Matthew A. Adamo

Emergency decompressive craniectomy for fulminating infectious encephalitis.

In patients who develop fulminant cerebral edema and elevated intracranial pressures, viral encephalitis can result in devastating neurological and cognitive sequelae despite antiviral therapy. The benefits of decompressive craniectomy, if any, in this group of patients are unclear. In this manuscript, the authors report their experience with 2 patients who presented with herpes simplex virus requiring surgical decompression resulting in excellent neurocognitive outcomes. They also review the literature on decompressive craniectomy in patients with fulminating infectious encephalitis. Four published articles consisting of 13 patients were identified in which the authors had reported their experience with decompressive craniectomy for fulminant infectious encephalitis. Herpes simplex virus was confirmed in 6 cases, Mycoplasma pneumoniae in 2, and an unidentified viral infection in 5 others. All patients developed clinical signs of brainstem dysfunction and underwent surgical decompression resulting in good (Glasgow Outcome Scale [GOS] Score 4) or excellent (GOS Score 5) functional recoveries. The authors conclude that infectious encephalitis is a neurosurgical disease in cases in which there is clinical and imaging evidence of brainstem compression. Surgical decompression results in excellent recovery of functional independence in both children and adults despite early clinical signs of brainstem dysfunction.

Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic brain injuries.

OBJECT Infants with severe traumatic brain injury represent a therapeutic challenge. The internal absence of open space within the infant cranial vault makes volume increases poorly tolerated. This report presents 7 cases of decompressive craniectomy in infants with cerebral edema. METHODS The authors reviewed the medical charts of infants with brain injuries who presented to Albany Medical Center Hospital between January 2004 and July 2007. Variables that were examined included patient age, physical examination results at admission, positive imaging findings, surgery performed, complications, requirement of permanent CSF diversion, and physical examination results at discharge and outpatient follow-up using the Kings Outcome Scale for Childhood Head Injury. Seven infants met the inclusion criteria for the study. Six infants experienced nonaccidental trauma, and 1 had a large infarction of the middle cerebral artery territory secondary to a carotid dissection. At admission, all patients were minimally responsive, 4 had equal and minimally reactive pupils, 3 had anisocoria with the enlarged pupil on the same side as the brain lesion, and all had right-sided hemiparesis. Six patients received a left hemicraniectomy, whereas 1 received a left frontal craniectomy. In all cases, bone was cultured and stored at the bone bank. RESULTS Postoperatively, 3 patients who developed draining CSF fistulas needed insertions of external ventricular drains, with incisions oversewn using nylon sutures and a liquid bonding agent. After prolonged CSF drainage and wound care, these patients all developed epidural and subdural empyemas necessitating surgical drainage and debridement. Methicillin-resistant Staphylococcus aureus was found in 2 patients and Enterococcus in the third. All patients developed hydrocephalus necessitating the insertion of a ventriculoperitoneal shunt, and all had bone replaced within 1-6 months from the time of the original operation. Two patients required reoperation due to bone resorption. At outpatient follow-up visits, all had scores of 3 or 4 on the Kings Outcome Scale for Childhood Head Injury. Each patient was awake, interactive, and could sit, as well as either crawl or walk with assistance. All had persistent, improving right-sided hemiparesis and spasticity. CONCLUSIONS Despite poor initial examination results, infants with severe traumatic brain injury can safely undergo decompressive craniectomy with reasonable neurological recovery. Postoperative complications must be anticipated and treated appropriately. Due to the high rate of CSF fistulas encountered in this study, it appears reasonable to recommend both the suturing in of a dural augmentation graft and the placement of either a subdural drain or a ventriculostomy catheter to relieve pressure on the healing surgical incision. Also, one might want to consider using a T-shaped incision as opposed to the traditional reverse question mark-shaped incision because wound healing may be compromised due to the potential interruption of the circulation to the posterior and inferior limb with this latter incision.

A single-center experience with symptomatic postoperative calvarial growth restriction after extended strip craniectomy for sagittal craniosynostosis

OBJECT Sagittal synostosis accounts for the most common form of craniosynostosis, occurring with an incidence of 1 in 2000-5000 live births. In most cases of single-suture, nonsyndromic sagittal synostosis, a single operation is all that is required to achieve a reasonable cosmetic result. However, there are a number of patients who may experience symptomatic postoperative calvarial growth restriction secondary to fibrosis of newly formed bone and pericranium that replace the surgically removed sagittal suture, or due to fusion of other previously open sutures leading to increased intracranial pressure, necessitating a second operation. METHODS A retrospective review was conducted of all cases involving infants who had undergone an extended sagittal strip craniectomy with bilateral parietal wedge osteotomies at our institution between 1990 and 2006 for single-suture, nonsyndromic sagittal craniosynostosis. The frequency with which subsequent operations were required for cranial growth restriction was then defined. RESULTS There were a total of 164 patients with single-suture nonsyndromic sagittal synostosis. Follow-up data were available for 143 of these patients. The average age at time of initial operation was 5.25 months, and the mean duration of follow-up was 43.85 months. There were 2 patients (1.5%) who required a second operation for symptomatic postoperative calvarial growth restriction. CONCLUSIONS Recurrence of synostosis with resultant increased intracranial pressure in cases of single-suture, nonsyndromic sagittal craniosynostosis is an uncommon event, but does occur sporadically and unpredictably. Therefore, we recommend routine neurosurgical follow up for at least 5 years, with regular ophthalmological examinations to assess for papilledema.

Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas

OBJECT The subdural evacuating port system (SEPS; Medtronic, Inc.) is a minimally invasive means of draining subacute or chronic subdural fluid collections. The purpose of this study was to examine a single institutions results with the SEPS. METHODS A retrospective chart review was undertaken for all patients who underwent SEPS drainage of subdural collections. Demographic and radiographic characteristics were evaluated. Both pre- and post-SEPS CT studies were analyzed to determine the volume of subdural collection and midline shift. Hospital charts were reviewed for SEPS output, and periprocedural complications were noted. RESULTS were classified as a success (S) or failure (F) based on the need for further subdural drainage procedures. Groups were then compared to identify factors predictive of success. Results Eighty-five subdural collections were treated in 74 patients (unilateral collections in 63 patients and bilateral in 11). Sixty-three collections (74%) were successfully drained. In a comparison of the success and failure groups, there were no statistically significant differences (p < 0.05) in the mean age pre-SEPS, Glasgow Coma Scale score, presenting symptoms, underlying coagulopathy or use of anticoagulation/antiplatelet agents, laterality of SDH, pre-SEPS subdural volume or midline shift, or any of the measurements used to characterize SEPS placement. There were a greater number of male patients in the success group (45 [82%] of 55 patients vs 11 [58%] of 19 patients; p = 0.04). The only statistically significant (p < 0.05) factor predictive of success was the radiographic appearance of the subdural collection. More hypodense collections were successfully treated (32 [51%] of 63 collections vs 4 [18%] of 22 collections; p = 0.005), whereas mixed density collections were more likely to fail SEPS treatment (S: 11 [17%] of 63 collections vs F: 14 [64%] of 22 collections; p < 0.00001). In the success group, the percentage of the collection drained after SEPS was greater (S: 47.1 ± 32.8% vs F: 19.8 ± 28.2%; p = 0.001) and a larger output was drained (S: 190.7 ± 221.5 ml vs F: 60.2 ± 63.3 ml; p = 0.001). In the patients with available but delayed scans (≥ 30 days since SEPS placement), the residual subdural collection following successful SEPS evacuation was nearly identical to that remaining after open surgical evacuation in the failure group. In 2 cases (2.4% of total devices used), SEPS placement caused a new acute subdural component, necessitating emergency evacuation in 1 patient. CONCLUSIONS The SEPS is a safe and effective treatment option for draining subacute and chronic SDHs. The system can be used quickly with local anesthesia only, making it ideal in elderly or sick patients who might not tolerate the physiological stress of a craniotomy under general anesthesia. Computed tomography is useful in predicting which subdural collections are most amenable to SEPS drainage. Specifically, hypodense subdural collections drain more effectively through an SEPS than do mixed density collections. Although significant bleeding after SEPS insertion was uncommon, 1 patient in the series required urgent surgical hematoma evacuation due to iatrogenic injury.

Onyx embolization of a thoracolumbar perimedullary spinal arteriovenous fistula in an infant presenting with subarachnoid and intraventricular hemorrhage

Identifying a source of spontaneous subarachnoid hemorrhage (SAH) or intraventricular hemorrhage (IVH) in patients with negative results on cranial angiographic imaging can be a diagnostic challenge. The authors present the case of a 14-month-old girl who presented with lethargy and spontaneous SAH and IVH, and later became acutely paraplegic. Except for the SAH and IVH, findings on neuroimages of the brain were normal. Magnetic resonance imaging revealed an intramedullary thoracolumbar spinal cord hemorrhage that was found to be associated with arterialized veins intraoperatively. Catheter-based diagnostic angiography identified a spinal perimedullary macroarteriovenous fistula (macro-AVF) that was completely embolized with Onyx, negating the need for further surgical intervention. The authors believe this to be the first reported case of a thoracolumbar perimedullary macro-AVF presenting with SAH and IVH. In addition, descriptions of Onyx embolization of a spinal AVF in the literature are rare, especially in pediatric patients.

Fractures of the clivus and traumatic diastasis of the central skull base in the pediatric population

OBJECT Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence. METHODS A Boolean search of the electronic medical record database at the Childrens Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes. RESULTS Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1-16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%. CONCLUSIONS Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.

Chronic granulomatous herpes encephalitis: a rare entity posing a diagnostic challenge

Herpesviruses can cause an acute, subacute, or chronic disease state in both immunocompetent and immunocompromised individuals. Herpes simplex virus (HSV) encephalitis is most often an acute monophasic disease process. Rarely, however, it may progress to a chronic state, and more rarely still to a granulomatous encephalitis. Prior studies have suggested that antiviral immunity with Toll-like receptors determines susceptibility to herpesviruses. The authors report the case of a 14-year-old girl with a remote history of treated HSV encephalitis, who had intractable seizures and worsening MR imaging changes that were concerning for either a neoplastic or an inflammatory process. She was found to have granulomatous herpes simplex encephalitis and had a low cytokine response to Toll-like receptor 3 stimulation.

Recanalization of a symptomatic extracranial internal carotid artery near occlusion with proximal and distal protection: technical case report.

OBJECTIVE To describe a novel approach to recanalizing symptomatic extracranial internal carotid artery near occlusion using proximal and distal emboli protection devices. METHODS Patients presenting with symptomatic extracranial internal carotid artery near occlusion who underwent endovascular recanalization between October 2004 and July 2005 were included in this study. During these procedures, a 9-French Concentric Balloon Guide Catheter (Concentric Medical, Mountain View, CA) was advanced into the common carotid artery proximal to the site of occlusion. During the prestent angioplasty of the lesion, the proximal balloon was inflated and aspiration was performed. After initial angioplasty and before stent placement, a distal filter protection device was placed in the distal internal carotid artery. Stent placement and repeat angioplasty were performed with both protection devices active. All patients were placed on dual antiplatelet therapy. RESULTS There were four patients treated with a mean age of 74 years; three of these four patients were men. All patients had signs of ischemia and carotid occlusion or near occlusion on noninvasive imaging. Three right internal carotid arteries were treated. All patients were successfully recanalized. No procedurally related complications or deaths occurred. CONCLUSION This series demonstrates the feasibility of recanalization of symptomatic carotid artery occlusion or near occlusion using proximal and distal emboli protection devices. Such an approach may provide an added level of safety during carotid recanalization procedures.

Surgical treatment of sagittal synostosis by extended strip craniectomy: cranial index, nasofrontal angle, reoperation rate, and a review of the literature.

BACKGROUND Sagittal synostosis is the most common non-syndromic single suture craniosynostosis. Different techniques of surgical correction, including extended strip craniectomy (ESC), have been used to treat this condition. The aim of this study is to evaluate radiologic changes and rate of symptomatic restenosis after ESC in a large group of patients less than 12 months of age with non-syndromic sagittal synostosis. METHODS A retrospective study of patients from 1990 to 2012 was performed comparing cranial index (CI) and nasofrontal angle (NFA) before and after surgical correction by ESC. Also, the frequency of subsequent reoperations for symptomatic restricted head growth was determined. RESULTS A total of 238 patients underwent ESC. Follow-up information was available for 182 patients. The average age at the time of the operation was 4.5 months and the mean duration of follow-up was 49.6 months. The average post procedure radiologic follow-up (22 patients) was 40.7 months. CONCLUSIONS The mean CI increased from 0.68 to 0.75 (p < 0.001) after ESC. Also, mean NFA increased from 127 to 133° (p < 0.001). Five patients (2.7%) required a second operation due to symptomatic cranial growth restriction. Reoperation occurred at an average of 26.5 months after the initial procedure. The most common symptom reported was headache. ESC is effective in treating non-syndromic sagittal synostosis. It significantly improved NFA without the need for direct frontal bone resection or frontal orbital osteotomy and significantly increased CI without adjunctive helmet treatment. Patients should be followed for at least 5 years after surgical correction as symptomatic restenosis, although rare, can occur.

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome treated successfully with transsphenoidal resection of a growth hormone-secreting pituitary adenoma

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone-secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.