Surgical intervention for hydrocephalus in infancy; etiology, age and treatment data in a Dutch cohort.

PURPOSE: To gain insight into the patient characteristics of surgically treated hydrocephalus in the Netherlands, we report the first data from the Dutch Quality Registry NeuroSurgery (QNRS) database for infants with hydrocephalus requiring surgical intervention. METHODS: We used the prospectively gathered database concerning infants ≤ 2 years of age surgically treated for hydrocephalus. We report data from start of registry, concerning etiology, age, and treatment of patients registered. We compared data with the Hydrocephalus Clinical Research Network (HCRN), a multicenter network of pediatric neurosurgical institutions in North America. RESULTS: A total of 359 operated infants was registered in the period from 2010 to 2017. A drop in patients registered was seen in 2015, possibly due to revisions of the database. Most infants were operated on between 1 and 6 months of age. Cause of hydrocephalus was predominantly intracranial hemorrhage, followed by congenital causes. The proportion of infants with aqueduct stenosis and myelomeningocele as cause of hydrocephalus stayed relatively stable during this period of registration. Initial shunting was performed in 40% and reservoir/ETV as initial treatment was done in 60%. In both groups, 50% needed revision surgery. CONCLUSIONS: The first data concerning surgically treated pediatric hydrocephalus from a prospectively collected Dutch register are presented, showing similar results when comparing to the HCRN database.

Wound drains in non-complex lumbar surgery: a systematic review.

AIMS: Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage. PATIENTS AND METHODS: Studies were identified from PubMed and EMBASE, up to and including 27 August 2015, for papers describing one- or two-level lumbar discectomy and/or laminectomy for degenerative disease in adults which reported any form of subcutaneous or subfascial drainage. RESULTS: Eight papers describing 1333 patients were included. Clinically relevant post-operative epidural haematomas occurred in two (0.15%), and wound infections in ten (0.75%) patients. Epidural haematomas occurred in two (0.47%) patients who had wound drainage (n = 423) and in none of those without wound drainage (n = 910). Wound infections occurred in two (0.47%) patients with wound drainage and in eight (0.88%) patients without wound drainage. CONCLUSION: These data suggest that the routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas and that the absence of a drain does not lead to a significant change in the incidence of wound infection. Cite this article: Bone Joint J 2016;98-B:984-9.

The predictive value of 3D time-of-flight MR angiography in assessment of brain arteriovenous malformation obliteration after radiosurgery.

BACKGROUND AND PURPOSE: The purpose of radiosurgery of bAVMs is complete angiographic obliteration of its nidus. We assessed the diagnostic accuracy of 1.5T T2-weighted MR imaging and TOF-MRA images for detecting nidus obliteration after radiosurgery. MATERIALS AND METHODS: The pre- and postradiosurgery MR images and DSA images from 120 patients who were radiosurgically treated for a bAVM were re-evaluated by 2 observers for patency of the nidus (preradiosurgery) and obliteration (postradiosurgery: final follow-up MR imaging), by using a 3-point scale of confidence. Consensus reading of the DSA after radiosurgery was considered the criterion standard for obliteration. Sensitivity, specificity, PPVs, and NPVs, and overall diagnostic performance by using ROC were determined. RESULTS: Mean bAVM volume during radiosurgery was 3.4 mL (95% CI, 2.6-4.3 mL). Sixty-six patients (55%) had undergone previous endovascular embolization. The mean intervals between radiosurgery and follow-up MR imaging and for DSA, respectively, were 35.6 months (95% CI, 32.3-38.9 months) and 42.1 months (95% CI, 40.3-44.0 months). With ROC, an area under curve of 0.81-0.83 was found. PPVs of final follow-up MR-imaging for definitive obliteration varied between 0.89 [corrected] and 0.95. NPV was 0.52 [corrected] . An average false-positive rate, meaning overestimation of nidus obliteration of 0.10 [corrected] and an average false-negative rate, meaning underestimation of nidus obliteration of 0.42 [corrected] were found. CONCLUSIONS: MRA is insufficient to diagnose obliteration in the follow-up of bAVMs after radiosurgery. A remaining nidus diameter <10 mm seems to be the major limiting factor for reliable assessment of obliteration. We highly recommend follow-up DSA for definitive diagnosis of complete obliteration.

Brain arteriovenous malformations: from diagnosis to treatment.

Brain arteriovenous malformations (bAVM) are a major cause of morbidity in young people. The main mode of presentation is with a cerebral bleeding or seizures, although nowadays, due to the increased use of MRI, more asymptomatic bAVMs are encountered. The clinical course of asymptomatic bAVMs seems to be mild in comparison to bAVMs that presented with a cerebral hemorrhage. This finding may lead to a paradigm shift regarding treatment of asymptomatic bAVMs. This review discusses the latest findings in bAVM epidemiology and natural history, and compares the optimal imaging modalities and best treatment options.

Repeated surgery for glioblastoma multiforme: only in combination with other salvage therapy.

BACKGROUND: The purpose of the study was to evaluate the effects, frequency, and complications of repeated surgical resection for GBM relapse. METHODS: A group of 32 patients with tumor recurrence, derived from a total of 126 consecutive patients with prior GBM, treated between 1999 and 2005 in the VU University Medical Center, Amsterdam, Netherlands, were retrospectively studied. Survival, functional status, morbidity, and mortality after starting salvage therapy for recurrent GBM were studied. Survival was analyzed using Kaplan-Meier survival curves, and log-rank statistics were used for group comparison. RESULTS: Of the 32 patients with recurrent primary GBM, 20 received repeated surgery as salvage therapy. In 11 (55%) cases, repeated surgery was followed by CT or SRS. Nine (45%) patients receiving only repeated surgery showed significantly lower survival rates compared with the aforementioned 11 cases. The remaining 12 patients received only salvage CT or SRS and showed a significantly prolonged survival compared with the 9 cases receiving repeated surgery only. Surgical morbidity was 15%, and surgical mortality, 5%. CONCLUSION: Despite inherent selection bias, this retrospective analysis suggests that repeated surgery for GBM relapse should only be considered in patients with severe symptoms and if additional salvage treatment can be administered postoperatively.

Radiosurgery of brain arteriovenous malformations in children.

OBJECTIVE: The authors describe their experience in treating 22 children with a single brain arteriovenous malformation (bAVM) using a dedicated LINAC stereotactic radiosurgery unit. METHODS: The findings of 22 consecutive patients < or = 18 years of age who underwent radiosurgery for a single bAVM and with at least 24 months of follow-up, or earlier proven obliteration,were reviewed. The median age at radiosurgery was 13.8 years,with a hemorrhagic presentation in 86%. Median bAVM-volume was 1.8 ml, with a median prescribed marginal dose of 19.0 Gy. RESULTS: The crude complete obliteration-rate was 68% (n = 15) after a median follow-up of 24 months. The actuarial obliteration- rate was 45 % after two years and 64 % after three years. Patients with a radiosurgery-based AVM score < or = 1 more frequently had an excellent outcome than patients with a bAVM score > 1 (71% vs. 20%, P = 0.12), as well as an increased obliteration rate (P = 0.03) One patient died from a bAVM-related hemorrhage 27 months after radiosurgery, representing a postradiosurgery hemorrhage rate of 1.3%/year for the complete followup interval. Overall outcome was good to excellent in 68% (n = 15). Radiation-induced changes on MR imaging were seen in 36% (n = 8) after a median interval of 12.5 months, resulting in deterioration of pre-existing neurological symptoms in one patient. CONCLUSIONS: Radiosurgery is a relatively effective, minimally invasive treatment for small bAVMs in children. The rebleeding rate is low, provided that known predilection places for bleeding had been endovascularly eliminated.Our overall results compare unfavourably to recent pediatric microsurgical series, although comparison between series remains imprecise. Nevertheless, when treatment is indicated in a child with a bAVM that is amenable to both microsurgery or radiosurgery, microsurgery should carefully be advocated over radiosurgery, because of its immediate risk reduction.

Acquired encephaloceles and epilepsy in osteopetrosis.

Osteopetrosis is a condition in which there is a defect in bone resorption by osteoclasts. With thickening of the skull and skull base, the cranial capacity becomes compromised and skull foramina gradually occlude, resulting in a wide range of neurological symptoms and signs. We present a case of autosomal dominant osteopetrosis with temporal lobe epilepsy and nasal obstruction due to acquired bifrontal encephaloceles associated with a decreased intracranial capacity. Neurosurgical reconstruction of the frontal skull base alleviated the symptoms of epilepsy and nasal obstruction.

Air in the carotid canal as a predictor of distal internal carotid artery laceration.

The authors describe a 25-year old patient with blunt trauma-induced bilateral, distal segment internal carotid artery (ICA) lacerations, resulting in a left-sided direct carotid-cavernous sinus fistula (CCF) and presenting with massive oronasal bleeding. The combination of severe oronasal bleeding, with air in the carotid canal should alarm the treating physician to the presence of a distal internal carotid artery laceration.

Intracranial aneurysms in children under 1 year of age: a systematic review of the literature.

OBJECTIVE: Intracranial aneurysms are very rare in early childhood. Because the location, morphology as well as the clinical and radiological presentation of these aneurysms seem to be different from those in adults, we performed a systematic review of the literature to discuss the clinical, morphological, and radiological features of intracranial aneurysms in the first year of life. MATERIALS AND METHODS: A computerized search of both Pubmed and EMBASE from before 1966 to 2005 was performed. Included were all articles that dealt with cases in which an intracranial aneurysm was demonstrated in children under 1 year of age. RESULTS: We found 110 articles in which 131 cases of an intracranial aneurysm in children under 1 year were presented. The mean age at diagnosis of the aneurysm was 4.9+/-3.5 months with a male to female ratio of 1.1. There was a hemorrhagic presentation in 73% (n=96). The patients presenting with a hemorrhage were younger (mean 4.3 vs 6.7 months, P<0.001) and tended to have smaller-sized (i.e.<2.5 cm) aneurysms (P=0.07). The aneurysm was defined as traumatic or infectious in 15 and 13 cases, respectively. In 21% (n=27), there was various vascular or congenital co-morbidity. In 76%, the aneurysm was located in the anterior circulation. The prevalence of aneurysms on the middle cerebral artery (MCA) was nearly three times higher than on any other vessel. The mean aneurysm size was 1.8+/-1.4 cm, with 30 giant aneurysms (>2.5 cm). The giant aneurysms were significantly more often located in the posterior circulation (43 vs 16%, P=0.01). The mean period of follow-up was 13.6+/-24.8 months. The Glasgow Outcome Scale (GOS) could be derived in 106 cases: 50% had an excellent outcome (GOS of 5). CONCLUSIONS: The presentation of arterial aneurysms in children under the age of 1 year differs from that in adults with a significantly higher prevalence of giant aneurysms in the posterior circulation. The prevalence of aneurysms on the MCA is nearly three times higher than on any other vessel. The patients presenting with a hemorrhage were younger and tended to have smaller-sized aneurysms. Our study did not confirm the male predominance that has thus far been associated with pediatric aneurysms. The outcome is comparable or slightly better than in adults.

Metastatic adenocarcinoma in the cerebellopontine angle, presenting as a meningioma: a case report of rare occurrence.

We present the case of a 36-year old woman who was referred to our hospital with an 8 weeks history of walking difficulties, nausea and vomiting, diminished hearing on the right side and diplopia. On Magnetic Resonance-Imaging (MRI) a tumour in the right cerebellopontine angle (CPA) was diagnosed. The tumour was resected and histopathological examination revealed an adenocarcinoma, suspicious for a metastasis from carcinoma of the breast considering the aspect of the cells, immunochemical profile, age and gender of the patient. No primary tumour was found. In cases without histopathological diagnosis, radiosurgery should be withheld when there is doubt about the clinical or radiological diagnosis.