Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience.

BACKGROUND: In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors. METHODS: During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified. RESULTS: We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005). CONCLUSIONS: In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Retrocerebellar arachnoid cyst resulting in syringomyelia in a patient without tonsillar herniation: successful surgical treatment with reconstruction of CSF flow in the foramen magnum region.

A retrocerebellar arachnoid cyst causing syringomyelia is extremely rare without tonsillar herniation. The authors present a 44-year-old woman with symptoms of foramen magnum compression and syringomyelia. Magnetic resonance imaging demonstrated a large retrocerebellar arachnoid cyst with a large cervicothoracic syrinx but no signs of tonsillar herniation or hydrocephalus. The patient underwent a foramen magnum decompression with C1 laminectomy, microsurgical fenestration of the cyst, and duraplasty. After successful reconstruction of CSF flow, the patient experienced a relief of symptoms and a significant reduction of the syrinx. The intraoperative findings support the theory of a piston mechanism in the development of syringomyelia. Additional arachnoidal adhesions may also obstruct the CSF flow around the craniocervical junction. We recommend the surgical treatment should consist of an adequate decompression of the foramen magnum, wide microsurgical arachnoidal debridement, and duraplasty with autologous grafts sutured in a watertight way.

Burr hole is not burr hole: technical considerations to the evacuation of chronic subdural hematomas.

BACKGROUND: The organization of a multicenter survey about chronic subdural hematomas has triggered the discussion on different surgical techniques of burr hole evacuation. Such a standard operation gives neurosurgeons plenty of scope for creating their own way. METHODS: The procedure presented is one burr hole with a closed drainage system. In detail, each single step is enrolled: the planning of the burr hole, positioning, direction of skin incision, opening of the dura, drain positioning, channeling through the galea, and postoperative care. CONCLUSIONS: We present a thorough summary that could serve as a common standard and as a basis for comparison of future trials.

The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma--the DRESH study: straightforward study protocol for a randomized controlled trial.

BACKGROUND: Chronic subdural hematoma (cSDH) is a common neurosurgical disease. It is often considered to be a rather benign entity. In spite of well established surgical procedures cSDH is complicated by a recurrence rate up to 30%. Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol. OBJECTIVE: to test the efficacy of dexamethasone on reduction inthe reoperation rate of cSDH. METHODS/DESIGN: The study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative. DISCUSSION: This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH. TRIAL REGISTRATION: EudraCT 201100354442.

The role of MRI in spinal stab wounds compared with intraoperative findings.

INTRODUCTION: Spinal stab wound injuries are quite rare and only few patients have been reported on the basis of MRI scan. METHODS: A 25-year-old man was stabbed at C1/2 and had an incomplete Brown-Sequard syndrome. He underwent surgical exploration because of CSF leakage on the fourth day. RESULTS: After a follow-up period of 32 months, he was left with a remaining loss of the proprioception of the right foot. We show detailed CT and MR images with the focus on the lesions of the dura and myelon and compared them with intraoperative images. In addition, we contrast our findings with a review of literature published over the last three decades. CONCLUSION: MRI gives the most detailed view of soft tissue lesions in SSWs and is in accordance with our intraoperative findings.