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Sandeep Sood, Cherukuri Ravi Kumar, Mohammad Jamous, Martin U. Schuhmann, Steven D. Ham and Alexa I. Canady

Object. Patients undergoing long-term shunt therapy following shunt malfunction often present with acute neurological deterioration, high intracranial pressure (ICP), and yet small or slit ventricles. It is believed that low brain compliance prevents ventricle enlargement in such cases. To elucidate the underlying pathophysiology, the authors estimated compliance as a function of cerebrovascular distensibility in 45 patients undergoing chronic shunt therapy.

Methods. The ICP and pressure—volume index (PVI) were measured at end-tidal CO2 of 30 mm Hg (PVI30) and 40 mm Hg (PVI40). The ventricle volume was dichotomized as slit/small/normal or dilated based on the frontooccipital horn ratio. In 18 patients PVI30 was normal (18.4 ± 4 ml), whereas in 27 patients it was significantly elevated (45.5 ± 14 ml). Clinical symptoms or ventricle size at presentation did not correlate with the PVI30. The ICP and PVI at end-tidal CO2 of 40 mm Hg were significantly higher than those at end-tidal CO2 of 30 mm Hg (p < 0.001 and < 0.02, respectively) suggesting an increased cerebrovascular distensibility.

Conclusions. The authors did not observe a low compliance in patients undergoing chronic shunt therapy who, at shunt malfunction, presented with a slit/small/normal ventricle; however, analysis of the findings strongly indicated that an increased cerebrovascular distensibility was present in these patients. This may explain the high ICP and acute clinical deterioration following shunt malfunction in such cases.

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Ravi Kumar, Ramesh Kumar, Grant W. Mallory, Jeffrey T. Jacob, David J. Daniels, Nicholas M. Wetjen, Andrew B. Foy, Brent R. O’Neill and Michelle J. Clarke


Nonpowder guns, defined as spring- or gas-powered BB or pellet guns, can be dangerous weapons that are often marketed to children. In recent decades, advances in compressed-gas technology have led to a significant increase in the power and muzzle velocity of these weapons. The risk of intracranial injury in children due to nonpowder weapons is poorly documented.


A retrospective review was conducted at 3 institutions studying children 16 years or younger who had intracranial injuries secondary to nonpowder guns.


The authors reviewed 14 cases of intracranial injury in children from 3 institutions. Eleven (79%) of the 14 children were injured by BB guns, while 3 (21%) were injured by pellet guns. In 10 (71%) children, the injury was accidental. There was 1 recognized assault, but there were no suicide attempts; in the remaining 3 patients, the intention was indeterminate. There were no mortalities among the patients in this series. Ten (71%) of the children required operative intervention, and 6 (43%) were left with permanent neurological injuries, including epilepsy, cognitive deficits, hydrocephalus, diplopia, visual field cut, and blindness.


Nonpowder guns are weapons with the ability to penetrate a child’s skull and brain. Awareness should be raised among parents, children, and policy makers as to the risk posed by these weapons.

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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.

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Ravi Sharma, Sachin A. Borkar, Manoj Phalak, Sumit Sinha and Ashok K. Mahapatra

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Arun Kumar Gupta, Vedula Rajani Kanth Rao, Dandu Ravi Varma, Tirur R. Kapilamoorthy, Chandrasekharan Kesavadas, Thamburaj Krishnamoorthy, Bejoy Thomas, Narendra K. Bodhey and Sukalyan Purkayastha


Vein of Galen malformations (VGMs) are extremely rare intracranial lesions. Clinical presentation and management strategies vary significantly in different areas of the world. The authors report their experience in evaluation, management, and long-term follow up of these lesions in India.


Between October 1983 and June 2003, 25 patients with VGMs were referred to the authors’ institution for evaluation and management. Ten children younger than 2 years of age presented with rapidly increasing head size as the chief complaint. Among 11 children 2 years of age or older, the most common presenting symptom was chronic headache. Four patients who presented during adulthood had chronic headache for many years before presentation. Angiographic evaluation of the lesion was performed in 21 patients. Fifteen patients were treated using endovascular techniques. Injection of the embolic material was performed after induction of systemic hypotension when the flow in the fistula was high.

Complete occlusion of the arteriovenous shunt could be achieved in two patients with vein of Galen aneurysmal dilation (100% of patients with this type of malformation) and in five of the six patients with the mural type of malformation (83%). Among patients with the choroidal type of malformation, complete obliteration of the shunt could be achieved in three patients. In three patients with high-flow choroidal malformations, embolization carried out in a single sitting resulted in shunt reduction of nearly 90%. These patients received clinical follow up.


The authors’ experience in evaluation and management of VGMs reveals that in areas of the world where access to dedicated specialist care is limited, the clinical presentation of VGMs can differ appreciably from the classic descriptions in the literature. Endovascular management of these lesions results in excellent angiographic and clinical results.