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  • Author or Editor: Luke D. Tomycz x
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Jonathan A. Forbes, Adam S. Reig, Luke D. Tomycz and Noel Tulipan

Object

Intracranial hypertension resulting from compression of the superior sagittal sinus (SSS) by an overlying depressed calvarial fracture is a rare condition. Primary surgical treatment for the symptomatic patient in this setting traditionally involves elevation of the fracture, which often carries significant associated morbidity.

Methods

The authors report a case involving a 6-year-old boy who suffered a closed, depressed, parietooccipital fracture as the result of an unhelmeted all-terrain vehicle accident. This fracture caused compression and subsequent thrombosis of the SSS, which resulted in CSF malabsorption and progressive intracranial hypertension. Initially headache free following the injury, he had developed severe and unremitting headaches by postinjury Day 7. A CT angiography study of the head obtained at this time exhibited thrombosis of the SSS underlying the depressed calvarial fracture. Subsequent lumbar puncture demonstrated markedly elevated intrathecal pressures. Large volumes of CSF were removed, with temporary improvement in symptoms. After medical management with anticoagulation failed, the decision was made to proceed with image-guided ventriculoperitoneal shunt insertion.

Results

The patient's headaches resolved immediately following the procedure, and anticoagulation therapy was reinstituted. Follow-up images obtained 4 months after the injury demonstrated evidence of resolution of the depressed fracture, with recanalization of the SSS. The anticoagulation therapy was then discontinued. To the authors' knowledge, this report is the first description of ventriculoperitoneal shunt insertion as the primary treatment of this infrequent condition.

Conclusions

This report demonstrates that select patients with this presentation can undergo CSF diversion in lieu of elevation of the depressed skull fracture—a surgical procedure shown to be associated with increased risks when the depressed fracture overlies the posterior SSS. The literature on this topic is reviewed and management of this condition is discussed.

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Kevin Carr, Scott L. Zuckerman, Luke Tomycz and Matthew M. Pearson

The endoscopic resection of intraventricular tumors represents a unique challenge to the neurological surgeon. These neoplasms are invested deep within the brain parenchyma and are situated among neurologically vital structures. Additionally, the cerebrospinal fluid system presents a dynamic pathway for resected tumors to be mobilized and entrapped in other regions of the brain. In 2011, the authors treated a 3-year-old girl with a third ventricular mass identified on stereotactic brain biopsy as a WHO Grade IV CNS primitive neuroectodermal tumor. After successful neoadjuvant chemotherapy, endoscopic resection was performed. Despite successful resection of the tumor, the operation was complicated by mobilization of the resected tumor and entrapment in the atrial horn of the lateral ventricle. Using a urological stone basket retriever, the authors were able to retrieve the intact tumor without additional complications. The flexibility afforded by the nitinol urological stone basket was useful in the endoscopic removal of a free-floating intraventricular tumor. This device may prove to be useful for other practitioners performing these complicated intraventricular resections.

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Mayshan Ghiassi, Mahan Ghiassi, Elyne Kahn, Luke Tomycz, Michael Ayad and Oran Aaronson

The authors report on the case of a 24-year-old man who presented with back pain and radiculopathy due to epidural venous engorgement in the setting of a congenitally absent inferior vena cava. Despite initial improvement after steroid administration, the patient's health ultimately declined over a period of weeks, and signs and symptoms of cauda equina syndrome manifested. Lumbar decompression was performed and involved coagulation and resection of the compressive epidural veins. No complications occurred, and the patient made a full neurological recovery.