Walter Grand and Jody Leonardo
Jody Leonardo and Walter Grand
Causes of unilateral hydrocephalus resulting from an obstruction at the Monro foramen include foraminal atresia, tumors, gliosis, contralateral shunting, and infectious and inflammatory conditions. However, few reports in the literature cite vascular lesions as the cause of the obstruction. To their knowledge, the authors present the first report of unilateral hydrocephalus occurring due to an abnormally enlarged thalamostriate vein independent of an arteriovenous malformation or developmental venous angioma. The condition was treated successfully by endoscopic septum pellucidum fenestration. A 28-year-old man was referred for evaluation due to a 10-year history of chronic headaches that worsened in severity over the past year. A CT scan of the head revealed unilateral right ventricular dilation. Cranial MR imaging with and without contrast administration showed a dilated right thalamostriate–internal vein complex without any evidence of associated arteriovenous malformation or venous angioma. Endoscopic exploration of the right lateral ventricle showed an enlarged subependymal thalamostriate vein obstructing the Monro foramen. An endoscopic fenestration of the septum pellucidum was performed, resulting in alleviation of the patient's symptoms. Abnormally enlarged venous structures may cause obstructive unilateral hydrocephalus and can be a rare cause of chronic, intermittent headaches in adults. Endoscopic fenestration of the septum pellucidum is an effective treatment.
Endoscopic septostomy for headache
Jeffrey E. Florman
Curtis J. Rozzelle, Jody Leonardo and Veetai Li
Implantation of cerebrospinal fluid (CSF) shunting devices is associated with a 5–15% risk of infection as cited in contemporary pediatric neurosurgical literature. Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement. Moreover, shunt infections are commonly associated with prolonged hospital stays, potential comorbidity, and the increased risk of neurological compromise due to ventriculitis or surgical complications. The authors prospectively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture (AMS) or conventional suture.
In a single-center, prospective, double-blinded, randomized controlled trial, the authors enrolled 61 patients, among whom 84 CSF shunt procedures were performed over 21 months. Randomization to the study (AMS) or control (placebo) group was stratified to minimize the effect of known shunt infection risk factors on the findings. Antibacterial shunt components were not used. The primary outcome measure was the incidence of shunt infection within 6 months of surgery.
The shunt infection rate in the study group was 2 (4.3%) of 46 procedures and 8 (21%) of 38 procedures in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups (procedure type and time, age < 6 months, weight < 4 kg, recent history of shunt infection). No suture-related adverse events were reported in either group.
These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection. A larger randomized controlled trial is needed to confirm this association.
Walter Grand and Jody Leonardo
An opaque (neural) floor of the third ventricle is considered an obstacle to safe penetration of the floor of the third ventricle in endoscopic third ventriculostomy (ETV). The direct technique of endoscopic coring (“cookie cut”) of the opaque (neural) floor of the third ventricle is described in 41 cases among a total of 101 consecutive adult ETVs.
A 0° endoscope in a 4.6-mm irrigating sheath was used to press and core (“cookie cut”) a section of the tuber cinereum, thereby exposing the underlying membranes and vasculature. Thereafter, the endoscopic apparatus was used to penetrate the membrane into the prepontine space.
Among 101 consecutive ETVs performed in adults, there were 41 instances of an opaque floor in which the coring technique was used. The basilar artery (BA) complex was in the intended path of penetration in 13 cases. There were no perioperative deaths or vascular injuries. No cases were aborted because of the opaque floor or the configuration of the BA complex. The clinical success rate in the opaque floor group was 80% (33 of 41 patients).
An opaque (neural) floor is frequently seen in adults during ETV. Removing the floor by the core (“cookie cut”) method is a safe means of revealing the underlying BA complex and membranous structures prior to penetration into the prepontine cistern. On occasion, the BA complex may be in the path of penetration, and one can maneuver the endoscope to displace the vasculature to successfully accomplish the ETV.
Stephan A. Munich, Mona Sazgar, Walter Grand and Jody Leonardo
Intraoperative neuromonitoring utilizing electroencephalography (EEG) is rarely performed during neuroendoscopy. The authors present a case in which this monitoring modality was used for a patient with a colloid cyst in preparation for an open craniotomy should an endoscopic approach fail. In this case, EEG serendipitously captured near-complete cessation of electrocerebral activity that occurred during intraventricular irrigation in response to ventricular collapse and resulted in no postoperative deficits. To the authors' knowledge, this is the first reported case of severe suppression of electrical activity captured by EEG during neuroendoscopy. Although they describe a transient phenomenon that resulted in no residual cognitive or neurological deficits, the importance of cautious introduction of ventricular irrigation, the need to carefully monitor intracranial pressure during neuroendoscopic procedures, and the need to pay close attention to irrigation temperature and composition should not be underestimated. Additional studies regarding the utility of EEG in alerting neurosurgeons to adverse electrical cerebral activity during neuroendoscopy are warranted.
John R. W. Kestle
Simon Morr, Hakeem J. Shakir, Lindsay J. Lipinski, Vassilios G. Dimopoulos, Jody Leonardo and John Pollina
Vertebral fractures are the most common osteoporotic fracture. Bone density testing and medical treatment with bisphosphonates or parathormone are recommended for all patients with an osteoporotic fracture diagnosis. Inadequate testing and treatment of patients presenting with low-impact fractures have been reported in various specialties. Similar data are not available from academic neurosurgery groups. The authors assessed compliance with treatment and testing of osteoporosis in patients with vertebral compression fractures evaluated by the authors’ academic neurosurgery service, and patient variable and health-systems factors associated with improved compliance.
Data for patients who underwent percutaneous kyphoplasty for compression fractures was retrospectively collected. Diagnostic and medical interventions were tabulated. Pre-, intra-, and posthospital factors that had been theorized to affect the compliance of patients with osteoporosis-related therapies were tabulated and statistically analyzed.
Less than 50% of patients with kyphoplasty received such therapies. Age was not found to correlate with other variables. Referral from a specialist rather than a primary care physician was associated with a higher rate of bone density screening, as well as vitamin D and calcium therapy, but not bisphosphonate/parathormone therapy. Patients who underwent preoperative evaluation by their primary care physician were significantly more likely to receive bisphosphonates compared with those only evaluated by a hospitalist. Patients with unprovoked fractures were more likely to undergo multiple surgeries compared with those with minor trauma.
These results suggest poor compliance with current standard of care for medical therapies in patients with osteoporotic compression fractures undergoing kyphoplasty under the care of an academic neurosurgery service.
Erik J. van Lindert, Hans Delye and Jody Leonardo
The authors conducted a study to compare the complication rate (CR) of pediatric neurosurgical procedures in a general neurosurgery department to the CRs that are reported in the literature and to establish a baseline of CR for further targeted improvement of quality neurosurgical care.
The authors analyzed the prospectively collected data from a complication registration of 1000 consecutive pediatric neurosurgical procedures in 581 patients from the beginning of the registration in January 2004 through August 2008. A pediatric neurosurgeon was involved in 50.5% of the procedures. All adverse events (AEs) from induction of anesthesia until 30 days postoperatively were recorded.
Overall, 229 complications were counted in 202 procedures. The overall CR was 20.2%, with a 2.7% intraoperative CR and a 17.5% postoperative CR. Tumor surgery was associated with the highest CR (32.7%), followed by CSF disorders (21.8%). The mortality rate was 0.3%. An unplanned return to the operating room in relation to an AE happened in 10.5% of all procedures and in 52% of procedures associated with AEs, the majority of which were related to CSF disorders.
The CR in pediatric neurosurgical procedures was significant, and more than half of the patients with an AE required a repeat surgical procedure. Analysis of CRs should be a prerequisite for the prevention of complications and for the development of targeted interventions to reduce the CR (for example, infection rates).