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Aadil S. Chagla, Suhas Udayakumaran and Srikant Balasubramaniam

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Suhas Udayakumaran, Naresh Biyani, David P. Rosenbaum, Liat Ben-Sira, Shlomi Constantini and Liana Beni-Adani

Object

Trapped fourth ventricle (TFV) is a rare late complication of postinfectious or posthemorrhagic hydrocephalus. This entity is distinct from a large fourth ventricle because TFV entails pressure in the fourth ventricle and posterior fossa due to abnormal inflow and outflow of CSF, causing significant symptoms and signs. As TFV is mostly found in children who were born prematurely and have cerebral palsy, diagnosis and treatment options are a true challenge.

Methods

Between February 1998 and February 2007, 12 children were treated for TFV in Dana Children's Hospital by posterior fossa craniotomy/craniectomy and opening of the TFV into the spinal subarachnoid space. The authors performed a retrospective analysis of relevant data, including pre- and postoperative clinical characteristics, surgical management, and outcome.

Results

Thirteen fenestrations of trapped fourth ventricles (FTFVs) were performed in 12 patients. In 6 patients with prominent arachnoid thickening, a stent was left from the opened fourth ventricle into the spinal subarachnoid space. One patient underwent a second FTFV 21 months after the initial procedure. No perioperative complications were encountered. All 12 patients (100%) showed clinical improvement after FTFV. Radiological improvement was seen in only 9 (75%) of the 12 cases. The follow-up period ranged from 2 to 9.5 years (mean 6.11 ± 2.3 years) after FTFV.

Conclusions

Fenestration of a TFV via craniotomy is a safe and effective option with a very good long-term outcome and low rate of morbidity.

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Suhas Udayakumaran, Sajesh K. Menon, Chiazor U. Onyia and Naveen Tahasildar

OBJECTIVE

Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3–6 months from each other. The aim of this study was to report the authors’ experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment.

METHODS

Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology.

RESULTS

Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700–1550 ml), and the mean operative time was 4.4 hours (range 3–5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°.

CONCLUSIONS

Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

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Suhas Udayakumaran and Ticini Joseph

OBJECTIVE

The incidence of focal suppurative infections (FSIs) of the brain has significantly decreased owing to the better health and fundamental conditions of the population on the one hand and earlier detection and the availability of more potent antibiotics on the other. Interestingly, the antibiotic protocols have not been well defined in terms of duration despite a prompter diagnosis, definitive management of the etiology, and the advent of various higher-generation antibiotics. In this study, the authors evaluated the current treatment protocol. Their aim was to optimize management protocols for FSIs of the central nervous system based on clinical parameters.

METHODS

The study was a retrospective analysis of all children who had undergone surgical management for an FSI at the Division of Paediatric Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, in the period from January 2001 to February 2018. In addition to demographic characteristics, the details of culture reports and antibiotic regimens were collected. The response to treatment was compared to changes in the infective profile (C-reactive protein) and imaging. Instances of reaspiration were compared with clinical signs, imaging findings, and infective profiles. Treatment response was separated into two groups: responders within or at 2 weeks and responders beyond 2 weeks. The clinical characteristics of these two groups were compared.

RESULTS

Forty-eight children were treated in the study period. Nineteen patients benefited from the 2-week (short-term) protocol of intravenous antibiotics. Twenty-nine patients required more than 2 weeks (approximately 4 weeks; long-term protocol) for resolution. Of those requiring more than 2 weeks, 69% had cardiogenic etiology. All patients were followed up with a minimum of 3 weeks of oral antibiotics. In a comparative analysis between short-term and long-term responders, only etiology was significantly different. None of the patients who had the short-term protocol had a recurrence.

CONCLUSIONS

A shorter antibiotic protocol can be used successfully in carefully selected patients who are surgically treated and followed up. It is clear that the 2-week intravenous antibiotic protocol is more suitable for immunocompetent patients who have a noncardiogenic etiology.