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Open access

Enlarged tumefactive perivascular, or Virchow-Robin, spaces and hydrocephalus: do we need to treat? Illustrative cases

Belal Neyazi, Vanessa Magdalena Swiatek, Klaus-Peter Stein, Karl Hartmann, Ali Rashidi, Seraphine Zubel, Amir Amini, and I. Erol Sandalcioglu

BACKGROUND

Perivascular spaces (PVSs) are spaces in brain parenchyma filled with interstitial fluid surrounding small cerebral vessels. Massive enlargements of PVSs are referred to as “giant tumefactive perivascular spaces” (GTPVSs), which can be classified into three types depending on their localization. These lesions are rare, predominantly asymptomatic, and often initially misinterpreted as cystic tumor formations. However, there are several reported cases in which GTPVSs have induced neurological symptoms because of their size, mass effect, and location, ultimately leading to obstructive hydrocephalus necessitating neurosurgical intervention. Presented here are three diverse clinical presentations of GTPVS.

OBSERVATIONS

Here, the authors observed an asymptomatic case of type 1 GTPVS and two symptomatic cases of type 3 GTPVS, one causing local mass effect and the other hydrocephalus.

LESSONS

GTPVSs are mostly asymptomatic lesions. Patients without symptoms should be closely monitored, and biopsy is discouraged. Hydrocephalus resulting from GTPVS necessitates surgical intervention. In these cases, third ventriculostomy, shunt implantation, or direct cyst fenestration are surgical options. For patients presenting with symptoms from localized mass effect, a thorough evaluation for potential neurosurgical intervention is imperative. Follow-up in type 3 GTPVS is recommended, particularly in untreated cases. Given the infrequency of GTPVS, definitive guidelines for neurosurgical treatment and subsequent follow-up remain elusive.

Open access

Approaches to ventriculoperitoneal shunt scalp erosion: countersinking into the calvarium. Illustrative case

Denise Brunozzi, Melissa A LoPresti, Jennifer L McGrath, and Tord D Alden

BACKGROUND

Ventriculoperitoneal shunting (VPS) is a standard procedure for the treatment of hydrocephalus, and the management of its complications is common in the practice of pediatric neurosurgery. Shunt exposure, though a rare complication, can occur because of thin, fragile skin, a young patient age, protuberant hardware, poor scalp perfusion, and a multitude of other patient factors.

OBSERVATIONS

The authors report a complex case of VPS erosion through the scalp in a young female with Pfeiffer syndrome treated with external ventricular drainage, empirical antibiotics, and reinternalization with countersinking of replaced shunt hardware into the calvarium to prevent internal skin pressure points, reduce wound tension, and allow wound healing.

LESSONS

Recessing the shunt hardware, or countersinking the implant, into the calvarium is a simple technique often used in functional neurosurgical implantation surgeries, providing a safe surgical strategy to optimize wound healing in select cases in which the skin flap is unfavorable.

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.