✓ The authors report the case of a patient who sustained traumatic two-level noncontiguous ligamentous flexion-distraction injuries in the thoracolumbar spine. To the best of their knowledge, this is the first reported case of this combined injury pattern.
John P. Ketz and Robert W. Molinari
John P. Kapp and Robert R. Smith
✓ The authors review the literature concerning spontaneous resolution of occlusive lesions involving the carotid artery. They add four cases illustrating three pathological vascular processes that may resolve spontaneously, namely, arterial dissection, atheromatous lesions at the carotid bifurcation, and an arteriopathy involving the intracranial vessels which is poorly understood at this time.
Donald P. Becker, Cavett M. Robert Jr. and John Seelig
Robert C. Pendergrass, A. Earl Walker and John P. Bond
Report of two cases
John M. McLean, Robert M. Wright, John P. Henderson and J. Richard Lister
✓ The authors report two patients with closed head injury who suffered laceration with rupture of the third portion of the vertebral artery. One patient died suddenly, with angiographic evidence of bilateral vertebral artery rupture. The mechanism of injury to the C1–2 segment of the vertebral artery relating to head and neck injury is discussed.
Robert P. Naftel, R. Shane Tubbs, Gavin T. Reed and John C. Wellons III
The authors describe a new technique that may be used in conjunction with neuronavigation or freehand techniques for obtaining small ventricular access. Using this modification, the introducer sheath and trocar can be guided down a ventriculostomy tract with endoscopic visual control. With increasing focus on endoscopic therapies in patients without hydrocephalus, this adjunct, based on the authors' experience, may provide an additional technique for safely treating patients.
John P. Kapp, Robert L. Ross and Elton M. Tucker
✓ The ocular complications of intracarotid infusion of drugs for brain-tumor chemotherapy may be eliminated by infusion of the chemotherapeutic agent into the carotid artery above the origin of the ophthalmic artery. The authors have developed a catheter that can negotiate the carotid siphon. This catheter is not balloon-tipped but incorporates a flexible tip with an expanded end to facilitate drag by flowing blood. The exit hole is placed to allow remote manipulation of the tip by hydraulic forces. Using this catheter, the authors have been consistently able to infuse the supraophthalmic carotid artery.
Bart Chernow, Robert Vigersky, John T. O'Brian and Leon P. Georges
✓ A 38-year-old man developed secondary adrenal insufficiency as a consequence of intrathecal methylprednisolone administration. Evidence in support of this diagnosis included an absent plasma cortisol response to insulin-induced hypoglycemia, an inadequate adrenal response to exogenous corticotropin stimulation, a typical delayed response to prolonged corticotropin infusion over 3 days, and the finding of an elevated level of prednisolone in the cerebrospinal fluid a full 2 months after its administration. It is therefore recommended that patients receiving intrathecal steroids be carefully observed for the possible development of secondary adrenal insufficiency.
Robert P. Naftel, Gavin T. Reed, Abhaya V. Kulkarni and John C. Wellons III
Endoscopic third ventriculostomy (ETV) success is dependent on patient characteristics including age, origin of hydrocephalus, and history of shunt therapy. Using these factors, an Endoscopic Third Ventriculostomy Success Score (ETVSS) model was constructed to predict success of therapy. This study reports a single-institution experience with ETV and explores the ETVSS model validity.
A retrospective chart review identified 151 consecutive patients who underwent ETV at a pediatric hospital between August 1995 and December 2009. Of these 151, 136 patients had at least 6 months of clinical follow-up. Data concerning patient characteristics, operative characteristics, radiological findings, complications, and success of ETV were collected. The actual success rates were compared with those predicted by the ETVSS model.
The actual success rate of ETV at 6 months was 68.4% (93 of 136 patients), which compared well to the predicted ETVSS of 76.5% ± 12.5% (± SD). The C-statistic was 0.74 (95% CI 0.65–0.83), suggesting that the ability of the ETVSS to discriminate failures from successes was good. Secondary ETV was found to have a hazard ratio for failure of 4.2 (95% CI 2.4–7.2) compared with primary ETV (p < 0.001). The complication rate was 9.3% with no deaths. At the first radiological follow-up, the increased size of ventricles had a hazard ratio for failure of 3.0 (95% CI 1.5–6.0) compared with patients in whom ventricle size either remained stable or decreased (p = 0.002).
The ETVSS closely predicts the actual success of ETV, fitting the statistical model well. Shortcomings of the model were identified in overestimating success in patients with ETVSS ≤ 70, which may be attributable to the poor success of secondary ETVs in the authors' patient population.
Robert P. Naftel, Nicole A. Safiano, Michael Falola, Jeffrey P. Blount, W. Jerry Oakes and John C. Wellons III
Children experiencing frequent shunt failure consume medical resources and represent a disproportionate level of morbidity in hydrocephalus care. While biological causes of frequent shunt failure may exist, this study analyzed demographic and socioeconomic patient characteristics associated with frequent shunt failure.
A survey of 294 caregivers of children with shunt-treated hydrocephalus provided demographic and socioeconomic characteristics. Children experiencing at least 10 shunt failures were considered frequent shunt-failure patients. Multivariate regression models were used to control for variables.
Frequent shunt failure was experienced by 9.5% of the patients (28 of 294). By univariate analysis, white race (p = 0.006), etiology of hydrocephalus (p = 0.022), years-with-shunt (p < 0.0001), and surgeon (p = 0.02) were associated with frequent shunt failure. Upon multivariate analysis, white race remained the key independent factor associated with frequent shunt failure (OR 5.8, 95% CI 1.2–27.8, p = 0.027). Race acted independently from socioeconomic factors, including income, level of education, and geographic location, and clinical factors, such as etiology of hydrocephalus, surgeon, and years-with-shunt. Additionally, after multivariate analysis surgeon and years-with-shunt remained associated with frequent shunt failure (p = 0.043 and p = 0.0098, respectively), although etiology of hydrocephalus was no longer associated (p = 0.1).
White race was the primary independent factor associated with frequent shunt failure. Because races use health care differently and the diagnosis of shunt failure is often subjective, a disparity in diagnosis and treatment has arisen. These findings call for objective criteria for the preoperative and intraoperative diagnosis of shunt failure.