Eisha Christian

A review of selective hypothermia in the management of traumatic brain injury.

OBJECT Traumatic brain injury (TBI) remains a significant cause of morbidity and death in the US and worldwide. Resuscitative systemic hypothermia following TBI has been established as an effective neuroprotective treatment in multiple studies in animals and humans, although this intervention carries with it a significant risk profile as well. Selective, or preferential, methods of inducing cerebral hypothermia have taken precedence over the past few years in order to minimize systemic adverse effects. In this report, the authors explore the current methods available for inducing selective cerebral hypothermia following TBI and review the literature regarding the results of animal and human trials in which these methods have been implemented. METHODS A search of the PubMed archive (National Library of Medicine) and the reference lists of all relevant articles was conducted to identify all animal and human studies pertaining to the use of selective brain cooling, selective hypothermia, preferential hypothermia, or regional hypothermia following TBI. RESULTS Multiple methods of inducing selective cerebral hypothermia are currently in the experimental phases, including surface cooling, intranasal selective hypothermia, transarterial or transvenous endovascular cooling, extraluminal vascular cooling, and epidural cerebral cooling. CONCLUSIONS Several methods of conferring preferential neuroprotection via selective hypothermia currently are being tested. Class I prospective clinical trials are required to assess the safety and efficacy of these methods.

Deep brain stimulation: a mechanistic and clinical update.

Deep brain stimulation (DBS), the practice of placing electrodes deep into the brain to stimulate subcortical structures with electrical current, has been increasing as a neurosurgical procedure over the past 15 years. Originally a treatment for essential tremor, DBS is now used and under investigation across a wide spectrum of neurological and psychiatric disorders. In addition to applying electrical stimulation for clinical symptomatic relief, the electrodes implanted can also be used to record local electrical activity in the brain, making DBS a useful research tool. Human single-neuron recordings and local field potentials are now often recorded intraoperatively as electrodes are implanted. Thus, the increasing scope of DBS clinical applications is being matched by an increase in investigational use, leading to a rapidly evolving understanding of cortical and subcortical neurocircuitry. In this review, the authors discuss recent innovations in the clinical use of DBS, both in approved indications as well as in indications under investigation. Deep brain stimulation as an investigational tool is also reviewed, paying special attention to evolving models of basal ganglia and cortical function in health and disease. Finally, the authors look to the future across several indications, highlighting gaps in knowledge and possible future directions of DBS treatment.

Surgical management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant

OBJECT Posthemorrhagic hydrocephalus (PHH) in the preterm infant remains a major neurological complication of prematurity. The authors first described insertion of a specially designed low-profile subcutaneous ventricular catheter reservoir for temporary management of hydrocephalus in 1983. This report presents the follow-up experience with the surgical management of PHH in this population and describes outcomes both in infants who were stable for permanent shunt insertion and those initially temporized with a ventricular reservoir (VR) prior to permanent ventriculoperitoneal (VP)/ventriculoatrial (VA) shunt placement. METHODS A retrospective review was undertaken of the medical records of all premature infants surgically treated for posthemorrhagic hydrocephalus (PHH) between 1997 and 2012 at Childrens Hospital Los Angeles. RESULTS Over 14 years, 91 preterm infants with PHH were identified. Fifty neonates received temporizing measures via a VR that was serially tapped for varying time periods. For the remaining 41 premature infants, VP/VA shunt placement was the first procedure. Patients with a temporizing measure as their initial procedure had undergone CSF diversion significantly earlier in life than those who had permanent shunting as the initial procedure (29 vs 56 days after birth, p < 0.01). Of the infants with a VR as their initial procedure, 5/50 (10%) did not undergo subsequent VP/VA shunt placement. The number of shunt revisions and the rates of loculated hydrocephalus and shunt infection did not statistically differ between the 2 groups. CONCLUSIONS Patients with initial VR insertion as a temporizing measure received a CSF diversion procedure significantly earlier than those who received a permanent shunt as their initial procedure. Otherwise, the outcomes with regard to shunt revisions, loculated hydrocephalus, and shunt infection were not different for the 2 groups.

Endoscopic endonasal transsphenoidal surgery: implementation of an operative and perioperative checklist

Endoscopic endonasal surgery relies heavily on specialized operative instrumentation and optimization of endocrinological and other critical adjunctive intraoperative factors. Several studies and worldwide initiatives have previously established that intraoperative and perioperative surgical checklists can minimize the incidence of and prevent adverse events. The aim of this article was to outline some of the most common considerations in the perioperative and intraoperative preparation for endoscopic endonasal transsphenoidal surgery. The authors implemented and prospectively evaluated a customized checklist at their institution in 25 endoscopic endonasal operations for a variety of sellar and skull base pathological entities. Although no major errors were detected, near misses pertaining primarily to missing components of surgical equipment or instruments were identified in 9 cases (36%). The considerations in the checklist provided in this article can serve as a basic template for further customization by centers performing endoscopic endonasal surgery, where their application may reduce the incidence of adverse or preventable errors associated with surgical treatment of sellar and skull base lesions.

200 Age as a Novel Risk Factor for Revision of Ventriculopleural Shunt in Pediatric Patients.

INTRODUCTION The first choice for distal end location of a cerebrospinal fluid-diverting device is the abdomen. However, for patients in whom the peritoneal cavity is not suitable, a ventriculopleural shunt (VPl) is an alternative. METHODS With institutional review board approval we performed a retrospective review of all patients with ventriculopleural shunts inserted at our institution from 1977 to 2013. RESULTS One-hundred thirty-one (78 male) patients were identified. Mean age at insertion of VPl was 14 ± 5 years. Before VPl insertion, 58 patients with available preoperative data had experienced of mean of 2 ± 3 revisions. These patients underwent a mean of 1 ± 1 subsequent revisions of their VPl (P < .01). Fifty-nine of 131 (45%) patients underwent revision of VPl; malfunction 32 of 59 (54%), pleural effusion 18 of 59 (31%), and infection 9 of 59 (15%). Median revision-free duration was 3.6 years. All effusions required the distal end of the shunt be removed from the pleural space, in contrast to 20% of other indications (P < .001). Binary regression found that, for each additional year in age at the time of VPl insertion, patients experienced an almost 10% reduced risk of revision (Exp B = 0.91; CI, 0.84-1.00). More precisely, 11 years of age was the threshold value at which revision rate differentiated. Among 112 patients with minimum 1 year follow-up, 38 of 82 (46%) patients 11 years or older underwent revision in contrast to 21 of 30 (70%) under 11 (P < .05). Strengthening this finding, binary regression found a risk ratio for revision of 2.9 (CI, 1.1-7.5) for patients under 11. CONCLUSION The mean number of revisions dropped significantly after VPl shunt insertion. Malfunction accounted for the majority of indications for VPl revision, but the site of distal drainage was changed mainly in the case of pleural effusions. Younger patients in our population experienced a higher risk for revision, with the rate differentiating at 11 years.

Giant, calcified colloid cyst of the lateral ventricle

We report a patient with a giant, calcified colloid cyst in the left lateral ventricle. Colloid cysts are slow growing, benign lesions, commonly originating in the roof of the anterior third ventricle near the foramen of Monro. Many colloid cysts are small lesions which are either discovered incidentally or cause headache, visual changes, memory deficits, and/or syncope. Giant colloid cysts are rare. A 40-year-old man presented with a month long history of worsening headaches and was found to have a multiloculated 5 cm intraventricular mass with an anterior hyperdensity, suggestive of calcification, arising within the lateral ventricles. He underwent an interhemispheric transcallosal approach for resection of the mass. The pathology was consistent with a giant colloid cyst with calcification in the anterior cyst wall. Giant, calcified mass is a rare presentation of colloid cyst. Although rare, this diagnosis remains an important consideration in the differential diagnosis of any calcified, cystic intraventricular mass.

Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

OBJECTIVE Competency in endoscopic endonasal approaches (EEAs) to repair high-flow cerebrospinal fluid (CSF) leaks is an essential component of the neurosurgical training process. The objective of this study was to demonstrate the feasibility of a simulation model for EEA repair of anterior skull base CSF leaks. METHODS Human cadaveric specimens were utilized with a perfusion system to simulate a high-flow CSF leak. Neurological surgery residents (postgraduate year 3 or greater) performed a standard EEA to repair a CSF leak using a combination of fat, fascia lata, and pedicled nasoseptal flaps. A standardized 5-point Likert questionnaire was used to assess the knowledge gained, techniques learned, degree of safety, benefit of CSF perfusion during repair, and pre- and posttraining confidence scores. RESULTS Intrathecal perfusion of fluorescein-infused saline into the ventricular/subarachnoid space was successful in 9 of 9 cases. The addition of CSF reconstitution offered the residents visual feedback for confirmation of intraoperative CSF leak repair. Residents gained new knowledge and a realistic simulation experience by rehearsing the psychomotor skills and techniques required to repair a CSF leak with fat and fascial grafts, as well as to prepare and rotate vascularized nasoseptal flaps. All trainees reported feeling safer with the procedure in a clinical setting and higher average posttraining confidence scores (pretraining 2.22 ± 0.83, posttraining 4.22 ± 0.44, p < 0.001). CONCLUSIONS Perfusion-based human cadaveric models can be utilized as a simulation training model for repairing CSF leaks during EEA.

Versatile utilization of real-time intraoperative contrast-enhanced ultrasound in cranial neurosurgery: technical note and retrospective case series

OBJECTIVE Intraoperative contrast-enhanced ultrasound (iCEUS) offers dynamic imaging and provides functional data in real time. However, no standardized protocols or validated quantitative data exist to guide its routine use in neurosurgery. The authors aimed to provide further clinical data on the versatile application of iCEUS through a technical note and illustrative case series. METHODS Five patients undergoing craniotomies for suspected tumors were included. iCEUS was performed using a contrast agent composed of lipid shell microspheres enclosing perflutren (octafluoropropane) gas. Perfusion data were acquired through a time-intensity curve analysis protocol obtained using iCEUS prior to biopsy and/or resection of all lesions. RESULTS Three primary tumors (gemistocytic astrocytoma, glioblastoma multiforme, and meningioma), 1 metastatic lesion (melanoma), and 1 tumefactive demyelinating lesion (multiple sclerosis) were assessed using real-time iCEUS. No intraoperative complications occurred following multiple administrations of contrast agent in all cases. In all neoplastic cases, iCEUS replicated enhancement patterns observed on preoperative Gd-enhanced MRI, facilitated safe tumor debulking by differentiating neoplastic tissue from normal brain parenchyma, and helped identify arterial feeders and draining veins in and around the surgical cavity. Intraoperative CEUS was also useful in guiding a successful intraoperative needle biopsy of a cerebellar tumefactive demyelinating lesion obtained during real-time perfusion analysis. CONCLUSIONS Intraoperative CEUS has potential for safe, real-time, dynamic contrast-based imaging for routine use in neurooncological surgery and image-guided biopsy. Intraoperative CEUS eliminates the effect of anatomical distortions associated with standard neuronavigation and provides quantitative perfusion data in real time, which may hold major implications for intraoperative diagnosis, tissue differentiation, and quantification of extent of resection. Further prospective studies will help standardize the role of iCEUS in neurosurgery.

310 Predictors of Preoperative Developmental Delay in Nonsyndromic Sagittal Craniosynostosis.

Patients with nonsyndromic sagittal craniosynostosis (SC) were previously thought to have normal neurocognitive development; however, a pattern of mild delays has been described in these patients. We reviewed our patients with SC to identify potential perinatal risk factors that serve as indicators for subsequent developmental delay.Nonsyndromic patients with SC (n = 66) completed preoperative Bayley Scales of Infant and Toddler Development (III) with a single examiner between August 2009 and April 2015. Patients were classified as having no delays (n = 52; 79%) or having delays (n = 14; 21%) below the ninth percentile in one or more area(s) of development. Mean differences were compared using Multivariate Analyses of Variance.Participants were mostly male (79%) and aged 2 to 12 months at testing. There were no group differences in sociodemographic categories. Prenatally, patients in the group with delays vs the group with no delays had lower gestational age in weeks (36.9 vs 39.2, P <.000) with higher rates of gestational diabetes (36% vs 6%, P =.002) and premature rupture of membranes (14% vs 0%, P =.006). There were no group differences in maternal hypertension, maternal age, breech position, preterm labor, emergency cesarean delivery, or failure to progress. At birth, patients with delays had lower birth weight in grams (2982 vs 3359, P =.041), higher rates of respiratory distress (29% vs 4%, P =.005), additional medical diagnoses (57% vs 15%, P =.001), and longer NICU stays in weeks (1.6 vs 0.2, P =.001). There were no differences for infection, hyperbilirubinemia, age at SC diagnosis, or subsequent surgery age.Patients with SC with delays in development had a lower gestational age and birth weight with more prenatal and birth complications. Further studies are required to validate appropriate follow-up and genetic testing in these groups.INTRODUCTION Patients with nonsyndromic sagittal craniosynostosis (SC) were previously thought to have normal neurocognitive development; however, a pattern of mild delays has been described in these patients. We reviewed our patients with SC to identify potential perinatal risk factors that serve as indicators for subsequent developmental delay. METHODS Nonsyndromic patients with SC (n = 66) completed preoperative Bayley Scales of Infant and Toddler Development (III) with a single examiner between August 2009 and April 2015. Patients were classified as having no delays (n = 52; 79%) or having delays (n = 14; 21%) below the ninth percentile in one or more area(s) of development. Mean differences were compared using Multivariate Analyses of Variance. RESULTS Participants were mostly male (79%) and aged 2 to 12 months at testing. There were no group differences in sociodemographic categories. Prenatally, patients in the group with delays vs the group with no delays had lower gestational age in weeks (36.9 vs 39.2, P < .000) with higher rates of gestational diabetes (36% vs 6%, P = .002) and premature rupture of membranes (14% vs 0%, P = .006). There were no group differences in maternal hypertension, maternal age, breech position, preterm labor, emergency cesarean delivery, or failure to progress. At birth, patients with delays had lower birth weight in grams (2982 vs 3359, P = .041), higher rates of respiratory distress (29% vs 4%, P = .005), additional medical diagnoses (57% vs 15%, P = .001), and longer NICU stays in weeks (1.6 vs 0.2, P = .001). There were no differences for infection, hyperbilirubinemia, age at SC diagnosis, or subsequent surgery age. CONCLUSION Patients with SC with delays in development had a lower gestational age and birth weight with more prenatal and birth complications. Further studies are required to validate appropriate follow-up and genetic testing in these groups.

A Modified Gaines Approach for Lumbosacral Traumatic Spondyloptosis: A Historical Review and Case Illustration

Spondyloptosis is defined as greater than 100% subluxation of one vertebra over another; it most commonly develops due to dysplastic spondyloslisthesis but can also develop as a result of traumatic fracture-dislocations. In the past, given the significant force associated with this injury, most patients did not survive the initial trauma and resuscitation. However, as early care of patients with multiple traumatic injuries continues to improve, a larger number of patients with traumatic spondyloptosis will require treatment. In general, the goals of surgical intervention are to treat symptoms, preserve and improve neurologic status, restore and maintain sagittal balance, and obtain a solid arthrodesis while fusing as few segments as possible. There is, however, considerable controversy about specific surgical management in achieving these goals. We present a case of traumatic spondyloptosis including a discussion of our surgical approach, which is a modified Gaines procedure with a corpectomy, interbody fusion, and posterior spinal decompression and fusion. Alternate approaches are also discussed from both our institutional experience and from a review of the current literature.