Monica S. Tandon

Endoscopic observations of blocked ventriculoperitoneal (VP) shunt: a step toward better understanding of shunt obstruction and its removal

Abstract Objectives. Most of our understanding of ventriculoperitoneal (VP) shunt blockage (ventricular end) is based on in vitro studies of blocked VP shunts. Not much information is available regarding the in vivo changes that occur in the tube and in the surrounding ventricle. The primary aim of our study was to observe and analyse these changes, directly, through the endoscope, in patients with blocked shunts undergoing an endoscopic third ventriculostomy (ETV). Based on these findings, we have also suggested criteria for safe removal of the VP shunt tube following ETV. Material and methods. ETV was performed with standard technique in patients with blocked VP shunt. The ventricular end of the shunt tube was inspected through the endoscope, for changes in ventricle linings as well as in the shunt tube. These changes were correlated with the age of the patient, etiology of HC, type or make of the shunt tube, duration of shunt placement to ETV and the CSF findings. Results. Fifty-three patients of blocked VP shunt underwent ETV from July 2006 to April 2010. Thirty patients had Chhabra (CH) V P Shunt (Surgiwear, India) and 23 had ceredrain (CD) shunt (Hindustan Latex, India). The age of the patients ranged from 2 months to 60 years (mean – 13.33 years.). Various causes of hydrocephalus (HC) included congenital hydrocephalus (aqueductal stenosis) in 18 patients, post-meningitis hydrocephalus (PMH) in 32 cases, neuro-cysticercosis (NCC) in 2 patients and intraventricular haemorrhagic (IVH) in 1 patient. Clinical and radiological improvement occurred in 33 (62.21%), and 24 (45%) patients, respectively. Freedom from shunt was attained in 20 (38%) patients. The changes around the shunt tube were seen in 41 (77%). Hyperaemia and neovascularised ependyma was seen in 20 (37%) and 15 (28%) patients. Encasement of the tube was seen in 41%. Ependymal growth and neovascularised shunt tubes were noticed in 15% each. Choroid plexus blocking the tube was seen in only four cases (7%). VP shunt was revised in 14 patients (26.4%). Patient with infective etiology had more changes (p < 0.005). Age, CSF findings and make of shunt tube had no relation with endoscopic observations (p< 0.02). Conclusions. ETV has a role in shunt failures. It can offer patient a chance of shunt free life. Endoscopic observation of shunt tube and ventricle can unfold several interesting in vivo findings pertaining to shunt obstruction. Shunt should only be removed if there are no adhesions and neovascularisation.

Ostomy closure and the role of repeat endoscopic third ventriculostomy (re-ETV) in failed ETV procedures

BACKGROUND Endoscopic third ventriculostomy (ETV) has replaced shunt surgery for several indications. Failure of ETV secondary to restenosis can result in recurrence of symptoms of raised intracranial pressure. OBJECTIVE To analyze the rates of restenosis due to ostomy closure and factors resulting in failures and to assess the role of re-ETV in such cases. MATERIALS AND METHODS Re-ETV was performed after counselling and obtaining informed consent. The technique of re-ETV was essentially the same as in primary ETV. Video analysis of primary ETV was performed before selecting a patient for re-ETV. Factors analyzed included age, gender, etiology of hydrocephalus, cerebrospinal fluid (CSF) findings, presence of shunt tube and adequacy of ETV and bleeding at the time of ETV. RESULTS Thirty-two patients underwent re-ETV. The mean interval between the first ETV and re-ETV was 1.4 years (3 days to 2.9 years). Overall failure of ETV due to restenosis was 8.78%. The technical success rate of performing re-ETV was 93.2%. The overall clinical recovery following surgery was observed in 89% of the patients, three from early and 25 from delayed ETV failures. The radiological recovery was seen in 20 (63%) patients. The good flow of CSF via the re-ETV site was documented with cine mode magnetic resonance imaging (MRI) in seven patients. Unlike primary ETV, the success of re-ETV in children aged less than 2 years was 90% (P < 0.005). There were 56.25% failure of ETV in patients with previous infection or foreign body within the ventricle (P < 0.001). While the chances of restenosis were high in the procedure with some infections, the outcome was equally better. Gender of the patients and CSF findings had no influence on ostomy closure. CONCLUSIONS re-ETV can be considered in carefully selected patients of failed ETV. It is more useful in delayed ETV failures and can be offered before a patient is advised VP shunt.

Guide wire loss during central venous cannulation

Indian Journal of Anaesthesia | Vol. 54| Issue 6 | Nov-Dec 2010 It is well known that contamination of the anaesthesia work area with potential bacterial pathogens and blood occurs intraoperatively[1] following general anaesthesia. It has been demonstrated that bacterial contamination occurs early (within as little as 4 min) and is unrelated to factors of case duration, urgency, or patient American Society of Anaesthesiologists physical status. Contamination with saliva represents a potential risk, since saliva is the main vehicle of infection for nonparenteral transmission of hepatitis-B.[2] Bacterial transfer to patients is associated with the variable aseptic practice of anaesthesia personnel. Placing the laryngoscope blade in a container (e.g. a kidney tray) following intubation with subsequent contamination of the anaesthesia work area is unwanted but not an uncommon feature in the operation theatre.

Surgery for brain abscess in children with cyanotic heart disease: An anesthetic challenge

Context: Patients with cyanotic congenital heart disease (cCHD) are prone to develop frequent brain abscesses. Surgery for these abscesses is often limited to aspiration under local anesthesia because excision under general anesthesia (GA) is considered a riskier option. Perioperative hemodynamic instability, cyanotic spells, coagulation defects, electrolyte and acid base imbalance, and sudden cardiac arrest are among the major anesthetic concerns. Most of our current knowledge in this area has been gained from a neurosurgical standpoint while there is a paucity of corresponding anesthesia literature. Aims: To highlight the anesthesia issues involved in cCHD children undergoing brain abscess excision under GA. Settings and Design: Retrospective study of our institutional experience over a 5 year period. Materials and Methods: Of all the children with cCHD who underwent brain abscess surgery from January 2005 to December 2009, only 4 were operated under GA. Surgery was done after correcting fever, dehydration, electrolyte imbalance, coagulopathy and acid-base abnormalities, and taking appropriate intraoperative steps to maintain hemodynamic stability and prevent cyanotic spells and arrhythmias. Results: All 4 patients had a successful abscess excision though with varying degrees of intraoperative problems. There was one death, on postoperative day 34, due to septicemia. Conclusions: Brain abscess excision under GA in children of cCHD can be safely carried out with proper planning and attention to detail.

Complete heart block complicating intracranial aneurysm surgery in a pregnant patient.

A primigravida at 28 weeks of gestation was diagnosed with a left internal carotid artery aneurysm with subarachnoid hemorrhage, World Federation of Neurosurgical Societies (WFNS) Grade-2, necessitating urgent aneurysm clipping. Relevant preoperative checkup included no apparent history of syncopal episodes, a BP of 90/60 mm of Hg, a heart rate of 41 beats/min, a CHB on ECG and no evidence of underlying cardiac disease on echocardiography. The patient was paced with a temporary transvenous pacemaker at a rate of 80 beats/ min; her post-pacing BP was 118/72 mm of Hg. During surgery, the patient’s BP fell abruptly to 82/56 mm of Hg which was normalized by resetting the pacemaker rate at 90 beats/min. Repeated pacemaker adjustments became necessary in the postoperative period to maintain stable post-clipping systolic BP in the range of 140-160 mmHg; a permanent pacemaker was then inserted in her.

Perioperative challenges in patients with giant occipital encephalocele with microcephaly and micrognathia.

Meninigo-encepahlocoele (MEC) is a common neurosurgical operation. The size of MEC may vary which has bearing with its management. The association of MEC with micrognathia and microcephaly is rarely reported. The association poses special problem for intubation and maintenance of anaesthesia. Giant MEC may lead to significant CSF loss resulting in hemodynamic alteration. The prior knowledge and care in handling the patient can avoid minor as well as major complications.

Delayed brain abscess after embolization of arterio-venous malformation: Report of two cases and review of literature

Infections of central nervous system are rare complications of endovascular procedures. Review of literature revealed only four reported cases of brain abscesses after embolization of intracranial arteriovenous malformations (AVMs). We report two new cases of delayed brain abscess after embolization of AVM. In one of the patients, it was due to an unusual organism, Burkholderia caeci.

Suboccipital double barrel twin meningocoele: Another new theory?

Meningomyelocoele (MMC) forms one of the commonest forms of neural tube defect (NTD). It commonly affects lumbosacral area. Double or triple MMC has been reported at various sites of the spine. This supports multiple site closure of neural tube. We report a case of double MMC located at back of head, adjacent to each other like twin MMC. To our best knowledge, such defect has never been reported in the literature and raises query of our current understanding of embryogenesis of NTDs.

Perioperative complications in endovascular neurosurgery: Anesthesiologist's perspective

Background: Endovascular neurosurgery is known to be associated with potentially serious perioperative complications that can impact the course and outcome of anesthesia. We present here our institutional experience in the anesthetic management of various endovascular neurosurgical procedures and their related complications over a 10-year period. Methods: Data was obtained in 240 patients pertaining to their preoperative status, details of anesthesia and surgery, perioperative course and surgery-related complications. Information regarding hemodynamic alterations, temperature variability, fluid-electrolyte imbalance, coagulation abnormalities and alterations in the anesthesia course was specifically noted. Results: Among the important complications observed were aneurysm rupture (2.5%), vasospasm (6.67%), thromboembolism (4.16%), contrast reactions, hemodynamic alterations, electrolyte abnormalities, hypothermia, delayed emergence from anesthesia, groin hematomas and early postoperative mortality (5.14%). Conclusion: Awareness of the unique challenges of endovascular neurosurgery and prompt and appropriate management of the associated complications by an experienced neuroanesthesiologist is vital to the outcome of these procedures.

Armoured brain of unknown etiology

Armoured brain is a rare condition where dense calcification occurs over the brain. It can result in mass effect and raised intracranial pressure. Most often, it happens due to trauma, subdural effusion, infection, or after VP shunt. There is controversy in its treatment. Most published literature does not support removing the calcification. We describe a rare case of idiopathic chronic calcified subdural hematoma with relatively short history which was successfully treated by microsurgical removal of calcification over the brain. This resulted in complete expansion of the brain with relief in symptoms.