Long-Term Outcomes in Ventriculoatrial Shunt Surgery in Patients with Pediatric Hydrocephalus: Retrospective Single-Center Study.

OBJECTIVE: Long-term outcomes are rarely reported for patients with pediatric hydrocephalus. Ventriculoperitoneal shunting is the surgical standard; nevertheless, in selected patients, a ventriculoatrial shunt (VAS) remains an important alternative. This study aimed to analyze the causes of VAS revisions and complications. METHODS: Pediatric patients who underwent their first shunt operation between 1982 and 1992 were included. The timing, cause, and modality of VAS revisions were retrospectively determined. RESULTS: Overall, 138 patients were treated for hydrocephalus and 61 patients received a VAS during the follow-up period. A primary VAS was the first shunt type in 42 (68.85%) patients. In 19 (31.15%) patients, conversions to second-line VAS were carried out. The rates of VAS revisions performed for dysfunction or elective lengthening of a short atrial catheter were 52.2% and 22.9%, respectively. There was no difference in the number of VAS revisions between patients with primary VASs and second-line VASs. Age at VAS and etiology of hydrocephalus had no effect on the number of revisions. Specific VAS complications were observed in 2 patients. Deep positioning of the distal catheter led to asymptomatic tricuspid regurgitation that was reversible after shortening of the atrial catheter. Another patient presented with shunt nephritis and completely recovered after the atrial catheter was replaced with a peritoneal catheter. CONCLUSIONS: VAS remains an appropriate second-line alternative in selected patients. Specific VAS complications were rarely observed and completely reversible after treatment. However, regular and specific follow-up examinations are strongly recommended to avoid cardiopulmonary or renal complications.

Adult Outcome in Shunted Pediatric Hydrocephalus: Long-Term Functional, Social, and Neurocognitive Results.

OBJECTIVE: Very long-term outcomes are rarely reported for patients with shunted pediatric hydrocephalus. This study aimed to determine the functional, social, and neurocognitive outcomes of such patients after transition to adulthood. METHODS: Adult patients with pediatric hydrocephalus who underwent their first shunt operation between 1982 and 1992 were included. Functional, social, educational, working aspects, and verbal intelligence were evaluated. In patients with average or above average verbal intelligence, detailed neuropsychological testing was performed and memory, executive functioning, selective attention, and concentration were assessed. RESULTS: Overall, 137 patients underwent primary surgery because of pediatric hydrocephalus, 53 (38.7%) of whom died during the follow-up period. Of the 84 long-term survivors, 65 (77.4%) agreed to participate and were included for further analysis. Forty-five patients (69.2%) had completed secondary school, but only 34 (52.3%) were integrated in the open labor market. Although the verbal intelligence of 31 patients (47.7%) was within the normal range, 19 (29.2%) had a severe mental handicap. Shunt infections (P = 0.0025), epilepsy (P < 0.0001), and the number of shunt operations (P = 0.0082) were associated with reduced verbal intelligence. Most patients with average or above average verbal intelligence had deficits in detailed neuropsychological testing. In 23 patients, detailed neuropsychological testing was performed. CONCLUSIONS: The overall long-term outcome of patients with shunted pediatric hydrocephalus is poor. These results highlight the importance of lifelong routine controls to avoid later complications. Further, repeated neuropsychological examinations might be important to understand the patient's special needs to optimize professional support.

Abdominal Pseudocysts and Peritoneal Catheter Revisions: Surgical Long-Term Results in Pediatric Hydrocephalus.

OBJECTIVE: An abdominal pseudocyst (APC) is a distal catheter site-specific failure in patients treated with ventriculoperitoneal shunts. Few studies with more than 10 patients have been reported. The aim of this study was to analyze causes of peritoneal catheter revisions with special emphasis on revisions because of an APC. METHODS: Pediatric patients with first shunt operation between 1982 and 1992 were included, and time, cause, and modality of peritoneal catheter revision were determined retrospectively. RESULTS: One hundred thirty-eight patients were treated for hydrocephalus, and 112 patients received a peritoneal catheter during the follow-up. An APC was diagnosed in 14 (12.5%) patients, and 28 revisions were needed for its treatment. The rate of shunt infection in patients with APC was 50%, but bacterial examination of the pseudofluid culture revealed infection in only 3 patients. Age at first surgical procedure, type of first surgical procedure, and etiology of hydrocephalus were not associated with APC diagnosis. APC recurred in 4 patients. These patients had a catheter repositioning directly into the peritoneum as first surgical treatment. No recurrences were observed in patients with shunt externalization or replacement of the peritoneal catheter. CONCLUSIONS: An APC is a major long-term complication after ventriculoperitoneal shunt treatment. Although a sterile inflammatory response cannot be excluded completely, our results favor the hypothesis of low-level shunt infection. In both cases, the surgical consequences are the same. An infected APC should be treated as a shunt infection. Uninfected patients can be treated with shunt externalization and replacement of only the peritoneal catheter.

Long-term mortality rates in pediatric hydrocephalus-a retrospective single-center study.

PURPOSE: Very long-term follow-up and outcome are rare for pediatric patients with hydrocephalus and shunt operations. The aim of this study was to determine the long-term mortality rates in these patients. METHODS: Pediatric patients with first shunt operation between 1982 and 1992 were included. For each patient, time and cause of death were determined. Further, patients with first operation from 1982 to 1987 were compared to those first operated from 1988 to 1992. RESULTS: One-hundred thirty-seven patients were included. Etiologies of hydrocephalus were intraventricular hemorrhage (31.4 %), meningomyelocele (25.5 %), postinfectious (11.7 %), congenital (10.2 %), posterior fossa cyst (8.8 %), aqueductal stenosis (8 %), and others (4.4 %). Overall, 53 patients (38.7 %) died. The percentage of patients surviving 1, 2, 10, and 20 years after first operation were 82.6, 73.6, 69.4, and 65.3 %, respectively. In 23 patients, the cause of death was related to shunt treatment: shunt infection was diagnosed in 18 and acute shunt dysfunction in 5 patients. Mortality was considerably higher for patients with their first operation in time period 1982-1987 compared to time period 1988-1992 (51 versus 25 %). The reduction of mortality was mainly due to an increased survival after shunt infection. Eighty-seven patients survived more than 20 years after initial shunt operation. Of those long-term survivors, three (3.4 %) patients died 22-24 years after first operation. CONCLUSION: Mortality in hydrocephalic pediatric patients is high especially in the first postoperative years but is even significant in adult patients with pediatric hydrocephalus. As deaths occur even after 20 years, routine follow-up of long-term survivors remains necessary.

Long-term outcome of accessory nerve to suprascapular nerve transfer in obstetric brachial plexus lesion: functional, morphological, and electrophysiological results.

PURPOSE: An accessory to suprascapular nerve (XIN-SSN) transfer is considered in patients with obstetric brachial plexus lesion who fail to recover active shoulder external rotation. The aim of this study was to evaluate the quality of extraplexal suprascapular nerve neurotization and to perform a detailed analysis of the infraspinatus muscle (IM) and shoulder external rotation. METHODS: A XIN-SSN transfer was performed in 14 patients between 2000 and 2007. Patients had been operated at the age of 3.7 ± 2.8 years. Follow-up examinations were conducted up to 8.5 ± 2.5 years. Magnetic resonance imaging was performed to investigate muscle trophism. Fatty muscle degeneration of the IM was classified according to the Goutallier classification. We conducted nerve conduction velocity studies of the suprascapular nerve and needle electromyography of the IM to assess pathologic spontaneous activity and interference patterns. Active glenohumeral shoulder external rotation and global shoulder function were evaluated using the Mallet score. RESULTS: Postoperatively, growth of the IM increased equally on the affected and unaffected sides, although significant differences of muscle thickness persisted over time. There was only grade 1 or 2 fatty degeneration pre- and postoperatively. Electromyography of the IM revealed a full interference pattern in all except one patient, and there was no pathological spontaneous activity. Glenohumeral external rotation as well as global shoulder function increased significantly. CONCLUSION: Our results indicate that the anastomosis after XIN-SSN transfer is functional and that successful reinnervation of the infraspinatus muscle may enable true glenohumeral active external rotation.

Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions.

OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

Prospective study on cranioplasty with individual carbon fiber reinforced polymer (CFRP) implants produced by means of stereolithography.

BACKGROUND: The aim of this study was to evaluate the value of carbon fiber reinforced polymer (CFRP) cranial implants produced by means of 3-dimensional (3D) stereolithography (SL) and template modeling for reconstructions of complex or extensive cranial defects. PATIENTS: A series of 41 cranioplasties with individual CFRP implants was performed in 37 patients between April 1996 and November 2002. Only patients with complex and/or large cranial defects were included, most of them having extended scarring or dural calcification and poor quality of the overlying soft-tissue cover after infection or multiple preceding operations. Involvement of frontal sinus, a known risk factor for complications after cranioplasty, was the case in 21 patients (51.2%). METHODS: A computer-based 3D model of the skull with the bony defect was generated by means of stereolithography after acquisition, evaluation and transfer of the patient's helical computed tomography (CT) data. A wax template of the defect that was used to design the individual prosthesis-shape was invested in dental stone. Then, the cranial implant was fabricated out of CFRP by loosen mold. RESULTS: Reconstruction of defects measuring up to 17 x 9 cm was performed. The intra-operative fit of the implants was excellent in 36 (87.8%), good in 1 (2.4%), and fair in 4 (9.8%) of the cases. Problems of implant fit occurred because of extended scarring and poor quality of soft-tissue cover. Adverse reactions were observed in 5 patients (1 subdural, 1 subcutaneous hematoma, 2 infections, 1 allergic reaction). Excellent contours and a solid stable reconstruction have been maintained in 30 out of 35 remaining plates (mean follow-up 3.6 years). No adverse effects concerning postoperative imaging, the accuracy of electroencephalograms and radiation therapy have been observed. CONCLUSIONS: The authors believe that this relatively new technique represents an advance in the management of complex and large cranial defects, but seems less suitable for simple defects because of cost-intensive techniques. Because of the high mechanical strength, biocompatibility, innovative design, and especially radiolucency, CFRP implants should, however, be considered in smaller defects if further imaging investigations or irradiation therapies are necessary.

Reduction of ischemic sequelae following spontaneous subarachnoid hemorrhage: a double-blind, randomized comparison of enoxaparin versus placebo.

BACKGROUND: Cerebral vasospasm, including its ischemic sequelae, remains a leading cause of death and disability following subarachnoid hemorrhage (SAH). This study was designed to evaluate whether the low-molecular-weight heparin (LMWH) enoxaparin reduces the occurrence of cerebral vasospasm and ischemia following spontaneous SAH. METHODS: A prospective, double-blind, randomized study was conducted in 120 consecutive patients with SAH (Hunt Hess Scale (HHS) I-III). Patients received one subcutaneous injection per day of either 20mg enoxaparin or placebo for 3 weeks following SAH. Efficacy endpoints were the occurrence of cerebral vasospasm, delayed ischemic deficit (DID), cerebral infarction, and overall outcome at 1 year following SAH. RESULTS: At 1-year follow-up, enoxaparin significantly reduced DID and cerebral infarction. Delayed ischemic deficit occurred in 8.8% of the enoxaparin group versus 66.7% of the placebo group (P<0.001), while 3.5% of vasospasm-related cerebral infarctions occurred in enoxaparin-treated patients and 28.3% in placebo-treated patients (P<0.001). Severe shunt-dependent hydrocephalus was significantly lower in the enoxaparin group (1.8% versus 16.7%; P=0.019). Compared with the placebo group, the enoxaparin group had fewer intracranial bleeding events and better overall outcomes at 1-year follow-up. Although there was potential bias as a result of patients in the placebo group being more severely affected (in terms of HHS), treatment with enoxaparin for 3 weeks improved long-term outcome following SAH. CONCLUSIONS: Enoxaparin is safe and effective in reducing cerebral vasospasm and ischemia following SAH (Hunt Hess grades I-III), resulting in a better long-term outcome for the patient.

Cerebrovascular stereolithographic biomodeling for aneurysm surgery. Technical note.

Stereolithographic (SL) biomodeling is a new technology that allows three-dimensional (3D) imaging data to be used in the manufacture of accurate solid plastic replicas of anatomical structures. The authors describe their experience with a patient series in which this relatively new visualization method was used in surgery for cerebral aneurysms. Using the rapid prototyping technology of stereolithography, 13 solid anatomical biomodels of cerebral aneurysms with parent and surrounding vessels were manufactured based on 3D computerized tomography scans (three cases) or 3D rotational angiography (10 cases). The biomodels were used for diagnosis, operative planning, surgical simulation, instruction for less experienced neurosurgeons, and patient education. The correspondence between the biomodel and the intraoperative findings was verified in every case by comparison with the intraoperative video. The utility of the biomodels was judged by three experienced and two less experienced neurosurgeons specializing in microsurgery. A prospective comparison of SL biomodels with intraoperative findings proved that the biomodels replicated the anatomical structures precisely. Even the first models, which were rather rough, corresponded to the intraoperative findings. Advances in imaging resolution and postprocessing methods helped overcome the initial limitations of the image threshold. The major advantage of this technology is that the surgeon can closely study complex cerebrovascular anatomy from any perspective by using a haptic, "real reality" biomodel, which can be held, allowing simulation of intraoperative situations and anticipation of surgical challenges. One drawback of SL biomodeling is the time it takes for the model to be manufactured and delivered. Another is that the synthetic resin of the biomodel is too rigid to use in dissecting exercises. Further development and refinement of the method is necessary before the model can demonstrate a mural thrombus or calcification or the relationship of the aneurysm to nonvascular structures. This series of 3D SL biomodels demonstrates the feasibility and clinical utility of this new visualization medium for cerebrovascular surgery. This medium, which elicits the intuitive imagination of the surgeon, can be effectively added to conventional imaging techniques. Overcoming the present limitations posed by material properties, visualization of intramural particularities, and representation of the relationship of the lesion to parenchymal and skeletal structures are the focus in an ongoing trial.