Factors Associated with Ventriculoperitoneal Shunt Failures in the First 30 Postoperative Days in Pediatric Patients.

OBJECTIVE: Placing of a ventriculoperitoneal shunt (VPS) is one of the most common procedures performed by neurosurgeons. Surgical revision of VPS is a significant cause of patient morbidity and mortality. This study was aimed to provide an analysis of factors related to VPS failures in the first 30 postoperative days in a pediatric cohort. METHODS: This was a retrospective cohort study of 83 pediatric patients (<18 years old), shunted for the first time at a referral care center, between January 2012 and December 2016. Univariate analysis was used to detect potential predictors of VPS failures within the first 30 postoperative days and in the first 6 months of follow-up. Kaplan-Meier survival curves were used to examine the occurrence of VPS failures over time. RESULTS: During the first 30 postoperative days, VPS failures occurred in 21 patients (25.3%). Intraventricular hemorrhage (IVH) (odds ratio [OR], 4.41; 95% confidence interval [CI], 1.44-13.48), cerebrospinal fluid (CSF) alterations (OR, 5.11; 95% CI, 1.37-19.1), and previous external ventricular drain (EVD) (OR, 7.05; 95% CI, 1.18-41.8) were significantly associated with shunt failure during the first postoperative month. Kaplan-Meier survival analysis showed decreased shunt survival for patients with IVH, both during the first 30 days after surgery (P = 0.005, log-rank), and during the 6 months after surgery (P = 0.005, log-rank). CONCLUSIONS: In this study, we found that in pediatric patients, IVH was associated with VPS failure within the first 30 postoperative days and decreased shunt survival over time. Further larger prospective randomized studies are needed to better understand these results.

Caracterización de 95 pacientes adultos con trauma craneoencefálico debido a herida por proyectil de arma de fuego en un centro de referencia en Cali, Colombia / Characterization of 95 patients with traumatic brain injury due to gunshot wounds at a referral center in Cali, Colombia

Objetivo: Este estudio busca describir casos de trauma craneoencefálico debido a heridas por proyectil de arma de fuego, en población civil mayor de 18 años, atendidos en un hospital de referencia y realizar una comparación de los pacientes de acuerdo a los resultados clínicos al egreso. Métodos: Se trata de un estudio descriptivo, observacional, retrospectivo a través de la revisión de historias clínicas de los pacientes mayores de 18 años que ingresaron en la sala de urgencias de la Fundación Valle del Lili en Cali, Colombia con trauma craneoencefálico secundario a heridas por proyectil de arma de fuego, en contexto civil, entre enero del 2010 y febrero del 2016. Se realizó un análisis univariado para determinar factores asociados a muerte y resultados clínicos adversos. Resultados: Se incluyó un total de 95 pacientes con trauma craneoencefálico por heridas por proyectil de arma de fuego en el contexto civil. El 91,6% fue de sexo masculino, el principal contexto fue violencia interpersonal en un 54,7%, el método de transporte más común fue ambulancia terrestre en un 79%, el puntaje de Glasgow (GCS) al ingreso fue 3-8 = 64,2%; 9-12 = 6,3%; 13-15=28,4%. Al ingreso se le tomó TAC simple a 82 (86,3%) pacientes dentro de la primera hora, encontrando una clasificación de Marshall entre I-III en 60,9%, un valor de IV en el 17,8% y entre V-VI en un 4,1%. La trayectoria era penetrante no transfixiante en el 43,2%, transfixiante en el 27,4% y tangencial en el 9,5%. La mortalidad fue del 45,3%, de esta 39% ocurrió en las primeras 24h. Conclusiones: Un mayor compromiso en el estado general del paciente al ingreso determina un pobre pronóstico y mayor probabilidad de muerte en las primeras 24 h

Objective: This study aims to describe cases of traumatic brain injury due to gunshot wounds in civilian population over 18 years of age, treated at a referral hospital in Cali, Colombia and compare the clinical outcomes at discharge. Methods: An observational, descriptive cross-sectional study was conducted by retrospectively collecting clinical data related to adult patients that presented traumatic brain injury due to civil gunshot-wounds and that consulted to the emergency room at Fundación Valle del Lili Hospital in Cali, Colombia between January 2010 and February of 2016. A univariate analysis was performed to determine factors associated with death and adverse clinical outcomes. Results: A total of 95 patients older than 18 years, with traumatic brain injury by gunshot were included in the civil context. The 91.6% were male. The main context was interpersonal violence with 54.7%. The most common method of transportation was by ambulance (79%). The Glasgow score at admission was 3-8 in 64.2% of cases; 9-12 in 6.32% and 13-15 in 28.4%. On admission, head CT scan was performed in 82 (86.3%) patients within the first hour, finding a Marshall-Score between I-III in 60.9%, of IV in 17.8% of cases and a score between V-VI and in 4.1%. The trajectory was non-transfixing penetrating in 43.2%, transfixing in 27.3% and tangential in 9.5%. Mortality was 45.3% in total, 39% died within the first 24hours. Conclusions: A major compromise on admission determines an overall poorer prognosis and a high likelihood of death in the first 24-hours

Characterization of 95 patients with traumatic brain injury due to gunshot wounds at a referral center in Cali, Colombia. / Caracterización de 95 pacientes adultos con trauma craneoencefálico debido a herida por proyectil de arma de fuego en un centro de referencia en Cali, Colombia.

OBJECTIVE: This study aims to describe cases of traumatic brain injury due to gunshot wounds in civilian population over 18 years of age, treated at a referral hospital in Cali, Colombia and compare the clinical outcomes at discharge. METHODS: An observational, descriptive cross-sectional study was conducted by retrospectively collecting clinical data related to adult patients that presented traumatic brain injury due to civil gunshot-wounds and that consulted to the emergency room at Fundación Valle del Lili Hospital in Cali, Colombia between January 2010 and February of 2016. A univariate analysis was performed to determine factors associated with death and adverse clinical outcomes. RESULTS: A total of 95 patients older than 18 years, with traumatic brain injury by gunshot were included in the civil context. The 91.6% were male. The main context was interpersonal violence with 54.7%. The most common method of transportation was by ambulance (79%). The Glasgow score at admission was 3-8 in 64.2% of cases; 9-12 in 6.32% and 13-15 in 28.4%. On admission, head CT scan was performed in 82 (86.3%) patients within the first hour, finding a Marshall-Score between I-III in 60.9%, of IV in 17.8% of cases and a score between V-VI and in 4.1%. The trajectory was non-transfixing penetrating in 43.2%, transfixing in 27.3% and tangential in 9.5%. Mortality was 45.3% in total, 39% died within the first 24hours. CONCLUSIONS: A major compromise on admission determines an overall poorer prognosis and a high likelihood of death in the first 24-hours.

Deep Brain Stimulation Surgery for Status Dystonicus: A Single-Center Experience and Literature Review.

BACKGROUND: Status dystonicus (SD) is a life-threatening complication in which episodes of dystonic movements become increasingly frequent and severe, requiring urgent hospital admission, and can lead to respiratory, metabolic, and bulbar complications. Pharmacologic treatment has been the mainstay management for this complication; however, many refractory patients will still require further treatment. Deep brain stimulation (DBS) is an established therapeutic strategy that has been used for dystonia, and now it has been proposed to be used for SD. METHODS: In this case series, we describe our experience with early DBS placement in 5 patients with SD to control symptoms that are refractory to pharmacologic therapy. In addition, we present a literature review of this therapy in the treatment of SD. RESULTS: Before discharge, symptomatic relief (decrease of dystonic movements and resolution of abnormal postures) was evidenced in all patients with a median of 3 days (interquartile range, 1-7) after surgery was performed. A follow-up Unified Dystonia Rating Scale score and Burke-Fahn-Marsden rating scale motor subscale score, at 6 months after hospital discharge with values being inferior to 20 and 30, respectively, for all cases. None of the patients had a recurrence of SD in the last follow-up period. CONCLUSIONS: DBS surgery is a suitable, versatile, reversible and adequate therapy in the treatment of SD that is refractory to initial pharmacologic treatment.

Lymphomatoid granulomatosis of the brain: A case report.

BACKGROUND: Lymphomatoid granulomatosis is a rare disorder of the central nervous system (CNS) with few cases being reported in literature. We present the case of an adult with an unusual lesion of the CNS who presented with motor seizures and was diagnosed with lymphomatoid granulomatosis, followed by a discussion of the process of evaluation and management. CASE DESCRIPTION: A 42-year-old male presented with motor seizures and loss of consciousness for 10 minutes along with dysarthria and left hemiplegia. Neurological examination and imaging with magnetic resonance imaging (MRI) of the brain revealed a mass in the right striatum. The patient was hospitalized and underwent an image-guided right frontal craniotomy using the Leksell Stereotactic G-Frame. Pathology reported a lymphomatoid granulomatosis. Being immunocompetent, the patient received medical treatment with prednisone and rituximab. Two years after his diagnosis, the patient had no active disease and his brain MRI did not show contrast enhancement. After almost 3 years of follow-up, the patient has a mild weakness in the left-side of his body (4/5), is seizure-free, and can walk and perform daily activities. CONCLUSIONS: This rare lesion in an adult, immunocompetent patient, debuting with motor seizures represents a challenge in terms of diagnosis and treatment. After surgical and medical treatment, the patient had a satisfactory recovery. Clinical features, imaging, differential diagnosis, and pathology are discussed.

Intracavitary Irradiation as a Safe Alternative for Cystic Craniopharyngiomas: Case Report and Review of the Literature.

Craniopharyngioma treatment remains a challenge for clinicians and patients. There are many treatment alternatives; however one of them (intracavitary irradiation) seeks to control this type of benign brain tumor using minimally invasive techniques, with the specific aim of avoiding causing significant damage to important structures surrounding the sellar/suprasellar region. We present the case of a 3-year-old patient with a predominantly cystic craniopharyngioma who underwent intracavitary irradiation by stereotactic placement. Using this approach, the patient showed a successful response with remission of headaches and hydrocephalus. A reduction in the size of the cyst was achieved, without deterioration of visual fields, with no hormonal supplementation being needed, and with no evidence of focal neurological signs.

Outcome predictors after gamma knife radiosurgery for recurrent trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) that recurs after surgery can be difficult to manage. OBJECTIVE: To define management outcomes in patients who underwent gamma knife stereotactic radiosurgery (GKSR) after failing 1 or more previous surgical procedures. METHODS: We retrospectively reviewed outcomes after GKSR in 193 patients with TN after failed surgery. The median patient age was 70 years (range, 26-93 years). Seventy-five patients had a single operation (microvascular decompression, n=40; glycerol rhizotomy, n=24; radiofrequency rhizotomy, n=11). One hundred eighteen patients underwent multiple operations before GKSR. Patients were evaluated up to 14 years after GKSR. RESULTS: After GKSR, 85% of patients achieved pain relief or improvement (Barrow Neurological Institute grade I-IIIb). Pain recurrence was observed in 73 of 168 patients 6 to 144 months after GKSR (median, 6 years). Factors associated with better long-term pain relief included no relief from the surgical procedure preceding GKSR, pain in a single branch, typical TN, and a single previous failed surgical procedure. Eighteen patients (9.3%) developed new or increased trigeminal sensory dysfunction, and 1 developed deafferentation pain. Patients who developed sensory loss after GKSR had better long-term pain control (Barrow Neurological Institute grade I-IIIb: 86% at 5 years). CONCLUSION: GKSR proved to be safe and moderately effective in the management of TN that recurs after surgery. Development of sensory loss may predict better long-term pain control. The best candidates for GKSR were patients with recurrence after a single failed previous operation and those with typical TN in a single trigeminal nerve distribution.

T1/T2 matching to differentiate tumor growth from radiation effects after stereotactic radiosurgery.

OBJECTIVE: We define magnetic resonance imaging (MRI) and clinical criteria that differentiate radiation effect (RE) from tumor progression after stereotactic radiosurgery (SRS). METHODS: We correlated postoperative imaging and histopathological data in 68 patients who underwent delayed resection of a brain metastasis after SRS. Surgical resection was required in these patients because of clinical and imaging evidence of lesion progression 0.3 to 27.7 months after SRS. At the time of SRS, the median target volume was 7.1 mL (range, 0.5-26 mL), which increased to 14 mL (range, 1.3-81 mL) at the time of surgery. After initial SRS, routine contrast-enhanced MRI was used to assess tumor response and to detect potential adverse radiation effects. We retrospectively correlated these serial MRIs with the postoperative histopathology to determine if any routine MRI features might differentiate tumor progression from RE. RESULTS: The median time from SRS to surgical resection was 6.9 months (range, 0.3-27.7 months). A shorter interval from SRS to resection was associated with a higher rate of tumor recurrence (P = .014). A correspondence between the contrast-enhanced volume on T1-weighted images and the low signal-defined lesion margin on T2-weighted images ("T1/T2 match") was associated with tumor progression at histopathology (P < .0001). Lack of a clear and defined lesion margin on T2-weighted images compared to the margin of contrast uptake on T1-weighted images ("T1/T2 mismatch") was significantly associated with a higher rate of RE in pathological specimens (P < .0001). The sensitivity of the T1/T2 mismatch in identifying RE was 83.3%, and the specificity was 91.1%. CONCLUSIONS: We found that time to progression and T1/T2 mismatch were able to differentiate tumor progression from RE in most patients. When REs are suspected, surgery may not be necessary if patients respond to conservative measures. When tumor progression is suspected, resection or repeat radiosurgery can be effective, depending on the degree of mass effect.

Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Trigeminal neuralgia pain causes severe disability. Stereotactic radiosurgery is the least invasive surgical option for patients with trigeminal neuralgia. Since different medical and surgical options have different rates of pain relief and morbidity, it is important to evaluate longer-term outcomes. METHODS: The authors retrospectively reviewed outcomes in 503 medically refractory patients with trigeminal neuralgia who underwent Gamma Knife surgery (GKS). The median patient age was 72 years (range 26-95 years). Prior surgery had failed in 205 patients (43%). The GKS typically was performed using MR imaging guidance, a single 4-mm isocenter, and a maximum dose of 80 Gy. RESULTS: Patients were evaluated for up to 16 years after GKS; 107 patients had > 5 years of follow-up. Eighty-nine percent of patients achieved initial pain relief that was adequate or better, with or without medications (Barrow Neurological Institute [BNI] Scores I-IIIb). Significant pain relief (BNI Scores I-IIIa) was achieved in 73% at 1 year, 65% at 2 years, and 41% at 5 years. Including Score IIIb (pain adequately controlled with medication), a BNI score of I-IIIb was found in 80% at 1 year, 71% at 3 years, 46% at 5 years, and 30% at 10 years. A faster initial pain response including adequate and some pain relief was seen in patients with trigeminal neuralgia without additional symptoms, patients without prior surgery, and patients with a pain duration of < or = 3 years. One hundred ninety-three (43%) of 450 patients who achieved initial pain relief reported some recurrent pain 3-144 months after initial relief (median 50 months). Factors associated with earlier pain recurrence that failed to maintain adequate or some pain relief were trigeminal neuralgia with additional symptoms and > or = 3 prior failed surgical procedures. Fifty-three patients (10.5%) developed new or increased subjective facial paresthesias or numbness and 1 developed deafferentation pain; these symptoms resolved in 17 patients. Those who developed sensory loss had better long-term pain control (78% at 5 years). CONCLUSIONS: Gamma Knife surgery proved to be safe and effective in the treatment of medically refractory trigeminal neuralgia and is of value for initial or recurrent pain management. Despite the goal of minimizing sensory loss with this procedure, some sensory loss may improve long-term outcomes. Pain relapse is amenable to additional GKS or another procedure.

Gamma knife radiosurgery in younger patients with vestibular schwannomas.

OBJECTIVE: Management options for patients with vestibular schwannoma include observation, surgical resection, stereotactic radiosurgery (SRS), and stereotactic radiation therapy. In younger patients, resection is often advocated because of concern regarding the long-term effects of radiation. We studied tumor response and clinical outcomes after SRS in such patients. METHODS: We reviewed long-term outcomes in 55 patients with vestibular schwannomas. Patients were 40 years of age or younger, underwent gamma knife (GK) SRS between 1987 and 2003, and were followed up for a minimum of 4 years. The median patient age was 35 years (range, 13-40 years). Forty-one patients had Gardner-Robertson class 1 to 4 hearing. Thirteen patients (24%) had undergone surgical removal. The median tumor volume was 1.7 mm. The median tumor margin dose was 13.0 Gy (range, 11-20 Gy). RESULTS: At a median of 5.3 years, (range, 4-20 years), 2 of 55 patients underwent GK SRS for a second time; 1 of these patients had had a recurrence after initial resection. The 5-year rate of freedom from additional management was 96%. Hearing preservation rates (i.e., remaining within the same Gardner-Robertson hearing class) were 93%, 87%, and 87% at 3, 5, and 10 years, respectively. In patients with serviceable hearing before SRS, it was maintained in 100%, 93%, and 93% of patients at 3, 5, and 10 years, respectively. Hearing preservation was related to a margin dose lower than 13 Gy (P = 0.017). At the last assessment, facial and trigeminal nerve function was preserved in 98.2% and 96.4% of patients, respectively; the only facial deficit (House-Brackmann grade III) occurred in a patient who received a tumor dose of 20 Gy early in our experience (1988). None of the patients treated with doses lower than 13 Gy experienced facial or trigeminal neuropathy. All patients continued their previous level of activity or employment after GK SRS. No patient developed a secondary radiation-related tumor. CONCLUSION: Our experience indicates that GK SRS is an effective management strategy for younger patients with vestibular schwannoma, most of whom have no additional cranial nerve dysfunction.

The results of resection after stereotactic radiosurgery for brain metastases.

OBJECT: Radiosurgery for brain metastasis fails in some patients, who require further surgical care. In this paper the authors' goal was to evaluate prognostic factors that correlate with the survival of patients who require a resection of a brain metastasis after stereotactic radiosurgery (SRS). METHODS: During the last 14 years when surgical navigation systems were routinely available, the authors identified 58 patients who required resection for various brain metastases after SRS. The median patient age was 54 years. Prior adjuvant treatment included whole-brain radiation therapy alone (17 patients), chemotherapy alone (9 patients), both radiotherapy and chemotherapy (10 patients), and prior resection before SRS (8 patients). The median target volumes at the time of SRS and resection were 7.7 cm(3) (range 0.5-24.9 cm(3)) and 15.5 cm(3) (range 1.3-81.2 cm(3)), respectively. RESULTS: At a median follow-up of 7.6 months, 8 patients (14%) were living and 50 patients (86%) had died. The survival after surgical removal was 65, 30, and 16% at 6, 12, and 24 months, respectively (median survival after resection 7.7 months). The local tumor control rate after resection was 71, 62, and 43% at 6, 12, and 24 months, respectively. A univariate analysis revealed that patient preoperative recursive partitioning analysis classification, Karnofsky Performance Scale status, systemic disease status, and the interval between SRS and resection were factors associated with patient survival. The mortality and morbidity rates of resection were 1.7 and 6.9%, respectively. CONCLUSIONS: In patients with symptomatic mass effect after radiosurgery, resection may be warranted. Patients who had delayed local progression after SRS (> 3 months) had the best outcomes after resection.