Cerebrovascular injuries in traumatic brain injury.

Traumatic brain injury is a complex and highly heterogeneous disease due to the host of concomitant injuries that may accompany the initial insult. Due to the dynamic interplay between the injuries that may arise, the management of these injuries is challenging. In a small subset of patients with traumatic brain injury, cerebral vascular injury may occur, which presents its own diagnostic and therapeutic challenges. These vascular injuries often present in a delayed fashion, thereby going unnoticed by clinicians. Early recognition and treatment of these injuries is crucial, given their high morbidity and mortality. Through a critical review of the literature, we present the spectrum of cerebrovascular injuries that may occur with traumatic brain injury and discuss classification systems that are used to stratify cerebrovascular injury. We then focus on the diagnosis of cerebral vascular injury using different neuroimaging modalities. Lastly, we explore the treatment of these injuries ranging from antiplatelet therapies to endovascular and open vascular procedures. By highlighting the pitfalls and challenges of this complex disease, we hope to provide clinicians with the framework to recognize and treat vascular injuries that are seen in patients with traumatic brain injury.

Delayed Rupture of an Anterior Communicating Artery Aneurysm After Elective Woven Endobridge Embolization, Re-Treated With Microsurgical Clipping: Operative Technique and Systematic Review.

BACKGROUND: The Woven EndoBridge (WEB) device is designed for intrasaccular flow disruption for embolization of intracranial aneurysms. In limited experience so far, the rate of rupture after adequate occlusion by embolization has been low. METHODS: A 58-year-old man initially had an incidental, unruptured 10.4-mm anterior communicating artery aneurysm treated with WEB embolization. Although his 6 months follow-up angiogram showed adequate occlusion of the aneurysm, he presented to our facility with aneurysmal recurrence caused by WEB compaction and rupture. This condition was treated with surgical clipping of the aneurysm. The literature was systematically reviewed for cases of delayed rupture after WEB embolization. Statistical analyses included studies with at least 20 patients and follow-up of 3 months. RESULTS: We identified 36 studies, which were primarily retrospective observational studies. The rate of complete occlusion ranged from 33% to 89%, and the rate of re-treatment ranged from 1.5% to 27%. Across 4 studies, the rate of recanalization ranged from 8.7% to 13%. Two cases of delayed rupture were reported; an additional 4 cases were found in case reports and case series. In only 1 previous case, the aneurysm was reported as previously untreated. CONCLUSIONS: Early retrospective data have begun to define the history of WEB-treated aneurysms. Rupture of a previously unruptured, WEB-treated aneurysm with adequate initial occlusion is rare. We describe such a case with techniques for management, showing that aneurysm recurrence and delayed rupture are possible despite good interim angiographic results. This report raises questions about follow-up for WEB-treated aneurysms.

Endoscope-assisted microsurgical retrosigmoid approach to the lateral posterior fossa: Cadaveric model and a review of literature.

BACKGROUND: The advancement of endoscopic techniques in the past decade has improved the surgical management of cerebellopontine angle (CPA) tumors. Endoscope-assisted microsurgery improves the ability to evaluate the extent of resection, achieve safe tumor resection and reduce the risk of surgery-related morbidity. METHODS: In this study, we used a cadaveric model to demonstrate a step by step endoscope-assisted microsurgery of the retrosigmoid approach to the lateral posterior fossa. RESULTS: Retrosigmoid craniotomies were performed on four latex-injected cadaver heads (eight CPAs). Microsurgical exposures were performed to identify neurovascular structures in each segment. 0° and 30° rigid endoscope lenses were subsequently introduced into each corridor and views were compared in this manner. The endoscopic images were compared with the standard microscopic views to determine the degree of visualization with each technique. In each case, better visualization was provided by both the 0° and 30° endoscope lenses. Endoscopic views frequently clarified neurovascular relationships in obscured anatomic regions. CONCLUSION: Endoscope-assisted microsurgery could allow better visualization of various regions of the posterior fossa. Surgical planning for posterior fossa lesions should include consideration of this combined approach.

Endoscopic surgical treatment of bilateral coronal craniosynostosis.

Endoscopic surgery for single-suture synostosis has been widely adopted since its introduction over 2 decades ago. Its role in syndromic synostosis is emerging, both as a primary treatment and as the first stage in a multimodal treatment paradigm aimed at preventing the vexing turribrachycephaly seen in these children. In this video, the authors review the technique for endoscopic treatment of bilateral coronal craniosynostosis and discuss both the benefits and some of the concerns to look out for over time. They also review the long-term outcomes in a consecutive series of patients treated in this fashion. The video can be found here: https://vimeo.com/516351348.

Craniometric Analysis of Endoscopic Suturectomy for Bilateral Coronal Craniosynostosis.

BACKGROUND: Endoscopic suturectomy and helmeting represents a successful first-line surgical treatment for bilateral coronal craniosynostosis. Its effect on cranial morphology has not been previously described. METHODS: Patients were identified who had bilateral coronal craniosynostosis treated with endoscopic suturectomy and postoperative helmeting at Boston Children's Hospital between 2005 and 2013 and who underwent preoperative and postoperative computed tomography. Two normative patient populations were identified from our trauma registry with computed tomographic scans completed at the same age as our pretreatment and posttreatment scans. Craniometric indices were used to quantify the effect of treatment. RESULTS: Twenty-seven patients were identified who underwent bilateral coronal suturectomy. Twelve patients had preoperative and postoperative computed tomographic studies. Eight patients (66.7 percent) were syndromic. The average ages for preoperative and postoperative computed tomographic scan were 1.1 months (range, 0.03 to 2.6 months) and 19.6 months (range, 10.8 to 37.5 months). Thirteen patients with an average age of 1.1 months (range, 0.5 to 1.6 months) were identified as a preoperative control group. Fourteen patients with an average age of 18.5 months (range, 15.5 to 22.9 months) were identified as a postoperative control group. The anterior cranial height stabilized with treatment and the anterior cranial base length increased. The anterior cranial height-to-anterior cranial base length ratio significantly decreased with treatment (p = 0.128). Frontal bossing normalized with endoscopic suturectomy (craniosynostosis versus control: preoperatively, p = 0.001; postoperatively, p = 0.8). Cephalic indices also normalized with treatment (craniosynostosis versus control: preoperatively, p = 0.02; postoperatively, p = 0.13). No cases of hydrocephalus were observed. CONCLUSION: Endoscopic suturectomy and helmeting improves anterior turricephaly and corrects frontal bossing and brachycephaly in patients with bilateral coronal craniosynostosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Transtentorial transcollateral sulcus approach to the ventricular atrium: an endoscope-assisted anatomical study.

OBJECTIVE Conventional approaches to the atrium of the lateral ventricle may be associated with complications related to direct cortical injury or brain retraction. The authors describe a novel approach to the atrium through a retrosigmoid transtentorial transcollateral sulcus corridor. METHODS Bilateral retrosigmoid craniotomies were performed on 4 formalin-fixed, colored latex-injected human cadaver heads (a total of 8 approaches). Microsurgical dissections were performed under 3× to 24× magnification, and endoscopic visualization was provided by 0° and 30° rigid endoscope lens systems. Image guidance was provided by coupling an electromagnetic tracking system with an open source software platform. Objective measurements on cortical thickness traversed and total depth of exposure were recorded. Additionally, the basal occipitotemporal surfaces of 10 separate cerebral hemisphere specimens were examined to define the surface topography of sulci and gyri, with attention to the appearance and anatomical patterns and variations of the collateral sulcus and the surrounding gyri. RESULTS The retrosigmoid approach allowed for clear visualization of the basal occipitotemporal surface. The collateral sulcus was identified and permitted easy endoscopic access to the ventricular atrium. The conical corridor thus obtained provided an average base working area of 3.9 cm2 at an average depth of 4.5 cm. The mean cortical thickness traversed to enter the ventricle was 1.4 cm. The intraventricular anatomy of the ipsilateral ventricle was defined clearly in all 8 exposures in this manner. The anatomy of the basal occipitotemporal surface, observed in a total of 18 hemispheres, showed a consistent pattern, with the collateral sulcus abutted by the parahippocampal gyrus medially, and the fusiform and lingual gyrus laterally. The collateral sulcus was found to be caudally bifurcated in 14 of the 18 specimens. CONCLUSIONS The retrosigmoid supracerebellar transtentorial transcollateral sulcus approach is technically feasible. This approach has the potential advantage of providing a short and direct path to the atrium, hence avoiding violation of deep neurovascular structures and preserving eloquent areas. Although this approach appears unconventional, it may provide a minimally invasive option for the surgical management of selected lesions within the atrium of the lateral ventricle.

Treatment Type Is Associated with Population Hand Preferences in Patients with Unilateral Coronal Synostosis: Implications for Functional Cerebral Lateralization.

BACKGROUND: Left-handedness is a highly conserved marker of cerebral functional laterality in the human population; elevated rates of left-handedness have been documented in patients with unilateral coronal synostosis treated with fronto-orbital advancement. The purpose of this study was to determine whether the prevalence of left-handedness in patients with nonsyndromic unilateral coronal synostosis is related to treatment. METHODS: The incidence of left-handedness was compared among three groups: patients who were previously treated for unilateral coronal synostosis with endoscopic suturectomy and postoperative helmet therapy (group I); patients with unilateral coronal synostosis managed with fronto-orbital advancement (group II); and healthy, unaffected controls (group III). RESULTS: Group I was composed of 19 patients; the side of synostosis was equally distributed (nine right and 10 left), and female gender was more common (n = 13). Mean age at endoscopic suturectomy and helmet therapy was 85.3 days, and the determination of handedness was performed at a mean age of 89.3 months. The rate of left-handedness in group I was 5.3 percent, not significantly different from that of the controls (group III) (11.5 percent) (p = 0.69) but significantly less than that observed in the fronto-orbital advancement patients (group II) (30.2 percent) (p = 0.023). CONCLUSIONS: Patients who underwent endoscopic suturectomy and helmet therapy for nonsyndromic unilateral coronal synostosis and healthy controls demonstrated functional cerebral lateralization with respect to handedness that differed from patients who underwent fronto-orbital advancement. The reason may be related to the type of procedure, secondary effects of general anesthesia, or age at which the procedure was performed.

Risk factors for hydrocephalus and neurological deficit in children born with an encephalocele.

OBJECT: There is a known association of hydrocephalus with encephaloceles. Risk factors for hydrocephalus and neurological deficit were ascertained in a series of patients born with an encephalocele. METHODS: A retrospective analysis was undertaken of patients treated for encephaloceles at Children's Hospital Los Angeles between 1994 and 2012. The following factors were evaluated for their prognostic value: age at presentation, sex, location of encephalocele, size, contents, microcephaly, presence of hydrocephalus, CSF leak, associated cranial anomalies, and neurological outcome. RESULTS: Seventy children were identified, including 38 girls and 32 boys. The median age at presentation was 2 months. The mean follow-up duration was 3.7 years. Encephalocele location was classified as anterior (n = 14) or posterior (n = 56) to the coronal suture. The average maximum encephalocele diameter was 4 cm (range 0.5-23 cm). Forty-seven encephaloceles contained neural tissue. Eight infants presented at birth with CSF leaking from the encephalocele, with 1 being infected. Six patients presented with hydrocephalus, while 11 developed progressive hydrocephalus postoperatively. On univariate analysis, the presence of neural tissue, cranial anomalies, encephalocele size of at least 2 cm, seizure disorder, and microcephaly were each positively associated with hydrocephalus. On multivariate logistic regression modeling, the single prognostic factor for hydrocephalus of borderline statistical significance was the presence of neural tissue (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 0.8-74.0). Fourteen patients had severe developmental delay, 28 had mild/moderate delay, and 28 were neurologically normal. On univariate analysis, the presence of cranial anomalies, larger size of encephalocele, hydrocephalus, and microcephaly were positively associated with neurological deficit. In the multivariable model, the only statistically significant prognostic factor for neurological deficit was presence of hydrocephalus (OR 17.2, 95% CI 1.7-infinity). CONCLUSIONS: In multivariate models, the presence of neural tissue was borderline significantly associated with hydrocephalus and the presence of hydrocephalus was significantly associated with neurological deficit. The location of the encephalocele did not have a statistically significant association with incidence of hydrocephalus or neurological deficit. In contrast to modestly good/fair neurological outcome in children with an encephalocele without hydrocephalus, the presence of hydrocephalus resulted in a far worse neurological outcome.

Congenital dermal sinus with an infected dermoid cyst in the cervico-thoracic spinal cord.

Congenital dermal sinuses (CDS) are epithelium-lined tracts that result from incomplete separation of cutaneous ectoderm from the underlying neuroectoderm. CDS may be associated with dermoid cysts and can cause complications by mass effect and by functioning as a pathway for infection. Cervical and thoracic tracts are rare, making up 1 and 10% of all CDS, respectively. We present an unusual case of a cervico-thoracic CDS with concomitant infected dermoid leading to neurological dysfunction. A 1-year-old male with a normal developmental history presented with a several-week history of progressive weakness. Previous visits to two outside emergency departments diagnosed the patient with acute otitis media. After another episode of fever and worsening of neurological symptoms, the patient was correctly diagnosed as having CDS with an infected dermoid cyst. Antibiotics were initiated, the lesion was resected, and the patient improved neurologically. Although cervical and thoracic CDS with infected dermoids are rare, one should have a high index of suspicion when cutaneous stigmata of spinal dysraphism are identified. Due to the risk of neurological deterioration, the recommended treatment of CDS with or without a concomitant intraspinal dermoid is prompt administration of antibiotics and definitive surgical intervention.

Closed neural tube defects in children with caudal regression.

INTRODUCTION: Infants born with caudal regression (CR) may have serious multisystem abnormalities that require prompt attention in the neonatal period. The presence of a closed neural tube defect (NTD) that can lead to future neurological deterioration may be overlooked. MATERIALS AND METHODS: An IRB-approved retrospective review was conducted among patients with CR and a closed NTD that underwent neurosurgical operative intervention between 1996 and 2012 at a single institution. RESULTS: Twenty-two patients who met the above criteria were identified. Of this group, 13 were identified and surgically addressed in the first year of life; however, nine additional children were diagnosed with a closed NTD after a year of age with progressive neurological deterioration. Of the entire group, none had any cutaneous markers that are often seen with a closed NTD. CONCLUSION: The frequent finding of a closed NTD associated with major CR abnormalities, even in the absence of any cutaneous markers for dysraphism, recommends that infants with CR undergo a MRI screening in early infancy to exclude the presence of a closed NTD.

Congenital hydrocephalus associated with myeloschisis.

BACKGROUND: Neural tube defects (NTDs) can be divided into two main groups, one being open NTDs wherein visible neural tissue and cerebrospinal fluid leakage are present and the other, closed NTDs without exposed neural tissue and no drainage of CSF. METHODS: This communication is devoted to open NTDs that can be further subdivided into myelomeningoceles, myeloschisis, and hemimyelomeningoceles. RESULTS: Common to all these is the loss of CSF during fetal development that leads to an extensive malformation of the central nervous system with hydrocephalus being a frequent feature. CONCLUSION: The only known difference between a newborn with myelomeningocele versus a newborn with myeloschisis is the initial presence (myelomeningocele) or absence (myeloschisis) of a cystic component with the overall clinical picture the same for these two forms of open neural tube defects.