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William C. Gump and John W. Walsh

✓ Nosocomial infections with organisms resistant to multiple antibiotic agents represent an evolving challenge in the intensive care setting, particularly in patients requiring surgical diversion of cerebrospinal fluid. The authors present the case of a 51-year-old woman who endured protracted hospitalization and required multiple surgeries including placement of a ventriculoperitoneal shunt. The shunt subsequently became colonized with Pseudomonas aeruginosa, which demonstrated intermediate sensitivity to amikacin and full resistance to all other antibiotics tested. After failing to respond to intravenous imipenem as well as intravenous and intrathecal amikacin, the patient was successfully treated with intravenous and intrathecal colistin. Colistin is a polymyxin-type antibiotic, rarely used outside of topical application because of reported nephrotoxicity associated with parenteral administration. With activity limited to Gram-negative organisms, colistin is bactericidal by directly disrupting the structure of cell membranes. Authors of a few case reports in the literature have described successful treatment of various ventriculitis with the intrathecal administration of colistin. With bacterial resistances outpacing the pharmaceutical industry's ability to develop novel antibiotics, colistin represents an important alternative in situations involving multidrug-resistant organisms.

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William C. Gump, Karen L. Skjei and Shefali N. Karkare

Reports on seizure outcomes following surgery for lesional epilepsy consistently cite extent of resection as a significant predictor of outcome. Unfortunately, gross-total resection is not technically feasible in all cases of medically refractory tumor-associated epilepsy. Here, the authors present the case of a 4-year-old girl whose epilepsy was medically controlled after 1-stage electrocorticography-guided subtotal resection (STR) of a large diffuse protoplasmic astrocytoma. They also review the modern literature on epilepsy associated with brain tumors. Outcomes are compared with those following surgical treatment of focal cortical dysplasia and vascular lesions. Gross-total lesional resection shows significant superiority across pathologies and anatomical regions. Despite a considerable number of STRs yielding seizure freedom, other favorable treatment factors have not been defined. Although gross-total lesional resection, if possible, is clearly superior, tailored surgery may still offer patients a significant opportunity for a good outcome. Treatment factors yielding successful seizure control following STR remain to be fully elucidated.

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William C. Gump, Ian S. Mutchnick and Thomas M. Moriarty

Children with spastic diplegia from cerebral palsy (CP) experience measurable improvement in their spasticity and motor function following selective dorsal rhizotomy (SDR). The role of this operation in the treatment of other spasticity causes is less well defined. A literature review was undertaken to survey outcomes from SDRs performed outside the CP population. Multiple sclerosis was the most common diagnosis found, accounting for 74 of 145 patients described. Selective dorsal rhizotomies have also been reported in patients with traumatic brain and spinal cord injuries, ischemic and hemorrhagic stroke, neurodegenerative disease, hypoxic encephalopathy, and other causes of spasticity. Outcomes from surgery are generally described as favorable, although postoperative assessments and follow-up times are not standardized across reports. Long-term outcomes are sparsely reported. Larger numbers of patients and more detailed outcomes data have the potential to form a basis for expanding the inclusion criteria for SDR.

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William C. Gump, Ian S. Mutchnick and Thomas M. Moriarty

Molding helmet therapy is a widely accepted treatment for positional plagiocephaly that is generally considered to be low risk. Multiple large outcome studies have shown good results, but adverse events are rarely reported. The literature on helmet therapy was reviewed to clarify the clinical experience with associated complications. Although significant complications were extremely rare, there was a large degree of variability in detection of lesser problems such as minor skin irritation. Patients with a primarily brachycephalic morphology may be at higher risk for poorly fitting orthoses. Most reported complications are minor and self-limited. Maintenance of good helmet hygiene appears to be the most effective strategy for reducing or eliminating complications.