Endovascular Retrieval of Migrated Distal End of Ventriculoperitoneal Shunt from Bilateral Pulmonary Arteries: A Technical Note.

Ventriculoperitoneal (VP) shunting of cerebrospinal fluid is one of the most common procedures performed by neurosurgeons around the world. Migration of distal VP shunt catheter into bilateral segmental pulmonary arteries is an extremely rare complication of VP shunt placement. In the present case, a 30-year-old male underwent VP shunting complicated by migration of distal VP shunt catheter into the bilateral pulmonary arteries. Despite manual attempt at externalizing the distal VP shunt catheter at the level of the clavicle, a small piece of distal VP shunt catheter in bilateral pulmonary arteries was noted on computed tomography of the chest obtained after manual externalization. This persistent distal VP shunt catheter was likely left behind after a break in the distal VP shunt catheter during manual externalization procedure. Given the small size of the segmental pulmonary arteries, a novel endovascular technique was used to move the distal VP shunt catheter from the bilateral segmental pulmonary arteries to the main pulmonary trunk. Once in the main pulmonary trunk, a snare device was used to retrieve the distal shunt catheter through the femoral vein. In this technical note, the authors highlight the relevant endovascular technical details to first move the VP shunt catheter from the bilateral segmental arteries followed by successful catheter retrieval using snare device.

Outcome of ventriculoperitoneal shunt and predictors of shunt revision in infants with posthemorrhagic hydrocephalus.

OBJECT: Ventriculoperitoneal (VP) shunts in infants with posthemorrhagic hydrocephalus (PHH) are prone to failures, with some patients at risk for multiple revisions. The objective of our study is to observe long-term outcomes and identify factors leading to proximal and distal multiple failures. METHODS: We performed a retrospective review of infants with PHH that required VP shunt placement between 1982 and 2014. These patients were monitored clinically and radiographically after VP shunt placement. RESULTS: A total of 502 surgical procedures (initial shunt insertion and revisions) were performed, with 380 shunt revisions in 102 (84 %) patients. Median shunt survival time was 54 months (0.03-220 months). Shunt survival was significantly affected by the following factors: intraventricular hemorrhage (IVH, grade II-III, 95 months vs. grade IV, 28 months, p = 0.022), birth weight (<1.5 kg, 59 months vs. >1.5 kg, 22 months, p = 0.005), gestational age (>27 weeks, 90 months vs. <27 weeks, 20 months, p < 0.0001), distal vs. proximal revision (133 months vs. 48 months, p = 0.013), obstruction (yes, 78 months vs. no, 28 months, p = 0.007), and infection (no, 75 months vs. yes, 39 months, p = 0.045). Regression analysis revealed that multiple gestation, head circumference (>27 cm), congenital anomalies, infection, and obstruction increased the proximal and distal shunt malfunction. CONCLUSION: Long-term outcome of VP shunt placement in infants revealed a relatively high rate of complications requiring shunt revision as late as 30 years after initial placement. Infants with VP shunts should be monitored lifelong of these patients by neurosurgeons.

Role of apolipoprotein E polymorphism as a prognostic marker in traumatic brain injury and neurodegenerative disease: a critical review.

OBJECT The difference in course and outcome of several neurodegenerative conditions and traumatic injuries of the nervous system points toward a possible role of genetic and environmental factors as prognostic markers. Apolipoprotein E (Apo-E), a key player in lipid metabolism, is recognized as one of the most powerful genetic risk factors for dementia and other neurodegenerative diseases. In this article, the current understanding of APOE polymorphism in various neurological disorders is discussed. METHODS The English literature was searched for various studies describing the role of APOE polymorphism as a prognostic marker in neurodegenerative diseases and traumatic brain injury. The wide ethnic distribution of APOE polymorphism was discussed, and the recent meta-analyses of role of APOE polymorphism in multiple diseases were analyzed and summarized in tabular form. RESULTS Results from the review of literature revealed that the distribution of APOE is varied in different ethnic populations. APOE polymorphism plays a significant role in pathogenesis of neurodegeneration, particularly in Alzheimer's disease. APOE ε4 is considered a marker for poor prognosis in various diseases, but APOE ε2 rather than APOE ε4 has been associated with cerebral amyloid angiopathy-related bleeding and sporadic Parkinson's disease. The role of APOE polymorphism in various neurological diseases has not been conclusively elucidated. CONCLUSIONS Apo-E is a biomarker for various neurological and systemic diseases. Therefore, while analyzing the role of APOE polymorphism in neurological diseases, the interpretation should be done after adjusting all the confounding factors. A continuous quest to look for associations with various neurological diseases and wide knowledge of available literature are required to improve the understanding of the role of APOE polymorphism in these conditions and identify potential therapeutic targets.

Rare pathologies in the posterior third ventricular region in children: case series and review.

Tumors of the pineal region in children often belong to 2 categories, namely germ cell tumors and pineal parenchymal tumors. Very rare pathologies have previously been reported in this region. Most of these tumors may be similar radiologically, while their management differs. The present series reports 2 children with pineal region tumors, each one being a rare pathological entity by itself, namely an embryonal tumor with abundant neuropil and true rosettes (ETANTR) and a rosette-forming glioneuronal tumor (RGNT). Very few such cases in each pathology have been reported in the literature for the pediatric age group up to now. Our series consists of 2 children, both presenting with a raised intracranial pressure of short duration. Imaging revealed lesions in the pineal region with similar radiological features. Both ETANTR and RGNT demonstrated mild enhancement. The 2 patients underwent surgical decompression either by Poppen's approach (n = 1) or a supracerebellar infratentorial approach (n = 1). The patient with ETANTR was advised radiotherapy, while the child with RGNT was advised a regular follow-up. This series presents some rare pathologies which can occur in the posterior third ventricular region with similar radiological features. Management differs based on the histology of the case.

Computed tomography-based classification of axis vertebra: choice of screw placement.

PURPOSE: The purpose of the study was to: (1) introduce a new CT-based parameter: free facet area and provide its normative data; (2) standardize the method of measuring isthmus width and height of the axis vertebra; (3) propose a new grading system to predict the difficulty in inserting transarticular and C2 pedicle screws. METHODS: Spiral CT scans of 47 adult dry axis vertebrae were studied. The methods of measuring isthmus width, isthmus height and free facet area are described. RESULTS: The mean isthmus width was 5.04 mm on the right side and 5.42 mm on the left side. The mean isthmus height was 5.21 mm on the right side and 5.45 mm on the left side. Mean free facet area was 61.23 % on the right side and 70.18 % on the left side. A novel grading system is proposed on the basis of these three parameters. As per this grading system, 40.4 % of the sides were found to be difficult for transarticular and 24.5 % sides for C2 pedicle screw insertion (total score 2, 3, 4). A Management protocol is suggested on the basis of the grading system. CONCLUSION: Inserting a transarticular screw was more frequently difficult as compared to pedicle screw. A new CT-based parameter (free facet area) and an efficient grading have been proposed to help surgeons choose the appropriate screw options, appreciate the complex anatomy of this region and compare data across various studies.

Spontaneous occlusion of a pial arteriovenous fistula after angiography: The role of iodinated contrast media.

Intracranial non-galenic pial arteriovenous fistula (PAVF) is an extremely rare vascular malformation, where one or more pial arteries feeds directly into a cortical vein without any intervening nidus. Though occasionally they can be asymptomatic, neurological symptoms such as headache, seizure, or focal neurological deficit are more common presenting features. Life threatening or fatal hemorrhage is not uncommon, hence needed to be treated more often than not. Spontaneous occlusion of PAVF is reported only four times before. We report a 49-year-old gentleman, who was diagnosed to have a PAVF, possibly secondary to trauma. He presented 5 months and 22 days from initial digital subtraction angiography (DSA) for treatment, and follow-up angiogram showed complete obliteration. He denied any significant event, medication or alternate treatment during this period. His clinical symptoms were stable as well. We postulate iodinated contrast medium induced vasculopathy as a possible cause, which has been described for other vascular pathologies, but never for PAVF.

The benefit and risk of stereotactic radiosurgery for prolactinomas: an international multicenter cohort study.

OBJECTIVE: The most common functioning pituitary adenoma is prolactinoma. Patients with medically refractory or residual/recurrent tumors that are not amenable to resection can be treated with stereotactic radiosurgery (SRS). The aim of this multicenter study was to evaluate the role of SRS for treating prolactinomas. METHODS: This retrospective study included prolactinomas treated with SRS between 1997 and 2016 at ten institutions. Patients' clinical and treatment parameters were investigated. Patients were considered to be in endocrine remission when they had a normal level of prolactin (PRL) without requiring dopamine agonist medications. Endocrine control was defined as endocrine remission or a controlled PRL level ≤ 30 ng/ml with dopamine agonist therapy. Other outcomes were evaluated including new-onset hormone deficiency, tumor recurrence, and new neurological complications. RESULTS: The study cohort comprised 289 patients. The endocrine remission rates were 28%, 41%, and 54% at 3, 5, and 8 years after SRS, respectively. Following SRS, 25% of patients (72/289) had new hormone deficiency. Sixty-three percent of the patients (127/201) with available data attained endocrine control. Three percent of patients (9/269) had a new visual complication after SRS. Five percent of the patients (13/285) were recorded as having tumor progression. A pretreatment PRL level ≤ 270 ng/ml was a predictor of endocrine remission (p = 0.005, adjusted HR 0.487). An increasing margin dose resulted in better endocrine control after SRS (p = 0.033, adjusted OR 1.087). CONCLUSIONS: In patients with medically refractory prolactinomas or a residual/recurrent prolactinoma, SRS affords remarkable therapeutic effects in endocrine remission, endocrine control, and tumor control. New-onset hypopituitarism is the most common adverse event.

Direct Comparison of Gamma Knife Radiosurgery and Microsurgery for Small Size Meningiomas.

BACKGROUND: Patients with small (<3 cm) intracranial meningiomas can be either observed or treated. Treatment can be either radiosurgery or microsurgery if and when tumor progression occurs. We compared local tumor growth control and recurrence-free survival (RFS) of microsurgical resection and radiosurgery in small intracranial meningiomas and identified predictors of unfavorable outcome. METHODS: A retrospective review (2005-2016) was performed of 90 consecutive patients with intracranial meningiomas who underwent either microsurgery (n = 31) or Gamma Knife radiosurgery (GKRS) (n = 59). The study population was evaluated clinically and radiographically after treatment. RESULTS: GKRS in meningiomas showed a significantly higher percentage of local control of tumor growth compared with microsurgery (P = 0.02) 5 and 10 years (P = 0.003) after treatment. The median RFS was also significantly higher in the GKRS group compared with the microsurgery group (P = 0.04). There was no difference in RFS between Simpson grade I resection and GKRS (P = 0.69). In univariate analysis, RFS after procedures was significantly affected by tumor involvement of cranial nerves, presence of comorbidities, and preoperative Karnofsky performance scale score ≤70. In multivariate analysis, only preoperative Karnofsky performance scale score ≤70 was a predictor of unfavorable outcome. CONCLUSIONS: GKRS offers a high rate of tumor control and longer RFS that is comparable to Simpson grade I resection. Subtotal resection is not a good choice for small meningiomas. The treatment procedure should be tailored according to the presence of comorbidities and the maximum benefit for the patient.

Atypical presentation and outcome of cervicogenic headache in patients with cervical degenerative disease: A single-center experience.

OBJECTIVE: Cervicogenic headache affects a significant portion of the entire population. This type of headache especially with atypical presentation is often hard to diagnose and manage since its etiopathophysiology is not been yet well understood. We have investigated the prevalence of cervicogenic headache with atypical presentation and discussed the etiology of it, and the outcome of surgical intervention on this type of headache in patients with cervical degenerative disease. PATIENTS AND METHODS: Radiological and clinical data of 160 patients (from 2001 through 2016) were retrospectively reviewed. Significant differences between the groups were determined by chi-square test. Logistic regression analysis was performed to identify the predictors of unfavorable outcome. RESULTS: In this study, 10% of the patients had atypical presentation of cervicogenic headache. In overall cohort, after surgical intervention, there was significant improvement in symptoms and pain control, whether the presentation is typical or atypical. Sixty-one percent of the patients had no complaints, and 90% of the patients were headache-free (p<0.0001). Sixty-nine percent of the patients were free of neck, shoulder and extremity pain, and visual analogue scale pain score was reduced by 7 points (pre-op, 8.4 vs. last follow-up, 1.5, p<0.0001). However, number of patients with reduced headache was significantly higher in the group with typical presentation of headache (90.1%) compared to group with atypical (80%) presentation, p=0.04. In this study, female gender, smoking, obesity and depression were identified as predictors of overall unfavourable outcome. In addition, in a separate analysis, smoking and depression were revealed as risk factors for persistent headache. CONCLUSIONS: A notable portion of patients with cervicogenic headache can have an atypical presentation mimicking a primary type headache. However, cervicogenic headaches with atypical presentation can be difficult to diagnose and manage at the initial visit of the patients. Etiopathophysiology of this type of headache could be explained by the theories including discogenic, convergence and sensitization-desensitization theories. When cervicogenic headache is accompanied with CDD, performing ACDF or laminectomy would be the treatment of choice. Surgical intervention can also relieve the accompanying neck, shoulder and extremity pain with minimal complications. Lastly, outcomes of surgical intervention depend on the patients' morbidities including obesity, smoking and depression.

Modified Far Lateral Approach for Posterior Circulation Aneurysms: An Institutional Experience.

OBJECTIVE: The modified far lateral approach is a modified version of the far lateral approach without drilling of the condyle. This approach can be used for accessing aneurysms anterior and anterolateral to the brainstem and craniovertebral junction. We describe the surgical outcome and complications of the modified far lateral approach for vertebrobasilar, proximal posterior inferior cerebellar artery, and vertebral artery aneurysms. METHODS: The records of 26 patients with vertebrobasilar aneurysms who underwent surgery using the modified far lateral approach from 1994 to 2015 were retrospectively reviewed to analyze the clinical outcomes. RESULTS: Mean age of patients was 61 years (range, 38-84 years), and 18 patients were women. The most common presenting symptoms were sudden-onset headache (77%) and dizziness (35%). Of patients, 21 (81%) had saccular aneurysms, and 5 (19%) had fusiform aneurysms. The modified far lateral approach was used in 16 patients with posterior inferior cerebellar artery aneurysms, 6 patients with vertebral artery aneurysms, 2 patients with basilar aneurysms, 1 patient with a vertebrobasilar junction aneurysm, and 1 patient with an anterior inferior cerebellar artery aneurysm. All aneurysms were clipped successfully. Follow-up data were available for 25 patients (median duration 67 months). At last follow-up, 22 patients had a good recovery (modified Rankin Scale score 1-3), and 3 patients had a poor outcome (modified Rankin Scale score 4-6). Four patients developed lower cranial nerve palsy, and 7 patients developed new-onset hydrocephalus. CONCLUSIONS: The modified far-lateral approach without condyle resection and vertebral artery mobilization is associated with low procedure-related morbidity and comparable outcomes to the more extensive traditional approach.

Overall outcomes following early interventions for intracranial arteriovenous malformations with hematomas.

We evaluated the timing and predictors of surgical intervention for intracranial arteriovenous malformations (AVM) with hematoma. A ruptured intracranial AVM with hematoma is an emergency condition, and the optimal timing for surgical intervention is not well understood. In addition, the outcome predictors of surgical intervention have rarely been reported. We identified and analyzed 78 patients treated with microsurgical resection for pathologically proven AVM at Louisiana State University Health in Shreveport from February 1992 to December 2004. All 78 patients were diagnosed with ruptured AVM before surgery. The independent variables, including patient demographics, timing of surgery, location of the AVM and comorbidities were analyzed to assess outcome. The results of this series revealed that surgical intervention after 48hours resulted in poor outcomes for patients with hematoma, following a ruptured AVM. Several other prognostic factors, including younger age (11-40years), Spetzler-Martin Grade I and II, and AVM in a supratentorial location, had significant positive effects on outcomes. However, hypertension, smoking, and a prior embolization showed significant negative effects on outcomes after surgery. The multiple logistic regression analyses also revealed that the timing of surgical intervention had a significant effect on outcomes in patients with hematoma following ruptured AVM. Early intervention is the key to success in these patients.

Mirror Meningioma at Foramen Magnum: A Management Challenge.

BACKGROUND: Meningiomas of the foramen magnum are among the most challenging of all skull base lesions. Controversies continue regarding the most appropriate approach to this critical anatomic region. The authors report a first case in English literature about twin meningiomas arising from both sides of the ventrolateral dura at the foramen magnum. CASE DESCRIPTION: Preoperative imaging showed a solitary mass engulfing the lower medulla. However, intraoperatively a twin mass was discovered. It encased the right side vertebral artery (VA) and abutted the left side. The unilateral far lateral transcondylar approach is not enough to resect both tumors at the same time. However, the far lateral transcondylar approach in both sides may compromise the stability and increase the risk of injury to either side of the neurovascular structures. CONCLUSIONS: We suggest that resection can be safely achieved via the unilateral far lateral transcondylar approach followed by Gamma Knife radiosurgery (GKRS) or a staged bilateral approach.

Anomalous Origin of the Right Vertebral Artery: Incidence and Significance.

OBJECTIVE: Detailed knowledge about anatomic variations of the aortic arch and its multiple branches is extremely important to endovascular and diagnostic radiologists. It is often hypothesized that anomalous origin and distribution of large aortic vessels may alter the cerebral hemodynamics and potentially lead to a vascular pathology. METHODS: In this article, we describe a case of anomalous origin of the right vertebral artery, which was detected during an intervention. We further reviewed the available literature of anomalous origin of the right vertebral artery. The probable embryologic development and clinical significance are discussed. RESULTS: The incidence of anomalous origin of a vertebral artery seems to be underestimated in recent literature. A careful review of the literature shows more than 100 such cases. The right vertebral artery can arise from the aortic arch or one of its branches. Dual origin of the vertebral artery is not uncommon. The embryologic developmental hypotheses are contradictory and complex. CONCLUSIONS: Anomalous origin of the right vertebral artery may not be the sole reason behind a disease process. However, it can certainly lead to a misdiagnosis during diagnostic vascular studies. Detailed information is essential for any surgery or endovascular intervention in this location.