Intracranial aneurysms: role of multidetector CT angiography in diagnosis and endovascular therapy planning.

PURPOSE: To evaluate the sensitivity of 16-detector row computed tomographic (CT) angiography in diagnosis of intracranial aneurysms and to determine whether multidetector CT angiography provides sufficient diagnostic information to guide endovascular treatment, with combined imaging and clinical data as the reference standard. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Eighty-seven patients clinically suspected of having subarachnoid hemorrhage underwent multidetector CT angiography and digital subtraction angiography (DSA). Aneurysm detection with multidetector CT angiography and DSA was analyzed on a per-patient and a per-aneurysm basis. For each aneurysm deemed ruptured on multidetector CT angiograms, the same multidetector CT angiography data set was used to determine whether the aneurysm was suitable for endovascular coil placement or whether a neurosurgical procedure was preferable. Criteria were based on neck width in relation to aneurysm size and the presence of vessels originating from the aneurysm. Results were compared with actual treatment that had been performed in each aneurysm after full diagnostic work-up, including DSA. Sensitivity, specificity, and positive and negative predictive values for aneurysm presence were determined. RESULTS: The reference standard revealed 84 aneurysms in 63 patients. Multidetector CT angiography was used to correctly identify 62 of 63 patients with 80 of 84 aneurysms and to correctly rule out aneurysms in 24 patients. DSA was used to correctly identify 62 of 63 patients with 79 of 84 aneurysms and to correctly rule out aneurysms in 23 patients. Per patient, the sensitivity, specificity, and positive and negative predictive values, respectively, for presence of aneurysm(s) were 98%, 100%, 100%, and 96% for multidetector CT angiography and 98%, 100%, 98%, and 96% for DSA. Per aneurysm, the possibility of coil embolization was correctly assessed with multidetector CT angiography in 69 (93%) of 74 target aneurysms for acute occlusive treatment. CONCLUSION: Multidetector CT angiography offers high diagnostic accuracy-equivalent to that of DSA-in the detection of intracranial aneurysms. Also, the possibility of coil embolization can be reliably determined with multidetector CT angiography.

Laparoscopy-guided insertion of peritoneal catheters in ventriculoperitoneal shunt procedures: analysis of 39 children.

Ventriculoperitoneal shunting is the mainstay in the treatment of hydrocephalus in childhood. Repeated shunt revision and previous laparotomy may complicate the implantation of the distal catheter. We describe our experience with laparoscopic insertion of peritoneal catheters in 21 male and 18 female children with an age range from 3 months to 18 years, operated between 2002 and 2004. Fourteen patients (36%) had laparotomy due to previous shunt operations and 5 patients (13%) due to other reasons. Laparoscopy was carried out concurrently with the cranial part of the procedure. In all cases, successful insertion of the peritoneal catheter was carried out with visual documentation of the patency of the distal catheter. There were no procedure-related complications. We recommend this minimally invasive procedure for all children with a body weight >5 kg, especially in cases of repeated shunt operations with intraperitoneal adhesions.

Management of meningiomas en plaque of the sphenoid wing.

OBJECT: The authors present their findings on growth patterns in a large series of surgically treated meningiomas en plaque of the sphenoid wing. METHODS: A retrospective case analysis was performed in 67 patients (53 of whom were female) harboring meningiomas en plaque originating from the sphenoid wing, who underwent surgery between 1991 and 2002. The standard surgical approach consisted of pterional craniotomy and extradural resection of any infiltrated bone. The intracranial tumor was removed, and the dura mater and bone were reconstructed. The follow-up period ranged from 6 to 118 months (mean 45.7 months). Total macroscopic resection was achieved in 40 patients. Forty-eight meningiomas extended to the orbital roof and/ or the lateral orbital wall, 34 involved the extraconal space, and eight the intraconal space. Fifty-four tumors involved the superior orbital fissure, 46 the optic canal, and 21 the inferior orbital fissure. Twelve tumors infiltrated the cavernous sinus and 27 involved the anterior clinoid process. There were no deaths in this group of patients; the rate of minor morbidity was 11.9% and the rate of major morbidity was 3%. Subtotal resections were performed in 27 patients because there was intraorbital tumor (eight patients), tumor in the cavernous sinus (nine patients), tumor beyond the tentorial notch (three patients), tumor invading the superior orbital fissure (four patients), and tumor of the skull base (three patients). Five patients underwent postoperative three-dimensional conformal radiotherapy, which resulted in stable tumor volume at follow up. Tumor recurrence was identified in seven patients (10.4%) postoperatively (range of follow up 13-47 months). CONCLUSIONS: The goal of surgery is complete tumor removal without morbidity. An exact analysis of tumor growth and its involvement of different structures is mandatory before performing surgery.

Minimally invasive implantation of the peritoneal catheter in ventriculoperitoneal shunt placement for hydrocephalus: analysis of data in 151 consecutive adult patients.

OBJECT: The authors report on their experience with laparoscopy-guided implantation of a peritoneal catheter in ventriculoperitoneal shunt placement procedures in adults. METHODS: In performing the conventional method of shunt placement in 2001, 8% of the cases resulted in malposition and dislocation of the distal catheter; therefore, the authors together with personnel from the Department of General Surgery decided to utilize an interdisciplinary approach involving laparoscopy-guided implantation of the catheter. Between October 2001 and January 2005, 202 ventriculoperitoneal shunt placement procedures were conducted in adult patients for hydrocephalus of various origins. In 152 patients, laparoscopy-guided implantation of the distal catheter was performed. In all except one of these patients, implantation was successful. Laparoscopy and the cranial part of the surgery were performed simultaneously. There was an 8% rate of malposition of the distal catheter in the nonlaparoscopy group. In contrast, there was no dislocation or malposition of the distal catheter in the laparoscopy group. Two cases (1.3%) of shunt infection occurred in the laparoscopy group. CONCLUSIONS: Laparoscopic implantation of a distal catheter is a simple, minimally invasive, and easy procedure to perform and allows exact localization of the peritoneal catheter and confirmation of its patency.

Atlantooccipital distraction: a diagnostic and therapeutic dilemma: report of two cases.

STUDY DESIGN: Two cases of severe atlantooccipital distraction, one with a fatal outcome and one with survival and 2 years of follow-up evaluation, are reported. OBJECTIVE: To show the problems in diagnosing and the dilemma in treating patients with severe atlantooccipital distraction in two cases with different outcomes. SUMMARY OF BACKGROUND DATA: Isolated severe traumatic atlantooccipital distraction without bony injuries is rarely seen in clinical practice. Because of high neurologic morbidity, most patients with the disorder are dead after the accident and before medical attention has arrived. However, because of improved immediate medical care for victims of motor vehicle accidents, an increased number of survivors are reported in the last years. METHODS: Two cases of isolated atlantooccipital distraction are described. The first case involved a 13-year-old cyclist hit by a car. In the second case, a 40-year-old woman sustained a severe accident as a motorcycle driver. Both patients were found to have severe atlantooccipital distraction on the lateral topogram of the computed tomography. In both cases, the initial MRI of the craniocervical junction failed to show medullary contusion. The diagnosis of severe medullary contusion was made by follow-up MRI performed 48 hours later. RESULTS: Both patients were treated initially with halo vest. Patient 1 survived the injury with tetraplegia and was referred to a spinal center for rehabilitation. At this writing, he is improving neurologically. Patient 2 did not recover and died 4 days after delivery to the neurosurgical intensive care unit because of circulatory failure. CONCLUSIONS: Because of high neurologic morbidity and mortality, atlantooccipital distraction represents a diagnostic and therapeutic problem. The therapy should be symptomatic, with life supporting measures, allowing the recovery of consciousness and then further neurologic evaluation.

Indications for and benefits of lumbar facet joint block: analysis of 230 consecutive patients.

OBJECT: The authors evaluated the effectiveness of using a facet joint block with local anesthetic agents and or steroid medication for the treatment of low-back pain in a medium-sized series of patients. METHODS: Over a period of 4 years, the authors performed 715 facet joint injections in 230 patients with variable-length histories of low-back pain. The main parameter for the success or failure of this treatment was the relief of the pain. For the first injection--mainly a diagnostic procedure--the authors used a local anesthetic (1 ml bupivacaine 1%). In cases of good response, betamethasone was injected in a second session to achieve a longer-lasting effect. Long-lasting relief of the low-back pain and/or leg pain was reported by 43 patients (18.7%) during a mean followup period of 10 months. Thirty-five patients (15.2%) noticed a general improvement in their pain. Twenty-seven patients (11.7%) reported relief of low-back pain but not leg pain. Nine patients (3.9%) suffered no back pain but still leg pain. One hundred sixteen patients (50.4%), however, experienced no improvement of pain at all. In two cases the procedure had to be interrupted because of severe pain. There were no cases of infection or hematoma. CONCLUSIONS: Lumbar facet joint block is a minimally invasive procedure to differentiate between facet joint pain and other causes of lower-back pain. The procedure seems to be useful for distinguishing between facet joint pain from postoperative pain due to inappropriate neural decompression after lumbar surgery. It can be also recommended as a possible midterm intervention for chronic low-back pain.