Successful Treatment of Postneurosurgical Ventriculitis Caused by Extensively Drug-resistant Acinetobacter baumannii in a Child: Case Report

Introduction: The incidence of postneurosurgical Acinetobacter baumannii ventriculitis/meningitis, primarily due to drug-resistant strains, has increased considerably in recent years. However, limited therapeutic options are available because most antibiotics poorly penetrate the blood-brain barrier, especially in pediatric patients. Case Presentation: A five-year-old boy developed ventriculitis due to extensively drug-resistant A. baumannii (XDRAB) after bilateral frontal external ventricular drainage for spontaneous intraventricular hemorrhage. The boy was safely and successfully treated with intraventricular (IVT)/intrathecal (ITH) polymyxin B together with intravenous tigecycline plus cefoperazone/sulbactam. Conclusions: In the present case, postneurosurgical XDRAB ventriculitis was closely associated with intraventricular hemorrhage and the placement of external ventricular drainage. IVT/ITH polymyxin B combined with intravenous tigecycline and cefoperazone sulbactam could be a therapeutic option against XDRAB ventriculitis in children.

Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to perform a comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

Intraoperative Measurement of Intracranial Pressure During Cranial Vault Remodeling in Children with Craniosynostosis

Purpose In this study, we analyzed the utility of intracranial pressure (ICP) monitoring intraoperatively for deciding height reduction and need for cerebrospinal fluid (CSF) diversion during cranial vault remodeling in children with multisutural craniosynostosis (CS). Methods This is a retrospective observational study of children who underwent surgery for CS and ICP monitoring during surgery. The ICP was monitored using an external ventricular drainage catheter. The ICP monitoring was continued during the entire procedure. Results A total of 28 (19 boys) children with the involvement of two or more sutures underwent ICP monitoring during surgery. The commonest pattern of suture involvement was bicoronal seen in 16 (57.1%) children followed by pancraniosynostoses in eight (28.6%) cases. The mean opening ICP was 23 mm Hg, which dropped to 10.9 mm Hg after craniotomy. The ICP increased transiently to 19.5 mm Hg after height reduction, and the mean ICP at closure was 16.2 mm Hg. The ICP recordings helped in undoing the height reduction in two children and ventriculoperitoneal shunt after surgery in two children. Conclusions Intraoperative monitoring of ICP helps in deciding the type of cranial vault remodeling and the need for CSF diversion after surgery.

Intraventricular tuberculosis abscess in an immunocompromised patient: clinical vignette

Tuberculosis is caused by Mycobacterium tuberculosis. Tuberculosis of the central nervous system is common and manifestations include meningeal and intraparenchymal diseases. However, intraventricular tuberculous abscess is a rare manifestation of intracranial tuberculous infection. We present a case of an immunocompromised female patient with high-grade fever and signs of meningism. The computed tomography and magnetic resonance imaging (MRI) of the brain showed hydrocephalus with rim-enhancing lesion in the right lateral ventricle. The MRI demonstrated a hypointense signal on T1-weighted imaging, hyperintense signal on T2-weighted imaging, and mild restricted diffusion in diffusion-weighted imaging. She underwent emergency external ventricular drainage and frank pus was drained. Diagnosis of tuberculosis was made via polymerase chain reaction analysis and culture. Understanding the intracranial manifestation of neurotuberculosis is imperative to arrive at the diagnosis correctly and ensure prompt treatment.

Intracranial Infection Caused by Multidrug-resistant Acinetobacter Baumannii

Objective: To report the successful treatment of a patient who underwent vestibular schwannoma resection and developed intracranial infection caused by multidrug-resistant Acinetobacter baumannii (MRAB), and to review the recent relevant literature. Methods: The patient was diagnosed with MRAB infection based on clinical manifestations and cerebrospinal fluid (CSF) culture. The treatment included external ventricular drainage, posterior fossa decompressive craniectomy, and endoscopic lavage for fourth ventricle, subdural drainage, and intravenous injection /ventricular irrigation of sulperazone. Results: The MRAB-induced intracranial infection was successfully cured. The follow-up lasted for 84 months, and the patient has resumed normal life and work. Conclusion: Active individualized treatment should be administered at the earliest. The drainage of CSF, ventricular lavage, and proper choice of antibiotics are key to treat intracranial infections caused by MRAB.

A nationwide prospective multicenter study of external ventricular drainage: accuracy, safety, and related complications

OBJECTIVE External ventricular drainage (EVD) catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH), and suboptimal placement. The aim of this study was to investigate the rates of EVD catheter complications and their associated risk factor profiles in order to optimize the safety and accuracy of catheter insertion. METHODS A total of 348 patients with urgently placed EVD catheters were included as a part of a prospective multicenter observational cohort. Strict definitions were applied for each complication category. RESULTS The rates of misplacement, ECI/ventriculitis, and ICH were 38.6%, 12.2%, and 9.2%, respectively. Catheter misplacement was associated with midline shift (p = 0.002), operator experience (p = 0.031), and intracranial length (p < 0.001). Although mostly asymptomatic, ICH occurred more often in patients receiving prophylactic low-molecular-weight heparin (LMWH) (p = 0.002) and those who required catheter replacement (p = 0.026). Infectious complications (ECI/ventriculitis and suspected ECI) occurred more commonly in patients whose catheters were inserted at the bedside (p = 0.004) and those with smaller incisions (≤ 1 cm) (p < 0.001). ECI/ventriculitis was not associated with preinsertion antibiotic prophylaxis (p = 0.421), catheter replacement (p = 0.118), and catheter tunneling length (p = 0.782). CONCLUSIONS EVD-associated complications are common. These results suggest that the operating room setting can help reduce the risk of infection, but not the use of preoperative antibiotic prophylaxis. Although EVD-related ICH was associated with LMWH prophylaxis for deep vein thrombosis, there were no significant clinical manifestations in the majority of patients. Catheter misplacement was associated with operator level of training and midline shift. Information from this multicenter prospective cohort can be utilized to increase the safety profile of this common neurosurgical procedure.

Abstract 1122‐000061: Initial Experience Using the Transvenous Embolization for Intracranial Arteriovenous Malformations in a Reference Endovascular Center

Introduction : Transvenous embolization (TVE) is used in cases of arteriovenous malformations (AVMs) with specific characteristics such as small size (<3 cm), deep location, single draining vein and the absence of adequate feeders. High complete obliteration rates have been reported. Therefore, our study aimed to analyze our initial experience using the TVE for treatment of AVMs. Methods : Between May 2018 and January 2021, consecutive patients who underwent TVE of AVMs were selected. Demographics, radiological and clinical variables were collected. The modified Rankin Scale (mRS) was used to determine clinical outcomes and was dichotomized (good clinical condition: mRS £2; poor clinical condition: mRS >2). Complete obliteration was defined as the total absence of the nidus and vein, subtotal obliteration was defined as the embolization of >95% of nidus and partial obliteration was defined as the embolization of <95% of nidus. Procedure‐related complications were defined as those that occurred during the procedure and were divided as intraoperative rupture and thrombosis. Results : Twenty‐one patients harboring 21 AVMs were evaluated. Fourteen patients (67%) were women. The mean age was 24.5 ± 14.1 years (7 – 48 years). A good preoperative clinical condition was present in 20 patients. Twenty AVMs were ruptured (95.2%). The most frequent locations were thalamus/basal ganglia in 6 patients (29%), followed by temporal/insular in 5 patients (24%). Spetzler‐Martin grades III, II and I were present in 11, 9 and 1 patients, respectively. The mean number of feeders was 2.1 per AVM. The feeders arised from the MCA in 9 cases, followed by PCA in 5 cases, ACA and AChoA in 3 cases, AICA in 2 cases, and ECA and PCom in 1 case, respectively. The mean number of veins was 1.3 per AVM. Deep venous drainage was present in 12 cases (57%). The mean size of the AVM nidus was 15.7 ± 7.8 mm (3.7 – 34 mm). Previous trans‐arterial embolization was done in 10 patients (47.6%). Pre‐embolization hematoma evacuation was done in 4 patients (19%). An immediate complete obliteration was achieved in 18 patients (85.7%), whereas a subtotal and partial obliteration were achieved in 2 and 1 patients, respectively. A poor post‐operative clinical condition occurred in 4 patients (20%). Procedure‐related complications occurred in 4 patients (20%): 3 cases with intra‐operative rupture of the AVM nidus and 1 case of a thrombus in the M1 treated with stent retriever. Mortality occurred in 3 patients (14.2%) of which two presented intra‐operative rupture with intracerebral hematomas that required decompressive craniectomy. One patient presented a post‐operative bleeding of the AVM nidus that required external ventricular drainage and decompressive craniectomy. Follow‐up angiography was done in 4 cases with total obliteration of all the cases (100%). Conclusions : The transvenous approach has emerged as an alternative to trans‐arterial approach with high grades of immediate total obliteration rates, but with potential procedure‐related complications. Thus, this technique should be used in selected cases in order to achieve complete cure rates.

Predictors of hydrocephalus after lateral ventricular tumor resection

The aim of this study was to identify the predictors of postoperative hydrocephalus in patients with lateral ventricular tumors (LVTs) and to guide the management of perioperative hydrocephalus. We performed a retrospective analysis of patients who received LVT resection at the Department of Neurosurgery, Zhongnan Hospital of Wuhan University between January 2011 and March 2021. Patients were divided between a prophylactic external ventricular drainage (EVD) group and a non-prophylactic EVD group. We analyzed the non-prophylactic EVD group to identify predictors of acute postoperative hydrocephalus. We analyzed all enrolled patients to determine predictors of postoperative ventriculoperitoneal shunt placement. A total of 97 patients were included in this study. EVD was performed in 23 patients with postoperative acute obstructive hydrocephalus, nine patients with communicative hydrocephalus, and two patients with isolated hydrocephalus. Logistic regression analysis showed that tumor anterior invasion of the ventricle (P = 0.020) and postoperative hemorrhage (P = 0.004) were independent risk factors for postoperative acute obstructive hydrocephalus, while a malignant tumor (P = 0.004) was an independent risk factor for a postoperative ventriculoperitoneal shunt. In conclusion, anterior invasion of the lateral ventricle and postoperative hemorrhage are independent risk factors for acute obstructive hydrocephalus after LVT resection. Patients with malignant tumors have a greater risk of shunt dependence after LVT resection.