Ahmed Ammar

Intraventricular migration of VP shunt

The proximal migration of a ventriculoperitoneal shunt into the ventricles is very rate. Only 5 cases have been previously reported [4, 8, 10, 11]. We believe that this unusual phenomenon has not been well-studied in the literature. We report a case of a 16-month-old baby girl who suffered a shunt malfunction due to complete migration of the VP shunt into the lateral ventricle. This case and the other 5 cases are studied, and a possible cause is hypothesized. The group of patients at risk is also identified and methods of management are reported.

Reversibility of severe brain stem dysfunction in children.

SummaryThe very popular concept of brain death can lead to a defeatist attitude when confronted by a patient with severe brain stem dysfunction. This problem is compounded by the constant controversy surrounding the establishing of criteria to determine brain death. Many young doctors tend to accept the precondition of irreversibility as being any condition that is not explicitly listed in the examples of potentially reversible conditions. In children, however, with compressive brain stem dysfunction, decompressive surgery can lead to a reversal of the dysfunction.In the last three years, we have had the opportunity to observe 5 children who were deeply comatose and apnoeic. All were suffering from compression of the brain stem and experienced dramatic return of brain stem function following emergency decompression.The implications of these findings on the therapeutic attitude towards compressive brain stem lesions in children are exposed. In children with severe brain stem dysfunction, and no evidence of brain stem destruction, decompressive surgery should be undertaken before a diagnosis of brain death is considered.

Repair of skull base dural defects: the dura sandwich

SummaryA technique for skull base dural defect repair is presented, using two layers of periosteum and biological (Tisseel glue), one on either side of the defect. The method is reliable and relatively simple, and was used to repair a recurrent skull base encephalocoele with great success. The method has application in the reconstruction of any dural defect, whether congenital, traumatic or surgical.

The influence of different cultures on neurosurgical practice.

Abstract It is popularly believed that advances in technology and the increasingly widespread availability of such technology will lead to a lessening of the influence of culture on the practice of medicine. However, this spread of techology is in fact having the opposite effect, since it is more likely that a given patient will receive treatment in a different cultural community than his or her own, possibly administered by care-givers from yet another culture. The cultural backgrounds of the patient, medical staff, disease, community and technology all play a part in influencing the treatment and its outcome. This paper attempts to highlight some of the cultural factors that most influence medical treatment and to suggest ways in which the negative effects of the impact of culture on medicine can be overcome.

Ammar shunt: an option to overcome shunt complications in premature and term neonates

It has been hypothesized, and generally accepted, that the final outcome of the treatment of hydrocephalus is to a great extent related to the earliness of intervention and treatment. However, there is special concern regarding the higher risk of infection and shunt malfunctions in neonates as compared with older infants. Therefore, two new shunt systems have been designed specifically to tip the balance in favor of early shunting. The first shunt is made for premature neonates and the second for neonates in general. The general characteristics of these two shunts are: (1) the entire shunt is a low-pressure valve, with double distal slit valves; (2) the shunts are made of soft silicon material; (3) they are of very small configuration, without any compressing elements which may lead to skin necrosis over the shunt; (4) no metal has been used in them, so they are MRI compatible.

Exploratory Analysis into Reasonable Timeframes for the Provision of Neurosurgical Care in Low- and Middle-Income Countries

BACKGROUND In low- and middle-income countries (LMICs), 11.8% of the need for neurosurgical care is met. Delays in seeking and receiving care may further exacerbate this situation. Objective analysis of delay and its consequences is contingent on reference to established resource-appropriate acceptable timeframes. This study sought to 1) establish an estimate of the landscape of care provided in LMICs and 2) explore reasonable timeframes for various stages of patient-health care interaction. METHODS Consensus input from neurosurgeons in select LMICs was collected; 1 high-income country was included for comparison. In phase 1, participants were asked to select neurosurgical procedures performed at their centers. In phase 2, based on procedures shared among all LMICs, representative case scenarios were generated and participants provided input on acceptable timeframes for each stage of patient-health care interaction: 1) presentation to health services, 2) diagnosis by primary care physician, 3) referral to neurosurgical specialist care, and 4) definitive neurosurgical management. RESULTS Twenty neurosurgeons across 18 centers were identified; 12 participated in phase 1 and 7 in phase 2. The range of procedures offered was broad, similar in scope to high-income countries, and included pediatric and adult neurosurgery, trauma, degenerative spine, and hemorrhagic stroke. Acceptable timeframes had wide ranges in certain cases; however, the overall trend showed agreement between the participants. CONCLUSIONS This exploratory analysis identified reasonable timeframes for the provision of neurosurgical care in LMICs. If validated, these data can be used to more objectively assess the prevalence of delay in neurosurgical care in individual LMICs, along with its consequences.

The Dilemma of Prenatal Hydrocephalus: Grading and Classification of Fetal Hydrocephalus

The values of prenatal diagnosis of hydrocephalus have been recognized. In many centers, the regular and frequent fetus examination by ultrasonography is a right for every pregnant lady to have. Prenatal examination is a routine procedure in most obstetric departments. The recent improvement of the methods of investigations such as 3D ultrasonography and MRI has allowed early prenatal diagnosis of several congenital anomalies (Depp et al., Obstet Gynecol 61(6):710–4, 1983; Glick et al., J Pediatr Surg 19(6):870–1, 1984; Glick et al., J Pediatr 105(1):97–105, 1984; Mrozik et al., Geburtshilfe Frauenheilkd 45(8):503–10, 1985; Schott et al., Arch Gynecol Obstet 280(2):293–6, 2009; Ville, Bull Acad Natl Med 192(8):1611–21, 2008), and CNS congenital anomalies are not an exception! Several CNS congenital anomalies are possible to be diagnosed in utero (Awary et al., Pan Arab Neurosurg J 1:31–35, 1997; Birnholz and Frigoletto, N Engl J Med 304(17):1021–3, 1981; Bruner, Semin Fetal Neonatal Med 12(6):471–6, 2007; Dolk et al., Adv Exp Med Biol 686:349–64, 2010; Dukanac Stamenkovic et al., Clin Exp Obstet Gynecol 43(1):63–9, 2016; Frigoletto et al., JAMA 248(19):2496–7, 1982; Ortega et al., BMC Neurol 16:45, 2016; von Koch et al., Childs Nerv Syst 19(7–8):574–86, 2003). The diagnosis of prenatal fetal spina bifida hydrocephalus, IVH, and other congenital anomalies provoked serious questions and challenges to the treating teams usually composed of neurosurgeons, neonatologists, obstetricians, anesthetist, pediatricians, and others. The questions and challenges are What to do?, What are the advantages of early intrauterine intervention?, and What are the possible complications and consequences for both the mother and the fetus? (Davis, Clin Perinatol 30(3):531–9, 2003; Dolk et al., Adv Exp Med Biol 686:349–64, 2010; Holzgreve et al., Childs Nerv Syst 9(7):408–12, 1993; Serlo et al., Childs Nerv Syst 2(2):93–7, 1986). Taking into consideration the safety and well-being of the pregnant mother should always be absolutely observed and never be compromised. There are several options in facing these challenges that have been performed and suggested such as: 1. Abortion 2. Intrauterine intervention, either open or through endoscope 3. Early and preterm induced delivery or performed elective Cesarean section (CS) to deliver the fetus 4. Follow-up and observation

Evidence Based Medicine- Hydrocephalus Guideline for Systemic Reviews, Meta-analysis and Evidence Based Medicine

The optimum and proper management of hydrocephalus is the main goal for all neurosurgeons all over the world. Some neurosurgeons or general practitioners see the hydrocephalus as a simple and straightforward problem; however, the fact is that hydrocephalus is a very complex problem, and the etiology, pathophysiology, complication, success of treatment, and failures vary from case to case. Failing to provide on time proper treatment has its serious consequences not only on the current health and well-being of a child who suffers from this disease but also his entire future, career, life, and the life of his families as well. Therefore the search for the best treatment for each and every type of hydrocephalus is a necessity. Hydrocephalus is a clear symbol of the need for evidence-based medicine (Berry et al., JAMA 309:372–80, 2013; Williams, et al., J Neurosurg 107(5 Suppl):345–57, 2007).

Idiopathic Normal-Pressure Hydrocephalus Syndrome: Is It Understood? The Comprehensive Idiopathic Normal-Pressure Hydrocephalus Theory (CiNPHT)

The best description of idiopathic normal-pressure hydrocephalus (iNPH) is it is a multifactorial syndrome and is progressive in nature, while the secondary normal-pressure hydrocephalus (sNPH) is a disease. It has been long striving to reveal the causes, pathophysiology, and best possible of treatment of that syndrome. More than a dozen of concepts and theories have been produced to explain most of the phenomena, which are related to iNPH. Unfortunately, there is no single theory could explain it all. Therefore, we carried on a research to prove the role of venous and small blood vessel ischemia in advancing of this syndrome. We merged the results of this research with the concepts of most of the previous iNPH theories into one theory, which we called “comprehensive idiopathic normal-pressure hydrocephalus syndrome theory.” This concept may provide a wider and deeper understanding of this syndrome and carries within it several suggestions to find new management plans in order to get better outcome.

Psychological Management of Hydrocephalic Patients and Its Parents

Receiving a prenatal diagnosis of hydrocephalus is often traumatizing for parents. The attitudes and beliefs of the healthcare practitioners have a great impact on the psychological state of the parents and the decisions they make regarding their fetus. Some meet this diagnosis with distress and anxiety, and others with shocked and disbelief. Trying to manage the psychological distress of the parents should be a priority for all practitioners. After receiving the diagnosis, the mother usually has to make the decision on whether or not to terminate the pregnancy due to fetal abnormality. This decision will depend on a variety of conditions that needed careful consideration. If the mother decides to progress with the pregnancy, and delivers an infant that survives into childhood, there is a possibility that psychological adjustment issues will begin to manifest. At the end of this chapter, there will be an advice section for the parents or children with hydrocephalus.