UpToDate: Agitation

Agitation

Hyperactive delirium (agitation) is an emotional state of excitement or restlessness.

Hyperactive delirium (agitation) is a common complication in patients on intensive care units.

Psychomotor agitation, an extreme form of the above, which can be part of a mental illness or a side effect of anti-psychotic medication.

Assesment

Sedation Agitation Scale.


Postoperative agitation frequently occurs after general anesthesia and may be associated with serious consequences. However, studies in neurosurgical patients have been inadequate.

Huang et al., from the Beijing Tiantan Hospital and the Mongolia People’s Hospital, China. aimed to investigate the incidence and risk factors for early postoperative agitation in patients after craniotomy, specifically focusing on the association between postoperative pneumocephalus and agitation. Adult intensive care unit admitted patients after elective craniotomy under general anesthesia were consecutively enrolled. Patients were assessed using the Sedation Agitation Scale during the first 24 hours after operation. The patients were divided into two groups based on their maximal Sedation-Agitation Scale: the agitation (Sedation-Agitation Scale ≥ 5) and non-agitation groups (Sedation-Agitation Scale ≤ 4). Preoperative baseline data, intraoperative and intensive care unit admission data were recorded and analyzed. Each patient’s computed tomography scan obtained within six hours after operation was retrospectively reviewed. Modified Rankin Scale and hospital length of stay after the surgery were also collected. Of the 400 enrolled patients, agitation occurred in 13.0% (95% confidential interval: 9.7-16.3%). Body mass index, total intravenous anesthesia, intraoperative fluid intake, intraoperative bleeding and transfusionconsciousness after operation, endotracheal intubation kept at intensive care unit admission and mechanical ventilation, hyperglycemia without a history of diabetes, self-reported pain and postoperative bi-frontal pneumocephalus were used to build a multivariable model. Bi-frontal pneumocephalus and delayed extubation after the operation were identified as independent risk factors for postoperative agitation. After adjustment for confounding, postoperative agitation was independently associated with worse neurologic outcome (odd ratio: 5.4, 95% confidential interval: 1.1-28.9, P = 0.048).

The results showed that early postoperative agitation was prevalent among post-craniotomy patients and was associated with adverse outcomes. Improvements in clinical strategies relevant to bi-frontal pneumocephalus should be considered 1).


Sauvigny et al., from the University Medical Centre Hamburg-Eppendorf Germany, performed a retrospective analysis in three hundred thirty-eight patients with aneurysmal subarachnoid hemorrhage resulting in 212 patients which reached at least once a Richmond Sedation Agitation Scale(RASS) of 0 and were eligible for further analysis. Clinical characteristics were analysed towards the occurrence of a hyperactive delirium. Neurological outcome at discharge and follow-up was assessed using the Glasgow Outcome Scale. Seventy-eight of 212 patients (36.8%) developed a hyperactive delirium; the duration ranged from 1 to 11 days. Multivariate regression revealed initial hydrocephalus (odds ratio (OR) 3.21 95% confidence interval (CI) [1.33-7.70]; p = 0.01), microsurgical clipping (OR 3.70 95%CI 1.71-8.01]; p = 0.001), male gender (OR 1.97 95%CI [1.05-3.85]; p = 0.047) and a higher Graeb score (OR 1.11 95%CI [1.00-1.22]; p = 0.043) to be significantly associated with the development of agitation. Medical history of psychiatric disorders, alcohol or nicotine abuse showed no correlation with agitation. Cox regression analysis revealed no significant influence of agitation towards unfavourable outcome at discharge or follow-up.

They provided four independent risk factors for the development of agitation in SAH patients. The study emphasizes the specific entity of agitation in patients with SAH and underscores its relevance in neurological patients 2).

References

1)

Huang HW, Yan LM, Yang YL, He X, Sun XM, Wang YM, Zhang GB, Zhou JX. Bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor: A prospective cohort study. PLoS One. 2018 Jul 19;13(7):e0201064. doi: 10.1371/journal.pone.0201064. eCollection 2018. PubMed PMID: 30024979.
2)

Sauvigny T, Mohme M, Grensemann J, Dührsen L, Regelsberger J, Kluge S, Schmidt NO, Westphal M, Czorlich P. Rate and risk factors for a hyperactivity delirium in patients with aneurysmal subarachnoid haemorrhage. Neurosurg Rev. 2018 Jun 9. doi: 10.1007/s10143-018-0990-9. [Epub ahead of print] PubMed PMID: 29948495.

UpToDate: Diffuse axonal injury outcome

Diffuse axonal injury outcome

Diffuse axonal injury, and more generally TBI, often results in physical, cognitive, and behavioral impairments that can be temporary or permanent1) 2) 3) 4) 5) 6) 7) 8) 9) 10).


The outcome of patients after DAI has been linked to the number of lesions identified through imaging. A longitudinal study that analyzed the evolution of traumatic axonal injury using magnetic resonance imaging (MRI) of 58 patients with moderate or severe TBI showed that the greater the number of lesions observed early after trauma, the greater the impairment of functionality after 12 months 11).

A study of 26 DAI patients indicated that the volume and number of lesions identified by MRI performed within 48 h of hospital admission strongly correlated with the level of disability observed at the time of hospital discharge 12).


DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with New Injury Severity Score (NISS) value – had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence 13).


Clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival 14).


Brain atrophy progresses over time, but patients showed better executive function (EF) and verbal episodic memory (EVM) in some of the tests, which could be due to neuroplasticity 15).

References

1)

Gennarelli TA. Cerebral concussion and diffuse brain injuries. 2nd ed In: Cooper PR, editor. , editor. Head Injury. Baltimore: Williams & Wilkins; (1987). p. 108–24.
2)

Gennarelli TA. Cerebral concussion and diffuse brain injuries. 3rd ed In: Cooper PR, editor. , editor. Head Injury. Baltimore: Williams & Wilkins; (1993). p. 137–58.
3)

Lagares A, Ramos A, Alday R, Ballenilla F, Pérez-Nuñez A, Arrese I, et al. Magnetic resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR. Neurocirugia (Astur) (2006) 17(2):105–18.10.1016/S1130-1473(06)70351-7
4)

Esbjörnsson E, Skoglund T, Sunnerhagen KS. Fatigue, psychosocial adaptation and quality of life one year after traumatic brain injury and suspected traumatic axonal injury; evaluations of patients and relatives: a pilot study. J Rehabil Med (2013) 45:771–7.10.2340/16501977-1170
5)

Chelly H, Chaari A, Daoud E, Dammak H, Medhioub F, Mnif J, et al. Diffuse axonal injury in patients with head injuries: an epidemiologic and prognosis study of 124 cases. J Trauma (2011) 71(4):838–46.10.1097/TA.0b013e3182127baa
6)

Jeong JH, Kim YZ, Cho YW, Kim JS. Negative effect of hypopituitarism following brain trauma in patients with diffuse axonal injury. J Neurosurg (2010) 113(3):532–8.10.3171/2009.10.JNS091152
7)

Ham TE, Sharp DJ. How can investigation of network function inform rehabilitation after traumatic brain injury? Curr Opin Neurol (2012) 25(6):662–9.10.1097/WCO.0b013e328359488f
8)

Sousa RMC. Comparisons among measurement tools in traumatic brain injury outcomes. Rev Esc Enferm USP (2006) 40(2):203–13.10.1590/S0080-62342006000200008
9)

Scholten AC, Haagsma JA, Andriessen TM, Vos PE, Steyerberg EW, van Beeck EF, et al. Health-related quality of life after mild, moderate and severe traumatic brain injury: patterns and predictors of suboptimal functioning during the first year after injury. Injury (2015) 46(4):616–24.10.1016/j.injury.2014.10.064
10)

Liew BS, Johari SA, Nasser AW, Abdullah J. Severe traumatic brain injury: outcome in patients with diffuse axonal injury managed conservatively in hospital Sultanah Aminah, Johor Bahru – an observational study. Med J Malaysia (2009) 64(4):280–8.
11)

Moen KG, Skandsen T, Folvik M, Brezova V, Kvistad KA, Rydland J, et al. A longitudinal MRI study of traumatic axonal injury in patients with moderate and severe traumatic brain injury. J Neurol Neurosurg Psychiatry (2012) 83(12):1193–200.10.1136/jnnp-2012-302644
12)

Schaefer PW, Huisman TA, Sorensen AG, Gonzalez RG, Schwamm LH. Diffusion-weighted MR imaging in closed head injury: high correlation with initial Glasgow Coma Scale score and score on modified Rankin scale at discharge. Radiology (2004) 233(1):58–66.10.1148/radiol.2323031173
13)

Vieira RC, Paiva WS, de Oliveira DV, Teixeira MJ, de Andrade AF, de Sousa RM. Diffuse Axonal Injury: Epidemiology, Outcome and Associated Risk Factors. Front Neurol. 2016 Oct 20;7:178. eCollection 2016. PubMed PMID: 27812349; PubMed Central PMCID: PMC5071911.
14)

Humble SS, Wilson LD, Wang L, Long DA, Smith MA, Siktberg JC, Mirhoseini MF, Bhatia A, Pruthi S, Day MA, Muehlschlegel S, Patel MB. Prognosis of diffuse axonal injury with traumatic brain injury. J Trauma Acute Care Surg. 2018 Jul;85(1):155-159. doi: 10.1097/TA.0000000000001852. PubMed PMID: 29462087; PubMed Central PMCID: PMC6026031.
15)

Stewan Feltrin F, Zaninotto AL, Guirado VMP, Macruz F, Sakuno D, Dalaqua M, Magalhães LGA, Paiva WS, Andrade AF, Otaduy MCG, Leite CC. Longitudinal changes in brain volumetry and cognitive functions after moderate and severe diffuse axonal injury. Brain Inj. 2018 Jul 19:1-10. doi: 10.1080/02699052.2018.1494852. [Epub ahead of print] PubMed PMID: 30024781.

UpTodate: Astroplasticity

Astroplasticity

Astrocytes exhibit dynamic and complex reactions to various insults.

Investigations into the transitions that occur during cellular specification, differentiation, maturation and disease responses have provided insights into understanding the mechanisms that underlie these altered states of reactivity and function.

Patel et al.,from the Center for Neuroregeneration and Department of Neurosurgery of the Houston Methodist Research Institute, TexasUSAsummarize current concepts in how astrocyte state transitions, termed ‘astroplasticity’, are regulated and also how this affects neural circuit function through extracellular signaling.

They postulate that a promising future approach towards enhancing functional repair after injury and disease would be to steer astrocytes away from an inhibitory response and towards one that is beneficial to neuroplasticity and neuroregeneration. Toward this goal, they discuss emerging biotechnological advancements, with a focus on human pluripotent stem cell bioengineering, which have high potential for effective manipulation and control of astroplasticity. Highlights include innovations in cellular transdifferentiation techniques, nanomedicine, organoid and 3D spheroid microcircuit development, and the use of biomaterials to influence the extracellular environment. Current barriers and future applications are also summarized in order to augment the design of future preclinical trials aimed towards astrocyte-targeted neuroregeneration with a concept termed ‘astrocellular therapeutics’ 1).

1)

Patel R, Muir M, Cvetkovic C, Krencik R. Concepts towards directing human astroplasticity to promote neuroregeneration. Dev Dyn. 2018 Jul 17. doi: 10.1002/dvdy.24655. [Epub ahead of print] Review. PubMed PMID: 30016584.

UpToDate: Facet-Link

Facet-Link

Facet-Link, Inc., Rockaway, New JerseyUnited States.

http://www.linkspine.com/

From a biomechanical point of view, facet screw fixation seems to provide equal stiffness during flexion-extension movements and lesser stiffness in axial rotation and lateral bending compared with pedicle screw fixation. However, the addition of the central cross-link in the Facet-Link System should theoretically increase the resistance to axial torque and ensure similar biomechanical features of the pedicle screw systems.

Video

Facetlink Mini & Hemi – HD from Ghost Productions on Vimeo.


Trungu et al., from Rome and, Tricase, Italy reported a total of 25 patients between May 2015 and June 2016 affected by radiologically demonstrated one-level Lumbar spinal stenosis (LSS) with facet joint degeneration and grade I spondylolisthesis in a prospective study. All the patients underwent laminectomyforaminotomy, and one-level facet fixation (Facet-Link, Inc., Rockaway, New Jersey, United States). Pre- and postoperative clinical (Oswestry Disability Index [ODI], Short Form 36 [SF-36]) and radiologic (radiographs, magnetic resonance imaging, computed tomography) data were collected and analyzed.

Mean follow-up was 12 months. The L4-L5 level was involved in 18 patients (72%) and L5-S1 in 7 patients (28%); the average operative time was 80 minutes (range: 65-148 minutes), and the mean blood loss was 160 mL (range: 90-200 mL). ODI and SF-36 showed a statistically significant (p < 0.05) improvement at last follow-up.

Lumbar transfacet screw fixation is a safe and effective treatment option in patients with single-level LSS, facet joint degeneration, and mild instability 1).

1)

Trungu S, Pietrantonio A, Forcato S, Tropeano MP, Martino L, Raco A. Transfacet Screw Fixation for the Treatment of Lumbar Spinal Stenosis with Mild Instability: A Preliminary Study. J Neurol Surg A Cent Eur Neurosurg. 2018 Jul 16. doi: 10.1055/s-0038-1655760. [Epub ahead of print] PubMed PMID: 30011420.

UpToDate: Barricaid®

Barricaid®

https://www.barricaid.com

Barricaid is designed to close large defects in the annulus, so to prevent recurrent disc herniation, while allowing the surgeon to preserve more of the patient’s lumbar disc.

The Barricaid Anular Closure device consists of a woven polyester occlusion component intended to block an anular defect, while anchored to the adjacent vertebral body by a titanium bone anchor.

Reinforcing the annulus fibrosus with Barricaid during lumbar discectomy may slow the progression of facet joint degeneration 1).


The polymer mesh is placed on the inner surface of the disc annulus, using the disc pressure to help seal the defect against leakage of nucleus. Once wound dissection and (partial, hemi-) laminectomy have been done, discectomy is followed. However, aggressive nucleus removal has been shown to result in significant back pain and worsened clinical outcomes. After discectomy, the annular defect size is measured and the appropriate sized device is chosen. The titanium anchor is inserted into the bone (parallel to the surface of the endplate) and the mesh forms a barrier that blocks the defect.

The device provides permanent fixation through bone anchorage and remains inside the disc. During the procedure, fluoroscopic guidance is required to ensure appropriate location of the device.

Annular closure device insertion allows more nucleus to be left inside of annulus and restores intra-discal pressure. Because only partial volume is removed from the intervertebral disc, this procedure can preserve disc height and motion and reduce facet degeneration.

Case series

Forty-six consecutive patients undergoing lumbar discectomy for single-level herniated disk at 2 institutions were followed prospectively with clinical and radiographic evaluations at 6 weeks and 3, 6, 12, and 24 months (control cohort). A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed similarly. Incidence of recurrent disk herniation, disk height loss, the leg and back pain visual analog scale (VAS), and the Oswestry Disability Index were assessed at each follow-up.

Cohorts were well matched at baseline. By 2 years of follow-up, symptomatic recurrent same-level disk herniation occurred in 3 (6.5%) patients in the control cohort versus 0 (0%) patients in the annular repair cohort (P=0.27). A trend of greater preservation of disk height was observed in the annular repair versus the control cohort 3 months (7.9 vs. 7.27 mm, P=0.08), 6 months (7.81 vs. 7.18 mm, P=0.09), and 12 months (7.63 vs. 6.9 mm, P=0.06) postoperatively. The annular closure cohort reported less leg pain (VAS-LP: 5 vs. 16, P<0.01), back pain (VAS-BP: 13 vs. 22, P<0.05), and disability (Oswestry Disability Index: 16 vs. 22, P<0.05) 1 year postoperatively.

Implantation of a novel annular repair device was associated with greater maintenance of disk height and improved 1-year leg pain, back pain, and low-back disability. Recurrent disk herniation did not occur in any patient after annular repair. Closure of annular defect after lumbar discectomy may help preserve the physiological disk function and prevent long-term disk height loss and associated back and leg pain 2).


Hahn et al., demonstrated the preliminary reports of Barricaid® insertion in 3 patients who underwent surgery for lumbar disc herniation.

The early experience of Barricaid® implantation showed preserved disc heights and delayed disc degeneration, and improved leg and back pain. However, greater number of cohort and longer duration of follow-up would be necessary in the future study to estimate the effectiveness and safety of this device. We hope our experience to be shared with others and helpful to future trial of Barricaid® insertion. 3).


While widely perceived as a successful procedure, discectomy surgery has a high failure rate over time. The overall risk of recurrent disc herniation varies between 2-18% in reported literature. The Barricaid® anular closure device was designed as an adjunct to lumbar limited microdiscectomy to block large anular defects while maintaining as much native nucleus within the disc space. Patients that are considered for anular closure have a minimum posterior disc height of 5mm, and an intra-operatively measured anular defect between 5mm and 12mm wide. The aim of this study was determined as to assess the cost effectiveness of the use of Barricaid® in this group of patients in Turkey. Methods: A simple decision analysis model was used to assess the cost effectiveness of the use of Barricaid®. The primary clinical endpoint was determined as the number of prevented reherniations. According to the literature, the use of Barricaid® reduced the number of reherniations by 18%. Resource utilization data were obtained via expert clinical opinion and included pre-op, post-op and follow-up costs, etc. Unit costs were taken from the Social Security Institution’s official price list. Results were presented as incremental cost/number of prevented reherniations. The comparison was made between using and not using the Barricaid®. Results: According to the results of the cost effectiveness analysis, the incremental number of prevented reherniation was 4.398 with Barricaid® and incremental cost was 119.343.000 TL. The ICER was within the limits of the threshold recommended by the World Health Organization with 27.136 TL. Conclusions: Use of Barriciad® in lumbar discectomy surgery is a cost-effective treatment option in Turkey 4).


Trummer et al., investigated whether implantation with the Barricaid annular closure device (ACD) during discectomy reduced the rate of facet degeneration. Inclusion criteria were primary lumbar disc herniation failing conservative treatment, Visual Analog Scale (VAS) Leg≥40/100, Oswestry Disability Index (ODI)≥40/100 and defects that were ≤60 mm2 (Barricaid arm only), and patient age 18-75. CT interpretations were collected preoperatively and 12 months post-discectomy. Patients implanted with Barricaid had significantly reduced rates and grades of facet degeneration than patients without Barricaid. Reinforcing the annulus fibrosus with Barricaid during lumbar discectomy may slow the progression of facet joint degeneration 5).

Case reports

Lange et al., from the Department of Neurosurgery, Klinikum Rechts der Isar, Technische Universität MunichGermany, report the unusual case of a young patient with reoperation after annuloplasty using the Barricaid® (Intrinsic Therapeutics, Woburn, MA, USA) closure device.

A 32-year-old man underwent lumbar discectomy and annuloplasty of the level L5-S1. Five years later, the patient presented with a new onset of low back pain radiating into the right legImaging revealed loosening of the annulus repair device. The device was removed surgically and the patient was pain free thereafter. Annular closure devices such as the Barricaid system aim to improve outcome after lumbar discectomy by reducing the risk of recurrent disc herniation of the same level. Data on long-term follow-up are missing. This is the first case of symptomatic device loosening 6).


Krutko et al.,described a case of reoperation after microdiscectomy and annuloplasty using the Barricaid®.

A month after the operation, the patient complained of back and right leg pain. Examination revealed bone resorption around the implant and signs of inflammatory changes in the adjacent tissues. Laboratory analysis revealed no increase in acute-phase response indicators. Taking into account the clinical data, the data obtained by instrumental methods, and resistance to conservative therapy, the patient underwent revision surgery. No signs of purulent inflammation around the implant were revealed intraoperatively. The implant resided at a typical site but was easy to displace. The adjacent tissue was harvested for bacteriological examination. The revealed changes were regarded as aseptic loosening of the implant. A decision was made to remove the implant and perform transpedicular and interbody fixation of the functional spinal unit. The bacteriological study of peri-implant tissues revealed no microflora growth. The patient was mobilized on the day of surgery. The wounds healed by primary intention. On day 7, the patient was discharged for outpatient treatment. At discharge, the VAS scores of leg pain and back pain were 0 and 4, respectively. Patient’s condition remained stable within the subsequent 9 months: he had no complaints and experienced no pain 7).

References

1) , 5)

Trummer M, Eustacchio S, Barth M, Klassen PD, Stein S. Protecting facet joints post-lumbar discectomy: Barricaid annular closure device reduces risk of facet degeneration. Clin Neurol Neurosurg. 2013 Aug;115(8):1440-5. doi: 10.1016/j.clineuro.2013.01.007. Epub 2013 Mar 6. PubMed PMID: 23473658.

2)

Parker SL, Grahovac G, Vukas D, Vilendecic M, Ledic D, McGirt MJ, Carragee EJ. Effect of an Annular Closure Device (Barricaid) on Same-Level Recurrent Disk Herniation and Disk Height Loss After Primary Lumbar Discectomy: Two-year Results of a Multicenter Prospective Cohort Study. Clin Spine Surg. 2016 Dec;29(10):454-460. PubMed PMID: 27879508.

3)

Hahn BS, Ji GY, Moon B, Shin DA, Ha Y, Kim KN, Yoon do H. Use of Annular Closure Device (Barricaid®) for Preventing Lumbar Disc Reherniation: One-Year Results of Three Cases. Korean J Neurotrauma. 2014 Oct;10(2):119-22. doi: 10.13004/kjnt.2014.10.2.119. Epub 2014 Oct 31. PubMed PMID: 27169045; PubMed Central PMCID: PMC4852609.

4)

Tatar M, Senturk A, Dalgali Y. Cost-Effectiveness of Use of Barricaid® In Lumbar Discectomy Surgery in Turkey. Value Health. 2014 Nov;17(7):A380. doi: 10.1016/j.jval.2014.08.2614. Epub 2014 Oct 26. PubMed PMID: 27200843.

6)

Lange N, Meyer B, Shiban E. Symptomatic annulus-repair-device loosening due to a low-grade infection. Acta Neurochir (Wien). 2018 Jan;160(1):199-203. doi: 10.1007/s00701-017-3371-1. Epub 2017 Oct 26. PubMed PMID: 29075906.

7)

Krutko AV, Baykov ES, Sadovoy MA. Reoperation after microdiscectomy of lumbar herniation: Case report. Int J Surg Case Rep. 2016;24:119-23. doi: 10.1016/j.ijscr.2016.04.043. Epub 2016 May 12. PubMed PMID: 27236580; PubMed Central PMCID: PMC4887591.

UpToDate: Anterior temporal lobectomy complications

Anterior temporal lobectomy complications

Anterior temporal lobectomy is often complicated by quadrantanopia. In some cases this can be severe enough to prohibit driving, even if a patient is free of seizures. These deficits are caused by damage to Meyers loop of the optic radiation, which shows considerable heterogeneity in its anterior extent. This structure cannot be distinguished using clinical magnetic resonance imaging sequences.

Optic radiation tractography by DTI could be a useful method to assess an individual patient’s risk of postoperative visual deficit 1)2).

van Lanen et al., developed a score method for the assessment of postoperative visual field defects after temporal lobe epilepsy surgery and assessed its feasibility for clinical use. A significant correlation between VFD and resection size for right-sided ATL was confirmed 3).

Cranial nerve (CN) deficits following anterior temporal lobectomy (ATL) are an uncommon but well-recognized complication. The usual CNs implicated in post-ATL complications include the oculomotor nervetrochlear nerve, and facial nerves.

Injury to the trigeminal nerve leading to neuropathic pain are described in 2 cases following temporal lobe resections for pharmacoresistant epilepsy. The possible pathophysiological mechanisms are discussed and the microsurgical anatomy of surgically relevant structures is reviewed.4).

Complications

Dickerson et al., from the Department of Neurosurgery, University of Mississippi Medical Center, JacksonUSA report the third known case and first of diffuse vasospasm. A 48-year-old woman underwent a transcortical anterior left temporal lobectomy. Eleven days later, she had new-onset expressive aphasia with narrowing of the anterior, middle, and posterior cerebral arteries, and increased velocities via transcranial Doppler. She was treated with fluids, nimodipine, and permissive hypertension. At 6 months, her speech was near baseline. Cerebral vasospasm may represent a rare cause of morbidity after anterior temporal lobectomy; a literature review on the subject is presented 5).

References

1)

Borius PY, Roux FE, Valton L, Sol JC, Lotterie JA, Berry I. Can DTI fiber tracking of the optic radiations predict visual deficit after surgery? Clin Neurol Neurosurg. 2014 Jul;122:87-91. doi: 10.1016/j.clineuro.2014.04.017. Epub 2014 May 5. PubMed PMID: 24908224.
2)

James JS, Radhakrishnan A, Thomas B, Madhusoodanan M, Kesavadas C, Abraham M, Menon R, Rathore C, Vilanilam G. Diffusion tensor imaging tractography of Meyer’s loop in planning resective surgery for drug-resistant temporal lobe epilepsy. Epilepsy Res. 2015 Feb;110:95-104. doi: 10.1016/j.eplepsyres.2014.11.020. Epub 2014 Nov 27. PubMed PMID: 25616461.
3)

van Lanen RHGJ, Hoeberigs MC, Bauer NJC, Haeren RHL, Hoogland G, Colon A, Piersma C, Dings JTA, Schijns OEMG. Visual field deficits after epilepsy surgery: a new quantitative scoring method. Acta Neurochir (Wien). 2018 Jul;160(7):1325-1336. doi: 10.1007/s00701-018-3525-9. Epub 2018 Apr 5. PubMed PMID: 29623432; PubMed Central PMCID: PMC5995984.
4)

Gill I, Parrent AG, Steven DA. Trigeminal neuropathic pain as a complication of anterior temporal lobectomy: report of 2 cases. J Neurosurg. 2016 Apr;124(4):962-5. doi: 10.3171/2015.5.JNS15123. Epub 2015 Oct 30. PubMed PMID: 26517768.
5)

Dickerson JC, Hidalgo JA, Smalley ZS, Shiflett JM. Diffuse vasospasm after transcortical temporal lobectomy for intractable epilepsy. Acta Neurochir (Wien). 2018 Jul 10. doi: 10.1007/s00701-018-3606-9. [Epub ahead of print] PubMed PMID: 29987392.

UpToDate: Race

Race

A race is a grouping of humans based on shared physical or social qualities into categories generally viewed as distinct by society.

First used to refer to speakers of a common language and then to denote national affiliations, by the 17th century the term race began to refer to physical (phenotypical) traits. Modern scholarship regards race as a social construct, that is, a symbolic identity created to establish some cultural meaning. While partially based on physical similarities within groups, race is not an inherent physical or biological quality.


Black and Hispanic patients are at higher risk of intracerebral hemorrhage recurrence; hypertension severity (average BP and its variability) does not fully account for this finding. Additional studies will be required to further elucidate determinants for this health disparity 1).


In spine surgery, racial disparities have been shown to impact various aspects of surgical care. Previous studies have associated racial disparities with inferior surgical outcomes, including increased complication and 30-day readmission rates after spine surgery.

Patient-reported outcomes (PROs) and satisfaction measures have been proxies for overall quality of care and hospital reimbursements. However, the influence that racial disparities have on short- and long-term PROs and patient satisfaction after spine surgery is relatively unknown.

The aim of a study of Elsamadicy et al., was to investigate the impact of racial disparities on 3- and 12-month PROs and patient satisfaction after elective lumbar spine surgery.

This study was designed as a retrospective analysis of a prospectively maintained database. The medical records of adult (age ≥ 18 years) patients who had undergone elective lumbar spine surgery for spondylolisthesis (grade 1), disc herniation, or stenosis at a major academic institution were included in this study. Patient demographics, comorbidities, postoperative complications, and 30-day readmission rates were collected. Patients had prospectively collected outcome and satisfaction measures. Patient-reported outcome instruments-Oswestry Disability Index (ODI), visual analog scale for back pain (VAS-BP), and VAS for leg pain (VAS-LP)-were completed before surgery and at 3 and 12 months after surgery, as were patient satisfaction measures. RESULTS The authors identified 345 medical records for 53 (15.4%) African American (AA) patients and 292 (84.6%) white patients. Baseline patient demographics and comorbidities were similar between the two cohorts, with AA patients having a greater body mass index (33.1 ± 6.6 vs 30.2 ± 6.4 kg/m2, p = 0.005) and a higher prevalence of diabetes (35.9% vs 16.1%, p = 0.0008). Surgical indications, operative variables, and postoperative variables were similar between the cohorts. Baseline and follow-up PRO measures were worse in the AA cohort, with patients having a greater baseline ODI (p < 0.0001), VAS-BP score (p = 0.0002), and VAS-LP score (p = 0.0007). However, mean changes from baseline to 3- and 12-month PROs were similar between the cohorts for all measures except the 3-month VAS-BP score (p = 0.046). Patient-reported satisfaction measures at 3 and 12 months demonstrated a significantly lower proportion of AA patients stating that surgery met their expectations (3 months: 47.2% vs 65.5%, p = 0.01; 12 months: 35.7% vs 62.7%, p = 0.007).

The study data suggest that there is a significant difference in the perception of health, pain, and disability between AA and white patients at baseline and short- and long-term follow-ups, which may influence overall patient satisfaction. Further research is necessary to identify patient-specific factors associated with racial disparities that may be influencing outcomes to adequately measure and assess overall PROs and satisfaction after elective lumbar spine surgery 2).


A total of 9950 patients underwent transsphenoidalpituitary surgery; 7122 (72%), 2394 (24%), and 434 (4%) patients were treated at high volume center, medium-volume, and low-volume centers, respectively. Patient factors associated with treatment at high-volume centers (HVCs) included: top income quartile, private insurance, urban residence, and white or Asian race (p < 0.05). Patient variables associated with treatment at low-volume centers (LVCs) included: age >65 years, elevated Charlson comorbidity index (CCI) scores, bottom income quartile, Medicaid and Medicare insurance, rural residence, black race, and Hispanic ethnicity (p < 0.05). Variables predictive of prolonged hospitalizations in our multivariable model included black race, Hispanic ethnicity, Medicaid insurance, low income, female gender, LVC, and comorbidities (panhypopituitarismhypothyroidismdiabetes insipidus [DI], visual disturbances, CCI) while predictors of readmissions included Asian race, female gender, and comorbidities (Cushing syndrome, DI, CCI) 3).


Studies have shown an increased risk of traumatic brain injury (TBI) for individuals who suffer an initial TBI.

study of Hayward et al., St. John Hospital & Medical CenterDetroitMichiganUSA hypothesized that individuals with recurrent neurotraumawould originate from populations considered ‘vulnerable’, i.e. low income and/or with neuropsychiatric disorders.

Data from the Michigan State Inpatient Database from 2006 to 2014 for the Detroit metropolitan area enlisted a study population of 50 744 patients with neurotraumaBinary logistic regression was used to assess risk factors associated with admission for subsequent neurotrauma compared with single neurotrauma admission.

Patients with repeated neurotrauma admissions were similar to those with one-time trauma in terms of age at first admission and neighbourhood income levels. However, patients with repeated neurotrauma admissions were more likely to be male (p < .001) and African-American (p < .001). Comorbid alcohol use and drug use were 39% and 15% less likely to be readmitted with neurotrauma, respectively. Comorbid conditions associated with greater risk of repeat neurotrauma included depressionpsychosis, and neurological disorders, increasing risk by 38%, 22%, and 58%, respectively.

This study validated the hypothesis that comorbid psychiatric conditions are a significant risk factor for recurrent neurotrauma and validate prior studies showing gender and race as significant risk factors. 4).


The junction of the transverse sinus with the sigmoid sinus can differ up to 0.5 cm in the craniocaudal axis depending on race. As neuronavigationis not standard to the approach to the cerebellopontine angle, the study aimed to provide the neurosurgeon operating in the retrosigmoid area additional knowledge to avoid sinus injury with subsequent complications, such as blood loss, sinus occlusion, or air embolism 5).

References

1)

Rodriguez-Torres A, Murphy M, Kourkoulis C, Schwab K, Ayres AM, Moomaw CJ, Young Kwon S, Berthaud JV, Gurol ME, Greenberg SM, Viswanathan A, Anderson CD, Flaherty M, James ML, Birnbaum L, Yong Sung G, Parikh G, Boehme AK, Mayson D, Sheth KN, Kidwell C, Koch S, Frankel M, Langefeld CD, Testai FD, Woo D, Rosand J, Biffi A. Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals. Neurology. 2018 Jul 3;91(1):e37-e44. doi: 10.1212/WNL.0000000000005729. Epub 2018 Jun 6. PubMed PMID: 29875221.
2)

Elsamadicy AA, Kemeny H, Adogwa O, Sankey EW, Goodwin CR, Yarbrough CK, Lad SP, Karikari IO, Gottfried ON. Influence of racial disparities on patient-reported satisfaction and short- and long-term perception of health status after elective lumbar spine surgery. J Neurosurg Spine. 2018 Jul;29(1):40-45. doi: 10.3171/2017.12.SPINE171079. Epub 2018 Apr 27. PubMed PMID: 29701564.
3)

McKee S, Yang A, Kidwai S, Govindaraj S, Shrivastava R, Iloreta A. The socioeconomic determinants for transsphenoidal pituitary surgery: a review of New York State from 1995 to 2015. Int Forum Allergy Rhinol. 2018 Jul 14. doi: 10.1002/alr.22148. [Epub ahead of print] PubMed PMID: 30007017.
4)

Hayward RD, Fessler MM, Buck J, Fessler RD. Risk factors for recurrent neurotrauma: a population-based study in Southeastern Michigan. Brain Inj. 2018 Jun 18:1-4. doi: 10.1080/02699052.2018.1487584. [Epub ahead of print] PubMed PMID: 29913083.
5)

Dao Trong P, Beynon C, Unterberg A, Schneider T, Jesser J. Racial Differences in the Anatomy of the Posterior Fossa: Neurosurgical Considerations. World Neurosurg. 2018 Jun 20. pii: S1878-8750(18)31305-6. doi: 10.1016/j.wneu.2018.06.089. [Epub ahead of print] PubMed PMID: 29935317.

UpToDate: Shunt dependency syndrome

Shunt dependency syndrome

Intraventricular hemorrhage (IVH) is a common affliction of preterm infants and often results in posthemorrhagic hydrocephalus (PHH). These patients typically eventually require permanent CSF diversion and are presumed to be indefinitely shunt-dependent.

In a cohort of patients with clinical grade aneurysmal subarachnoid hemorrhage (aSAH) at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome 1).

Aneurysmal subarachnoid hemorrhage (SAH) has been reported to induce an intrathecal inflammatory reaction reflected by cytokine release, particularly interleukin 6 (IL-6), which correlates with early brain damage and poor outcome.

CSF IL-6 values of ≥10,000 pg/ml in the early post-SAH period may be a useful diagnostic tool for predicting shunt dependency in patients with acute posthemorrhagic hydrocephalus. The development of shunt-dependent posthemorrhagic hydrocephalus remains a multifactorial process 2).

Graeb Score or LeRoux scores improve the prediction of shunt dependency and in parts of case fatality rate (CFR) in aneurysmal SAH patients therefore confirming the relevance of the extent and distribution of intraventricular hemorrhage for the clinical course in SAH 3).

A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis 4).

In a study SD after aSAH showed no correlations with three of the parameters previously identified as risk factors for shunt dependent hydrocephalus, namely, the amount of SAH, the presence of IVH, or acute hydrocephalus. Instead, a longer duration of CSF drainage correlated with SD as an independent factor. These data suggest that a longer duration of CSF drainage may be one of the risk factors for SD after aSAH 5).

Case series

2015

A total of 471 patients who were part of the Barrow Ruptured Aneurysm Trial (BRAT) from 2003 to 2007 were retrospectively reviewed. All variables including demographic data, medical history, treatment, imaging, and functional outcomes were included as part of the trial. No additional variables were retrospectively collected.

Ultimately, 147 patients (31.2%) required a ventriculoperitoneal shunt (VPS) in this series. Age, dissecting aneurysm type, ruptured vertebrobasilar aneurysm, Fisher grade, Hunt and Hess grade, admission intraventricular hemorrhage, admission intraparenchymal hemorrhage, blood in the fourth ventricle on admission, perioperative ventriculostomy, and hemicraniectomy were significant risk factors (P < .05) associated with shunt-dependent hydrocephalus on univariate analysis. On multivariate analysis, intraventricular hemorrhage and intraparenchymal hemorrhage were independent risk factors for shunt dependency (P < .05). Clipping vs coiling treatment was not statistically associated with VPS after SAH on both univariate and multivariate analyses. Patients who did not receive a VPS at discharge had higher Glasgow Outcome Scale and Barthel Index scores and were more likely to be functionally independent and to return to work 72 months after surgery (P < .05).

There is no difference in shunt dependency after SAH among patients treated by endovascular or microsurgical means. Patients in whom shunt-dependent hydrocephalus does not develop after SAH tend to have improved long-term functional outcomes 6).


Wang et al. analyzed retrospectively collected data for 89 preterm patients diagnosed with grades III and IV IVH and PHH from 1998 to 2011.

Sixty-nine out of 89 patients (77.5 %) underwent ventriculoperitoneal shunt placement, and 33 (47.8 %) required at least one shunt revision and 18 (26.1 %) required multiple revisions. The mean ± standard deviation follow-up time for shunted patients was 5.0 ± 3.3 years. The majority of early failures were due to proximal catheter malfunction, while later failures were mostly due to distal catheter problems. There was a significant difference in the number of patients requiring revisions in the first 3 years following initial VP shunt insertion compared after 3 years, with 28 revisions versus 10 (p < 0.004). In 8 out of 10 patients who underwent shunt revisions after 3 years, evidence of obstructive hydrocephalus was found on imaging either in the form of an isolated fourth ventricular cyst or aqueductal stenosis.

The results suggest that in a distinct subset of patients with PHH, obstructive hydrocephalus may develop, resulting in long-term dependence on CSF diversion. Further study on the factors associated with long-term shunt dependence and revision requirements within the PHH group is warranted 7).

2014

88 consecutive patients with aneurysmal SAH requiring external ventricular drain placement and endovascular aneurysm closure were included. Functional outcome and shunt dependency were assessed 90 days after event. A matched controlled sub-analysis was carried out to investigate the effects of IVF treatment (n = 14; matching criteria: age, neuro-status and imaging). Multivariate modeling was performed to identify independent predictors for permanent shunt dependency.

In IVF-patients neurological status was significantly poorer [Hunt&Hess: IVF = 4(3-5) vs. non-IVF = 3(1-5); p = 0.035] and the extent of ventricular hemorrhage was increased [Graeb Score: IVF = 7(6-8) vs. non-IVF = 3(1-4); p ≤ 0.001]. Consecutive matched controlled sub-analysis revealed no significant therapeutic effect of IVF with respect to shunt dependency rate and functional outcome. Multivariate analysis revealed Graeb score [OR = 1.34(1.02-1.76); p = 0.035] and sepsis [OR = 11.23(2.28-55.27); p = 0.003] as independent predictors for shunt dependency, whereas IVF did not exert significant effects (p = 0.820).

In endovascular-treated SAH patients IVF neither reduced permanent shunt dependency nor influenced functional outcome. Despite established effects on intraventricular clot resolution IVF appears less powerful in SAH as compared to ICH. Given the reported positive effects of lumbar drainage (LD) in SAH, a prospective analysis of a combined treatment approach of IVF and subsequent lumbar drain sOeems warranted aiming to reduce permanent shunting and improve functional outcome 8).

1999

Of 138 patients treated for ruptured aneurysms the development of shunt dependent hydrocephalus was evaluated regarding possible predictive factors. In 15 patients (11%) ventriculo-atrial shunt was implanted due to hydrocephalus. One predictive factor was the localisation of aneurysms as patients with hydrocephalus had PcoA aneurysms in 40% compared to 20% in the group of patients without hydrocephalus and only 7% compared to 28% MCA aneurysms. An other predictive factor was the severity of the subarachnoid haemorrhage (SAH) as 7 patients out of the 15 were graded Fisher IV on admission. Furthermore, an important predictive factor was the presence of acute hydrocephalus as 13 out of the 15 patients (87%) with shunt dependent hydrocephalus had acute hydrocephalus requiring external ventricular drainage. An other possible factor was the intraoperative opening of the lamina terminalis as in 73% of the patients with shunt dependent hydrocephalus compared to 82% in the group of patients without hydrocephalus this procedure was performed during surgery. The results suggest that shunt dependency is more likely after severe SAH especially in the presence of an acute hydrocephalus and in patients with aneurysms located in the basal cisterns. Therefore treatment of the acute hydrocephalus and possible the opening of the lamina terminalis could have a positive effect on the development of shunt dependent hydrocephalus after SAH 9).

1979

Five patients with shunt dependency were observed to have apparently normal ventricular size despite marked increases in ventricular pressure after shunt malfunctionElastance (dP/dV) was determined in four of these patients by removing increments of cerebrospinal fluid and measuring the resulting pressure. These patients without ventricular enlargement and with markedly increased ventricular pressure had high elastance. This group of patients with “normal volume” hydrocephalus had distal shunt occlusions, in contrast to previously reported patients with cephalic shunt obstructions after ventricular decompression. Initial shunting in early infancy, prolonged shunt dependency, and lack of recent shunt revision were common factors in these patients. Markedly elevated pressure with normal volume is a threatening clinical entity, requiring prompt surgical intervention 10).

1975

In suitable cases, intermittent cranial compression by means of an elastic bandage or a helmet with an inflatable inner-lining may be effective. There was arrested hydrocephalus in nine of 14 children treated with this method, eight of whom have developed normally. When cranial compression is contra-indicated or not successful, the preferred method of treatment is an ‘on-off’ type of valve which is used intermittently to drain a fixed volume of cerebrospinal fluid. Of 18 children who had such shunts inserted, 10 have become totally independent of their shunts and their hydrocephalus has become compensated. All are of normal intelligence. Subtemporal craniectomy was performed on seven shunt-dependent children with recurrent catheter obstruction. Four have been followed for six months and three for two years and in no case has there been further malfunction of the proximal catheter 11).

Case reports

Dong et al., from the Tongji Hospital, Huazhong University of Science and Technology, WuhanChina report two children with middle fossa arachnoid cysts who underwent cystoperitoneal shunt with fixed pressure valve at an opening pressure of 7 cmH2O and then developed dependency syndrome. Both patients were effectively treated by mini-invasive cyst wall excision with the shunts reserved. The clinical manifestation, radiological findings, treatment methods, and therapeutic outcomes were reviewed retrospectively.

The time from shunt surgery to shunt dependency syndrome occurrence was 4 and 2 years, respectively. Computed tomography/magnetic resonance findings of the brain showed remarkably collapsed cysts with normal or small ventricles. Both patients underwent secondary mini-invasive cyst wall excision and shunt catheters were reserved. After the operations, their symptoms were resolved except one case with marginally improved visual impairment.

Shunt dependency syndrome is a rare but dangerous complication of CP shunt and should be treated in time. Collapsed and thickened cyst wall intermittent covering the catheter head end, decreased brain compliance due to chronic fibrosis, as well as regression of cerebrospinal fluidabsorption could be the pathogenesis. They suggest keyhole resection of the residual cyst wall as an effective and mini-invasive treatment option12).


Sonobe et al. report two cases of high shunt dependency, which were first thought to be shunt independent arrested hydrocephalus. Though their shunt systems didn’t seem to work, symptoms of rapid increasing intracranial pressure were observed after obstruction or replacement of shunt tube. Their ventricles looked so small like a slit on CT scan and PVG that the apex of the ventricular tube were easily obstructed by a ventricle wall. This is the reason why we misjudged them to be shunt independent arrested hydrocephalus. The cause of slit-like ventricles was overflow of CSF fluid due to the low pressure valve and the siphon effect. In general, after the shunt operation, most of the cases with thickening of cerebral mantle show the shunt dependency. Especially the cases showing rapid and marked thickening of the cerebral mantle are highly shunt dependent. Therefore, we must observe such cases carefully, in which the ventricle becomes small. Short interval follow-ups by CT scan after the shunt operation are quite necessary in order to observe the ventricle size. Easy and reliable judging method to know whether the shunt system is working or not is required to be developed 13).

References

1)

Erixon HO, Sorteberg A, Sorteberg W, Eide PK. Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial. Acta Neurochir (Wien). 2014 Nov;156(11):2059-69. doi: 10.1007/s00701-014-2200-z. Epub 2014 Aug 22. PubMed PMID: 25143185.
2)

Wostrack M, Reeb T, Martin J, Kehl V, Shiban E, Preuss A, Ringel F, Meyer B, Ryang YM. Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: The Role of Intrathecal Interleukin-6. Neurocrit Care. 2014 May 20. [Epub ahead of print] PubMed PMID: 24840896.
3)

Czorlich P, Ricklefs F, Reitz M, Vettorazzi E, Abboud T, Regelsberger J, Westphal M, Schmidt NO. Impact of intraventricular hemorrhage measured by Graeb and LeRoux score on case fatality risk and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien). 2015 Mar;157(3):409-15. doi: 10.1007/s00701-014-2334-z. Epub 2015 Jan 21. PubMed PMID: 25599911.
4)

Bae IS, Yi HJ, Choi KS, Chun HJ. Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients. J Cerebrovasc Endovasc Neurosurg. 2014 Jun;16(2):78-84. doi: 10.7461/jcen.2014.16.2.78. Epub 2014 Jun 30. PubMed PMID: 25045646; PubMed Central PMCID: PMC4102754.
5)

Sugawara T, Maehara T, Tadashi N, Aoyagi M, Ohno K. Independent predictors of shunt-dependent normal pressure hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg Sci. 2014 Jul 29. [Epub ahead of print] PubMed PMID: 25069541.
6)

Zaidi HA, Montoure A, Elhadi A, Nakaji P, McDougall CG, Albuquerque FC, Spetzler RF, Zabramski JM. Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the BRAT trial: revisiting the clip vs coil debate. Neurosurgery. 2015 May;76(5):608-13; discussion 613-4; quiz 614. doi: 10.1227/NEU.0000000000000677. PubMed PMID: 25714521.
7)

Wang JY, Jackson EM, Jallo GI, Ahn ES. Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: insight into the time course of shunt dependency. Childs Nerv Syst. 2015 Nov;31(11):2123-30. doi: 10.1007/s00381-015-2865-5. Epub 2015 Aug 7. PubMed PMID: 26248674.
8)

Gerner ST, Kuramatsu JB, Abel H, Kloska SP, Lücking H, Eyüpoglu IY, Doerfler A, Schwab S, Huttner HB. Intraventricular fibrinolysis has no effects on shunt dependency and functional outcome in endovascular-treated aneurysmal SAH. Neurocrit Care. 2014 Dec;21(3):435-43. doi: 10.1007/s12028-014-9961-3. PubMed PMID: 24566979.
9)

Schmieder K, Koch R, Lücke S, Harders A. Factors influencing shunt dependency after aneurysmal subarachnoid haemorrhage. Zentralbl Neurochir. 1999;60(3):133-40. PubMed PMID: 10726336.
10)

Engel M, Carmel PW, Chutorian AM. Increased intraventricular pressure without ventriculomegaly in children with shunts: “normal volume” hydrocephalus. Neurosurgery. 1979 Nov;5(5):549-52. PubMed PMID: 534062.
11)

Epstein FJ, Hochwald GM, Wald A, Ransohoff J. Avoidance of shunt dependency in hydrocephalus. Dev Med Child Neurol Suppl. 1975;(35):71-7. PubMed PMID: 812752.
12)

Dong F, Wang Z, Li Y, Chen Z, Zhang S, Wan F. Shunt Dependency Syndrome after Cyst-Peritoneal Shunt Resolved by Keyhole Microsurgical Cyst Resection: Two Case Reports and Literature Review. Neuropediatrics. 2018 Jul 12. doi: 10.1055/s-0038-1661395. [Epub ahead of print] PubMed PMID: 30001565.
13)

Sonobe M, Kodama N, Fujiwara S, Takaku A, Suzuki J. [On-off mechanism of shunt system due to slit ventricle (author’s transl)]. No Shinkei Geka. 1978 Dec;6(12):1193-6. Japanese. PubMed PMID: 732936.

UpToDate: Intercostal neurolysis

Intercostal neurolysis

Cappellari et al., from the Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Italy.investigated the possible role of intercostal surgical neurolysis in relieving chronic neuropathic painrefractory to other non-surgical treatments in patients with postsurgical thoracic pain.

They retrospectively collected clinical data on ten patients (age range: 20-68 years) suffering from neuropathic pain for at least two months following thoracic surgery underwent intercostal neurolysis.

Compared to pre-neurolysis, pain intensity decreased one month post-neurolysis and remained stable two months post-neurolysis [median score (IQR): 8 (6; 9) pre-neurolysis, 4 (3; 5) one month after and 3 (2; 5) two months after, p<0.0001]. Antiepileptic drugs for pain control decreased after neurolysis (10/10 vs. 2/10, p= 0.008).

Surgical intercostal neurolysis may be a promising therapeutic option in patients with chronic neuropathic pain in association with neurological deficits 1).


11 patients with intractable cancer-associated chest wall pain were treated with a diagnostic intercostal nerve block. Six patients subsequently received chemical neurolysis with phenol using the same approach. No serious adverse events were observed. Radiopaque contrast dye spread into the paravertebral space in all 11 patients, and in 1 patient contrast dye spread into the epidural space. Seven of 11 patients experienced pain relief from the diagnostic blockade. Four of six patients experienced pain relief from the neurolytic blockade. The principal reportable finding from this case series is the observation that contrast dye spread liberally from the intercostal space into other anatomic spaces, even though very small volumes of injectate (less than 5 mL) were used. Definitive evidence of safety and efficacy of intercostal nerve block and neurolysis for cancer pain will require a prospective randomized clinical trial 2).

Complications

Kim et al., report a case in which a lung cancer patient developed paraplegia after receiving left T8-10 and 11th intercostal nerve neurolysis and T9-10 interlaminar epidural injections 3).

References

1)

Cappellari AM, Tiberio F, Alicandro G, Spagnoli D, Grimoldi N. Intercostal neurolysis for the treatment of postsurgical thoracic pain: A case series. Muscle Nerve. 2018 Jul 11. doi: 10.1002/mus.26298. [Epub ahead of print] PubMed PMID: 29995980.
2)

Matchett G. Intercostal Nerve Block and Neurolysis for Intractable Cancer Pain. J Pain Palliat Care Pharmacother. 2016 Jun;30(2):114-7. doi: 10.3109/15360288.2016.1167804. Epub 2016 Apr 19. PubMed PMID: 27092398.
3)

Kim BH, No MY, Han SJ, Park CH, Kim JH. Paraplegia following intercostal nerve neurolysis with alcohol and thoracic epidural injection in lung cancer patient. Korean J Pain. 2015 Apr;28(2):148-52. doi: 10.3344/kjp.2015.28.2.148. Epub 2015 Apr 1. PubMed PMID: 25852838; PubMed Central PMCID: PMC4387461.

UpToDate: Pediatric intracranial tumor

Pediatric intracranial tumor

Epidemiology

Malignant brain tumors are not uncommon in infants as their occurrence before the age of three represents 20-25% of all malignant brain tumors in childhood.

The location of brain tumors in very young children differs from the posterior fossa predominance of older children. This is especially true in the first 6– 12 months of life, where supratentorial location is signicantly more common.

Approximately 20% of pediatric intracranial tumors arise from the thalamus or brainstem, with an incidence rate of 5% and 15%, respectively.

Medulloblastoma is the most common malignant pediatric intracranial tumor.

Diffuse intrinsic pontine glioma account for 10% to 25% of pediatric intracranial tumor.

Diagnosis

Bächli et al., from the Heidelberg University Hospital, Germany, report a single-institutional collection of pediatric brain tumor cases that underwent a refinement or a change of diagnosis after completion of molecular diagnostics that affected clinical decision-making including the application of molecularly informed targeted therapies. 13 pediatric central nervous system tumors were analyzed by conventional histology, immunohistochemistry, and molecular diagnostics including DNA methylation profiling in 12 cases, DNA sequencing in 8 cases and RNA sequencing in 3 cases. 3 tumors had a refinement of diagnosis upon molecular testing, and 6 tumors underwent a change of diagnosis. Targeted therapy was initiated in 5 cases. An underlying cancer predisposition syndrome was detected in 5 cases. Although this case series, retrospectiveand not population based, has its limitations, insight can be gained regarding precision of diagnosis and clinical management of the patients in selected cases. Accuracy of diagnosis was improved in the cases presented here by the addition of molecular diagnostics, impacting clinical management of affected patients, both in the first-line as well as in the follow-up setting. This additional information may support the clinical decision making in the treatment of challenging pediatric CNS tumors. Prospective testing of the clinical value of molecular diagnostics is currently underway 1).

Treatment

Malignant brain tumors represent a true therapeutic challenge in neurooncology. Before the era of modern imaging and modern neurosurgery these malignant brain tumors were misdiagnosed or could not benefit of the surgical procedures as well as older children because of increased risks in this age group.

The pediatric oncologists are more often confronted with very young children who need a complementary treatment. Before the development of specific approaches for this age group, these children received the same kind of treatment than the older children did, but their survival and quality of life were significantly worse. The reasons of these poor results were probably due in part to the fear of late effects induced by radiation therapy, leading to decrease the necessary doses of irradiation which increased treatment failures without avoiding treatment related complications.

At the end of the 80s, pilot studies were performed using postoperative chemotherapy in young medulloblastoma patients. Van Eys treated 12 selected children with medulloblastoma with MOPP regimen and without irradiation; 8 of them were reported to be long term survivors.

Subsequently, the pediatric oncology cooperative groups studies have designed therapeutic trials for very young children with malignant brain tumors.

Different approaches have been explored: * Prolonged postoperative chemotherapy and delayed irradiation as designed in the POG (Pediatric Oncology Group). * Postoperative chemotherapy without irradiation in the SFOP (Société Française d’Oncologie Pédiatrique) and in the GPO (German Pediatric Oncology) studies. *

The role of high-dose chemotherapy with autologous stem cells transplantation was explored in different ways: High-dose chemotherapy given in all patients as proposed in the Head Start protocol. High-dose chemotherapy given in relapsing patients as salvage treatment in the French strategy. In the earliest trials, the same therapy was applied to all histological types of malignant brain tumors and whatever the initial extension of the disease. This attitude was justified by the complexity of the classification of all brain tumors that has evolved over the past few decades leading to discrepancy between the diagnosis of different pathologists for a same tumor specimen. Furthermore, it has become increasingly obvious that the biology of brain tumors in very young children is different from that seen in older children. However, in the analysis of these trials an effort was made to give the results for each histological groups, according to the WHO classification and after a central review of the tumor specimens. All these collected data have brought to an increased knowledge of infantile malignant brain tumors in terms of diagnosis, prognostic factors and response to chemotherapy. Furthermore a large effort was made to study long term side effects as endocrinopathies, cognitive deficits, cosmetic alterations and finally quality of life in long term survivors. Prospective study of sequelae can bring information on the impact of the different factors as hydrocephalus, location of the tumor, surgical complications, chemotherapy toxicity and irradiation modalities. With these informations it is now possible to design therapeutic trials devoted to each histological types, adapted to pronostic factors and more accurate treatment to decrease long term sequelae 2).

Complications

Case series

1)

Bächli H, Ecker J, van Tilburg C, Sturm D, Selt F, Sahm F, Koelsche C, Grund K, Sutter C, Pietsch T, Witt H, Herold-Mende C, von Deimling A, Jones D, Pfister S, Witt O, Milde T. Molecular Diagnostics in Pediatric Brain Tumors: Impact on Diagnosis and Clinical Decision-Making – A Selected Case Series. Klin Padiatr. 2018 Jul 11. doi: 10.1055/a-0637-9653. [Epub ahead of print] PubMed PMID: 29996150.
2)

Kalifa C, Grill J. The therapy of infantile malignant brain tumors: current status? J Neurooncol. 2005 Dec;75(3):279-85. Review. PubMed PMID: 16195802.