Abdominal pseudocysts (APC) are rare complications of ventriculoperitoneal shunting for hydrocephalus. The authors studied retrospectively a series of 18 pediatric patients with APC. Signs and symptoms of shunt dysfunction were observed in 15 (83.3%), abdominal complaints in 10 (55.5%) and fever in 6 (33.3%). Prior to the diagnosis of APC, 2 patients suffered exploratory laparotomies due to important abdominal signs and symptoms. Ultrasonography was diagnostic in all cases and proved to be the method of choice in the evaluation of APC. Our series suggest that APC are strongly related to hardware infection and in some cases can result from a previous shunt infection not completely cured. The bacteriological examination of the tip of the peritoneal catheter was a reliable indicator of infection. According to our data, the best treatment seems to be the removal of the shunt system and the insertion of an external ventricular drainage. In our experience, almost half of the patients had a ventriculoatrial shunt replacing the peritoneal shunt at the end of the treatment.

All patients had epidural abscess, and one also presented subdural empyema. Five patients underwent drainage of all associated abscesses, bone resection, and sinusitis treatment. One was treated conservatively with broad-spectrum antibiotics, and no surgical intervention was required. All patients fully recovered their neurologic status, without further complications.

Cystic dysraphisms of the cervical and upper thoracic region differ clinically and structurally from meningomyelocele and have a more favorable outcome. We believe that these malformations have not been properly labeled and propose a classification based on the structures found inside the cyst.

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OBJECTIVEThe goal of this study was to analyze the factors that have an impact on morbidity and mortality in patients with myelomeningocele (MMC).METHODSA retrospective cohort study was conducted to analyze factors associated with MMC that influence the morbidity and mortality of the disease. Data were collected from medical records of children who underwent the primary repair of MMC at the Fernandes Figueira Institute–Oswaldo Cruz Foundation (IFF-Fiocruz) between January 1995 and January 2015, with a minimum follow-up of 1 year. The following variables were analyzed: demographic characteristics (gestational age, sex, and birth weight); clinical features (head circumference at birth, anatomical and functional levels of MMC, hydrocephalus, symptomatic Chiari malformation type II, neurogenic bladder, and urinary tract infection [UTI]); and surgical details such as timing of repair of MMC, age at first shunt placement, shunt surgery modality (elective or emergency), concurrent surgery (correction of MMC and shunt insertion in the same surgical procedure), incidence and cause of shunt dysfunction, use of external ventricular drain, transfontanelle puncture, surgical wound complications prior to shunting, and endoscopic treatment of hydrocephalus.RESULTSA total of 231 patients with MMC were included in the analysis. Patients were followed for periods ranging from 1 to 20 years, with a mean of 6.9 years. The frequency of shunt placement was observed mainly among patients with MMC at the highest spinal levels (p < 0.01). The main causes of morbidity and mortality in patients with MMC were shunt failures, diagnosed in 91 of 193 cases (47.2%) of hydrocephalus, and repeated UTIs, in 129 of 231 cases (55.8%) of MMC; these were the main causes of hospitalization and death. Head circumference ≥ 38 cm at birth was found to be a significant risk factor for shunt revision (p < 0.001; 95% CI 1.092–1.354). Also, the lumbar functional level of MMC was associated with less revision than upper levels (p < 0.014; 95% CI 0.143–0.805). There was a significant association between recurrent UTI and thoracic functional level.CONCLUSIONSMacrocephaly at birth and higher levels of the defect have an impact on worse outcome and, therefore, are a challenge to the daily practice of pediatric neurosurgery.

TRATAMENTO CIRÚRGICO E RESULTADOS EM 96 PACIENTES OPERADOS J. FRANCISCO SALOMÃO -RENÊ D. LEIBINGER -JOSÉ CARLOS LYNCHRESUMO -Os autores apresentam os resultados cirúrgicos de 96 casos de hematoma subdural crônico operados por meio de orifícios de trépano ou pequenas trefinas: 78 pacientes (81,3%) foram considerados curados, 6 (6,2%) apresentaram seqüelas e 12 (12,5%) faleceram. Os óbitos de natureza neurocirúrgica foram relacionados à intensidade do comprometimento neurológico por ocasião da cirurgia. A idade avançada associada à presença de doenças sistêmicas também teve influência na mortalidade. Seqüelas neurológicas foram observadas principalmente em pacientes submetidos a reoperações por reacúmulo do hematoma e em portadores de lesões bilaterais. Os autores chamam a atenção para a ocorrência de hipotensão intracraniana associada a colapso cerebral. A importância do diagnóstico precoce e cirurgia imediata são enfatizadas. Chronic subdural hematoma: surgical treatment and results in 96 operated patients.SUMMARY -Ninety-six patients with chronic subdural hematoma were treated surgically and their clinical features presented in detail. Carotid angiography gave the correct diagnosis in all patients. CT scan was performed in 38 and was diagnostic in 92.1% of the cases. The clots were removed through burr-holes or small trephines: 78 (81.3%) patients were cured, 6 (6.2%) had permanent disabilities and 12 (12.5%) died. Operative mortality was related to the degree of neurological impairment, advanced age and systemic diseases. Neurologic sequelae were mostly related to reoperations due to recurrence of the hematoma and bilateral clots, as well. Low intracranial pressure syndrome with brain colapse was seen in 3 cases and treated with lumbar injection of saline solution. The delay in diagnosis and operation as cause of bad outcome is stressed.Embora os hematomas subdurals crônicos sejam universalmente considerados uma das patologias intracranianas de evolução mais favorável, os resultados de seu tratamento cirúrgico nem sempre refletem esta benignidade 13. Esta constatação pode ser ilustrada analisando-se o resultado de diferentes séries com mortalidade amplamente variável 5,15,16,22,24,28,29.Estes dados se explicam basicamente em função do quadro clínico muitas vezes inespecífico, à ausência de relato ou banalidade dos antecedentes traumáticos e à falta de atenção para o diagnóstico da doença, freqüente-mente rotulada como acidente cerebrovascular ou demência aterosclerótica 21 .A escassez de relatos sobre o assunto na literatura nacional justifica o presente estudo.

Multiple shunt failure is a challenge in pediatric neurosurgery practice and one of the most feared complications of hydrocephalus. Objective: To demonstrate that laparoscopic procedures for distal ventriculoperitoneal shunt failure may be an effective option for patients who underwent multiple revisions due to repetitive manipulation of the peritoneal cavity, abdominal pseudocyst, peritonitis or other situations leading to a "non reliable" peritoneum. Method: From March 2012 to February 2013, the authors reviewed retrospectively the charts of six patients born and followed up at our institution, which presented with previous intra-peritoneal complications and underwent ventriculoperitoneal shunt revision assisted by video laparoscopy. Results: After a mean follow-up period of nine months, all patients are well and no further shunt failure was identified so far. Conclusion: Laparoscopy assisted shunt revision in children may be, in selected cases, an effective option for patients with multiple peritoneal complications due to ventriculo-peritoneal shunting.Keywords: hydrocephalus, ventriculoperitoneal shunt, abdominal pseudocyst, laparoscopic surgery. RESUMOMúltiplas disfunções de derivações ventrículo-peritoneais em pacientes crônicos são complicações temidas no tratamento das hidrocefalias e um desafio na prática neurocirúrgica. Objetivo: Demonstrar que a abordagem laparoscópica para o tratamento das obstruções distais das derivações ventrículo-peritoneais é uma opção eficaz em pacientes submetidos a múltiplas revisões, manipulação repetitiva da cavidade abdominal, pseudocisto abdominal, peritonite ou outras complicações indutoras de peritônio "não confiável". Método: Os autores revisaram retrospectivamente, de março de 2012 a fevereiro de 2013, os prontuários de seis pacientes nascidos e acompanhados em um hospital pediátrico, que apresentaram múltiplas complicações intraperitoneais e tiveram a revisão de derivações ventrículo-peritoneais assistida por videolaparoscopia. Resultados: Todos os pacientes melhoraram clinicamente e nenhuma outra disfunção foi identificada após um período de acompanhamento médio de 9 meses. Conclusão: Revisão distal de derivações ventrículo-peritoneais assistida por videolaparoscopia em crianças é, em casos selecionados, uma opção eficaz para pacientes crônicos com história de múltiplas complicações peritoneais.Palavras-chave: hidrocefalia, derivação ventrículo-peritoneal, pseudocisto abdominal, cirurgia laparoscópica.Surgical treatment of hydrocephalus accounts for most of pediatric neurosurgical procedures and ventriculo-peritoneal shunting (VP shunt) remains the main option of treatment and also a major concern regarding complications 1,2,3 . Shunt complications, defined as obstruction, overdrainage, loculation or infection, sometimes demands difficult solutions with high surgical morbidity and mortality 1,2,3,4 .Abdominal complications of VP shunt are not rare and the main causes of distal catheter failure are related to extra peritoneal retraction of the catheter, incis...