Search Results

You are looking at 1 - 10 of 28 items for

  • Author or Editor: Brandon A. Miller x
Clear All Modify Search
Restricted access

Brandon Miller, Mirza Baig, John Hayes and Scott Elton

Object

The authors performed an analysis of retrospectively obtained data to compare the outcomes of pediatric patients admitted to their institution for traumatic injuries resulting from car, motorcycle, and all-terrain vehicle (ATV) accidents.

Methods

The authors conducted a retrospective review of Columbus Children’s Hospital’s Trauma Registry data collected between January 1993 and December 2003. Data obtained in patients admitted with motor vehicle–related injuries were compiled for a total of 1608 patient records. Data regarding sex, age, hospital length of stay (LOS), Glasgow Coma Scale (GCS) score, revised trauma score, injury severity score (ISS), and use of a protective device were analyzed.

Conclusions

Of 1608 patients, 1257 (78%) were injured in automobile accidents, 123 (7.6%) in motorcycle accidents, and 228 (14.2%) in ATV accidents. Injuries sustained in all vehicle types peaked during the summer months. Patients involved in automobile crashes presented with significantly lower GCS scores than those injured in motorcycle and ATV accidents; however, there was no statistically significant difference in LOS among all three injury modalities. Protective devices were underutilized in all three motor vehicle categories but, when used, were associated with significantly higher GCS scores, ISSs, and shorter LOSs among patients admitted after automobile accidents. The correlation of seat belt use with better outcomes underscores the necessity to improve motor vehicle safety education for children, who are less likely to be restrained as they age.

Full access

Brandon A. Miller, Afshin Salehi, David D. Limbrick Jr. and Matthew D. Smyth

OBJECTIVE

The ROSA device is a robotic stereotactic arm that uses a laser system to register the patient’s head or spine with MR or CT images. In this study, the authors analyze their experience with this system in pediatric neurosurgical applications and present selected cases that exemplify the usefulness of this system.

METHODS

The authors reviewed all cases that utilized the ROSA system at their institution. Patient demographics, pathology, complications, electrode placement, laser ablation, and biopsy accuracy were analyzed. Patient disposition and condition at follow-up were also analyzed.

RESULTS

Seventeen patients underwent 23 procedures using the ROSA system. A total of 87 electroencephalography electrodes were placed, with 13% deviating more than 3 mm from target. Six patients underwent stereotactic needle biopsy, and 9 underwent laser interstitial thermotherapy (LITT). One patient who underwent LITT required a subsequent craniotomy for tumor resection. Another patient experienced an asymptomatic extraaxial hematoma that spontaneously resolved. No patient suffered neurological complications during follow-up. Follow-up from the last procedure averaged 180 days in epilepsy patients and 309 days in oncology patients.

CONCLUSIONS

The precision, ease of use, and versatility of the ROSA system make it well suited for pediatric neurosurgical practice. Further work, including long-term analysis of results and cost-effectiveness, will help determine the utility of this system and if its applications can be expanded.

Restricted access

Brandon A. Miller, David I. Bass and Joshua J. Chern

Arteriovenous malformations (AVMs) are typically considered congenital lesions, although there is growing evidence for de novo formation of these lesions as well. The authors present the case of an AVM in the same cerebral cortex that had been affected by a severe traumatic brain injury (TBI) more than 6 years earlier. To the best of the authors' knowledge, this is the first report attributing the formation of an AVM directly to TBI.

Full access

Jason K. Chu, Brandon A. Miller, Michael P. Bazylewicz, John F. Holbrook and Joshua J. Chern

Subarachnoid-pleural fistulas (SPFs) are rare clinical entities that occur after severe thoracic trauma or iatrogenic injury during anterolateral approaches to the spine. Treatment of these fistulas often entails open repair of the dural defect. The authors present the case of an SPF in a 2-year-old female after a penetrating injury to the chest. The diagnosis of an SPF was suspected given the high chest tube output and was confirmed with a positive β2-transferrin test of the chest tube fluid, as well as visualization of dural defects on MRI. The dural defects were successfully repaired with CT-guided percutaneous epidural injection of fibrin glue alone. This case represents the youngest pediatric patient with a traumatic SPF to be treated percutaneously. This technique can be safely used in pediatric patients, offers several advantages over open surgical repair, and could be considered as an alternative first-line therapy for the obliteration of SPFs.

Free access

Oluwaseun O. Akinduro, Brandon A. Miller, Diogo C. Haussen, Gustavo Pradilla and Faiz U. Ahmad

OBJECT

The authors’ aim in this paper was to review the intraoperative use of epidural steroids in lumbar discectomy surgery with a focus on surgical complications.

METHODS

A comprehensive literature search was done using PubMed, MEDLINE, and the Cochrane Central Registry of Controlled Trials. Relevant papers were retrieved and analyzed. The authors performed a meta-analysis of all available data. Search terms included epidural, steroids, discectomy, lumbar disc surgery, herniated lumbar disc, methylprednisolone, and perioperative.The primary outcome was surgical complications such as wound infection or need for reoperation. Secondary outcomes were pain and postoperative narcotic usage.

RESULTS

Sixteen trials and 1 retrospective study (a total of 1933 patients) were eligible for inclusion in this study. In all studies, steroids were added epidurally over the nerve root before closure in cases, and control patients underwent discectomy alone. The mean age (42.7 years vs 42.4 years; RR 0.30 [95% CI −0.30 to 0.90], p = 0.32), overall complication rates (2.69% vs 1.18%; RR 1.94 [95% CI 0.72–5.26], p = 0.19), and infectious complication rates (0.94% vs 0.08%; RR 4.58 [95% CI 0.75–27.95], p = 0.10) were similar between the steroid group and control group, respectively.

CONCLUSIONS

There is good evidence that epidural steroids can decrease pain in the short term and decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal disease. The authors’ results demonstrate a trend toward increased infection with epidural steroid use, but there was not a statistically significant difference. More studies are needed to validate the long-term risk/benefit ratio of epidural steroids in lumbar discectomy.

Full access

Jarod L. Roland, Richard L. Price, Ashwin A. Kamath, S. Hassan Akbari, Eric C. Leuthardt, Brandon A. Miller and Matthew D. Smyth

The authors describe 2 cases of triventricular hydrocephalus initially presenting as aqueductal stenosis that subsequently developed tumors of the pineal and tectal region. The first case resembled late-onset idiopathic aqueductal stenosis on serial imaging. Subsequent imaging revealed a new tumor in the pineal region causing mass effect on the midbrain. The second case presented in a more typical pattern of aqueductal stenosis during infancy. On delayed follow-up imaging, an enlarging tectal mass was discovered. In both cases hydrocephalus was successfully treated by cerebrospinal fluid diversion prior to tumor presentation. The differential diagnoses, diagnostic testing, and treatment course for these unusual cases are discussed. The importance of follow-up MRI in cases of idiopathic aqueductal stenosis is emphasized by these exemplar cases.

Restricted access

Martha-Conley E. Ingram, Anna L. Huguenard, Brandon A. Miller and Joshua J. Chern

Object

Intraventricular hemorrhage (IVH) is the most common cause of hydrocephalus in the pediatric population and is particularly common in preterm infants. The decision to place a ventriculoperitoneal shunt or ventricular access device is based on physical examination findings and radiographic imaging. The authors undertook this study to determine if head circumference (HC) measurements correlated with the Evans ratio (ER) and if changes in ventricular size could be detected by HC measurements.

Methods

All cranial ultrasound (CUS) reports at the authors' institution between 2008 and 2011 were queried for terms related to hydrocephalus and IVH, from which a patient cohort was determined. A review of radiology reports, HC measurements, operative interventions, and significant clinical events was performed for each patient in the study. Additional radiographic measurements, such as an ER, were calculated by the authors. Significance was set at a statistical threshold of p < 0.05 for this study.

Results

One hundred forty-four patients were studied, of which 45 (31%) underwent CSF diversion. The mean gestational age and birth weight did not differ between patients who did and those who did not undergo CSF diversion. The CSF diversion procedures were reserved almost entirely for patients with IVH categorized as Grade III or IV. Both initial ER and HC were significantly larger for patients who underwent CSF diversion. The average ER and HC at presentation were 0.59 and 28.2 cm, respectively, for patients undergoing CSF diversion, and 0.34 and 25.2 cm for those who did not undergo CSF diversion. There was poor correlation between ER and HC measurements regardless of gestational age (r = 0.13). Additionally, increasing HC was not found to correlate with increasing ERs on consecutive CUSs (φ = −0.01, p = 0.90). Patients who underwent CSF diversion after being followed with multiple CUSs (10 of 45 patients) presented with smaller ERs and HC than those who underwent CSF diversion after a single CUS. Just prior to CSF diversion surgery, the patients who received multiple CUSs had ERs, but not HC measurements, that were similar to those in patients who underwent CSF diversion after a single CUS.

Conclusions

The HC measurement does not correlate with the ER or with changes in ER and therefore does not appear to be an adequate surrogate for serial CUSs. In patients who are followed for longer periods of time before CSF shunting procedures, the ER may play a larger role in the decision to proceed with surgery. Clinicians should be aware that the ER and HC are not surrogates for one another and may reflect different pathological processes. Future studies that take into account other physical examination findings and long-term clinical outcomes will aid in developing standardized protocols for evaluating preterm infants for ventriculoperitoneal shunt or ventricular access device placement.

Restricted access

Robert A. Hirschl, Jeff Wilson, Brandon Miller, Sergio Bergese and E. Antonio Chiocca

Object

Neurosurgeons have been utilizing intraoperative MR (iMR) imaging to evaluate the extent of tumor resection since the 1990s. A low–field strength (0.12 T) MR imaging unit (PoleStar N20, Medtronic) is a practical and relatively inexpensive iMR imaging system that has found increased use in neurosurgery. The gold standard for postoperative detection of residual tumor has been high-strength MR imaging performed within 48 hours of resection. The object of this study was to determine the predictive concordance of low-strength iMR imaging with standard high-strength MR imaging for detection of residual tumor.

Methods

The authors retrospectively evaluated the MR images from 74 intracranial tumor resections, comparing the intraoperative images obtained using a 0.12-T iMR imaging unit to the immediate postoperative images obtained using a standard 1.5-T MR imaging unit within 48 hours after surgery.

Results

The sensitivity of low-field MR imaging for detection of residual tumor was 0.74 (95% CI 0.58–0.86), and its specificity was 0.97 (95% CI 0.83–1). When only glial tumors (42 of the 74 lesions) were analyzed, the sensitivity was 0.82 (95% CI 0.59–0.94) and the specificity was 0.95 (95% CI 0.73–1).

Conclusions

These data could assist the neurosurgeon who has to decide intraoperatively whether the observed iMR images show residual tumor or not.

Full access

Anna L. Huguenard, Brandon A. Miller, Samir Sarda, Meredith Capasse, Andrew Reisner and Joshua J. Chern

OBJECT

Of the 1.7 million traumatic brain injuries (TBIs) in the US, a third occur in patients under 14 years of age. The rate of posttraumatic epilepsy (PTE) may be as high as 19% after severe pediatric TBI, but the risk for seizures after mild TBI is unknown. Although the rate of seizures after mild TBI may be low, current practice is often driven by high clinical concern for posttraumatic seizures. In this study, the authors evaluated electroencephalography (EEG) results and antiepileptic drug (AED) use in a large cohort of children with mild TBI to estimate the incidence of posttraumatic seizures in this population.

METHODS

Patients presenting to Children’s Hospital of Atlanta for mild TBI from 2010 to 2013 were evaluated. Five thousand one hundred forty-eight patients with mild TBI were studied and divided into 3 groups: 4168 who were discharged from the emergency department, 868 who were admitted without neurosurgical intervention, and 112 who underwent neurosurgical procedures (craniotomy for hematoma evacuation or elevation of depressed skull fractures) but were discharged without an extended stay. Demographic information, CT characteristics, EEG reports, and prescriptions for AEDs were analyzed. Long-term follow-up was sought for all patients who underwent EEG. Correlation between EEG result and AED use was also evaluated.

RESULTS

All patients underwent head CT, and admitted patients were more likely to have an abnormal study (p < 0.0001). EEG evaluations were performed for less than 1.0% of patients in all 3 categories, without significant differences between groups (p = 0.97). Clinicians prescribed AEDs in less than 2.0% of patients for all groups, without significant differences between groups (p = 0.094). Even fewer children continue to see a neurologist for long-term seizure management. The EEG result had good negative predictive value, but only an abnormal EEG reading that was diagnostic of seizures correlated significantly with AED prescription (p = 0.04).

CONCLUSIONS

EEG utilization and AED prescription was low in all 3 groups, indicating that seizures following mild TBI are likely rare events. EEG has good negative predictive value for patients who did not receive AEDs, but has poorer positive predictive value for AED use.

Free access

Anil K. Roy, , Brandon A. Miller, Christopher M. Holland, Arthur J. Fountain Jr., Gustavo Pradilla and Faiz U. Ahmad

OBJECT

The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ.

METHODS

A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma.

RESULTS

The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings.

CONCLUSIONS

Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.