Is the use of antibiotic-impregnated external ventricular drainage beneficial in the management of iatrogenic ventriculitis?

Background: Profound evidence substantiates significantly reduced risk of catheter-related infections with prophylactic use of rifampin- and clindamycin-impregnated silicone catheters (Bactiseal®, Codman Johnson & Johnson, Raynham, MA, USA) for external ventricular drainage (EVD). However, whether Bactiseal®-EVD (B-EVD) influences the treatment of EVD-related ventriculitis remains controversial. Methods: We performed a retrospective analysis of patients who developed ventriculitis after EVD or ventriculoperitoneal (VP) shunt placement and consequently underwent either placement of B-EVD (group 1) or a standard non-antibiotic-impregnated EVD (group 2). Analyzed parameters included demographic and clinical data, hospitalization time, time until remission of the infection parameters, detection of new bacterial resistance on antibiograms, and clinical outcome in terms of the modified Rankin scale (mRS). Results: Time until remission of cerebrospinal fluid (CSF) pleocytosis was significantly longer in patients undergoing B-EVD (8 ± 3.8days; n = 15; group 1) than in patients who underwent standard EVD (5.1 ± 1.8days; n = 10; group 2). There was no significant difference between both groups for the time until polymorphonuclear cells dropped below 50% of peak value (5.8 ± 1.6 vs. 4.1 ± 2.9days), CRP dropped below 10mg/l (4.2 ± 3.5 vs. 5.6 ± 3.3days), the time of plasma neutrophil remission (5.7 ± 2.6 vs. 5.3 ± 3.2days) and hospitalization time (28 ± 12.5 vs. 35 ± 19.4days). The mRS for both groups was 2. Development of new antibiotic resistance did not occur in either group. Conclusions: This retrospective pilot study indicates that B-EVD might have no major advantage in the management of EVD or VP-shunt-related ventriculitis. Based on published reports and the results of this study, data support only the prophylactic use of B-EVD for prevention of EVD-related infections. Prospective randomized clinical trials are warranted to further evaluate the role of B-EVD in the treatment of ventriculiti

Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

BACKGROUND: Antiplatelet therapy in patients with chronic subdural hematoma (cSDH) presents significant neurosurgical challenges. Given the lack of guidelines regarding perioperative management with antiplatelet therapy, it is difficult to balance the patient's increased cardiovascular risk and prevalence of cSDH. OBJECTIVE: To better understand the risk and recurrence rates related to resuming low-dose acetylsalicylic acid (ASA) by evaluating our patients' resumption of low-dose ASA at various times after burr-hole drainage of the hematoma. METHODS: In our retrospective study, 140 consecutive patients taking low-dose ASA undergoing surgical evacuation of cSDH were included. Data included baseline characteristics and rates of recurrence, morbidity, and mortality. A multivariate logistic regression model analyzed the association between ASA resumption time and recurrence rates. RESULTS: No statistically significant association was observed between early postoperative resumption of low-dose ASA and recurrence of cSDH (odds ratio, 1.01; 95% confidence interval, 1.001-1.022; P = .06). Corresponding odds ratios and risk differences for restarting ASA treatment on postoperative days 1, 7, 14, 21, 28, 35, or 42 were estimated at 1.53 and 5.9%, 1.42 and 5.1%, 1.33 and 4.1%, 1.23 and 3.2%, 1.15 and 2.2%, 1.07 and 1.1%, and 1.01 and 0.2%, respectively (P < .05). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with or without ASA therapy. CONCLUSION: Given the few published studies regarding ASA use in cranial neurosurgery, our findings elucidate one issue, showing comparable recurrence rates with early or late resumption of low-dose ASA after burr-hole evacuation of cSDH. ABBREVIATIONS: ASA, acetylsalicylic acidCAD, coronary artery diseaseCI, confidence intervalcSDH, chronic subdural hematomaGCS, Glasgow Coma ScalemRS, modified Rankin ScaleOR, odds ratioRD, risk difference

Pediatric and Adult Low-Grade Gliomas: Where Do the Differences Lie?

Two thirds of pediatric gliomas are classified as low-grade (LGG), while in adults only around 20% of gliomas are low-grade. However, these tumors do not only differ in their incidence but also in their location, behavior and, subsequently, treatment. Pediatric LGG constitute 65% of pilocytic astrocytomas, while in adults the most commonly found histology is diffuse low-grade glioma (WHO II), which mostly occurs in eloquent regions of the brain, while its pediatric counterpart is frequently found in the infratentorial compartment. The different tumor locations require different skillsets from neurosurgeons. In adult LGG, a common practice is awake surgery, which is rarely performed on children. On the other hand, pediatric neurosurgeons are more commonly confronted with infratentorial tumors causing hydrocephalus, which more often require endoscopic or shunt procedures to restore the cerebrospinal fluid flow. In adult and pediatric LGG surgery, gross total excision is the primary treatment strategy. Only tumor recurrences or progression warrant adjuvant therapy with either chemo- or radiotherapy. In pediatric LGG, MEK inhibitors have shown promising initial results in treating recurrent LGG and several ongoing trials are investigating their role and safety. Moreover, predisposition syndromes, such as neurofibromatosis or tuberous sclerosis complex, can increase the risk of developing LGG in children, while in adults, usually no tumor growth in these syndromes is observed. In this review, we discuss and compare the differences between pediatric and adult LGG, emphasizing that pediatric LGG should not be approached and managed in the same way as adult LCG

Acute cerebellar edema after traumatic brain injury in a child. a case report

Traumatic brain injuries (TBI) are a major cause of morbidity and mortality in children. Malignant cerebral edema is described to occur more often in children than in adults. Its infratentorial analogous, a malignant cerebellar edema, has not been reported yet. A 10-year-old boy fell from a height of 3 m where he sustained a TBI. Approximately 36 h after trauma, a significant drop in Glasgow Coma Scale (GCS) occurred accompanied by bilateral fixed and dilated pupils. A computed tomography (CT) scan revealed an underlying acute cerebellar edema without evidence of a sinus vein thrombosis or cerebellar contusions. Immediate suboccipital decompressive surgery and insertion of an external ventricular drain (EVD) were performed. Early postoperative CT imaging showed increasing, space-occupying frontal contusions and perilesional edema, which is why an additional bifrontal craniectomy was performed. A posttraumatic hydrocephalus occurring on the 27th day after trauma was treated with a ventricular-peritoneal shunt. On follow-up, 6 months after trauma, he showed a GCS of 15 with no evident neurological findings. This case report is the first to describe and discuss an acute cerebellar edema occurring after TBI. Its acute complications of brainstem compression and obstructive hydrocephalus are effectively treated by immediate suboccipital decompression and EVD insertion

Transforaminal Lumbar Interbody Fusion Using LOOP® PEEK Cage Implants: Safety, Feasibility, Radiographic and Clinical Outcome

Objective: A variety of newly designed grafts for  transforaminal lumbar interbody fusion (TLIF) have been introduced for clinical application. Biomechanical properties of the LOOP ® PEEK cage (Medtronic GmbH, Meerbusch, Germany) have been shown in cadaver laboratory investigations, but not in clinical studies so far. In this study we analyze the safety, clinical and radiological outcome of the LOOP ® PEEK cage implant in a clinical setting. Methods : Forty one consecutive patients undergoing fluoroscopic-guided posterior pedicle screw fixation combined with TLIF using the LOOP ® PEEK cage for degenerative spine disease s between January 2010 and December 2011 were included. Time intervals for follow-up, clinical and radiological outcome data collection were at 1, 3 and 12 months. Visual analog pain scales (VAS), neurological exam, patient-reported SF-12 ® , CT- scans and plain x-rays of the lumbar spine were used as clinical and radiologic outcome measures. Following data were recorded for safety evaluation: procedure duration, intraoperative blood loss, number of levels fused, intraoperative complications, hospitalization time, and postoperative complications. Results:  A total of 49 cages were implanted during 41 procedures with an average procedure time of 225.25 minutes. Four patients (9.8%) experienced a dural tear, While new sensory and motor deficits were seen in 2 (4.9%) and 1 (2.4%) patients respectively. complications were not associated with  implant insertion. Significantly reduced pain scores (p&lt;0.05, paired t-test) were reported by 29 patients (70%) at 1, 3 and 12 months. SF-12 ® results showed PCS and MCS scores below the healthy population average, one year post-op. Cage dislocation was observed in 2 (4.9%) patients, one required late revision. Implant fracture did not occur. Inchoate fusion of the vertebra was seen in 39 patients (95.1%) at one year. Conclusion:  TLIF procedure combined with lumbar fusion using LOOP ® -PEEK cage, provides a safe and feasible intraoperative alternative as well as good clinical and radiologic outcome, without increasing the overall complication rate of TLIF procedures

Direct syrinx drainage in patients with Chiari I malformation

While FMD is, to date, the primary treatment of symptomatic CM I, the treatment of Chiari malformation type I (CM I) associated syrinx remains controversial. In cases of persistent, progressive, or recurrent syrinx following FMD, direct syrinx drainage (DSD) is described as a safe and efficient option, leading to a good clinical and radiological outcome. However, studies at hand mostly include very heterogeneous patient populations, small cohorts, and are of retrospective nature. We provide an overview of the possible indications and outcome for DSD in CM I-associated syrinx. We discuss the different surgical techniques of DSD and review the available literature comparing different DSD techniques. Finally, we discuss the possible complications that might occur after DSD and how they can be prevented

Dizygotic opposite-sex twins with surgically repaired concordant myelomeningocele conceived by in vitro fertilization using intracytoplasmic sperm injection: a case report and review of the literature

BACKGROUND: Myelomeningocele (MMC) is a common subtype of congenital neural tube defects (NTD). Although congenital malformations including NTD are more common in twins, concordance, especially in dizygotic twins, is extremely rare and is found mostly in same-sex twins. The role of genetic and environmental factors in the etiology of MMC is unclear. CASE REPORT: Dizygotic twins of opposite sex were born at term to a 35-year-old woman conceived with in vitro fertilization (IVF) using intracytoplasmic sperm injection (ICSI). Prenatal ultrasonography (US) revealed concordant lumbosacral MMC at 18 weeks of gestation as well as ventriculomegaly and Arnold-Chiari malformation type II at 28 weeks. Both twins underwent surgical repair of the MMC within 48 h after birth and required a ventriculoperitoneal shunt in the second week of life. DISCUSSION: The case presented raises questions concerning the etiology of MMC, since in twins, it is compelling to attribute the etiology to genetic factors. In the literature, 22 pairs of twins with concordant MMC have been reported, and of the 10 dizygotic twins described, four were of opposite sex. However, in monozygotic twins, most of the cases are non-concordant; therefore, the role of genetics remains unclear. In addition, environmental factors such as nutrition, metabolic folic acid deficiency, and assisted conception with IVF and ICSI might play a role as well. CONCLUSION: The appearance of concordant MMC in opposite-sex dizygotic twins, conceived by IVF using ICSI, intrigues questions concerning the etiology of MMC. In such cases, genetic counseling and evaluation should be considered