Primary calvarial cryptococcal osteomyelitis in a patient with idiopathic lymphopenia.

An example of primary calvarial cryptococcal osteomyelitis in a patient with idiopathic lymphopenia is presented. The patient was a suboptimally immunocompetent host with an isolated skull involvement without any systemic infection. The Magnetic Resonance Imaging radiographic findings of the head are reviewed. The patient underwent surgical debridement of the lesion as well as receiving a course of oral antifungal medication. We discuss cryptococcal osteomyelitis and review the reports of cryptococcal disease and Idiopathic Lymphopenia.

Chronic headaches in adults with spina bifida and associated hydrocephalus.

INTRODUCTION: Adults with spina bifida and associated hydrocephalus are exposed to multiple risk factors for the development of chronic headache. The management of these patients can be complex and misdiagnosis can precipitate unnecessary shunt revision. This study aims to evaluate the usefulness of intracranial pressure (ICP) monitoring as a diagnostic tool in these cases and to look at the causes of chronic headaches and treatment outcomes for this patient population. METHODS: All patients over the age of 18 years with a diagnosis of spina bifida and shunted hydrocephalus who had undergone inpatient or outpatient neurosurgical review within the last 10 years were identified in our hospital database. Case notes were then retrospectively reviewed to identify all patients who had undergone either inpatient or outpatient evaluation of chronic headaches (defined as a headache of at least one month's duration) occurring in the absence of any other symptoms or signs suggestive of raised intracranial pressure (ICP). The incidence, causes, management and outcome of chronic headache in these patients was determined. RESULTS: 42 patients were identified, mean age 30 years (range 18 - 59). All had undergone lifelong follow-up. All had previously undergone shunt insertion for hydrocephalus. 16 had undergone endoscopic third ventriculostomy (ETV). 11 had undergone choroid plexus coagulation. 55 % (23/42) of patients underwent investigation for 1 or more episodes of chronic headache. Recurrent hydrocephalus due to shunt malfunction or ETV failure was excluded by ICP monitoring using either an intraparenchymal transducer or monitoring via a ventricular access device. All patients underwent repeat imaging, using CT and/or MR imaging. Identified causes of headache included: shunt blockage; shunt overdrainage; ETV failure and symptomatic Arnold-Chiari malformation. A history of choroid plexus coagulation (CPC) as an infant was associated with a decreased risk of chronic headache in later life (p = 0.02). In 8 patients no definite cause for headaches was identified, in 4 of these patients symptoms resolved spontaneously, the remainder required specialist pain management. CONCLUSIONS: The aetiology of chronic headaches in this patient group is multifactorial. In the absence of other clinical symptoms or signs of raised ICP, ICP monitoring is an invaluable adjunct to management. 10 % of hydrocephalic adult spina bifida patients required specialist pain management for control of chronic idiopathic headache.

The role of endoscopic biopsy and third ventriculostomy in the management of pineal region tumours.

The best surgical strategy for treating patients with pineal tumours presenting with acute hydrocephalus remains undermined. During the past 17 years we have used transventricular endoscopic biopsy and third ventriculostomy as a one-step procedure in the initial management of these cases, and present the largest consecutive case series illustrating the value of this technique. We have successfully managed 34 consecutive patients with pineal region tumours, carrying out third ventriculostomy in 18 patients. Histological diagnosis was obtained in 32/34 (94%) of the cases. There were no deaths or major complications and only one patient required a ventriculo-peritoneal shunt owing to ventriculostomy failure. According to current management protocols and depending on histology, tumours were treated by a combination of resection via craniotomy followed by radiotherapy or chemotherapy, or by the latter therapies alone. This one step procedure is minimally invasive and safely achieves adequate biopsy with control of hydrocephalus, whilst definitive histology and biochemical marker studies are obtained. Definitive treatment for each tumour is designed according to diagnosis.

Endoscopic methods of hydrocephalus treatment.

This article discusses the use of the endoscope in treatment of hydrocephalus without shunting. The selection of candidates for third ventriculostomy and choroid plexus coagulation are described together with the overall published rates of success with each technique. A summary of the nature and frequency of complications of third ventriculostomy are given after reviewing published data on over a thousand patients who have had the operation to date. The role of other endoscopic techniques, such as septal fenestration and decompression of obstructing cysts, also are discussed.

Use of antibiotics in penetrating craniocerebral injuries. "Infection in Neurosurgery" Working Party of British Society for Antimicrobial Chemotherapy.

The Working Party was instituted to investigate the rationale of prophylactic and therapeutic antibiotic use in penetrating craniocerebral injuries (PCCI), and to make recommendations for current practice. A systematic review of papers on civilian and military PCCI over the past 25 and 50 years, respectively, was done via electronic databases and secondary sources, and data were evaluated. Guidelines on the removal of indriven bone or metal fragments only if further neural damage can be avoided were supported. However, no publications were identified where the data on infection or its treatment and prevention were complete or satisfactorily derived, and no controlled trials have been published. All studies were retrospective or anecdotal. Working Party recommendations are based on the data available and the professional experience and knowledge of the members. Broad-spectrum antibiotic prophylaxis is recommended for both military and civilian PCCI, Including those due to sports or recreational injuries.

Inhibition of epidural fibrosis with ADCON-L: effect on clinical outcome one year following re-operation for recurrent lumbar radiculopathy.

In a prospective multicenter study, 20 patients underwent re-operation for recurrent radiculopathy after lumbo-sacral discectomy, and were treated with ADCON-L (Adhesion Control in a Barrier Gel) to inhibit epidural fibrosis following secondary surgery. Outcomes after re-operation were assessed at six and 12 months using: Visual Analog Scales to measure radicular and back pain, straight leg raising exams, and self-assessment of activity-related radicular pain. Each parameter was compared to baseline values, obtained immediately prior to the re-operation. The long term clinical results at 12 months after re-operation (summarized below) demonstrate a significant improvement of all clinical parameters, and correlated with the results seen at six months. Radicular pain, measured when most severe, was reduced from an average pre-operative score of 8.1-3.7 (p < 0.005). The straight leg raising angle increased from an average pre-operative value of 41 degrees-67 degrees (p < 0.005). Activity-related pain mean score was 4.6, vs. 17.0 pre-operatively (p < 0.005). Low back pain, measured when most severe, was reduced from an average pre-operative score of 6.1 to 3.1 (p < 0.012). These clinical findings compare very favorably with data reported in the literature. There were no adverse events or complications related to the use of ADCON-L.

Clinical presentation and management of 100 infants with occipital plagiocephaly.

One hundred consecutive infants who presented with occipital plagiocephaly over 15 years were analyzed retrospectively to determine results of both surgical and nonsurgical management. Eighteen infants who showed obvious progression of their deformity or radiological signs of fusion of the lambdoid suture had surgical resection of one or both lambdoid sutures and the remaining 82 infants were treated nonsurgically with physical therapy and advice on sleeping position. Of the 18 surgical cases 9 were found at operation to have true lambdoid synostosis, 7 had marked internal ridging of the lambdoid suture and 2 had an open suture. After a mean follow-up period of 6 months all parents of the 82 children treated nonsurgically were satisfied with their child's cosmetic appearance: 63% showed improvement in their plagiocephaly and 27% stabilized. There were no surgical complications in the 18 operative cases, all of whom had a good cosmetic result. From these results we conclude that the majority of infants referred to neurosurgeons with occipital plagiocephaly can be successfully managed nonsurgically. A small proportion of cases (18% with radiological signs of fusion or pronounced ridging of the suture) appeared to benefit from surgery. The clinical, radiological and pathological differentiating features of the surgical and nonsurgical cases are discussed.

The role of endoscopic choroid plexus coagulation in the management of hydrocephalus.

Endoscopic choroid plexus coagulation has been used for the treatment of hydrocephalus at this unit for the past 20 years, and 156 operations have been performed on 116 patients. These patients were analyzed retrospectively to determine the rate of long-term clinical control of hydrocephalus, factors associated with successful control, change in ventricular size after surgery, and rate of surgical complications. Data were found for 104 patients with a median age at surgery of 5 months (range, 1 wk-30 yr) and a mean follow-up of 10.5 years. Control of hydrocephalus by choroid plexus coagulation was found to be best in children with communicating hydrocephalus and a slow to moderate rate of increase in head circumference (18 of 28, 64% long-term control), whereas those who presented with tense fontanels and rapidly progressive hydrocephalus had the lowest rate of success. Overall, 36 of 104 (35%) achieved long-term control without cerebrospinal fluid shunts. The ventricular size was not significantly reduced by choroid plexus coagulation (ventricular index before and after surgery, 0.64 and 0.58, respectively; P = 0.13), although sulcal markings became more prominent in all successfully treated patients, indicating reduced intracranial pressure. There were no deaths resulting from surgery, and serious morbidity was low. Eight patients developed infections (five meningitis and three implant infections). Other complications included postoperative fits (two patients), respiratory arrest in a premature infant (one patient), low-pressure state (one patient), ventricular drain displacement or blockage (eight patients), subdural effusion (one patient), and intraoperative minor ventricular bleeding, forcing abandonment of the procedure (two patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Revisional lumbar microdiscectomy: an analysis of operative findings and clinical outcome.

Forty-one consecutive patients who underwent a revision microlumbar exploration for recurrent or persistent sciatica were reviewed retrospectively to analyse the operative findings and assess the clinical outcome following surgery. Thirty-three (80%) patients were found to have a recurrent intervertebral disc protrusion at the previous site, two patients had a disc herniation at a new site, one had severe perineural scarring, two had lateral recess stenosis, one patient had undergone previous exploration at an incorrect site and in two patients no cause for ongoing symptoms was found. Nineteen of the 33 patients with a re-prolapse presented with persistent or recurrent sciatica within 1 year of their first operation. The other 14 patients presented with a late re-prolapse (after 1 year) and their clinical outcome was better than for those patients with an early re-prolapse (12/14 vs 11/19 satisfactory result, respectively). The result of operating on patients with a late re-prolapse was comparable to the 80-95% satisfactory outcomes following primary lumbar microdiscectomy reported by other authors.

Results and complications of intracranial pressure monitoring in 303 children.

303 consecutive children who had insertion of an intracranial pressure (ICP) monitor for various reasons were reviewed to determine clinical value and complications rate of ICP monitoring in this age group. 286 patients had a Camino fiberoptic monitor. Of the remaining cases, 9 had a ventricular catheter, 7 had an extradural Gaeltec monitor, and 1 had a subdural feeding tube. The reasons for monitoring the ICP were: trauma in 132 children, postoperative monitoring after tumor surgery in 91, head injury due to child abuse in 30, severe medical conditions such as meningitis, encephalitis, and near-drowning in 30, intracranial hemorrhage in 15, and hydrocephalus in 5 children. The median age at insertion was 6 years (range from 1 month to 17 years), and the median Glasgow coma score before insertion was 7. Median duration of monitoring was 3 days, and 35 children (10%) had surgical procedures performed for raised ICP detected by monitoring. 238 (78%) had nonsurgical measures to control raised ICP. 6 (15%) of 40 children with an initial ICP > 50 mm Hg made a good recovery, but there were no survivors among 37 children who had an ICP consistently > 60 mm Hg and only 1 disabled survivor among 42 children with an ICP consistently > 50 mm Hg. The outcome in all 303 children correlated with averaged readings of ICP over 24 h and initial Glasgow coma score, but did not correlate with initial ICP measurements. Complications of monitoring were few and consisted of infection in 1 (0.3%) child, intracranial hemorrhage in 1 (0.3%) who had low platelet counts, displacement of monitor in 3 (1%), and malfunction of monitor in 8 (2.6%) children. We conclude that ICP monitoring in the pediatric age group substantially influences our clinical management of unconscious children and is safe.

Intracranial meningiomas following irradiation--a growing problem?

We present 10 cases of meningiomas occurring after high-dose irradiation for other brain tumours. These constitute 3.7% of 272 patients with meningiomas treated in our unit over 10 years. The clinical and pathological features of the 10 cases were added to those of 69 previous cases documented in the literature and compared with the features of our 262 spontaneous meningiomas. The literature on 119 cases of low-dose radiation-induced meningiomas was also reviewed. Malignant histological features and multiplicity were more common in the radiation-induced meningiomas (p < 0.01). Increasing long-term survival rates following radiotherapy for primary intracranial tumours, particularly in childhood, may lead to an increased incidence of postirradiation meningiomas.

Prediction of an extruded fragment in lumbar disc patients from clinical presentations.

To determine whether the presence of an extruded lumbar disc prolapse could be predicted from clinical symptoms, the authors compared the relative proportions of back and leg pain, with operative findings in a prospective observational study of 100 lumbar discectomy patients. All cases were assessed by an independent observer, blind to the knowledge of the operative findings. Of the 58 men and 42 women (mean age 42, range 19-75), 47 patients had a subligamentous disc protrusion and 53 had an extruded disc fragment. Of 27 patients who presented with leg pain only, 26 (96%) were found subsequently to have an extruded fragment. Patients with an extruded fragment had a significantly higher proportion of leg:back pain (median 99:1) than those with a subligamentous disc protrusion (median 75:25, P < 0.001). Patients with leg pain only and those with a marked predominance of leg pain over back pain have a high probability of harboring an extruded disc fragment.

Control of hydrocephalus by endoscopic choroid plexus coagulation--long-term results and complications.

Endoscopic choroid plexus coagulation has been used for the control of hydrocephalus regularly at this unit for the past 20 years. 156 of these operations have been performed on 116 patients and the aim of this study was to assess the rate of long-term control of hydrocephalus and the complications of the procedure. Data have so far been found for 98 patients with a median age at operation of 5 months (range 1 week-30 years). After a mean follow-up period of 10.5 years there were 32 (33%) patients continuing without a ventricular shunt. One patient developed papilloedema and required ventricular shunting 16 years after choroid plexus coagulation. There were no deaths resulting from operation. 5 patients developed post-operative meningitis and 3 patients had post-operative infections of implants (2 shunts and 1 reservoir). No cases of post-operative meningitis have occurred since vancomycin and gentamicin have been added to the solution used to perfuse the ventricles after operation (28 cases). Other complications included post-operative fits (2), respiratory arrest in a premature baby (10, low-pressure state (1), blocked or leaking external ventricular drain (4), drain displacement (4), subdural effusion (1) and per-operative minor ventricular bleeding forcing abandonment of the procedure (2).

Intrinsic malignant glioma of the pineal gland.

The case of a 6-year-old girl who presented with a glioblastoma multiforme arising from the pineal gland is reported. Most so-called gliomas of the pineal region originate from neighbouring structures; authentic malignant gliomas of the pineal itself are extremely rare. This appears to be only the second fully documented case reported in the world literature.