Joanna Kemp

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 3: Endoscopic computer-assisted electromagnetic navigation and ultrasonography as technical adjuvants for shunt placement

OBJECT This systematic review was undertaken to answer the following question: Do technical adjuvants such as ventricular endoscopic placement, computer-assisted electromagnetic guidance, or ultrasound guidance improve ventricular shunt function and survival? METHODS The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of cerebrospinal fluid shunts for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been delineated a priori were then examined, and data were abstracted and compiled in evidentiary tables. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider evidence-based treatment recommendations. RESULTS The search yielded 163 abstracts, which were screened for potential relevance to the application of technical adjuvants in shunt placement. Fourteen articles were selected for full-text review. One additional article was selected during a review of literature citations. Eight of these articles were included in the final recommendations concerning the use of endoscopy, ultrasonography, and electromagnetic image guidance during shunt placement, whereas the remaining articles were excluded due to poor evidence or lack of relevance. The evidence included 1 Class I, 1 Class II, and 6 Class III papers. An evidentiary table of relevant articles was created. CONCLUSIONS/RECOMMENDATION: There is insufficient evidence to recommend the use of endoscopic guidance for routine ventricular catheter placement. STRENGTH OF RECOMMENDATION Level I, high degree of clinical certainty. RECOMMENDATION The routine use of ultrasound-assisted catheter placement is an option. STRENGTH OF RECOMMENDATION Level III, unclear clinical certainty. RECOMMENDATION The routine use of computer-assisted electromagnetic (EM) navigation is an option. STRENGTH OF RECOMMENDATION Level III, unclear clinical certainty.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 9: Effect of ventricular catheter entry point and position

OBJECT The objective of this guideline was to answer the following question: Do the entry point and position of the ventricular catheter have an effect on shunt function and survival? METHODS Both the US National Library of Medicine/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of CSF shunts for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been delineated a priori were then examined, and data were abstracted and compiled in evidentiary tables. RESULTS The search yielded 184 abstracts, which were screened for potential relevance to the clinical question of the effect of ventricular catheter entry site on shunt survival. An initial review of the abstracts identified 14 papers that met the inclusion criteria, and these were recalled for full-text review. After review of these articles, only 4 were noted to be relevant for an analysis of the impact of entry point on shunt survival; an additional paper was retrieved during the review of full-text articles and was included as evidence to support the recommendation. The evidence included 1 Class II paper and 4 Class III papers. An evidentiary table was created including the relevant articles. CONCLUSION/RECOMMEndation: There is insufficient evidence to recommend the occipital versus frontal point of entry for the ventricular catheter; therefore, both entry points are options for the treatment of pediatric hydrocephalus. STRENGTH OF RECOMMENDATION Level III, unclear degree of clinical certainty.

Proposed clinical internal carotid artery classification system.

Introduction: Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. Materials and Methods: We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. Results: The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%];P< 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%];P< 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%];P< 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%;P< 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%];P< 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. Conclusions: The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.

Life-threatening neonatal epidural hematoma caused by precipitous vaginal delivery.

Patient: Male, 0 Final Diagnosis: Epidural hematoma Symptoms: Apnea Medication: — Clinical Procedure: Craniotomy Specialty: Pediatrics and Neonatology Objective: Unusual clinical course Background: Neonatal in-hospital falls occur relatively frequently, although they are likely underreported. Significant intracranial head trauma from a fall or birth injury is not common in the immediate newborn period. Furthermore, intracranial bleeding requiring surgical intervention is exceedingly rare. We present an unusual case of an inhospital fall in the delivery room requiring neurosurgical intervention. Case Report: A term infant, appropriate for gestational age, delivered precipitously from a maternal standing position. The vertex neonate struck the linoleum floor after an approximate 80-cm fall, landing headfirst. The physical and neurological exams were initially normal, and skull films did not demonstrate an obvious fracture. The baby was closely observed, undergoing continuous cardiorespiratory monitoring. After the patient had an episode of apnea, a scalp hematoma was noted. A computed tomography (CT) scan revealed a left parietal fracture with an acute epidural hematoma, which required emergent craniotomy. The infant had an unremarkable post-operative course and had a normal neurodevelopmental assessment at 15 months of age. Conclusions: Close, continuous observation is recommended for infants following an in-hospital fall or after significant birth trauma. A high degree of suspicion for intracranial hemorrhage must be maintained. Fall prevention strategies should focus on careful baby handling by the convalescing mother.

Holocord syringomyelia secondary to tethered spinal cord associated with anterior sacral meningocele and tailgut cyst: case report and review of literature.

Background and importanceAnterior sacral meningoceles are lesions that are uncommonly reported and can be associated with other pathology including presacral masses, tethered spinal cord, and syringomyelia. Tethered spinal cord and syringomyelia can result in neurologic deficits, while large meningoceles and presacral masses can have gastroenterologic, urologic, reproductive, and oncologic consequences.Clinical presentationThe authors report a case of a 14-year-old girl with an anterior sacral meningocele, tailgut cyst, and tethered cord with holocord syringomyelia who presented with a tethered cord syndrome, manifested by constipation, urinary retention, bilateral lower extremity weakness, and sensory deficits. After extensive radiographic and urodynamic workups were performed, the patient was treated by the neurosurgery and pediatric surgery teams with a posterior sagittal approach for cord detethering, resection of an intradural cystic mass, resection of the anterior sacral meningocele, and resection of the adjacent presacral mass. After surgical treatment, motor weakness and sensory deficits were resolved, though urinary symptoms persisted. The syrinx resolved after detethering alone. Pathology of the intradural cystic mass and the presacral mass inferior to the anterior sacral meningocele were consistent with tailgut cyst.ConclusionThe patient’s clinical and surgical management are discussed, and a literature review related to anterior sacral meningoceles and their related pathologies is presented. An interdisciplinary approach is required for the best treatment of this constellation of findings.

The Role of Catheter Angiography in the Diagnosis of Central Nervous System Vasculitis

Background: Central nervous system vasculitis (CNSV) is a rare disorder, the pathophysiology of which is not fully understood. It involves a combination of inflammation and thrombosis. CNSV is most commonly associated with headache, gradual changes in mental status, and focal neurological symptoms. Diagnosis requires the effective use of history, laboratory testing, imaging, and biopsy. Catheter angiography can be a powerful tool in the diagnosis when common and low-frequency angiographic manifestations of CNSV are considered. We review these manifestations and their place in the diagnostic algorithm of CNSV. Summary: We reviewed the PubMed database for case series of CNSV that included 5 or more patients. Demographic and angiographic findings were collected. Angiographic findings were dichotomized between common and low-frequency findings. A system for incorporating these findings into clinical decision-making is proposed. Key Message: CNSV is a diagnostic challenge due to the absence of a true gold standard test. In the absence of such a test, catheter angiography remains a central piece of the diagnostic puzzle when appropriately employed and interpreted.

Arteriovenous Malformations of the Brain

Arteriovenous malformations (AVM) of the brain (also known as pial or parenchymal AVMs) are defined as intracranial space-occupying lesions composed of feeding arteries, draining veins, and a nidus of tangled vessels without an intervening capillary bed. There is no normal interposed brain tissue, but there can be surrounding gliosis. Morphology can vary, but AVMs are typically triangular in shape with the base towards the cortex and the apex towards the ventricular system [Brown et al. Mayo Clin Proc 80(2):269–81, 2005; Winn. Youmans neurological surgery. 6th edn. Elsevier, Philadelphia, PA, 2011; Moftakhar et al. Neurosurg Focus 26(5):E10, 2009]. While much of the pathophysiology, epidemiology, and natural history remain unclear, there has been successful advancement in the understanding and management of these complex lesions, especially with regard to the application of microsurgical, radiosurgical, and endovascular therapies.