Complications following cerebrospinal fluid (CSF) diversion procedures are protean. The formation of pseudoaneurysms after the placement of a ventricular catheter as part of a CSF diversion procedure is presumably quite rare. The authors report the case of a child in whom a pericallosal artery pseudoaneurysm developed following the endoscopic insertion of a ventricular catheter as part of a ventriculoperitoneal shunt placement procedure. Significant intraventricular bleeding signaled vascular injury. Angiography revealed a right pericallosal artery pseudoaneurysm. The patient subsequently underwent surgical trapping of his pseudoaneurysm and physical therapy for left leg monoparesis. This appears to be the first reported case of pseudoaneurysm formation following the placement of a ventricular catheter for a CSF diversion procedure. This case underlines a rare but serious risk involved with the routine placement of CSF shunts.
Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that, 1) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy associated tumours) will progress to drug-resistance, 2) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe, and 3) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to anti-seizure medications (ASM), which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Lastly, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care.
Subgaleal hematomas (SGHs) in neonates may result from trauma to the scalp sustained during delivery. In the majority of cases, these lesions will resolve on their own without serious or long-term consequences. The authors report on a case of SGH resulting in hypotension, anemia, coagulopathy, and eventually direct hyperbilirubinemia in a neonate. After several weeks of medical management failed to resolve the hyperbilirubinemia, surgical evacuation of the clot was undertaken and yielded favorable results. The direct bilirubinemia in this case was believed to be the result of an overload of iron to the hepatocytes. It is the authors' contention that the evacuation of the hematoma resulted in a reduction in the amount of iron being presented to the liver for metabolism and significantly contributed to this patient's recovery.
IntroductionUnderstanding outcomes after Vein of Galen malformation (VOGM) embolization has been limited by small sample size in reported series and predominantly single center studies. To address these limitations, we perform an individual-participant meta-analysis (IPMA) to identify risk factors associated with all-cause mortality and clinical outcome after VOGM endovascular embolization.MethodsWe performed a systematic review and IPMA of VOGM endovascular outcomes according to PRISMA guidelines. Individual patient characteristics including demographic, intra/post-operative adverse events, treatment efficacy (partial or complete occlusion), and clinical outcome were collected. Mixed-effects logistic regression with random effects modeling and Bonferroni correction was used (p ≤ 0.003 threshold for statistical significance). The primary and secondary outcomes were all-cause mortality and poor clinical outcome (moderate/severe developmental delay or permanent disabling injury), respectively. Data are expressed as (mean ± standard deviation (SD)) or (odds ratio (OR), 95% confidence interval (CI), I2, p-value)ResultsThirty-five studies totaling 307 participants quantifying outcomes after endovascular embolization for VOGM were included. Follow up time was 42 (±57) months. Our analysis contained 42% neonates (<1 month) at first embolization, 45% infants (1 month ≤2 years), and 13% children (>2 years). Complete occlusion was reported in 48% of participants. Overall all-cause mortality was 16%. Overall, good clinical outcome was achieved in 68% of participants. First embolization as a neonate [OR = 6.93; 95% CI (1.99–24.08); I2 < 0.01; p < 0.001] and incomplete embolization [OR = 10.87; 95% CI (1.86–63.55); I2 < 0.01; p < 0.001] were associated with mortality. First embolization as a neonate [OR = 3.24; 95% CI (1.47–7.15); I2 < 0.01; p < 0.001], incomplete embolization [OR = 5.26; 95% CI (2.06–13.43); I2 < 0.01; p < 0.001], and heart failure at presentation [OR = 3.10; 95% CI (1.03–9.33); I2 < 0.01; p = 0.002] were associated with poor clinical outcomes. Sex, angioarchitecture of lesion, embolization approach (transvenous vs. transarterial), and single or multistage embolization were not associated with mortality or clinical outcome.ConclusionsWe identify incomplete VOGM embolization independently associated with mortality and poor clinical outcome. While this study provides the highest level of evidence for VOGM embolization to date, prospective multicenter studies are needed to understand the optimal treatment strategies, outcomes, and natural history after VOGM embolization.
ENTRICULOPERITONEAL shunting is the most commonly performed neurosurgical procedure for hydrocephalus. Complications are protean and range from shunt infection to bowel perforation. 5 We report three seemingly unusual cases of right shoulder pain in children in whom VP shunts had been implanted.The authors report on three pediatric patients with ventriculoperitoneal (VP) shunts who presented with chronic right shoulder pain. Imaging revealed that the distal peritoneal catheter was positioned between the right hemidiaphragm and liver. Following surgical repositioning of the distal tubing, all patients experienced resolution of their shoulder pain, which has not recurred. Although seemingly rare, referred shoulder pain from a VP shunt should be added to the list of complications seen with this method of cerebrospinal fluid diversion. The clinician who cares for patients with VP shunts may wish to evaluate cases of shoulder pain without obvious neural or musculoskeletal cause by performing imaging of the distal shunt tubing. KEY WORDS • peripheral nerve • visceral • cerebrospinal fluid • referred pain• pediatric neurosurgery V J. Neurosurg: Pediatrics / Volume 102 / March, 2005 Abbreviation used in this paper: VP = ventriculoperitoneal.
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