Endovascular reconstruction of extracranial traumatic internal carotid artery dissections: a systematic review

Neurosurgical Review - Extracranial internal carotid artery dissection (ICAD) is a potential source of morbidity and mortality in trauma patients and requires high degree of suspicion for diagnosis...     

Pediatric golf-related head injuries

Objectives Golf-related head injuries constitute an increasingly common mechanism of head trauma in children. We present our experience with 33 pediatric cases of golf-associated head injury, with special emphasis in the type of injury, management strategy, and outcome.Materials and methods A thorough review of all children admitted to our hospital with golf-related head injury during a period of 10 years (1 January 1994 to 31 December 2003) was undertaken. The patients’ charts, operative reports, imaging studies, and follow-up data were analyzed. A comparison of our findings with those described in the pertinent literature was subsequently performed.Conclusions Pediatric golf-related head trauma is a significant cause of sport-associated head injury, sometimes harboring a very dismal prognosis. The significance of establishing a task force for the prevention of these injuries cannot be overemphasized.     

Review of the literature regarding the relationship of rebleeding and external ventricular drainage in patients with subarachnoid hemorrhage of aneurysmal origin

Acute hydrocephalus is a well-documented complication of subarachnoid hemorrhage. The insertion of external ventricular drainage (EVD) has been the standard of care in the management of this complication, aiming primarily at immediate improvement of the clinical condition of these patients, making them more suitable candidates for surgical or endovascular intervention. In our current communication, we review the pertinent literature regarding the relationship of rebleeding and EVD. Several studies have implicated a significantly increased risk of rebleeding in patients with EVD, compared with patients without it. Abrupt lowering of the intracranial pressure could lead to rebleeding due to decreased transmural pressure or removal of the clot sealing the previously ruptured aneurysm. However, a variety of parameters that could affect the rebleeding rate, such as the timing of surgery, the timing and duration of drainage, the size of the aneurysm, as well as the severity of the initial hemorrhage, do not seem to have been adequately explored in the majority of these studies. In addition, a number of clinical trials have failed to provide evidence for the negative role of EVD in the development of rebleeding. Conclusively, further long-term multi-center studies are required in order to establish the exact nature of the relationship between EVD and rebleeding after aneurysmal subarachnoid hemorrhage.A commentary on this paper is available at     

Extrusion of a screw into the gastrointestinal tract after anterior cervical spine plating

In this case report of a screw extrusion into the gastrointestinal tract of a patient 16 months after anterior cervical discectomy and fusion (ACDF), the authors describe a rare but potentially lethal complication and review the literature on this topic. A 70-year-old white man with a surgical history of ACDF at C3-4 underwent an ACDF at C5-6 with autologous bone graft and a dynamic plate using locking, expanding screws. Sixteen months after the operation the patient presented with severe dysphagia. Radiographic findings indicating pulling out of the implanted plate and screws prompted a surgical removal of the instrumentation. One of the screws was not found during the operation and was visualized after surgery by abdominal radiography in the right lower abdominal quadrant. A subsequent Gastrografin swallowing test revealed an esophageal tear. The screw was removed endoscopically and the patient received antibiotics and had no oral intake for 4 days. He was discharged without symptoms on a soft mechanical diet; at 24 weeks, follow-up revealed no changes or symptoms. Screw extrusion into the gastrointestinal tract following ACDF is a rare but potentially lethal complication. The use of locking, expanding screws does not extinguish the risk of this complication, particularly in cases of suboptimal initial placement of the anterior instrumentation. Close follow-up is of paramount importance in detecting any pull-out of the implanted plate. Any signs of postoperative dysphagia or throat soreness should prompt immediate evaluation of the patient and, if indicated, surgical removal of the failed instrumentation.     

Ocular Ischemic Syndrome

Ocular ischemic syndrome encompasses a spectrum of clinical findings that result from chronic ocular hypoperfusion. It is relatively uncommon, and the diagnosis may be difficult to make because of its variable presentations. The presence of an ocular ischemic syndrome always implies underlying severe carotid occlusive disease and may be its sole clinical manifestation. It may also result from other causes of reduced blood flow to the eye and the orbit such as systemic vasculitis. Besides visual loss and ocular/orbital pain, affected patients are also at risk for developing cerebral and myocardial infarction. Establishing the diagnosis is therefore essential with respect not only to visual prognosis but also to patient survival. Ophthalmologists have an important role in early diagnosis and in coordinating the systemic evaluation of patients. Referral to the neuroradiologist and the neurovascular specialist is warranted. We present the current knowledge on the ocular ischemic syndrome.     

Clinical implications of quantitative infrared pupillometry in neurosurgical patients

Pupillometry has been widely employed in the evaluation of a large number of pathological conditions, including intracranial pathology. The recent introduction of a portable, user-friendly, infrared pupillometer (ForSite, NeurOptics Inc., Irvine, CA) has enabled the accurate and reproducible measurement of several pupillary parameters, such as maximum and minimum apertures, constriction and dilation velocities, and latency period. It should be noted that various clinical conditions, especially neurological and ocular diseases, as well as numerous medications, may interfere with the measurements. Furthermore, a number of physiological parameters, such as the intensity of retinal illumination, the level of patient's alertness, the intensity of ambient light, as well as the time of day that the examination is performed may alter the obtained values. The potential implications of pupillometry in the clinical assessment of neurosurgical patients, including its complex relationship to intracranial pressure changes, mandate the undertaking of prospective clinical studies validating the clinical significance of this noninvasive, diagnostic modality.     

Bilateral periventricular heterotopias in an X-linked dominant transmission in a family with two affected males

We report on the case of dizygotic twin boys, born prematurely to an asymptomatic mother. Bilateral periventricular heterotopias with enlarged ventricles were discovered at birth in both twins. One of the twins died prematurely of bronchopulmonary complications, and was shown to have several neuropathological anomalies (microgyria, thin corpus callosum, and reduced white matter). The surviving twin had mental retardation, without epilepsy. MRI of the mother showed asymptomatic periventricular heterotopias without ventricular enlargement. She had two affected daughters also with asymptomatic periventricular heterotopias. A point mutation in the last coding exon 48 of the Filamin A (FLNA) gene (7922c > t) was discovered on sequencing and segregated with the affected individuals. This family has a classical X-linked dominant BPNH pathology, with greater severity in males than females. The location of the FLNA mutation is discussed in light of the neuropathological anomalies and mental retardation in male patients.     

Accurate placement of the distal end of a ventriculoatrial shunt with the aid of real-time transesophageal echocardiography. Technical note

OBJECTIVE: Ventriculoatrial (VA) shunts remain a valid option for the treatment of hydrocephalus, especially in patients in whom ventriculoperitoneal (VP) shunts fail. Correct positioning of the distal end of the catheter in the right atrium is of paramount importance for maintaining shunt patency and reducing the incidence of VA shunt-associated morbidity. The authors present their experience with real-time transesophageal echocardiography (TEE) monitoring for the accurate placement of the distal catheter of a VA shunt. METHODS: Four patients underwent conversion of a VP shunt to a VA shunt under the guidance of intraoperative fluoroscopy and TEE between May 2003 and December 2004. After induction of general anesthesia, the TEE transducer was advanced into the esophagus. A cervical incision was made and the external jugular vein was visualized. An introducer was passed through an opening in the jugular vein and a guidewire was placed through the introducer. Under continuous TEE guidance, the guidewire was carefully advanced into the superior vena cava. A distal shunt catheter overlying a J-wire was then passed to the superior vena cava, again under TEE guidance. The catheter was advanced to the right atrium after removing the guidewire. Final visualization with TEE and fluoroscopy revealed a good position of the catheter in the right atrium in all four cases. The mean duration of the operation was 91 minutes (range 65-120 minutes) and the mean operative blood loss was 23 ml (range 10-50 ml). No procedure-related complication was noted. CONCLUSIONS: Real-time TEE is a safe and simple technique for the accurate placement of the distal catheter of a VA shunt.