Hydrothorax after ventriculoperitoneal shunt placement in a premature infant: an iatrogenic postoperative complication. Case report.

The authors describe the case of a prematurely born infant who developed hydrothorax after ventriculoperitoneal (VP) shunt placement for treatment of posthemorrhagic communicating hydrocephalus. Prior to shunt placement a bout of necrotizing enterocolitis created intense abdominal and peritoneal scarring. The authors postulate that the scarring created poor peritoneal absorption capacity of cerebrospinal fluid (CSF), with preferential flow of CSF from the peritoneal to the pleural cavity. A (99m)Tc-diethylenetriamine pentaacetic acid radionucleotide study enabled the authors to rule out shunt malfunction, and preferential transdiaphragmatic flow of CSF from the abdomen to the thoracic cavity was demonstrated. The hydrothorax resolved after conversion of the VP shunt to a ventriculoatrial shunt. Respiratory distress after VP shunt placement should be considered an unusual but important sentinel symptom in the differential diagnosis of postoperative shunt complications.

Clinical and radiologic findings in progressive facial hemiatrophy (Parry-Romberg syndrome).

We describe the clinical and radiologic changes related to progressive facial hemiatrophy (Parry-Romberg syndrome) occurring during a 20-month period in a child who presented with unilateral neurologic deficits and facial hemiatrophy. CT and MR findings included unilateral focal infarctions in the corpus callosum, diffuse deep and subcortical white matter signal changes, mild cortical thickening, and leptomeningeal enhancement with dense mineral deposition. Angiographic findings were normal. We hypothesize that a noninfectious, unilateral inflammatory process, possibly associated with a chronic vasomotor disturbance and sympathetic nerve chain inflammation, was a major factor in the pathogenesis of this syndrome.

Congenital midline nasofrontal mass. Two case reports with a clinical review.

Because of aberrant embryologic development, encephalocele, nasal dermoid, and glioma may present as a nasofrontal midline mass in a newborn infant. Though uncommon, vascular malformation or hemangioma in the nasofrontal region may present similarly. The correct diagnosis and early management of a nasofrontal mass is imperative because complications such as brain herniation, hypertelorism, or cerebrospinal fluid rhinorrhea may ensue, resulting in poor facial or visual development, recurrent meningitis, and brain abscess. Nasofrontal encephalocele and midline frontal vascular malformation are rare congenital abnormalities presenting as a midline nasofrontal mass. We report two neonatal cases, one a frontoethmoidal encephalocele and another, a frontal vascular malformation. Both had uncomplicated surgical interventions. The physical findings and clinical review are presented. The diagnostic approach toward midline nasofrontal mass is discussed.

A no-touch technique protocol to diminish cerebrospinal fluid shunt infection.

BACKGROUND: Cerebrospinal fluid (CSF) shunts become infected primarily by bacterial organisms indigenous to the patient's skin flora, but bacteria from the operating room environment, hospital, or no obvious source may also infect a shunt. To decrease the incidence of shunt infection, a no-touch technique protocol was developed and utilized in a prospective manner. METHODS: A before-after trial analysis was performed to compare the infection rates between patients who had CSF shunts placed using the no-touch technique protocol versus patients who had surgery without the protocol. Patients were stratified by age, etiology of hydrocephalus, type of shunt surgery, and presence of a contaminated skin wound, namely, tracheostomy, gastrostomy-jejunostomy, colostomy, or halo. The differences in infection rates were analyzed with the Fisher exact test with midpoint value correction, and standard statistical methods were used to calculate the 90% confidence interval odds ratio and number to treat. RESULTS: The no-touch technique protocol resulted in a clinically significant threefold decrease in shunt infection rate from 9.1% to 2.9% (p = 0.058 at 0.10 level, odds ratio 0.305, confidence interval 0.084-1.11), and a near threefold decrease in the infection rate per patient from 11.3% to 3.9% (p = 0.032 at 0.10 level, odds ratio 0.243, confidence interval 0.065-0.906). CONCLUSIONS: The no-touch technique protocol as described herein is a useful method to decrease shunt infection. A larger prospective, randomized, multicenter clinical trial is encouraged to stringently assess the efficacy of the protocol.

1;19 translocation in human meningioma.

BACKGROUND: Loss of chromosome 22 represents the most common chromosome abnormality (70%) in meningiomas. The remainder (30%) have a normal karyotype. Not only are the structural changes rare, they also occur simultaneously with various chromosome losses. METHODS: The authors identified and studied the meningiomas of two patients with standard tumor cell culture technique and chromosome preparation. RESULTS: Twenty karyotypes from each meningioma had a 46 modal chromosome number with t(1;19) (q21;p13) in all cells. CONCLUSIONS: The sole change of the (1;19) translocation in meningioma, without any other changes such as chromosome loss, as shown in this study, is unique and has never been reported before in the literature, to the knowledge of the authors. Additional study is needed to learn more about the rate of occurrence and the significant impact on meningeal tumor genesis.

Lipoma of cervical spinal cord and posterior fossa. Case report.

A case is reported of cervical spinal cord lipoma with extension into the posterior fossa and a leading symptom of apnea. A C1-C7 laminectomy and debulking of the medullary portion of the lipoma were performed with good results. The apneic spells were completely resolved. Intraspinal lipoma with posterior fossa extension is a rare condition and requires surgical intervention to relieve symptoms.

Cerebrospinal fluid shunt malfunction signaled by new or recurrent seizures.

We have observed two patient groups with seizure activity as the primary presentation of shunt malfunction. Eight patients had a first-time seizure, and seven patients had a history of prior seizures, none more recently than 1 year prior to the seizure recurrence. Five of seven patients with prior seizures who seized were on anticonvulsant medication, three of these seven patients had therapeutic anticonvulsant levels. Shunt malfunction was diagnosed via a combination of tests. The electroencephalograms of nine patients were diffusely abnormal with regions of slowing and focal spike activity. Seizure activity stopped in all patients after preoperative stabilization with anticonvulsant medication and shunt revision. These 15 patients represent 2% of all patients treated for shunt malfunction during a 3-year period. The assessment of new or recurrent seizure activity in a previously stable shunted patient should include evaluation of shunt function whatever the anticonvulsant levels.

Paraplegia after lumbar puncture. In an infant with previously undiagnosed hemophilia A. Treatment and peri-operative considerations.

We report a 3-month-old infant who became paraplegic from an epidural hematoma caused by a diagnostic lumbar puncture for work-up of sepsis. The differential diagnosis of the cause of paraplegia was epidural hematoma formation versus spinal abscess. Hemophilia A was diagnosed when coagulation studies were discovered to be abnormal, and non-contrast CT scan revealed an epidural mass with spinal cord displacement. The coagulopathy was rapidly corrected preoperatively with an infusion of cryoprecipitate. A medially limited bilateral T8-L4 laminectomy allowed complete evacuation of the hematoma with maximum preservation of normal bone tissue, but no clinical improvement resulted. Coagulopathy should be highly suspect in an infant who becomes paraplegic after lumbar puncture. The coagulopathy may be rapidly corrected with deficient factor replacement, allowing major spinal surgery to be performed safely.

Pontomedullary infarction from sustained cervical spine hyperflexion.

A paraplegic but independent 26-year-old man developed pontomedullary infarction from a fall which placed him in a position of sustained cervical spine hyperflexion. An early noncontrast computed tomography scan displayed infarction of the pontomedullary region. The patient made partial recovery of his neurologic deficits. The infarct was thought to arise from compromise of blood flow through the vertebrobasilar vessels during hyperflexion of the cervical spine. The mechanisms that impeded blood flow in the vertebrobasilar territory and the prognostic factors of ischemic infarction in this area are discussed.

Neurocutaneous melanosis with extensive intracerebral and spinal cord involvement. Report of two cases.

Two unusual cases of neurocutaneous melanosis are presented. Both patients had congenital giant hairy nevi and both developed hydrocephalus, seizures, and myelopathy. The first patient displayed multicentric cerebral and spinal cord melanosis, as opposed to the more commonly described basilar leptomeningeal involvement. The second patient had total spinal leptomeningeal involvement, and ventriculoperitoneal shunting for hydrocephalus produced peritoneal metastasis of melanoma. An individual born with a congenital giant hairy nevus or marked generalized cutaneous pigmentation should be closely observed for the development of malignant melanoma of the nervous system.