Preventing cerebral spinal fluid leakage following endoscopy through a burr hole using a novel watertight closure: technical note

BACKGROUND

Cerebrospinal fluid (CSF) leakage is a common complication after neuroendoscopic surgery through a burr hole and can lead to further complications including infection.

METHODS

We describe the use of a dural substitute larger than the burr hole itself, placed over the burr hole and then secured underneath a burr hole cover by microscrews running through the graft itself into the underlying skull.

RESULTS

This simple technical modification contributes to achieving a watertight seal to aid in preventing CSF leakage in this setting.

CONCLUSIONS

Our technical modification of endoscopy through a burr hole may help to prevent postoperative CSF leak and secondary CSF infections.

Delayed migration of Onyx embolic agent after preoperative embolization of an arteriovenous malformation in a pediatric patient: A case report and review of the literature

INTRODUCTION

Brain arteriovenous malformations (AVMs) are increasingly being treated with Onyx liquid embolic agent (Onyx, Medtronic, Inc.). The phenomenon of delayed Onyx migration is not well documented in the literature. Moreover, the clinical presentation associated with Onyx migration is not well understood.

CASE PRESENTATION

A pediatric patient with a history of neonatal seizures was referred to our institution upon experiencing daily headaches with photophobia, phonophobia, and sleep disturbance. Cerebral angiography revealed an arteriovenous malformation (AVM) of the medial left cerebellar hemisphere. Preoperative embolization with Onyx liquid embolic achieved 25% closure of the AVM nidus. Upon developing worsening headaches the following day, new perinidal parenchymal edema was revealed on MRI, and urgent angiography demonstrated delayed migration of Onyx into the venous drainage. The patient underwent emergency resection of the AVM due to the risk of hemorrhage resulting from venous outflow obstruction.

DISCUSSION/CONCLUSION

Our report and literature review demonstrate that while the delayed, unexpected migration of Onyx embolic material has been alluded to in a handful of papers, this phenomenon is not well documented. Future research is needed to understand the frequency of delayed Onyx migration from brain AVMs and the possible clinical presentations to look for. The sudden development of headaches and other signs of perilesional edema, in particular, should prompt repeat angiographic examination due to the possibility of delayed liquid embolic migration.

Expression of and correlational patterns among neuroinflammatory, neuropeptide, and neuroendocrine molecules from cerebrospinal fluid in cerebral palsy

Background

The underlying pathogenesis of cerebral palsy (CP) remains poorly understood. The possibility of an early inflammatory response after acute insult is of increasing interest. Patterns of inflammatory and related biomarkers are emerging as potential early diagnostic markers for understanding the etiologic diversity of CP. Their presence has been investigated in plasma and umbilical cord blood but not in cerebrospinal fluid (CSF).

Methods

A clinical CP sample was recruited using a single-time point cross-sectional design to collect CSF at point-of-care during a standard-of-care surgical procedure (intrathecal pump implant). Patient demographic and clinical characteristics were sourced from medical chart audit.

Results

Significant (p ≤ 0.001) associations were found among neuroinflammatory, neuroendocrine, and nociceptive analytes with association patterns varying by birth status (term, preterm, extremely preterm). When between birth-group correlations were compared directly, there was a significant difference between preterm and extremely preterm birth subgroups for the correlation between tumour necrosis factor alpha (TNFα) and substance P.

Conclusion

This investigation shows that CSF can be used to study proteins in CP patients. Differences in inter-correlational patterns among analytes varying by birth status underscores the importance of considering birth status in relation to possible mechanistic differences as indicated by biomarker signatures. Future work should be oriented toward prognostic and predictive validity to continue to parse the heterogeneity of CP’s presentation, pathophysiology, and response to treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02333-2.

Transport of patients with giant disfiguring cranial tumors from Africa to the US for collaborative multidisciplinary treatment

Background

Giant disfiguring cranial tumors are exceptionally rare and develop over the course of many years, typically in patients who lack access to medical care. Here, we describe four patients who were flown to our center for treatment by a multidisciplinary surgical team, who had previously been turned down for treatment at multiple international centers in Africa, Europe, and the United States (US) due to complexity and financial concerns. The case series describes socioeconomic implications and the feasibility of offering such care to patients from outside the US.

Case Descriptions

Four patients with giant skull disfiguring tumors were flown internationally and treated by a surgical team consisting of a complex cranial neurosurgeon, a craniofacial reconstructive plastic surgeon, and an oculoplastic surgeon. All patients underwent aggressive surgical therapy with the aim of complete tumor removal and simultaneous cranial reconstruction. A patient with osteogenic sarcoma underwent two additional resections in 3 years, with delayed reconstruction. They returned home but ultimately succumbed to the disease. A patient with ossifying fibroma required two follow-up procedures for cosmetic reconstruction and sought asylum in the US, where they remain today. Two additional patients, one with a giant plexiform neurofibroma and one with a cerebellopontine angle meningioma, achieved good results and returned to Africa 1 month and 3 weeks after surgery, respectively.

Conclusion

Resection of giant disfiguring cranial tumors and reconstruction of the impacted region requires an experienced multidisciplinary team. These cases can be managed by transporting such patients from areas without access to medical care to specialized centers able to provide excellent care.

Delayed Onset of an Intradural Epidermoid Tumor in the Lumbar Region Seven Years After Spinal Anesthesia for Childbirth: A Case Report

Epidural or spinal anesthesia is commonly administered in births in the US, and the potential risks for epidermoid tumors are not well-characterized. We present the case of a 29-year-old female patient who developed an intradural epidermoid tumor in the lumbar spine, discovered seven years after spinal anesthesia for childbirth. MRI revealed a 4 cm tumor filling the entire spinal canal. Pathology confirmed the mass to be an epidermoid. Complete surgical resection of the intradural lesion was accomplished with full symptomatic relief. This case supports the relationship between delayed development of epidermoid tumors and spinal puncture in adult populations.

Microvascular decompression with partial occipital condylectomy in a case of pediatric spasmodic torticollis

Spasmodic torticollis is a rare, neurologic disorder that is caused by abnormal nerve compression of the 11th cranial nerve by blood vessels or bony protrusions. It is typically treated pharmacologically and, if necessary, with surgical intervention. We report a unique case of spasmodic torticollis in a 15-year-old female that involved abnormal compression of the left 11th cranial nerve (CN) by the left vertebral artery, displaced by a hypertrophic left occipital condyle. After treatment with Botox was unsuccessful, the patient was treated with microvascular decompression and occipital condylectomy that adequately relieved the abnormal compression of CN XI. Mild symptoms persisted, and the patient underwent a partial section of the sternocleidomastoid muscle 1 year later, after which torticollis symptoms resolved.

Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note

We report a 45-year-old man who suffered a penetrating nail gun injury resulting in damage to the lateral edge of the superior sagittal sinus. The injury was successfully treated via a parasagittal craniotomy that enabled removal of the nail under direct vision, allowing for rapid suturing of the sagittal sinus. Two neurosurgeons worked together; one carefully withdrew the tip of the nail back into the sinus itself while the second rapidly sutured the hole in the inner superior sagittal sinus leaflet. Postoperatively, the patient made a rapid recovery without neurological deficit.

Air gun orbitocranial penetrating injury: emergency endovascular treatment and surgical bypass following pellet migration to middle cerebral artery: case report

The authors describe a 14-year-old boy presenting with an orbitocranial penetrating injury (OPI) from a metallic air gun pellet to the left eye who developed hemiparesis and speech difficulty due to migration of the pellet to the left middle cerebral artery. They highlight the potential complications associated with both OPIs and intravascular foreign body migration and occlusion by describing the patient's presentation, results of imaging evaluation, and the combined endovascular treatment and extracranial-intracranial bypass, which resulted in rapid restoration of blood flow and full neurological recovery with intact vision. Based on this case and a review of the literature on intracranial foreign body migration with resultant vascular occlusion, the authors recommend that complex OPIs be treated at centers that offer both neuroendovascular and neurovascular surgical capabilities on an urgent basis to manage both the primary injury and potential secondary vascular compromise.

Limited vertical dural opening for lesions of the vermis, 4(th) ventricle, and distal PICA segments

Background:

Lesions of the vermis and 4^th ventricle are commonly addressed through a midline suboccipital approach. Most neurosurgeons use either a Y-shaped or a curvilinear dural opening in this setting. Although these approaches offer a wide intraoperative surgical exposure, in occasion, the dural opening is difficult to repair primarily, often necessitating the use of a patch, which may increase the risk for development of CSF fistula. We are describing our experience with a limited, vertical, midline, dural opening for approaches to the vermis, tentorium, 4^th ventricle, and distal posterior-inferior cerebellar artery (PICA) segments as an alternative to the classic Y-shaped or curvilinear incision.

Methods:

We report our experience with a limited vertical midline durotomy in five patients with posterior fossa lesions. The lesions treated included a PICA dissecting aneurysm, three metastatic lesions (located in the vermian, floor of the 4^th ventricle, and undersurface of the tentorium cerebelli), and one intra-axial tumor (ependymoma). All patients were positioned prone, and the lesions were accessed without difficulty through a limited, vertical, midline durotomy.

Results:

Mass lesions and vascular abnormalities located from the midline as far lateral as the outlet foramina of the 4^th ventricle can be accessed comfortably via a limited midline dural opening when combined with microsurgical techniques, and the use of a frameless Stealth Station Neuronavigation System (SSNS) [Medtronic Sofamor Danek, Inc., Memphis, TN]. By doing this, simple primary dural closure was achieved with a single running absorbable suture without tension in each case.

Conclusion:

In our experience, a suboccipital linear dural opening appears to be as effective as the more traditional Y-shaped incision, yet allows for quicker and easier primary dural repair.

Pentasomy 49,XXXXY associated with a Chiari type 1 malformation and cervical syrinx

Pentasomy 49,XXXXY occurs in 1/85,000 newborn males. The origin of this particular form of aneuploidy is believed to be a result of consecutive nondisjunction events during maternal meiosis. Typical presentation consists of hypotonia, developmental delay, various dysmorphic features, and severe hypogenitalism. A 13-year-old with pentasomy 49,XXXXY and a Chiari type 1 malformation with an associated cervical syrinx is presented.

Nonaccidental head trauma as a cause of childhood death

OBJECT

The authors present the demographic and clinical information in 36 children who died as a result of abusive head trauma at a Level 1 pediatric trauma center between January 1, 1997, and January 1, 2004.

METHODS

Abusive head trauma was defined as radiographic evidence of intracranial injury and documentation from a multidisciplinary child protection team that the injury was nonaccidental. There was no sex bias for the children in the 1st year of life (nine girls, nine boys). In children older than 1 year of age, boys were much more likely to be victims (14 boys, four girls). At the time of admission, every child exhibited a seriously impaired level of consciousness and 81% had retinal hemorrhages. Injuries to other organ systems were rare (17%). The most common abnormality found on neuroimaging studies was subdural hematoma. Six children underwent craniotomy for extraaxial hematomas. Death occurred within 24 hours after hospital admission in one half of the cases.

CONCLUSIONS

Abusive head trauma was the cause of death in 36 (86%) of the 42 children whose deaths were classified as nonaccidental at the Children's Hospital in Denver between 1997 and 2003. The authors were unable to identify anything that could have been done from a medical or neurosurgical viewpoint to prevent the deaths of these children after they came to medical attention.

Using the superior sagittal sinus for emergency venous access in an infant. Case report

Emergency venous access in an infant suffering from multiple trauma and shock can be difficult. Peripheral venous access and central line placement are not always successful. Death following underresuscitation due to the lack of adequate access occurs, although it is not often reported in the literature. The author presents a case in which successful resuscitation was achieved by injecting blood into the superior sagittal sinus through an open fontanelle in a 2-week-old infant who presented in shock and with ventricular fibrillation after nonaccidental trauma.

Correction of metabolic, craniofacial, and neurologic abnormalities in MPS I mice treated at birth with adeno-associated virus vector transducing the human alpha-L-iduronidase gene

Murine models of lysosomal storage diseases provide an opportunity to evaluate the potential for gene therapy to prevent systemic manifestations of the disease. To determine the potential for treatment of mucopolysaccharidosis type I using a gene delivery approach, a recombinant adeno-associated virus (AAV) vector, vTRCA1, transducing the human iduronidase (IDUA) gene was constructed and 1 x 10(10) particles were injected intravenously into 1-day-old Idua(-/-) mice. High levels of IDUA activity were present in the plasma of vTRCA1-treated animals that persisted for the 5-month duration of the study, with heart and lung of this group demonstrating the highest tissue levels of gene transfer and enzyme activity overall. vTRCA1-treated Idua(-/-) animals with measurable plasma IDUA activity exhibited histopathological evidence of reduced lysosomal storage in a number of tissues and were normalized with respect to urinary GAG excretion, craniofacial bony parameters, and body weight. In an open field test, vTRCA1-treated Idua(-/-) animals exhibited a significant reduction in total squares covered and a trend toward normalization in rearing events and grooming time compared to control-treated Idua(-/-) animals. We conclude that AAV-mediated transduction of the IDUA gene in newborn Idua(-/-) mice was sufficient to have a major curative impact on several of the most important parameters of the disease.

Craniofacial abnormalities in a murine knock-out model of mucopolysaccharidosis I H: a computed tomography and anatomic study

The genetic mucopolysaccharidoses are a group of lysosomal storage diseases in which mucopolysaccharides (glycosaminoglycans) accumulate as the result of a malfunction or lack of a lysosomal degradation enzyme. There are currently seven known forms of mucopolysaccharidoses. Type I results from an enzymatic deficiency of alpha-L-iduronidase. There are three subtypes of mucopolysaccharidoses I that are commonly recognized: Hurler syndrome, Hurler-Scheie syndrome, and Scheie syndrome. Of the three subtypes, Hurler syndrome has the most severe clinical picture. Craniofacial anomalies and cognitive impairment are some of the more pronounced features of Hurler syndrome. Hurler syndrome has been described in cats, dogs, mice, and human beings and is inherited as an autosomal recessive trait. The biochemical nature of the disease is preserved across species lines. Clinically, the disease has similar effects in human beings and animals. It has been difficult to reverse the phenotype of the disease even with replacement of the defective alpha-L-iduronidase enzyme. The purpose of this study is to characterize the cranio-facial differences in the murine knock-out model of Hurler syndrome objectively. Twenty-three measurements were taken from computed tomographic scans in a coronal and sagittal plane on 24 black C57/B6 knock-out Hurler syndrome mice. The seven statistically significant measurements are width of the cervical canal, height of the foramen magnum, width between the external auditory canals, width of the skull base at the mandibular condyles, midocular distance, spread of the mandibular condyles, and width of the zygoma at the maxilla. This information now provides researchers with objective data from living Hurler syndrome-affected mice that will allow them to follow therapies directed at improving craniofacial outcomes for any therapy over time.