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Sandeep Sood, Arlene Rozzelle, Blerina Shaqiri, Natasha Sood, and Steven D. Ham

Object

Sagittal craniosynostosis is traditionally considered to be a surgical condition. Poor results of simple suturectomy follow from early reclosure of the suture. A wider craniectomy or use of interposing materials has not improved the outcome. However, endoscopic suturectomy supplemented with postoperative use of a molding helmet has shown good results. Because suturectomy reunites within 8–12 weeks of surgery, the authors questioned if the improved outcome was primarily related to use of the helmet.

Methods

In 4 patients whose families opted for calvarial reconstruction when the infant was 4–6 months old, instead of endoscopic suturectomy, a molding helmet was used to minimize compensatory changes in the interim. Patients underwent 3D CT scanning to confirm craniosynostosis. Follow-up visits were made at intervals of 4 weeks for adjustment of the helmet, head circumference measurements, clinical photographs, and cranial index measurement.

Results

There was significant improvement in the head shape within 6 weeks of use of the molding helmet. The cranial index score improved from a mean (± SD) of 67% ± 3% to 75% ± 2%.

Conclusions

These cases demonstrate that molding helmets improve head shape even without a suturectomy in patients with sagittal craniosynostosis, challenging the traditional view.

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Sandeep Sood, Jaliya Lokuketagoda, and Steven D. Ham

Object. The failure of ventricles to enlarge after acute shunt malfunction in long-term shunt-dependent patients is generally attributed to the presence of periventricular rigidity resulting from gliosis. The aim of this study was to test the hypothesis that periventricular rigidity is present in these patients.

Methods. Fifteen pediatric patients who presented with acute shunt malfunction were studied; slit ventricles were detected in all of these patients. Pressure measurements were recorded simultaneously in both the ventricle and the brain parenchyma during shunt revision and then repeated after bolus infusion of fluid into the ventricle.

The mean intraventricular pressure (IVP) at presentation was 24.1 mm Hg (standard deviation 10 mm Hg). The mean baseline IVP after drainage of cerebrospinal fluid but prior to the infusion was 7.5 ± 4.3 mm Hg. There was no significant difference in the increase in the IVP and the intraparenchymal pressure (IPP) after bolus infusion into the ventricle (3.6 ± 2.4 mm Hg and 3.3 ± 2.1 mm Hg, respectively; p = 0.39). The mean pressure volume index was 24.1 ml (standard error of the mean 4.6 ml).

Conclusions. The profile of the changes in IVP and IPP indicates that the periventricular wall does not restrict ventricular enlargement following shunt malfunction in long-term shunt-dependent patients.

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Neena I. Marupudi, Sandeep Sood, Arlene Rozzelle, and Steven D. Ham

OBJECTIVE

Cranial vault expansion is performed in pediatric patients with craniosynostosis to improve head shape. Another argument for performing total cranial vault reconstruction is the potential reduction in the harmful effects of elevated intracranial pressure (ICP) that are associated with craniosynostosis. Alternatively, molding helmets have been shown to improve the cranial index (CI) in patients with sagittal synostosis without surgery. However, it is unknown if the use of molding helmets without surgery contributes to adverse changes in ICP. The effect of molding helmets on ICP and CI in patients with sagittal synostosis was investigated.

METHODS

A prospective cohort study of 24 pediatric patients with sagittal synostosis who planned to undergo total cranial reconstruction was performed from 2011 to 2014 at the Children's Hospital of Michigan. A preoperative molding helmet was used in 13 patients, and no molding helmet was used in 11 patients. End-tidal carbon dioxide, patient positioning, level of sedation, type of anesthetic, and the monitoring site at the time of intraoperative recording were regulated and standardized to establish the accuracy of the ICP readings. CI and head circumference were monitored for each patient.

RESULTS

The mean duration of the preoperative use of the molding helmet was 17 weeks (range 7–37 weeks). Under controlled settings, the average intraoperative ICP was 7.2 mm Hg (range 2–18 mm Hg) for patients treated with a preoperative molding helmet and 9.5 mm Hg (range 2–22 mm Hg) for patients with no preoperative molding helmet. ICP was not significantly different between the 2 groups, suggesting that the use of a molding helmet in this population is safe. The average CI at the time of helmet placement was 0.70 (range 0.67–0.73), and this improved to an average of 0.74 (range 0.69–0.79) after using the molding helmet for a mean of 17 weeks.

CONCLUSIONS

ICPs were not significantly different with the use of a preoperative molding helmet, refuting the prevailing thought that molding helmets would be detrimental in children who have craniosynostosis. The use of molding helmet in this population of patients improves head shape and does not adversely affect ICP.

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Sandeep Sood, Jaliya Lokuketagoda, and Steven D. Ham

Object

The failure of ventricles to enlarge after acute shunt malfunction in long-term shunt-dependent patients is generally attributed to the presence of periventricular rigidity resulting from gliosis. The aim of this study was to test the hypothesis that periventricular rigidity is present in these patients.

Methods

Fifteen pediatric patients who presented with acute shunt malfunction were studied; slit ventricles were detected in all of these patients. Pressure measurements were recorded simultaneously in both the ventricle and the brain parenchyma during shunt revision and then repeated after bolus infusion of fluid into the ventricle.

The mean intraventricular pressure (IVP) at presentation was 24.1 mm Hg (standard deviation 10 mm Hg). The mean baseline IVP after drainage of cerebrospinal fluid but prior to the infusion was 7.5 ± 4.3 mm Hg. There was no significant difference in the increase in the IVP and the intraparenchymal pressure (IPP) after bolus infusion into the ventricle (3.6 ± 2.4 mm Hg and 3.3 ± 2.1 mm Hg, respectively; p = 0.39). The mean pressure volume index was 24.1 ml (standard error of the mean 4.6 ml).

Conclusions

The profile of the changes in IVP and IPP indicates that the periventricular wall does not restrict ventricular enlargement following shunt malfunction in long-term shunt-dependent patients.

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Sandeep Sood, Holly Gilmer-Hill, and Steven D. Ham

Object

The aim of this study was to define the origin and management of lumbar shunt site swelling/cerebrospinal fluid (CSF) leak seen in children who underwent placement of a percutaneous lumbar shunt due to recurrent problems with a ventricular shunt.

Methods

Fifty-seven children with a lumbar shunt were analyzed. Episodes of swelling along the lumbar shunt site, presenting symptoms, origin of the CSF leak, and surgical outcome were recorded.

Results

Twenty patients had 30 episodes of CSF leak/swelling at a mean interval of 92 ± 233 days (± standard deviation) after placement or revision. There were 7 episodes of an external CSF leak; 5 of marked swelling; and 18 episodes of headache, dizziness, and swelling. In 4 patients, the cause of CSF leakage was a fracture/disconnection or dislocation of the proximal catheter. In the remaining patients, CSF leakage was from around the proximal catheter entry point into the spinal dura (with a rate of 16.9% for placement and 15.7% for revision/reinsertion). Interlaminar removal of the existing catheter, microsurgical repair of the leak, and replacement through an opening made with the stylet of a 14-gauge Tuohy needle (Medtronic Neurosurgery) was most effective compared with percutaneous blood patch, pericatheter fascial suture, and percutaneous repositioning of the proximal catheter or downgrading valve pressure.

Conclusions

Lumbar shunt site swelling is predominantly a consequence of pericatheter CSF leakage from the mismatch in the dural opening, which corresponds to the outer diameter of the 14-gauge Tuohy needle and the smaller proximal lumbar catheter. It is best managed by direct repair of the defect through a microsurgical interlaminar approach and recannulation of the dura by using only the stylet of a 14-gauge Tuohy needle.

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Sandeep Sood, Neelesh Nundkumar, and Steven D. Ham

A transfrontal route is the traditional endoscopic approach to intraventricular tumors. Small lesions can be biopsied using the parallel port channel of the endoscope. For larger tumors a ventriculoport can be used for resection. This technique nevertheless requires traversing the brain tissue, is difficult in the setting of small ventricles, and allows only limited mobility. The authors describe the endoscopic resection of large intraventricular tumors via an interhemispheric route using rigid suction with a mounted endoscope, and thus circumventing some of the problems with the traditional approach.

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Sandeep Sood, Eishi Asano, and Harry T. Chugani

Object

Preservation of the vein of Labbé is recommended to prevent temporal lobe infarction after skull base surgery. However, the importance of preserving the vein in epilepsy surgery involving resection of the temporal lobe is unclear.

Methods

Retrospective analysis was performed in 47 cases, in which patients underwent temporal lobe resection, out of 148 cases in which patients underwent surgery for intractable seizures over a 5-year period. Standard temporal lobe resection anterior to the vein of Labbé was performed in 11 patients. In 24 patients, the temporal lobe resection extended posterior to the vein of Labbé; the vein was preserved in eight patients, who underwent surgery prior to 2002, and resected in the other 16 patients, who underwent surgery after 2002. Twelve patients underwent a temporopari-etooccipital resection.

There was no significant difference in the pattern of venous anatomy (based on analysis of the relative size of veins [chi-square test, p = 0.1] and the number of superficial veins draining the temporal lobe [p = 1]) in patients in whom the vein was resected compared with those in whom it was preserved. No patient experienced postoperative infarction.

Conclusions

The authors conclude that the vein of Labbé may be safely resected in epilepsy surgery involving temporal lobe resection. The decision whether to resect the vein need not be based on the surface venous drainage pattern or number of veins draining the temporal lobe.

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Sandeep Sood, Eishi Asano, Deniz Altinok, and Aimee Luat

Traditionally corpus callosotomy is done through a craniotomy centered at the coronal suture, with the aid of a microscope. This involves dissecting through the interhemispheric fissure below the falx to reach the corpus callosum. The authors describe a posterior interhemispheric approach to complete corpus callosotomy with an endoscope, which bypasses the need to perform interhemispheric dissection because the falx is generally close to the corpus callosum in this region.

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Sandeep Sood, Neena I. Marupudi, Eishi Asano, Abilash Haridas, and Steven D. Ham

OBJECT

Corpus callosotomy and hemispherotomy are conventionally performed via a large craniotomy with the aid of a microscope for children with intractable epilepsy. Primary technical considerations include completeness of disconnection and blood loss. The authors describe an endoscopic technique performed through a microcraniotomy for these procedures.

METHODS

Four patients with drop attacks and 2 with intractable seizures related to a neonatal stroke underwent endoscopic complete corpus callosotomy and hemispherotomy, respectively. The surgeries were performed through a 2- to 3-cm precoronal microcraniotomy. Interhemispheric dissection to the corpus callosum was done using the standard technique. Subsequently, the bimanual technique with a suction device mounted on an endoscope was used to perform a complete corpus callosotomy, including interforniceal and anterior commissure disconnection. In patients who had hemispherotomy, the fornix was resected posteriorly and lateral disconnection was done by unroofing the temporal horn. Anteriorly, endoscopic corticectomy was done along the ipsilateral anterior cerebral artery to reach the bifurcation of the internal carotid artery to complete the anterior disconnection. Postoperative MRI and diffusion tensor imaging (DTI) of the brain were performed to confirm complete disconnection.

RESULTS

The procedure was accomplished successfully in all patients, with excellent visualization secured. None of the patients required a blood transfusion. Postoperative MRI and DTI confirmed completeness of the disconnection. Patients who underwent corpus callosotomy had complete resolution of drop attacks at a mean follow-up of 6 months, and patients who underwent hemispherotomy became seizure free.

CONCLUSIONS

Endoscopic corpus callosotomy and hemispherotomy are surgically feasible procedures associated with minimal blood loss, minimal risk, and excellent visualization.

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Sandeep Sood, Martin U. Schuhmann, Nedim Cakan, and Steven D. Ham

P The authors describe their experience with endoscopic fenestration of suprasellar cysts followed by shrinkage coagulation of the cysts to restore the anatomy in eight patients.

Seven children ranging in age from 8 months to 4.5 years and one adult 24 years of age were treated. Four of the children presented with megacephaly and the other patients with malfunction of a shunt that had been placed previously for hydrocephalus. Endoscopic fenestration of the cyst dome was performed followed by shrinkage of the lesion by means of endoscopic coagulation. Follow-up studies included immediate and late postoperative magnetic resonance imaging, assessment of growth velocity and the body mass index (BMI), and an endocrine profile if indicated by a failure of growth or precocious puberty.

Good intraoperative cyst shrinkage was achieved in all seven children. This was maintained on imaging studies at a mean follow-up period of 35 months. There was no significant procedure-associated morbidity. Hydrocephalus resolved in four patients who did not have a preexisting shunt. One of the four patients who had a shunt preoperatively became shunt free. The rest of the patients with preexisting shunts remained shunt dependent despite good resolution of the cyst. During a mean follow-up period of 52 months, the height, growth velocity, and BMI of each patient remained within two standard deviations of normal. In one patient there was a suspicion of precocious puberty, but the endocrine profile was normal; in another patient precocious puberty developed and required treatment.

The presented technique is safe and prevents cyst recurrence and obstruction of the aqueduct by remnants of the cyst wall—the two main reasons for failure of a simple endoscopic fenestration.