William O. Bell

Surgical repair of aneurysms of the posterior inferior cerebellar artery—A clinical series☆

Aneurysms of the posterior inferior cerebellar artery are relatively rare. Fourteen such aneurysms (10 vertebral, 4 peripheral) are reported, and their clinical presentation, surgical therapy, and outcome are discussed. All 14 patients had suffered a subarachnoid hemorrhage; 93% (n = 13) underwent direct clipping of the aneurysm while 7% (n = 1) underwent coating of the aneurysm. Two patients died in the perioperative period (one from vasospasm and one from rebleeding). Full activity was achieved by all but one (92%) of the remaining patients in extended follow-up.

One-stage Meningomyelocele Closure and Ventriculoperitoneal Shunt Placement

Thirteen myelodysplastic neonates were observed to have birth head circumferences below the 90th percentile but ventriculomegaly on preoperative computed tomograms. These infants all required later shunting for hydrocephalus. We then began performing a one-stage procedure of meningomyelocele closure and shunt insertion in all neonates with ventriculomegaly on preoperative computed tomograms without regard to head circumference. Seventeen of 24 additional patients have had the one-stage procedure; 4 have required later shunting; 1 shunt infection (6%) was encountered. We conclude that neonatal head circumference does not predict hydrocephalus, and that ventriculomegaly on preoperative computed tomograms identifies neonates who will require shunting.

Prenatal Diagnosis and Pediatric Neurosurgery

Advances in realtime ultrasound imaging and a greater availability of high-quality ultrasound equipment have resulted in an increased number of congenital abnormalities being diagnosed prenatally in the last 10-15 years. In addition, testing for maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, and serum unconjugated estriol has allowed for more sensitive screening for congenital abnormalities. In response to this, in 1989 the Prenatal Diagnosis and Treatment Center was established at our institution to coordinate the care of fetuses and newborns with congenital malformations and to provide alternatives for the parents should the fetus not be carried to term. From January 1990 through June 1993, our group diagnosed 50 singleton pregnancies with various types of central nervous system disorders by the methods outlined above. Thirty-seven fetuses were diagnosed with neural tube defects. Of these, 5 were anencephalic and 1 had an encephalocele. The remaining 31 fetuses had meningomyeloceles with associated hydrocephalus. Of these 31, 18 fetuses were terminated prior to the age of viability as a result of our counseling and 13 fetuses were brought to term. Of the remaining 13 fetuses, 8 had hydrocephalus and 5 had various other diagnoses. Three of the eight hydrocephalic fetuses were either terminated, stillborn, or died following birth. Of the other 5 fetuses with hydrocephalus, 3 had shunts placed, 1 was followed with normal head growth, and 1 had normal ventricular size at birth. Using the methods available, the accuracy of diagnosis is very high, with only 1 fetus in this series being incorrectly diagnosed. Additionally the advantages of being able to counsel the parents regarding their unborn child allows them to make informed decisions. Accurate prenatal diagnosis plays a major role in the care of the fetus and in counseling parents prenatally for pediatric neurosurgical problems.

Granuloma annulare: A rare occipital lesion in infants and children

Subcutaneous granuloma annulare is a rare scalp lesion that occurs in infants and children. Occurrence in the occipital region, absence of bone involvement, slow growth, and foci of necrosis of collagen surrounded by palisading granulomatous inflammation are characteristic of this lesion. Although the cause remains unknown, it is not infectious and is more likely due to a defect in cell-mediated immunity. The prognosis after excision is excellent. Increased awareness that this peculiar granulomatous lesion can rarely occur in the soft tissue of the occipital region will help prevent confusion with neoplastic or infectious processes.

Removal of Adherent Ventricular Catheters

William O. Bell, MD, Section on Neurosurgery, The Bowman Gray School of Medicine, Wake Forest University, 300 S Hawthorne Road, Winston-Salem, NC 27103 (USA) Dear Sir, I read with interest the recent article by Chambi and Hendrick [1]. Since 1985, I have been using a similar technique to remove adherent ventricular catheters after reading a similar report by Chehrazi and Duncan [2]. I have had no complications with its use in over 50 patients. I believe this technique represents a useful adjunct in the avoidance of intraventricular bleeding during removal of catheters adhering to the choroid plexus. References Chambi I, Hendrick EB: A technique for removal of an adherent ventricular catheter. Pediatr Neurosci 1989;14:216–217. Chehrazi B, Duncan CC: Removal of retained ventricular shunt catheter without craniotomy. Technical note. J Neurosurg 1982; 56:106–161.