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1.
Surg Neurol Int ; 15: 287, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39246759

RESUMO

Background: Human herpesvirus 6 (HHV-6) is a double-stranded DNA virus well established in the clinical literature to cause the near-universal childhood infection roseola infantum (exanthema subitum/sixth disease). Primary HHV-6 infection has been reported to cause meningoencephalitis in pediatric patients, although generally in the immunocompromised. Case Description: The authors treated an immunocompetent 18-month-old female who transferred to our institution for a higher level of care given concerns for meningitis in the setting of decreased level of arousal (Glasgow Coma Scale 12), and bradycardia 9 days after the onset of nasal congestion, fatigue, and repeated bouts of emesis. Outside hospital cerebrospinal fluid (CSF) studies were notable for hypoglycorrhachia, elevated protein, elevated nucleated cells with a mononuclear predominance, and a meningitis polymerase chain reaction panel that was positive only for HHV-6. Brain magnetic resonance imaging with and without contrast revealed a basal cistern predominant leptomeningeal enhancement pattern as well as moderate ventriculomegaly with associated periventricular edema concerning acute communicating hydrocephalus. Considering the CSF studies, neuroimaging, and recent travel history to Mexico, central nervous system (CNS) tuberculosis (TB) was the leading suspicion, and antimicrobial therapy was initiated for this presumptive diagnosis with culture data only proving the TB suspicion correct after nearly 2 months in culture. Anti-viral therapy was initially not felt to be necessary as the HHV-6 was interpreted as incidental and not a cause of symptomatic meningitis in our immunocompetent host. The patient's hydrocephalus was treated with temporary CSF diversion followed by performance of an endoscopic third ventriculostomy. Despite appropriate hydrocephalus management, clinical improvement ultimately seemed to correlate with the initiation of antiviral therapy. Conclusion: The authors present this case and review the literature on HHV-6-associated CNS infections with the goal of informing the neurosurgeon about this often clinically underestimated pathogen.

2.
Surg Neurol Int ; 14: 179, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37292407

RESUMO

Background: Aneurysmal bone cysts (ABCs) are locally invasive bone tumors that most commonly arise in long bone metaphyses, the vertebral column, and pelvis, often presenting in the second decade of life. ABCs can be treated with resection, radiation, arterial embolization, and intralesional curettage. More recently intralesional doxycycline foam injections, which appear to act through the inhibition of matrix metalloproteinases and angiogenesis, have been used successfully, although multiple treatments are often required with this approach. Case Description: A 13-year-old male with an incidentally discovered ABC filling much of the odontoid process but not violating the native odontoid cortex was treated with a single intralesional doxycycline foam injection delivered through a transoral approach with an excellent radiographic result. After placing a Crowe-Davis retractor, a transoral exposure of the odontoid process was performed with neuronavigation guidance. A fluoroscopy-guided Jamshidi needle biopsy was performed and via the needle doxycycline foam (2 mL 50 mg/mL doxycycline, 2 mL 25% albumin, and 1 mL Isovue 370 mixed with 5 mL of air) was infused, filling the cystic cavities of the odontoid process. The patient tolerated the operation well. Two months postoperatively, a computed tomography (CT) scan demonstrated a decrease in the size of the lesion with substantial new bone formation. Repeat CT at 6 months showed no residual cystic lucency, formation of dense new bone, and only minimal irregularity of the cortex at the prior needle biopsy site. Conclusion: This case illustrates that the use of doxycycline foam can be an excellent option when managing ABCs that cannot be resected without incurring significant morbidity.

3.
Pediatr Neurosurg ; 58(3): 179-184, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37232030

RESUMO

INTRODUCTION: Achondroplasia is the most common form of short-limb dwarfism in humans, with an incidence of 1 in 25,000-40,000 live births. About one-third of achondroplasia patients will require operative intervention for lumbar spinal stenosis, generally presenting with progressive neurogenic claudication. The anatomy of the achondroplastic lumbar spine, with shortened pedicles, hypertrophic zygapophyseal joints, and thickened laminae frequently results in the development of multilevel interapophyseolaminar stenosis, while stenosis is usually absent at the mid-laminar levels secondary to pseudo-scalloping of the vertebral bodies. Treatment remains controversial, as disrupting the posterior tension band with complete laminectomies in the pediatric population puts patients at risk of developing post-laminectomy kyphosis. CASE PRESENTATION: A 15-year-old girl with achondroplasia presented to clinic with debilitating neurogenic claudication in the setting of multilevel lumbar interapophyseolaminar stenosis. We present a technical case report of her successful surgical treatment using a midline posterior tension band sparing modification to the interapophyseolaminar decompression technique proposed by Thomeer et al. [J Neurosurg. 2002;96(3 Suppl l):292-7]. CONCLUSION: We demonstrate that an adequate interapophyseolaminar decompression can be achieved through the performance of bilateral laminotomies, bilateral medial facetectomies, and undercutting of the ventral spinous process while preserving supraspinous and interspinous ligament attachments. Given the generally multilevel nature of lumbar stenosis and longer life expectancies of pediatric achondroplasia patients, decompressive surgical interventions must aspire to minimize disruption of spine biomechanics if fusion surgery is to be avoided.


Assuntos
Acondroplasia , Descompressão Cirúrgica , Feminino , Humanos , Criança , Adolescente , Constrição Patológica/complicações , Constrição Patológica/cirurgia , Descompressão Cirúrgica/métodos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Acondroplasia/complicações , Acondroplasia/diagnóstico por imagem , Acondroplasia/cirurgia , Resultado do Tratamento
4.
Adv Mater ; 35(21): e2205709, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-36871193

RESUMO

Fibrosis remains a significant cause of failure in implanted biomedical devices and early absorption of proteins on implant surfaces has been shown to be a key instigating factor. However, lipids can also regulate immune activity and their presence may also contribute to biomaterial-induced foreign body responses (FBR) and fibrosis. Here it is demonstrated that the surface presentation of lipids on implant affects FBR by influencing reactions of immune cells to materials as well as their resultant inflammatory/suppressive polarization. Time-of-flight secondary ion mass spectroscopy (ToF-SIMS) is employed to characterize lipid deposition on implants that are surface-modified chemically with immunomodulatory small molecules. Multiple immunosuppressive phospholipids (phosphatidylcholine, phosphatidylinositol, phosphatidylethanolamine, and sphingomyelin) are all found to deposit preferentially on implants with anti-FBR surface modifications in mice. Significantly, a set of 11 fatty acids is enriched on unmodified implanted devices that failed in both mice and humans, highlighting relevance across species. Phospholipid deposition is also found to upregulate the transcription of anti-inflammatory genes in murine macrophages, while fatty acid deposition stimulated the expression of pro-inflammatory genes. These results provide further insights into how to improve the design of biomaterials and medical devices to mitigate biomaterial material-induced FBR and fibrosis.


Assuntos
Corpos Estranhos , Reação a Corpo Estranho , Humanos , Camundongos , Animais , Materiais Biocompatíveis/química , Fibrose , Lipídeos
5.
J Neurosurg Pediatr ; 28(4): 469-475, 2021 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-34330098

RESUMO

OBJECTIVE: Torcular dural sinus malformations (tDSMs) are rare pediatric cerebrovascular malformations characterized by giant venous lakes localized to the midline confluence of sinuses. Historical clinical outcomes of patients with these lesions were poor, though better prognoses have been reported in the more recent literature. Long-term outcomes in children with tDSMs are uncertain and require further characterization. The goal of this study was to review a cohort of tDSM patients with an emphasis on long-term outcomes and to describe the treatment strategy. METHODS: This study is a single-center retrospective review of a prospectively maintained data bank including patients referred to and cared for at The Hospital for Sick Children for tDSM from January 1996 to March 2019. Each patient's clinical, radiological, and demographic information, as well as their mother's demographic information, was collected for review. RESULTS: Ten patients with tDSM, with a mean follow-up of 58 months, were included in the study. Diagnoses were made antenatally in 8 patients, and among those cases, 4 families opted for either elective termination (n = 1) or no further care following delivery (n = 3). Of the 6 patients treated, 5 had a favorable long-term neurological outcome, and follow-up imaging demonstrated a decrease or stability in the size of the tDSM over time. Staged embolization was performed in 3 patients, and anticoagulation was utilized in 5 treated patients. CONCLUSIONS: The authors add to a growing body of literature indicating that clinical outcomes in tDSM may not be as poor as initially perceived. Greater awareness of the lesion's natural history and pathophysiology, advancing endovascular techniques, and individualized anticoagulation regimens may lead to continued improvement in outcomes.


Assuntos
Anticoagulantes/uso terapêutico , Dura-Máter/anormalidades , Embolização Terapêutica/métodos , Malformações do Sistema Nervoso/terapia , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Tratamento Conservador , Bases de Dados Factuais , Dura-Máter/diagnóstico por imagem , Feminino , Seguimentos , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Lactente , Recém-Nascido , Imageamento por Ressonância Magnética , Masculino , Mães , Malformações do Sistema Nervoso/tratamento farmacológico , Malformações do Sistema Nervoso/cirurgia , Gravidez , Diagnóstico Pré-Natal , Estudos Retrospectivos , Resultado do Tratamento
6.
J Clin Neurosci ; 87: 125-131, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33863519

RESUMO

Decompressive craniectomy (DC) is a life-saving procedure in severe traumatic brain injury, but is associated with higher rates of post-traumatic hydrocephalus (PTH). The relationship between the medial craniectomy margin's proximity to midline and frequency of developing PTH is controversial. The primary study objective was to determine whether average medial craniectomy margin distance from midline was closer to midline in patients who developed PTH after DC for severe TBI compared to patients that did not. The secondary objective was to determine if a threshold distance from midline could be identified, at which the risk of developing PTH increased if the DC was performed closer to midline than this threshold. A retrospective review was performed of 380 patients undergoing DC at a single institution between March 2004 and November 2014. Clinical, operative and demographic variables were collected, including age, sex, DC parameters and occurrence of PTH. Statistical analysis compared mean axial craniectomy margin distance from midline in patients with versus without PTH. Distances from midline were tested as potential thresholds. No significant difference was identified in mean axial craniectomy margin distance from midline in patients developing PTH compared with patients with no PTH (n = 24, 12.8 mm versus n = 356, 16.6 mm respectively, p = 0.086). No significant cutoff distance from midline was identified (n = 212, p = 0.201). This study, the largest to date, was unable to identify a threshold with sufficient discrimination to support clinical recommendations in terms of DC margins with regard to midline, including thresholds reportedly significant in previously published research.


Assuntos
Craniectomia Descompressiva/métodos , Craniectomia Descompressiva/normas , Hidrocefalia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adulto , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Hidrocefalia/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
7.
Expert Rev Med Devices ; 18(7): 669-696, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33539198

RESUMO

INTRODUCTION: Computer-assisted surgery (CAS) is a broad surgical methodology that utilizes computer technology to both plan and execute surgical intervention. CAS is widespread in both medicine and dentistry as it allows for minimally invasive and precise surgical procedures. Key innovations in volumetric imaging, virtual surgical planning software, instrument tracking, and robotics have assisted in facilitating the transfer of surgical plans to precise execution of surgical procedures. CAS has long been used in certain medical specialties including neurosurgery, cardiology, orthopedic surgery, otolaryngology, and interventional radiology, and has since expanded to oral and maxillofacial application, particularly for computer-assisted implant surgery. AREAS COVERED: This review provides an updated overview of the most current research for CAS in medicine and dentistry, with a focus on neurosurgery and dental implant surgery. The MEDLINE electronic database was searched and relevant original and review articles from 2005 to 2020 were included. EXPERT OPINION: Recent literature suggests that CAS performs favorably in both neurosurgical and dental implant applications. Computer-guided surgical navigation is well entrenched as standard of care in neurosurgery. Whereas static computer-assisted implant surgery has become established in dentistry, dynamic computer-assisted navigation is newly poised to trend upward in dental implant surgery.


Assuntos
Robótica , Cirurgia Assistida por Computador , Humanos , Imageamento Tridimensional , Planejamento de Assistência ao Paciente , Software
8.
Oper Neurosurg (Hagerstown) ; 20(2): 183-188, 2021 01 13.
Artigo em Inglês | MEDLINE | ID: mdl-32974661

RESUMO

BACKGROUND: Given the morbidity and cost associated with cerebrospinal fluid shunt infections, many neurosurgical protocols implement "no-touch" technique to minimize infection. However, current surgical tools are not designed specifically for this task and surgeons often resort to using their hands to connect the shunt catheter to the valve. OBJECTIVE: To develop an efficient and effective shunt assembly tool. METHODS: Prototypes were designed using computer assisted software and machined in stainless steel. The amount of time and number of attempts it took volunteers to connect a Bacticel shunt catheter to a Delta valve were recorded using the new tool and standard shodded mosquitos. Scanning electron microscopy (SEM) was done on manipulated catheters to assess potential damage. Practicing neurosurgeons provided feedback. RESULTS: Nonsurgeon (n = 13) volunteers and neurosurgeons (n = 6) both completed the task faster and with fewer attempts with the new tool (mean 7.18 vs 15.72 s and 2.00 vs 6.36 attempts, P < .0001; mean 2.93 vs 5.96 s and 1.06 vs 2.94 attempts, P < .001, respectively). SEM of 24 manipulated catheters showed no microscopic damage. 100% of neurosurgeons surveyed (n = 10) would adapt the tool in their practice, 90% preferred use of the new tool compared to their existing method, and 100% rated it easier to use compared to existing instruments. CONCLUSION: The new tool shortened the time and number of attempts to connect a shunt catheter to a valve. Neurosurgeons preferred the new tool to existing instruments. There was no evidence of catheter damage with the use of this tool.


Assuntos
Hidrocefalia , Catéteres , Derivações do Líquido Cefalorraquidiano , Humanos , Hidrocefalia/cirurgia , Neurocirurgiões , Próteses e Implantes
9.
Spine (Phila Pa 1976) ; 45(11): 718-726, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31923127

RESUMO

STUDY DESIGN: Retrospective study. OBJECTIVE: To define distinct Klippel-Feil syndrome (KFS) patient phenotypes that are associated with the need for surgical intervention. SUMMARY OF BACKGROUND DATA: KFS is characterized by the congenital fusion of cervical vertebrae; however, patients often present with a variety of other spinal and extraspinal anomalies suggesting this syndrome encompasses a heterogeneous patient population. Moreover, it remains unclear how the abnormalities seen in KFS correlate to neurological outcomes and the need for surgical intervention. METHODS: Principal component (PC) analysis was performed on 132 KFS patients treated at a large pediatric hospital between 1981 and 2018. Thirty-five variables pertaining to patient/disease-related factors were examined. Significant PCs were included as independent variables in multivariable logistic regression models designed to test associations with three primary outcomes: cervical spine surgery, thoracolumbar/sacral spine surgery, and cranial surgery. RESULTS: Fourteen significant PCs accounting for 70% of the variance were identified. Five components, representing four distinct phenotypes, were significantly associated with surgical intervention. The first group consisted of predominantly subaxial cervical spine fusions, thoracic spine abnormalities and was associated with thoracolumbar/sacral spine surgery. The second group was largely represented by axial cervical spine anomalies and had high association with cervical subluxation and cervical spine surgery. A third group, heavily represented by Chiari malformation, was associated with cranial surgery. Lastly, a fourth group was defined by thoracic vertebral anomalies and associations with sacral agenesis and scoliosis. This phenotype was associated with thoracolumbar/sacral spine surgery. CONCLUSION: This is the first data-driven analysis designed to relate KFS patient phenotypes to surgical intervention and provides important insight that may inform targeted follow-up regimens and surgical decision-making. LEVEL OF EVIDENCE: 3.


Assuntos
Síndrome de Klippel-Feil/diagnóstico , Síndrome de Klippel-Feil/cirurgia , Fenótipo , Escoliose/diagnóstico , Escoliose/cirurgia , Fusão Vertebral/métodos , Adolescente , Malformação de Arnold-Chiari/diagnóstico , Malformação de Arnold-Chiari/epidemiologia , Malformação de Arnold-Chiari/cirurgia , Vértebras Cervicais/cirurgia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Luxações Articulares/diagnóstico , Luxações Articulares/epidemiologia , Luxações Articulares/cirurgia , Síndrome de Klippel-Feil/epidemiologia , Vértebras Lombares/cirurgia , Masculino , Estudos Retrospectivos , Sacro/cirurgia , Escoliose/epidemiologia , Vértebras Torácicas/cirurgia , Resultado do Tratamento
10.
Childs Nerv Syst ; 36(4): 877, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31955216

RESUMO

The original version of this article unfortunately contained an error. The author apologizes for having provided an incorrect name: "Ali Moghadammjou" should be "Ali Moghaddamjou". Given in this article is the correct author name.

11.
Childs Nerv Syst ; 36(1): 189-195, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31705188

RESUMO

The supplementary motor area (SMA) syndrome is characterized by transient weakness and akinesia contralateral to the side of the affected hemisphere. The underlying pathology of the syndrome is not fully understood but is thought to be related to lesions in the SMA, residing principally in the mesial superior frontal gyrus (Broadmann's area 6c). Although the SMA syndrome a well-characterized clinical entity, we report herein, to our knowledge, the first case of isolated lower extremity SMA syndrome in the literature. This case highlights the importance of considering this rare clinical entity in the context of new or worsening postoperative neurologic deficits. Moreover, early studies did not support somatotopic organization of the SMA as in the primary motor cortex; emerging evidence suggests that delicate somatotopic representation may underlie distinct presentations like that reported in the present case.


Assuntos
Neoplasias Encefálicas , Córtex Motor , Humanos , Extremidade Inferior , Período Pós-Operatório , Síndrome
12.
World Neurosurg ; 112: 161-165, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29409926

RESUMO

Craniectomy is a frequently performed neurosurgical procedure, and coverage of the cranial defect is necessary for protection of the underlying brain, cosmesis, and patient satisfaction. We report a new technique for intraoperative in situ synthetic cranioplasty that provides one-step resection of skull osteomas and reconstruction of cranial defects. Strategies of intraoperative cranioplasty are reviewed. A 48-year-old man who presented with a suspected benign osteoma over his forehead was offered surgical excision and primary cranioplasty in a one-step procedure using hydroxyapatite bone cement, a dural prosthetic, and a resorbable plate. Following craniectomy around the lesion, there was evidence of dural and bone involvement. The craniectomy was enlarged, and the involved dura was resected. SYNTHECEL dura repair was used to repair the dural defect and at the same time fashioned to form a receptacle for the cranioplasty by fixation of the dural substrate to the cut vertical bone edges. DirectInject hydroxyapatite bone cement was used to fill the receptacle and contoured to the curvature of the adjacent skull. A Delta resorbable plate was then placed over the bone cement and fixed to the skull. This technique provided a satisfactory cosmetic outcome following craniectomy for benign skull tumor excision. When possible, one-step surgery with primary cranioplasty should be considered.


Assuntos
Cimentos Ósseos , Craniotomia/métodos , Osteoma/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Neoplasias Cranianas/cirurgia , Crânio/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
13.
J Biomed Mater Res B Appl Biomater ; 106(3): 1268-1279, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28631360

RESUMO

The majority of patients with hydrocephalus are dependent on ventriculoperitoneal shunts for diversion of excess cerebrospinal fluid. Unfortunately, these shunts are failure-prone and over half of all life-threatening pediatric failures are caused by obstruction of the ventricular catheter by the brain's resident immune cells, reactive microglia and astrocytes. Poly(2-hydroxyethyl methacrylate) (PHEMA) hydrogels are widely used for biomedical implants. The extreme hydrophilicity of PHEMA confers resistance to protein fouling, making it a strong candidate coating for ventricular catheters. With the advent of initiated chemical vapor deposition (iCVD), a solvent-free coating technology that creates a polymer in thin film form on a substrate surface by introducing gaseous reactant species into a vacuum reactor, it is now possible to apply uniform polymer coatings on complex three-dimensional substrate surfaces. iCVD was utilized to coat commercially available ventricular catheters with PHEMA. The chemical structure was confirmed on catheter surfaces using Fourier transform infrared spectroscopy and X-ray photoelectron spectroscopy. PHEMA coating morphology was characterized by scanning electron microscopy. Testing PHEMA-coated catheters against uncoated clinical-grade catheters in an in vitro hydrocephalus catheter bioreactor containing co-cultured astrocytes and microglia revealed significant reductions in cell attachment to PHEMA-coated catheters at both 17-day and 6-week time points. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1268-1279, 2018.


Assuntos
Catéteres , Adesão Celular/efeitos dos fármacos , Derivações do Líquido Cefalorraquidiano , Materiais Revestidos Biocompatíveis , Poli-Hidroxietil Metacrilato/farmacologia , Animais , Astrócitos/efeitos dos fármacos , Técnicas de Cocultura , Falha de Equipamento , Imuno-Histoquímica , Camundongos , Microglia/efeitos dos fármacos , Espectroscopia Fotoeletrônica , Ratos , Espectroscopia de Infravermelho com Transformada de Fourier , Derivação Ventriculoperitoneal
14.
Neurosurgery ; 83(4): 732-739, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29029289

RESUMO

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a potentially treatable cause of poor recovery from traumatic brain injury (TBI) that remains poorly understood, particularly among children. OBJECTIVE: To better understand the risk factors for pediatric PTH using a large, multi-institutional database. METHODS: We conducted a retrospective cohort study using administrative data from 42 pediatric hospitals participating in the Pediatric Health Information System. All patients ≤21 yr surviving a hospitalization with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for TBI were identified. The primary outcome was PTH, defined by an ICD-9-CM procedure code for surgical management of hydrocephalus within 6 mo. Data were analyzed using multivariable logistic regression. RESULTS: We identified 91 583 patients ≤21 yr with TBI, 846 of whom developed PTH. Odds of PTH were significantly higher in children <1 yr compared to older age groups. A total of 48.7% of PTH cases were victims of abuse (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 2.16-3.18). PTH was more common after craniotomy (aOR 1.60, 95% CI 1.30-1.97). Craniectomy without early cranioplasty was associated with markedly increased odds of PTH (aOR 3.67, 95% CI 2.66-5.07), an effect not seen in those undergoing cranioplasty within 30 d (aOR 1.19, 95% CI 0.75-1.89). CONCLUSION: PTH was seen in 0.9% of children who sustained a TBI and was more common in those <1 yr. Severe injury, abuse, and craniectomy with delayed cranioplasty were associated with greatly increased likelihood of PTH. Early cranioplasty in children who require craniectomy may reduce the risk for PTH.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/epidemiologia , Sistemas de Informação em Saúde/tendências , Hospitais Pediátricos/tendências , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/epidemiologia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Craniotomia/efeitos adversos , Feminino , Humanos , Hidrocefalia/cirurgia , Lactente , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X/tendências , Adulto Jovem
15.
Oper Neurosurg (Hagerstown) ; 13(5): 566-575, 2017 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-28922884

RESUMO

BACKGROUND: Pineal region tumors are rare intracranial tumors that are more common in children than adults. Surgical management of tumors in this region using a tailored approach is a strategy that enhances extent of resection and neurological outcome. OBJECTIVE: To review our institutional experience with pineal region tumors in children and adults over the past 10 years. METHODS: Our institutional pathology database and patient records were retrospectively reviewed for details regarding clinical and radiological presentation, surgical management, extent of resection, morbidity, and neurological outcome. Statistical analysis was performed to assess for variables related to functional outcomes. RESULTS: Fifty patients were identified as having undergone surgical management of a pineal region tumor with at least 1 year of follow-up. Forty-one percent presented with a Karnofsky Performance Scale (KPS) score of 70 or less, all of whom had concomitant hydrocephalus that required urgent treatment. The following variables were statistically significant to KPS score on admission: age, tumor volume, preoperative hydrocephalus, length of hospitalization (total and intensive care unit), and elevations in serum tumor markers. The median postoperative (2 months) KPS score was 90. The following variables were statistically significant with respect to change in KPS score postoperatively: tumor maximum diameter, KPS score on admission, and intensive care unit length of stay. The specific surgical strategy did not correlate to extent of tumor resection, morbidity, immediate neurological outcome, and progression-free survival. CONCLUSION: Extent of resection, neurological outcome, and progression-free survival in the patients in our series were not related to the specific surgical approach employed and its perioperative complications.


Assuntos
Neoplasias Encefálicas/cirurgia , Glândula Pineal/cirurgia , Pinealoma/cirurgia , Ventriculostomia/métodos , Adolescente , Adulto , Fatores Etários , Neoplasias Encefálicas/complicações , Criança , Pré-Escolar , Feminino , Humanos , Hidrocefalia/etiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Pinealoma/complicações , Estudos Retrospectivos , Adulto Jovem
16.
Pediatr Neurosurg ; 52(6): 381-400, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28249297

RESUMO

Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.


Assuntos
Derivações do Líquido Cefalorraquidiano/efeitos adversos , Falha de Equipamento , Hidrocefalia/cirurgia , Hidrocefalia/terapia , Complicações Pós-Operatórias , Catéteres/efeitos adversos , Derivações do Líquido Cefalorraquidiano/instrumentação , Humanos , Neurocirurgiões , Pediatria , Próteses e Implantes
17.
J Neurosurg Pediatr ; 18(2): 213-23, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27035548

RESUMO

OBJECTIVE Shunt obstruction by cells and/or tissue is the most common cause of shunt failure. Ventricular catheter obstruction alone accounts for more than 50% of shunt failures in pediatric patients. The authors sought to systematically collect explanted ventricular catheters from the Seattle Children's Hospital with a focus on elucidating the cellular mechanisms underlying obstruction. METHODS In the operating room, explanted hardware was placed in 4% paraformaldehyde. Weekly, samples were transferred to buffer solution and stored at 4°C. After consent was obtained for their use, catheters were labeled using cell-specific markers for astrocytes (glial fibrillary acidic protein), microglia (ionized calcium-binding adapter molecule 1), and choroid plexus (transthyretin) in conjunction with a nuclear stain (Hoechst). Catheters were mounted in custom polycarbonate imaging chambers. Three-dimensional, multispectral, spinning-disk confocal microscopy was used to image catheter cerebrospinal fluid-intake holes (10× objective, 499.2-µm-thick z-stack, 2.4-µm step size, Olympus IX81 inverted microscope with motorized stage and charge-coupled device camera). Values are reported as the mean ± standard error of the mean and were compared using a 2-tailed Mann-Whitney U-test. Significance was defined at p < 0.05. RESULTS Thirty-six ventricular catheters have been imaged to date, resulting in the following observations: 1) Astrocytes and microglia are the dominant cell types bound directly to catheter surfaces; 2) cellular binding to catheters is ubiquitous even if no grossly visible tissue is apparent; and 3) immunohistochemical techniques are of limited utility when a catheter has been exposed to Bugbee wire electrocautery. Statistical analysis of 24 catheters was performed, after excluding 7 catheters exposed to Bugbee wire cautery, 3 that were poorly fixed, and 2 that demonstrated pronounced autofluorescence. This analysis revealed that catheters with a microglia-dominant cellular response tended to be implanted for shorter durations (24.7 ± 6.7 days) than those with an astrocyte-dominant response (1183 ± 642 days; p = 0.027). CONCLUSIONS Ventricular catheter occlusion remains a significant source of shunt morbidity in the pediatric population, and given their ability to intimately associate with catheter surfaces, astrocytes and microglia appear to be critical to this pathophysiology. Microglia tend to be the dominant cell type on catheters implanted for less than 2 months, while astrocytes tend to be the most prevalent cell type on catheters implanted for longer time courses and are noted to serve as an interface for the secondary attachment of ependymal cells and choroid plexus.


Assuntos
Astrócitos , Derivações do Líquido Cefalorraquidiano/efeitos adversos , Falha de Equipamento , Hidrocefalia/cirurgia , Macrófagos , Complicações Pós-Operatórias/etiologia , Criança , Pré-Escolar , Compreensão , Desenho de Equipamento/tendências , Feminino , Humanos , Hidrocefalia/diagnóstico , Lactente , Masculino , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos
18.
J Neurointerv Surg ; 8(10): 1084-94, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26475475

RESUMO

BACKGROUND AND PURPOSE: Hemangiopericytomas (HPCs) are rare dural-based neoplasms. Preoperative embolization of these notoriously hypervascular tumors can be challenging as they often receive their dominant blood supply from pial feeders arising from the internal carotid artery (ICA) or vertebrobasilar (VB) circulation. This study reviews our historical experience with HPC embolization and introduces the transtumoral technique for backfilling pial tumor vasculature by delivering Onyx-18 through diminutive external carotid artery (ECA) feeders. METHODS: A retrospective review of all preoperative HPC embolizations performed at Anonymous University #1 (September 2002-November 2014) and Anonymous University #2 (January 2014-November 2014) is presented. RESULTS: Fifteen patients with pathologically confirmed HPC underwent 17 embolizations. More extensive devascularization percentages were achieved for HPCs with primarily ECA blood supply (76.4±10.7%; n=6) than with HPCs supplied via the ICA/VB circulation (57.9±26.9%; n=8; p=0.046). There was a trend towards greater devascularization of ICA/VB-dominant HPCs embolized with Onyx (70.0±34.6%; n=4) versus polyvinyl alcohol particles (33.3±15.3%; n=3). The extent of angiographic devascularization negatively correlated with intraoperative blood loss (rho=-0.71; p=0.005). There were no embolization-related complications. CONCLUSIONS: The extent of preoperative embolization of HPCs correlates with decreased intraoperative blood loss. However, HPCs with an ICA/VB-dominant blood supply remain challenging embolization targets, demonstrating reduced devascularization percentages compared with ECA-dominant counterparts. The authors favor the use of Onyx for ICA/VB-dominant HPCs, noting a trend towards an improved devascularization rate.


Assuntos
Neoplasias Encefálicas/terapia , Embolização Terapêutica/métodos , Hemangiopericitoma/terapia , Adulto , Idoso , Perda Sanguínea Cirúrgica , Neoplasias Encefálicas/diagnóstico por imagem , Artéria Carótida Externa/diagnóstico por imagem , Combinação de Medicamentos , Procedimentos Endovasculares/métodos , Feminino , Hemangiopericitoma/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Álcool de Polivinil , Polivinil , Estudos Retrospectivos , Stents , Tantálio , Resultado do Tratamento , Adulto Jovem
19.
Surg Neurol Int ; 7: 105, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28168091

RESUMO

BACKGROUND: Complications of intrathecal baclofen (ITB) pump implantation for treatment of pediatric patients with spasticity and dystonia associated with cerebral palsy remain unacceptably high. To address the concern that some patients may have underlying arrested hydrocephalus, which is difficult to detect clinically because of a low baseline level of neurological function, and may contribute to the high rates of postoperative cerebrospinal fluid leak, wound breakdown, and infection associated with ITB pump implantation, the authors implemented a standardized protocol including mandatory cranial imaging and assessment of intracranial pressure (ICP) by lumbar puncture prior to ITB pump implantation. METHODS: A retrospective case series of patients considered for ITB pump implantation between September 2012 and October 2014 at Seattle Children's Hospital is presented. All patients underwent lumbar puncture under general anesthesia prior to ITB pump implantation and, if the opening pressure was greater than 21 cmH2O, ITB pump implantation was aborted and alternative management options were presented to the patient's family. RESULTS: Eighteen patients were treated during the study time period. Eight patients (44.4%) who had ICPs in excess of 21 cmH2O on initial LP were identified. Eleven patients (61.1%) ultimately underwent ITB pump implantation (9/10 in the "normal ICP" group and 2/8 in the "elevated ICP" group following ventriculoperitoneal shunt placement), without any postoperative complications. CONCLUSIONS: Given the potentially high rate of elevated ICP and arrested hydrocephalus, the authors advocate pre-implantation assessment of ICP under controlled conditions and a thoughtful consideration of the neurosurgical management options for patients with elevated ICP.

20.
Fluids Barriers CNS ; 12: 26, 2015 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-26578355

RESUMO

BACKGROUND: Shunt obstruction in the treatment of hydrocephalus is poorly understood, is multi-factorial, and in many cases is modeled ineffectively. Several mechanisms may be responsible, one of which involves shunt infiltration by reactive cells from the brain parenchyma. This has not been modeled in culture and cannot be consistently examined in vivo without a large sample size. METHODS: We have developed and tested a three-dimensional in vitro model of astrocyte migration and proliferation around clinical grade ventricular catheters and into catheter holes that mimics the development of cellular outgrowth from the parenchyma that may contribute to shunt obstruction. RESULTS: Cell attachment and growth was observed on shunt catheters for as long as 80 days with at least 77% viability until 51 days. The model can be used to study cellular attachment to ventricular catheters under both static and pulsatile flow conditions, which better mimic physiological cerebrospinal fluid dynamics and shunt system flow rates (0.25 mL/min, 100 pulses/min). Pulsatile flow through the ventricular catheter decreased cell attachment/growth by 63% after 18 h. Under both conditions it was possible to observe cells accumulating around and in shunt catheter holes. CONCLUSIONS: Alone or in combination with previously-published culture models of shunt obstruction, this model serves as a relevant test bed to analyze mechanisms of shunt failure and to test catheter modifications that will prevent cell attachment and growth.


Assuntos
Astrócitos/patologia , Derivações do Líquido Cefalorraquidiano/efeitos adversos , Hidrocefalia/fisiopatologia , Modelos Anatômicos , Falha de Prótese , Líquido Cefalorraquidiano/fisiologia , Desenho de Equipamento , Humanos , Hidrogel de Polietilenoglicol-Dimetacrilato , Alicerces Teciduais
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