Aristotelis V. Kalyvas

Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature

BackgroundTo define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life.MethodsA systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews.ResultsForty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost.ConclusionsNo surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.

Maternal environmental risk factors for congenital hydrocephalus: a systematic review

OBJECTIVE Congenital hydrocephalus (CH) is one of the most frequent CNS congenital malformations, representing an entity with serious pathological consequences. Although several studies have previously assessed child-related risk factors associated with CH development, there is a gap of knowledge on maternal environmental risk factors related to CH. The authors have systematically assessed extrinsic factors in the maternal environment that potentially confer an increased risk of CH development. METHODS The Cochrane Library, MEDLINE, and EMBASE were systematically searched for works published between 1966 and December 2015 to identify all relevant articles published in English. Only studies that investigated environmental risk factors concerning the mother-either during gestation or pregestationally-were included. RESULTS In total, 13 studies (5 cohorts, 3 case series, 3 case-control studies, 1 meta-analysis, and 1 case report) meeting the inclusion criteria were identified. Maternal medication or alcohol use during gestation; lifestyle modifiable maternal pathologies such as obesity, diabetes, or hypertension; lack of prenatal care; and a low socioeconomic status were identified as significant maternal environmental risk factors for CH development. Maternal infections and trauma to the mother during pregnancy have also been highlighted as potential mother-related risk factors for CH. CONCLUSIONS Congenital hydrocephalus is an important cause of serious infant health disability that can lead to health inequalities among adults. The present study identified several maternal environmental risk factors for CH, thus yielding important scientific information relevant to prevention of some CH cases. However, further research is warranted to confirm the impact of the identified factors and examine their underlying behavioral and/or biological basis, leading to the generation of suitable prevention strategies.

The Superior Frontal Transsulcal Approach to the Anterior Ventricular System: Exploring the Sulcal and Subcortical Anatomy Using Anatomic Dissections and Diffusion Tensor Imaging Tractography

OBJECTIVE To explore the superior frontal sulcus (SFS) morphology, trajectory of the applied surgical corridor, and white matter bundles that are traversed during the superior frontal transsulcal transventricular approach. METHODS Twenty normal, adult, formalin-fixed cerebral hemispheres and 2 cadaveric heads were included in the study. The topography, morphology, and dimensions of the SFS were recorded in all specimens. Fourteen hemispheres were investigated through the fiber dissection technique whereas the remaining 6 were explored using coronal cuts. The cadaveric heads were used to perform the superior frontal transsulcal transventricular approach. In addition, 2 healthy volunteers underwent diffusion tensor imaging and tractography reconstruction studies. RESULTS The SFS was interrupted in 40% of the specimens studied and was always parallel to the interhemispheric fissure. The proximal 5 cm of the SFS (starting from the SFS precentral sulcus meeting point) were found to overlie the anterior ventricular system in all hemispheres. Five discrete white matter layers were identified en route to the anterior ventricular system (i.e., the arcuate fibers, the frontal aslant tract, the external capsule, internal capsule, and the callosal radiations). Diffusion tensor imaging studies confirmed the fiber tract architecture. CONCLUSIONS When feasible, the superior frontal transsulcal transventricular approach offers a safe and effective corridor to the anterior part of the lateral ventricle because it minimizes brain retraction and transgression and offers a wide and straightforward working corridor. Meticulous preoperative planning coupled with a sound microneurosurgical technique are prerequisites to perform the approach successfully.

Finger tapping and verbal fluency post-tap test improvement in INPH: its value in differential diagnosis and shunt-treatment outcomes prognosis

BackgroundIdiopathic normal pressure hydrocephalus (INPH) diagnosis is challenging as it can be mimicked by other neurological conditions, such as neurodegenerative dementia and motor syndromes. Additionally, outcomes after lumbar puncture (LP) tap test and shunt treatment may vary due to the lack of a common protocol in INPH assessment. The present study aimed to assess whether a post-LP test amelioration of frontal cognitive dysfunctions, characterizing this syndrome, can differentiate INPH from similar neurological conditions and whether this improvement can predict INPH post–shunt outcomes.MethodSeventy-one consecutive patients referred for INPH suspicion and LP testing, were enrolled. According to the consensus guidelines criteria, 29 patients were diagnosed as INPH and 42 were assigned an alternative diagnosis (INPH-like group) after reviewing clinical, neuropsychological and imaging data, and before LP results. A comprehensive neuropsychological assessment for frontal executive, upper extremity fine motor functions, aphasias, apraxias, agnosias and gait evaluation were administered at baseline. Executive, fine motor functions and gait were re-examined post-LP test in all patients and post-shunt placement in INPH patients.ResultsOf the INPH patients, 86.2% showed cognitive amelioration in the post-LP test; in addition, all but one (97%) presented with neurocognitive and gait improvement post-shunt. Verbal phonological fluency and finger tapping task post-LP improvement predicted positive clinical outcome post-shunt. None of the INPH-like group presented with neurocognitive improvement post-LP.ConclusionsPost-LP amelioration of verbal fluency and finger tapping deficits can differentiate INPH from similar disorders and predict positive post-shunt clinical outcome in INPH. This becomes of great importance when gait assessment is difficult to perform in clinical practice.

Concerns about Evaluating the Effect of Noise and Music in the Operating Room

This short video reports 2 operative procedures performed in 2002 using a transdiaphragmatic extrapericardial approach of the IVC (see video). The first case was a 68year-old man with a 10-cm hepatocellular carcinoma, which developed on postviral C cirrhosis. At the time of diagnosis, this tumor invaded the right hepatic vein,with tumor thrombus development in the IVC. A total vascular liver exclusionwas required and a classical approach seemed hazardous due to the risk of thrombus fragmentation. A right hepatectomywith thrombus extractionwas performed under 8minutes of total vascular liver exclusion.The second case concerned a 47-year-oldman with a peripheral cholangiocarcinoma, 15 cm in diameter, which developed in the left part of the liver associated with an important IVC compression and possible venous wall invasion (see cavography). To harvest this tumor, a total liver vascular exclusion was required, and the usual IVC approach was difficult to carry out due to local tumor development (see video). A left hepatic trisegmentectomy was performed under 33 minutes of total vascular exclusion. To check the absence of transmural venous tumoral invasion, a long cavotomy was achieved instead of troncular IVC resection.

Intrathecal Baclofen Therapy for Painful Muscle Spasms in a Patient with Friedreich’s Ataxia

Friedreich’s ataxia (FA) is the most frequent hereditary ataxia syndrome, while painful muscle spasms and spasticity have been reported in 11–15% of FA patients. This report describes the successful management of painful spasms in a 65-year-old woman with FA via intrathecal baclofen (ITB) therapy following unsuccessful medical treatments. To our knowledge, this is the third reported case in the literature. Unfortunately, the pathophysiological characteristics of muscle spasms in FA are not well explored and understood while the therapeutic mechanisms of the different treatments are rather vague. Taking into consideration the suggested spinal atrophy in FA, the clinical resemblance of FA and chronic spinal injury muscle spasms, together with the rapid ITB therapy effectiveness in alleviating FA muscle spasms, we attempted to suggest a putative pathophysiological mechanism acting at the spinal level and possibly explained by the presence of independent spinal locomotor systems producing muscle spasms. Specifically, overexcitement of these centers, due to loss of normal regulation from upper CNS levels, may result in the uncontrolled firing of secondary motor neurons and may be the key to producing muscle spasms. However, further research under experimental and clinical settings seems to be necessary.

Defining the relationship of the optic radiation to the roof and floor of the ventricular atrium: a focused microanatomical study

Objective The authors investigated the specific topographic relationship of the optic radiation fibers to the roof and floor of the ventricular atrium because the current literature is ambiguous. Methods Thirty-five normal, adult, formalin-fixed cerebral hemispheres and 30 focused MRI slices at the level of the atrium were included in the study. The correlative anatomy of the optic radiation with regard to the atrial roof and floor was investigated in 15 specimens, each through focused fiber microdissections. The remaining 5 hemispheres were explored with particular emphasis on the trajectory of the collateral sulcus in relation to the floor of the atrium. In addition, the trajectory of the collateral sulcus was evaluated in 30 MRI scans. Results The atrial roof was observed to be devoid of optic radiations in all studied hemispheres, whereas the atrial floor was seen to harbor optic fibers on its lateral part. Moreover, the trajectory of the intraparietal sulcus, when followed, was always seen to correspond to the roof of the atrium, thus avoiding the optic pathway, whereas that of the collateral sulcus was found to lead to either the lateral atrial floor or outside the ventricle in 88% of the cases, therefore hitting the visual pathway. Conclusions Operative corridors accessing the ventricular atrium should be carefully tailored through detailed preoperative planning and effective use of intraoperative navigation to increase patient safety and enhance the surgeons maneuverability. The authors strongly emphasize the significance of accurate anatomical knowledge.