CT findings of Meckel's diverticulum perforation in a geriatric patient.

Meckel's diverticulum is a remnant of the omphalomesenteric duct, found only in approximately 2% of the population. Although Meckel's diverticulum is often diagnosed in nonsymptomatic patients as incidental radiologic findings, complications of Meckel's diverticulum can also be seen on radiologic evaluation. We present a rare care of perforated Meckel's diverticulum in a geriatric patient demonstrated on contrast computed tomography. This was later confirmed during laparoscopic surgery with pathologic evaluation.

Stereotactic radiosurgery for high-grade metastatic epidural cord compression.

PURPOSE: The standard of care of patients with high-grademetastatic epidural compression is open decompression with or without stabilization. However, many patients are unwilling or unable to undergo open surgical decompression. This study investigated the outcomes of treating patients with high-grade (Ryu/Rock radiographic grade IV and V, Spine Oncology Study Group Grade II and III) metastatic epidural spinal cord compression with spinal radiosurgery as first-line therapy in lieu of surgical decompression. METHODS: Utilizing the Henry Ford Spinal Tumor Database, patients with metastatic lesions causing advanced radiographical grade (IV or V) epidural spinal cord compression who received stereotactic radiosurgery (SRS)with adequate clinical and radiological follow-up were identified from 2007-2011. These patients were retrospectively reviewed for clinical and radiological response to radiosurgery. RESULTS: 33 patients with 35 metastatic lesions causing Ryu/Rock radiographical grade IV or V compression were identified with a median follow-up of 435 days. Of the 34 lesions in 32 patients who were ambulatory pre-SRS, 23 (67%) were ambulatory at last follow-up. 6/33 progressed early (less than 2 months) neurologically and an additional 5 patients developed late progressive neurologic deficit. The one patient who was initially non-ambulatory was able to regain ambulatory status. Radiologically, there was a significant epidural tumor response rate of 74%. Ultimately, 9 patients (27%) eventually required surgery for neurologic compromise or mechanical instability. There was one patient who received EBRT previously who experienced radiation myelopathy as a complication of SRS. CONCLUSION: Radiosurgery as an initial therapy for high-grade metastatic epidural compression appears to be a viable treatment paradigm for selected patients with close clinical and radiological follow-up. However, a significant minority will progress necessitating the need for rigorous monitoring. Further study is needed prospectively analyze the effectiveness of SRS with or without open surgical decompression.

Intraoperative magnetic resonance imaging to reduce the rate of early reoperation for lesion resection in pediatric neurosurgery.

OBJECT: This study describes the pediatric experience with a dual-multifunction-room IMRIS 1.5-T intraoperative magnetic resonance imaging (iMRI) suite and analyzes its impact on clinical variables associated with neurosurgical resection of intracranial lesions, including safety and efficacy. METHODS: Since the inception of the iMRI-guided resection program in April 2008 at both Barnes-Jewish and St. Louis Children's Hospital, a prospective database recorded the clinical variables associated with demographics and outcome with institutional review board approval. A similarly approved retrospective database was constructed from February 2006 to March 2010 for non-iMRI resections. These databases were retrospectively reviewed for clinical variables associated with resection of pediatric (age 20 months-21 years) intracranial lesions including brain tumors and focal cortical dysplasia. Patient demographics, operative time, estimated blood loss, additional resection, length of stay, pathology, and complications were analyzed. RESULTS: The authors found that 42 iMRI-guided resections were performed, whereas 103 conventional resections had been performed without the iMRI. The mean patient age was 10.5 years (range 20 months-20 years) in the iMRI group and 9.8 years (range 2-21 years) in the conventional group (p = 0.41). The mean duration of surgery was 350 minutes in the iMRI group and 243 minutes in the conventional group (p < 0.0001). The mean hospital stay was 8.2 days in the iMRI group, and 6.6 days in the conventional group, and this trended toward significance (p = 0.05). In the first 2 weeks postoperatively, there were 8 reoperations (7.77%) in the conventional group compared with none in the iMRI group, which was not significant in a 2-tailed test (p = 0.11) but trended toward significance in a 1-tailed test (p = 0.06). The significant complications included reoperation for hydrocephalus or infection: 6.8% (conventional) versus 4.8% (iMRI). CONCLUSIONS: Intraoperative MR imaging-guided resections resulted in a trend toward reduction in the need for repeat surgery in the immediate 2-week postoperative period compared with conventional pediatric neurosurgical resections for tumor or focal cortical dysplasia. Although there is an increased operative time, the iMRI suite offers a comparable safety and efficacy profile while potentially reducing the per-case cost by diminishing the need for early reoperation.

Frameless stereotactic endoscope-assisted transoccipital hippocampal depth electrode placement: cadaveric demonstration of a new approach.

PURPOSE: Hippocampal recording using depth electrodes is indicated in a small subgroup of patients with medically intractable seizures. There are several conventional techniques for implantation of hippocampal depth electrodes. We describe a new method for hippocampal depth electrode placement using an image-guided endoscopic transoccipital route. This technique is simple and effective, eliminating several drawbacks of conventional techniques. METHODS: One silicone-injected cadaver head was used. A rigid endoscope sheath was inserted through a transoccipital corridor into the atrium of the lateral ventricle and then advanced to the temporal horn. Each of the hemispheres was cannulated. The hippocampus was identified visually, and a depth electrode was inserted into the substance of the hippocampus along its long axis under direct vision. RESULTS: In both hemispheres we were able to successfully implant the depth electrode within the hippocampus. The advantages of our technique over conventional approaches are (1) there is no need for frame-based stereotaxy, thus reducing operating time and patient discomfort, (2) the electrodes are inserted into the hippocampus under direct endoscopic visualization, reducing the chance of injury to vascular structures, (3) there is no need to insert a larger cannula into the hippocampus before placement of the electrodes, reducing trauma to the hippocampus, and (4) the number of electrodes within the hippocampus can be assessed at the end of the procedure, reducing malposition. CONCLUSION: We believe that image-guided endoscopic transoccipital hippocampal depth electrode placement can be performed with precision equal or superior to conventional techniques but without their major disadvantages.