Neurogenic stunned myocardium (NSM) is a potentially fatal cause of sudden cardiogenic dysfunction due to an acute neurological event, most commonly aneurysmal subarachnoid hemorrhage in adults. Only two pediatric cases of hydrocephalus-induced NSM have been reported. Here the authors report a third case in a 14-year-old boy who presented with severe headache, decreased level of consciousness, and shock in the context of acute hydrocephalus secondary to fourth ventricular outlet obstruction 3 years after standard-risk medulloblastoma treatment. He was initially stabilized with the insertion of an external ventricular drain and vasopressor treatment. He had a profoundly reduced cardiac contractility and became asystolic for 1 minute, requiring cardiopulmonary resuscitation when vasopressors were inadvertently discontinued. Over 1 week, his ventricles decreased in size and his cardiac function returned to normal. All other causes of heart failure were ruled out, and his impressive response to CSF diversion clarified the diagnosis of NSM secondary to hydrocephalus. He was unable to be weaned from his drain during his time in the hospital, so he underwent an endoscopic third ventriculostomy and has remained well with normal cardiac function at more than 6 months’ follow-up. This case highlights the importance of prompt CSF diversion and cardiac support for acute hydrocephalus presenting with heart failure in the pediatric population.
Gabriel Crevier-Sorbo, Jeffrey Atkinson, Tanya Di Genova, Pramod Puligandla, and Roy W. R. Dudley
Ravi Kumar, Jeffrey T. Jacob, Kirk M. Welker, Fred M. Cutrer, Michael J. Link, John L. D. Atkinson, and Nicholas M. Wetjen
This report reviews a series of 3 patients who developed superficial siderosis following posterior fossa operations in which dural closure was incomplete. In all 3 patients, revision surgery and complete duraplasty was performed to halt the progression of superficial siderosis. Following surgery, 2 patients experienced resolution of their CSF xanthochromia while 1 patient had reduced CSF xanthochromia. In this paper the authors also review the etiology, pathophysiology, diagnosis, and treatment of this condition. The authors suggest that posterior fossa dural patency and pseudomeningocele are risk factors for the latent development of superficial siderosis and recommend that revision duraplasty be performed in patients with posterior fossa pseudomeningoceles and superficial siderosis to prevent progression of the disease.
Jeffrey D. Atkinson, D. Louis Collins, Gilles Bertrand, Terry M. Peters, G. Bruce Pike, and Abbas F. Sadikot
Object. Renewed interest in stereotactic neurosurgery for movement disorders has led to numerous reports of clinical outcomes associated with different treatment strategies. Nevertheless, there is a paucity of autopsy and imaging data that can be used to describe the optimal size and location of lesions or the location of implantable stimulators. In this study the authors correlated the clinical efficacy of stereotactic thalamotomy for tremor with precise anatomical localization by using postoperative magnetic resonance (MR) imaging and an integrated deformable digital atlas of subcortical structures.
Methods. Thirty-one lesions were created by stereotactic thalamotomy in 25 patients with tremor-dominant Parkinson disease. Lesion volume and configuration were evaluated by reviewing early postoperative MR images and were correlated with excellent, good, or fair tremor outcome categories. To allow valid comparisons of configurations of lesions with respect to cytoarchitectonic thalamic boundaries, the MR image obtained in each patient was nonlinearly deformed into a standardized MR imaging space, which included an integrated atlas of the basal ganglia and thalamus. The volume and precise location of lesions associated with different clinical outcomes were compared using nonparametric statistical methods. Probabilistic maps of lesions in each tremor outcome category were generated and compared.
Statistically significant differences in lesion location between excellent and good, and excellent and fair outcome categories were demonstrated. On average, lesions associated with excellent outcomes involved thalamic areas located more posteriorly than sites affected by lesions in the other two outcome groups. Subtraction analysis revealed that lesions correlated with excellent outcomes necessarily involved the interface of the nucleus ventralis intermedius (Vim; also known as the ventral lateral posterior nucleus [VLp]) and the nucleus ventrocaudalis (Vc; also known as the ventral posterior [VP] nucleus). Differences in lesion volume among outcome groups did not achieve statistical significance.
Conclusions. Anatomical evaluation of lesions within a standardized MR image—atlas integrated reference space is a useful method for determining optimal lesion localization. The results of an analysis of probabilistic maps indicates that optimal relief of tremor is associated with lesions involving the Vim (VLp) and the anterior Vc (VP).
Jack Lam, Patricia Tomaszewski, Guillaume Gilbert, Jeremy T. Moreau, Marie-Christine Guiot, Steffen Albrecht, Jean-Pierre Farmer, Jeffrey Atkinson, Christine Saint-Martin, Pia Wintermark, Boris Bernhardt, Sylvain Baillet, and Roy W. R. Dudley
The authors sought to assess the utility of arterial spin labeling (ASL) perfusion 3T-MRI for the presurgical evaluation of poorly defined focal epilepsy in pediatric patients.
Pseudocontinuous ASL perfusion 3T-MRI was performed in 25 consecutive children with poorly defined focal epilepsy. ASL perfusion abnormalities were detected qualitatively by visual inspection and quantitatively by calculating asymmetry index (AI) maps and significant z-score cluster maps based on successfully operated cases. ASL results were prospectively compared to scalp EEG, structural 3T-MRI, FDG-PET, ictal/interictal SPECT, magnetoencephalography (MEG), and intracranial recording results, as well as the final surgically proven epileptogenic zone (EZ) in operated patients who had at least 1 year of good (Engel class I/II) seizure outcome and positive histopathology results.
Qualitative ASL perfusion abnormalities were found in 17/25 cases (68%), specifically in 17/20 MRI-positive cases (85.0%) and in none of the 5 MRI-negative cases. ASL was concordant with localizing scalp EEG findings in 66.7%, structural 3T-MRI in 90%, FDG-PET in 75%, ictal/interictal SPECT in 62.5%, and MEG in 75% of cases, and with intracranial recording results in 40% of cases. Eleven patients underwent surgery; in all 11 cases the EZ was surgically proven by positive histopathology results and the patient having at least 1 year of good seizure outcome. ASL results were concordant with this final surgically proven EZ in 10/11 cases (sensitivity 91%, specificity 50%). All 10 ASL-positive patients who underwent surgery had positive surgical pathology results and good long-term postsurgical seizure outcome at a mean follow-up of 39 months. Retrospective quantitative analysis based on significant z-score clusters found 1 true-positive result that was missed by qualitative analysis and 3 additional false-positive results (sensitivity 100%, specificity 23%).
ASL supports the hypothesis regarding the EZ in poorly defined focal epilepsy cases in children. Due to its convenience and noninvasive nature, the authors recommend that ASL be added routinely to the presurgical MRI evaluation of epilepsy. Future optimized quantitative methods may improve the diagnostic yield of this technique.
Benjamin T. Himes, Grant W. Mallory, Arnoley S. Abcejo, Jeffrey Pasternak, John L. D. Atkinson, Fredric B. Meyer, W. Richard Marsh, Michael J. Link, Michelle J. Clarke, William Perkins, and Jamie J. Van Gompel
Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series.
The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure.
In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2–70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12–0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4–39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09–5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery.
In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.