A new Subcutaneously Anchored Device for Securing External Cerebrospinal Fluid Catheters: Our Preliminary Experience

BACKGROUND: Accidental dislocation or removal is a well-known complication of external cerebrospinal fluid (CSF) drainage in daily clinical practice. At present, no data about the incidence of such complications are available in the scientific literature. SecurAcath (Interrad Medical, Plymouth, Minnesota, USA) is a subcutaneously anchored device recently adopted for securement of central venous catheters, known to be highly effective (and cost-effective) in reducing the risk of catheter dislodgement and/or accidental removal. METHODS: We report our preliminary experience with the use of SecurAcath to secure CSF drainage, either ventricular or spinal, to the skin. RESULTS: SecurAcath was used in 29 consecutive patients (age range: 3 weeks-16 years, median age 6.3 years). In particular, the device was used for 25 ventricular catheters (a patient received 2 catheters in the same procedure for bilateral brain abscess) and 5 spinal drainages. Period in place ranged from 1-4 weeks (median 22 days). No complication related to the use of the device was observed, in particular there was no case of dislocation or accidental removal of the catheter. The removal procedure was extremely easy. The device has proven its utility also in 3 cases requiring an adjustment of the length of the catheter. CONCLUSIONS: In our experience, SecurAcath is a safe and effective device to secure CSF external catheters to the skin, with several relevant advantages: its placement and maintenance are easy; it may stay in place for the entire duration of the catheter; it allows a more complete antisepsis of the exit site, thus reducing local skin complications; it eliminates the risk of suture-related needlestick injuries

Intracranial pressure wave morphological classification: automated analysis and clinical validation

BACKGROUND: Recently, different software has been developed to automatically analyze multiple intracranial pressure (ICP) parameters, but the suggested methods are frequently complex and have no clinical correlation. The objective of this study was to assess the clinical value of a new morphological classification of the cerebrospinal fluid pulse pressure waveform (CSFPPW), comparing it to the elastance index (EI) and CSF-outflow resistance (Rout), and to test the efficacy of an automatic ICP analysis. METHODS: An artificial neural network (ANN) was trained to classify 60 CSFPPWs in four different classes, according to their morphology, and its efficacy was compared to an expert examiner's classification. The morphology of CSFPPW, recorded in 60 patients at baseline, was compared to EI and Rout calculated at the end of an intraventricular infusion test to validate the utility of the proposed classification in patients' clinical evaluation. RESULTS: The overall concordance in CSFPPW classification between the expert examiner and the ANN was 88.3 %. An elevation of EI was statistically related to morphological class' progression. All patients showing pathological baseline CSFPPW (class IV) revealed an alteration of CSF hydrodynamics at the end of their infusion test. CONCLUSIONS: The proposed morphological classification estimates the global ICP wave and its ability to reflect or predict an alteration in CSF hydrodynamics. An ANN can be trained to efficiently recognize four different CSF wave morphologies. This classification seems helpful and accurate for diagnostic use

Cranial repair: how complicated is filling a "hole"?

In general, cranioplasty is viewed as a straightforward surgical procedure, and for many years the complications associated with the procedure have been underestimated. We reviewed our 5-year experience consisting of 218 cranioplasties. Study outcomes focused specifically on the occurrence of complications after cranioplasty. Autologous bone-assisted and prosthetic cranioplasties were considered. Variables described by other authors to be associated with complications were studied, including history of previous cranioplasty, wider craniectomy size, bifrontal craniectomy, and delayed cranioplasty. We also analyzed the influence of material used for craniectomy on the occurrence of complications. The overall complication rate was 19.7%. Nineteen cases of infection (8.7%), 5 cases of postoperative wound dehiscence (2.3%), 6 cases of epidural hemorrhage (2.8%), and 13 cases of cranioplasty dislocation (5.9%) were observed. Bifrontal cranioplasties were more frequently associated with complications (p=0.01; Fisher's exact test) and infection (p<0.0001; Fisher's exact test). Postoperative wound dehiscence was more frequently observed with hand-made or custom-made cranioplasties compared with autologous cranioplasties (p=0.02). Early cranioplasty (<3 months from craniectomy) was significantly associated with cranioplasty dislocation (p=0.03). Logistical regression analysis showed that the only factor independently associated with complication was the site of cranioplasty (p=0.01). In particular, patients with a bifrontal cranioplasty had a 2-fold increased risk of complication (CI 95 1.1-3.6, p=0.017) and a 2.5-fold increased risk of developing infection (CI 95 1.3-4.9, p=0.009) compared with hemispheric/bihemispheric cranioplasty. Our analysis confirms that cranioplasty is burdened by a significant complication rate. In this context, bifrontal cranioplasty is related to a higher risk of complication and, in particular, infection

Giant frontal mucocele complicated by subdural empyema: treatment of a rare association

Giant frontal mucocele (GFM) is an extremely rare cause of frontal lobe syndrome. Subdural empyema (SDE) is an uncommon complication of paranasal sinisutis, for which craniotomy and decompressive craniotomy are the most effective surgical procedures. A 54-year-old man was brought unconscious to the emergency room where recurrent generalized seizures occurred. Heroine abuse, HCV-related hepatitis, prolonged antibiotic therapy for treatment of purulent rhinorrhea, along with recent personality changes were reported. High white blood cell count, pansinusitis, GFM, SDE and cerebritis were documented. The patient underwent bifrontal craniotomy in emergency, extensive drilling of the inner aspect of the frontal bone, surgical toilet of the enlarged frontal sinus and its "cranialization". Prevotella intermedia and Fusobacterium nucleatum were isolated and antibiotic therapy was started intravenously and then continued orally for 3\ua0months. 2\ua0years later the patient has recovered, though minor signs of frontal lobe syndrome persist. To the authors knowledge, this is the first case of GFM with SDE reported in the literature. Although decompressive craniectomy is advocated in extreme conditions, as in this case, "internal decompressive craniectomy", obtained with craniotomy and cranialization of the frontal sinuses, is strongly advocated in cases of SDE associated with megasinuses

"Blinding" Empty Sella: Can Lumbar Puncture Be Avoided?

Primary empty sella syndrome is an anatomicoclinical condition characterized by radiological evidence of sellar arachnoidocele (unrelated to previous surgical or radiotherapeutic treatment of this region) and is associated with endocrine disturbances and signs of intracranial hypertension (headache, visual disturbances, and papilledema), especially in young women. We report on an unusual case of empty sella disguising the diagnosis of an ocular inflammatory disease

Internal decompressive craniectomy with craniotomy: a novel surgical therapy of giant frontal mucocele complicated by subdural empyema

Giant frontal mucocele (GFM) is an extremely rare cause of frontal lobe syndrome. Subdural empyema (SDE) is an uncommon complication of paranasal sinisutis, for which craniotomy and decompressive craniotomy are the most effective surgical procedures

Comparative evaluation of genome-wide gene expression profiles in ruptured and unruptured human intracranial aneurysms

Few studies have evaluated the over or the underexpression of genes directly in samples of aneurysmal wall and extracranial pericranial vascular tissue to investigate the genetic influence in formation and rupture of intracranial aneurysms. We present the results obtained using the DNA microarray technique analysis on sample tissues collected during surgery. We collected and analyzed 12 aneurismal and 9 peripheral arteries (superficial temporal (STA) and middle meningeal artery (MMA) specimens from ruptured aneurysm group patients (13 cases), 10 aneurismal and 12 STA and MMA samples from unruptured aneurysm group patients (14 cases) and 5 STA and MMA artery specimens from control group patients (4 cases). Total RNA was isolated from samples and subjected to cDNA microarray analysis with the use of the human genome U133A GeneChip oligonucleotide microarray (Affymetrix, Santa Clara, CA), which allows to analyze a total number of 14,500 genes in the same time. For genes of interest, real-time RT-PCR was performed to confirm their expression level. Total RNA was isolated from samples and subjected to DNA microarray analysis with the use of the human genome U133A GeneChip oligonucleotide microarray, which allows to analyze a total number of 14,500 genes at the same time. For genes of interest, real-time RT-PCR was performed to confirm their expression level. Regarding ruptured aneurysms, genes were identified showing differential expressions (overexpressed or downregulated) pertaining to specific pathways, particularly those for the structural proteins of the extracellular matrix, members of matrix metalloproteinase (MMP) family (which resulted as being overexpressed) and genes involved in apoptotic phenomena. Particularly, real-time RT-PCR analysis confirmed the upregulation of MMP-2, MMP-9 and pro-apoptotic genes, such as Fas, Bax and Bid, and the downregulation of anti-apoptotic genes, such as Bcl-X(L) and Bcl-2. In a compared analyses of ruptured vs unruptured aneurysms, a different expression was also detected regarding gene coding the tissue inhibitor of matrix metalloproteinases 3 (TIMP-3), which appeared markedly downregulated in unruptured aneurysms, where its expression in unruptured aneurysms was similar to that observed in controls. Another gene differently expressed is nitric oxide synthase (iNOS), which appeared overexpressed in ruptured aneurysms when compared to unruptured aneurysms. Our study is the first, to our knowledge, that compares gene expression profiles (genoma-wide) in intracranial aneurysms. The results of our study suggest that the inhibitor of the metalloproteinase, the pathway of nitric oxide and the apoptotic process play a key-role in reducing the resistance of the arterial wall, that can result in formation and rupture of the intracranial aneurysms

Subacute Sclerosing Panencephalitis in Children: The Archetype of Non-Vaccination

Subacute sclerosing panencephalitis (SSPE) is a late complication of measles virus infection that occurs in previously healthy children. This disease has no specific cure and is associated with a high degree of disability and mortality. In recent years, there has been an increase in its incidence in relation to a reduction in vaccination adherence, accentuated by the COVID-19 pandemic. In this article, we take stock of the current evidence on SSPE and report our personal clinical experience. We emphasise that, to date, the only effective protection strategy against this disease is vaccination against the measles virus