Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.
Robert H. Bonow, James W. Bales, Ryan P. Morton, Michael R. Levitt and Fangyi Zhang
Michael R. Levitt, Jeffrey G. Ojemann and John Kuratani
The insular cortex is an uncommon epileptogenic location from which complex partial seizures may arise. Seizure activity in insular epilepsy may mimic temporal, parietal, or other cortical areas. Semiology, electroencephalography, and even surface electrocorticography recordings may falsely localize other cortical foci, leading to inaccurate diagnosis and treatment. The use of insular depth electrodes allows more precise localization of seizure foci. The authors describe the case of a young girl with seizures falsely localized to the cortex, with foci arising from the insula, as proven by depth electrode recordings. Resection of the insula yielded seizure control.
Michael R. Levitt, Toba N. Niazi, Richard A. Hopper, Richard G. Ellenbogen and Jeffrey G. Ojemann
Chiari malformation Type I (CM-I) is associated with syndromic and nonsyndromic craniosynostosis in pediatric patients, and the surgical management of CM-I in such cases is controversial. Previous guidelines have recommended simultaneous cranial vault expansion and suboccipital decompression. However, spontaneous resolution of CM-I has been observed, and the combined procedure carries additional surgical risks. The authors report the case of a 6-month-old boy with Crouzon syndrome, CM-I, and a cervical syrinx who underwent posterior cranial vault release without suboccipital decompression. Imaging at the 3-month follow-up visit demonstrated complete resolution of the CM-I, improvement in CSF flow, and reduction in the size of the syrinx. This case suggests that up-front suboccipital decompression may not be necessary in patients with craniosynostosis and CM-I. A strategy of initial cranial vault release, followed by watchful waiting and radiographic surveillance, is proposed.
Michael R. Levitt, Joshua W. Osbun, John D. Nerva and Louis J. Kim
A 71-year-old woman presented with headache and dilated vessels on CTA. Angiography demonstrated a complex dural arteriovenous fistula with retrograde cortical venous hypertension, supplied by branches of internal and external carotids bilaterally into a fistulous pouch paralleling the left transverse and sigmoid sinuses, which was occluded at the jugular bulb. The patient refused treatment and was lost to follow-up, returning with sudden confusion and hemianopsia from left temporo-occipital hemorrhage. Transvenous endovascular embolization was performed using the dual-microcatheter technique with a combination of coiling and Onyx copolymer, completely occluding the sinus and fistula while preserving normal venous drainage.
The video can be found here: http://youtu.be/u_4Oc7tSmDM.
Ryan P. Morton, Renee M. Reynolds, Rohan Ramakrishna, Michael R. Levitt, Richard A. Hopper, Amy Lee and Samuel R. Browd
In this study, the authors describe their experience with a low-dose head CT protocol for a preselected neurosurgical population at a dedicated pediatric hospital (Seattle Children's Hospital), the largest number of patients with this protocol reported to date.
All low-dose head CT scans between October 2011 and November 2012 were reviewed. Two different low-dose radiation dosages were used, at one-half or one-quarter the dose of a standard head CT scan, based on patient characteristics agreed upon by the neurosurgery and radiology departments. Patient information was also recorded, including diagnosis and indication for CT scan.
Six hundred twenty-four low-dose head CT procedures were performed within the 12-month study period. Although indications for the CT scans varied, the most common reason was to evaluate the ventricles and catheter placement in hydrocephalic patients with shunts (70%), followed by postoperative craniosynostosis imaging (12%). These scans provided adequate diagnostic imaging, and no patient required a follow-up full-dose CT scan as a result of poor image quality on a low-dose CT scan. Overall physician comfort and satisfaction with interpretation of the images was high. An additional 2150 full-dose head CT scans were performed during the same 12-month time period, making the total number of CT scans 2774. This value compares to 3730 full-dose head CT scans obtained during the year prior to the study when low-dose CT and rapid-sequence MRI was not a reliable option at Seattle Children's Hospital. Thus, over a 1-year period, 22% of the total CT scans were able to be converted to low-dose scans, and full-dose CT scans were able to be reduced by 42%.
The implementation of a low-dose head CT protocol substantially reduced the amount of ionizing radiation exposure in a preselected population of pediatric neurosurgical patients. Image quality and diagnostic utility were not significantly compromised.
M. Yashar S. Kalani, Mark E. Oppenlander, Michael Levitt, Sam Safavi-Abbasi, Robert F. Spetzler and Joseph M. Zabramski
Unruptured posterior circulation aneurysms pose a treatment challenge. Although data supports the use of endovascular technique for select ruptured cases, in unruptured cases, there may be clinical equipoise. Furthermore, wide-necked basilar apex aneurysms commonly require the use of stents and placement of patients on dual therapy. We present a case of a healthy 50-year-old woman with an incidental basilar tip aneurysm treated via an orbitozygomatic craniotomy. This video highlights the steps of dynamic retraction, which is retraction without placement of permanent rigid retraction system, and the added maneuverability afforded by the use of the mouthpiece on the microscope.
The video can be found here: http://youtu.be/jVfC6CCXdZY.
Mahmud Mossa-Basha, Thien J. Huynh, Daniel S. Hippe, Peter Fata, Ryan P. Morton and Michael R. Levitt
The aim of this paper was to evaluate the association between intracranial vessel wall MRI enhancement characteristics and the development of angiographic vasospasm in endovascularly treated aneurysm patients.
Consecutive cases of both ruptured and unruptured intracranial aneurysms that were treated endovascularly, followed by intracranial vessel wall MRI in the immediate postoperative period, were included. Two raters blinded to clinical data and follow-up imaging independently evaluated for the presence, pattern, and intensity of wall enhancement. Development of angiographic vasospasm was independently evaluated. Delayed cerebral ischemia; cerebral infarct; procedural details; and presence and grade of subarachnoid, parenchymal, and intraventricular hemorrhage were evaluated. Statistical associations were determined on a per–vessel segment and per-patient basis.
Twenty-nine patients with 30 treated aneurysms (8 unruptured and 22 ruptured) were included in this study. Interobserver agreement was substantial for the presence of enhancement (κ = 0.67) and nearly perfect for distribution (κ = 0.87) and intensity (κ = 0.84) of wall enhancement. Patients with ruptured aneurysms had a significantly greater number of enhancing segments than those with unruptured aneurysms (29.9% vs 7.2%; OR 5.5, 95% CI 2.2–13.7). For ruptured cases, wall enhancement was significantly associated with subsequent angiographic vasospasm while controlling for grade of hemorrhage (adjusted OR 3.9, 95% CI 1.7–9.4). Vessel segments affected by balloon, stent, or flow-diverter use demonstrated greater enhancement than those not affected (OR 22.7, 95% CI 5.3–97.2 for ruptured; and OR 12.9, 95% CI 3.3–49.8 for unruptured).
Vessel wall enhancement after endovascular treatment of ruptured aneurysms is associated with subsequent angiographic vasospasm.
Ryan P. Morton, Brian W. Hanak, Michael R. Levitt, Kathleen R. Fink, Eric C. Peterson, Marcelo D. Vilela, Louis J. Kim and Randall M. Chesnut
The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management.
A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution.
Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates.
At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.
Michael R. Levitt, Brent R. O'Neill, Gisele E. Ishak, Paritosh C. Khanna, Nancy R. Temkin, Richard G. Ellenbogen, Jeffrey G. Ojemann and Samuel R. Browd
Cerebrospinal fluid shunt placement has a high failure rate, especially in patients with small ventricles. Frameless stereotactic electromagnetic image guidance can assist ventricular catheter placement. The authors studied the effects of image guidance on catheter accuracy and shunt survival in children.
Pediatric patients who underwent placement or revision of a frontal ventricular CSF shunt were retrospectively evaluated. Catheters were placed using either anatomical landmarks or image guidance. Preoperative ventricular size and postoperative catheter accuracy were quantified. Outcomes of standard and image-guided groups were compared.
Eighty-nine patients underwent 102 shunt surgeries (58 initial, 44 revision). Image guidance was used in the placement of 56 shunts and the standard technique in 46. Shunt failure rates were not significantly different between the standard (22%) and image-guided (25%) techniques (p = 0.21, log-rank test). Ventricular size was significantly smaller in patients in the image-guided group (p < 0.02, Student t-test) and in the surgery revision group (p < 0.01). Small ventricular size did not affect shunt failure rate, even when controlling for shunt insertion technique. Despite smaller average ventricular size, the accuracy of catheter placement was significantly improved with image guidance (p < 0.01). Shunt accuracy did not affect shunt survival.
The use of image guidance improved catheter tip accuracy compared with a standard technique, despite smaller ventricular size. Failure rates were not dependent on shunt insertion technique, but an observed selection bias toward using image guidance for more at-risk catheter placements showed failure rates similar to initial surgeries.
Michael R. Levitt, Randall J. Hlubek, Karam Moon, M. Yashar S. Kalani, Peter Nakaji, Kris A. Smith, Andrew S. Little, Kerry Knievel, Jane W. Chan, Cameron G. McDougall and Felipe C. Albuquerque
Cerebral venous pressure gradient (CVPG) from dural venous sinus stenosis is implicated in headache syndromes such as idiopathic intracranial hypertension (IIH). The incidence of CVPG in headache patients has not been reported.
The authors reviewed all cerebral venograms with manometry performed for headache between January 2008 and May 2015. Patient demographics, headache etiology, intracranial pressure (ICP) measurements, and radiographic and manometric results were recorded. CVPG was defined as a difference ≥ 8 mm Hg by venographic manometry.
One hundred sixty-four venograms were performed in 155 patients. There were no procedural complications. Ninety-six procedures (58.5%) were for patients with IIH. The overall incidence of CVPG was 25.6% (42 of 164 procedures): 35.4% (34 of 96 procedures) in IIH patients and 11.8% (8 of 68 procedures) in non-IIH patients. Sixty procedures (36.6%) were performed in patients with preexisting shunts. Seventy-seven patients (49.7%) had procedures preceded by an ICP measurement within 4 weeks of venography, and in 66 (85.7%) of these patients, the ICP had been found to be elevated. CVPG was seen in 8.3% (n = 5) of the procedures in the 60 patients with a preexisting shunt and in 0% (n = 0) of the 11 procedures in the 77 patients with normal ICP (p < 0.001 for both). Noninvasive imaging (MR venography, CT venography) was assessed prior to venography in 112 (68.3%) of 164 cases, and dural venous sinus abnormalities were demonstrated in 73 (65.2%) of these cases; there was a trend toward CVPG (p = 0.07). Multivariate analysis demonstrated an increased likelihood of CVPG in patients with IIH (OR 4.97, 95% CI 1.71–14.47) and a decreased likelihood in patients with a preexisting shunt (OR 0.09, 95% CI 0.02–0.44).
CVPG is uncommon in IIH patients, rare in those with preexisting shunts, and absent in those with normal ICP.