M. Javad Mirzayan

The adjustable proGAV shunt: a prospective safety and reliability multicenter study.

OBJECTIVETo evaluate the reliability of the gravitation-assisted adjustable proGAV shunt system with a prospective multicenter study conducted in 10 German hospitals. METHODSEnrollment for this observational study began in April 2005 and concluded in February 2006. The protocol required re-examinations 3 and 6 months postoperatively and fixed the endpoint of follow-up at 12 months after implantation. Patients with different types of adult, juvenile, and pediatric hydrocephalus were included and 165 patients were enrolled; 9 died and 12 had incomplete follow-up. RESULTSOf the assessable 144 patients, 130 completed the protocol after 12 months, whereas 14 failed because of the need to explant the device, mainly because of infection. In 12 patients, components of the shunt, not the valve, were revised. In 65 of the 144 patients, there were 102 readjustments of the valve in 67 incidences because of underdrainage and in 35 because of overdrainage. In 1 case, readjustment was not possible. Determination of pressure level with the verification instrument was safe and corresponded to the required x-ray controls after adjustments. No unintended readjustments were noted. CONCLUSIONThe proGAV is a safe and reliable device.

Coma due to meteorism and increased intra-abdominal pressure subsequent to ventriculoperitoneal shunt dysfunction.

In October, 2005, a 76-year-old woman was admitted to the emergency room with subacute loss of consciousness. She had a history of hydrocephalus and had undergone ventriculo-peritoneal shunt surgery at the age of 53 years. On admission she presented with stupor and appropriate responses on painful stimuli. Her abdomen was distended. She had a 1-week history of severe constipation and recent onset of oliguria. CT scan of the head showed a distinct hydrocephalic ventricular system; this was more prominent than seen on her last available CT scans from 1998 (fi gure A). Radiography of the abdomen showed severe meteorism with huge bowel dilatation (fi gure B). We ruled out mechanical dysfunction of the shunt system. After releasing 50 ml of cerebrospinal fl uid (CSF) from the shunt reservoir, our patient gradually became more alert. Diagnostic work-up, including CT scan of the abdomen, revealed diverticulitis of the colon as the cause of the meteorism. She was treated conservatively, including the use of simeticone and amidotrizoic acid for meteorism and constipation, and her state of consciousness normalised over the next 2 days. There was no need for shunt revision and her consciousness was completely normal within 3 days. During follow-up over 11 months until September, 2006, there was no other episode of shunt malfunction and she remained generally well. A diff erence in pressure between the intracranial space and the peritoneal cavity is necessary for ventriculoperitoneal shunts to allow CSF fl ow between these two compartments. This pressure gradient leads to drainage of the CSF from the ventricular system to the peritoneal cavity. The fl ow rate is controlled by the shunt valve. Changes in this pressure gradient have been reported in pregnant women. Shunt malfunction with symptoms of increased intracranial pressure during pregnancy, especially in the third trimester, is a well known condition. Spontaneous improvement usually occurs usually postpartum. When the increased intra-abdominal pressure overcomes the pressure diff erences required for adequate CSF fl ow, symptoms of hydrocephalus become apparent, and coma can occur. Similarly, as in pregnancy, constipation and meteorism may aff ect distal fl ow by obstruction of the catheter outlets by distended bowel. Because increased intra-abdominal pressure is a well known cause of renal dysfunction, the transient oliguria experienced by our patient during the period of extensive meteorism is not surprising. During treatment of a gastroenterological disease in patients with a ventriculoperitoneal shunt, special attention should be given to the intra-abdominal pressure and level of consciousness. Although shunt dysfunction due to raised intra-abdominal pressure is well recognised in pregnancy and in paediatric neurosurgery, it should be considered in cases of elderly hydrocephalic patients with dysfunctional CSF shunts. With the increase in life expectancy we are seeing, such occurrences may be more likely in the future. Management of such patients requires team-work across the specialities, including emergency medicine, gastroenterology, and neurosurgery.

Cavernous hemangioma of the cavernous sinus, skin, and retina: hemodynamic changes after treatment: case report.

OBJECTIVEThere are several reports concerning cavernous hemangiomas of the skin and central nervous system. Additional retinal involvement has also been reported. CLINICAL PRESENTATIONThe authors report a 69-year-old woman with a giant extra-axial cavernous hemangioma of the right cavernous sinus involving the supra- and parasellar region, retina, and skin. INTERVENTIONShrinkage of its cutaneous part lead to subsequent increase of the volume of the intracranial part. Owing to compression of the optic and the oculomotor nerves, oculomotor disturbances, ptosis, and visual impairment to 0.2 occurred. Via a pterional approach microsurgical removal of the tumor except for a remnant of the intracavernous part was performed. CONCLUSIONHemodynamic connection between cutaneous, retinal, and intracranial hemangiomas should be considered.

Fatal outcome despite bilateral decompressive craniectomy for refractory intracranial pressure increase in butane intoxication

Butane gas can be accessed easily in household appliances like iquid petroleum gas, camping stoves, aerosol deodorant and glade ir freshener. Thus far, its abuse is not legally prosecuted. It is bused mainly by teenagers and adolescents in gas fuel form to each an euphoric state [1]. The most recent epidemiologic data rovided by Marsolek et al. analyzing the National Poison Data ystem of the United States for a 15 year-period from 1993 to 008 detected 738 cases of butane abuse with a fatal outcome in 8.1% [2]. While extensive knowledge about its cardiopulmonary mpact is available, little is known about the pathophysiology of NS damage [1]. Here, we report on a patient who underwent bilateral decomressive craniectomy for treatment of increased intracranial ressure (ICP) which developed after butane intoxication. Despite aximal intensive care treatment and adequate decompression he uccumbed 3 days later due to cardiogenic shock.

MRI safety of a programmable shunt assistant at 3 and 7 Tesla

Abstract Objective. Several new shunt technologies have been developed to optimize hydrocephalus treatment within the past few years. Overdrainage, however, still remains an unresolved problem. One new technology which may reduce the frequency of this complication is the use of a programmable shunt assistant (proSA). Inactive in a horizontal position, it impedes CSF flow in a vertical position according to a prescribed pressure level ranging from 0 to 40 cm H2O. Methods. We exposed the proSA valve in an ex vivo protocol to MR systems operating at 3 and 7 Tesla to investigate its MRI safety. Results. Following 3 Tesla exposure, no changes in valve settings were noted. Adjustment to any pressure level was possible thereafter. The mean deflection angle was 23 ± 3°. After exposure to 7 Tesla, however, there were unintended pressure changes, and the mechanism for further adjustment of the valves even disintegrated. Conclusion. According to the results of this study, proSA is safe with heteropolar vertical magnet alignment at 3 Tesla. Following 7 Tesla exposure, the valves lost their functional capability.

The diagnostic value of erythrocyte sedimentation rate in management of brain tumors

Abstract Objective: Erythrocyte sedimentation rate (ESR) is considered as an indicator of inflammatory processes, and it has a prognostic value in the management of specific neoplastic diseases. It also responds to surgical intervention. There is very little data about the alteration of ESR in patients with brain tumors and information on its course after intracranial tumor surgery is completely lacking. Methods: ESR was measured for 10 days in 46 patients (19 women and 27 men; mean age: 49.7 years; range: 13–70 years) who underwent elective craniotomy for tumor microsurgery (70–425 minutes with a mean of 230 minutes) under general anaesthesia. Blood samples were taken on the day before surgery and on each consecutive day after surgery for 10 days. The standard method of measuring ESR was based on the technique first described by Westergren. Results: The mean ESR level on the day before surgery was 8.26 ± 7.27 mm/h after 1 hour and 14.80 ± 10.36 mm/h after 2 hours. After tumor surgery, ESR increased stepwise. The mean peak value of 22.89 ± 13.41 mm/h after the first hour was reached on the third post-operative day. Whereas mean values varied over time, ESR remained increased and did not decline to normal values until the tenth post-operative day. The mean ESR peak value was higher in patients having undergone surgery for intra-axial lesions (31.36 ± 30.43 mm/h on the post-operative day 6) as compared to patients with extra-axial lesions (21.31 ± 12.20 mm/h on the post-operative day 3). Conclusion: ESR is not relevantly increased in patients harboring brain tumors. Because it remains elevated until the tenth post-operative day after uneventful craniotomy and generally responds more slowly than other indicators like C-reactive protein, it is also not suitable for the detection of post-operative infective complications.

Erratum to: Subacute steroid-induced paraparesis: surgical treatment of a devastating “invisible” side effect

The online version of the original article can be found under doi:10.1007/s00586-012-2185-3.

Subacute steroid-induced paraparesis: surgical treatment of a devastating “invisible” side effect

PurposeTo emphasize an underestimated side effect following long-term use of steroids.MethodsWe report on surgical treatment of two patients with serious neurologic deficits caused by epidural spinal lipoma following long-term intake of cortisone.ResultsEarly decompression of the spinal cord by removal of epidural lipoma was the most effective treatment in these patients with progressive symptoms.ConclusionDiagnostic work-up of such patients should include early spinal MRI resulting in surgical intervention, if indicated. Decompression of the spinal cord eventually combined with fusion is necessary.