Posthemorrhagic hydrocephalus and shunts: what are the predictors of multiple revision surgeries?

OBJECT: Cerebrospinal fluid shunts in patients with posthemorrhagic hydrocephalus are prone to failure, with some patients at risk for multiple failures. The objective of this study was to identify factors leading to multiple failures. METHODS: The authors performed a retrospective analysis of cases of posthemorrhagic hydrocephalus requiring neurosurgical intervention between 1982 and 2010. RESULTS: In the 109 cases analyzed, 54% of the patients were male, their mean birth weight was 1223 g, and their mean head circumference 25.75 cm. The mean duration of follow-up was 6 years, and 9 patients died. Grade III intraventricular hemorrhage was seen in 47.7% and Grade IV in 43.1%. Initial use of a ventricular access device was needed in 65 patients (59.6%), but permanent CSF shunting was needed in 104 (95.4%). A total of 454 surgical procedures were performed, including 304 shunt revisions in 78 patients (71.6%). Detailed surgical notes were available for 261 of these procedures, and of these, 51% were proximal revisions, 13% distal revisions, and 17% total shunt revisions. Revision rates were not affected by catheter type, patient sex, presence of congenital anomalies, or type of hydrocephalus. Age of less than 30 days at the initial procedure was associated with decreased survival of the first shunt. Regression analysis revealed that lower estimated gestational age (EGA) and obstructive hydrocephalus were significant predictors of multiple shunt revisions. CONCLUSIONS: We found a high rate of need for permanent CSF shunts (95.4%) in patients with posthemorrhagic hydrocephalus. Shunt revision was required in 71.6% of patients, with those with lower birth weight and EGA at a higher risk for revisions.

How bullet trajectory affects outcomes of civilian gunshot injury to the spine.

We analysed retrospectively the effect of missile trajectory on outcomes from civilian gunshot injury to the spine (GSIS) between 1994 and 2008. Most of the 98 patients were male (88.8%). A minority (8%) of patients had multiple column injuries and a bone or bullet fragment in the spinal canal (14%). Neurologic injury was seen in 33%; and external bracing was applied to 30% of patients. The odds of bracing among patients with multiple levels of damage were 3.4 times than for patients with a single vertebral level of damage. The odds of paralysis among black patients were 6.33 times the odds among non-black patients. The odds of paralysis among patients with a fragment in the spinal canal were 12.99 times those without. We conclude that the supero-inferior trajectory affects the number of vertebral levels involved and consequently the need for bracing. The lateral trajectory affects neurological outcomes.

Cerebellar lesion.

Lhermitte-Duclos disease is a rare cerebellar lesion that poses many diagnostic, pathophysiologic and therapeutic conundrums. Here we present a case that highlights the most important imaging characteristics for diagnosis, the pathophysiology of the disease, and the current management recommendations.

Role of stereotactic radiosurgery as a primary treatment option in the management of newly diagnosed multiple (3-6) intracranial metastases.

OBJECTIVE: The objective of this study was to assess the role of stereotactic radiosurgery in the management of newly diagnosed multiple intracranial metastases from known primary cancer locations. METHODS: Fifty (29 women and 21 men) patients received radiosurgery for newly diagnosed 3 or more metastatic brain tumors. Their mean age was 53 years. Lung cancer was the most common primary cancer (66%). RESULTS: Arrest in the growth of irradiated tumors was achieved in 41 (82%) patients. Eight patients (16%) required further intervention for tumors in other brain locations. Mean survival after diagnosis of brain disease was 12 months and the brain disease-controlled period was 19 months. The period of brain disease control prolonged (P=.03) with decreasing tumor volumes (<10 mL). Control of treated tumors positively affected survival after diagnosis of brain disease (P=.0001). CONCLUSION: Radiosurgery as an adjuvant improves survival in patients with cancer who have newly diagnosed multiple intracranial metastases by arresting the growth of tumors.

Ventriculosubgaleal shunts for posthemorrhagic hydrocephalus in premature infants.

OBJECTIVE: The early management of posthemorrhagic hydrocephalus in premature infants is challenging and controversial. These infants need a temporary cerebrospinal fluid (CSF) diversion procedure until they gain adequate weight, and the blood and protein levels in CSF are reasonably low before permanent shunt can be placed. Various options are available with their associated advantages and disadvantages. Ventriculosubgaleal shunts have been recommended as a more physiologic and less invasive means of achieving this goal. We have performed this procedure in 6 premature infants to evaluate their effectiveness and complications. METHODS: Six consecutive premature infants with posthemorrhagic hydrocephalus underwent placement of ventriculosubgaleal shunts over a 1-year period of time. We reviewed their clinical and imaging progress to assess the ability of the shunt to control hydrocephalus and the complication rates. RESULTS: In all 6 patients, the ventriculosubgaleal shunt controlled the progression of hydrocephalus as assessed by clinical and imaging parameters. A permanent shunt was avoided in 1 patient (16.6%). However, 4 patients developed shunt infections, 1 involving the ventriculosubgaleal shunt itself, and 3 immediately after conversion to ventriculoperitoneal shunt. The total infection rate of the series was 66.6%. All infections were caused by staphylococcus species. There was only a 1% shunt infection rate in our institution for all nonventriculosubgaleal shunts during the same period of time. CONCLUSION: Placement of ventriculosubgaleal shunts for interim CSF diversion in neonates with posthemorrhagic hydrocephalus is effective as a temporary method of CSF diversion. However, our experience has shown that it is associated with a unacceptably high CSF infection rate. A potential cause for infection is CSF stasis just beneath the extremely thin skin of the premature infants, promoting colonization by skin flora. CSF sampling before conversion to a permanent shunt and replacement of the proximal hardware, which has been in situ for a prolonged period, may decrease the infection rates. At present, the procedure is no longer performed at our institution.

Diffuse back pain and urological symptoms: recognizing tethered cord syndrome early.

Tethered cord syndrome (TCS) is a rare entity in adults, with only about 100 cases being reported in the literature. It is a syndrome in which patients have neurologic, urologic, and orthopedic signs and symptoms. We present a case of a 40-year-old man with back pain and urinary incontinence who was diagnosed with tethered cord syndrome. After the cord de-tethering in the operating room, his pain improved. TCS is an important condition to consider in the differential diagnosis of an adult who presents with back pain and urological symptoms. Imaging studies should be done, and operative treatment may be required to alleviate the symptoms. TCS should be in the differential diagnosis of any patient who presents with back and lower extremity complaints with superimposed urological problems. If TCS is confirmed radiologically by MRI, surgery can be performed with reasonable results provided that the disease process has not progressed.

Metastatic lesions involving the sella: report of three cases and review of the literature.

Metastatic cancer must be considered as a possibility for intrasellar masses. Newer treatment modalities, such as gamma knife radiosurgery needs to be explored for these lesions. Three cases of intrasellar metastatic lesions were retrospectively reviewed. Presenting complaints, radiographic studies, operative procedure, and histopathological confirmation were recorded for each patient. All had an unknown primary malignancy prior to the presentation with the intrasellar lesion detected by magnetic resonance imaging (MRI). Presenting symptoms were diplopia with extraocular movement deficits in all patients. Transsphenoidal resection or biopsy was performed. Histopathological analysis revealed small cell carcinoma in two patients and plasmacytoma in one. All patients received postoperative radiation and/or chemotherapy. Survival following initial presentation was 2 months and 6 months for two of the patients; the third patient is alive at 2-month follow-up.

Survival trends in elderly patients with glioblastoma multiforme: resective surgery, radiation, and chemotherapy.

BACKGROUND: It is appropriate to investigate and to determine survival trends following glioblastoma multiforme treatment using resective surgery, radiation therapy, and/or chemotherapy in patients aged 59 years and higher. METHODS: We retrospectively reviewed 30 elderly patients (> or =59 years old) who were treated for histopathologically confirmed glioblastoma multiforme at our tertiary care institution from 1990 through 2002. All patients were treated with steroids. In addition, 22 patients underwent resective surgery (RS), 17 patients underwent radiation therapy (RT), and 10 patients underwent chemotherapy (C). Many patients underwent these treatments in various combinations: 6 underwent biopsy only, 7 RS only, 6 RS+RT only, and 9 RS+RT+C. For each case, pre-treatment Karnofsky performance scores (KPS), tumor location, presenting symptoms and signs, associated surgical morbidity, and pre-existing medical conditions were also recorded. Patients were categorized into one of four treatment subgroups: Biopsy only, RS only, RS+RT, and RT+RS+C. For each of these subgroups, pretreatment KPS and post-treatment survival were compared. RESULTS: Post-treatment survival following biopsy only was 3.2 +/- 0.8 months (mean +/- SE); RS 2.2 +/- 0.5; RS+RT 5.5 +/- 1.2; RS+RT+C 13.6 +/- 2.1. A longer survival trend was noted for the RS+RT versus RS group (two-tailed unpaired t test, p = 0.02;), as well as the RS+RT+C group, which showed consistently higher survival in comparison to most of the other groups (p = 0.0021, 0.00039, 0.013 vs. the biopsy only, RS only, and RS+RT groups, respectively). No significant difference was found in KPS, comparing all individual groups versus each other (p > or = 0.06). Remarkably, 6 patients survived over 14 months (range, 14.1-22.7 months), all of which received RS+RT+C. CONCLUSIONS: This study suggests a significant improvement in elderly patients treated with the combination of resective surgery, radiation therapy, and chemotherapy, rather than either treatment alone or other combination. This significant improvement does not appear to be biased by pretreatment KPS, as mean KPS values did not significantly differ between any of these groups. However, a greater number of patients in each group must be considered to achieve the power to make more definitive treatment guidelines.

A case report of complete disappearance of essential tremor after Gamma Knife radiosurgery.

Pharmacological therapy for essential tremor (ET), the most common movement disorder, remains largely unsatisfactory. Surgical options such as radiofrequency or thermocoagulation are only suitable for a select group of patients, the young and those free of pre-existing medical conditions. Radiosurgery using the Leksell Gamma Knife has recently gained acceptance as a viable treatment option for tremor control in ET patients. We describe our experience with the first reported ET patient treated with radiosurgery in Louisiana.

Gamma knife surgery in the management of brain metastases from lung carcinoma: a retrospective analysis of survival, local tumor control, and freedom from new brain metastasis.

OBJECT: The objective of this retrospective study was to analyze the results of stereotactic radiosurgery performed using a gamma knife in the treatment of 44 consecutive patients with brain metastases from lung carcinoma. METHODS: Forty-four patients with lung carcinoma were treated for metastatic brain tumors by performing radiosurgery with a Leksell Gamma Knife. Twenty-one patients (47.7%) were women and 23 were men. The mean age of the patients was 56 years (range 35-77 years). Twenty-two patients (50%) had solitary tumors and the rest had multiple tumors (two-six lesions). Eighteen patients (40.9%) presented with a recurrent and/or progressive brain disease that previously had been treated with other modalities (surgery, external-beam radiotherapy, or both). Fifteen patients had controlled lung disease and 19 patients had systemic metastases (in lymph nodes, liver, and/or bones) at the time of radiosurgery. The median follow-up period was 18.25 months. All patients were followed up for three different end points: 1) death caused by the disease; 2) clinical and/or radiological evidence of progression of the tumor that had been treated with radiosurgery; and 3) appearance of new lesions. At the last follow-up review, 17 patients (38.6%) were alive and 27 (61.4%) had died. Ten patients (22.7%) died as a result of brain disease (failure of local control or new metastases). Controlled primary disease at the time of detection of metastases and the ability to achieve local tumor control after radiosurgery significantly improved the patient survival (p < 0.01). Control of the treated tumor(s) was achieved in 32 of 44 patients (72 tumors) and 10 patients experienced treatment failure. In addition to the 44 patients comprising the study population, two other patients were treated, but died of lung disease too early in the follow-up period to have been assessed. As of the last follow-up review, no new brain metastasis had occurred in 36 patients (81.8% [includes surviving and nonsurviving patients]). The median duration of overall survival was 7 months, the median period of controlled brain disease was 21 months, and the median period of freedom from new brain metastases was 17 months (95% confidence interval 13-19 months). CONCLUSIONS: Gamma knife surgery has significantly reduced the incidence of mortality from brain disease by effectively accomplishing local tumor control in patients with metastatic lung cancer. Local control and freedom from new brain metastases is not influenced by prior external-beam radiotherapy.

Gamma knife radiosurgery for trigeminal neuralgia: a study of predictors of success, efficacy, safety, and outcome at LSUHSC.

BACKGROUND: Trigeminal neuralgia (TN) is a painful condition of controversial origin; however, vascular compression of the root entry zone of the trigeminal nerve is thought to be responsible in some cases. Recently, stereotactic radiosurgery has been established as an alternative treatment for medically intractable TN. METHODS: Forty patients with medically refractory TN underwent gamma knife surgery for pain control at our institution. Dose planning was based on high-resolution, contrast-enhanced, axial, volume acquisition magnetic resonance images. Images were reviewed to detect vascular compression of the trigeminal nerve at the root entry zone by an observer blinded to the affected side and the outcome. Another observer, blinded to radiologic findings, conducted the patient follow-up. Results were classified as excellent and good (favorable outcomes) and failure (unfavorable) based upon the intensity of pain, frequency of episodes, pain medications, and need for additional interventions after radiosurgery. RESULTS: Pain was left-sided in 22 patients and right-sided in 18 patients. Vascular compression of the affected nerve at the root entry zone was demonstrable in 14 patients. Prescription dose ranged from 70 to 90 Gy. At a median follow-up of 14 months (range, 3-31 months), 16 patients (40%) had excellent pain control, 12 (30%) had good control, while 12 (30%) had failed treatment. The Kaplan-Meier actuarial pain control rate at 15 months was 82.25 +/- 0.8% (95%CI). Magnetic resonance detectable vascular compression did not affect the outcome (p = 0.6). Increasing marginal dose (> or =40Gy) was a significant predictor of favorable outcome (p = 0.015). CONCLUSIONS: gamma knife surgery is an effective and safe treatment for TN. In our study, we found that vascular compression of the nerve at the root entry zone was not a predictor of the outcome of gamma surgery for TN. The outcome improves with marginal prescription dose of 80 Gy or higher.

Management of epidural cauda equina disease of prostate cancer by radiotherapy.

OBJECTIVE: Secondary prostate cancer affection of the cauda equina (SPCCE) can be an ultimate cause of morbidity and mortality. Since the results of management of this particular disease condition remain largely unknown, a retrospective case review was undertaken to determine the effects of treatment by radiation in SPCCE patients. METHODS: The records of 12 patients with SPCCE treated at the Division of Therapeutic Radiology during the period 1984 to 1998 were reviewed. The administered total radiation dosage ranged from 6 Gy to 32 Gy (average, 26.6 +/- 2.0 Gy). Two individuals underwent decompressive laminectomy and bilateral orchiectomy at the time of SPCCE and prostate cancer diagnoses. Ten patients had prior hormonal manipulative treatment (orchiectomy, estrogen, or Flutamide therapy). RESULTS: Pain was relieved in three of four symptomatic patients (75%). Five of nine patients unable to walk before therapy could walk after treatment. One of two individuals with anal or bladder sphincter dysfunction improved following irradiation. The overall mean duration of survival was five months. With treatment, survival was approximately three times as long for ambulatory versus non-ambulatory patients. CONCLUSION: We conclude that radiation treatment is efficacious in promoting palliation of SPCCE, although it may not prolong life.

Management of carotid artery injuries: Louisiana State University Shreveport experience.

BACKGROUND: Traumatic carotid artery injury is an infrequently encountered surgical entity. Carotid artery injuries in polytrauma patients can be easily missed in the absence of clinical findings and/or presence of confounding concurrent injuries. METHODS: Between 1991 and 1998, 23 patients were diagnosed with various carotid artery injuries at the trauma center of Louisiana State University Health Sciences Center, Shreveport, Louisiana. Injuries were assessed by angiography and/or surgical exploration of the neck. Clinical presentations, radiologic features, management strategies, and neurologic outcomes were statistically analyzed and compared with the existing literature. RESULTS: Twelve patients (52%) had penetrating carotid artery injuries, while 11 (48%) had blunt trauma. The diagnosis of carotid injury was significantly delayed in the group with blunt trauma as opposed to those with penetrating wounds. Surgical repair was performed in 6 (26%) patients; 2 (8%) underwent balloon occlusion, while ligation was conducted in 2 (8%) patients. Thirteen patients (57%) were treated conservatively with anticoagulants. Six patients (26%) died, while another 6 (26%) had permanent neurologic deficit. Mortality and morbidity was significantly higher in the group with penetrating injuries. A statistical analysis showed that multi-level carotid injury (p < 0.002) and increasing age (p < 0.001) had a significantly higher mortality. CONCLUSIONS: Injury to carotid arteries results in significant mortality and morbidity. Our results indicate that penetrating carotid injury at more than one level carries higher mortality and morbidity rates than blunt injury. Furthermore, early identification of the injured segment may favorably influence the outcome for such patients.

Selective intraoperative angiography in intracranial aneurysm surgery: intraoperative factors associated with aneurysmal remnants and vessel occlusions.

BACKGROUND: The objective of this study was to assess the role of selective intraoperative angiography and to analyze the factors associated with faulty clip application. METHODS: Two hundred thirty-eight patients undergoing surgery for intracranial aneurysms were studied consecutively for intraoperative angiography (IOA)-related events. The procedure was performed in 155 operations. Demographic details, clinical grade of the patient, location and size of the aneurysm, intraoperative rupture, application of the temporary clip, IOA findings, and final outcome were analyzed. RESULTS: In the 155 patients in the series, there were 125 anterior circulation aneurysms and 30 on the vertebrobasilar system. Aneurysms were smaller than 10 mm in 63% of the patients, and 19 were giant aneurysms. Thirty-eight percent were unruptured, 36% were Hunt and Hess Grades I and II, 21% were Grade III, and 5% were Grades IV and V. An intraoperative rupture occurred in 18 operations. Intraoperative angiography was normal in 88%; in 11 cases (7%) there was a residual neck, and in 8 (5%), occlusion of the artery was observed. An incomplete clipping was significantly related to intraoperative rupture of the aneurysm (p < 0.008) and anterior location of the aneurysm (p = 0.05), whereas vessel occlusion had a significant association with posterior location of the aneurysm (p < 0.0005). An eventful IOA had significant association with poor outcome (p < 0.003). CONCLUSION: Intraoperative rupture and a posterior location of the aneurysm had a significant correlation with residual aneurysm and vessel occlusion, respectively. The use of IOA is justified in aneurysms associated with these factors.

First 100 cases of gamma knife radiosurgery in Louisiana: analysis of demographics and early results.

Louisiana's first ever Leksell Gamma Knife was commissioned at Louisiana State University Health Sciences Center (LSUHSC) in Shreveport in January 2000. Between January 2000 and January 2001,113 patients with various indications were treated using the 201-source Co-60 Leksell model "B" Gamma Knife (Elekta Instruments, Atlanta, Georgia) at LSUHSC-Shreveport. Sixty-three patients were female and 50 were male. The patient age ranged between 13 and 87 years (mean age = 57 years). Fifty-eight (51.3%) patients received radiosurgery as the first line of treatment for their disease, while 55 (48.7%) had previous operations or radiation therapy. The median Karnofsky Performance Score of the patients was 80 (range = 70 to 100). Cerebral metastases were the main indication for radiosurgery at our center accounting for 35% of the patients, while meningioma, arteriovenous malformation, trigeminal neuralgia, and primary central nervous system malignant tumors were the other indications.

Gamma knife radiosurgery for brain metastases: do patients benefit from adjuvant external-beam radiotherapy? An 18-month comparative analysis.

OBJECTIVE: To analyze 18 months of results of gamma knife stereotactic radiosurgery in the treatment of brain metastases and determine factors affecting outcome by examining the effectiveness of additional external-beam radiotherapy (XRT). MATERIALS AND METHODS: Between January 2000 and September 2001, 61 patients with 103 tumors diagnosed as cerebral metastases were treated with gamma knife. Mean patient age was 57 years (range = 36-81). Lung carcinoma (55.7%) was the most common primary cancer, followed by melanoma (14.8%) and breast carcinoma (11.5%). Mean KPS of the patients was 70 (range = 50-90). Twenty-seven patients had solitary metastases while 34 had multiple tumors. Forty-three patients (59 tumors in total) received only radiosurgery, while 18 patients (44 tumors in total) had prior XRT. Tumor volume ranged from 0.5 to 33 cm(3) (mean = 9.74 cm(3)). Mean marginal dose prescription to the tumor was 15 Gy (range = 11-21 Gy). RESULTS: Median follow-up was 11 months. Twenty-one patients (34.4%) were alive at last follow-up and 40 (65.6%) had died. Seventeen deaths (42.5%) were reported to be due to progressive brain disease, while 23 deaths (57.5%) were due to uncontrolled primary. Control of the treated lesions was achieved in 45 patients (73.8%) and 84 tumors (81.6%). Mean overall survival of the patients is 8 months (range = 1-19 months). The actuarial 12-month tumor control rate using the Kaplan-Meier method for this series is 68.2 +/- 0.06%. Results of the log-rank test revealed that younger age (<55 years), small tumor volume (<10 cm(3)), and increasing tumor dose (>15 Gy) correlated with improved brain disease-free survival (p < 0.05). Overall survival, local tumor control rate and the freedom from brain disease period (based on the appearance of new brain tumors after radiosurgery) were analyzed separately for the groups receiving radiosurgery alone and those with prior XRT to detect any additional benefit of XRT. No statistically significant difference was found between the two groups for any of the considered outcomes. CONCLUSION: Gamma knife stereotactic radiosurgery is a safe and effective treatment option for patients with cerebral metastases. It provides survival benefits and improves quality of life by achieving excellent control of the brain disease, irrespective of patients' age or number of brain tumors. The addition of XRT in younger patients with small brain metastases does not improve survival and/or control of the brain disease.