RESUMO
BACKGROUND: Intracranial arachnoid cysts (ACs) are a cerebral spinal fluid (CSF) collection within the meninges. They typically arise during embryologic development. Some are stable overtime with little consequence, but large or growing cysts may require surgical intervention. The optimal surgical technique is debated and may be more technically challenging in the infant age group. CASE DESCRIPTION: Our unique case report details a 10-month-old (6 months corrected age) infant who presented with a drastic increase in head circumference and was found to have midline shift and three cysts - one large and two smaller ones. He was treated with an innovative surgical approach combining stereotactic introduction of a catheter to facilitate subsequent flexible endoscopy allowing three separate cysts to be treated through one small surgical incision with no complications and a stable examination on 2-year follow-up. CONCLUSION: Symptomatic ACs in the infant population that require treatment can be addressed with open surgery to fenestrate the cyst, endoscopic cyst fenestration, or cystoperitoneal shunting. Typically, surgeons must choose between a rigid endoscope which allows stereotactic navigation or a flexible endoscope which allows multiple trajectories but precludes navigation. Our case demonstrates that combining stereotactic ventricular placement before flexible endoscopy provides the benefit of both approaches and allows for successful endoscopic treatment in a young patient with durable results.
RESUMO
BACKGROUND: The surgical treatment of normal pressure hydrocephalus (NPH) with shunting remains controversial due to the difficulty in distinguishing such pathology from other neurological conditions that can present similarly. Thus, patients with suspected NPH should be carefully selected for surgical intervention. Historically, clinical improvement has been measured by the use of functional grades, alleviation of symptoms, and/or patient/family-member reported surveys. Such outcome analysis can be subjective, and there is difficulty in quantifying cognition. Thus, a push for a more quantifiable and objective investigation is warranted, especially for patients with idiopathic NPH (INPH), for which the final diagnosis is confirmed with postoperative clinical improvement. We aimed to use Apple Health (Apple Inc., Cupertino, CA) data to approximate physical activity levels before and after shunt placement for NPH as an objective outcome measurement. The patients were contacted and verbally consented to export Apple Health activity data. The patient's physical activity data were then analyzed. A chart review from the patient's EMR was performed to understand and better correlate recovery. CASE DESCRIPTION: Our first patient had short-term improvements in activity levels when compared to his preoperative activity. The patient's activity level subsequently decreased at 6 months and onward. This decline was simultaneous to new-onset lumbar pain. Our second patient experienced sustained improvements in activity levels for 12 months after his operation. His mobility data were in congruence with his subjectively reported improvement in clinical symptoms. He subsequently experienced a late-decline that began at 48-months. His late deterioration was likely confounded by exogenous factors such as further neurodegenerative diseases coupled with old age. CONCLUSION: The use of objective activity data offers a number of key benefits in the analysis of shunted patients with NPH/INPH. In this distinctive patient population, detailed functional outcome analysis is imperative because the long-term prognosis can be affected by comorbid factors or life expectancy. The benefits from using smartphone-based accelerometers for objective outcome metrics are abundant and such an application can serve as a clinical aid to better optimize surgical and recovery care.