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Open access

Ultrasound-assisted neuroendoscopic lavage for intraventricular hemorrhage in a newborn: illustrative case

Luca Sartori, Giulia Melinda Furlanis, Samuel Luciano Caliri, Elisa Garbin, Valentina Baro, and Luca Denaro

BACKGROUND

The optimal treatment for posthemorrhagic hydrocephalus in newborns has not been established yet. Moreover, despite many valid therapeutic alternatives, unfavorable neurodevelopmental outcomes are frequent. According to recent literature, these discouraging results could be related to secondary inflammatory damage of the white matter due to the gradual dissolution of the intraventricular hematoma, which should be removed.

OBSERVATIONS

Neuroendoscopic lavage (NEL) has proven to be a safe and reliable procedure, able to adequately remove the intraventricular clots and the products of blood degradation. To increase surgical control of the entire ventricular system, the authors illustrated a case in which they associated real-time transfontanellar ultrasound monitoring with NEL.

LESSONS

Coupling these two techniques, the authors performed a rapid ventricular wash and obtained intraoperative confirmation of complete and accurate clot removal.

Open access

Intraoperative ventricular volume restoration by intraventricular Ringer solution injection in a normal-pressure hydrocephalus patient with traumatic bilateral acute subdural hematoma and ventricular system collapse caused by cerebrospinal fluid shunt overdrainage: illustrative case

Dalibor Sila, Karim Morsi, Markus Lenski, and Stefan Rath

BACKGROUND

The authors report a case of a patient with normal-pressure hydrocephalus treated with a ventriculoperitoneal shunt who developed a traumatic hemispheric bilateral acute subdural hematoma caused by quick cerebrospinal fluid (CSF) overdrainage. The authors present active ventricular CSF volume restoration as a novel treatment option. CSF overdrainage in patients with shunts may facilitate acute subdural hematoma formation even in cases of minor head trauma. Therapeutic options include CSF shunt function restriction or ligation, hematoma evacuation, or a combination of both.

OBSERVATIONS

In this case, the authors performed emergency surgery with hematoma evacuation through a bilateral craniotomy and actively restored the volume of the ventricular system with a slow intraventricular injection of 37°C warmed Ringer solution through a shunt burr hole reservoir.

LESSONS

In addition to hematoma evacuation and restriction of shunt function, the intraoperative restoration of ventricular volume could be a treatment option to prevent postoperative rebleeding or a space-occupying air collection in the subdural space. The risk of possible complications, such as ventricular or parenchymal bleeding, shunt dysfunction, or infections, requires further investigation. Restoration of the ventricular CSF volume by intraventricular injection of Ringer solution was in this case an efficient treatment method to prevent subdural rebleeding and a space-occupying air collection after subdural hematoma evacuation.

Open access

Distal ventriculoperitoneal shunt catheter tightly coiled around the valve in the absence of a subgaleal cerebrospinal fluid collection: illustrative case

Goichiro Tamura, Kerry A. Vaughan, Sara Breitbart, Helen M. Branson, and George M. Ibrahim

BACKGROUND

Among the known complications of ventriculoperitoneal (VP) shunts, subcutaneous or subgaleal migration of distal catheters is rare. Prior case reports have proposed several risk factors, including inadequate fixation of the shunt device, presence of a large subgaleal space filled with cerebrospinal fluid (CSF), and repetitive flexion/extension movement of the head producing a “windlass effect.” Tight coiling of a distal catheter around the valve without a large subgaleal space has not been reported.

OBSERVATIONS

The patient was born prematurely and underwent VP shunt placement for posthemorrhagic ventricular dilatation at 3 months of age with reassuring postoperative imaging. At approximately 3 years of age, shunt radiography and head computed tomography unexpectedly showed excess tubing coiled extracranially around the shunt valve. The patient did not exhibit any clinical symptoms of shunt malfunction and underwent an uneventful revision of the VP shunt system. No CSF-filled subgaleal space was observed intraoperatively.

LESSONS

Distal catheter migration can occur without the clear presence of a subgaleal CSF collection and symptoms of acute hydrocephalus. Appropriate fixation of the shunt system using nonabsorbable stitches is recommended to prevent catheter migration caused by the windlass effect.

Open access

Rare large colloid cyst obstructing the posterior third ventricle: illustrative case

Jakob V. E. Gerstl, Kristian Aquilina, and Jeffrey E. Florman

BACKGROUND

Colloid cysts of the posterior third ventricle are exceedingly rare. This location is a high-risk zone for colloid cysts because of potential obstruction of the cerebral aqueduct.

OBSERVATIONS

The authors report a case of a 57-year-old man who presented with a 6-month history of progressive headache, short-term memory loss, visual blurring, and an episode of double vision. Magnetic resonance imaging (MRI) revealed a colloid cyst, 22 mm in diameter, attached to the roof of the posterior third ventricle. The posterior third ventricle was obstructed, but both foramina of Monro were patent. The entirety of the cyst was resected via a right frontal parasagittal, interhemispheric, transventricular approach through the foramen of Monro. It was not contained within the velum interpositum. The patient did not experience any postoperative deficits.

LESSONS

This case supports the theoretical evidence that colloid cysts in the posterior zone of the third ventricle pose a risk for obstructive hydrocephalus. This report of a large cyst in a rare location describes a unique lesion and provides the first published MRI description.

Open access

Blistering skin reaction with Mastisol in a patient with spina bifida: illustrative case

Robin M. Bowman, Vineeth Thirunavu, and Sandi Lam

BACKGROUND

Patients with spina bifida have repeated interactions with the healthcare system and often require multiple surgeries throughout their lifetime. Latex precautions are often indicated owing to the high risk of anaphylactic reactions. The choice of dressing for these patients represents an opportunity for learning and standardization if appropriate. The authors discuss the various cases of skin reactions to Mastisol in the literature in comparison with their case and explore the possible mechanisms underlying this skin reaction given the high prevalence of latex allergy in patients with spina bifida.

OBSERVATIONS

The authors present the case of a 17-year-old girl with a history of spina bifida and shunted hydrocephalus who underwent a shunt externalization operation and subsequently developed an allergic contact dermatitis reaction to Mastisol liquid adhesive. Topical steroid cream was then administered, and signs and symptoms resolved over the next 3 days.

LESSONS

The choice of dressing should be considered carefully in patients with spina bifida given their repeated exposures and possible sensitivities. The authors aim to increase the awareness of the possibility of Mastisol-induced skin reactions in patients with spina bifida and set a foundation for future studies to investigate the relationship between latex allergy and sensitization to Mastisol.

Open access

Mixed germ cell tumor infiltrating the pineal gland without elevated tumor markers: illustrative case

Koji Shiomi, Yoshiki Arakawa, Sachiko Minamiguchi, Haruki Yamashita, Yukinori Terada, Masahiro Tanji, Yohei Mineharu, Katsutsugu Umeda, Megumi Uto, Junko Takita, Hironori Haga, Takashi Mizowaki, and Susumu Miyamoto

BACKGROUND

Tumors in the pineal region consist of various histological types, and correct diagnosis from biopsy specimens is sometimes difficult. The authors report the case of a patient with a mixed germ cell tumor infiltrating into the pineal gland despite showing no elevation of tumor markers.

OBSERVATIONS

An 18-year-old man complained of headache and nausea and showed disturbance of consciousness. Magnetic resonance imaging showed hydrocephalus associated with a cystic pineal tumor. The patient underwent tumor biopsy followed by endoscopic third ventriculostomy for hydrocephalus in a local hospital. A pineocytoma was diagnosed, and the patient was referred to the authors’ hospital for treatment. Concentrations of placental alkaline phosphatase, alpha-fetoprotein (AFP), and beta-human chorionic gonadotropin in cerebrospinal fluid were not elevated. However, the authors’ review of the tumor specimen revealed some immature cells infiltrating the pineal gland. These cells were positive for AFP, Sal-like protein 4, and octamer-binding transcription factor 3/4; and the diagnosis was changed to mixed germ cell tumor. Chemoradiotherapy was initiated, followed by surgical removal of the residual tumor.

LESSONS

Careful examination of all tumor specimens and immunohistochemical analyses are important for accurate diagnosis of pineal tumors.

Open access

Subcutaneous emphysema of the neck after shunt surgery for hydrocephalus in a case of metastatic ovarian cancer: illustrative case

Smrithi Sathish, M. Manoranjitha Kumari, Shyama S. Prem, and Gopalakrishnan M. Sasidharan

BACKGROUND

A 46-year-old female, a patient with a relapsed carcinoma in her ovary, had undergone ventriculoperitoneal (VP) shunt surgery for obstructive hydrocephalus due to vermian metastasis. Two weeks after the shunt surgery, she complained of discomfort in the neck. There was subcutaneous emphysema along the shunt track without tenderness or signs of inflammation. She was afebrile, and her vital parameters were stable.

OBSERVATIONS

The authors ruled out pneumothorax and airway trauma as potential sources of emphysema. They tapped the shunt chamber and detected gram-negative bacilli. Ascitic fluid culture grew gas-forming Escherichia coli.

LESSONS

Although some amount of air can get trapped in the subcutaneous plane during the tunneling procedure of a VP shunt tube insertion, the reappearance of a new, large column of air along the shunt track can be an ominous sign of shunt infection. The shunt became contaminated by bacteria of gut origin, which seeded the ascitic fluid, and a florid bacterial growth ascended up the shunt track, producing gas along the subcutaneous plane. Physicians should consider this rare etiology in their differential diagnoses of subcutaneous emphysema following VP shunt surgery.

Open access

Evidence for increased intraabdominal pressure as a cause of recurrent migration of the distal catheter of a ventriculoperitoneal shunt: illustrative case

Christopher Lee, Lucinda Chiu, Pawan Mathew, Gabrielle Luiselli, Charles Ogagan, Rrita Daci, Brittany Owusu-Adjei, Rona S. Carroll, and Mark D. Johnson

BACKGROUND

Placement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear.

OBSERVATIONS

The authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure.

LESSONS

In this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

Open access

Endoscopic third ventriculostomy for VP shunt malfunction during the third trimester of pregnancy: illustrative case

Ahmad K. Alhaj, Tariq Al-Saadi, Marie-Noëlle Hébert-Blouin, Kevin Petrecca, and Roy W. R. Dudley

BACKGROUND

Endoscopic third ventriculostomy (ETV) is a successful procedure for treating noncommunicating hydrocephalus as an alternative to initial ventriculoperitoneal (VP) shunt placement and as a salvage procedure when a VP shunt fails. Physiological changes of pregnancy can lead to VP shunt failure and complicate the management of shunt malfunction, particularly in the third trimester.

OBSERVATIONS

The authors present a case in which an ETV was successfully used in the third trimester (31 weeks of gestation) of pregnancy for acute hydrocephalus due to VP shunt malfunction, and the patient went on to deliver a healthy baby at term; the patient remained well in the long-term follow-up. An English-language PubMed literature review revealed four cases of VP shunt failure successfully treated with an ETV in the first or second trimester but no such reports in the third trimester of pregnancy.

LESSONS

ETV appears to be a safe and effective alternative to VP shunt replacement in the late prenatal period of pregnancy.

Open access

Negative-pressure hydrocephalus in the course of a complex postoperative intracranial pressure disturbance: illustrative case

Tomoya Suzuki, Shogo Kaku, Kostadin Karagiozov, and Yuichi Murayama

BACKGROUND

Negative-pressure hydrocephalus (NePH) is a rare clinical entity that presents on the background of ventriculomegaly with atypical symptoms. Its diagnosis is difficult, and some patients experience several shunt revisions until the proper solution is found.

OBSERVATIONS

The authors present a patient who developed acute deterioration due to iatrogenic NePH after surgery for a vertebral artery thrombosed giant aneurysm. The deterioration occurred after the insertion of a lumbar drain by which the authors intended to reduce a postoperative subcutaneous cerebrospinal fluid (CSF) collection. The drainage created an unexpected negative-pressure gradient in the CSF spaces, which resulted in NePH. Interventions, such as extraventricular drainage and blood patch, corrected the negative transmantle pressure and stabilized the patient’s condition.

LESSONS

Because the pathophysiology of NePH is theoretically considered to be caused by negative transmantle pressure, the intervention should be performed in order to deal with the coexistence of obstruction in the CSF pathways and a CSF leak. A blood patch would be an effective option in treating the CSF leak when the site of leakage is certain. This is the first case in which a blood patch was effectively applied in the treatment for NePH with a favorable outcome without any permanent CSF diversion.