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Erin N. Kiehna and Robert J. Bollo

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Erin N. Kiehna, Catherine F. McClung-Smith and Robert J. Bollo

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Robert J. Bollo, Judith L. Gooch and Marion L. Walker

Continuous infusion of baclofen is a treatment option for severe generalized dystonia. Catheter insertion within the third ventricle has been described as an alternative to standard intrathecal placement to maximize intracranial concentrations of baclofen. The authors describe their experience with a novel technique for stereotactic endoscopic insertion of baclofen infusion catheters in the third ventricle in 3 patients with severe secondary generalized dystonia. Insertion was successful in all 3 patients, and all of them experienced significant improvement in dystonia scores on the Barry-Albright Dystonia Scale. Follow-up ranged from 5.5 to 7 months (mean 6 months), and no mechanical complications or CSF leaks were observed. The stereotactic endoscopic insertion of a baclofen infusion catheter into the third ventricle appears to be a safe method for continuous intraventricular baclofen infusion in patients with generalized secondary dystonia.

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Michael Karsy, Daxa M. Patel and Robert J. Bollo

Magnetic resonance imaging–guided stereotactic laser ablation of intracranial targets, including brain tumors, has expanded dramatically over the past decade, but there have been few reports of complications, especially those occurring in a delayed fashion. Laser ablation of subependymal giant cell astrocytomas (SEGAs) is an attractive alternative to maintenance immunotherapy in some children with tuberous sclerosis complex (TSC); however, the effect of treatment on disease progression and the nature and frequency of potential complications remains largely unknown. The authors report the case of a 5-year-old boy with TSC who underwent stereotactic laser ablation of a SEGA at the right foramen of Monro on 2 separate occasions. After the second ablation, immediate posttreatment MRI revealed gadolinium extravasation from the tumor into the lateral ventricle. Nine months later, the patient presented with papilledema and delayed obstructive hydrocephalus secondary to intraventricular adhesions causing a trapped right lateral ventricle. This was successfully treated with endoscopic septostomy. The authors discuss the potential cause and clinical management of a delayed complication not previously reported after a relatively novel surgical therapy.

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Sarah T. Garber, Robert J. Bollo and Jay K. Riva-Cambrin

Pediatric spinal pilomyxoid astrocytoma (PMA) is an extremely rare tumor that merits recognition as a specific, unique entity. The authors present the case of an intramedullary PMA in the thoracic spinal cord of an 11-year-old boy who presented with back pain, scoliosis, and multiple lung nodules. The patient underwent T5–11 laminoplasty and near-total resection of the spinal tumor. The final pathological diagnosis was WHO Grade II PMA. The patient did well for 14 months until the tumor progressed both clinically and radiographically. A literature review focusing on the clinical characteristics, histology, and treatment of PMAs provides a better understanding of these rare lesions. Because of the small number of cases optimal treatment guidelines have not been established, but gross-total resection and adjuvant chemotherapy with alkylating agents appear to confer a better long-term prognosis. Pediatric patients with PMAs can remain recurrence free at least 5 years after surgery, although these tumors may disseminate or dedifferentiate into more malignant gliomas. Recognition of intramedullary PMA as a unique entity in children is vital to the development of specific surgical and adjuvant treatment regimens.

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Robert J. Bollo, Jay Riva-Cambrin, Meghan M. Brockmeyer and Douglas L. Brockmeyer

Object

Chiari malformation Type I (CM-I) is a congenital anomaly often treated by decompressive surgery. Patients who fail to respond to standard surgical management often have complex anomalies of the craniovertebral junction and brainstem compression, requiring reduction and occipitocervical fusion. The authors hypothesized that a subgroup of “complex” patients defined by specific radiographic risk factors may have a higher rate of requiring occipitocervical fusion.

Methods

A retrospective review was conducted of clinical and radiographic data in pediatric patients undergoing surgery for CM-I between 1995 and 2010. The following radiographic criteria were identified: scoliosis, syringomyelia, CM Type 1.5, medullary kinking, basilar invagination, tonsillar descent, craniocervical angulation (clivoaxial angle [CXA] < 125°), and ventral brainstem compression (pB–C2 ≥ 9 mm). A multivariate Cox regression analysis was used to determine the independent association between occipitocervical fusion and each variable.

Results

Of the 206 patients who underwent CM decompression with or without occipitocervical fusion during the study period, 101 had preoperative imaging available for review and formed the study population. Mean age at surgery was 9.1 years, and mean follow-up was 2.3 years. Eighty-two patients underwent suboccipital decompression alone (mean age 8.7 years). Nineteen patients underwent occipitocervical fusion (mean age 11.1 years), either as part of the initial surgical procedure or in a delayed fashion. Factors demonstrating a significantly increased risk of requiring fusion were basilar invagination (HR 9.8, 95% CI 2.2–44.2), CM 1.5 (HR 14.7, 95% CI 1.8–122.5), and CXA < 125° (HR 3.9, 95% CI 1.2–12.6).

Conclusions

Patients presenting with basilar invagination, CM 1.5, and CXA < 125° are at increased risk of requiring an occipitocervical fusion procedure either as an adjunct to initial surgical decompression or in a delayed fashion. Patients and their families should be counseled in regard to these findings as part of a preoperative CM evaluation.

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Heather S. Spader, Robert J. Bollo, Christian A. Bowers and Jay Riva-Cambrin

OBJECTIVE

Intrathecal baclofen infusion systems to manage severe spasticity and dystonia are associated with higher infection rates in children than in adults. Factors unique to this population, such as poor nutrition and physical limitations for pump placement, have been hypothesized as the reasons for this disparity. The authors assessed potential risk factors for infection in a multivariate analysis.

METHODS

Patients who underwent implantation of a programmable pump and intrathecal catheter for baclofen infusion at a single center between January 1, 2000, and March 1, 2012, were identified in this retrospective cohort study. The primary end point was infection. Potential risk factors investigated included preoperative (i.e., demographics, body mass index [BMI], gastrostomy tube, tracheostomy, previous spinal fusion), intraoperative (i.e., surgeon, antibiotics, pump size, catheter location), and postoperative (i.e., wound dehiscence, CSF leak, and number of revisions) factors. Univariate analysis was performed, and a multivariate logistic regression model was created to identify independent risk factors for infection.

RESULTS

A total of 254 patients were evaluated. The overall infection rate was 9.8%. Univariate analysis identified young age, shorter height, lower weight, dehiscence, CSF leak, and number of revisions within 6 months of pump placement as significantly associated with infection. Multivariate analysis identified young age, dehiscence, and number of revisions as independent risk factors for infection.

CONCLUSIONS

Young age, wound dehiscence, and number of revisions were independent risk factors for infection in this pediatric cohort. A low BMI and the presence of either a gastrostomy or tracheostomy were not associated with infection and may not be contraindications for this procedure.

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Michael Karsy, Daxa M. Patel, Kyle Halvorson, Vance Mortimer and Robert J. Bollo

Anterior two-thirds corpus callosotomy is a common palliative surgical intervention most commonly employed in patients with atonic or drop seizures. Recently, stereotactic laser ablation of the corpus callosum without a craniotomy has shown promise in achieving similar outcomes with fewer side effects and shorter hospitalizations. The authors demonstrate ablation of the anterior two-thirds corpus callosum in a patient with Lennox-Gastaut syndrome and drug-resistant drop seizures. Technical nuances of laser ablation with 3 laser fibers are described. Postoperatively, the patient showed a significant reduction in seizure frequency and severity over a 9-month follow-up period.

The video can be found here: https://youtu.be/3-mMq5-PLiM.

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Brandon A. Sherrod, Winson S. Ho, Alec Hedlund, Anne Kennedy, Betsy Ostrander and Robert J. Bollo

OBJECTIVE

Prenatal imaging has several critical roles in the diagnosis and management of myelomeningocele, including specific family counseling and the selection of fetal surgery or postnatal repair. In this study, the authors compared the accuracy of fetal MRI and prenatal ultrasonography (US) in predicting the spinal lesion level and assessed the correlation between imaging findings and motor function as independently evaluated by a physical therapist (PT) after birth.

METHODS

A retrospective review of demographic and clinical data was performed to identify children who had been treated with postnatal myelomeningocele closure at a single institution between March 2013 and December 2018. Patients were eligible for inclusion if they had all of the following: prenatal US identifying the neural tube defect level, fetal MRI identifying the neural tube defect level, and postoperative PT evaluation identifying the motor deficit level. Statistical analysis was performed using Cohen’s kappa coefficient to compare the US- and MRI-demonstrated lesion level and correlate these findings with the motor level assigned postnatally by a PT via manual muscle testing.

RESULTS

Thirty-four patients met the inclusion criteria. The mean gestational age at US was 23.0 ± 4.7 weeks, whereas the mean gestational age at MRI was 24.0 ± 4.1 weeks. The mean time from surgery to the PT evaluation was 2.9 ± 1.9 days. Prenatal US and MRI were in agreement within one spinal level in 74% of cases (25/34, k = 0.43). When comparing the US-demonstrated spinal level with the PT-assigned motor level, the two were in agreement within one level in 65% of cases (22/34, k = 0.40). When comparing MRI-demonstrated spinal level with the PT motor level, the two were in agreement within one level in 59% of cases (20/34, k = 0.37). MRI and US were within two spinal levels of the PT evaluation in 79.4% and 85.3% of cases, respectively. MRI and US agreed within two levels in 97.1% of cases. Prenatal US and MRI were equivalent when comparing the difference between the imaged level and the postnatal motor deficit level (mean level difference: 1.12 ± 1.16 vs 1.17 ± 1.11, p = 0.86).

CONCLUSIONS

Prenatal US and MRI equivalently predicted the postnatal motor deficit level in children with myelomeningocele. These data may be valuable in prenatal prognostication.

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Loyola V. Gressot, Akash J. Patel, Robert J. Bollo, Carrie A. Mohila and Andrew Jea

Juvenile xanthogranuloma (JXG) is a rare disease that is part of a spectrum of histiocytic dendritic cell disorders. The authors report an unusual case of a 6-week-old male who presented with seizures. Neuroimaging revealed disseminated intracranial disease involving the optic apparatus, basal ganglia, lateral ventricles, and brainstem. The patient did not have any cutaneous lesions or evidence of extracranial disease. The patient underwent open biopsy of a large right midbrain lesion; pathology was consistent with JXG. He underwent postoperative chemotherapy and is doing well 7 months after surgery with regression of the intracranial lesions. To the best of the authors' knowledge, this is the first report of a neonate with disseminated intracranial JXG without cutaneous stigmata.