Krishnapundha Bunyaratavej

Is Postoperative CT Scanning Predictive of Subdural Electrode Placement Complications in Pediatric Epileptic Patients

Aims: To understand the reliability of postoperative CT scans to predict the development of intracranial hemorrhagic complications associated with subdural electrode implants for monitoring intractable seizure, we reviewed the data of a consecutive series of children treated at our institution. Methods: Forty children (mean age: 11.4 years) with subdural electrode implants were reviewed. The immediate postoperative CT scans were evaluated for the presence of hemorrhagic complications and/or brain swelling resulting in a midline shift. Results: Twenty-six patients (65%) presented a postoperative midline shift (range = 2–10 mm; mean shift = 4.0 mm). Two children had a midline shift of >5 mm. Two patients with a shift of <5 mm at the first CT scan required a repeat craniotomy. These patients experienced worsening neurologic symptoms in a delayed fashion on postoperative days 1 and 4, respectively. This was correlated to an increase in midline shift of >5 mm. Conclusions: Subdural electrode implants in children are safe. The presence of a midline shift of <5 mm is common postoperatively. The presence and extension of the midline shift at the first CT scan does not seem to be predictive of the development of symptomatic complications with a mass effect. Complications happened in a delayed fashion.

A 4-YEAR-OLD GIRL WITH MASS IN THE FRONTOTEMPORAL BONE

CLINICAL HISTORY A 4-month-old female infant presented with a growing extracranial mass at the left frontotemporal region. Covered with intact skin, the lesion measured 3.5 × 3 × 3 cm; it was well-defined, bony hard in consistency, and fixed to the underlying skull. There were no other abnormal symptoms, and routine laboratory tests were within normal limits. The mass appeared sclerotic on skull film. Computerized tomography scan of the brain (Figure 1A) showed a homogeneously

Continuous physical examination during subcortical resection in awake craniotomy patients: Its usefulness and surgical outcome.

OBJECTIVES To evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes. PATIENTS AND METHODS Authors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area. RESULTS Between January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups. CONCLUSION Continuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions.

A levering technique for open reduction of traumatic unilateral locked facets of cervical spine: technical note.

Reduction of traumatic unilateral locked facets of the cervical spine can be accomplished by closed or open means. If closed reduction is unsuccessful, then open reduction is indicated. The previously described techniques of open reduction of a unilateral locked facets of the cervical spine in the literature included drilling facet, forceful manipulation or using special equipment. We describe a reduction technique that uses a basic spinal curette, in a forceless manner, and it does not need facet drilling. We have successfully used this technique in 5 consecutive patients with unilateral locked facets. There have been no complications related to this technique.

Three-Dimensional Cortical Surface Reconstruction Versus Operative Findings: Their Similarity and Applications

BACKGROUND Three-dimensional cortical surface reconstruction (3DCSR) is an important tool for operations involving cerebral cortex, but data on its similarity to actual cortical architecture are lacking. In this study, the authors systematically tested the similarity between operative findings and 3DCSR built by a neuronavigation system and illustrated its applications. METHODS The authors retrospectively retrieved operative photographs and 3DCSR of patients who underwent craniotomy with the aid of 3DCSR and asked 4 evaluators to perform a series of matching tests. Test 1 was to match 3DCSR and operative photographs. Test 2 was a repetition of test 1 to determine the consistency of matching ability. Test 3 was to match detailed anatomy of the 3DCSR with operative photographs. Scores on all tests were analyzed to measure the degree of similarity between 3DCSR and operative findings. The scores between patients with and without cortical distortion were compared to determine the impact of distortion on matching ability. RESULTS Tests of similarity were performed on 22 patients. Mean scores of tests 1, 2, and 3 were 84.09%, 93.18%, and 89.77%, respectively. The Kappa statistic for agreement between test 1 and 2 ranged from 0.76 to 0.88. There was no statistically significant difference between average score of patients with and without cortical distortion in all tests. CONCLUSIONS Authors have systematically demonstrated that 3DCSR built by neuronavigation system in this study provides detailed anatomy of cortical surface with a high degree of similarity to operative findings even in the presence of cortical distortion, leading to various applications beyond navigation alone.

Localizing Value of Pain Distribution Patterns in Cervical Spondylosis

Study Design Prospective observational study. Purpose To investigate the value of pain distribution in localizing appropriate surgical levels in patients with cervical spondylosis. Overview of Literature Previous studies have investigated the value of pain drawings in its correlation with various features in degenerative spine diseases including surgical outcome, magnetic resonance imaging findings, discographic study, and psychogenic issues. However, there is no previous study on the value of pain drawings in identifying symptomatic levels for the surgery in cervical spondylosis. Methods The study collected data from patients with cervical spondylosis who underwent surgical treatment between August 2009 and July 2012. Pain diagrams drawn separately by each patient and physician were collected. Pain distribution patterns among various levels of surgery were analyzed by the chi-square test. Agreement between different pairs of data, including pain diagrams drawn by each patient and physician, intra-examiner agreement on interpretation of pain diagrams, inter-examiner agreement on interpretation of pain diagrams, interpretation of pain diagram by examiners and actual surgery, was analyzed by Kappa statistics. Results The study group consisted of 19 men and 28 women with an average age of 55.2 years. Average duration of symptoms was 16.8 months. There was no difference in the pain distribution pattern at any level of surgery. The agreement between pain diagram drawn by each patient and physician was moderate. Intra-examiner agreement was moderate. There was slight agreement of inter-examiners, examiners versus actual surgery. Conclusions Pain distribution pattern by itself has limited value in identifying surgical levels in patients with cervical spondylosis.