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Branavan Manoranjan and Sheila K. Singh

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Mohsin Ali, Michael Bennardo, Saleh A. Almenawer, Nirmeen Zagzoog, Alston A. Smith, Dyda Dao, BHSc, Olufemi Ajani, Forough Farrokhyar and Sheila K. Singh

OBJECT

Although intracranial arachnoid cysts are a common incidental finding on pediatric brain imaging, only a subset of patients require surgery for them. For the minority who undergo surgery, the comparative effectiveness of various surgical approaches is debated. The authors explored predictors of surgery and compared operative techniques for pediatric patients with an intracranial arachnoid cyst seen at a tertiary care center.

METHODS

The authors reviewed records of pediatric patients with an intracranial arachnoid cyst. For each patient, data on baseline characteristics, the method of intervention, and surgical outcomes for the initial surgery were extracted, and cyst size at diagnosis was calculated (anteroposterior × craniocaudal × mediolateral). Baseline variables were analyzed as predictors of surgery by using logistic regression modeling, excluding patients whose surgery was not related to cyst size (i.e., those with obstructive hydrocephalus secondary to the cyst compressing a narrow CSF flow pathway or cyst rupture/hemorrhage). Data collected regarding surgical outcomes were analyzed descriptively.

RESULTS

Among 83 pediatric patients with an intracranial arachnoid cyst seen over a 25-year period (1989–2013), 27 (33%) underwent surgery; all had at least 1 cyst-attributed symptom/finding. In the multivariate model, age at presentation and cyst size at diagnosis were independent predictors of surgery. Cyst size had greater predictive value; specifically, the area under the curve for the receiver-operating-characteristic curve was 0.89 (95% CI 0.82–0.97), with an ideal cutoff point of ≥ 68 cm3. This cutoff point had 100% sensitivity (95% CI 79%–100%), 75% specificity (95% CI 61%–85%), a 53% positive predictive value (95% CI 36%–70%), and a 100% negative predictive value (95% CI 91%–100%); the positive likelihood ratio was 4.0 (95% CI 2.5–6.3), and the negative likelihood ratio was 0 (95% CI 0–0.3). Although the multivariate model excluded 7 patients who underwent surgery (based on prespecified criteria), excluding these 7 cases did not change the overall findings, as shown in a sensitivity analysis that included all the cases. Descriptive results regarding surgical outcomes did not indicate any salient differences among the surgical techniques (endoscopic fenestration, cystoperitoneal shunting, or craniotomy-based procedures) in terms of symptom resolution within 6 months, need for reoperation to date, cyst-size change from before the operation, morbidity, or mortality.

CONCLUSIONS

The results of these exploratory analyses suggest that pediatric patients with an intracranial arachnoid cyst are more likely to undergo surgery if the cyst is large, compresses a narrow CSF flow pathway to cause hydrocephalus, or has ruptured/hemorrhaged. There were no salient differences among the 3 surgical techniques for several clinically important outcomes. A prospective multicenter study is required to enable more robust analyses, which could ultimately provide a decision-making framework for surgical indications and clarify any differences in the comparative effectiveness of surgical approaches to treating pediatric intracranial arachnoid cysts.

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Sheila K. Singh, Lynda Rickards, Ronald I. Apfelbaum, R. John Hurlbert, Dennis Maiman and Michael G. Fehlings

Object. Stabilization of the craniocervical junction (CCJ) remains a significant challenge. In this multicenter study, the authors present the results of an evaluation of a precontoured titanium implant, the Ohio Medical Instruments (OMI) Loop, for craniocervical fixation.

Methods. In this multicenter retrospective study the authors evaluated 30 patients (16 female, 14 male; mean age 53.8 years) with rheumatoid arthritis (15 cases), traumatic occipitoatlantoaxial instability (six cases), congenital vertebral anomalies (two cases), instability due to basilar invagination in the setting of Chiari malformation (two cases), or Down syndrome (one case), tumor (one case), os odontoideum (two cases), and pseudarthrosis/other (one case), who underwent OMI Loop—assisted occipitocervical reconstruction. The mean follow-up period was 25.4 months (range 6–60 months).

A solid reconstruction was achieved in 29 of 30 cases; there was only one case of hardware failure requiring reoperation. Noncritical hardware failure occurred in two patients in whom partial occipital screw backout occurred but did not necessitate reoperation. There were no perioperative neurological complications. One patient (3.3%) experienced a delayed postoperative worsening of myelopathy at 1 year that resolved with further surgery. Postoperatively, in 66.6% of patients the degree of myelopathy remained stable (as measured by American Spinal Injury Association [ASIA] scores), whereas 30% improved by one or more ASIA grade. The rate of osseous fusion was 96.6% at a mean follow-up period of 25.4 months.

Conclusions. The authors found that the OMI Loop is a versatile precontoured occipitocervical fixation device that can be applied to a wide range of CCJ lesions. It provides excellent immediate rigid fixation of the CCJ, a high rate of osseous fusion, and a low rate of hardware failure.

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Ana P. C. P. Carlotti, Desmond Bohn, James T. Rutka, Sheila Singh, W. A. David Berry, Asheer Sharman, Michael Cusimano and Mitchell L. Halperin

Object. Two major criteria are necessary to diagnose cerebral salt wasting (CSW): a cerebral lesion and a large urinary excretion of Na+ and Cl at a time when the extracellular fluid (ECF) volume is contracted. Nevertheless, it is difficult for the physician to confirm from bedside observation that a patient has a contracted ECF volume. Hyponatremia, although frequently present, should not be a criterion for a diagnosis of salt wasting. A contracted ECF volume is unlikely if there are positive balances of Na+ and Cl.

The goal of this study was to assess the accuracy of calculating balances for Na+ plus K+ and of Cl over 1 to 10 days in an intensive care unit (ICU) setting.

Methods. A prospective comparison of measured and estimated quantities of Na+ plus K+ and of Cl excreted over 1 to 10 days in 10 children and 12 adults who had recently received a traumatic brain injury or undergone recent neurosurgery. Plasma concentrations of electrolytes were recorded at the beginning and end of the study period. The total volumes infused and excreted and the concentrations of Na+, K+, and Cl in the infusate were obtained from each patient's ICU chart. The electrolytes in the patients' urine were measured and calculated. Correlations between measured and calculated values for excretions of Cl and of Na+ plus K+ were excellent.

Conclusions. Mass balances for Na+ plus K+ and for Cl can be accurately estimated. These data provide information to support or refute a clinical diagnosis of CSW. The danger of relying on balances for these electrolytes measured within a single day to diagnose CSW is illustrated.