Michael S. Muhlbauer

Results and Complications of Intracranial Pressure Monitoring in 303 Children

303 consecutive children who had insertion of an intracranial pressure (ICP) monitor for various reasons were reviewed to determine clinical value and complications rate of ICP monitoring in this age group. 286 patients had a Camino fiberoptic monitor. Of the remaining cases, 9 had a ventricular catheter, 7 had an extradural Gaeltec monitor, and 1 had a subdural feeding tube. The reasons for monitoring the ICP were: trauma in 132 children, postoperative monitoring after tumor surgery in 91, head injury due to child abuse in 30, severe medical conditions such as meningitis, encephalitis, and near-drowning in 30, intracranial hemorrhage in 15, and hydrocephalus in 5 children. The median age at insertion was 6 years (range from 1 month to 17 years), and the median Glasgow coma score before insertion was 7. Median duration of monitoring was 3 days, and 35 children (10%) had surgical procedures performed for raised ICP detected by monitoring. 238 (78%) had nonsurgical measures to control raised ICP. 6 (15%) of 40 children with an initial ICP > 50 mm Hg made a good recovery, but there were no survivors among 37 children who had an ICP consistently > 60 mm Hg and only 1 disabled survivor among 42 children with an ICP consistently > 50 mm Hg. The outcome in all 303 children correlated with averaged readings of ICP over 24 h and initial Glasgow coma score, but did not correlate with initial ICP measurements. Complications of monitoring were few and consisted of infection in 1 (0.3%) child, intracranial hemorrhage in 1 (0.3%) who had low platelet counts, displacement of monitor in 3 (1%), and malfunction of monitor in 8 (2.6%) children. We conclude that ICP monitoring in the pediatric age group substantially influences our clinical management of unconscious children and is safe.

Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury.

BACKGROUND The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and chi2 tests where appropriate. RESULTS One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

Mycobacterium tuberculosis meningitis: a report of twelve cases and a literature review.

Twelve recent cases of Mycobacterium tuberculosis meningitis were presented, and the literature was reviewed. There are no particularly new or unique therapies or approaches to the management of this most serious disease. The major obstacle to successful diagnosis and treatment of tuberculous meningitis continues to be a lack of clinical suspicion of its presence. As illustrated in the cases presented, it has been our experience that patients already moribund or nonresponsive do not respond, regardless of the intervention undertaken. The most sensitive and economical method of detecting M. tuberculosis in the CSF may be LPA. However, this has not yet been widely validated or accepted. Larger volumes of CSF should be sent to the laboratory for testing and centifuged to about 5x concentrations before both acid-fast bacilli staining and culture are attempted. If tuberculous meningitis is suspected, three-drug therapy can be started immediately without jeopardizing subsequent culture confirmation of the presence of the TB bacillus. In addition, these patients must be followed closely to detect hydrocephalus at the earliest possible moment. When patients fail to respond to appropriate antituberculosis and pressure-reducing therapy, hydrocephalus should be actively sought by either CT or radioisotope cisternography. Although the decision to proceed to ventricular drainage or shunting must be individually made in adult patients with infection-related hydrocephalus, we agree with others that surgical intervention should be considered early and should be performed if the level of consciousness deteriorates, intracranial pressure increases, or ventricular enlargement or enhancing basal exudates are identified on CT.

Gliomas of the Tectum and Periaqueductal Region of the Mesencephalon

Gliomas that arise in the tectal and periaqueductal region of the mesencephalon usually present with hydrocephalus secondary to occlusion of the aqueduct of Sylvius. A review of 486 brain tumors in children treated during a 5-year period revealed 6 children with gliomas of the tectal plate. The 6 children were shunted for hydrocephalus, presumed secondary to aqueductal stenosis, prior to establishing the diagnosis of tectal plate glioma. No abnormalities were noted on the initial, uncontrasted computed tomography (CT) scans. The tumors are isodense without contrast enhancement which makes the CT diagnosis difficult. Magnetic resonance imaging (MRI) is diagnostic and demonstrates the characteristic enlargement of the tectum with increased density on T2 images. T1 density and gadolinium enhancement are variable. Pathological confirmation was obtained by open biopsy in 2 patients, a stereotaxic biopsy was performed on 2 children; 2 children were not biopsied. The tumor histology obtained was that of pilocytic astrocytoma. Two patients were treated with radiation therapy at the time of diagnosis. One child was followed closely and subsequently irradiated after tumor progression. All patients in this series are alive and functioning adequately 2-10 years after the onset of symptoms.

Optimal Outcomes for Patients with Blunt Cerebrovascular Injury (BCVI): Tailoring Treatment to the Lesion

BACKGROUND Blunt cerebrovascular injuries (BCVI) once went unrecognized until cerebral ischemia or death occurred. We previously demonstrated that screening of high-risk asymptomatic patients and early treatment improved outcomes. However, major dissections, pseudoaneurysms, and fistulas rarely heal with antithrombotic therapy alone. Endovascular therapy in these lesions has increased without reports of outcomes. We sought to determine ischemic stroke and death rates after BCVI with and without endovascular treatment. STUDY DESIGN Patients with BCVI during a 53-month period ending May 2009 were identified. Antithrombotic therapy with heparin (goal partial thromboplastin time 40-60 s) or antiplatelets (aspirin and/or clopidogrel) was instituted after diagnosis of BCVI. Endovascular treatment was performed in patients with pseudoaneurysms, major dissections, and fistulas, whereas minor dissections and occluded vessels were treated with medical therapy alone. Outcomes evaluated were ischemic stroke and mortality, both in hospital and long term. RESULTS A total of 222 patients had 263 BCVI (115 carotid, 148 vertebral injuries); 22 patients had ischemic strokes before their angiographic diagnosis (17 present on arrival, 5 before angiography); 41% of patients underwent endovascular treatment for their BCVI, 50% were placed on heparin drips, and 76% and 52% were given aspirin and clopidogrel, respectively. Seven patients developed infarcts after BCVI diagnosis for a postdiagnosis rate of 4%. Follow-up was achieved in 85% of patients at a mean of 22 months. In-hospital mortality was 11%, and overall mortality rate was 16% at last follow-up. CONCLUSIONS Endovascular therapy of appropriate lesions in conjunction with medical therapy leads to the lowest ischemic stroke rates reported. Despite being used for more severe lesions with higher potential for ischemia, endovascular therapy had outcomes similar to medical therapy. Aggressive screening and treatment of BCVI leads to the lowest reported mortality and stroke rates.

Clinical Presentation and Management of 100 Infants with Occipital Plagiocephaly

One hundred consecutive infants who presented with occipital plagiocephaly over 15 years were analyzed retrospectively to determine results of both surgical and nonsurgical management. Eighteen infants who showed obvious progression of their deformity or radiological signs of fusion of the lambdoid suture had surgical resection of one or both lambdoid sutures and the remaining 82 infants were treated nonsurgically with physical therapy and advice on sleeping position. Of the 18 surgical cases 9 were found at operation to have true lambdoid synostosis, 7 had marked internal ridging of the lambdoid suture and 2 had an open suture. After a mean follow-up period of 6 months all parents of the 82 children treated nonsurgically were satisfied with their childs cosmetic appearance: 63% showed improvement in their plagiocephaly and 27% stabilized. There were no surgical complications in the 18 operative cases, all of whom had a good cosmetic result. From these results we conclude that the majority of infants referred to neurosurgeons with occipital plagiocephaly can be successfully managed nonsurgically. A small proportion of cases (18% with radiological signs of fusion or pronounced ridging of the suture) appeared to benefit from surgery. The clinical, radiological and pathological differentiating features of the surgical and nonsurgical cases are discussed.

Childhood survival of atlantooccipital dislocation: underdiagnosis, recognition, treatment, and review of the literature

Traumatic childhood atlantooccipital dislocation (AOD) may be overlooked, especially in patients with concomitant closed head injury and multiple trauma. We diagnosed and treated 4 children with traumatic AOD seen in less than a 2-year period. We found published descriptions of only 15 other survivors of childhood traumatic AOD in the literature. Clinical histories, radiographic findings, treatment, outcome, and complications in these 15 children as well as our 4 patients were reviewed. The age distribution of childhood AOD survivors (average age 6.8 years) closely resembles that of pediatric multiple trauma patients. Early diagnosis of traumatic AOD hinges on precise interpretation of the lateral cervical radiograph. Longitudinal AOD was seen most often. Usually these children presented with cranial nerve palsies, major motor deficits, and depressed level of consciousness. Most underwent posterior atlantooccipital fusion. Outcome varied from normal neurological function to prolonged ventilator dependency and delayed demise. AOD must be diagnosed early to avoid attributing potentially reversible neurologic changes to irreversible injuries since closed head injury and high spinal cord dysfunction may be confused clinically and the outcome of a patient with AOD is unpredictable.

The relationship between serum sodium and intracranial pressure when using hypertonic saline to target mild hypernatremia in patients with head trauma

IntroductionLimited data suggest mild hypernatremia may be related to lower intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The practice at the study center has been to use hypertonic saline (HTS) to generate a targeted serum sodium of 145 to 155 mEq/l in patients with TBI. The purpose of this study was to determine the relationship between serum sodium values and ICP, and to evaluate the acute effect of HTS on ICP.MethodsA retrospective review of patients who were admitted to the trauma ICU for TBI, had an ICP monitor placed, and received at least one dose of HTS between January 2006 and March 2011 was performed. Data were collected for up to 120 hours after ICP monitor placement. The primary outcome was the relationship between serum sodium and maximum ICP. Secondary outcomes were the relationship between serum sodium and the mean number of daily interventions for ICP control, and the acute effect of HTS on ICP during the 6 hours after each dose. Linear regression was used to analyze the primary outcome. Analysis of variance on ranks and repeated measures analysis of variance were used to evaluate the number of interventions and the acute effect of HTS on ICP, respectively.ResultsEighty-one patients were enrolled with mean ± standard deviation age of 36 ± 15 years and median Glasgow Coma Scale score of 7 (interquartile range, 4 to 7). A total of 1,230 serum sodium values (range, 118 to174 mEq/l) and 7,483 ICP values (range, 0 to 159 mmHg) were collected. There was no correlation between serum sodium and maximum ICP (R2 = 0.0052). The overall mean ± standard deviation number of interventions for elevated ICP per day was 4.2 ± 2.9, 2.9 ± 2.0, and 2.6 ± 2.3 for patients with a mean serum sodium of < 145, 145 to 155, and > 155 mEq/l, respectively (P < 0.001). Regarding the acute effect of HTS on ICP, there was no statistical difference in mean ICP compared with baseline during hours 1 through 6 following HTS doses (baseline, 13.7 ± 8.4 mmHg; hour 1, 13.6 ± 8.3 mmHg; hour 2, 13.5 ± 8.8 mmHg; hour 3, 13.3 ± 8.7 mmHg; hour 4, 13.4 ± 8.7 mmHg; hour 5, 13.4 ± 8.3 mmHg; hour 6, 13.5 ± 8.3 mmHg; P = 0.84).ConclusionsSerum sodium concentrations did not correlate with ICP values. These results warrant further evaluation and possible reassessment of sodium goals for ICP management in patients with TBI.

Malignant nerve sheath tumor of the facial nerve: case report and discussion

The third reported case of a malignant nerve sheath tumor of the facial nerve is presented. The clinical course and pathological findings are described and serve as the basis for a discussion concerning malignant nerve sheath tumors arising in the cranial nerves.

Occipitocervical fusion using a contoured rod and wire construct in children: a reappraisal of a vintage technique

OBJECT Many methods to stabilize and fuse the craniocervical junction have been described. One of the early designs was a contoured (Luque) rod fixated with wires, the so-called Hartshill-Ransford loop. In this study, the authors report their 20-year experience with this surgical technique in children. METHODS The authors reviewed the medical records of patients 18 years of age or younger who underwent dorsal occipitocervical fusion procedures between March 1992 and March 2012 at Le Bonheur Childrens Hospital using a contoured rod and wire construct. Data on basic patient characteristics, causes of instability, neurological function at presentation and at last follow-up, details of surgery, complications, and radiographic outcome were collected. RESULTS Twenty patients (11 male) were identified, with a mean age of 5.5 years (range 1-18 years) and a median follow-up of 43.5 months. Fourteen patients had atlantooccipital dislocation, 2 patients had atlantoaxial fracture-dissociations, 2 had Down syndrome with occipitocervical and atlantoaxial instability, 1 had an epithelioid sarcoma from the clivus to C-2, and 1 had an anomalous atlas with resultant occipitocervical instability. Surgical stabilization extended from the occiput to C-1 in 3 patients, C-2 in 6, C-3 in 8, and to C-4 in 3. Bone morphogenetic protein was used in 2 patients. Two patients were placed in a halo orthosis; the rest were kept in a hard collar for 6-8 weeks. All patients were neurologically stable after surgery. One patient with a dural tear experienced wound dehiscence with CSF leakage and required reoperation. Eighteen patients went on to achieve fusion within 6 months of surgery; 1 patient was initially lost to follow-up, but recent imaging demonstrated a solid fusion. There were no early hardware or bone failures requiring hardware removal, but radiographs obtained 8 years after surgery showed that 1 patient had an asymptomatic fractured rod. There were no instances of symptomatic junctional degeneration, and no patient was found to have increasing lordosis over the fused segments. Five (31%) of the 16 trauma patients required a shunt for hydrocephalus. CONCLUSIONS Despite the proliferation of screw-fixation techniques for craniocervical instability in children, the contoured rod-wire construct remains an effective, less expensive, and technically easier alternative that has been in use for almost 30 years. It confers immediate stability, and therefore most patients will not need to be placed in a halo device postoperatively. A secondary observation in our series was the high (30%) rate of hydrocephalus requiring a shunt in patients with traumatic instability.