shunt for Hydra-
nencephaly and Near Hydranencephaly: A Prospective Study by
Malheros et al in the March 2010 issue of Neurosurgery. The
authors have used the term near hydranencephaly for very
severe form of hydrocephalus with very thin cortical mantle,
which I think is not correct, because both are so different both in
their pathogenetic mechanisms and prognosis. Hydranencephaly
is thought to arise from intrauterine vascular occlusion, resulting
in the infarction of the area supplied by the carotid circulation
and these areas are replaced by cerebrospinal fluid. Most often,
the head size is small or normal and only on rare occasions one
sees the head size to the degree of gross hydrocephalus. Irre-
spective of the shunt surgery or not, this carries poor prognosis.
On the contrary, hydrocephalus arises from a disorder of cere-
brospinal fluid physiology. Whatever be the thickness of the
cortical mantle or the head size, there always a scope for treat-
ment, as the prognosis is definitely much better than the
E1472 | VOLUME 67 | NUMBER 5 | NOVEMBER 2010
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hydranencephaly. I think the term near hydranencephaly is
better avoided for the severe form of hydrocephalus.
Vengalathur Ganesan Ramesh
Chennai, India
1. Malheiros JA, Trivelato FP, Oliveira MM, Gusmao S, Cochrane DD, Steinbok P.
Endoscopic choroid plexus cauterization versus ventriculoperitoneal shunt for
hydranencephaly and near hydranencephaly: a prospective study. Neurosurgery.
2010;66(3):459464.
10.1227/NEU.0b013e3181f36010
Cervical Disk Prostheses in Clinical Practice
To the Editor:
I read with particular interest the article by Bartels et al.1 In
September 2008 I presented the results of a similar meta-analysis,
in Auckland for the Annual Scientific Meeting of the Neuro-
surgical Society of Australasia (unpublished).
At that point in time there were a number of devices for which
no comprehensive peer reviewed scientific publication had yet
appeared in the literature. I therefore took the somewhat unusual
step of including the Food and Drug Administration
(FDA) submission documents as sources of patient data for the
meta-analysis (in addition to journal articles and conference
proceedings).2-4
Notwithstanding the differences in inputs to the meta-
analysis I note that the outcomes are very similar to those
calculated in my 2008 meta-analysis. Specifically, each of the
analyses favored arthroplasty to an approximately similar ex-
tent found in the article by Bartels et al. I also calculated
a number of other outcomes and found a reduction in the risk
of symptomatic adjacent segment disease favoring arthro-
plasty, relative risk of 0.43 (95% confidence interval [CI],
0.19-0.96, P = .04, n = 1101).
That the studies had a high risk of bias due to serious
methodological flaws or incomplete reporting, was a major
conclusion of the authors and I had reached exactly the same
conclusion during my own meta-analysis.
would like to raise 2 additional points. Firstly, I would strongly
contest the assumption of a low risk of bias based on a study being
approved by the FDA. The results for the 3 FDA studies I had
included are listed in the Table.2-4 Reporting of the factors rel-
evant to minimizing bias was incomplete. There was no study for
which a low risk of bias can be safely assumed given the data
available.
Secondly, and perhaps most importantly, analysis by intention
to treat was unclear (6/8 studies) or not performed (2/8 studies)
in the reports I examined, including the FDA documents.216
www.neurosurgery-online.com
 CORRESPONDENCE

16. Sasso RC, Smucker JD, Hacker RJ, et al. Clinical outcomes of BRYAN cervical
disc arthroplasty: a prospective, randomized, controlled, multicenter trial with 24-
TABLE. Methodological Properties of FDA Submitted Cervical month follow-up. J Spinal Disord Tech. 2007;20(7):481-491.
Disk Prosthesis Trialsa
Study Bryan Prestige II Prodisc C
10.1227/NEU.0b013e3181f36034
FDA FDA FDA
Sequence Generation Unclear Adequate Unclear
Allocation Concealment Unclear Unclear Unclear
Blinding Inadequate Inadequate Inadequate In Reply:
First, I want to thank Dr Jonker for his thoughtful comments,
a
FDA, Food and Drug Administration. and his kind compliment.
He raised an important question: what is the value of approval of
the design of a study by the Food and Drug Administration (FDA)?
Many authors end their presentation of the design with the state-
This seriously undermines the value of randomization, and ment that it was approved by the FDA. For the reader who is not
introduces further potential for bias. familiar with the FDA, it seems that the FDA is a super ethical
Bartels et al are to be congratulated on their important board with extensive epidemiological knowledge. However, when I
contribution to the literature recently presented the results of this study to the Dutch Spine
Society and later to individual European spine surgeons, I heard
Benjamin P. Jonker
a similar comment. FDA approval does not mean a low risk for bias.
Sydney, New South Wales, Australia
The comment of Dr Jonker urged me to search PubMed again for
evidence that FDA approval does not mean a low risk of bias. The
1. Bartels RHMA, Donk R, Verbeek ALM. No Justification for cervical disk search string included (FDA AND risk for bias), and later (FDA
prostheses in clinical practice. Neurosurgery. 2010;66(6):1153-1160. AND bias). I did not find any article answering my question ex-
2. Bryan FDA Study. http://www.fda.gov/OHRMS/DOCKETS/ac/07/briefing/ plicitly. However, many comments are possible on the functioning of
2007-4305b1-09.pdf. Accessed June 1, 2008.
3. Prestige FDA Study. http://www.fda.gov/cdrh/pdf6/p060018b.pdf. Accessed June the FDA. Especially, the important contribution of users fees to the
1, 2008. budget of the FDA1 could introduce a conflict of interest. This
4. Prodisc-C FDA Study. http://www.fda.gov/cdrh/pdf7/p070001b.pdf. conflict of interest could influence the approval of the design of
Accessed June 1, 2008.
5. Coric D, Finger F, Boltes P, Coric D, Finger F, Boltes P. Prospective randomized
studies. It still remains unproven and is assumed. Therefore, it re-
controlled study of the Bryan Cervical Disc: early clinical results from a single mains an interpretation that is always subjective. I invite Dr Jonker to
investigational site. J Neurosurg Spine. 2006;4(1):31-35. epidemiologically investigate the relationship between FDA and bias.
6. Hacker RJ, Hacker RJ. Cervical disc arthroplasty: a controlled randomized pro- Regarding the table, we did not look at the FDA protocols, but
spective study with intermediate follow-up results. Invited submission from the
joint section meeting on disorders of the spine and peripheral nerves, March to the published reports.
2005.[erratum appears in J Neurosurg Spine. 2006 Feb;4(2):189]. J Neurosurg After reviewing again the included manuscripts, I agree with
Spine. 2005;3(6):424-428. Dr Jonker that it is unclear in most of the manuscripts that
7. Mummaneni PV, Burkus JK, Haid RW, et al. Clinical and radiographic analysis of
cervical disc arthroplasty compared with allograft fusion: a randomized controlled
analysis was performed according to the intention to treat
clinical trial.[see comment]. J Neurosurg Spine. 2007;6(3):198-209. principle. This would be a serious problem if the studies include
8. Musante D, Coric D, Liebelt R, Henegar M, Finger F, Dimmig T. Prospective many crossovers. However, the patients are assigned to an in-
Randomized U.S. Trial Comparing Kineflex/C Cervical Total Disc Replacement to vestigational group (prosthesis) or a control group. Only a very,
Fusion for Single-level Disc Degeneration. Paper presented at: SAS 20082008; Miami.
9. Nabhan A, Ahlhelm F, Pitzen T, et al. Disc replacement using Pro-Disc C versus
very few patients were initially offered the treatment that they
fusion: a prospective randomised and controlled radiographic and clinical study. were not assigned to due to intraoperative technical problems or
Eur Spine J. 2007;16(3):423-430. administrative problems. The number of re-surgeries to address
10. Nabhan A, Ahlhelm F, Shariat K, et al. The ProDisc-C prosthesis: clinical and problems at the index level or adjacent level was well reported,
radiological experience 1 year after surgery. Spine (Phila Pa 1976). 2007;32(18):
1935-1941. and was also small. The percentage of last follow-up was in all
11. Peng-Fei S, Yu-Hua J. Cervical disc prosthesis replacement and interbody fusion - studies very high in each cohort. Therefore, I contest with Dr
A comparative study. Int Orthop. 2008;32(1):103-106. Jonker that the absence of the intention to treat principle un-
12. Porchet F, Metcalf NH. Clinical outcomes with the Prestige II cervical disc:
preliminary results from a prospective randomized clinical trial. Neurosurg Focus.
dermined for these studies the value of randomization.
2004;17(3):36-43. Ronald H.M.A. Bartels
13. Regan JJ, Phillips FM, Cappuccino A, DeVine J, Ahrens J, McAfee PC. Results of Nijmegen, The Netherlands
a Prospective Randomized, Multi-Center Clinical Trial of PCM Cervical Disc Re-
placement: Two Year Clinical Outcomes. Paper presented at: SAS 20082008; Miami.
14. Sasso RC, Heller JG, Anderson PA, Papadopoulos S, Fessler RG. Comparison of 1. Deyo RA. Gaps, tensions, and conflicts in the FDA approval process: implications
BRYAN Cervical Disc Arthroplasty with Anterior Cervical Decompression and Fusion: for clinical practice. J Am Board Fam Pract. 2004;17(2):142-149.
Clinical Results of a Randomized Clinical Trial. Paper presented at: SAS 2008; Miami.
15. Sasso RC, Smucker JD, Hacker RJ, Heller JG. Artificial disc versus fusion:
a prospective, randomized study with 2-year follow-up on 99 patients. Spine (Phila 10.1227/NEU.0b013e3181f3d2c7
Pa 1976). 2007;32(26):2933-2940.

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CORRESPONDENCE
Diffusion Tensor Imaging in Patients With Adult
Chronic Idiopathic Hydrocephalus
To the Editor:
With great interest we read the article by E. Hattingen et al1
who showed the interesting characteristic of diffusion tensor
imaging in patients with possible/probable idiopathic normal
pressure hydrocephalus (iNPH). They revealed that patients with
possible/probable iNPH had significantly higher fractional
anisotropy (FA) values in the corticospinal tract (CST) and lower
in the corpus callosum (CC) compared with the control subjects.
Moreover, FA value of the CST correlated with the severity of gait
disturbances.
Similarly to this report, we examined the FA values in several
points around the lateral ventricles of chronic hydrocephalus
containing definite iNPH and secondary NPH.2 The CC and
periventricular white matter showed remarkably decreased values
of FA compared with the control subjects. Although several
regions including the posterior limb of the internal capsule and
the caudate nucleus showed increased FA values, the value only in
the caudate nucleus increased with statistical significance. We
think that definite chronic hydrocephalus can be differentiated
from ventriculomegaly associated with brain atrophy as well as in
normal brain by the measurement of FA values. In our study, the
increase of FA values in caudate nucleus was the most valuable,
because the change in this region is seen only in definite NPH
group. In contrast, the FA change in CC was less important,
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because the FA values in definite NPH group and brain atrophy
group were similar.
The authors should clarify whether FA values in caudate
nucleus were assessed or not. And it should be clarified, that the
FA increase in CST is specific only for definite iNPH, but not for
ventriculomegaly associated with brain atrophy; in other words,
whether the increase of FA in CST is valuable for distinguishing
definite iNPH from other types of ventriculomegaly in the
published article or further studies.
Anyway, we think that the FA studies are the breakthrough in
non-invasive diagnosis of iNPH. Further detailed analysis of FA
changes in iNPH may be promising.
Satoru Osuka
Akira Matsumura
Eiichi Ishikawa
Akira Matsushita
Tsukuba, Japan
1. Hattingen E, Jurcoane A, Melber J, et al. Diffusion tensor imaging in patients with
adult chronic idiopathic hydrocephalus. Neurosurgery. 2010;66(5):917-924.
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www.neurosurgery-online.com