Laszlo Nagy

Epidural Lysis of Adhesions and Percutaneous Neuroplasty

Epidural adhesiolysis has been accepted as a treatment for post laminectomy syndrome, failed back syndrome, and cervical and thoracic radicular syndromes and spinal stenosis. Additional studies are underway to further refine the technique and indications.

Image-guided surgery and craniofacial applications: mastering the unseen

Image-guided surgery potentially enhances intraoperative safety and outcomes in a variety of craniomaxillofacial procedures. We explore the efficiency of one intraoperative navigation system in a single complex craniofacial case, review the initial and recurring costs, and estimate the added cost (e.g., additional setup time, registration). We discuss the potential challenges and benefits of utilizing image-guided surgery in our specific case and its benefits in terms of educational and teaching purposes and compare this with traditional osteotomies that rely on a surgeon’s thorough understanding of anatomy coupled with tactile feedback to blindly guide the osteotome during surgery. A 13-year-old presented with untreated syndromic multi-suture synostosis, brachycephaly, severe exorbitism, and midface hypoplasia. For now, initial costs are high, recurring costs are relatively low, and there are perceived benefits of imaged-guided surgery as an excellent teaching tool for visualizing difficult and often unseen anatomy through computerized software and multi-planar real-time images.

Familial Aggregation of Chiari Malformation: Presentation, Pedigree, and Review of the Literature.

This article reports the largest familial aggregation of Chiari malformation in a single family to date as reported in the literature. This study is a retrospective case series of a family of whom five individuals have a confirmed case of Chiari malformation and three additional individuals have Chiari signs and symptoms. This contribution further supports the implication of genetics in the transmission of Chiari malformation. The family reported in this study also has a significant incidence of Ehlers-Danlos. Three sisters, including a set of twins, presented with confirmed cases of Chiari malformation and four of the five children of the twin sisters presented with confirmed or suspected Chiari malformation. Of note, the non-twin sister has three children who are unaffected. This report provides further evidence for a shared loci between the Chiari malformation and Ehlers-Danlos.

Hydranencephaly: Considering Prolonged Survival and Treatment by Endoscopic Choroid Plexus Coagulation.

Arachnoid collapse is a previously unreported complication of endoscopic choroid plexus coagulation (ECPC) treatment of hydranencephaly and is demonstrated in this case report. The variable anatomy found in hydranencephaly supports the use of ECPC as the preferred treatment option. However, the same anatomical anomalies predispose the procedure to this unique complication. A brief literature review of hydranencephaly has also been performed and is reported through the discussion. Neurosurgeons must be aware of this very dangerous complication and a discussion of preventative measures are made. The use of ECPC and the clinical expectations of treating patients with hydranencephaly is also discussed.

Spontaneously Improving Occipitocondylar Hyperplasia: A Case Report

This case report presents a pediatric patient with the extremely rare craniovertebral junction anomaly of occipitocondylar hyperplasia. This 4-year old boy presented with macrocephaly and mild to moderate pontomedullary compression from the unilateral occipitocondylar hyperplasia. Based on the asymptomatic clinical presentation, it was decided to follow the patient with serial magnetic resonance images without surgical intervention. Upon further imaging the occipitocondylar hyperplasia spontaneously resolved. This case report offers watchful waiting as an alternative treatment approach to surgical intervention as was reported in the literature previously. Possible pathophysiologic mechanisms are also briefly explored.

Innovative Treatment for Pre- Operative Occipital Nerve Pain Associated with Chiari 0 Malformation

Chiari 0 malformation is a disorder within the spectrum of Arnold- Chiari malformations characterized by cerebellar changes present during fetal development and early childhood. Specifically, Chiari 0 is classified by characteristics that include either lack of protrusion of the cerebellar tonsils into the foramen magnum or protrusion less than 5 millimeters, which is the current minimum cutoff for Chiari I classification. Due to the subtle changes in the cerebellar region regarding Chiari 0, patients with this malformation often present with neck and occipital pain along with occipital headaches. It is suggested that this may be due to abnormal blockage of cerebrospinal fluid (CSF) that causes entrapment and impingement of the occipital nerve. In the cases of two teenage patients, both were referred to Pediatric Neurosurgery in Lubbock, Texas for complaints of chronic headaches and neck pain. After previous pain remedies proved to be unsuccessful in providing lasting relief, the patients were deemed candidates to receive an innovative treatment option to manage their chronic headaches and neck pain. The patients were referred to receive epidural lysis of adhesions (LOA) which would provide the lasting relief that the patients were seeking. LOA is a procedure that includes using a needle, Racz catheter, and injectable contrast guided with fluoroscopy to locate the entrapment of the occipital nerve. LOA utilizes the injection of hyaluronidase dissolved in normal saline to free the entrapped nerve so that a local anesthetic/steroid solution can be injected to provide pain relief. Lysis of adhesions should be considered as a minimally invasive treatment for Chiari 0 malformations, whose primary symptoms are intractable occipital headaches.

Isolated Spontaneous Midbrain Hemorrhage in a 14-Year-Old Boy

Isolated spontaneous midbrain hemorrhages are rare because they are usually secondary to hemorrhages from inferior structures such as the pons and cerebellum, or superior structures such as the thalamus and putamen. While the etiologies are largely unidentified, the most common ones are vascular malformations and bleeding diathesis with hypertension being relatively uncommon. We report midbrain hemorrhage in a 14-year-old boy with a long-standing history of frequent migraine headaches and attention deficit/hyperactivity disorder (ADHD). Neurologic examinations, noncontrast computed tomography (CT) scans, and magnetic resonance imaging (MRI) suggested that the lesion likely affected the dorsal part of the midbrain. The neurologic symptoms improved following endoscopic third ventriculostomy (ETV) with the placement of external ventricular drains (EVDs). In this report, anatomical correlations to the case are discussed and previous reports of midbrain hemorrhages are reviewed.

Blood loss and transfusion requirements with epsilon-aminocaproic acid use during cranial vault reconstruction surgery

OBJECTIVE To determine whether epsilon-aminocaproic acid (EACA) load of 50 mg∙kg-1 before skin incision, and infusion of 25 mg∙kg-1∙h-1 until skin closure during cranial vault reconstruction (CVR) were associated with decreased estimated blood loss and transfusion requirements. BACKGROUND Antifibrinolytic medications decrease bleeding and transfusion requirements during cardiothoracic and orthopedic surgeries with high blood loss, but practical reductions in blood loss and transfusion requirements have not been consistently realized in children undergoing CVR. Current dosing recommendations are derived from adult extrapolations, and may or may not have clinical relevance. METHOD Retrospective case-controlled study of 45 consecutive infants and children undergoing primary craniosynostosis surgery at Covenant Childrens Hospital during years 2010-2014. Exclusion criteria included revision surgery, and chromosomal abnormalities associated with bleeding disorders. Blood loss and blood transfusion volumes as a percent of estimated blood volume were compared in the presence of EACA while controlling for age, suture phenotype, use of bone grafting, and length of surgery. Secondary outcomes measures included volume of crystalloid infused, length of hospital stay, and any postoperative intubation requirement. RESULTS When analyzed based on length of surgery, EACA did reduce blood loss and blood transfusion (R2=0.19, P=.005 and R2=0.18, P=.010, respectively) with shorter surgeries. CONCLUSIONS AND RELEVANCE Using a standardized dosing regimen of EACA during craniosynostosis surgery, we found statistical significance in blood loss and transfusion requirements in surgeries of the shortest duration. We suspect this may be due to our selected dosing regimen, which may be lower than recently recommended. This study contributes to the growing body of evidence supporting EACA in CVR for craniosynostosis.

Moyamoya Disease in an 18-Month-Old Female Caucasian Complicated by Cerebral Hyperperfusion Syndrome Following Indirect Revascularization

Patient: Female, 18-month-old Final Diagnosis: Moyamoya disease Symptoms: Seizures Medication: — Clinical Procedure: — Specialty: Neurosurgery Objective: Rare co-existance of disease or pathology Background: Cerebral hyperperfusion syndrome is a rare complication of indirect revascularization due to moyamoya disease, but has not been reported previously in the pediatric population. We present a case of an 18-month-old girl with moyamoya disease that was treated with bilateral pial synangiosis and had complications consistent with cerebral hyperperfusion syndrome. This case report discusses the pathophysiological mechanisms involved in cerebral hyperperfusion in moyamoya syndrome. Case Report: An 18-month-old female Caucasian presented with seizures and weakness of the left side. Angiography confirmed bilateral cerebral moyamoya disease that was worse on the right side. Indirect revascularization with pial synangiosis was first performed on the right side to allow for healing. Five months later, pial synangiosis was then performed on the left side. Postoperatively, the patient experienced increased intracranial pressure (ICP), suggesting cerebral hyperperfusion syndrome. She was treated with a repeat lumbar puncture, a lumbar drain, and a lumbar shunt. Conclusions: This report demonstrates a case of cerebral hyperperfusion syndrome as a complication of moyamoya disease in a pediatric patient. Although the patient progressed well after placement of a lumbar shunt, this case demonstrates the occurrence of cerebral hyperperfusion syndrome as a complication of revascularization in pediatric patients and highlights the need for further research in this area.