Aaron Mohanty

Failed Endoscopic Third Ventriculostomy in Children: Management Options

Endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus has a failure rate of 20–50% in various series. The present study analyzes ETV failures in 72 patients over a 2-year period and attempts to outline a management plan. Of the 72 patients who underwent ETV, it failed in 13. Seven of these failures occurred within 1 month, and in 5 others, ETV failed after 1–2 months. Another patient had a delayed failure 2 years after the initial surgery. Upon clinical failure, MRI scans were performed in all patients using either T2 fast spin echo or two-dimensional phase contrast MRI techniques. Of these, no flow could be demonstrated in 12 patients, whereas in 1 patient, good flow was observed. Endoscopic exploration was undertaken in the 12 patients in whom flow could not be demonstrated. Of the 12 who underwent endoscopic exploration, a patent stoma was observed in 7, necessitating insertion of a ventriculoperitoneal shunt (VPS). In the other 5, the stoma had closed by gliosis and a repeat ETV was performed. In 3 of these patients, in addition to the ETV, a VPS was also inserted in accordance with the family’s wishes. VPS insertion was carried out in the patient with suggestion of good flow through the stoma. In failed ETV, MRI with flow studies is essential to identify the possible cause of failure. Endoscopic exploration is indicated for patients with no evidence of flow. A repeat ETV is indicated in patients with a closed stoma. Patients with a patent stoma could require insertion of a cerebrospinal fluid shunt.

Experience with cerebellopontine angle epidermoids.

OBJECTIVE Cerebellopontine angle (CPA) epidermoids, although of benign nature, are of considerable neurosurgical interest because of their close proximity and adherence to the cranial nerves and the brain stem. We describe our experience and attempt to correlate the final outcomes with the extent of surgical removal. METHODS Twenty-five consecutive patients with CPA epidermoids that were surgically treated were reviewed, and the final outcomes were assessed. RESULTS Thirteen patients had trigeminal neuralgia. In 7 of the 13 patients, trigeminal neuralgia was the only presenting feature. The epidermoid was confined to the CPA in each of 6 patients, and in each of 18, it had varying degrees of supratentorial extension. One patient had a predominant supratentorial epidermoid with extension to the CPA. The lesions were totally excised in 12 patients. Near-total removal was accomplished in eight patients, and in the remaining five, partial removal was accomplished. Transient worsening of the cranial nerve functions occurred in 11 patients, probably as a result of aggressive dissection of the capsule from the cranial nerves. In 9 of the 11 patients, the cranial nerve functions improved by the time of discharge. All of the patients who had trigeminal neuralgia were relieved of their symptoms. Eighteen patients were followed up for a mean period of 42 months, and none had symptoms of recurrence. CONCLUSION Aggressive surgical removal results in transient but significant cranial nerve dysfunction in the postoperative period. A conservative approach is indicated for patients in whom the capsule is adherent to the brain stem and the cranial nerves.

Spinal intramedullary cysticercosis

OBJECTIVE Spinal intramedullary cysticercosis is an uncommon manifestation of neurocysticercosis. We review our experience with eight cases of intramedullary cysticercosis. METHODS Eight patients who were surgically treated for spinal intramedullary cysticercosis between 1982 and 1991 were retrospectively reviewed, and the final outcomes were assessed. RESULTS In six patients, the cysticercosis involved the thoracic cord, whereas in the other two, the cysticercosis was cervical in location. Only one patient had multiple soft tissue calcifications, as revealed by plain radiography. Myelography indicated an intramedullary lesion in each of seven patients; two of the seven patients had partial myelographic block, suggesting the segmental nature of the lesion. Cerebrospinal fluid studies were noncontributory. One patient had three cysts, whereas the other seven had one cyst each. Four patients had adjacent soft purulent materials, which were revealed by histopathological examination to be granulation tissue. The neurological statuses of seven patients improved after surgery. Six patients were followed up for a mean of 30.6 months (3 mo-5 yr). Three could resume their previous occupations, two others could manage their daily activities, and one required only minimal assistance for daily activities. CONCLUSION The outcome of intramedullary cysticercosis is not as dismal as reported earlier, and patients with paraplegia also have favorable outcomes. A preoperative diagnosis of cysticercosis can be suspected in an endemic area in the presence of multiple soft tissue calcifications and segmental lesions revealed by myelography or magnetic resonance imaging studies.

Prognosis of extradural haematomas in children

102 children treated surgically for intracranial extradural haematoma from 1982 to 1991 were evaluated retrospectively and their prognosis was compared with 387 adults treated during the same period. Children had a better prognosis than adults even with a low Glasgow Coma Scale (GSC) score at surgery. Children had a higher incidence of frontal and posterior fossa haematomas. The GCS score and the associated parenchymal injuries had a strong correlation with the outcome both in adult and children, whereas the site of haematoma had no correlation with the final outcome.

Efficacy of endoscopic third ventriculostomy in fourth ventricular outlet obstruction.

OBJECTIVEFourth ventricular outlet obstruction (FVOO), an uncommon cause of obstructive hydrocephalus, is most commonly associated with prior intraventricular hemorrhage or intraventricular infection in children. There have been few reports of FVOO in an adult population. METHODSTwenty-two patients with FVOO treated with endoscopic third ventriculostomy (ETV) were analyzed retrospectively. RESULTSOf the 22 patients, 10 were younger than 2 years, 6 were between 2 and 18 years, and 6 were older than 18 years of age. Predisposing factors included tubercular meningitis (1 patient), ventriculitis (2 patients), and intraventricular hemorrhage (3 patients). Twelve patients (mostly >2 years of age) had no prior significant history. The third ventricular floor and the adhesions in the basal cisterns were individually graded (I–IV). An inflamed floor was encountered in 3 patients. ETV was successfully performed in 20 patients. Fourth ventricular exploration was carried out in 5 patients, with outlet membrane fenestration in 2 patients. The follow-up period was 1 to 8 years (mean, 4.2 years). The ETV failed in 7 patients, requiring shunt insertion. The overall success rate was 65%; 91% success was achieved in patients who were more than 2 years of age, whereas the procedure failed in all patients younger than 6 months of age. The cerebrospinal fluid yielded a positive bacterial culture (1 patient), antitubercular antibody (1 patient), anticysticercal antibody (1 patient), and cryptococcosis (1 patient). With a successful procedure, lateral ventricular size was reduced in all patients, whereas fourth ventricular size decreased in 12 patients. The extent of adhesions in the basal cisterns directly correlated with failure. None of the patients demonstrated isolated fourth ventricle on follow-up magnetic resonance imaging. In 4 of the 7 patients with failure, endoscopic exploration was performed, and a patent stoma was observed in all of these patients. CONCLUSIONETV is a viable option for treatment of patients with FVOO. The high failure rate in infants younger than 6 months of age suggests that ventriculoperitoneal shunting is a favorable option in this age group, rather than ETV. Isolated fourth ventricle is uncommon after ETV in hydrocephalus attributable to FVOO.

Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients.

Severe diffuse brain injury in children has a devastating influence on their physical and psychological development. This retrospective study was undertaken to analyse the factors that influence outcome in children with such injuries. The short-term outcomes (Glasgow outcome score) of 74 children (age ≤15 years) with severe diffuse brain injury and no focal operable mass lesions on CT scan, admitted between 1992 and 1998 at the National Institute of Mental Health and Neurosciences were analysed. The prognostic factors analysed were age, gender, time after injury to admission, nature of injury, highest post-resuscitation Glasgow coma score (GCS), pupillary reaction, horizontal oculocephalic reflex and CT scan findings. The following factors were found to be independent predictors of poor outcome: GCS 3–5 (p < 0.003), absent verbal response (p < 0.001), motor response score of 1–3 (p < 0.001), absent pupillary reaction (p < 0.001), absent oculocephalic reflex (p < 0.001) and presence of traumatic subarachnoid haemorrhage on CT scan (p < 0.002). These independent variables were then subjected to a stepwise logistic regression analysis, and the most important variables for predicting outcome were oculocephalic reflex and GCS, which together correctly predicted unfavourable outcome with a sensitivity of 79% and a specificity of 65%. An early CT scan or a single CT scan did not have any prognostic significance.

Endoscopic third ventriculostomy in the management of Chiari I malformation and syringomyelia associated with hydrocephalus

BACKGROUND Chiari malformation with syringomyelia is conventionally managed with foramen magnum decompression and duroplasty. In presence of hydrocephalus, a ventriculoperitoneal shunt insertion has been the initial preferred mode of treatment. METHODS Two patients of Chiari I malformation with syringomyelia who had associated hydrocephalus were initially treated with endoscopic third ventriculostomy (ETV). RESULTS At follow up, both the patients symptomatically improved. Repeat MRI studies revealed collapse of the syrinx cavity and reduction of the Chiari malformation. CONCLUSIONS Chiari malformation and syrinx associated with hydrocephalus may be effectively managed with endoscopic third ventriculostomy.

Neuro-Endoscopic Fenestration of Occluded Foramen of Monro Causing Unilateral Hydrocephalus

An uncommon case of unilateral hydrocephalus due to membranous occlusion of the ipsilateral foramen of Monro is presented. The patient successfully underwent neuroendoscopic fenestration of the occluded foramen of Monro along with septum pellucidum fenestration.

Diagnostic efficacy of stereotactic biopsies in intracranial tuberculomas

BACKGROUND Stereotactic biopsies for diagnosing intracranial tuberculomas are often reported to be inconclusive, being confirmatory in only 28% of cases. We analyzed the role and diagnostic efficacy of stereotactic biopsies in the management of intracranial tuberculomas. METHODS Twenty patients diagnosed with intracranial tuberculomas based on neuroimaging procedures underwent computerized tomography (CT) guided stereotactic biopsies for histological confirmation. In 10 patients (Group A), biopsies were obtained from the center of the lesion; in the other 10 (Group B), biopsies were obtained from both the enhancing rim and the isodense center and examined separately. The tissues were processed for paraffin sections and hematoxylin eosin staining. In addition, in the first five patients a squash smear from a small portion of the biopsy was prepared, and the cytological features of the cells were examined. All the patients received antitubercular medication and CT scans were repeated 4 months posttreatment. RESULTS Histopathological features of the paraffin sections in 17 patients (Group A: 8, Group B: 9) were diagnostic of tuberculoma, whereas the other three revealed only chronic nonspecific inflammation. Based on the cytological features in squash smears, diagnosis could be made in one of five. In two, although the smear was not diagnostic, the histological section from the same specimen confirmed the tuberculous pathology. There was no procedural morbidity or mortality. One patient had a small asymptomatic hematoma at the biopsy site. Three patients died during the follow-up period, due to secondary complications of tuberculosis. Repeat CT scans during follow-up after antituberculous treatment confirmed the reduction in the size of the lesion in 15/17 patients. CONCLUSION The high positive yield of stereotactic biopsies in diagnosing tuberculomas argues for their inclusion in the management protocol for tuberculous mass lesions.

Role of stereotactic aspiration in the management of tuberculous brain abscess.

BACKGROUND Intracranial tuberculous abscesses are uncommon clinical entities, even in countries where tuberculosis is endemic. Surgical excision and antituberculous treatment is the treatment of choice. The role of stereotactic aspiration in the management of these lesions is highlighted in this communication. METHODS Three patients, all receiving treatment for pulmonary tuberculosis, presented with symptoms of raised intracranial pressure and neurological deficits. Computed tomography (CT) scans revealed cystic lesions with enhancing rim in the thalamus in two patients and multiple coalescing cystic lesions in the deep temporal region in another. RESULTS Stereotactic aspiration of the cyst and biopsy of the cyst wall were performed in all. In two, the pus revealed acid fast bacilli (AFB). In another, though the pus did not reveal any AFB, the wall showed tuberculous granuloma. Antituberculous treatment was continued in all the patients. Follow-up CT revealed resolution of the lesions in all patients. CONCLUSION Stereotactic aspiration is an useful alternative modality of management of tuberculous abscesses in a selected group of patients.