OBJECT Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructi... more OBJECT Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a "closed-skull" population, including patients 2 years of age and older. METHODS In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival. RESULTS This study included 168 primary ETVs. The mean age was 40 years (range 3-85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90. In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03). CONCLUSIONS The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.
Journal of neurological surgery. Part A, Central European neurosurgery, 2015
Background Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstru... more Background Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstructive hydrocephalus due to various pathologies, its role in hemorrhage-related obstructive hydrocephalus is poorly defined. We report our experience with ETV for hemorrhage-related obstructive hydrocephalus, demonstrate it feasibility, and discuss potential advantages over more conventional treatment modalities. Methods We performed a retrospective analysis of 78 consecutive patients who underwent ETV in our institution between January 2003 and January 2011. We identified 17 consecutive patients who underwent ETV for obstructive hydrocephalus related to intraventricular hemorrhage (IVH). Results ETV was performed in 9 men and 8 women (mean age: 58 years; range: 42-79). All patients had IVH (n = 17), either alone (n = 3) or with intracranial hemorrhage (n = 4) or subarachnoid hemorrhage (SAH) (n = 10). Endoscopic clot evacuation was performed in seven cases (41%). External ventricular dra...
Introduction L’endoscopie 3D permet une exploration anatomique améliorant la visualisation per-op... more Introduction L’endoscopie 3D permet une exploration anatomique améliorant la visualisation per-opératoire dans de nombreuses interventions chirurgicales. Peu d’intervention sont réalisées uniquement sous endoscopie 3D. Nous présentons le cas du traitement d’une fistule durale artério-veineuse médullaire thoracique par exclusion exclusivement sous magnification endoscopique 3D. Matériel et méthode Il s’agit d’un patient de 66 ans présentant des troubles de la marche évoluant depuis plusieurs mois. L’aggravation progressive évoluait vers un syndrome de Brown-Séquard droit. Les explorations d’imagerie montraient un hypersignal intra-médullaire à l’IRM en regarde Th12, l’artériographie diagnostiquait une fistule durale artério-veineuse Th12 gauche (l’artère du renflement lombaire se situait en L1 gauche. Le traitement endovasculaire n’a pas été retenu et il a été décidé d’un abord chirurgical par une exclusion de la fistule sous endoscopie 3D. Résultats Abord de 5cm pour réaliser une la...
Both tracheotomy and ventriculoperitoneal shunting procedures may be required for the same critic... more Both tracheotomy and ventriculoperitoneal shunting procedures may be required for the same critically ill patient. However, the risk of surgical site infection (SSI) may be increased if both procedures are performed simultaneously. We performed a retrospective analysis of 41 consecutive patients who underwent both procedures simultaneously in our institution between March 2000 and January 2008. Analysis revealed no difference in SSI rate between patients undergoing both procedures simultaneously and in staged procedures. VP shunting and tracheotomy procedures could be performed simultaneously without increasing the risk of surgical site infection. Such strategy may shorten the length of stay in critical care units.
Cavernous angiomas (CAs) of cranial nerves are rare, and their occurrence on the third cranial ne... more Cavernous angiomas (CAs) of cranial nerves are rare, and their occurrence on the third cranial nerve is particularly rare. Surgical management of such CAs involving the third nerve is controversial. We describe a case of a symptomatic CA of the oculomotor nerve and review the literature in order to ascertain the relevance of surgical intervention. A 71-year-old male patient presented with a 2-month history of progressive oculomotor nerve paralysis. CA of the oculomotor nerve was suspected on magnetic resonance imaging (MRI). The patient underwent complete resection of the CA through a subtemporal approach, preserving the integrity of the nerve. Histopathological analysis confirmed the diagnosis of CA. Despite optimal resection, the patient did not improve postoperatively. CAs of cranial nerves can cause rapid or progressive neurological deterioration. Whereas delayed treatment often leads to irreversible deficits, early nerve-sparing surgical excision of the CAs may potentially restore function.
Purely extradural lumbar schwannomas are rare lesions. Resection traditionally requires an open l... more Purely extradural lumbar schwannomas are rare lesions. Resection traditionally requires an open laminectomy and ipsilateral complete facectomy. Recent reports have demonstrated safety and efficacy of removal of these tumors using mini-open access devices with expandable retractors. We report a case of a giant L3 schwannoma successfully resected through a minimally invasive approach using the non-expandable Spotlight tubular retrator (Depuy Spine). A 77-year-old woman presented with a history of chronic right leg pain, paresthesias and proximal right leg weakness. Magnetic Resonance imaging (MRI) scan revealed a large dumbbell-shaped extradural foraminal lesion at the L3-L4 level with significant extraforaminal extension. The patient underwent a minimally invasive gross total resection (GTR) of the tumor using an 18-mm Spotlight tubular retractor system. Pathology confirmed the lesion to be a benign schwannoma. Postoperatively, the patient's symptoms resolved and she was discharged from the hospital on the second postoperative day. Postoperative MRI showed no residual tumor. The patient returned to normal activities after 2 weeks and remained asymptomatic with no neurological deficits at final 6 months follow-up. Giant lumbar extradural schwannomas can be safely and completely resected using minimally invasive surgery without the need for facectomy or subsequent spinal fusion.
Endoscopic third ventriculostomy (ETV) is an effective treatment of obstructive hydrocephalus (OH... more Endoscopic third ventriculostomy (ETV) is an effective treatment of obstructive hydrocephalus (OH). However, the presence of a large or giant basilar aneurysm is generally considered a contra-indication to ETV for treating hydrocephalus. We report the feasibility and efficacy of ETV for the treatment of hydrocephalus in the presence of such aneurysms. We performed a retrospective chart analysis of patients that underwent ETV for large or giant basilar aneurysm-associated hydrocephalus between January 2003 and January 2011. During this period, 78 patients were treated by ETV. Of these, three patients presented with symptomatic hydrocephalus associated with a large giant basilar aneurysm (n = 3). Two of those patients had a history of previous subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) 11 years and 13 years before ETV. Both aneurysms were embolized preoperatively. The third patient presented with OH due to an unruptured basilar artery aneurysm. There was no operative complication and symptoms resolution was observed in all patients at last follow-up. ETV is a safe and effective alternative to ventriculo-peritoneal shunting in patients with hydrocephalus caused by large or giant basilar artery aneurysms. In addition, a history of SAH/IVH should not be considered a contra-indication to ETV.
Intravesical instillations of live-attenuated Bacillus Calmette-Guérin (BCG) are a well-known and... more Intravesical instillations of live-attenuated Bacillus Calmette-Guérin (BCG) are a well-known and effective method for prevention and treatment of bladder carcinoma and carcinoma in situ. Although considered a safe procedure with rare side effects, local and systemic complications may occur. While long bone ostemolyelitis has been well described, very few reports of BCG spondylodiscitis exist in the literature. A 67-year-old man developed low back pain, anorexia, and weight loss 11 months after a 6-week course of intravesical BCG instillations for the treatment of bladder carcinoma in situ. Imaging studies revealed L1-L2 spondylodiscitis with epidural and bilateral psoas abscesses. Tissue cultures obtained by percutaneous computed tomography-guided aspiration were positive for Mycobacterium bovis. Despite triple antituberculous therapy (isoniazid, rifampin, and ethambutol), clinical and radiological progression occurred. Therefore, L1 and L2 corpectomies with extensive debridement were performed, followed by 360° anterior-posterior instrumented fusion. After 20 months of follow-up, the patient remains asymptomatic and recurrence-free. Mycobacterium bovis spondylodiscitis is a rare complication of intravesical BCG therapy. Although medical therapy with antituberculous agents is the first-line treatment, surgical decompression, debridement, and stabilization may be necessary in refractory cases.
OBJECT Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructi... more OBJECT Endoscopic third ventriculostomy (ETV) has become the first line of treatment in obstructive hydrocephalus. The Toronto group (Kulkarni et al.) developed the ETV Success Score (ETVSS) to predict the clinical response following ETV based on age, previous shunt, and cause of hydrocephalus in a pediatric population. However, the use of the ETVSS has not been validated for a population comprising adults. The objective of this study was to validate the ETVSS in a "closed-skull" population, including patients 2 years of age and older. METHODS In this retrospective observational study, medical charts of all consecutive cases of ETV performed in two university hospitals were reviewed. The primary outcome, the success of ETV, was defined as the absence of reoperation or death attributable to hydrocephalus at 6 months. The ETVSS was calculated for all patients. Discriminative properties along with calibration of the ETVSS were established for the study population. The secondary outcome is the reoperation-free survival. RESULTS This study included 168 primary ETVs. The mean age was 40 years (range 3-85 years). ETV was successful at 6 months in 126 patients (75%) compared with a mean ETVSS of 82.4%. The area under the receiver operating characteristic curve was 0.61, revealing insufficient discrimination from the ETVSS in this population. In contrast, calibration of the ETVSS was excellent (calibration slope = 1.01), although the expected low numbers were obtained for scores < 70. Decision curve analyses demonstrate that ETVSS is marginally beneficial in clinical decision-making, a reduction of 4 and 2 avoidable ETVs per 100 cases if the threshold used on the ETVSS is set at 70 and 60, respectively. However, the use of the ETVSS showed inferior net benefit when compared with the strategy of not recommending ETV at all as a surgical option for thresholds set at 80 and 90. In this cohort, neither age nor previous shunt were significantly associated with unsuccessful ETV. However, better outcomes were achieved in patients with aqueductal stenosis, tectal compressions, and other tumor-associated hydrocephalus than in cases secondary to myelomeningocele, infection, or hemorrhage (p = 0.03). CONCLUSIONS The ETVSS did not show adequate discrimination but demonstrated excellent calibration in this population of patients 2 years and older. According to decision-curve analyses, the ETVSS is marginally useful in clinical scenarios in which 60% or 70% success rates are the thresholds for preferring ETV to CSF shunt. Previous history of CSF shunt and age were not associated with worse outcomes, whereas posthemorrhagic and postinfectious causes of the hydrocephalus were significantly associated with reduced success rates following ETV.
Journal of neurological surgery. Part A, Central European neurosurgery, 2015
Background Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstru... more Background Although endoscopic third ventriculostomy (ETV) is the first-line treatment for obstructive hydrocephalus due to various pathologies, its role in hemorrhage-related obstructive hydrocephalus is poorly defined. We report our experience with ETV for hemorrhage-related obstructive hydrocephalus, demonstrate it feasibility, and discuss potential advantages over more conventional treatment modalities. Methods We performed a retrospective analysis of 78 consecutive patients who underwent ETV in our institution between January 2003 and January 2011. We identified 17 consecutive patients who underwent ETV for obstructive hydrocephalus related to intraventricular hemorrhage (IVH). Results ETV was performed in 9 men and 8 women (mean age: 58 years; range: 42-79). All patients had IVH (n = 17), either alone (n = 3) or with intracranial hemorrhage (n = 4) or subarachnoid hemorrhage (SAH) (n = 10). Endoscopic clot evacuation was performed in seven cases (41%). External ventricular dra...
Introduction L’endoscopie 3D permet une exploration anatomique améliorant la visualisation per-op... more Introduction L’endoscopie 3D permet une exploration anatomique améliorant la visualisation per-opératoire dans de nombreuses interventions chirurgicales. Peu d’intervention sont réalisées uniquement sous endoscopie 3D. Nous présentons le cas du traitement d’une fistule durale artério-veineuse médullaire thoracique par exclusion exclusivement sous magnification endoscopique 3D. Matériel et méthode Il s’agit d’un patient de 66 ans présentant des troubles de la marche évoluant depuis plusieurs mois. L’aggravation progressive évoluait vers un syndrome de Brown-Séquard droit. Les explorations d’imagerie montraient un hypersignal intra-médullaire à l’IRM en regarde Th12, l’artériographie diagnostiquait une fistule durale artério-veineuse Th12 gauche (l’artère du renflement lombaire se situait en L1 gauche. Le traitement endovasculaire n’a pas été retenu et il a été décidé d’un abord chirurgical par une exclusion de la fistule sous endoscopie 3D. Résultats Abord de 5cm pour réaliser une la...
Both tracheotomy and ventriculoperitoneal shunting procedures may be required for the same critic... more Both tracheotomy and ventriculoperitoneal shunting procedures may be required for the same critically ill patient. However, the risk of surgical site infection (SSI) may be increased if both procedures are performed simultaneously. We performed a retrospective analysis of 41 consecutive patients who underwent both procedures simultaneously in our institution between March 2000 and January 2008. Analysis revealed no difference in SSI rate between patients undergoing both procedures simultaneously and in staged procedures. VP shunting and tracheotomy procedures could be performed simultaneously without increasing the risk of surgical site infection. Such strategy may shorten the length of stay in critical care units.
Cavernous angiomas (CAs) of cranial nerves are rare, and their occurrence on the third cranial ne... more Cavernous angiomas (CAs) of cranial nerves are rare, and their occurrence on the third cranial nerve is particularly rare. Surgical management of such CAs involving the third nerve is controversial. We describe a case of a symptomatic CA of the oculomotor nerve and review the literature in order to ascertain the relevance of surgical intervention. A 71-year-old male patient presented with a 2-month history of progressive oculomotor nerve paralysis. CA of the oculomotor nerve was suspected on magnetic resonance imaging (MRI). The patient underwent complete resection of the CA through a subtemporal approach, preserving the integrity of the nerve. Histopathological analysis confirmed the diagnosis of CA. Despite optimal resection, the patient did not improve postoperatively. CAs of cranial nerves can cause rapid or progressive neurological deterioration. Whereas delayed treatment often leads to irreversible deficits, early nerve-sparing surgical excision of the CAs may potentially restore function.
Purely extradural lumbar schwannomas are rare lesions. Resection traditionally requires an open l... more Purely extradural lumbar schwannomas are rare lesions. Resection traditionally requires an open laminectomy and ipsilateral complete facectomy. Recent reports have demonstrated safety and efficacy of removal of these tumors using mini-open access devices with expandable retractors. We report a case of a giant L3 schwannoma successfully resected through a minimally invasive approach using the non-expandable Spotlight tubular retrator (Depuy Spine). A 77-year-old woman presented with a history of chronic right leg pain, paresthesias and proximal right leg weakness. Magnetic Resonance imaging (MRI) scan revealed a large dumbbell-shaped extradural foraminal lesion at the L3-L4 level with significant extraforaminal extension. The patient underwent a minimally invasive gross total resection (GTR) of the tumor using an 18-mm Spotlight tubular retractor system. Pathology confirmed the lesion to be a benign schwannoma. Postoperatively, the patient's symptoms resolved and she was discharged from the hospital on the second postoperative day. Postoperative MRI showed no residual tumor. The patient returned to normal activities after 2 weeks and remained asymptomatic with no neurological deficits at final 6 months follow-up. Giant lumbar extradural schwannomas can be safely and completely resected using minimally invasive surgery without the need for facectomy or subsequent spinal fusion.
Endoscopic third ventriculostomy (ETV) is an effective treatment of obstructive hydrocephalus (OH... more Endoscopic third ventriculostomy (ETV) is an effective treatment of obstructive hydrocephalus (OH). However, the presence of a large or giant basilar aneurysm is generally considered a contra-indication to ETV for treating hydrocephalus. We report the feasibility and efficacy of ETV for the treatment of hydrocephalus in the presence of such aneurysms. We performed a retrospective chart analysis of patients that underwent ETV for large or giant basilar aneurysm-associated hydrocephalus between January 2003 and January 2011. During this period, 78 patients were treated by ETV. Of these, three patients presented with symptomatic hydrocephalus associated with a large giant basilar aneurysm (n = 3). Two of those patients had a history of previous subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) 11 years and 13 years before ETV. Both aneurysms were embolized preoperatively. The third patient presented with OH due to an unruptured basilar artery aneurysm. There was no operative complication and symptoms resolution was observed in all patients at last follow-up. ETV is a safe and effective alternative to ventriculo-peritoneal shunting in patients with hydrocephalus caused by large or giant basilar artery aneurysms. In addition, a history of SAH/IVH should not be considered a contra-indication to ETV.
Intravesical instillations of live-attenuated Bacillus Calmette-Guérin (BCG) are a well-known and... more Intravesical instillations of live-attenuated Bacillus Calmette-Guérin (BCG) are a well-known and effective method for prevention and treatment of bladder carcinoma and carcinoma in situ. Although considered a safe procedure with rare side effects, local and systemic complications may occur. While long bone ostemolyelitis has been well described, very few reports of BCG spondylodiscitis exist in the literature. A 67-year-old man developed low back pain, anorexia, and weight loss 11 months after a 6-week course of intravesical BCG instillations for the treatment of bladder carcinoma in situ. Imaging studies revealed L1-L2 spondylodiscitis with epidural and bilateral psoas abscesses. Tissue cultures obtained by percutaneous computed tomography-guided aspiration were positive for Mycobacterium bovis. Despite triple antituberculous therapy (isoniazid, rifampin, and ethambutol), clinical and radiological progression occurred. Therefore, L1 and L2 corpectomies with extensive debridement were performed, followed by 360° anterior-posterior instrumented fusion. After 20 months of follow-up, the patient remains asymptomatic and recurrence-free. Mycobacterium bovis spondylodiscitis is a rare complication of intravesical BCG therapy. Although medical therapy with antituberculous agents is the first-line treatment, surgical decompression, debridement, and stabilization may be necessary in refractory cases.
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