Allan Taylor

Advantages of delayed VP shunting in post-haemorrhagic hydrocephalus seen in low-birth-weight infants

Abstract. The optimal timing of ventriculo-peritoneal (VP) shunt insertion in a neonate with post-haemorrhagic hydrocephalus (PHH) is uncertain. During the 8-year period from January 1989 to December 1996, 41 patients had VP shunts inserted for PHH at Red Cross War Memorial Childrens Hospital. Data on 36 patients were sufficient for review in order to determine whether the timing of surgery in any way influenced the complication incidence of this intervention. Nine of the 36 patients had a serious complication, either infection or mechanical shunt obstruction, during their initial hospital admission (early period). Nineteen patients had surgery performed before day 35 after birth and all those with early complications were in this group. Seventeen patients had surgery delayed until after day 35, and none of these patients had an early complication. In this study a higher complication incidence was noted when a VP shunt was inserted prior to day 35 (Chi-square test P<0.01). This most probably correlates with a high concentration of blood breakdown products in the cerebrospinal fluid during the first month after intra-ventricular haemorrhage.

Target Embolization of AVMs: Identification of Sites and Results of Treatment

Although cure of cerebral arteriovenous malformations (AVMs) is the ideal goal it is often only possible with smaller sized lesions. This is certainly true if surgery or radiotherapy is used as the treatment strategy. Endovascular treatment, however, allows the possibility of partial treatment directed at specific areas of AVM architecture. With this in mind we retrospectively reviewed our cohort of AVMs to establish which morphological areas we had identified as targets and how the treatment of the AVM influenced the clinical picture. Over a 36-month period 42 AVMs were treated. In 22 of the patients who presented with a hemorrhage an intranidal aneurysm was identified as a target and treated in nine patients. Other patients presented with headaches (2), neurological deficit (4) and seizures (16) with two patients having their AVM picked up coincidentally. Targets identified included high flow fistulas (12), decreasing venous flow (17) and cure of the AVM (8). Results of targeted treatment showed a lower rehemorrhage rate than anticipated by the natural history. Patients cured did best and targeted embolization improved seizures in nine patients, neurological deficit in four patients and headache in 20 patients. Until safer methods exist to cure large AVMs the use of targeted embolization is acceptable as it protects patients against rehemorrhage and translates into an improvement in their clinical picture.

Angioarchitecture and treatment modalities in posttraumatic carotid cavernous fistulae.

Posttraumatic carotid cavernous fistulae are abnormal direct hole communications between the intracavernous carotid artery and the cavernous sinus that can result from both blunt and penetrating trauma. They can be challenging lesions to treat and a variety of modalities and approaches have been proposed since endovascular treatment has become the standard treatment. An analysis of the angioarchitecture of 32 consecutive patients treated in our service demonstrated that seven could be classified as small hole, eight medium and 17 large. Different size fistulae required varying endovascular tools. Small fistulae were best treated using coils and large and medium lesions with balloons. Large lesions were more likely to require multiple tools in order to achieve closure and had a lower chance of ipsilateral carotid preservation. All patients in the series were cured with a carotid preservation rate of 66%. There was no permanent morbidity associated with endovascular treatment.

Bleeding source identification and treatment in brain arteriovenous malformations.

Arteriovenous malformation (AVM) patients who initially present with intracerebral haemorrhage may have an identifiable source of bleeding on angiogram, which can be a treatment target. Previous work suggests that the re-bleed rate may be lowered if a weak area is eliminated. A retrospective cohort study was conducted on patients who presented over a six-year period with a bled AVM. Cases were reviewed looking for the source of the hemorrhage by correlating haematoma location on CT or MRI and any angio-architectural weakness seen on digital subtraction angiography (DSA). Neuroendovascular notes were reviewed to identify the treatment targets. One hundred patients presented with a brain AVM with a 1.7:1 male: female ratio, 41 patients had an initial presentation of hemorrhage. The source of hemorrhage was identified in 18 subjects with 11 intranidal false aneurysms, five flow-related aneurysms, two associated aneurysms and one venous pouch. The location of haemorrhage on the presenting scan significantly correlated with the identified bleeding source using Chi-square analysis (P-value 0.039). Partial targeted embolization was used successfully in 90% with a 9% related technical complication rate not resulting in long-term morbidity or mortality. The mean follow-up period was 34 months with an annual hemorrhage rate of 0.7%. In just under half the patients with AVM bleeding a source of haemorrhage can be identified on DSA and in most cases this will be an intranidal false aneurysm. Flow-related and associated aneurysms in patients with brain AVM can cause haemorrhage and these patients are more likely to have SAH than intracerebral haemorrhage. These weak points are a good target for partial endovascular treatment, are usually accessible and may reduce the higher haemorrhage rate expected over the next two years.

Traumatic brain injury, the hidden pandemic: A focused response to family and patient experiences and needs

INTRODUCTION Traumatic brain injury (TBI) has many potential cognitive, behavioural and psychological consequences, and contributes significantly to the national burden of disease and to ongoing violent behaviour. Few resources are available for the rehabilitation of patients with TBI in South Africa, and access to rehabilitation facilities in the public sector is limited. Consequently, it is the families impacted on by TBI that ultimately carry the care and rehabilitation burden once survivors are discharged from hospital. Families are generally ill equipped to cope with the complex and potentially long-term disabilities that accompany brain injury. METHODS Reviewing interviews with 175 family members and 354 patients recovering from TBI helped identify the key challenges that the survivors of TBI and their families face. RESULTS Nine problem areas were identified that formed the basis for development of a discharge resource, the S-Plan, which serves to inform patients and carers and provide practical solutions for the problems they face. CONCLUSION The experiences of TBI survivors and their family members served to inform the development of simple, integrated coping strategies, namely two S-Plan tools, one for survivors and their families/caregivers and the other for care workers, in conjunction with counselling and support group processes. The S-Plan constitutes a discharge resource to inform patients and carers and provide practical solutions for the problems they face in caring for family members who have suffered TBI.

Head and neck neurovascular trauma: Clinical and angiographic correlation.

A retrospective review of all angiograms done for craniocervical trauma, over an eight-year period at Groote Schuur Hospital identified 61 patients out of 823 angiographically studied who had extradural vascular injury and required endovascular treatment. Multiple lesions were identified in nine (14,8%) patients and associated injuries were found in 23 patients (37%). The mechanism of injury was blunt in nine (14.8%) patients and penetrating in 52 (85.2%). There was a statistically significant correlation between the presenting clinical feature and the underlying angiographic lesion. Patients with active bleeding were more likely to have a vessel laceration, an expanding hematoma was associated with false aneurysm and a pulsatile mass with arteriovenous fistula. Endovascular treatment with emphasis on vessel occlusion rather than preservation was successful in all cases except one which required surgical vessel ligation.

The management of very small/blister internal carotid artery aneurysms.

Blood blister aneuryms are uncommon lesions that have a poor natural history. Because there is no clear aneurysmal sac to treat they remain challenging lesions to manage whether the approach is endovascular or surgical. Although the management of intracranial cerebral aneurysms has changed subsequent to the results published by the ISAT trial, there still exist groups of aneurysms which do not lend themselves to endovascular management. There are recent reports of successful endovascular management using flow diverting approaches but experience is limited and relying on flow change may be insufficient to prevent re-rupture. Surgery when possible offers the advantage of immediate vessel wall reconstruction.

«Interventional Neuroradiology: a Neuroscience sub-specialty?»

Interventional Neuroradiology (INR) is not bound by the classical limits of a speciality, and is not restricted by standard formats of teaching and education. Open and naturally linked towards neurosciences, INR has become a unique source of novel ideas for research, development and progress allowing new and improved approaches to challenging pathologies resulting in better anatomo-clinical results. Opening INR to Neurosciences is the best way to keep it alive and growing. Anchored in Neuroradiology, at the crossroad of neurosciences, INR will further participate to progress and innovation as it has often been in the past.

Delayed massive epistaxis from traumatic cavernous carotid false aneurysms: A report of two unusual cases

Introduction Blunt head trauma can injure the cavernous segment of the internal carotid artery (ICA). This may result in a carotid cavernous fistula (CCF). Rarely, a traumatic aneurysm may bleed medially causing massive epistaxis. Case presentation We present two cases of traumatic intracavernous carotid pseudoaneurysms with delayed massive epistaxis. The patients were managed with endovascular treatment involving coil embolization with parent vessel sparing and detachable balloon occlusion with carotid sacrifice. Early clinical outcome was good in both patients. Wherever possible, the CARE1 guidelines were followed in the reporting. Conclusion These cases illustrate the delayed nature of traumatic aneurysms and the need for a high index of suspicion in the presence of skull base fractures. The use of endovascular detachable balloon occlusion and coil embolization treatment with parent vessel preservation is shown.

Endovascular treatment of cerebral aneurysms--a cost analysis.

OBJECTIVES To determine if endovascular treatment of cerebral aneurysms is cost effective when compared with conventional surgical treatment. DESIGN A retrospective study. SUBJECTS Seventeen patients treated between August 2002 and August 2003 had posterior communicating artery aneurysms. This group was selected for detailed analysis. OUTCOME MEASURES Total treatment costs, in South African rands (R), were calculated for each patient. Average treatment costs for each group were then compared. RESULTS Surgically clipped and endovascularly coiled groups were comparable for age, sex and clinical condition. The average cost for endovascular treatment per patient was R37 041. Surgical treatment was more expensive at R44 104, a difference of 16%. CONCLUSIONS Despite the high cost of endovascular devices, appropriate use of this technology ultimately offers less expensive treatment than microsurgical clipping of aneurysms.