Endoscopic third ventriculostomy for hydrocephalus in children younger than 1 year of age.

OBJECTIVE: The purpose of this study is to assess the role of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus in children under 1 year of age. The authors analyzed data of ETV in their institution. METHODS: Between January 1995 and December 2008, 52 ETV procedures were performed for the treatment of hydrocephalus in 49 infants (32 male and 17 female). Their age ranged from 6 days to just under 12 months (mean age 6.2 months). The cause of hydrocephalus was occlusive in 43 patients (aqueduct stenosis in 31, Chiari II malformation in eight, Dandy-Walker cyst in two, quadrigeminal lipoma in one, and cerebellopontine angle arachnoid cyst in one patient). Communicating hydrocephalus was caused by intraventricular hemorrhage, meningitis, and/or ventriculitis in six patients. RESULTS: The overall success rate was 69.4% with mean follow-up period of 68.2 months. Patients with aqueduct stenosis had a higher success rate of ETV which was 77.4%. Seven infants were born preterm, six of them required a permanent ventriculoperitoneal shunts (VPS; P = 0.003). Malfunctioned VPS was removed in two patients following ETV. There was one death from intracranial hemorrhage, two cerebrospinal fluid leaks, and one meningitis. CONCLUSION: Endoscopic third ventriculostomy can be considered a possible treatment procedure alternative to VPS for the treatment of occlusive hydrocephalus in infants. ETV was effective in full-term infants while the results in low birth weight, preterm infants were poor. Success of ETV is not only age dependent but also etiology dependent. Infants with occlusive hydrocephalus treated with VPS, who present with shunt failure, could be treated by ETV and removal of the shunt device.

Management strategies for acute brain lesions presenting during pregnancy: a case series.

BACKGROUND: The management of brain lesions diagnosed during pregnancy is challenging to both obstetricians and neurosurgeons. In this study, a series of nine pregnant women were admitted to neurosurgery presenting with different acute brain lesions. OBJECTIVE: To establish guidelines for the management of acute brain lesions that present during pregnancy. PATIENTS AND METHODS: Retrospective review of the medical records of all pregnant women admitted for urgent care to King Khalid University Hospital (KKUH) from 1995 to 2009. RESULTS: Eight patients were multiparous, and one was primigravida, two were in the first trimester, and seven were in the second or third trimester. The mean age was 30.5 years. Six patients had brain tumours, while one patient had tuberculoma, and two had aneurismal subarachnoid haemorrhages (SAH). Three patients completed a full term pregnancy following surgery. Two patients had emergency caesarean section (CS) immediately followed by neurosurgery in the same session. Two patients completed their pregnancies to full term and had craniotomies after delivery. Two patients had therapeutic abortions followed by neurosurgery. No maternal or foetal complications were recorded in this series. CONCLUSION: The management of pregnant patients with acute brain lesions should be individualised and multidisciplinary. As it is difficult to allocate a single, general treatment protocol to pregnant patients with brain lesions, we suggest the following guidelines: for patients in the second and early third trimesters, it is safe to perform a craniotomy first and allow the patient to complete a full term pregnancy. For patients at 34 weeks or more of gestation, emergency CS followed by a craniotomy is recommended. For patients in the 1st trimester, it is advisable to terminate the pregnancy to allow safe management, although the laws governing this will vary from country to country. For patients with benign tumours who respond to corticosteriods, it is possible to complete the pregnancy and postpone surgery until after delivery.

Attrition and Success Rates in the Saudi Board of Neurosurgery: Analysis of 115 Consecutive Residents Who Started Training From 2001 to 2014.

Objectives At present, the literature lacks data on the outcome of neurosurgery training programs in the Middle East. In this study we aim to assess the attrition, completion of training and success rates in the Saudi Board of Neurosurgery (SBNS). Methods A cohort of 115 trainees who started SBNS training during 2001-2014 was reviewed. The outcome was the rate of attrition, completion of training, and success in the final examination of the SBNS. Results Attrition rate was 29% (14% to neurosurgery training elsewhere and 15% to non-neurosurgery). Completion of training rate was 71%. Success in the final examination rate was 74% (60% on the first attempt). Attrition rate was significantly influenced by being sponsored by University Hospitals. Success rate was impacted positively by being sponsored by King Fahad Medical City and negatively by Ministry of Health Hospitals. Trainees who started during 2011-2014 had a significantly better success rate in the final examination. Conclusions SBNS attrition rate was high due to access to training opportunities abroad, particularly for university-sponsored trainees. Success rate in the final examination was considered comparable to some other neurosurgical qualifications. The first attempt pass rate was significantly impacted by being sponsored by certain hospitals. Factors contributing to attrition and failure should be identified and addressed during the selection process and during training.

Anesthesia for third ventriculostomy. A report of 128 cases.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become the standard surgical procedure for treatment of non-communicating hydrocephalus. The aim of this study is to report our results over the past ten years with reference to perioperative complications of ETV with a review of some specific anesthetic issues. METHODS: The computerized database (in the Department of Neurosurgery) and the medical records of 128 patients who underwent ETV between February 1998 and February 2007 at our Hospital, were reviewed. Data collected were, age, sex, weight, height, preoperative biochemical analysis, duration of the procedure, anesthetic drugs used, amount of irrigation fluid used, blood loss, postoperative biochemical analysis and perioperative complications. RESULTS: Preoperative biochemical analysis for all patients was within normal ranges. Normal saline 0.9% was used as irrigation fluid for all patients. The volume during the procedure used ranged from 2 to 6 L (mean 3 L). When correlating postoperative serum sodium mean values to the volume of irrigation fluid used, it showed non significant correlation (r= 0.07). Serum potassium level has shown significant decrease postoperatively compared to preoperative levels (P < 0.05). The other biochemical analysis parameters showed non-significant changes postoperatively compared to preoperative data (P > 0.05). CONCLUSION: Anesthesiologists should be aware of the intra and postoperative complications secondary to ETV. Intraoperative bradycardia is the commonest arrhythmia occuring during the procedure. Precautions, like alerting the surgeon and pulling out the scope, are enough to revert bradycardia if it occurs. Though postoperative electrolyte imbalance occurs we believe it has no clinical significance. We believe that either normal saline or lactated Ringer solutions could be safely used for intraoperative irrigation with minimal postoperative impact. Though the procedure is a minimally invasive procedure, close observation of vital signs, serum electrolytes as well as volume and temperature of the irrigation fluid and close communication between anesthesiologist and surgeon, are prerequisites for better outcome.

Craniopharyngioma. Analysis of factors that affect the outcome.

OBJECTIVE: The aim of this work is to find out factors that affect the outcome of treatment of patients with craniopharyngioma treated at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. METHODS: This study was carried out retrospectively by reviewing the medical records of all patients with craniopharyngiomas treated at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia in the last 10 years (January 1990 through to December 1999), and collecting clinical, radiological, surgical, and follow-up data and performing statistical analysis to find out factors that affect the outcome of such cases. RESULTS: There were 11 females (61%), and 7 males (39%), the median age was 24 years. The main presenting symptoms were reduced vision in 66.7%, symptoms of raised intracranial pressure in 50%, endocrinal problems in 33.3%, seizures in 16.7%, and hemiparesis in 5.6%. Radiologic studies showed 72% of tumors had mixed solid and cystic components, calcification in 83%, and ventricular dilatation in 50% of cases. The tumor extended to the posterior fossa in 11%, and to both middle and posterior fossae in 11% of cases. Eighty-nine percent of patients had tumor excision through pterional craniotomy and 11% through subfrontal approach. Gross total removal was achieved in 17% and subtotal resection in 83%. Tumor recurred in 9 patients (50%), 4 of them (44%) had postoperative radiotherapy. The outcome was good in 10 patients (56%), poor in 6 patients (33%), and 2 patients died (11%). The patient age, radiological appearance of tumors and their location were significantly correlated with the outcome (p 0.02, 0.02, 0.04). CONCLUSION: Ophthalmologists and Pediatricians should be aware of the clinical presentation and refer patients to specialized centers for treatment. Total resection of the tumor should be the goal of the Neurosurgeon as it offers the best chance of cure.

Craniopharyngioma: Analysis of factors that affect the outcome.

OBJECTIVE: The aim of this work is to find out factors that affect the outcome of treatment of patients with craniopharyngioma treated at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. METHODS: This study was carried out retrospectively by reviewing the medical records of all patients with craniopharyngiomas treated at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia in the last 10 years (January 1990 through to December 1999), and collecting clinical, radiological, surgical, and follow-up data and performing statistical analysis to find out factors that affect the outcome of such cases. RESULTS: There were 11 females (61%), and 7 males (39%), the median age was 24 years. The main presenting symptoms were reduced vision in 66.7%, symptoms of raised intracranial pressure in 50%, endocrinal problems in 33.3%, seizures in 16.7%, and hemiparesis in 5.6%. Radiologic studies showed 72% of tumors had mixed solid and cystic components, calcification in 83%, and ventricular dilatation in 50% of cases. The tumor extended to the posterior fossa in 11%, and to both middle and posterior fossae in 11% of cases. Eighty-nine percent of patients had tumor excision through pterional craniotomy and 11% through subfrontal approach. Gross total removal was achieved in 17% and subtotal resection in 83%. Tumor recurred in 9 patients (50%), 4 of them (44%) had postoperative radiotherapy. The outcome was good in 10 patients (56%), poor in 6 patients (33%), and 2 patients died (11%). The patient age, radiological appearance of tumors and their location were significantly correlated with the outcome (p 0.02, 0.02, 0.04). CONCLUSION: Craniopharyngiomas are a common tumor in children. Ophthalmologists and Pediatricians should be aware of the clinical presentation and refer patients to specialized centers for treatment. Total resection of the tumor should be the goal of the Neurosurgeon as it offers the best chance of cure.

Split cord malformation associated with spinal open neural tube defect.

OBJECTIVE: To illustrate the clinical and radiological findings of split cord malformation (SCM) in patients with spinal open neural tube defect (SONTD), and report the outcome of their treatment. METHODS: A retrospective study of the clinical and radiological findings of 11 patients diagnosed with SCM, identified among 83 patients with SONTD at King Khalid University Hospital, in Riyadh, Saudi Arabia between 1995 and 2010. RESULTS: There were 6 girls and 5 boys; their age ranged from less than a year to 9 years (mean 4.2 years). Six patients had type I SCM, and 5 patients type II SCM. The CT and MRI imaging showed characteristic bony, cartilaginous, or fibrous septum, and other SONTD-associated anomalies. Seven patients were graded A & B according to the Frankel grading score, and none of them required surgery, while worsening neurology led to surgical intervention in 3 patients, with clinical improvement after surgery, and one patient that underwent cord untethering remained stable. CONCLUSION: Split cord malformation is not uncommon among patients with SONTD. It tends to involve mainly the lumbar spine, and female predominance is more remarkable in type I. Neurological manifestations of SCM may be superimposed with SONTD. Surgery is effective for symptomatic patients, and not indicated in the severely disabled.

Agenesis of the corpus callosum associated with spinal open neural tube defect.

OBJECTIVE: To ascertain the incidence and clinical implications of agenesis of the corpus callosum (ACC) in spinal open neural tube defects (SONTD). METHODS: All cases of SONTD registered at the Spina Bifida Clinic in King Khalid University Hospital, Riyadh, Saudi Arabia between 1995 and 2010 were retrospectively reviewed, and mid-sagittal MRI of the corpus callosum (CC) area was analyzed in each case. Neurodevelopmental outcome was classified as poor in children with seizures, severe neurodevelopmental impairment, or death. RESULTS: Thirty-eight patients (45.8%) with ACC were identified among 83 cases with SONTD. Patients' age ranged between one and 16 years. Total ACC was found in 10 patients, partial ACC in 25, and in 3 patients, the CC was hypoplastic. Active hydrocephalus was an associated finding in 9 out of 10 patients with total ACC, 22 out of 25 with partial ACC, and in all patients with hypoplasia of the CC. Thirteen patients (34.2%) had normal intellectual function, whereas 24 patients presented with learning disability, epilepsy, or poor intellectual function; and one patient died of respiratory failure. CONCLUSION: Agenesis of the corpus callosum is found in a significant portion of patients with SONTD. When associated with hydrocephalus, its presence affects neuro-developmental outcome.

Efficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, double-blind, placebo-controlled study.

STUDY DESIGN: This is a double blind randomized placebo controlled study, after obtaining approval of ethics committee in the hospital and informed written consent, 64 patients were randomized equally into 2 groups (tranexamic acid (TA) and placebo). OBJECTIVE: To evaluate efficacy and safety of large doses of TA on blood loss during spinal operations. SUMMARY OF BACKGROUND DATA: Blood loss associated with spinal operations is a common potential cause of morbidity and often requires blood transfusion which subject patients to the known risks of blood transfusion including transmission of diseases. TA is used routinely to reduce bleeding in cardiac, orthopaedic, and hepatic surgery, however, its use in neurosurgery is uncommon and only few studies reported the use of antifibrinolytic drugs in spine surgery. METHODS: Sixty-four consecutive patients undergoing spinal surgery with expected significant blood loss at King Khalid University Hospital between June 2005 and December 2006 were randomly assigned to 2 groups, TA and placebo. Shortly after the induction of anesthesia, patients received either TA or placebo as a loading dose of 2 g (for adults) or 30 mg/kg (for children), followed immediately by continuous infusion of 100 mg/h (for adults) or 1 mg/kg/h (for children) during surgery and for 5 hours after the operation. Outcome measures included total (i.e., intraoperative and postoperative) blood loss, amount of blood transfusion, as well as postoperative hemoglobin, and hematocrite levels. The data were analyzed by means of Statistical Package for the Social Science Version 12.0. The results were presented as mean +/- SD. Independent Student t test was used to compare the 2 groups and differences were considered significant if the P-value was <0.05. RESULTS: There were 39 males and 25 females, ranging in age from 4 to 86 years with a mean of 51 and median of 56 years. Eighteen patients had multilevel anterior cervical discectomies with or without internal fixation, 22 patients had decompressive surgery (12 laminectomies and 10 intersegmental decompressions) for multiseg- ment spinal stenosis, 15 patients had laminectomy with posterior spinal fixation, and remaining 9 patients had laminectomy and excision of spinal tumor. Statistical analysis showed no significant differences between the 2 study groups with regard to age, sex, weight, preoperative hemoglobin, and hematocrite levels, type of surgery, as well as operative time. In contrast, patients who received TA had 49% reduction of blood loss (P < 0.007) and required 80% less blood transfusion (P < 0.008) than patients who received placebo. The hospital stay was shorter in the TA group, but it did not achieve statistical significance. There were no complications related to the use of large doses of TA in this study. CONCLUSIONS: Prophylactic use of large doses of TA provides an effective, safe, and cheap method for reducing blood loss during and after spinal operations. Hence, TAmay help in reducing not only transfusion related complications but also operative expenses. Considering the limited number of patients in this study, our results need, however, to be validated on a larger number of patients, probably in a multicenter study.

Factors affecting cerebrospinal fluid shunt revision rate in children at King Khalid University Hospital.

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