Because of the proximity of the oropharynx (a naturally contaminated region) to the spinal structures of the craniocervical junction, it is possible that small mucosal lacerations in the oropharynx caused by unstable traumatic craniocervical injuries may become contaminated and lead to secondary infection and osteomyelitis. In this report, the authors describe the case of a previously healthy and immunocompetent patient who developed a large retropharyngeal abscess with spinal osteomyelitis after a high-energy craniocervical injury. This unusual report of osteomyelitis with a delayed presentation after a high-energy traumatic injury of the craniocervical junction highlights the possibility of direct injury to a specific area in the oropharyngeal mucosa adjacent to the osteoligamentous structures of the craniocervical junction, an overall underrecognized complication of unstable craniocervical injuries.
Carlos R. Goulart, Tobias A. Mattei, Mariano E. Fiore, William J. Thoman and Ehud Mendel
Michael A. Galgano, Carlos R. Goulart, Hans Iwenofu, Lawrence S. Chin, William Lavelle and Ehud Mendel
Osteoblastomas are primary bone tumors with an affinity for the spine. They typically involve the posterior elements, although extension through the pedicles into the vertebral body is not uncommon. Histologically, they are usually indistinguishable from osteoid osteomas. However, there are different variants of osteoblastomas, with the more aggressive type causing more pronounced bone destruction, soft-tissue infiltration, and epidural extension. A bone scan is the most sensitive radiographic examination used to evaluate osteoblastomas. These osseous neoplasms usually present in the 2nd decade of life with dull aching pain, which is difficult to localize. At times, they can present with a painful scoliosis, which usually resolves if the osteoblastoma is resected in a timely fashion. Neurological manifestations such as radiculopathy or myelopathy do occur as well, most commonly when there is mass effect on nerve roots or the spinal cord itself. The mainstay of treatment involves surgical intervention. Curettage has been a surgical option, although marginal excision or wide en bloc resection are preferred options. Adjuvant radiotherapy and chemotherapy are generally not undertaken, although some have advocated their use after less aggressive surgical maneuvers or with residual tumor. In this manuscript, the authors have aimed to systematically review the literature and to put forth an extensive, comprehensive overview of this rare osseous tumor.
Tobias A. Mattei, Brandon J. Bond, Deepak Sambhara, Carlos R. Goulart and Julian J. Lin
Intracranial arachnoid cysts are a relatively common benign intracranial pathology, accounting for as many as 0.75%–1% of nontraumatic CNS lesions. Although it has already been demonstrated that rupture of arachnoid cysts may lead to subdural hematomas/hygromas, no study to date has investigated benign extracerebral collection in infancy as a possible predisposing factor for further development of arachnoid cysts.
The authors performed a retrospective imaging and chart review of macrocephalic infants 12 months old or younger who were referred to neurosurgical care at OSF St. Francis Medical Center from 2003 to 2010, and who were diagnosed with benign extracerebral fluid collection in infancy on thin-slice (1-mm) head CT scans. Special attention was given to the investigation of risk factors for further development of de novo arachnoid cysts. Several epidemiological factors in the infants and mothers were analyzed, including gestational age at delivery, mode of delivery, mother's age at delivery, delivery complications, birth weight, age of macrocephaly development, degree of macrocephaly, family history of macrocephaly, prenatal and postnatal history of infection, fontanel status, presence of papilledema, previous history of head trauma, and smoking status. Imaging characteristics of the initial scans, such as location of subdural collection (frontal vs frontoparietal and frontotemporal) and presence of ventriculomegaly, were also evaluated. For those patients in whom arachnoid cysts were identified on subsequent CT scans, the size and location of the cysts were also analyzed.
The authors identified 44 children with benign extracerebral fluid collection in infancy. From this group, over a mean follow-up of 13 months (range 6–13 months), 18 children developed intracranial arachnoid cysts (a 40.9% incidence of de novo development of arachnoid cysts), with 27.8% presenting with bilateral cysts. In the multiple logistic regression analysis, infants who presented with an extracerebral collection restricted to the bilateral frontal region were more likely to develop intracranial arachnoid cysts (p = 0.035) than those with collections involving the frontotemporal and frontoparietal regions (odds ratio [OR] = 5.73). Additionally, children with benign extracerebral fluid collections and plagiocephaly were more likely to develop intracranial arachnoid cysts (p = 0.043) than those without plagiocephaly (OR = 4.96).
This is the first report in the neurosurgical literature demonstrating that benign extracerebral fluid collections in infancy may constitute a significant risk factor for development of de novo arachnoid cysts. These findings support a 2-hit hypothesis for the development of arachnoid cysts, in which the combination of an embryological defect in arachnoid development followed by a second event leading to impairment of CSF fluid absorption in early childhood could lead to abnormal CSF dynamics and the consequent expansion of fluid collections in the intraarachnoid spaces.
Tobias A. Mattei, Martin Morris, Kathleen Nowak, Daniel Smith, Jeremy Yee, Carlos R. Goulart, Anne Zborowski and Julian J. Lin
Although several improvements have been observed in the past few years in shunt technology, currently available systems still present several associated problems. Among these, overdrainage along with its complications remains one of the great challenges for new shunt designs. To address the so-called siphoning effect, the authors provide a practical example of how it is possible to decouple the activation pressure and the pressure gradient across the valve through a 3–key component system. In this new shunt design, the flow is expected to depend only on the intracranial pressure and not on the pressure gradient across the valve, thus avoiding the so-called siphoning effect.
The authors used computer models to theoretically evaluate the mechanical variables involved in the operation of the newly designed valve, such as the fluid's Reynolds number, proximal pressure, distal pressure, pressure gradient, actual flow rate, and expected flow rate. After fabrication of the first superscaled model, the authors performed benchmark tests to analyze the performance of the new shunt prototype, and the obtained data were compared with the results predicted by the previous mathematical models.
The final design of the new paddle wheel valve with the 3–key component antisiphoning system was tested in the hydrodynamics laboratory to prove that the siphoning effect did not occur. According to the calculations obtained using the LabVIEW program during the experiments, each time the distal pressure decreased without an increase in the proximal pressure (despite the range of the pressure gradient), the pin blocked the spinning of the paddle wheels, and the calculated fluid velocity through the system tended to zero. Such a situation was significantly different from the expected flow rate for such a pressure gradient in a siphoning situation without the new antisiphon system.
The design of this new prototype with a 3–key component antisiphoning system demonstrated that it is possible to decouple the activation pressure and the pressure gradient across the valve, avoiding the siphoning effect. Although further developments are necessary to provide a model compatible to clinical use, the authors believe that this new prototype illustrates the possibility of successfully addressing the siphoning effect by using a simple 3–key component system that is able to decouple the activation pressure and the pressure gradient across the valve by using a separate pressure chamber. It is expected that such proof of concept may significantly contribute to future shunt designs attempting to address the problem of overdrainage due to the siphoning effect.
Tobias A. Mattei, Brandon J. Bond, Carlos R. Goulart, Chris A. Sloffer, Martin J. Morris and Julian J. Lin
Bicycle accidents are a very important cause of clinically important traumatic brain injury (TBI) in children. One factor that has been shown to mitigate the severity of lesions associated with TBI in such scenarios is the proper use of a helmet. The object of this study was to test and evaluate the protection afforded by a children's bicycle helmet to human cadaver skulls with a child's anthropometry in both “impact” and “crushing” situations.
The authors tested human skulls with and without bicycle helmets in drop tests in a monorail-guided free-fall impact apparatus from heights of 6 to 48 in onto a flat steel anvil. Unhelmeted skulls were dropped at 6 in, with progressive height increases until failure (fracture). The maximum resultant acceleration rates experienced by helmeted and unhelmeted skulls on impact were recorded by an accelerometer attached to the skulls. In addition, compressive forces were applied to both helmeted and unhelmeted skulls in progressive amounts. The tolerance in each circumstance was recorded and compared between the two groups.
Helmets conferred up to an 87% reduction in so-called mean maximum resultant acceleration over unhelmeted skulls. In compression testing, helmeted skulls were unable to be crushed in the compression fixture up to 470 pound-force (approximately 230 kgf), whereas both skull and helmet alone failed in testing.
Children's bicycle helmets provide measurable protection in terms of attenuating the acceleration experienced by a skull on the introduction of an impact force. Moreover, such helmets have the durability to mitigate the effects of a more rare but catastrophic direct compressive force. Therefore, the use of bicycle helmets is an important preventive tool to reduce the incidence of severe associated TBI in children as well as to minimize the morbidity of its neurological consequences.
Ricardo L. L. Dolci, Leo F. S. Ditzel Filho, Carlos R. Goulart, Smita Upadhyay, Lamia Buohliqah, Paulo R. Lazarini, Daniel M. Prevedello and Ricardo L. Carrau
The aim of this study was to evaluate the anatomical variations of the internal carotid artery (ICA) in relation to the quadrangular space (QS) and to propose a classification system based on the results.
A total of 44 human cadaveric specimens were dissected endonasally under direct endoscopic visualization. During the dissection, the anatomical variations of the ICA and their relationship with the QS were noted.
The space between the paraclival ICAs (i.e., intercarotid space) can be classified as 1 of 3 different shapes (i.e., trapezoid, square, or hourglass) based on the trajectory of the ICAs. The ICA trajectories also directly influence the volumetric area of the QS. Based on its geometry, the QS was classified as one of the following: 1) Type A has the smallest QS area and is associated with a trapezoid intercarotid space, 2) Type B corresponds to the expected QS area (not minimized or enlarged) and is associated with a square intercarotid space, and 3) Type C has the largest QS area and is associated with an hourglass intercarotid space.
The different trajectories of the ICAs can modify the area of the QS and may be an essential parameter to consider for preoperative planning and defining the most appropriate corridor to reach Meckel's cave. In addition, ICA trajectories should be considered prior to surgery to avoid injuring the vessels.
Tobias A. Mattei, Kalyani Nair, Martin Morris, Deric Cole, Michael Flatt, Carlos R. Goulart, Brian Kroeter, Shavonna Warren and Julian J. Lin
Addressing overdrainage and its associated complications is still one of the greatest challenges for future shunt designs for normal-pressure hydrocephalus and idiopathic intracranial hypertension. Nevertheless, as evidenced by tap test procedures, a small amount of CSF drainage seems to be enough to relieve patients' symptoms in most cases and, therefore, in opposition to other types of hydrocephalus, continuous CSF drainage may not be absolutely warranted. In such a clinical scenario, intermittent controlled drainage of a small amount of CSF during specific periods of the day through a 2-system pump may provide several advantages over continuous drainage of current single-system shunts. The goal in this study was to design and test an innovative concept of a bicorporal pump composed of a 2-part system. The first component was designed to be implanted in the patient and act as a pump connected to standard catheter tubing. The second component was designed to be used as an external device outside of the body and function as a power supply and control system. Ultimately, flow will only occur when the system is powered by the external device.
Testing and comparisons were performed to evaluate free fluid flow and the maximal flow after pumping in the standing and supine positions. After this, the authors compared the hydrodynamic effects of 2 different housing systems (2- and 3-in systems). An attenuation test was performed to show the effects of electromagnetic forces at progressively increasing distances. Finally, a biocompatibility report of the raw material used in the pilot design was completed.
In the supine position, the effect of pumping was observed to increase the volumetric flow at a rate similar to or higher than that yielded in the free-flow tests. In relation to the attenuation test, it was observed that the volume drops off fairly quickly as the air gap distance was increased until ultimately reaching zero, with approximately 15 mm between the 2 components. In relation to the testing force, the 2-in housing model showed a considerable increase in the required electromagnetic force over the 3-in housing.
The authors successfully designed and tested a new intermittent drainage system through a bicorporal shunt, which provides several advantages over current single-system continuous drainage pumps. According to the authors' benchmark results, the 3-in housing model seems to be a better choice as it requires less force from the external electromagnet control. Moreover, attenuation tests demonstrated that, for proper functioning, the gap distance between the external and implanted devices should not be greater than 15 mm. Such initial benchmark results confirm the feasibility of such innovative design and provide support for future testing of the system in in vivo animal models and in future clinical series.