Abdominal binders

Journal ArticleSklar and colleagues2 describe their experience managing "over-shunting headaches" with an abdominal binder. Seventy children with over-shunting headaches complied with application of a binder for about 1 month. In 61 patients (87%), the headaches "greatly improved or went away." This headache relief persisted even after use of the binder was discontinued. Among the 61 patients with relief, 36 (59%) eventually had recurrent headaches, but the recurrence was delayed (mean 1.5 years). Twenty-nine of these tried the binder again and among the 19 with follow-up, the binder was again effective in 15. These are interesting results. Children with chronic headaches and small ventricles can be very difficult to treat, often undergo repeated surgical interventions, and may have a poor quality of life. Anything that might help them is welcome, especially a simple noninvasive intervention

It's randomized and double blinded... what more do we want?

Journal ArticleThis issue of Journal of Neurosurgery: Pediatrics presents a randomized trial in which investigators have evaluated antimicrobial suture (AMS) in the prevention of shunt infection. The authors randomized 84 shunt procedures in 61 patients over 21 months. The surgeons and patients were blinded to treatment group. The groups appeared to be balanced with respect to shunt infection risk factors. Infection within 6 months of surgery occurred in 2 (4.3%) of 46 AMS procedures and in 8 (21%) of 38 control procedures. This study is a good first step. The authors should be applauded for conducting a double-blinded randomized trial, but the results need to be considered preliminary, and as they stand are not sufficient for a change in practice. As the authors state, they need further evaluation in a larger randomized trial

Ventriculoperitoneal shunts in children: indications, equipment and techniques

Journal ArticleThe decision to implant a ventriculoperitoneal shunt in a child with ventriculomegaly should not be taken lightly. Once a shunt has been implanted, it is very difficult to determine that it is no longer necessary, and therefore the initial decision is very important. Sometimes the need is obvious, such as a baby who presents with irritability, vomiting, a full fontanelle, splayed sutures, and increasing head circumference. Similarly, older children with headaches, vomiting, and papilledema clearly require intervention. At the other end of the spectrum are children with moderately enlarged ventricles, normal development, and no progression in head size or ventricle size on imaging. Although the ventricles may be bigger than average in these children, a shunt should not be implanted unless their symptoms progress

Tracking resident work hours: available software is not yet ideal, but it's helpful

Journal ArticleAn ideal system would be completely passive and would allow more detailed tracking of activity inside the hospital. A new reality began July 1. We are all now responsible for tracking our residents' work hours and ensuring compliance with the new regulations mandated by the Accreditation Council for Graduate Medical Education (ACGME). In order to do this in the Department of Neurosurgery at the University of Utah, a number of options involving commercial time-tracking software were considered

Comparison between magnetic resonance imaging and computed tomography for stereotactic coordinate determination

Journal ArticleThe spatial accuracy of magnetic resonance imaging (MRI) has not been established for stereotactic surgery. Magnetic susceptibility artifacts may lead to anatomical distortion and inaccurate stereotactic MRI coordinates, especially when targets are in regions of the brain out of the center of the magnetic field. MRI-guided stereotactic localization, however, provides better multiplanar target resolution than is available with computed tomographic (CT) scanning. Therefore, we compared the accuracy of stereotactic coordinates determined by MRI and CT studies in 41 patients (53 targets). Coordinates were measured in each plane and as vector distances between the target and the center of the stereotactic frame on axial or coronal MRI studies. Absolute axial plane MRI and CT distances varied an average of 2.13 ± 1.59 mm. The mean difference in measurements in the X (left-right) dimension was 1.19 mm and 1.55 mm in the Y (anteriorposterior) dimension. Central targets (located less than 2 cm from the frame center) had a mean MRI-CT difference of 2.09 ± 1.79 mm; peripheral targets (greater than 2 cm from the frame center) differed by 2.17 ± 1.3 mm. The voxel volumes were calculated for all compared images. Although differences between the physical properties of data acquisition with each imaging modality could explain the observed CT-MRI discrepancies, a 1-pixel difference in target selection could account totally for all the variance observed. MRI field strength (0.5 vs. 1.5 T) did not correlate with coordinate determination accuracy. We conclude that MRI-guided stereotactic localization can be used with confidence for most diagnostic, functional, and therapeutic stereotactic procedures

Role of angiography following aneurysm surgery

Journal ArticleThe postoperative angiograms in 66 patients who underwent craniotomy for clipping of 78 cerebral aneurysms were reviewed. Indications for urgent postoperative angiography included neurological deficit or repeat subarachnoid hemorrhage. Routine postoperative angiograms were carried out in the remaining patients. Postoperative angiograms were reviewed to determine the incidence of unexpected findings such as unclipped aneurysms, residual aneurysms, and unforeseen major vessel occlusions. Logistic regression analysis was used to test if the following were factors that predicted an unexpected finding on postoperative angiography: aneurysm site or size; the intraoperative impression that residual aneurysm was left or a major vessel was occluded; intraoperative aneurysm rupture; opening or needle aspiration of the aneurysm after clipping; or development of a new neurological deficit after surgery. Kappa values were calculated to assess the agreement between some of these clinical factors and unexpected angiographic findings. Unexpected residual aneurysms were seen in three (4%) of the 78 occlusions. In addition, three aneurysms were completely unclipped (4%); these three patients were returned to the operating room and had their aneurysms successfully obliterated. There were nine unexpected major vessel occlusions (12%); six of these resulted in disabling stroke and two patients died. Of six major arteries considered to be occluded intraoperatively and shown to be occluded by postoperative angiography, two were associated with cerebral infarction. Logistic regression analysis showed that a new postoperative neurological deficit predicted an unforeseen vessel occlusion on postoperative angiography. Factors could not be identified that predicted unexpected residual aneurysm or unclipped aneurysm. The inability to predict accurately the presence of residual or unclipped aneurysm suggests that all patients should undergo postoperative angiography. Since a new postoperative neurological deficit is one factor predicting unexpected arterial occlusion, intraoperative angiography may be necessary to help reduce the incidence of stroke after aneurysm surgery. With study of more patients or of factors not examined in this series, it may be possible to select cases more accurately for intraoperative or postoperative angiography

Significance of bacteriologically positive ventriculoperitoneal shunt components in the absence of other signs of shunt infection

Journal ArticleThe purpose of this study was to determine the significance of "asymptomatic bacteriological shunt contamination" (ABSC), defined as a positive bacteriological culture found on a ventricular shunt component in the absence of bacteria in the cerebrospinal fluid (CSF) culture and/or clinical evidence of infection. Of 174 ventriculoperitoneal shunt revisions, 19 cases of ABSC were identified and reviewed retrospectively. In all but one case, no antibiotic medications were instituted because of the positive bacteriological culture. The most common infecting organisms were coagulase-negative staphylococci (seven) and propionibacteria (eight). A comparison of the 19 study cases with the authors' overall shunt experience, as documented in the British Columbia's Children's Hospital shunt database for the time period of the study, lead the authors to suggest that ABSC was not of significance in causing the shunt failure at which contamination was identified and, more importantly, did not increase the risk of future shunt malfunction. The results of this study indicate that in the absence of clinical evidence of shunt infection or a positive bacteriological culture from CSF, bacteria in a shunt component removed at revision in a child almost always represents a contaminant that may be ignored. Therefore, the authors advise that routine culture of shunt components removed at revision of a shunt is not indicated

Reduction of transfusion rates in the surgical correction of sagittal synostosis

Journal ArticleObject. As public concern about the risks of blood transfusions increased in the mid-1990s, avoidance of transfusions became a goal of surgery for sagittal synostosis. This study was performed to confirm a hypothesized reduction in transfusion rates in recent years and to identify factors associated with both the need for transfusion and low postoperative levels of hemoglobin. Methods. Sagittal synostosis operations performed in children between 1986 and 1999 were reviewed retrospectively. Patients underwent a minimum of vertex strip craniectomy and parietal craniectomies. There were 118 patients whose median age at surgery was 4.2 months. The primary end point for analysis was defined as either the receipt of a blood transfusion or a postoperative level of hemoglobin less than 70 g/L. Forty-two percent of patients (95% confidence interval [CI] 31-52%) treated before 1996 and 11% of patients (95% CI 0-23%) treated from 1996 onward received blood. The reduction in the blood transfusion rate in later years was, in part, related to the acceptance of a lower postoperative hemoglobin level, often below 70 g/L. A univariate analysis showed that the only patient or surgical factors that correlated with reaching the primary end point in a statistically significant manner were the year of surgery and the extent of surgery. A logistic regression of the age and weight of the child, length of surgery time (from skin opening to skin closure), preoperative hemoglobin level, extent of surgery, and surgeon against the primary end point revealed that the best predictor of the need for a blood transfusion or the presence of a postoperative hemoglobin level lower than 70 g/L was the extent of surgery (β = 1.4, standard error of the β statistic = 0.44). Once the extent of surgery was accounted for in the model, no other covariates significantly improved the model. Techniques implemented to minimize blood loss since 1995 included the following: use of the Colorado needle for scalp incision, selection of the Midas Rex craniotome for cranial cuts, and application of microfibrillar collagen. Postoperative hemoglobin was allowed to decrease to 60 g/L if the child was stable hemodynamically, before blood was administered. There were no cardiovascular, wound healing, or infectious complications, and no surgeries were repeated for cosmetic reasons. Conclusions. Low blood transfusion rates were achieved using simple intraoperative techniques and by accepting a low level of postoperative hemoglobin

Outcomes after decompressive craniectomy for severe traumatic brain injury in children

Journal ArticleObject. Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution. Methods. Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months. Conclusions. Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high

Natural history of cerebral cavernous malformations

Journal ArticleTo determine the natural history of brain cavernous malformations, the authors entered patients referred to their center into a prospective registry between 1987 and 1993. All patients underwent magnetic resonance imaging, which showed the typical appearance of this lesion, and conservative management was recommended in all. Patients or their referring physicians were contacted for follow-up data. The purpose of the study was to define the rate of symptomatic hemorrhage and to determine the outcome in those patients who had suffered seizures. Follow-up data were available for 122 patients with a mean age at entry of 37 years (range 4-82 years). The malformation was located in the brainstem in 43 cases (35%), the basal ganglia/thalamus in 20 (17%), and a hemispheric area in 59 (48%). Fifty percent of patients had never had a symptomatic hemorrhage, 41% had one bleed, 7% had two, and 2% had three. Seizures were reported in 23% of patients and headaches in 15%. Lesions were solitary in 80% of patients and multiple in 20%. The retrospective annual hemorrhage rate (61 bleeds/4550.6 patient-years of life) was 1.3%. The mean prospective follow-up period was 34 months. There were nine bleeds during this time, six with new neurological deficits. In patients without a prior bleed, the prospective annual rate of hemorrhage was 0.6%. In contrast, patients with prior hemorrhage had an annual bleed rate of 4.5% (p = 0.028). Patient sex (p = 0.97) or the presence of seizures (p = 0.11), headaches (p = 0.06), or solitary versus multiple lesions (p = 0.15) were not significant predictors of later hemorrhage. There was no difference in the rate of bleeds between brain locations. Four patients with seizures became seizure-free and four patients without seizures later developed seizures; only one patient developed intractable seizures. Fourteen patients (11%) underwent surgery (two after hemorrhage, five with seizures, and seven with progressive deficits), and five had radiosurgery. No patient died in the follow-up period. This study indicates that conservative versus operative management strategies may need to be redefined, especially in patients who present with hemorrhage and who appear to have a significantly increased risk of subsequent rehemorrhage