It's not always the shunt: Microthombi formation in venous collaterals causing symptoms of shunt failure in the setting of shunted hydrocephalus.

We present a patient with a history of shunted hydrocephalus due to neonatal iatrogenic thoracic venous occlusion with subsequent interval development of spontaneous thoracic venous collateral occlusion as a young adult presenting with symptoms of ventriculoperitoneal shunt failure. Though the patient's presenting symptoms were suggestive of shunt failure in the setting of known shunt dependent hydrocephalus, specific ophthalmologic findings, including venous engorgement, retinal and subconjunctival hemorrhages as well as periorbital edema in conjunction with papilledema, led to the correct diagnosis of cranio-orbital congestion secondary to microthrombi formation in the venous collateral anomalies of her chest wall. This pathology was successfully managed with warfarin.

Oculomotor, Vestibular, and Reaction Time Effects of Sports-Related Concussion: Video-Oculography in Assessing Sports-Related Concussion.

OBJECTIVE: The purpose of the study was to test the ability of oculomotor, vestibular, and reaction time (OVRT) metrics to serve as a concussion assessment or diagnostic tool for general clinical use. SETTING AND PARTICIPANTS: Patients with concussion were high school-aged athletes clinically diagnosed in a hospital setting with a sports-related concussion (n = 50). Control subjects were previously recruited male and female high school student athletes from 3 local high schools (n = 170). DESIGN: Video-oculography was used to acquire eye movement metrics during OVRT tasks, combined with other measures. Measures were compared between groups, and a subset was incorporated into linear regression models that could serve as indicators of concussion. MEASURES: The OVRT test battery included multiple metrics of saccades, smooth pursuit tracking, nystagmoid movements, vestibular function, and reaction time latencies. RESULTS: Some OVRT metrics were significantly different between groups. Linear regression models distinguished control subjects from concussion subjects with high accuracy. Metrics included changes in smooth pursuit tracking, increased reaction time and reduced saccade velocity in a complex motor task, and decreased optokinetic nystagmus (OKN) gain. In addition, optokinetic gain was reduced and more variable in subjects assessed 22 or more days after injury. CONCLUSION: These results indicate that OVRT tests can be used as a reliable adjunctive tool in the assessment of concussion and that OKN results appear to be associated with a prolonged expression of concussion symptoms.

Postoperative Imaging Findings Associated with Transpalpebral Craniotomy Approach to Anterior Cranial Fossa.

Background and Purpose The transpalpebral "eyelid" approach is a novel alternative to the traditional ciliary or supraciliary incision for supraorbital frontal craniotomy and access to the anterior cranial fossa. Though a prior publication from our institution has described the surgical approach in detail along with cosmetic and clinical outcomes, postoperative imaging findings have not yet been described. As this surgical technique becomes more widely practiced, it is essential for neuroradiologists, oculoplastic surgeons, and skull base neurosurgeons to be familiar with the expected postoperative imaging findings, especially those that prompt subsequent intervention. Materials and Methods A retrospective, institutional review board approved review was performed of 102 patients who underwent transpalpebral surgical approach at Allegheny General Hospital from June 2007 through May 2015. Operative reports, pathology reports, preoperative imaging, postoperative imaging, and postoperative clinical documentation were reviewed. Results Forty-nine percent of patients had solely benign expected postoperative imaging findings, 37% had various atypical findings not requiring further intervention (most commonly asymmetric globe protrusion and bone cement in a paranasal sinus), 6% had findings prompting minimally invasive bedside procedures (most commonly pseudomeningocele), and 8% had findings requiring surgical intervention. Conclusion The majority of imaging following the transpalpebral approach showed typical, benign findings, such as minimal pneumocephalus and asymmetric globe protrusion. Nonetheless, members of the clinical team should be aware of the small number of findings requiring intervention, especially pseudomeningocele.

Minimally invasive transpalpebral "eyelid" approach to the anterior cranial base.

BACKGROUND: Supra orbital frontal minicraniotomy is one of the most commonly used minimally invasive approaches for anterior cranial fossa lesions. OBJECTIVE: To describe our experience with the transpalpebral "eyelid" incision to obtain access to the anterior cranial fossa. METHODS: We describe the approach and technique of the transpalpebral eyelid incision in a step-by-step fashion and discuss the results of 40 cases for which the eyelid incision was used. We retrospectively reviewed the charts of these patients to analyze outcomes with regard to opening and closing time, length of hospital stay, residual aneurysm or Simpson grade for resection, complications, and cosmetic result. RESULTS: We treated 31 anterior circulation aneurysms (28 unruptured and 3 ruptured), 7 anterior skull base meningiomas, 1 frontal low-grade glioma, and 1 frontal cavernoma using the transpalpebral incision. Opening time was about 45 to 60 minutes, and closure time from dura to skin was about 45 to 60 minutes. The hospital length of stay was similar to that in our open craniotomy cases. No residual aneurysm was demonstrated in the follow-up studies of all 31 aneurysms. Simpson grade I resection was achieved in 6 meningiomas. Complications included 1 postoperative eyelid hematoma, 2 postoperative infections, and a subclinical stroke discovered on postoperative imaging. Excellent cosmetic outcome was accomplished in 39 of 40 patients. CONCLUSION: The transpalpebral approach provides dissection in natural anatomical planes, affords preservation of the frontalis muscle, avoids injury to nerve VII branches, and results in an excellent cosmetic outcome.