Tyler J. Kenning, Ravi H. Gandhi and John W. German
Hinge craniotomy (HC) has recently been described as an alternative to decompressive craniectomy (DC). Although HC may obviate the need for cranial reconstruction, an analysis comparing HC to DC has not yet been published.
A retrospective review was conducted of 50 patients who underwent cranial decompression (20 with HC, 30 with DC). Baseline demographics, neurological examination results, and underlying pathology were reviewed. Clinical outcome was assessed by length of ventilatory support, length of intensive care unit stay, and survival at discharge. Control of intracranial hypertension was assessed by average daily intracranial pressure (ICP) for the duration of ICP monitoring and an ICP therapeutic intensity index. Radiographic outcomes were assessed by comparing preoperative and postoperative CT scans for: 1) Rotterdam score; 2) postoperative volume of cerebral expansion; 3) presence of uncal herniation; 4) intracerebral hemorrhage; and 5) extraaxial hematoma. Postoperative CT scans were analyzed for the size of the craniotomy/craniectomy and magnitude of extracranial herniation.
No significant differences were identified in baseline demographics, neurological examination results, or Rotterdam score between the HC and DC groups. Both HC and DC resulted in adequate control of ICP, as reflected in the average ICP for each group of patients (HC = 12.0 ± 5.6 mm Hg, DC = 12.7 ± 4.4 mm Hg; p > 0.05) at the same average therapeutic intensity index (HC = 1.2 ± 0.3, DC = 1.2 ± 0.4; p > 0.05). The need for reoperation (3 [15%] of 20 patients in the HC group, 3 [10%] of 30 patients in the DC group; p > 0.05), hospital survival (15 [75%] of 20 in the HC group, 21 [70%] of 30 in the DC group; p > 0.05), and mean duration of both mechanical ventilation (9.0 ± 7.2 days in the HC group, 11.7 ± 12.0 days in the DC group; p > 0.05) and intensive care unit stay (11.6 ± 7.7 days in the HC group, 15.6 ± 15.3 days in the DC group; p > 0.05) were similar. The difference in operative time for the two procedures was not statistically significant (130.4 ± 71.9 minutes in the HC group, 124.9 ± 63.3 minutes in the DC group; p > 0.05). The size of the cranial defect was comparable between the 2 groups. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. Although a smaller volume of cerebral expansion was associated with HC (77.5 ± 54.1 ml) than DC (105.1 ± 65.1 ml), this difference was not statistically significant.
Hinge craniotomy appears to be at least as good as DC in providing postoperative ICP control and results in equivalent early clinical outcomes.
Ken R. Winston and Kathryn M. Beauchamp
M. Reid Gooch, Greg E. Gin, Tyler J. Kenning and John W. German
Decompressive craniectomy is a potentially life-saving procedure used in the treatment of medically refractory intracranial hypertension, most commonly in the setting of trauma or cerebral infarction. Once performed, surviving patients are obligated to undergo a second procedure for cranial reconstruction. The complications following cranial reconstruction are not well described in the literature and may very well be underreported. A review of the complications would suggest measures to improve the care of these patients.
A retrospective chart review was undertaken of all patients who had undergone cranioplasty during a 7-year period. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded. Patients were classified as having no complications, any complications, and complications requiring reoperation. The groups were compared to identify risk factors predictive of poor outcomes.
The authors identified 62 patients who had undergone cranioplasty. The immediate postoperative complication rate was 34%. Of these, 46 patients did not require reoperation and 16 did. Of those requiring reoperation, 7 were due to infection, 2 from wound breakdown, 2 from intracranial hemorrhage, 3 from bone resorption, and 1 from a sunken cranioplasty, and 1 patient's cranioplasty procedure was prematurely ended due to intraoperative hypotension and bradycardia. The only factor statistically associated with need for reoperation was the presence of a bifrontal cranial defect (bifrontal: 8 [67%] of 12, requiring reoperation; unilateral: 8 [16%] of 49 requiring reoperation; p < 0.01)
Cranioplasty following decompressive craniectomy is associated with a high complication rate. Patients undergoing a bifrontal craniectomy are at significantly increased risk for postcranioplasty complications, including the need for reoperation.
Benjamin Yim, M. Reid Gooch, John C. Dalfino, Matthew A. Adamo and Tyler J. Kenning
Cerebrospinal fluid shunting can effectively lower intracranial pressure and improve the symptoms of idiopathic intracranial hypertension (IIH). Placement of ventriculoperitoneal (VP) shunts in this patient population can often be difficult due to the small size of the ventricular system. Intraoperative adjuvant techniques can be used to improve the accuracy and safety of VP shunts for these patients. The purpose of this study was to analyze the efficacy of some of these techniques, including the use of intraoperative CT (iCT) and frameless stereotaxy, in optimizing postoperative ventricular catheter placement.
The authors conducted a retrospective review of 49 patients undergoing initial ventriculoperitoneal shunt placement for the treatment of IIH. The use of the NeuroPEN Neuroendoscope, intraoperative neuronavigation, and iCT was examined. To analyze ventricular catheter placement on postoperative CT imaging, the authors developed a new grading system: Grade 1, catheter tip terminates optimally in the ipsilateral frontal horn or third ventricle; Grade 2, catheter tip terminates in the contralateral frontal horn; Grade 3, catheter terminates in a nontarget CSF space; and Grade 4, catheter tip terminates in brain parenchyma. All shunts had spontaneous CSF flow upon completion of the procedure.
The average body mass index among all patients was 37.6 ± 10.9 kg/m2. The NeuroPEN Neuroendoscope was used in 44 of 49 patients. Intraoperative CT scans were obtained in 24 patients, and neuronavigation was used in 32 patients. Grade 1 or 2 final postoperative shunt placement was achieved in 90% of patients (44 of 49). In terms of achieving optimal postoperative ventricular catheter placement, the use of iCT was as effective as neuronavigation. Two patients had their ventricular catheter placement modified based on an iCT study. The use of neuronavigation significantly increased time in the operating room (223.4 ± 46.5 vs 190.8 ± 31.7 minutes, p = 0.01). There were no shunt infections in this study.
The use of iCT appears to be equivalent to the use of neuronavigation in optimizing ventricular shunt placement in IIH. Additionally, it may shorten operating room time and limit overall costs.
Shiveindra B. Jeyamohan, Tyler J. Kenning, Karen A. Petronis, Paul J. Feustel, Doniel Drazin and Darryl J. DiRisio
Anterior cervical discectomy and fusion (ACDF) is an effective procedure for the treatment of cervical radiculopathy and/or myelopathy; however, postoperative dysphagia is a significant concern. Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process. The authors conducted a prospective, randomized, double-blinded, controlled study of the effects of steroids on swallowing, the airway, and arthrodesis related to multilevel anterior cervical reconstruction in patients who were undergoing ACDF at Albany Medical Center between 2008 and 2012. The objective of this study was to determine if perioperative steroid use improves perioperative dysphagia and airway edema.
A total of 112 patients were enrolled and randomly assigned to receive saline or dexamethasone. Data gathered included demographics, functional status (including modified Japanese Orthopaedic Association myelopathy score, neck disability index, 12-Item Short-Form Health Survey score, and patient-reported visual analog scale score of axial and radiating pain), functional outcome swallowing scale score, interval postoperative imaging, fusion status, and complications/reoperations. Follow-up was performed at 1, 3, 6, 12, and 24 months, and CT was performed 6, 12, and 24 months after surgery for fusion assessment.
Baseline demographics were not significantly different between the 2 groups, indicating adequate randomization. In terms of patient-reported functional and pain-related outcomes, there were no differences in the steroid and placebo groups. However, the severity of dysphagia in the postoperative period up to 1 month proved to be significantly lower in the steroid group than in the placebo group (p = 0.027). Furthermore, airway difficulty and a need for intubation trended toward significance in the placebo group (p = 0.057). Last, fusion rates at 6 months proved to be significantly lower in the steroid group but lost significance at 12 months (p = 0.048 and 0.57, respectively).
Dexamethasone administered perioperatively significantly improved swallowing function and airway edema and shortened length of stay. It did not affect pain, functional outcomes, or long-term swallowing status. However, it significantly delayed fusion, but the long-term fusion rates remained unaffected.
Clinical trial registration no.: NCT01065961 (clinicaltrials.gov)
Sebastian Rubino, Jiang Qian, Carlos D. Pinheiro-Neto, Tyler J. Kenning and Matthew A. Adamo
Hypothalamic hamartomas are benign tumors known to cause gelastic or dacrystic seizures, precocious puberty, developmental delay, and medically refractory epilepsy. These tumors are most often sporadic but rarely can be associated with Pallister-Hall syndrome, an autosomal dominant familial syndrome caused by truncation of glioblastoma transcription factor 3, a downstream effector in the sonic hedgehog pathway. In this clinical report, the authors describe two brothers with a different familial syndrome. To the best of the authors’ knowledge, this is the first report in the literature describing a familial syndrome caused by germline mutations in the Smoothened (SMO) gene and the first familial syndrome associated with hypothalamic hamartomas other than Pallister-Hall syndrome. The authors discuss the endoscopic endonasal biopsy and subtotal resection of a large hypothalamic hamartoma in one of the patients as well as the histopathological findings encountered. Integral to this discussion is the understanding of the hedgehog pathway; therefore, the underpinnings of this pathway and its clinical associations to date are also reviewed.
Tyler J. Kenning, Thomas O. Willcox, Gregory J. Artz, Paul Schiffmacher, Christopher J. Farrell and James J. Evans
Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors.
The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect.
The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months).
Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).
Tyler J. Kenning, D. David Beahm, Christopher J. Farrell, Madeleine R. Schaberg, Marc R. Rosen and James J. Evans
The authors present the case of a 21-year-old female with a progressive bitemporal hemianopsia. Cranial MR imaging revealed a large cystic suprasellar, retrochiasmatic lesion consistent with craniopharyngioma. The lesion was fully resected through an endoscopic endonasal transsphenoidal and transplanum approach. Closure of the resultant dural defect was performed with a bilayer fascia lata button and autologous mucoperichondrial nasoseptal flap. Each portion of this procedure was recorded and is presented in an edited high-definition format.
The video can be found here: http://youtu.be/i3-qieLlbVk.
Tyler J. Kenning, John C. Dalfino, John W. German, Doniel Drazin and Matthew A. Adamo
The subdural evacuating port system (SEPS; Medtronic, Inc.) is a minimally invasive means of draining subacute or chronic subdural fluid collections. The purpose of this study was to examine a single institution's results with the SEPS.
A retrospective chart review was undertaken for all patients who underwent SEPS drainage of subdural collections. Demographic and radiographic characteristics were evaluated. Both pre- and post-SEPS CT studies were analyzed to determine the volume of subdural collection and midline shift. Hospital charts were reviewed for SEPS output, and periprocedural complications were noted. Results were classified as a success (S) or failure (F) based on the need for further subdural drainage procedures. Groups were then compared to identify factors predictive of success.
Eighty-five subdural collections were treated in 74 patients (unilateral collections in 63 patients and bilateral in 11). Sixty-three collections (74%) were successfully drained. In a comparison of the success and failure groups, there were no statistically significant differences (p < 0.05) in the mean age pre-SEPS, Glasgow Coma Scale score, presenting symptoms, underlying coagulopathy or use of anticoagulation/antiplatelet agents, laterality of SDH, pre-SEPS subdural volume or midline shift, or any of the measurements used to characterize SEPS placement. There were a greater number of male patients in the success group (45 [82%] of 55 patients vs 11 [58%] of 19 patients; p = 0.04). The only statistically significant (p < 0.05) factor predictive of success was the radiographic appearance of the subdural collection. More hypodense collections were successfully treated (32 [51%] of 63 collections vs 4 [18%] of 22 collections; p = 0.005), whereas mixed density collections were more likely to fail SEPS treatment (S: 11 [17%] of 63 collections vs F: 14 [64%] of 22 collections; p < 0.00001). In the success group, the percentage of the collection drained after SEPS was greater (S: 47.1 ± 32.8% vs F: 19.8 ± 28.2%; p = 0.001) and a larger output was drained (S: 190.7 ± 221.5 ml vs F: 60.2 ± 63.3 ml; p = 0.001). In the patients with available but delayed scans (≥ 30 days since SEPS placement), the residual subdural collection following successful SEPS evacuation was nearly identical to that remaining after open surgical evacuation in the failure group. In 2 cases (2.4% of total devices used), SEPS placement caused a new acute subdural component, necessitating emergency evacuation in 1 patient.
The SEPS is a safe and effective treatment option for draining subacute and chronic SDHs. The system can be used quickly with local anesthesia only, making it ideal in elderly or sick patients who might not tolerate the physiological stress of a craniotomy under general anesthesia. Computed tomography is useful in predicting which subdural collections are most amenable to SEPS drainage. Specifically, hypodense subdural collections drain more effectively through an SEPS than do mixed density collections. Although significant bleeding after SEPS insertion was uncommon, 1 patient in the series required urgent surgical hematoma evacuation due to iatrogenic injury.