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Travis J. Atchley, Blake Sowers, Anastasia A. Arynchyna, Curtis J. Rozzelle, and Brandon G. Rocque

OBJECTIVE

The advent of neuroendoscopy revolutionized the management of complex hydrocephalus. Fenestration of the septum pellucidum (septostomy) is often a therapeutic and/or necessary intervention in neuroendoscopy. However, these procedures are not without risk. The authors sought to record the incidence and types of complications. They attempted to discern if there was decreased likelihood of septostomy complications in patients who underwent endoscopic third ventriculostomy (ETV)/choroid plexus cauterization (CPC) as compared with those who underwent other procedures and those with larger ventricles preoperatively. The authors investigated different operative techniques and their possible relationships to septostomy complications.

METHODS

The authors retrospectively reviewed all neuroendoscopic procedures with Current Procedural Terminology code 62161 performed from January 2003 until June 2019 at their institution. Septostomy, either alone or in conjunction with other procedures, was performed in 118 cases. Basic demographic characteristics, clinical histories, operative details/findings, and adverse events (intraoperative and postoperative) were collected. Pearson chi-square and univariate logistic regression analyses were performed. Patients with incomplete records were excluded.

RESULTS

Of 118 procedures, 29 (24.5%) septostomies had either intraoperative or postoperative complications. The most common intraoperative complication was bleeding, as noted in 12 (10.2%) septostomies. Neuroendocrine dysfunction, including apnea, bradycardia, neurological deficit, seizure, etc., was the most common postoperative complication and seen after 15 (12.7%) procedures. No significant differences in complications were noted between ventricular size or morphology or between different operative techniques or ventricular approaches. There was no significant difference between the complication rate of patients who underwent ETV/CPC and that of patients who underwent septostomy as a part of other procedures. Greater length of surgery (OR 1.013) was associated with septostomy complications.

CONCLUSIONS

Neuroendoscopy for hydrocephalus due to varying etiologies provides significant utility but is not without risk. The authors did not find associations between larger ventricular size or posterior endoscope approach and lower complication rates, as hypothesized. No significant difference in complication rates was noted between septostomy performed during ETV/CPC and other endoscopic procedures requiring septostomy.

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Travis J. Atchley, Nicholas M. B. Laskay, Brandon A. Sherrod, A. K. M. Fazlur Rahman, Harrison C. Walker, and Barton L. Guthrie

OBJECTIVE

Infection and erosion following implantable pulse generator (IPG) placement are associated with morbidity and cost for patients with deep brain stimulation (DBS) systems. Here, the authors provide a detailed characterization of infection and erosion events in a large cohort that underwent DBS surgery for movement disorders.

METHODS

The authors retrospectively reviewed consecutive IPG placements and replacements in patients who had undergone DBS surgery for movement disorders at the University of Alabama at Birmingham between 2013 and 2016. IPG procedures occurring before 2013 in these patients were also captured. Descriptive statistics, survival analyses, and logistic regression were performed using generalized linear mixed effects models to examine risk factors for the primary outcomes of interest: infection within 1 year or erosion within 2 years of IPG placement.

RESULTS

In the study period, 384 patients underwent a total of 995 IPG procedures (46.4% were initial placements) and had a median follow-up of 2.9 years. Reoperation for infection occurred after 27 procedures (2.7%) in 21 patients (5.5%). No difference in the infection rate was observed for initial placement versus replacement (p = 0.838). Reoperation for erosion occurred after 16 procedures (1.6%) in 15 patients (3.9%). Median time to reoperation for infection and erosion was 51 days (IQR 24–129 days) and 149 days (IQR 112–285 days), respectively. Four patients with infection (19.0%) developed a second infection requiring a same-side reoperation, two of whom developed a third infection. Intraoperative vancomycin powder was used in 158 cases (15.9%) and did not decrease the infection risk (infected: 3.2% with vancomycin vs 2.6% without, p = 0.922, log-rank test). On logistic regression, a previous infection increased the risk for infection (OR 35.0, 95% CI 7.9–156.2, p < 0.0001) and a lower patient BMI was a risk factor for erosion (BMI ≤ 24 kg/m2: OR 3.1, 95% CI 1.1–8.6, p = 0.03).

CONCLUSIONS

IPG-related infection and erosion following DBS surgery are uncommon but clinically significant events. Their respective timelines and risk factors suggest different etiologies and thus different potential corrective procedures.

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Elizabeth N Alford, Travis J Atchley, Tofey J Leon, Nicholas M. B Laskay, Anastasia A Arynchyna, Burkely P Smith, Inmaculada Aban, James M Johnston, Jeffrey P Blount, Curtis J Rozzelle, W. Jerry Oakes, and Brandon G Rocque

OBJECTIVE

In Chiari malformation type I (CM-I), a variety of imaging findings have been purported to be important; however, results have been inconclusive, inconsistent, or not replicated in independent studies. The purpose of this study was to report imaging characteristics for a large cohort of patients with CM-I and identify the imaging findings associated with surgical decompression.

METHODS

Patients were identified using ICD-9 codes for CM-I for the period from 1996 to 2017. After review of the medical records, patients were excluded if they 1) did not have a diagnosis of CM-I, 2) were not evaluated by a neurosurgeon, or 3) did not have available preoperative MRI. Retrospective chart review was performed to collect demographic and clinical data. Imaging parameters were measured according to the Chiari I Malformation Common Data Elements.

RESULTS

A total of 731 patients were included for analysis, having a mean follow-up duration of 25.5 months. The mean age at presentation was 8.5 years. The mean tonsil position was 11.4 mm below the foramen magnum, and 62.8% of patients had a pegged tonsil shape. Two hundred patients (27.4%) underwent surgery for life-dominating tussive headache, lower cranial nerve dysfunction, syrinx, and/or brainstem dysfunction. Surgical treatment was associated with a syrinx (OR 20.4, 95% CI 12.3–33.3, p < 0.0001), CM-1.5 (OR 1.797, 95% CI 1.08–2.98, p = 0.023), lower tonsil position (OR 1.130, 95% CI 1.08–1.18, p < 0.0001), and congenital fusion of cervical vertebrae (OR 5.473, 95% CI 1.08–27.8, p = 0.040). Among patients with benign CM-I, tonsil position was statistically significantly associated with future surgery.

CONCLUSIONS

Comprehensive imaging characteristics for a large cohort of patients with CM-I are reported. Analysis showed that a lower tonsillar position, a syrinx, and CM-1.5 were associated with undergoing posterior fossa decompression. This study demonstrates the importance of considering imaging findings in the context of patient symptomatology.

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Travis J. Atchley, Galal A. Elsayed, Blake Sowers, Harrison C. Walker, Gustavo Chagoya, Matthew C. Davis, Joshua D. Bernstock, Nidal B. Omar, Daxa M. Patel, and Barton L. Guthrie

OBJECTIVE

The objective of this study was to determine the incidence of seizures following deep brain stimulation (DBS) electrode implantation and to evaluate factors associated with postoperative seizures.

METHODS

The authors performed a single-center retrospective case-control study. The outcome of interest was seizure associated with DBS implantation. Univariate analyses were performed using the Student t-test for parametric continuous outcomes. The authors used the Kruskal-Wallis test or Wilcoxon rank-sum test for nonparametric continuous outcomes, chi-square statistics for categorical outcomes, and multivariate logistic regression for binomial variables.

RESULTS

A total of 814 DBS electrode implantations were performed in 645 patients (478 [58.7%] in men and 520 [63.9%] in patients with Parkinson’s disease). In total, 22 (3.4%) patients who had undergone 23 (2.8%) placements experienced seizure. Of the 23 DBS implantation–related seizures, 21 were new-onset seizures (3.3% of 645 patients) and 2 were recurrence or worsening of a prior seizure disorder. Among the 23 cases with postimplantation-related seizure, epilepsy developed in 4 (17.4%) postoperatively; the risk of DBS-associated epilepsy was 0.50% per DBS electrode placement and 0.63% per patient. Nine (39.1%) implantation-related seizures had associated postoperative radiographic abnormalities. Multivariate analyses suggested that age at surgery conferred a modest increased risk for postoperative seizures (OR 1.06, 95% CI 1.02–1.10). Sex, primary diagnosis, electrode location and sidedness, and the number of trajectories were not significantly associated with seizures after DBS surgery.

CONCLUSIONS

Seizures associated with DBS electrode placement are uncommon, typically occur early within the postoperative period, and seldom lead to epilepsy. This study suggests that patient characteristics, such as age, may play a greater role than perioperative variables in determining seizure risk. Multiinstitutional studies may help better define and mitigate the risk of seizures after DBS surgery.