Acute Endovascular Management of a Ruptured Choroidal Artery Arteriovenous Malformation in a Peripartum COVID-19-Positive Patient

Coronavirus disease 2019 (COVID-19) pandemic has led to significant reduction in specialty care causing delayed presentations and decreased resources for elective procedures. We present here a case of a 29-year-old female, 34 weeks primigravida who presented with a twice ruptured right choroidal artery arteriovenous malformation (AVM). She underwent an immediate external ventricular drain placement followed by an emergency cesarean. She underwent a diagnostic angiogram showing a right choroidal AVM with a feeder artery aneurysm along with small supply to its cortical component by the M4 segment of right middle cerebral artery, draining into the basal vein of Rosenthal and vein of Labbe. The patient underwent embolization of the aneurysm and the choroidal feeders. She improved symptomatically following the procedure with external cerebrospinal fluid diversion for 5 days. At follow-up magnetic resonance imaging, the residual AVM remained stable and is planned for Gamma knife radiosurgery. The newborn was taken care at a neonatal intensive care unit and was started on breastfeed on 16th day of birth once the mother had a negative COVID-19 reverse transcription polymerase chain reaction. In this study, we highlight our experience with the above-mentioned patient profile, the multidisciplinary effort during the pandemic, and the measures taken (isolation ward, COVID-19 dedicated Cath-lab and personal precautions) and advised for tackling COVID-19 patients for endovascular procedures.

Fourth ventricle neurocysticercosis presenting with Bruns’ syndrome: A case report

Background: Neurocysticercosis (NCC) is the most common helminthic infection of the central nervous system. We present a case of the fourth ventricle NCC that presented with Bruns’ syndrome (with headaches worsened by head movements, gait ataxia, and vomiting) and the operative technique used for cyst removal. Case Description: A 39-year-old woman was admitted to the emergency department with moderate-to-severe headaches that got worse in the afternoon and were triggered by head movements, relieved on prone position, and were associated with gait ataxia and vomiting. A brain magnetic resonance imaging (MRI) showed a fourth ventricle cyst, with an eccentric enhancing nodule compatible with a larvae scolex and associated obstructive hydrocephalus. The patient was positioned prone and underwent a microsurgical resection of the cyst without rupture through a telovelar approach to the fourth ventricle. The postoperative MRI confirmed complete cyst removal and resolution of the hydrocephalus. At 12-month follow-up, the patient remains with no signs of disease recurrence. Conclusion: In this report, we depict a case of intraventricular NCC successfully treated with a single surgery, allowing intact cyst removal and achieving effective hydrocephalus treatment with no need to resort to cerebrospinal fluid diversion techniques.

Shuntoscope-Guided Versus Free Hand Technique for Ventricular Catheter Placement: A Prospective Comparative Study of Intra-Ventricular Catheter Tip Position and Complication Rate

Background: The position of the ventricular catheter (VC) is essential for a proper function of cerebrospinal fluid diversion system. A shuntoscope-guided (SG) method might be helpful in reducing complications. Objective: The purpose of this study is to compare the accuracy of catheter placement and the complication and revision rates between SG and free hand (FH) techniques. Methods: A prospective study of patients who underwent VC placement between September 2018 and March 2021. Accuracy of catheter placement was graded on postoperative imaging using three-point Hayhurst grading system. Complication and revision rates were documented and compared between both groups with an average follow up period of 19.56 months. Results: Fifty-five patients were included. SG technique was used in 29 patients (mean age was 6.3 years, 1.4 –27.7 years, 48.1% females), and FH technique was used in 26 patients (mean age was 28.6 years, 1.0 – 79.5 years, 73.1% female). The success rate for the optimal placement of the VC with a grade I on the Hayhurst scale was significantly higher in the SG group (93.1%) than in the FH group (67%), P = 0.031. The revision rate was higher in the FH group with 31.8% vs. 20.7% of in the SG group, P = 0.396. Conclusion: VC placement using the SG technique is a safe and effective procedure, which enabled a significantly higher success rate and lower revision and complication rate. Accordingly, we recommend using the SG technique specially in patients with morbid anatomy.

Cervical Subarachnoid Drain for the Treatment of Cerebrospinal Fluid Leak: 2-Dimensional Operative Video

Cerebrospinal fluid (CSF) leak is a common phenomenon encountered by the neurosurgeon. It is most commonly come across after a neurosurgical procedure, but it can be seen idiopathically. Treatment usually ranges from conservative management through cerebrospinal fluid diversion to direct surgical repair. Continuous CSF drainage provides a path for diversion and allowing the site of the dural injury to heal effectively.1 Cervical subarachnoid drain is a safe and effective alternative when lumbar access is contraindicated or not achievable.2 Here we present a case of a 22-yr-old female with progressive symptomatic positional headaches due to a CSF leak from a prior deformity surgery treated with a cervical subarachnoid drain after a failed attempt at a direct repair. This 2-dimensional video illustrates the technique used for the placement of a cervical subarachnoid drain for the treatment of symptomatic CSF leak. Patient consented to the procedure and for the publication of their image.

Ventriculomegaly and postoperative lateral/third ventricular blood as predictors of cerebrospinal fluid diversion following posterior fossa tumor resection

OBJECTIVE Postoperative hydrocephalus occurs in one-third of children after posterior fossa tumor resection. Although models to predict the need for CSF diversion after resection exist for preoperative variables, it is unknown which postoperative variables predict the need for CSF diversion. In this study, the authors sought to determine the clinical and radiographic predictors for CSF diversion in children following posterior fossa tumor resection. METHODS This was a retrospective cohort study involving patients ≤ 18 years of age who underwent resection of a primary posterior fossa tumor between 2000 and 2018. The primary outcome was the need for CSF diversion 6 months after surgery. Candidate predictors for CSF diversion including age, race, sex, frontal occipital horn ratio (FOHR), tumor type, tumor volume and location, transependymal edema, papilledema, presence of postoperative intraventricular blood, and residual tumor were evaluated using a best subset selection method with logistic regression. RESULTS Of the 63 included patients, 26 (41.3%) had CSF diversion at 6 months. Patients who required CSF diversion had a higher median FOHR (0.5 vs 0.4) and a higher percentage of postoperative intraventricular blood (30.8% vs 2.7%) compared with those who did not. A 0.1-unit increase in FOHR or intraventricular blood was associated with increased odds of CSF diversion (OR 2.9 [95% CI 1.3–7.8], p = 0.02 and OR 20.2 [95% CI 2.9–423.1], p = 0.01, respectively) with an overfitting-corrected concordance index of 0.68 (95% CI 0.56–0.80). CONCLUSIONS The preoperative FOHR and postoperative intraventricular blood were significant predictors of the need for permanent CSF diversion within 6 months after posterior fossa tumor resection in children.

Bilateral Subdural Hematoma following Ventriculoperitoneal Shunt Insertion in a Ten-month Old Tanzanian Female with Congenital Hydrocephalus: An Uncommon Presentation

There is an unmet need for the treatment of hydrocephalus in Tanzania. Thousands of newborns each year in the region are affected by this condition and access to care remains a challenge. While treatment options like cerebrospinal fluid diversion through ventriculo-peritoneal shunting are within the skill set of general surgeons, the potential complications represent an additional challenge. We present a 10-month-old Tanzanian female who developed bilateral-subdural hematomas after insertion of a ventriculoperitoneal shunt.