ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEThe multicenter, randomized pediatric cerebrospinal fluid shunt valve design trial found no difference in the rate of shunt failure between a standard valve, a siphon-reducing valve (Delta; Medtronic PS Medical, Goleta, CA), and a flow-limiting valve (Orbis Sigma; Cordis, Miami, FL); however, the valves were expected to have different effects on ultimate ventricular size. Also, the catheter position or local environment of the ventricular catheter tip might have affected shunt failure. Therefore, we performed a post hoc analysis to understand what factors, other than valve design, affected shunt failure and to identify strategies that might be developed to reduce shunt failure.METHODSVentricular size was measured at as many as six different intervals, using a modified Evans’ ratio (with incorporation of the frontal and occipital dimensions), in 344 patients. Ventricular catheter location was defined as being in the frontal horn, occipital horn, body of the lateral ventricle, third ventricle, embedded in brain, or unknown. The ventricular catheter tip was described as surrounded by cerebrospinal fluid, touching brain, or surrounded by brain parenchyma within the ventricle (slit ventricle). Repeated measures analysis of variance for unbalanced data was used to analyze ventricular size. A Cox model (with incorporation of time-dependent covariates) was used to evaluate the contribution of age, etiology, shunt design, ventricular size, ventricular catheter location, and environment among the cases.RESULTSVentricular volume decreased in an exponential fashion, forming a plateau at 14 months, and was similar for the three valves (P= 0.4). Frontal and occipital ventricular catheter tip locations were associated with a reduced risk of shunt failure (hazard ratios, 0.60 [P= 0.02] and 0.45 [P= 0.001], respectively). Ventricular catheter tips surrounded by cerebrospinal fluid or touching the brain were associated with a reduced risk of failure (hazard ratios, 0.21 and 0.33, respectively;P= 0.0001). Patients with myelomeningocele or large ventricles had increased risk of malfunction (hazard ratios, 1.78 [P= 0.006] and 2.33 [P= 0.03], respectively).CONCLUSIONDecline of ventricular size over time is not affected by these different shunt valve designs. This suggests that the mechanical models of hydrocephalus on which the designs were based are inadequate. Ventricular catheter tip location and ventricular catheter environment are important. Techniques to accurately place ventricular catheters and new valve designs that effectively control ventricular size might reduce shunt malfunction.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEIdiopathic hypertrophic cranial pachymeningitis is a rare disease, of undetermined pathogenesis, that is characterized by inflammation and fibrosis of the dura mater.METHODSWe encountered six patients with idiopathic hypertrophic cranial pachymeningitis and analyzed their clinical presentations, radiological findings, and treatment.RESULTSIn the six patients, the main manifestations were cranial nerve palsies and headache. Three associations were present, namely optic neuropathy, Tolosa-Hunt syndrome, and diabetes insipidus. Gadolinium-enhanced magnetic resonance imaging was diagnostic, showing intense dural enhancement in a linear or nodular pattern. The responses to corticosteroid therapy were better for patients who exhibited linear, rather than nodular, dural enhancement. For one patient, surgical decompression of the superior orbital fissure provided lasting relief. The course of the disease followed one of three patterns, i.e., sustained remission, relapse with corticosteroid independence, or relapse with corticosteroid dependence. Pulse corticosteroid therapy provided significant relief, while reducing the daily corticosteroid requirement and avoiding side effects, for a corticosteroid-dependent relapsing patient.CONCLUSIONIdiopathic hypertrophic cranial pachymeningitis exhibits varied clinical courses. It is important to prevent irreversible cranial neuropathy during the active phase of the disease, using daily administration of corticosteroids, pulse corticosteroid therapy, or surgical decompression.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVETuberculosis is endemic in developing countries. However, calvarial tuberculosis is rare and only a few cases have been reported. In a review of the literature, we found only six cases of calvarial tuberculosis reported with computed tomographic findings. We report a series of seven patients with calvarial tuberculosis, and we discuss their presentations and treatments.METHODSThe patients were studied with respect to age and sex prevalences, previous histories of trauma and tuberculosis, and presenting complaints. Plain cranial x-ray films and computed tomographic scans were used for diagnoses. All patients underwent surgery and antituberculous chemotherapy.RESULTSOf the presenting patients, 71.42% were less than 20 years of age. There was a female predominance, with a male/female ratio of 1:6. Painless swelling and discharging sinuses over the scalp were the most common presenting features. One patient presented with osteomyelitis and sinus formation, with associated meningitis. All patients recovered well after surgery and antituberculous chemotherapy, except for one patient who discontinued drug treatment.CONCLUSIONAlthough calvarial tuberculosis is rare, the possibility of this disease should be considered when patients report previous histories of tuberculosis or are from areas in which the disease is endemic. Surgery is indicated in cases with associated neurological deficits or sinus formation. Antituberculous therapy should be continued for 18 months.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEWith the increasing use of magnetic resonance imaging, terminal syringomyelia (segmental cystic dilation of the caudal one-third of the spinal cord) in association with the tethered cord syndrome has become an appreciable finding. This study attempted to define the clinical significance of this associated pathological condition by describing its clinical and radiological characteristics and its contribution to the clinical status of patients with tethered spinal cords.METHODSOf 132 consecutive patients with tethered cord syndrome who presented to our department between 1990 and 1997, 32 patients with terminal syringomyelia were enrolled in this study. Clinical findings were correlated with syrinx morphological features, as defined using magnetic resonance imaging. Surgical treatment used two basic approaches, i.e., simple untethering or untethering with concurrent syrinx drainage.RESULTSAnalysis of the neurological deficits established a contribution of segmental symptoms, which were correlated with the extension and dilation of the syrinx cavity. Magnetic resonance imaging scans revealed the frequency of sacral tethering (40.6%), the intramedullary paracentral position of the syrinx (75%), and disturbances in regional cerebrospinal fluid flow (42%). The clinical outcomes seemed to be correlated with syrinx shrinkage; all patients who experienced collapse of the cavity achieved better symptom resolution.CONCLUSIONRadiologically significant terminal syringomyelia affects the clinical presentation of tethered cord syndrome, by increasing or inducing neurological deficits. Better clinical outcomes after syrinx decompression emphasize the importance of the recognition and treatment of this pathological condition.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

OBJECTIVEProximal ventricular catheter obstruction by the choroid plexus is a frequent occurrence in children with shunted hydrocephalus. In some cases, the flow is obstructed owing to membranous occlusion by a small amount of tissue. It has been shown that only a few of the multiple catheter openings need be patent to maintain adequate shunt function. Recent advances in technology have improved our ability to perform intraluminal endoscopic catheter dissection and minimize the morbidity associated with shunt maintenance.METHODSPercutaneous endoscopic shunt recanalization was performed in 20 cases (18 children) under institutional review board study protocol. The mean age was 32 months, and all children had signs and symptoms of shunt malfunction, confirmed by computed tomography and magnetic resonance imaging and verified by shunt taps. Under aseptic conditions in the operating room, the Rickham reservoir was entered with a 16-gauge intravenous catheter, and the obstruction was visualized with a fiber endoscope (0.5–0.8 mm). Intraluminal dissection using electrocautery was performed with endoscopic guidance to visualize the catheter and flushing of the valve.RESULTSAt a mean follow-up time of 20 months (range, 15–29 mo), the children are doing well, with computed tomographic and magnetic resonance imaging confirmation of adequate ventricular decompression in the 17 successful cases (85%). There were three failures in the study, necessitating a standard open shunt revision.CONCLUSIONThe percutaneous endoscopic shunt recanalization procedure can be used successfully to treat proximal shunt malfunction.

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:1999

数据来源: OVID