Laparoscopic-assisted distal ventriculoperitoneal shunt placement.

BACKGROUND: Intraperitoneal adhesions, obesity, and distorted abdominal anatomy in shunt-dependent hydrocephalic patients are patient characteristics that increase distal ventriculoperitoneal (VP) shunt failure rates. The use of laparoscopic-aided placement of the distal VP catheter as a technique to decrease the failure rate is evaluated in these patients. METHOD: Thirteen hydrocephalus patients considered to either have intra-abdominal adhesions, be obese, or have distorted abdominal anatomy underwent laparoscopic-aided distal VP catheter placement or revision. Two had shunts placed for the first time and eleven had revisions. Eight patients had revisions performed by both the standard minilaparotomy and laparoscopic methods, but at different times. The average surgical times for both techniques were looked at for these eight patients. Case illustrations are presented. RESULTS: In patients who had both types of abdominal approaches, the average surgical time was 81 min for the laparoscopic-aided technique versus 116 min for the minilaparotomy procedure. The only complication related directly to the laparoscopic procedure was one wound infection. CONCLUSION: In patients with intra-abdominal adhesions, obesity, or distorted abdominal anatomy, laparoscopic-aided distal shunt insertion increases the success rate by its direct visual capability and the ability to lyse abdominal adhesions and position the distal end of the catheter in a desired place.

Byron Stookey: "the old lion"--an unsung giant of neurosurgery.

BYRON POLK STOOKEY, an outstanding clinician and teacher, served as Director and Chief of Neurosurgery at the Neurological Institute of New York Columbia-Presbyterian Medical Center. Highlights of his clinical contributions include improved peripheral nerve and spine surgery and subtemporal trigeminal nerve section for tic douloureux. Through diverse activities in both the political and academic arenas of patient care, education, and research, stookey helped to build and strengthen neurosurgery between the world wars and helped to prepare the foundation for the accomplishments of recent decades.

Intraparenchymal hemorrhage.

Spontaneous hemorrhage into the cerebral parenchyma accounts for 8% to 13% of all strokes. It is more common in males, in blacks, and in the elderly. Fifty percent of cases are due to the effects of chronic hypertension on intracranial perforating arteries. The basal ganglia are the most frequent site of bleeding. Lobar hematomas tend to occur in younger patients, and may be due to specific causes such as vascular malformations. Many patients will have increased intracranial pressure and will require treatment in an intensive care unit. If surgery is necessary, stereotactic aspiration and pharmaceutical clot lysis are recent developments that may be advantageous. Prognosis is related to the patient's age and neurologic condition, and to the size, location, and rapidity of formation of the hematoma.

Adenocarcinoma of the ethmoid sinus.

BACKGROUND: Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this area has led to their inclusion in series that consist mainly of maxillary antral tumors. METHODS: A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRIs, operative notes, pathology, and final outcome were all analyzed. RESULTS: Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:1 with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-up of 45 months (9-71 months) 7 patients are disease free and 1 patient has died of disease. CONCLUSIONS: Obtaining clear margins by craniofacial resection is essential to the management of adenocarcinoma of the ethmoid sinuses. Radiotherapy is reserved for positive margins, cribriform plate penetration, dural invasion, and high-grade lesions that are close to the cribriform plate. Local control was obtained in 87% of our patients.

Spinal epidural metastases: a common problem for the primary care physician.

Spinal metastases are a common complication of cancer that should be managed quickly and aggressively. Most often from lung or breast cancer (or due to lymphoma), they usually seed from blood into vertebrae and extend into the epidural space. The most common presentation is pain and weakness, and the evolution can be rapid with paraplegia within days. Better prognosis is related to slower onset and pretreatment motor status, so spinal metastases are an emergency. Testing includes X-rays, neuroimaging, myelogram/CT and most recently MRI. Treatment is guided by the severity of neurological deficits, whether compression is by soft tissue or bone, and the presence of instability. A soft tissue mass with only mild to moderate deficits can be treated with radiation. Surgery is required for severely affected patients who are deteriorating rapidly with instability and bone in the canal. New approaches and fusion techniques facilitate decompression and stabilization.

Intracranial pressure changes during bilateral radical neck dissections.

The management of the contralateral neck in patients with head and neck cancer who have undergone a radical neck dissection (RND) is controversial. A number of these patients will require a second RND. Sacrifice of both internal jugular veins (IJV) has been felt to lead to increased intracranial pressure (ICP) with subsequent neurologic sequelae. From 1987 to 1991 four patients had staged bilateral RNDs at the West Virginia University. In these patients a subarachnoid bolt was placed to directly monitor ICP. Jugular bulb, mean arterial, pulmonary artery, and central venous pressures were monitored. Electroencephalographic (EEG) monitoring was also performed. All patients demonstrated elevations in ICP immediately on head rotation. Further marked elevations were noted immediately after IJV ligation with a maximum peak at 30 minutes. Pressure levels of greater than 40 mm Hg were observed in three of four patients. Systemic hypertension was observed in response to elevated ICP (Cushing's reflex). All patients studied recovered from surgery without significant sequelae. Within 24 hours the ICP had returned to normal in all patients. Three patients required intraoperative intervention to lower their ICP. We demonstrate that even in a staged second RND there are significant rises in ICP. These are to a level that suggests emergency medical intervention is required. We feel that when the second IJV is sacrificed an increase in ICP should be anticipated, monitored, and treated accordingly.

Treatment of calcified cephalohematoma.

This is a case report concerning the surgical treatment of a calcified cephalohematoma, which was possibly caused by an intrauterine fetal monitor. This is the first report of this particular entity as a complication of an intrauterine fetal monitor. As far as we can determine, there is no detailed information available about surgical decision making or surgical techniques for removing such lesions. We operated because of the size and persistence of the lesion. We developed a procedure in which we used the bony cap of the cephalohematoma for a cranioplasty, securing it with microplates.

Treatment of head injuries in the American Civil War.

At the time of the American Civil War (1861-1865), a great deal was known about closed head injury and gunshot wounds to the head. Compression was differentiated from concussion, but localization of lesions was not precise. Ether and especially chloroform were used to provide anesthesia. Failure to understand how to prevent infection discouraged physicians from aggressive surgery. Manuals written to educate inexperienced doctors at the onset of the war provide an overview of the advice given by senior surgeons. The Union experiences in the treatment of head injury in the Civil War were discussed in the three surgical volumes of The Medical and Surgical History of the War of the Rebellion. Wounds were divided into incised and puncture wounds, blunt injuries, and gunshot wounds, which were analyzed separately. Because the patients were not stratified by severity of injury and because there was no neuroimaging, it is difficult to understand the clinical problems and the effectiveness of surgery. Almost immediately after the war, increased knowledge about cerebral localization and the development of antisepsis (and then asepsis) permitted the development of modern neurosurgery.

Indications for carotid endarterectomy.

Stroke is a major health problem in the United States. Carotid endarterectomy has been performed to prevent stroke in symptomatic and asymptomatic patients with carotid atherosclerosis. The rationale for this approach has been questioned recently and several studies were begun to determine the proper role of surgery. The initial results from studies of symptomatic patients demonstrate that surgery is urgently indicated if stenosis is at least 70%, but not if it is less than 30%. Patients with intermediate amounts of stenosis are still being evaluated. Early evidence suggests that surgery is not indicated for asymptomatic patients, but two major trials are still in progress. Surgeons performing this procedure must demonstrate low perioperative morbidity and mortality. In addition, the use of ultrasound as a screening procedure is being re-evaluated. We suggest rapid referral and evaluation of symptomatic patients with angiography, and treatment of asymptomatic patients with aspirin.

Childhood meningioma associated with meningio-angiomatosis. Case report.

This paper reports childhood meningioma in association with meningioangiomatosis. The patient was an 11-month-old baby boy who presented with a left focal seizure. He had no stigmata of neurofibromatosis. Computerized tomography and magnetic resonance imaging revealed an extra-axial, contrast-enhancing mass in the interhemispheric fissure which indented the right frontal lobe. The tumor was totally removed. Microscopically, the lesion was a fibrous and transitional meningioma with foci of necrosis and scattered mitotic figures. The adherent neural parenchyma showed the histological features of meningioangiomatosis. It is concluded that meningioangiomatosis may accompany childhood meningiomas more often than is generally appreciated.

Ventriculopleural shunting used as a temporary diversion.

Due to the limited absorptive capacity of the pleural cavity, infants and young children are not generally ideal candidates for ventriculopleural shunts. We report using chest cavities as alternate for temporary diversion of CSF in a young child. Venous access to the cervical region could not be utilized because of scarring from previous procedures, while peritoneal access was contraindicated due to repeated pseudocyst formation. Pleural effusions were removed by thoracentesis when necessary, and the shunt catheter was changed to the opposite side of the chest when the effusions reaccumulated within one week. Utilizing the ventriculopleural shunts allowed us to temporize her non-communicating hydrocephalus for a period of one year, until a definitive CSF procedure by direct intracardiac placement of the distal catheter could be performed.

Chronic extradural haematomas: indications for surgery.

Non-invasive neuro-imaging has led to the detection of minimally symptomatic or asymptomatic chronic extradural haematomas. Our experience and review of the literature suggests that, as in the case of chronic subdural haematomas, there is development of membranes and liquifaction of the clot which may permit drainage of such collections through twist drill or burrholes. The time from development and the neuro-imaging chanes on CT and MRI can suggest the age and nature of the clot and thus permit timing of surgery so that drainage may be accomplished with a minor procedure.

Millipore analysis of valvular fluid in sterile valve malfunctions.

Malfunctions of sterile shunts may result from valvular dysfunction. The cerebrospinal fluid shunt valves of 14 patients were excised during surgery for sterile shunt malfunctions. In 6 patients, the malfunction was due specifically to a valve malfunction. Cerebrospinal fluid from each valve was passed through a millipore filter, which was then stained using either hematoxylin and eosin or periodic acid-Schiff. The stained millipore filters were examined by a neuropathologist who was unaware of the cause of the shunt malfunction. Although inflammatory cells were detected in all cases, the patients with valve malfunctions were found to have numerous macrophages and giant multinucleated reactive cells within their valves, while cerebrospinal fluid from valves that had been removed during shunt revisions for reasons other than a malfunctioning valve contained only rare mononuclear cells or macrophages. No valve contained erythrocytes, fibrinous matter, neural or glial tissue, or choroid plexus. The possible causes of valve malfunction, including infection and allergic reactions, are discussed. All patients did well after simple replacement of the valve.

Magnetic resonance imaging and posttraumatic Lhermitte's sign.

Two patients developed Lhermitte's sign after cervical spine fractures. The patients were otherwise without evidence of spinal cord dysfunction. Both patients were studied with magnetic resonance scans of the cervical spine. The magnetic resonance scans were normal. The possible etiology of Lhermitte's sign in these patients is discussed. The differential diagnosis including cervical spondylosis, combined systems degeneration, multiple sclerosis, neoplasm, and radiation myelopathy is reviewed. These patients should be carefully evaluated clinically, and flexion/extension lateral cervical spine films as well as a complete blood count and peripheral smear should be obtained. Magnetic resonance scanning may have an important role in evaluating these patients. Magnetic resonance is exquisitely sensitive in detecting demyelination; therefore, we speculate that subarachnoid scarring may be responsible for this symptom. Gadolinium-enhanced magnetic resonance scanning may confirm the presence of such scarring in the future.

Epidural lipomatosis simulating an epidural abscess: case report and literature review.

A case of epidural lipomatosis in a 49-year-old man presenting with paraparesis, midthoracic pain, and Staphylococcus aureus pneumonia is reported. The patient had been on low dose corticosteroid therapy for 7 years for rheumatoid arthritis. The clinical and myelographic findings suggested a diagnosis of epidural abscess, but the only abnormality discovered at operation was abundant fatty tissue in the dorsal epidural space significantly compressing the spinal cord, and this was partially removed. Postoperative neurological improvement suggested that the lipomatosis was responsible for the spinal cord compression and dysfunction. If this diagnosis had been suspected, it might have been confirmed by magnetic resonance imaging or postmyelography computed tomographic scanning. With such a diagnosis, an alternative treatment could have been to decrease the steroid dose, observe for clinical improvement, and perhaps avoid operation.

"High spinal" dysrhaphism. Case report of a complex cervical meningocele.

"High spinal" (cervical and upper thoracic) dysrhaphism usually involves either a meningocele or a dermal sinus tract. These high spinal lesions can have a complex intradural anatomy at the level of the lesion (as this case reports) and are associated with an increased incidence of lower spinal occult dysrhaphic anomalies. It is therefore recommended that patients with "high spinal" dysrhaphism undergo radiological evaluation of the entire spine to identify those patients with intradural anomalies, define the anatomy for surgery, and investigate the lower spine for associated occult anomalies.

Technique of stereotactic biopsy of two cranial target employing spherical coordinates to define a single trajectory.

A 'spherical coordinate system' has been developed to allow either stereotactic biopsy of two intracranial lesions using a single predetermined trajectory or biopsy of a single lesion through an existing burr hole. By means of the Gildenberg technique, the CT coordinates of the targets (or target and burr hole) are obtained. These are employed in three simple trigonometric equations to give three coordinates-two angles for the probe carrier (theta and alpha) and the radius (T) of a sphere, defined by one target as the center and the other target on the surface. These can be utilized in the Todd-Wells stereotactic frame. This system was evaluated using hollow skulls and crossed 30-gauge wire for phantom targets. The system was tried on ten different target combinations, and eight successful trajectories were obtained to within 3 mm. Two target combinations were inaccessible because of technical limitations of the Todd-Wells frame. This 'spherical coordinate system' can decrease the time to localize multiple targets as well as minimize the number of passes.

Teaching surgeons to operate--principles of psychomotor skills training.

Although the ultimate success of surgery depends on the use of adequate psychomotor skills, the evaluation of the abilities of a trainee and the teaching of these skills has not been systematized. The choice of a trainee in surgery should be based at least partially on his innate abilities, and his training should be begun at an appropriate level. The procedures he may do should be analyzed to determine the skills required for their performance. Then these skills should be taught specifically, initially in non-threatening situations such as laboratory settings, and their acquisition assessed so that he can be progressed to more advanced work at the appropriate time. Ultimately a decision must be made whether to train a candidate to a skill level or whether to train him for a set period and then counsel him regarding which procedures he has the skills to perform. There are well developed concepts in educational psychology that may be used in developing improved methods to assess and train prospective surgeons.