Epidemiology, clinical profile, and outcomes of CSF-diversion catheter-related infections - Prospective cohort study results from a single quaternary neurosurgery referral centre.

BACKGROUND: Device-associated CNS infections is a major subgroup of healthcare associated CNS infections. Healthcare-associated ventriculitis or meningitis differs considerably from community-acquired meningitis in its epidemiology, pathogenesis, clinical presentation and management. OBJECTIVES: This study aimed to identify the infection rates, the associated risk factors, and outcomes of these life-threatening infections. METHODS: This was a 2-year single center prospective cohort study. Patient's clinical data, laboratory parameters, treatment and their outcomes were collected using data collection tool, and device days were collected from the hospital information system (HIS). Patients were categorised using IDSA criteria as contamination or colonisation or infection. Cox regression model was used for multivariate analysis to estimate hazard risk. RESULTS: A total of 578 CSF diversion catheters were inserted in 472 patients. The average rate for EVD and LD infection were 11.12 and 11.86 per 1000 device days respectively. The average infection rates for VP and LP shunts were 6% and 5.2% per procedure, respectively. The commonest etiological agent causing CSF diversion catheter-related infection (CDRI) was Klebsiella pneumoniae (n = 14, 40%). The risk factors which were independently associated with increased infection risk by cox regression analysis were drain insertion ≥7 days [HR:11.73, p -0.03], posterior approach of EVD insertion (occipital) [HR:9.53, p - 0.01], pre-OP ASA score>3 [HR:8.28, p - 0.013] presence of EVD/LD leak [HR: 17.24, p < 0.0001], male gender [HR:2.05, p-0.05] and presence of associated peri-operative scalp infections [HR:3.531, p-0.005]. Shift to narrow spectrum surgical prophylactic antibiotic [Coefficient: -1.284, p-0.03] and reduction in CSF sampling frequency [Coefficient: -1.741, p-0.02] were found to be negatively associated with CDRI. CONCLUSIONS: The study demonstrated drain insertion ≥7 days, posterior approach of EVD insertion, presence of EVD/LD leak, male gender and presence of associated peri-operative scalp skin and soft tissue infections were associated with increased risk of infection.

Colloid Cyst: Revision of Third Ventricular Zones for Risk Stratification of Hydrocephalus.

OBJECTIVE: We sought to reclassify the "anatomic risk zones of colloid cysts" as proposed by Beaumont et al, by proposing newer landmarks, and to assess predictive value for the risk of occurrence of hydrocephalus with the new classification compared with the old. METHODS: A retrospective cohort of 122 cases of colloid cyst of third ventricle were categorized into zones 1, 2, or 3 based on Beaumont's classification (old zone) and our classification (new zone) based on radiologic images. We attempted to recategorize these zones by assigning new anatomic landmarks. The difference in zonal distribution of colloid cyst and association with hydrocephalus was studied using the 2 methods of zonal classification. RESULTS: Per the old zone classification, 3/122 patients were in zone 2, whereas 21/122 were in zone 2 per the new zone classification. The new zone method had a higher specificity (36.21% vs. 5.263 %) and positive predictive value (63.37% vs. 54.23%) for occurrence of hydrocephalus in patients with colloid cyst. The Spearman correlation showed better correlation with the new method for occurrence of hydrocephalus (rho = 0.4 [P < 0.00000] vs. 0.2 [P = 0.011]). CONCLUSIONS: Symptomatic colloid cysts are more likely to develop hydrocephalus and sudden acute deterioration. The colloid cyst risk score is a step towards objective decision making, with scope for modification such as the one that we have attempted with new zone classification to achieve superior prognostic ability.

Unique presentation of occipital condyle giant cell tumor as occipital condyle syndrome - A review.

Giant cell tumors (GCTs) of the skull are rare and only a few case series with limited number of cases have been reported till date. In the cranium, GCT usually occurs in the sphenoid and temporal bone, occipital condyle GCTs are very rare. We report a rare presentation of GCT of the occipital condyle manifested as occipital condyle syndrome. Despite gross total resection, they can recur aggressively; the presence of cortical breach might be an indicator of aggressiveness prompting early post-operative imaging and adjuvant therapy.

At the Eye of the Hurricane! Perioperative Management of an Unoptimized Metastatic Pheochromocytoma Presenting for Emergency Neurosurgery.

Metastatic pheochromocytoma (PCC) is a rare entity arising from extra-adrenal tissue. We report the perioperative management of a young woman presenting with metastatic PCC to the vertebral body resulting in vertebral collapse and spinal cord compression necessitating emergency surgery. There are no reports of anesthetic management of a patient with unoptimized metastatic PCC presenting for emergency neurosurgery under general anesthesia. Our anesthetic goals were to maintain a deep anesthetic plane with stable hemodynamics, facilitate intraoperative neuromonitoring, manage catecholamine surges during anesthetic induction, tumor resection, and manage perioperative massive blood loss. The successful perioperative management of metastatic PCC has become possible with the vast armamentarium of anesthetic drugs and intraoperative advanced monitoring techniques. In addition, our role in understanding the pathophysiology and course of the disease is essential to ensure low morbidity and mortality of such cases in their most vulnerable perioperative period.

Complex split cord malformation with split conus.

Split cord malformations are disorders of gastrulation. Disorders of secondary neurulation occur later and are traditionally considered separate from the former. Complex split cord malformations involving both the cord and the conus and encompassing the epochs of gastrulation, primary neurulation, junctional neurulation, and secondary neurulation have not been described in literature. We present a four-year-old boy with such a malformation and postulate the embryological mechanism involved. The clinical vignette of this unique case has been described. We report a good clinical outcome in this patient with surgical management.

Compressive vertebral hemangiomas with neurological deficits: diagnosis, surgical strategies and long term outcome.

PURPOSE: Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience. MATERIALS AND METHODS: The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed. RESULTS: There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up. CONCLUSIONS: Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.

Split Cord Malformation Type 2 with Double Dorsal Lipoma: A Sequela or a Chance.

An 11-month-old baby girl, with normal perinatal history, presented with a congenital lumbosacral swelling and a sacral dimple. Imaging revealed a split cord malformation (SCM) type 2 at L1-L3 with a lipomeningocoele extending intradurally and tethering both the hemicords, the conus was noted to be at L4. She underwent excision of the lipoma and detethering of the hemicords. Intraoperatively, the split cord was seen from L1 to L3 with an aberrant median vessel passing between the hemicords. Two lipomas were seen separately attached to each of the hemicords, the lipomas were dissected off the hemicords, and the hemicords were neurulated. The case helps revisit the unified theory proposed by Pang for SCM as well as the theory of premature disjunction in the pathogenesis of lipomeningocoele. Formation of the endomesenchymal tract splits the developing cord into two, whereas the premature detachment of neuroectoderm from the cutaneous ectoderm can lead to lipomeningocoeles. The present case is only the fourth case ever reported of an SCM type 2 with double lipoma. In the case report, we discuss the embryological basis of this condition and surgical nuances of management.

Spinal angiolipoma-a rare but reversible cause of paraplegia in a child.

PURPOSE: Spinal angiolipomas are benign spinal epidural tumors consisting of mature fat cells with angiomatous components. These tumors are rare in children and there are no definite management guidelines. METHOD: To the best of our knowledge, only five cases of spinal angiolipomas have been reported in children below 12 years. This article discusses the presentation, diagnostics, and surgical tips for the management of a case of spinal angiolipoma. RESULT: In this paper, we present a one and half-year-old child presenting with a spontaneous spinal epidural hematoma from a spinal angiolipoma and underscore the importance of early surgery in a benign disease for a good outcome. CONCLUSION: Overall neurological recovery and prognosis following timely intervention for spinal angiolipomas are good.