Sarah J. Gaskill

Pseudocysts of the Abdomen Associated with Ventriculoperitoneal Shunts: A Report of Twelve Cases and a Review of the Literature

Shunt complications are reported to occur at a rate of approximately 26%. One of the less frequent but important complications is that of the pseudocyst. Since Harshs first mention of a periumbilical cyst associated with a shunt in 1954, 44 cases have been reported in the literature. These are reviewed in addition to 12 cases of our own. From the collected series several features about the etiology and management become apparent. The most common presentation is that of abdominal distension and/or pain rather than shunt malfunction. Diagnosis is then readily made with ultrasonography. Etiologically, it is evident that an inflammatory process is a frequent predisposing factor. In our series 16% had acute infection, 41.6% had a past history of CSF infection (6 months to 6.2 years), and 16% had CNS tumor although tumor cells were not isolated from the peritoneal cysts. Our management of the cyst itself was different from that reported in other series; it was found that the cyst reabsorbed spontaneously without excision or aspiration once the CSF was diverted. The peritoneal cavity could then be used for shunting once the cyst had reabsorbed. This sometimes required conversion to an atrial or pleural shunt before reutilization of the peritoneal cavity. There were no problems with cyst recurrence despite the conversion of 58% of the shunts to ventriculoperitoneal shunts with follow-up ranging from 3 months to 4 years. The mode of management of both the cyst and the hydrocephalus is reviewed.

Glioblastoma multiforme masquerading as a pleomorphic xanthoastrocytoma

Since its first description by Kepes in 1979, pleomorphic xanthoastrocytoma (PXA) has been considered a tumor with a benign course. Two cases are presented here that support the concept that PXA may be more accurately considered part of a spectrum of astrocytomas that occasionally may act aggressively. These cases represent astrocytomas with PXA components and are characterized by meningeal proximity, a high number of mitoses, and subsequently aggressive clinical behavior. The importance of recognizing the potential of a “benign” PXA to transform into a malignant entity has obvious implications for the therapeutic management of these tumors.

The subcutaneous ventricular reservoir: an effective treatment for posthemorrhagic hydrocephalus

Use of the subcutaneous ventricular reservoir in the treatment of posthemorrhagic hydrocephalus was studied in a series of 38 patients. All of the patients were considered to be medically labile. Additionally, all had failed conservative modes of therapy consisting of lumbar punctures with or without furosemide or acetazolamide. Management of the hydrocephalus consisted of reservoir placement. Subsequently, taps were performed at various intervals and amounts, depending upon the degree of ventricular dilatation as determined by sonography and signs of increased intracranial pressure. The majority of reservoirs were left in place for 1–2 months. There were no reservoir infections. Once the patients were medically stable, the reservoir was removed and a shunt placed. Eight patients died before shunt placement and 2 patients died after shunting, reflecting a 29% mortality. In no case was a death related to the shunt, but rather reflected the medical lability of the patient population. Four patients (15% of surviving patients) did not require shunting. The total shunt infection rate was 6.9% (among survivors with a shunt in place, 7.7%). These results support the use of the reservoir as an easy and effective means of protecting the cortical mantle while decreasing morbidity related to future shunt placement.

The Currarino Triad: Its Importance in Pediatric Neurosurgery

Currarinos triad is a hereditary condition diagnosed when three abnormalities are noted: (1) an anorectal malformation; (2) an anterior sacral defect, and (3) a presacral mass. This condition often presents with symptoms related to the presacral mass or with an incidental finding of a sacral anomaly on plain radiographs. Presented here are 2 cases of Currarinos triad noted in siblings, both of whom underwent surgery for anorectal malformations in infancy. The importance of early diagnosis and treatment of this condition and the need for genetic counseling are emphasized.

Spontaneous Bacterial Peritonitis in Patients with Ventriculoperitoneal Shunts

Spontaneous bacterial peritonitis (SBP) is an infection of the peritoneal fluid in the absence of an obvious intra-abdominal source. It is most commonly diagnosed in patients with cirrhotic ascites, although it has been described in other syndromes as well. The organisms most frequently cultured from the peritoneum are those of intestinal flora; however, there are cases which have all the features of SBP, but remain culture negative. This article discusses 7 cases of SBP in patients with ventriculoperitoneal shunts; a combination which has previously not been described. The most significant features of these cases include: a remote history of shunt revision (mean 3.4 years), and cultures consistent with normal intestinal flora. None had a history of recent abdominal surgery, gastrostomy or wire-impregnated catheters. Cerebrospinal fluid cultures are often negative, and when positive, suggest SBP with an ascending shunt infection. While SBP is clearly differentiated from pseudocyst of the abdomen, it may represent a point on the continuum of intra-abdominal processes in the shunted patient. The precise etiology of SBP is unclear. A number of suggested theories are reviewed. It is proposed that patients with shunts may be predisposed to develop SBP because spinal fluid can behave as an ascitic fluid even in the absence of a peritoneal accumulation. Recommendations for the recognition and management of SBP in the shunted patient are discussed in detail.

Transient Eye Closure after Posterior Fossa Tumor Surgery in Children

Transient cerebellar eye closure following posterior fossa tumor surgery in children has recently been observed. This phenomenon is characterized by a transient inability to open the eyes postoperatively with complete resolution within 4-6 days. Presented are four cases of transient cerebellar eye closure after posterior fossa tumor surgery in children. Possible mechanisms are reviewed with regard to historical works of cerebellar stimulation in man, and anatomical structures and pathways which might be involved.

Laparoscopic surgery in a patient with a ventriculoperitoneal shunt : A new technique

With advances in the treatment of hydrocephalus, patients with ventriculoperitoneal shunts (VPS) often have normal life expectancies. They are therfore more commonly requiring abdominal surgery. Laparoscopic surgery has become the favored technique for performing many of these operations. However, the presence of a VPS has been considered a contraindication or hazard in performing many of these laparoscopic operations. We present a case report of a laparoscopic Toupet fundoplication in a patient with a VPS and describe a technique for the successful management of the VPS throughout the procedure with no adverse sequelae.

Diastematomyelia associated with ectopic renal tissue.

A case of diastematomyelia associated with ectopic renal tissue is presented. While findings of ectopic renal tissue and Wilms tumor in dysraphic conditions have been reported in the literature, there has been no incorporation of these findings into the theories of the development of neural tube defects. This case supports the hypothesis of neural tube defects secondary to rupture of a previously intact neural tube (secondary neural tube defect). A discussion and review of the literature regarding the hypotheses of primary and secondary neural tube defects is included.

Custom Fitted Thermoplastic Minerva Jackets in the Treatment of Cervical Spine Instability in Preschool Age Children

The options for cervical spine stabilization have traditionally been the Minerva jacket (MJ) or the halo brace. In the preschool age child both of these devices have significant drawbacks; the halo brace because of its erosion and difficulty providing adequate fixation due to the thin calvarium of the young child and the MJ because of its bulk and weight. With the advent of polyethylene plastics, MJs are a more viable option without the disadvantages noted above. Six cases of cervical spine instability in preschool age children treated with a custom-molded MJ are presented. All patients achieved cervical spine stability with minimal morbidity. This technique is recommended as an alternative to the halo brace, as it provides reliable and satisfactory treatment of these difficult problems in preschool children.

Continuous External Drainage in the Treatment of Subdural Hematomas of Infancy

A series of 16 patients with chronic or subacute subdural hematomas treated with continuous external drainage of the subdural space is reviewed. Of these only 44% went on to require subdural-peritoneal shunt placement. There were no complications in treatment and no clinical or laboratory evidence of infection in any case. The outcome, measured by neurological examination, was not different between the shunted and nonshunted groups. In conclusion, continuous external drainage of the subdural space in chronic and subacute hematomas of infancy frequently is an effective, definitive treatment. This approach should be considered as the initial procedure prior to subdural-peritoneal shunting.