Exposure of Dural Venous Sinuses: A Review of Techniques and Description of a Single-piece Troughed Craniotomy.

Intracranial lesions along the falx and tentorium often require exposure of a dural venous sinus. Craniotomies that cross a sinus should maximize exposure while minimizing the risk of sinus injury and provide a cosmetically appealing result with simple reconstruction techniques.  We describe the published techniques for exposing dural venous sinuses, and introduce a new technique for a single-piece craniotomy exposing the superior sagittal sinus or transverse sinus using drilled troughs. A review of the literature was performed to identify articles detailing operative techniques for craniotomies over dural venous sinuses. Our troughed craniotomy for dural sinus exposure is described in detail as well as our experience using this technique in 82 consecutive cases from 2007-2015. Five distinct techniques for exposure of the dural venous sinus were identified in the literature. In our series of patients undergoing a trough craniotomy, there were no sinus injuries despite a range of various locations and pathology along the sagittal and transverse sinuses. Our technique was found to be safe and simple to reconstruct compared to other techniques found in the literature. A variety of different techniques for exposing the dural venous sinuses are available. A single-piece craniotomy using a trough technique is a safe means to achieve venous sinus exposure with minimal reconstruction required. Surgeons should consider this method when removing lesions adjacent to the falx or tentorium.

Primary Seeding of Myxopapillary Ependymoma: Different Disease in Adult Population? Case Report and Review of Literature.

Myxopapillary ependymoma (MPE) is a slow-growing tumor, occurring most often in adults. It originates from the filum terminale in the area of the conus medullaris and cauda equina and is considered a benign lesion. Despite this classification, however, recurrence after both partial and gross total resection is well known. In the pediatric population, primary MPE seeding and generally more aggressive clinical course is well documented and treated through gross total resection, if possible, followed by irradiation. In adults, however, primary MPE seeding is rarely seen. There are few prior reports describing primary metastases into multiple spinal locations in an adult before resection of an MPE. The reason for this difference among pediatric and adult MPE remains unclear. We present the case of a 32-year-old man with primary seeding of an MPE into multiple lumbosacral areas. The patient underwent gross total resection of the lesions and had an uneventful postoperative course. Primary seeding could be a sign of aggressive behavior in this tumor. Complete craniospinal magnetic resonance imaging studies should be done before and after surgery in patients who present with a multifocal primary MPE. Furthermore, patients with a history of primary tumor seeding of MPE should be thoroughly evaluated radiologically. Unlike in pediatric populations, the need for postoperative irradiation in adults is less clear and further studies-particularly genetic ones-are warranted.

Should Levetiracetam or Phenytoin Be Used for Posttraumatic Seizure Prophylaxis? A Systematic Review of the Literature and Meta-analysis.

BACKGROUND: Posttraumatic seizure (PTS) is a significant complication of traumatic brain injury (TBI). OBJECTIVE: To perform a systematic review and meta-analysis to compare levetiracetam with phenytoin for seizure prophylaxis in patients diagnosed with severe TBI. METHODS: An inclusive search of several electronic databases and bibliographies was conducted to identify scientific studies that compared the effect of levetiracetam and phenytoin on PTS. Independent reviewers obtained data and classified the quality of each article that met inclusion criteria. A random effects meta-analysis was then completed. RESULTS: During June and July 2015, a systematic literature search was performed that identified 6097 articles. Of these, 7 met inclusion criteria. A random-effects meta-analysis was performed. A total of 1186 patients were included. The rate of seizure was 35 of 654 (5.4%) in the levetiracetam cohort and 18 of 532 (3.4%) in the phenytoin cohort. Our meta-analysis revealed no change in the rate of early PTS with levetiracetam compared with phenytoin (relative risk, 1.02; 95% confidence interval, 0.53-1.95; P = .96). CONCLUSION: The lack of evidence on which antiepileptic drug to use in PTS is surprising given the number of patients prescribed an antiepileptic drug therapy for TBI. On the basis of currently available Level III evidence, patients treated with either levetiracetam or phenytoin have similar incidences of early seizures after TBI. ABBREVIATIONS: ADE, adverse drug eventAED, antiepileptic drugCI, confidence intervalOR, odds ratioPTS, posttraumatic seizureTBI, traumatic brain injury.

Endovascular treatment of intracranial dural arteriovenous fistulas.

Endovascular treatment options for dural arteriovenous fistulas (DAVFs) have vastly expanded and become progressively safer in the last several years. Angiographic imaging systems have improved, catheter technology has advanced, and liquid embolic and coil options have increased. As a likely result, an increasing proportion of DAVFs are treated via an endovascular approach. In addition to allowing physicians to appreciate and treat lesions better, varied approaches have been developed. The "plug and push" technique and the new availability of dimethyl sulfoxide--compatible dual lumen balloons have allowed safer and more thorough transarterial treatments. Transvenous treatment has proved to be a valuable technique for some lesions. Hybrid approaches with surgical assisted access to vascular structures have been successfully used to treat more challenging fistulas.

An uncommon illness with a rare presentation: neurosurgical management of ADEM with tumefactive demyelination in children.

PURPOSE: This study determined the statewide incidence and prevalence of acute disseminated encephalomyelitis (ADEM) and examined the course of three pediatric patients treated for tumefactive demyelination (TD) at the Blair E. Batson Children's Hospital. METHODS: Analyses of ICD-9-CM code hospital records and clinical database were conducted. RESULTS: From 2001 through 2007 the incidence in pediatric patients under 20 years was 0.4/100,000/year, with a prevalence of 8.6/100,000 during 2008. Three patients presented with TD. Case 1 had a 3-week history of ataxia and diplopia; case 2 presented with a sudden onset of coma, while the third child had a 4-month history of increasing lethargy and clumsiness in all extremities. Cerebrospinal fluid examinations were nondiagnostic. MRI examinations revealed asymmetric T2/fluid-attenuated inversion recovery hyperintensity within the pons (case 1), a large heterogenously enhancing temporal lobe mass, with extensive edema (case 2), and multiple small brain lesions with occasional ring enhancement (case 3). In case 1, intralesional MR spectroscopy demonstrated changes consistent with ADEM. Case 2 required intracranial monitoring, and medical treatment to control elevated ICP. Cases 2 and 3 underwent cortical biopsies that revealed ADEM. All three patients improved with corticosteroid therapy. At a minimum of 15 months follow-up, cases 1 and 2 showed resolution of deficits and MRI lesions, while the third patient demonstrated additional MRI lesions and increasing paraparesis. CONCLUSIONS: These cases demonstrate that appropriate neuroradiological evaluation, treatment of acutely elevated ICP, and brain biopsy can play critical roles in the management of children with undiagnosed ADEM and TD.

Phenotypical manifestations of partial trisomy 9 and monosomy 4 in two siblings.

In this case report, we describe two siblings with a previously unreported partial monosomy 4q and partial trisomy 9q. The sibling karyotypes were determined to be 46,XX,der(4)t(4;9)(q33;q33)pat and 46,XY,der(4)t(4;9)-(q33;q33)pat. The siblings share several common pathological features, including VSD, PDA, low-set ears and digit anomalies as well as features consistent with Pierre-Robin syndrome and hydrocephalus. We review previously reported phenotypes associated with monosomy 4q and partial trisomy 9q and discuss potential mechanisms for these morphological insults with particular emphasis on neuropathology.