Management of hydrocephalus by endoscopic third ventriculostomy in patients with myelomeningocele

Endoscopic third ventriculostomy (ETV) was performed between July 1978 and July 1995 on 69 patients with hydrocephalus and myelomeningocele. Most of the patients had been previously shunted, although in 14 patients ETV was the initial treatment. Patient selection was based on preoperative imaging studies suggesting noncommunicating hydrocephalus. Only 2 patients exhibited transient hypothalamic dysfunction with complete resolution. Patients were assessed by their clinical status, imaging characteristics, and, in some cases, formal psychometric studies. The overall success rate was 72%, although selecting only patients who have been previously shunted or who were over 6 months of age at the time of endoscopy increases this to 80%. Our results indicate that ETV is a safe and effective means of treating hydrocephalus in the older spina bifida population and offers the hope of long-term, shunt-independent life for selected patients.

The pseudotumor syndrome. Disorders of cerebrospinal fluid circulation causing intracranial hypertension without ventriculomegaly

We report a series of eight cases that show a close resemblance to, but are not identical with, pseudotumor cerebri (PTC) as normally defined. The majority of these cases are characterized by raised intracranial pressure without ventriculomegaly. They include two cases of cranial venous outflow obstruction in which clinical or radiologic abnormalities precluded the diagnosis of PTC proper (cases 1 and 2); one case of chronic meningitis in which an abnormal cerebrospinal fluid (CSF) composition precluded the diagnosis of PTC (case 3); two cases without either papilledema or a measured increase of CSF pressure, which in other respects, particularly in response to treatment, resembled PTC (cases 4 and 5); and three cases of what is thought to represent an infantile form of PTC (cases 6 through 8). The purpose of the analysis of these cases is twofold. First, it is argued that these cases throw light on the mechanism of PTC itself, supporting a concept of a disturbance of CSF circulation in this condition, and that they are themselves illuminated by considerations of typical PTC. Second, the cases are used to frame a proposed classification of the pseudotumor syndrome aimed at broadening the diagnostic criteria applied currently to PTC. It is suggested that the pseudotumor syndrome has a single underlying mechanism (disturbed CSF circulation) and that recognition of this mechanism not only clarifies the pathophysiologic processes of PTC but also has important diagnostic and therapeutic implications.

Complications of endoscopic neurosurgery

Neuroendoscopy is rapidly becoming an essential part of the neurosurgeon's repertoire. Currently, very few studies have identified the complications of this new technique, yet many have warned of the steep learning curve associated with its practice. We have reviewed the last 173 neuroendoscopic procedures performed by one surgeon and identified two distinct groups of complications: those that have clinically significant sequelae and those that cause concern intraoperatively but no overt clinical problems. The 173 procedures were performed on 152 patients. Of these patients, 11 suffered significant complications (7%). Twenty-two of the procedures were complicated by intraoperative problems (13%). The incidence of insignificant complications appeared to decrease with experience, whereas that of the significant ones did not. These complications occurred in association with a wide variety of operations over a 2-year period. We conclude that neuroendoscopy is a relatively safe technique with an overall 7% complication rate and a steep learning curve, and that, with a few simple guidelines, it can be employed by all neurosurgeons for the betterment of their patients.

Status dystonicus and Hallervorden-Spatz disease: treatment with intrathecal baclofen and pallidotomy

Severe dystonia or status dystonicus is a life threatening disorder that develops in patients with both primary and secondary dystonia. We present the case of a 9-year-old boy with Hallervorden-Spatz disease (HVS) who developed status dystonicus, failing to respond to high dose oral therapy with multiple antidystonic agents. High dose intravenous sedating agents combined with endotracheal intubation and mechanical ventilation were required to control the spasms. Alleviation of the spasms was achieved by a combination of temporary intrathecal baclofen infusions and bilateral pallidotomy. Although it could be argued this is a situation where only palliative measures should be used, we believe a relatively aggressive approach was justified. It relieved the intense pain associated with the spasms and allowed the child to be discharged home without the prolonged stay in intensive care, morbidity and mortality, which characterize status dystonicus.

Decreased habituation of midlatency auditory evoked responses in Parkinson's disease

The P1 midlatency auditory evoked potential was studied in patients with Parkinson's disease and compared to that in age-matched controls. Habituation of the potential was determined by using a two-click stimulus paradigm in which the stimuli were presented at 250-, 500-, and 1,000-ms interstimulus intervals. Results showed that habituation of the P1 potential had a statistically significant decrease at the 250-ms and 500-ms interstimulus intervals in patients with Parkinson's disease compared to normal controls. The degree of decreased habituation was found to increase with severity of the disease such that stage 5 patients showed greater decreases in habituation compared to stage 4, as did stage 4 compared to stage 3. These findings may be explained by the presence of a dysregulation of sensory processing, possibly by elements of the reticular activating system, including the pedunculopontine nucleus, in Parkinson's disease.

Outcome analysis of 85 patients undergoing the pi procedure for correction of sagittal synostosis

The authors present a retrospective review of their experience with 85 cases using the pi procedure to correct sagittal synostosis. A male preponderance of four to one was recognized in this group. Sixty-five infants underwent computerized tomography scanning of the head prior to surgery; these scans revealed unexpected intracranial pathology in 5% of cases. Surgical complications included three intraoperative dural lacerations. All children received blood transfusions with no complications. Cosmetic outcomes were excellent in 53%, good in 43%, and poor in 4% of cases. One patient required reoperation. All poor outcomes were in infants who were younger than 8 weeks of age at the time of surgery and who underwent a "reverse pi" procedure. Most of the excellent outcomes occurred in infants who were between 3 and 6 months of age at the time of surgery. Although more extensive than strip craniectomy, the pi procedure can be accomplished with minimal morbidity. In the authors' opinion, the pi procedure provides better immediate and long-term cosmetic results than synostectomy alone.

Application of skull base techniques to pediatric neurosurgery

Techniques for skull base surgery have become well established over the last 10 years. Most of these techniques are used in adult patients for skull base tumors and neurovascular diseases. There are very few large series of pediatric patients in whom skull base approaches have been used, because of the rarity of these conditions. The authors would like to present a relatively large series of 26 pediatric patients who underwent skull base approaches for tumor resection. These tumors involved the anterior cranial base in 5 patients, the medial cranial skull base in 4 patients, and the posterior cranial base in 12 cases. Five patients had tumors that involved two or more fossae. The overall complication rate was 57%, which included temporary cranial nerve palsies, CSF leak and infection. Patients with permanent complications were 8 in number (37%). There was 1 postoperative death from pneumonia approximately 6 weeks after surgery. Complete tumor removal was achieved in 24 of the 26 patients. Skull base tumors in children are often extensive and present significant surgical challenges. Although complete tumor extirpation is the goal in most pediatric patients, this is often achieved only with some morbidity. This paper demonstrates the effectiveness of skull base approaches for these tumors and underscores the high stakes involved.

Bad design, bad practices, bad bugs: frustrations in controlling an outbreak of Elizabethkingia meningoseptica in intensive care units

BACKGROUND

Elizabethkingia meningoseptica is a nosocomial-adapted Gram-negative bacillus intrinsically resistant to antibiotics commonly used in the intensive care setting. An outbreak investigation commenced when five patients developed E. meningoseptica infection in two intensive care units (ICUs).

METHODS

Analysis of laboratory data, case reviews, ICU workflows and extensive environmental sampling were undertaken. Molecular typing was performed using repetitive element palindromic polymerase chain reaction. Follow-up studies after interventions included environmental monitoring and a survey of staff compliance with interventions.

FINDINGS

Laboratory data revealed increasing incidence of E. meningoseptica colonization or infection in ICU patients compared with preceding years. E. meningoseptica was cultured from 44% (35/79) of taps, but not from other sources. Hand hygiene sinks were used for disposal of patient secretions and rinsing re-usable patient care items. Sinks misused in this way were contaminated more often than sinks that were not misused (odds ratio 4.38, 95% confidence interval 1.68-11.39; P = 0.004). Molecular typing revealed that patient isolates had identical patterns to several isolates from hand hygiene taps. An urgent education programme was instituted to change these practices. Taps were cleaned systematically and aerators were changed. A temporary reduction in case numbers was achieved. Recolonization of taps was demonstrated on follow-up environmental screening, and cases recurred after two months. A survey revealed that 77.3% (163/213) of nursing staff still misused sinks due to time constraints or other problems adhering to the interventions.

CONCLUSION

Introduction of non-sanctioned practices due to suboptimal unit design may have unintentional consequences for ICU patients. Room design and staff workflows must be optimized for patient safety as lapses in procedure can inadvertently put patients at risk.

Telomeric associations in the progression of chromosome aberrations in pediatric solid tumors

Telomeric association (tas) is a cytogenetic phenomenon in which chromosome ends fuse to form dicentric, multicentric, and ring chromosomes. We observed clonal tas in six pediatric solid tumors of various types and histological grades studied using short-term in situ culture and G-banding techniques. These tumors included a neurilemoma, an undifferentiated (embryonal) sarcoma of the liver (UESL), two anaplastic astrocytomas (AA), one case of glioblastoma multiforme (GBM), and a neuroblastoma (NB) of the kidney. Cytogenetic data from all six tumors demonstrated multiple numerical and structural aberrations including tas. The tas appeared to be a secondary aberration in these tumors, however, it was possible to follow the progression of the telomeric chromosome aberrations in several cases. In all but one case (UESL) the loss of chromosome segments occurred. Tas of 11p was observed in three of the six tumors, two of which showed the subsequent loss of 11p (AA and AB). In addition, tas of 4p was seen in three tumors, two of which showed clonal tas of 4p with 22q. Tas of 10p, 21p, and 22q were all observed in at least two different tumors. The clonal telomeric fusions of 4p with 22q, recurring tas of 11p, and the subsequent loss of the short arm of 11 demonstrated here, suggests that some chromosome regions are subject to nonrandom instability and sometimes loss.

Disorders of CSF hydrodynamics

This article reviews the range of hydrodynamic disorders affecting the CSF circulation. Initially consideration is given to questions of definition and classification. A scheme for the practical, clinical analysis for the diagnosis of such disorders is then presented. The physiology and pathophysiology of the CSF circulation is reviewed, with particular emphasis on issues that remain unresolved. This provides a background to consideration of the adverse consequences of abnormal CSF hydrodynamics, again focusing on areas where further information is required. Methods of clinical investigation of CSF hydrodynamics are reviewed, followed by general considerations of treatment. Finally, each of the main, clinically important, forms of disordered CSF hydrodynamics is briefly considered, with particular emphasis, again, on areas where current knowledge is deficient. The conditions considered include hydrocephalus of various forms (childhood, adult, arrested, multi-compartment), infantile macrocephaly, arachnoid and glioependymal cysts, syringo- and hydromyelia, pseudotumour cerebri, impaired cranial venous outflow, altered CSF composition, shunt obstruction without ventricular enlargement and low-CSF-pressure states.

Ventriculosubgaleal shunt: a treatment option for progressive posthemorrhagic hydrocephalus

Among premature infants born at less than 1500 g, the incidence of intraventricular hemorrhage is greater than 45%. Of these, 40% will develop progressive posthemorrhagic hydrocephalus (PPHH). Optimum treatment remains controversial. Ventriculosubgaleal (VSG) shunts were first proposed as a means of temporarily diverting cerebrospinal fluid (CSF) in a more physiological manner for those infants less than 1500 g in weight who would not tolerate a ventriculoperitoneal (VP) shunt. The VSG shunt could then be converted into a VP shunt when the infant had gained the desired weight. Despite favourable reports, the procedure has not gained universal acceptance and is unknown to many neurosurgeons. The present authors report a series of 15 patients who had VSG shunts inserted with excellent temporary CSF diversion and no complications. Furthermore, 3 out of the 15 patients required no further treatment. We suggest that VSG shunting is a safe and effective means of treating the premature infant with PPHH.

Cystic schwannoma of the trochlear nerve mimicking a brain-stem tumor. Case report

A case is reported of a rare cystic schwannoma of the fourth cranial nerve which was interpreted as a probable intrinsic brain-stem lesion. The clinical approach to brain-stem tumors in terms of empirical treatment or surgical biopsy is discussed.

Adherence to clozapine vs. other antipsychotics in schizophrenia

BACKGROUND

To date, there have been no studies evaluating adherence to clozapine with electronic adherence monitoring (EAM) such as the Medication Event Monitoring System (MEMS^® ).

METHODS

In outpatients with schizophrenia, we conducted a 3-month prospective study investigating antipsychotic adherence with EAM (eCAP^® ). Participants were treated with different oral antipsychotics, including clozapine, and blind to EAM monitoring; all were on antipsychotic monotherapy administered once daily. Outcome measures included adherence rate, missed dose, and medication gap. Adherence trajectory patterns were also analyzed for clozapine vs. other antipsychotics collectively.

RESULTS

A total of 111 patients were included in the study; 33 and 78 patients received clozapine or other antipsychotics, respectively. Adherence rates, defined as proportion of days that the subject took the medication at the prescribed time ± 3 h and proportion of subjects with ≥80% adherence, were numerically higher in patients receiving clozapine vs. other antipsychotics (72.0% vs. 65.1%, P = 0.10; 49.5% vs. 35.7%, P = 0.11, respectively). Along similar lines, some of the missed dose and medication gap outcomes were significantly better in patients receiving clozapine vs. other antipsychotics. Three adherence trajectory patterns were identified for both clozapine and other antipsychotics, with two shared by both groups (i.e., low adherence with a slight decrease over time; high and stable adherence).

CONCLUSION

Findings suggest that in patients with schizophrenia clozapine adherence is at least comparable, if not slightly better, compared with other antipsychotics.

Prior fluoridation in childhood affects dental caries and tooth wear in a south east Queensland population

Fluoride exposure in early life has an effect on dental caries experience, but does it affect tooth wear in later life? Ninety-six South East Queensland subjects were studied. Their histories revealed three groups; a fluoride (F-) in water supply, a F- by supplement, and a non-fluoridated (non F-) group. Significantly higher caries experience was found in the non-F- group compared with F- in water group and the F- supplement group. No statistically significant difference in caries experience was found between the F- in water and F- supplement groups. Overall, tooth wear affected more sextants of the dentitions of non-fluoridated, high-caries subjects than of fluoridated low-caries subjects. Comparisons of wear patterns on sextants of the dentitions, between the fluoridated and non-fluoridated groups, revealed that in sextants where attrition was present no marked differences were discernible between the two groups. However, in most sextants where incisal, palatal, occlusal or non-occlusal erosion was found, this type of wear was commoner in non-fluoridated subjects. The exceptions were the mandibular molar sextants, where prior fluoride-exposure did not appear to protect against occlusal erosion patterns. This study showed that fluoride exposure during the first 12 years of life, which reduced dental caries in this population, may also protect teeth from wear to some extent.

Blindness, deafness, quadriparesis, and a retinal malformation: the ravages of neurofibromatosis 2

Advances in molecular biology have established that the diseases once collectively referred to as neurofibromatosis are actually genetically distinct and clinically heterogenous conditions. This realization has led to separate definitions for neurofibromatosis (NF) type 1 and 2. Although ophthalmologic manifestations of NF1 have long been recognized, the distinguishing ocular features of NF2 have only recently received attention. We describe an inferior retinopapillary malformation with an overlying glial hamartoma in a deaf, quadriparetic patient with NF2. Magnetic resonance (MR) imaging initially showed bilateral vestibular schwannomas and a large cervical ependymoma. Over six years of follow-up, the patient developed multiple intracranial meningiomas.

Blue dye is sufficient for sentinel lymph node biopsy in breast cancer

BACKGROUND

Most previous studies have reported superior results when blue dye and radiocolloids were used together for sentinel lymph node (SLN) biopsy in early breast cancer. Blue dye was reported to perform poorly when used alone, although more recent studies have found otherwise. This study reviewed the authors' practice of performing SLN biopsy with blue dye alone.

METHODS

This was a retrospective review of patients who underwent SLN biopsy using blue dye alone from 2001 to 2005, when SLN biopsy was performed selectively and always followed by axillary lymph node dissection (ALND), and from 2006 to 2010, when SLN biopsy was offered to all suitable patients and ALND done only when the SLN was not identified or positive for metastasis.

RESULTS

Between 2001 and 2005, 170 patients underwent SLN biopsy with blue dye alone. The overall SLN non-identification rate was 8·4 per cent. The overall false-negative rate was 34 per cent, but decreased with each subsequent year to 13 per cent in 2005. From 2006 to 2010, 610 patients underwent SLN biopsy with blue dye alone. The SLN was not identified in 12 patients (2·0 per cent) and no significant contributing factor was identified. A median of 2 (range 1-11) SLNs were identified. A non-SLN was found to be positive for metastasis in two patients with negative SLNs. Axillary nodal recurrence developed in one patient; none developed internal mammary nodal recurrence. Anaphylaxis occurred in one patient.

CONCLUSION

Blue dye performed well as a single modality for SLN biopsy. Non-identification, axillary nodal recurrence and serious allergic reactions were uncommon.

Intracranial pial arteriovenous fistula in infancy: a case report and literature review

Intracranial pial arteriovenous fistulas (AVF) are rare vascular malformation especially in the first 2 years of life. The pathology in this age group is associated with greater morbidity and mortality. We report a rare case of 36-day-old male infant with a pial AVF associated with an arterial aneurysm, who presented with intraventricular hemorrhage and hydrocephalus. In addition, an online review of the literatures on pediatric pial AVF was performed using PubMed on published case reports and articles from 1980 to April 2013.

Realistic loophole-free Bell test with atom-photon entanglement

The establishment of nonlocal correlations, guaranteed through the violation of a Bell inequality, is not only important from a fundamental point of view but constitutes the basis for device-independent quantum information technologies. Although several nonlocality tests have been conducted so far, all of them suffered from either locality or detection loopholes. Among the proposals for overcoming these problems are the use of atom-photon entanglement and hybrid photonic measurements (for example, photodetection and homodyning). Recent studies have suggested that the use of atom-photon entanglement can lead to Bell inequality violations with moderate transmission and detection efficiencies. Here we combine these ideas and propose an experimental setup realizing a simple atom-photon entangled state that can be used to obtain nonlocality when considering realistic experimental parameters including detection efficiencies and losses due to required propagation distances.

Multiple schwannomas of the sciatic nerve

Schwannomas are rare benign tumours of nerve sheath cells of neural crest origin. Often these tumours are solitary and encapsulated. Multiple schwannomas can arise from the peripheral nervous system including cranial nerves, spinal roots, the brachial and lumbar-sacral plexus or major peripheral nerves. We report an extremely rare case of schwannomatosis of the sciatic nerve in a young female and include a comprehensive literature review. Treatment options are discussed.

Endoscopic assisted posterior fossa decompression

Technical advances in neurosurgery follow a general philosophy favouring less invasive means of managing surgical disease. We describe a patient with a symptomatic type I Chiari malformation managed by posterior fossa decompression using endoscopic techniques. Technical considerations, including drawbacks of the procedure, are discussed.

Resolution of Trigeminal Neuralgia Following Third Ventriculostomy for Hydrocephalus Associated with Chiari I Malformation: Case Report

OBJECTIVE AND IMPORTANCE

Cranial nerve dysfunction, including trigeminal neuralgia, has been associated with Chiari I malformations. In such cases, trigeminal neuralgia is thought to be related to tonsillar compression of the brainstem or to traction on the cranial nerves. Hydrocephalus may be a contributing factor.

CLINICAL PRESENTATION

A 38-year-old woman had right-sided lancinating facial pain typical of trigeminal neuralgia but was otherwise neurologically intact. Magnetic resonance imaging showed no evidence of a compressing vessel. Moderate hydrocephalus and a Chiari I malformation were noted incidentally. The visibility of the aqueduct was poor.

INTERVENTION

The patient underwent a third ventriculostomy and her symptoms resolved completely.

CONCLUSION

This is the first case in which trigeminal neuralgia was treated with a third ventriculostomy and one of only four cases of isolated trigeminal neuralgia associated with a Chiari malformation. Acquired aqueductal stenosis may have caused the hydrocephalus which, in turn, caused the Chiari malformation configuration that caused the trigeminal neuralgia. The rationale for the treatment modality and possible causes of Chiari I-induced trigeminal neuralgia are discussed.

Management of cerebral abscess in adolescents and adults. Experience in the CT-scan era

Thirty-seven patients with non-traumatic intracerebral abscesses are presented. Two were not diagnosed during life. Where the possible cause could not ascertained, a metastatic origin was the commonest, followed by otogenic. A variety of causative organisms, including especially Streptococci, Staphylococci and Bacteroides were isolated. It is possible that the most effective treatment was primary excision of the abscess plus antibiotics, but the numbers were too small for a statistically significant difference to be shown. The reasons for recent improvements in outcome of brain abscesses, including more use of CT scanning and refinements in isolation of organisms and in antibiotic treatment, are discussed, along with possible steps towards more improvement in future.

The Chiari II malformation: a surgical series

Thirty patients between the ages of 7 months and 24 years were treated surgically for symptomatic Chiari II malformation at the Arkansas Children's Hospital. All patients underwent at least bony decompression of the malformation. Assessments of the patients' conditions were made at 6 weeks and 1 year after surgery, and complications of surgery were noted. For a majority of the patients, the presenting symptoms were resolved following treatment (74% at 6 weeks and 80% at 1 year). Partial resolution occurred in several of the patients (17% at 6 weeks and 14% at 1 year). A small number remained the same at 6 weeks (6%) and at 1 year (3%), while 1 patient was worse after surgery. Ten of the patients with complete resolution in the short term required repeat surgery an average of 49 months after their original operation, after which they again attained complete resolution of their symptoms. Scales for clinical, radiographic and operative grading of the patients' conditions as mild, moderate or severe were devised, and these were employed to characterize the condition of each patient. Patients in each grading category had good results, with rates of complete symptomatic resolution ranging from 67 to 100%. Severity in each category was found to be well correlated with eventual recurrence of symptoms and need for reoperation.