Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: a single-center observation.

OBJECTIVE: Intraventricular tissue plasminogen activator (alteplase) has been advocated for prevention of vasospasm in aneurysmal subarachnoid hemorrhage and treatment of traumatic or spontaneous intraventricular hemorrhage. External ventricular drain (EVD) insertion is often performed to manage increased intracranial pressure and hydrocephalus associated with these disease states. EVD-related ventriculitis is a serious infection with an up to 50% mortality rate. METHODS: We assessed the EVD infection rate in patients receiving intraventricular alteplase over a 12-month period. Patients were divided into intraventricular alteplase and non-intraventricular alteplase groups; ventriculitis rates were compared. RESULTS: EVDs were placed in 93 patients. Six of 7 (86%) patients who received intraventricular alteplase developed ventriculitis versus 4 of 86 (5%) patients in the non-intraventricular alteplase group (p<0.0001). CONCLUSION: Intraventricular alteplase use may increase ventriculitis risk. Currently, we reserve intraventricular alteplase for patients with EVDs obstructed by hematoma accompanied by increased intracranial pressure.

Intracranial meningiomas in patients with uterine sarcoma treated with long-term megestrol acetate therapy.

OBJECTIVE: To report a series of four patients with uterine sarcoma, including one with müllerian adenosarcoma (MA) and three with low-grade endometrial stromal sarcoma (LGESS), who developed intracranial meningiomas while receiving the progesterone agonist megestrol acetate. METHODS: The hospital records, imaging studies, and pathology slides of four patients who were treated for uterine sarcomas and subsequently developed intracranial meningiomas were reviewed. RESULTS: All patients underwent surgery for their gynecologic cancers and received maintenance therapy with long-term hormonal suppression with megestrol acetate. Each of the four patients later developed neurologic symptoms secondary to intracranial meningiomas. Three patients had more than one meningioma. Histopathologic examination of all excised tumors showed strong immunoreactivity for progesterone receptors (PRs). CONCLUSIONS: Patients with uterine sarcoma subtypes LGESS and MA may be predisposed to develop meningiomas, particularly in the setting of long-term treatment with megestrol acetate. Alternatively, preexisting, clinically silent meningiomas in these patients may have progressed to the point of clinical symptoms in the presence of the progesterone agonist megestrol acetate. Without previous imaging studies showing the presence or absence of meningioma before initiation of megestrol acetate treatment, there is no way to draw definitive conclusions regarding this possibility. Clinical and neuroradiologic surveillance for meningiomas should be strongly considered in patients with these uterine sarcoma subtypes, particularly in patients undergoing long-term suppressive therapy with megestrol acetate.

Endovascular treatment of a large aneurysm arising from a basilar trunk fenestration using the waffle-cone technique.

OBJECTIVE: Endovascular treatment of large intracranial aneurysms arising from a fenestrated parent vessel may prove particularly difficult. We present a case of a large, broad-based aneurysm arising from a proximal basilar artery (BA) fenestration treated with the waffle-cone technique. Technical nuances and indications for this treatment option are reviewed. CLINICAL PRESENTATION: A 38-year-old man presented with headache, blurred vision, and dizziness. Angiography demonstrated an 11 x 14-mm BA aneurysm associated with the proximal portion of a BA fenestration. TECHNIQUE: A 28 x 4.5-mm Enterprise stent was placed from the right vertebral artery directly into the aneurysm. The stent tines were allowed to flare out in the aneurysm neck creating the "waffle cone." The aneurysm was then coiled with a series of Presidio coils. CONCLUSION: Use of the waffle-cone technique for stent placement resulted in nearly complete embolization of the aneurysm, retention of the entire coil mass in the dome, and preservation of flow through both vertebral arteries and both limbs of the fenestration.

Healthcare savings associated with reduced infection rates using antimicrobial suture wound closure for cerebrospinal fluid shunt procedures.

BACKGROUND/AIMS/METHODS: This is a follow-up study from a recent randomized controlled trial conducted at the Women and Children's Hospital of Buffalo that investigated the use of antimicrobial sutures (AMS) for wound closure during cerebrospinal fluid shunting procedures. Our purpose was to determine the average cost of shunt infections at our institution and estimate the healthcare savings associated with reduced infection rates secondary to AMS use. RESULT: We found that the treatment and management of a shunt infection resulted in a 5.3-fold increase in hospital charges. CONCLUSION: The potential healthcare savings associated with reduced infection rates are significant. These calculations demonstrate the profound economic effect a reduction in shunt infection rates may have on a healthcare system.

Pediatric neurosurgical practice patterns designed to prevent cerebrospinal fluid shunt infection.

BACKGROUND/AIMS: Various factors have been associated with cerebrospinal fluid (CSF) shunt infection risk, leading to many recommendations intended to reduce that risk. We sought to assess current North American pediatric neurosurgical practice patterns in this regard via a web-based survey. Particular attention was paid to the use of antibiotic-impregnated materials and prophylactic perioperative antibiotics. METHODS: The membership of the section on pediatric neurological surgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons was invited to complete a survey of current practices intended to minimize CSF shunt infection risk. To be eligible for participation in this study, the respondent had to maintain an active neurosurgical practice within North America and place or revise at least 25 shunts in pediatric patients (<21 years) per year. Responses to the questionnaire were then analyzed. RESULTS: A total of 100 responses were analyzed. All respondents were familiar with antibiotic-impregnated shunt catheters, and 61 of 100 had actually used them. Eleven of 61 respondents use them universally, 20 of 61 in >50% of cases, and 30 of 61 in <50% of cases. Antibiotic-impregnated suture material was known to 59% of respondents, of whom 28% (14 of 59) reported having actually used antimicrobial suture. All respondents use perioperative intravenous antibiotics with vancomycin, first-generation cephalosporins, and then second-generation cephalosporins being the most common. Routine use of intraventricular antibiotics was reported by 27%. An assessment of surgical techniques revealed that 90% limit shunt contact with patient's skin, 62% use the double-gloving technique, 45% handle shunt components only with instruments, and 34% use an antiseptic shampoo preoperatively. CONCLUSION: Our survey reveals a wide range of practices intended to prevent shunt infection and captures, in particular, current trends in the use of antibiotic-impregnated materials and perioperative antibiotics for CSF shunting procedures.

Thoracolumbar spine subdural hematoma as a result of nonaccidental trauma in a 4-month-old infant.

The authors describe the previously unreported occurrence of thoracolumbar subdural hematoma (SDH) resulting from nonaccidental trauma and emphasize the need for a complete and thorough neurological, physical, and radiological examination in all cases of suspected nonaccidental trauma. A 4-month-old male infant presented to the authors' Level 1 pediatric trauma center in respiratory arrest. According to the family, he had been previously healthy with a 1-day history of fussiness and irritability. While with one of the parents, the patient was noted to be apneic and had been shaken in 2 separate episodes in an attempt to stimulate respiration. Emergency services personnel intubated the child's trachea and transported him to the hospital. On arrival in the emergency department, the child was unresponsive and exhibited signs of myelopathy. A CT scan of his head demonstrated SDH and subarachnoid hemorrhage. Magnetic resonance imaging of the spine demonstrated an SDH dorsal to the spinal cord with some mass effect on the conus medullaris and descending nerve roots. The patient underwent emergency T-12 to L-3 laminotomies, evacuation of the hematoma, and laminoplasty. The rigid nature of the rib cage provides a point of fixation around which the thoracolumbar spine can hyperflex and hyperextend when shaken, resulting in severe injury to the bony, vascular, and neural elements of the spine.

Transient ventriculomegaly in an adolescent presenting with shunted hydrocephalus, diabetic ketoacidosis, and hyperglycemia.

In this report, the authors describe a unique presentation of ventriculomegaly in the setting of diabetic ketoacidosis (DKA). A 15-year-old male, with a history of shunt placement for hydrocephalus and repair of a myelomeningocele, presented to the emergency room with DKA and was found to have ventriculomegaly. At the time of presentation, the patient had a 24- to 48-hour history of lethargy, nausea, vomiting, fever (102.2 degrees F), and polydipsia. A computed tomographic (CT) scan of the head indicated increased ventricular size compared with previous studies, thus prompting a neurosurgical evaluation. Blood glucose level at admission was found to be 1,551 mg/dl, bicarbonate level was 9 mmol/l, and pH was 7.08. The patient was treated for DKA; his fever, lethargy, nausea, and vomiting subsequently resolved. A repeat CT scan obtained 24 h after admission revealed a return of the ventricular system to its baseline size. On the basis of radiographic and laboratory evaluations, the authors hypothesize that the transient ventriculomegaly was directly related to extreme hyperglycemia.