Moyamoya Disease in an 8-Year-Old Boy : Direct Bypass Surgery in a Province of Peru

BACKGROUND: Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION: Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS: The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.Peer reviewe

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration

OBJECTIVE Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. METHODS A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. RESULTS One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3–15.4 years; 22% were \u3c 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28). CONCLUSIONS CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable

Three distal anterior cerebral artery aneurysms in the same branch associated with five additional intracranial aneurysms

Peer reviewe

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration.

Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3-15.4 years; 22% were CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable

Anatomic Risk Factors for S1 Segment Superior Cerebellar Artery Aneurysm Rupture : A Radiologic Study on 81 Consecutive Patients

Background: Due to treatment associated risks, it is still debatable which unruptured aneurysm should be treated. Anatomic and morphologic characteristics may aid to predict the rupture risk of superior cerebellar artery (SCA) aneurysm and possibly support in decision- making during treatment. Objectives: To identify morphologic characteristics that could predict the rupture of SCA aneurysms. Methods: A retrospective analysis of computed tomography angiography images of 81 consecutive patients harboring SCA aneurysm who were treated between 1980 to 2014 at Helsinki University Hospital was performed. Results: Of the 81 analyzed SCA aneurysms, 30 (37%) were unruptured and remaining 51 (63%) presented with subarachnoid hemorrhage. The mean ± SD size of unruptured SCA aneurysms was 6.2 ± 6.3 mm; mean size of ruptured SCA aneurysms was 5.9 ± 5.4 mm. The mean ± SD aspect ratio was 0.9 ± 0.3 in unruptured and 1.14 ± 0.44 in ruptured SCA aneurysms. The mean ± SD degree angle between basilar artery and aneurysm was 74.7 ± 24.4 in unruptured and 65.9 ± 23 ruptured SCA aneurysms. Patients with ruptured SCA aneurysm showed significantly higher aspect ratio (Mann-Whitney U, P = 0.01) and smaller aneurysm to basilar artery angle (Mann-Whitney U, P = 0.039). Aspect ratio >1.1 had 2.3 times higher risk of rupture (odds ration [OR] 2.3, 95% confidence interval [CI] 0.84–6.34). An aneurysm to basilar angle <70 degrees had 2.8 times higher risk of rupture (OR 2.75, 95% CI 1.086–6.96). Conclusions: Ruptured SCA aneurysms are usually small in size. Higher aspect ratio and smaller angle between SCA aneurysm and basilar artery had significantly higher risk of SCA (S1 segment) aneurysm rupture.Peer reviewe

Value of Cerebrospinal Fluid Lactate Levels in Diagnosing Shunt Infections in Pediatric Patients

OBJECTIVE: The diagnosis and timely treatment of shunt infections (SI) in children is of paramount importance. In some cases, the standard cerebrospinal fluid (CSF) variables will not be sufficient for an accurate diagnosis of SI. CSF lactate (LCSF) has been found to assist in differentiating bacterial from nonbacterial meningitis in non-neurosurgical patients. To the best of our knowledge, the use of lactate in diagnosing or confirming the presence of SI has not yet been discussed. The goal of the present study was to describe the role of LCSF levels in children with shunts and Ommaya reservoirs and to evaluate its role in the accurate diagnosis of shunt-related infection. METHODS: We retrospectively collected data for a consecutive series of pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples from shunts had been collected during a 2-year period (2016-2017). The lactate levels were correlated with the presence of SI. RESULTS: A total of 61 CSF samples were analyzed, with 6 SIs found. The LCSF levels and white blood cell count were both found to correlate with the presence of CSF infections. A cutoff value of ≥2.95 mmol/L reached a sensitivity of 83%, specificity of 83%, and positive predictive value of 50%. LCSF textless2.95 mmol/L had a negative predictive value of 96%. CONCLUSIONS: LCSF levels can be used as an additional chemical marker for the diagnosis and confirmation of SIs. An LCSF value of textless2.95 mmol/L had a high negative predictive value

The value of cerebrospinal fluid lactate levels in diagnosing CSF infections in pediatric neurosurgical patients

PURPOSE: Diagnosis of cerebrospinal fluid (CSF) infections in patients following neurosurgical procedures can be challenging. CSF lactate (LCSF) has been shown to assist in differentiating bacterial from non-bacterial meningitis in non-neurosurgical patients. The use of lactate in diagnosing CSF-related infections following neurosurgical procedures has been described in adults. The goal of this study was to describe the role of LCSF levels in diagnosing CSF-related infections among neurosurgical children. METHODS: We retrospectively collected data for all pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples were collected over a 2-year period. Lactate levels were correlated with other CSF parameters, surgical parameters, presence of CSF infection, and source of CSF sample (lumbar, ventricular, or pseudomeningocele). RESULTS: A total of 215 CSF samples from 162 patients were analyzed. We found a correlation between lactate levels and other CSF parameters. Lactate levels displayed an inconsistent correlation with infection depending on sample origin. Irrespective of the CSF source, lactate levels could not sufficiently discriminate between those with or without infection. Lactate levels were correlated with recent surgery, and, in some of the subgroups, to the extent of blood in CSF. CONCLUSIONS: LCSF levels are influenced by many factors, including the source of sample, recent surgery, and the presence of subarachnoid or ventricular blood secondary to surgery. The added value of LCSF for diagnosing CSF infections in children with a history of neurosurgical procedures is unclear and may be influenced by the extent of blood in the CSF

Slow-Closing Clip for the Treatment of Nonsaccular Vertebrobasilar Aneurysms: A Retrospective Case Series

OBJECTIVE: Vertebrobasilar artery nonsaccular aneurysms (VBANSAs) are associated with a 13% annual mortality. Revascularization and flow diversion are life-saving options in select cases; technical failures and rapid hemodynamic changes may contribute to unwanted outcomes. We describe a technique and report clinical outcomes of patients treated with an experimental slow-closing clip (SCC). METHODS: An experimental SCC was created to gradually close the parent artery of aneurysms. Clinical, radiographic, and outcome data from patients with VBANSAs who underwent experimental treatment with the SCC were retrospectively analyzed. RESULTS: Among 10 patients (7 men; mean age, 49.5 years; range, 18-73 years), 6 presented with mass effect symptoms, 1 with ischemic stroke, 2 with subarachnoid hemorrhage, and 1 with hydrocephalus. Five patients underwent revascularization plus SCC application, and 5 were treated with SCC alone. The mean follow-up was 6.7 years. The expected mortality among patients with unruptured VBANSAs with previous treatment options in this period was 52.7%, whereas the observed rate was 20%. Four patients died within 12 months after treatment. Causes of death were brainstem ischemic stroke, poor-grade subarachnoid hemorrhage, poor clinical presentation, and unknown. Six patients were alive at last follow-up, with unchanged or improved modified Rankin Scale scores. Mortality was associated with posterior-projecting aneurysms and late-stage treatment. CONCLUSIONS: In this small case series, use of SCC overcame the natural history of VBANSAs when treatment timing and aneurysm anatomy were suitable. The SCC potentially favors aneurysm thrombosis and collateral reactivation. More studies are necessary to better develop the SCC