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Jacob Cherian, Robert L. Atmar and Shankar P. Gopinath

OBJECT

Patients with cryptococcal meningitis often develop symptomatic intracranial hypertension. The need for permanent CSF diversion in these cases remains unclear.

METHODS

Cases of cryptococcal meningitis over a 5-year period were reviewed from a single, large teaching hospital. Sources of identification included ICD-9 codes, operative logs, and microscopy laboratory records.

RESULTS

Fifty cases of cryptococcal meningitis were identified. Ninety-eight percent (49/50) of patients were HIV positive. Opening pressure on initial lumbar puncture diagnosing cryptococcal meningitis was elevated (> 25 cm H2O) in 33 cases and normal (≤ 25 cm H2O) in 17 cases. Thirty-eight patients ultimately developed elevated opening pressure over a follow-up period ranging from weeks to years.

Serial lumbar punctures for relief of intracranial hypertension were performed in 29 cases. Thirteen of these patients ultimately had shunting procedures performed after failing to improve clinically. Two factors were significantly associated with the need for shunting: patients undergoing shunt placement were more likely to be women (5/13 vs 0/16; p = 0.01) and to have a pattern of increasing CSF cryptococcal antigen (10/13 vs 3/16 cases; p = 0.003). All patients re-presenting with mycological relapse either underwent or were offered shunt placement.

CONCLUSIONS

Neurosurgeons are often asked to consider CSF diversion in cases of cryptococcal meningitis complicated by intracranial hypertension. Most patients do well with serial lumbar punctures combined with antifungal therapy. When required, shunting generally provided sustained relief from intracranial hypertension symptoms. Ventriculoperitoneal shunts are the favored method of diversion. To the authors’ knowledge, the present study is the largest series on diversionary shunts in primarily HIV-positive patients with this problem.

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Travis S. Tierney and Andres M. Lozano

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George Al-Shamy, Jacob Cherian, Javier A. Mata, Akash J. Patel, Steven W. Hwang and Andrew Jea

Object

Lateral mass screws are routinely placed throughout the subaxial cervical spine in adults, but there are few clinical or radiographic studies regarding lateral mass fixation in children. The morphology of pediatric cervical lateral masses may be associated with greater difficulty in obtaining adequate purchase. The authors examined the lateral masses of the subaxial cervical spine in pediatric patients to define morphometric differences compared with adults, establish guidelines for lateral mass instrumentation in children, and define potential limitations of this technique in the pediatric age group.

Methods

Morphometric analysis was performed on CT of the lateral masses of C3–7 in 56 boys and 14 girls. Measurements were obtained in the axial, coronal, and sagittal planes.

Results

For most levels and measurements, results in boys and girls did not differ significantly; the few values that were significantly different are not likely to be clinically significant. On the other hand, younger (< 8 years of age) and older children (≥ 8 years of age) differed significantly at every level and measurement except for facet angularity. Sagittal diagonal, a measurement that closely estimates screw length, was found to increase at each successive caudal level from C-3 to C-7, similar to the adult population. A screw acceptance analysis found that all patients ≥ 4 years of age could accept at least a 3.5 × 10 mm lateral mass screw.

Conclusions

Lateral mass screw fixation is feasible in the pediatric cervical spine, particularly in children age 4 years old or older. Lateral mass screw fixation is feasible even at the C-7 level, where pedicle screw placement has been advised in lieu of lateral mass screws because of the small size and steep trajectory of the C-7 lateral mass. Nonetheless, all pediatric patients should undergo high-resolution, thin-slice CT preoperatively to assess suitability for lateral mass screw fixation.

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Jacob Cherian, Thomas P. Madaelil, Frank Tong, Brian M. Howard, C. Michael Cawley and Jonathan A. Grossberg

The video highlights a challenging case of bilateral vertebral artery dissection presenting with subarachnoid hemorrhage. The patient was found to have a critical flow-limiting stenosis in his dominant right vertebral artery and a ruptured pseudoaneurysm in his left vertebral artery. A single-stage endovascular treatment with stent reconstruction of the right vertebral artery and coil embolization sacrifice of the left side was performed. The case highlights the rationale for treatment and potential alternative strategies.

The video can be found here: https://youtu.be/e0U_JE2jISw.

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Visish M. Srinivasan, Andrew P. Carlson, Maxim Mokin, Jacob Cherian, Stephen R. Chen, Ajit Puri and Peter Kan

OBJECTIVE

The Pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, the PED has its own unique technical challenges, including the occurrence of device foreshortening or migration leading to prolapse into the aneurysm. The authors sought to determine the incidence of this phenomenon, the rescue strategies, and outcomes.

METHODS

Four institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with PEDs. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases involving device prolapse into the aneurysm.

RESULTS

A total of 413 intracranial aneurysms were treated with PEDs during the study period, by 5 neurointerventionalists. Large and giant aneurysms (≥ 2 cm) accounted for 32 of these aneurysms. Among these 32 PEDs, prolapse into the aneurysm occurred in 3 patients, with 1 of these PEDs successfully rescued and the other 2 left in situ. No patients suffered any severe complications. The 2 patients in whom the PEDs were left in situ remained on antiplatelet therapy.

CONCLUSIONS

The PED may foreshorten or migrate during or after deployment, leading to prolapse into the aneurysm. This phenomenon appears to be associated with large and giant aneurysms, vessel tortuosity, short landing zones, and use of balloon angioplasty. Future study and follow-up is needed to further evaluate this phenomenon, but some of the observations and techniques described in this paper may help to prevent or salvage prolapsed devices.

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Akash J. Patel, Jacob Cherian, Benjamin D. Fox, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen and Andrew Jea

Object

National and international meetings, such as the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) meetings, provide a central location for the gathering and dissemination of research. The purpose of this study was to determine the publication rates of both oral and poster presentations at CNS and AANS meetings in peer-reviewed journals.

Methods

The authors reviewed all accepted abstracts, presented as either oral or poster presentations, at the CNS and AANS meetings from 2003 to 2005. This information was then used to search PubMed to determine the rate of publication of the abstracts presented at the meetings. Abstracts were considered published if the data presented at the meeting was identical to that in the publication.

Results

The overall publication rate was 32.48% (1243 of 3827 abstracts). On average, 41.28% of oral presentations and 29.03% of poster presentations were eventually published. Of those studies eventually published, 98.71% were published within 5 years of presentation at the meeting. Published abstracts were published most frequently in the Journal of Neurosurgery and Neurosurgery.

Conclusions

Approximately one-third of all presentations at the annual CNS and AANS meetings will be published in peer-reviewed, MEDLINE-indexed journals. These meetings are excellent forums for neurosurgical practitioners to be exposed to current research. Oral presentations have a significantly higher rate of eventual publication compared with poster presentations, reflecting their higher quality. The Journal of Neurosurgery and Neurosurgery have been the main outlets of neurosurgical research from these meetings.

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Jacob Cherian, Kristen A. Staggers, I-Wen Pan, Melissa Lopresti, Andrew Jea and Sandi Lam

OBJECTIVE

Due to improved nutrition and early detection, myelomeningocele repair is a relatively uncommon procedure. Although previous studies have reviewed surgical trends and predictors of outcomes, they have relied largely on single-hospital experiences or on databases centered on hospital admission data. Here, the authors report 30-day outcomes of pediatric patients undergoing postnatal myelomeningocele repair from a national prospective surgical outcomes database. They sought to investigate the association between preoperative and intraoperative factors on the occurrence of 30-day complications, readmissions, and unplanned return to operating room events.

METHODS

The 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric database (NSQIP-P) was queried for all patients undergoing postnatal myelomeningocele repair. Patients were subdivided on the basis of the size of the repair (< 5 cm vs > 5 cm). Preoperative variables, intraoperative characteristics, and postoperative 30-day events were tabulated from prospectively collected data. Three separate outcomes for complication, unplanned readmission, and return to the operating room were analyzed using univariate and multivariate logistic regression. Rates of associated CSF diversion operations and their timing were also analyzed.

RESULTS

A total of 114 patients were included; 54 had myelomeningocele repair for a defect size smaller than 5 cm, and 60 had repair for a defect size larger than 5 cm. CSF shunts were placed concurrently in 8% of the cases. There were 42 NSQIP-defined complications in 31 patients (27%); these included wound complications and infections, in addition to others. Postoperative wound complications were the most common and occurred in 27 patients (24%). Forty patients (35%) had at least one subsequent surgery within 30 days. Twenty-four patients (21%) returned to the operating room for initial shunt placement. Unplanned readmission occurred in 11% of cases. Both complication and return to operating room outcomes were statistically associated with age at repair.

CONCLUSIONS

The NSQIP-P allows examination of 30-day perioperative outcomes from a national prospectively collected database. In this cohort, over one-quarter of patients undergoing postnatal myelomeningocele repair experienced a complication within 30 days. The complication rate was significantly higher in patients who had surgical repair within the first 24 hours of birth than in patients who had surgery after the 1st day of life. The authors also highlight limitations of investigating myelomeningocele repair using NSQIP-P and advocate the importance of disease-specific data collection.

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Jonathan N. Sellin, Jacob Cherian, James M. Barry, Sheila L. Ryan, Thomas G. Luerssen and Andrew Jea

Object

It is common to evaluate children with suspected CSF shunt malfunctions using CT of the head or, more recently, “quick brain” MRI. However, the reliability of using ventricular behavior, as assessed on cranial imaging during previous presentations with shunt obstructions, is not well defined. The authors conducted a study to determine if CT or MRI of ventricular morphology added useful clinical information in the evaluation of shunt malfunctions.

Methods

A retrospective chart review of children operated on at Texas Children's Hospital from February 20, 2011, to June 18, 2013, for shunt obstruction was conducted. Inclusion criteria involved age 3 years or older in patients who had undergone two or more shunt revisions for intraoperatively confirmed obstructions. Patients with shunt infection but without shunt obstruction and patients with fourth ventricular shunt failure were excluded from the study. Preoperative CT or MRI results were dichotomized into two distinct categories, as determined by a radiologist's report: either dilation of the ventricular system in comparison with prior scans at points the shunt was deemed functional, or no dilation of the ventricular system in comparison such scans. Determination of the presence of shunt obstruction was assessed by findings documented by the surgeon in the operative report. Each case was then analyzed to see if the patient has a reliable pattern of ventricular dilation, or no dilation, at times of shunt obstruction.

Results

Forty-two patients (25 males and 17 females) were included in the study. There were a total of 117 patient encounters analyzed and an average of 2.79 encounters per patient. The mean age at shunt failure presentation was 10.8 years (range 3–23 years). In 4 encounters, patients presented with a CSF leak or pseudomeningocele. Twenty-seven patients (64%) consistently demonstrated dilation of the ventricular system during episodes of shunt obstruction. Four patients (10%) consistently demonstrated no dilation during episodes of shunt obstruction. Eleven patients (26%) demonstrated inconsistent changes in ventricular size at times of shunt obstruction. In those first patient encounters with shunt obstruction presenting with ventricular dilation, 92% (49 of 53) of subsequent encounters demonstrated ventricular dilation with shunt obstruction presentations.

Conclusions

Historical CT or MRI data regarding ventricular morphology patterns seen during prior examinations of shunt obstructions may inform a clinician's judgment of shunt obstruction on subsequent presentations, but they are not conclusive. In the present series, the authors found that changes in the morphology of a given patient's ventricular system when shunt obstruction occurs were often consistent and predictable, but not always. It remains imperative, however, that cranial images obtained to rule out shunt malfunction be compared with prior studies.

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Akash J. Patel, Jacob Cherian, Daniel H. Fulkerson, Benjamin D. Fox, Joshua J. Chern, William E. Whitehead, Daniel J. Curry, Thomas G. Luerssen and Andrew Jea

Object

Translaminar screw (TLS) fixation can be used safely and efficaciously for upper cervical fusion in children. No published studies have evaluated this technique in the thoracic spine of the pediatric population, and thus the authors undertook such an analysis.

Methods

The upper thoracic spines (T1–4) of 130 patients, consisting of 70 boys and 60 girls, were studied using CT scans. Laminar height and thickness, screw length, and screw angle were measured. Exclusion criteria included the following: patients older than 18 years of age, trauma or congenital abnormalities of the thoracic spine, or absent demographic information or imaging studies through T-4. Statistical analysis was performed using paired or unpaired Student t-tests (p < 0.05) and linear regression analysis.

Results

The mean laminar heights for T-1, T-2, T-3, and T-4 were as follows: 12.3 ± 3.4, 13.0 ± 3.5, 13.4 ± 3.8, and 14.7 ± 4.1 mm, respectively. The mean laminar widths were 6.5 ± 1.3, 6.6 ± 1.3, 6.6 ± 1.3, and 6.6 ± 1.4 mm, respectively. The mean screw lengths were 29.9 ± 4.1, 25.2 ± 3.5, 22.7 ± 3.2, and 21.6 ± 3.1 mm, respectively. The mean screw angles were 47° ± 4°, 48° ± 4°, 51° ± 4°, and 53° ± 5°, respectively. There were no significant differences between the right and left sides. However, significant differences were found when comparing patients younger than 8 years with those who were 8 years or older, and when comparing boys and girls.

Conclusions

Careful preoperative thin-cut CT with sagittal reconstruction is mandatory to determine if the placement of TLSs is feasible in the pediatric population. Based on CT analysis, the insertion of TLSs in the pediatric thoracic spine is possible in all patients older than 8 years and in many patients younger than 8 years. Boys could accept longer screws in the upper thoracic spine compared with girls.