Bassel Zebian

Sudden death following cranioplasty: a complication of decompressive craniectomy for head injury

We read with great interest the short report by Stephen Honeybul in which three cases are presented having had autologous cranioplasties following bifrontal decompressive craniectomies for head injury. All three cases developed massive postoperative cerebral swelling and subsequently died. All three cases had previously developed hydrocephalus following the initial trauma and had ventriculoperitoneal shunts inserted. The paper highlights an important complication which we feel is under-reported in the literature currently. In our institution, we recently had a similar case with some differences. Our patient was a 40-year-old right handed female who had initially presented with a World Federation of Neurosurgeons (WFNS) grade 2 subarachnoid haemorrhage (SAH) having collapsed with a sudden onset headache, subsequently developing blurred vision, neck stiffness and nausea and vomiting. Her past medical history consisted of two caesarean sections, bronchitis and Bell’s palsy. She smoked 20 cigarettes a day. She underwent an uneventful craniotomy and clipping of a left middle cerebral artery (MCA) aneurysm following insertion of a lumbar drain. She was slow to wake up the following day and as a result an intracranial pressure (ICP) and tissue oxygenation monitors were inserted which demonstrated pressures as high as 40 mm of Hg. An external ventricular drain (EVD) was also inserted. Ten days later, she unfortunately suff ered a left MCA malignant infarct and underwent a left sided decompressive craniectomy. Ten days after that she underwent removal of the EVD and insertion of a programmable ventriculoperitoneal shunt. On discharge to a rehabilitation facility her eyes were open spontaneously, she had a tracheostomy in situ, and she occasionally obeyed commands. She was readmitted almost 2 years later for placement of a titanium cranioplasty (Fig. 1A). Her Glasgow Coma Score was unchanged, although she was able to recognize her family and was able to communicate with them. The only medication she was taking was Lamotrigine and Fortisip. The resistance of the programmable valve in the ventriculoperitoneal shunt was increased 3 days prior to her operation in order to allow the brain to slowly expand thus avoiding a sudden shift post cranioplasty. A repeat CT of the head demonstrated good expansion due to ventriculomegaly (Fig. 1B). The cranioplasty was uncomplicated, and the dura was hitched up through the cranioplasty. We placed a subgaleal drain on full vacuum to avoid subgaleal blood tracking down into the extradural space. Postoperatively, she unfortunately suffered two seizures, and her pupils became fixed and dilated. We carried out a CT scan which demonstrated a massive shift of the brain towards the cranioplasty associated with brainstem haemorrhage (Fig. 1C, D). After a discussion with the next of kin, it was decided not to intervene to remove the cranioplasty, and the patient later passed away. Our case is different from those presented by Stephen Honeybul in that the patient was a female and had suffered an aneurysmal SAH rather than a head injury. She also underwent a unilateral decompressive craniectomy rather than a bifrontal one. We increased the valve resistance rather than ligated our patient’s shunt whereas two of the cases in Stephen Honeybul’s paper had their shunts ligated at the time of the cranioplasty and one did not. We used a titanium cranioplasty as opposed to an autologous one. We also performed our cranioplasty at a later stage. The exact pathophysiological mechanism behind massive swelling and sudden death following cranio-

An unusual gall-bladder polyp - site of metastatic renal cell carcinoma: a case report

We report the case of a 64 year old woman who presented with symptomatology of gallstone disease but was radiologically shown to have a polyp within the gallbladder. Upon resection this was shown to be a metastasis from renal cell carcinoma for which she had had a nephrectomy six years previously.

Prevalence of recurrence and retreatment of ruptured intracranial aneurysms treated with endovascular coil occlusion

Abstract Object. Endovascular coiling is a common treatment for ruptured intracranial aneurysms. However, concerns have been raised over the durability of this treatment. The aim of this study was to establish the rate of recurrence and retreatment of coiled aneurysms treated in our unit. Methods. We performed a retrospective analysis of 264 surviving patients with ruptured aneurysms treated by endovascular coiling between November 2003 and April 2007. Data was collected on patient age, location of aneurysm, angiogram results and any subsequent retreatment. Results. Follow-up angiography performed at 6 months was available in 239 cases (91%) and revealed 158 (66%) aneurysms completely occluded, 51 (21%) had neck recurrence and 31 (13%) had significant recurrence. Thirty (12.6%) aneurysms required retreatment over a mean follow-up period of 46 (range 24–66) months. Younger age predisposed to a higher risk of recurrence and retreatment. Aneurysms of the anterior communicating and anterior cerebral arteries were less likely to recur or require retreatment (relative risk 0.42 and 0.29, respectively); aneurysms of the posterior communicating arteries were more likely to recur (relative risk 2.22). Aneurysms of the basilar and carotid arteries were more likely to undergo retreatment (relative risk 2.84 and 2.46, respectively). Conclusion. Long-term follow-up is required for ruptured aneurysms treated by coiling. Certain subgroups may require closer follow-up due to the increased risk of recurrence or retreatment, such as younger patients and those with aneurysms of the posterior communicating, basilar or carotid arteries.

Recent technological advances in pediatric brain tumor surgery

X-rays and ventriculograms were the first imaging modalities used to localize intracranial lesions including brain tumors as far back as the 1880s. Subsequent advances in preoperative radiological localization included computed tomography (CT; 1971) and MRI (1977). Since then, other imaging modalities have been developed for clinical application although none as pivotal as CT and MRI. Intraoperative technological advances include the microscope, which has allowed precise surgery under magnification and improved lighting, and the endoscope, which has improved the treatment of hydrocephalus and allowed biopsy and complete resection of intraventricular, pituitary and pineal region tumors through a minimally invasive approach. Neuronavigation, intraoperative MRI, CT and ultrasound have increased the ability of the neurosurgeon to perform safe and maximal tumor resection. This may be facilitated by the use of fluorescing agents, which help define the tumor margin, and intraoperative neurophysiological monitoring, which helps identify and protect eloquent brain.

Neonatal post-haemorrhagic hydrocephalus in the UK: a survey of current practice

Abstract Objectives: The management of neonatal post-haemorrhagic hydrocephalus (nPHH) varies considerably between centres and even between neurosurgeons in the same centre. We performed a nationwide survey to evaluate current practice in the UK and reviewed the evidence for each intervention. Methods: An online semi-structured questionnaire was emailed to all units registered on the British Paediatric Neurosurgery Group Mailing List. The survey consisted of 18 questions designed to establish the status quo in the management of nPHH, including preferred temporising procedure, factors guiding the timing of intervention and willingness to participate in a prospective study. Results: A total of 24 consultants responded to the survey. Ventricular access device (VAD), trans-fontanelle tap, ventriculosubgaleal shunt (VSGS) and lumbar puncture (LP) were used by 33, 25, 17 and 17%, respectively, as the first temporising measure. Almost all reported that the timing of this intervention was guided by increasing head circumference and tense fontanelle. If the first temporising procedure fails, VAD, external ventricular drainage (EVD), trans-fontanelle tap, VSGS and other procedures (including ventriculoperitoneal (VP) shunting and endoscopic third ventriculostomy (ETV)) were performed by 42, 17, 13, 8 and 21%, respectively. Almost all respondents reported that VP shunting would be their preferred method of definitive cerebrospinal fluid (CSF) diversion. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice. Conclusion: As expected there was a significant heterogeneity between respondents in the initial management of nPHH in the UK. VAD was the most popular first and second choice temporising measure. On reviewing the literature, it is clear that more work still needs to be done to establish which temporising measure is best. There is willingness in the UK to participate in a study to help determine this.

Yawning as a presenting symptom of Chiari malformation Type I: report of 2 cases

Yawning is thought to be a behavior regulated by the brainstem. Although excessive yawning has been reported in brainstem strokes, demyelination, and tumors, the cases presented here are the first reports of excessive yawning in patients with Chiari malformation Type I (CM-I). The authors believe that brainstem compression at the craniocervical junction and ensuing edema were implicated in this curious symptomatology. They describe excessive yawning as a presenting feature of CM-I in 2 adolescent females. The presentation was acute in the first case and more chronic in the second. Both patients underwent foramen magnum decompression, which resulted in complete cessation of the excessive yawning.

Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Intrathecal baclofen (ITB) is a reversible treatment that reduces muscle tone to ameliorate spasticity and dystonia in patients with cerebral palsy (CP). The resulting decrease in energy expenditure allows patients to gain much-needed weight, albeit temporarily. Modern techniques require sufficient abdominal musculature and subcutaneous fat to permit the implantation of an indwelling pump. In patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection. The authors describe a variation of the classical procedure in a young patient with severe cachexia. A 10-year-old boy with spastic-dystonic quadriplegic CP was admitted to the neuromedical unit. Numerous drug trials had failed, and surgical intervention was deemed necessary but was complicated by his cachectic body habitus. The authors inserted a lumbar intrathecal catheter and subcutaneously tunneled it to the anterolateral abdomen, where it was connected to a subcutaneous injection port. Baclofen was continuously infused into the subcutaneous port using a noncoring needle connected to an external pump. The needle and line were changed every 5 days to minimize the risk of sepsis. Although other techniques, such as intraventricular baclofen delivery, have been described, these are largely dependent upon sufficient musculature to support a visceral pump. A subcutaneous injection port system represents an alternative approach that reduces the risk of sepsis and may be better tolerated in cachectic patients.

Letter to the Editor. Endoscopic ultrasonic aspirator for the removal of intraventricular tumors

TO THE EDITOR: We read with the greatest of interest the article by Cinalli et al.1 in which the authors summarize their experience with the Söring endoscopic ultrasonic aspirator for the removal of intraventricular tumors (Cinalli G, Imperato A, Mirone G, et al: Initial experience with endoscopic ultrasonic aspirator in purely neuroendoscopic removal of intraventricular tumors. J Neurosurg Pediatr 19:325–332, March 2017). It is an excellent account describing the use of the aspirator in 12 children with intra/paraventricular and suprasellar/third ventricular lesions. We congratulate the authors as we believe that the advancement of neuroendoscopy will only be possible with the help of such reports. In this spirit we briefly share our experience using the same device, with the hope of expanding its use and overcoming some of its limitations. We had previously recounted our use of the aspirator to remove a choroid plexus papilloma in an infant2 and we have since used the device in a total of 19 patients (pediatric and adult) and 22 procedures (intra/paraventricular lesions as well as sellar/suprasellar ones extending into or towards the third ventricle). Although the Söring endoscopic handpiece was built for the sole use with the Gaab scope, we modified it to allow use with other endoscopes. Due to its large oval working channel, our preferred endoscope for tumors is the Aesculap InVent, and it is this scope that we use most commonly with the endoscopic aspirator. When using the aspirator, we found that minimal suction was required but we often required high cavitating power. We use copious wash under pressure to ensure that the ventricles/cavities are kept expanded. Pressured wash is safe using endoscopes with large channels, but extreme care should be exercised with smaller channels. We found the ability to sweep from side to side and angulate the aspirator within the large oval working channel most useful. The inability to do this was a limiting factor in Dr. Cinalli’s experience. We found soft tumors and cystic lesions easiest to address and harder or larger ones more difficult. There was no morbidity or mortality directly or indirectly related to our use of the aspirator. We agree with Cinalli et al. that the Söring endoscopic ultrasonic aspirator is safe and reliable. We echo their opinion that this tool has the potential to expand the spectrum of intracranial pathologies treatable by modern neuroendoscopic means, but not if it continues to be manufactured with only one endoscope in mind and not without further development. This development must not be driven by companies/product developers/engineers alone with neurosurgeons only involved at the end stage; it must be guided, from the outset, by the needs and ideas of the surgeons using it. Ensuring this happens is, of course, no easy feat, but perhaps with the assistance of the International Federation of Neuroendoscopy, it may become possible.

Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant

IntroductionArachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.Case reportWe report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

PP84. ENDOSCOPIC RESECTION OF A THIRD VENTRICULAR PILOCYTIC ASTROCYTOMA WITH PILOMYXOID FEATURES IN AN 86-YEAR OLD PATIENT: CASE REPORT AND REVIEW OF THE LITERATURE

AbstractOBJECTIVE: Pilocytic astrocytomas are extremely rare in octagenarians especially those occurring in the third ventricle. They are similar histopathologically to pilomyxoid astrocytomas but the latter are more aggressive. We report the case of an 86-year old patient presenting with confusion and lethargy secondary to a third ventricular lesion causing obstructive hydrocephalus. The lesion was approached endoscopically and sub-totally resected. Histologically the lesion was classified as a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery and did not require a shunt. MATERIALS AND METHODS: Case report with pictures and video of the operative approach as well as discussion of the imaging sequences and histology, and review of the literature. RESULTS: Sub-total resection of the tumour was achieved using a monoportal image-guided endoscopic approach. Normal cerebrospinal fluid circulation was restored and a shunt was not required. Histologically, the mass was confirmed to be a pilocytic astrocytoma with pilomyxoid features. The patient made a full recovery with resolution of her symptoms. No such case has been reported in the literature to date. CONCLUSION: This is the first report of a third-ventricular pilocytic astrocytomas with pilomyxoid features in an octogenarian. The endoscopic approach in the case at hand, allowed safe direct visualisation and sub-total resection of the lesion, providing histological diagnosis to guide management and obviating the need for a shunt. The minimally invasive nature of the approach translated into full recovery, despite the age of the patient.