RESUMEN
Amide peptide backbone methylation is a characteristic post-translational modification found in a family of ribosomally synthesized and post-translationally modified peptide natural products (RiPPs) called borosins. Previously, we bioinformatically identified >1500 putative borosin pathways in bacteria; however, none of the pathways were associated with a known secondary metabolite. Through in-depth characterization of a borosin pathway in Shewanella oneidensis MR-1, we have now identified a bacterially derived borosin natural product named Shewanellamide A. Borosin identification was facilitated by the creation and analysis of a series of precursor variants and crystallographic interrogation of variant precursor and methyltransferase complexes. Along with assaying two proteases from S. oneidensis, probable boundaries for proteolytic maturation of the metabolite were projected and confirmed via comparison of S. oneidensis knockout and overexpression strains. All in all, the S. oneidensis natural product was found to be a 16-mer linear peptide featuring two backbone methylations, establishing Shewanellamide A as one of the few borosin metabolites yet identified, and the first from bacteria.
RESUMEN
There is a need for standardized, efficient, and practical sampling methods to support large population-based studies of the internal and external epithelial microbiomes of the bovine udder. The primary objective of this study was to evaluate different sampling devices for the isolation of microbial DNA originating from the internal and external teat epithelium. Secondary objectives were to survey and compare the microbial diversity of external and teat canal epithelial microbiomes using amplicon and shotgun metagenomic sequencing approaches. To address these objectives, we enrolled a convenience sample of 24 Holstein dairy cows and collected samples from the external epithelium at the base of udder, the external teat barrel epithelium, the external teat apex epithelium, and the teat canal epithelium. Extracted DNA was quantified and subjected to PCR amplification of the V4 hypervariable region of the 16S rRNA gene and sequenced on the Illumina MiSeq platform (Illumina Inc., San Diego, CA). A subset of samples was subjected to a shallow shotgun metagenomic assay on the Illumina HiSeq platform. For samples collected from the external teat epithelium, we found that gauze squares consistently yielded more DNA than swabs, and Simpson's reciprocal index of diversity was higher for gauze than for swabs. The teat canal epithelial samples exhibited significantly lower diversity than the external sampling locations, but there were no significant differences in diversity between teat apex, teat barrel, and base of the udder samples. There were, however, differences in the microbial distribution and abundances of specific bacteria across external epithelial surfaces. The proportion of shotgun sequence reads classified as Bos taurus was highly variable between sampling locations, ranging from 0.33% in teat apex samples to 99.91% in teat canal samples. These results indicate that gauze squares should be considered for studying the microbiome of the external epithelium of the bovine udder, particularly if DNA yield must be maximized. Further, the relative proportion of host to non-host DNA present in samples collected from the internal and external teat epithelium should be considered when designing studies that utilize shotgun metagenomic sequencing.
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Bovinos/microbiología , Glándulas Mamarias Animales/microbiología , Microbiota , Piel/microbiología , Animales , Bacterias/clasificación , Bacterias/aislamiento & purificación , Femenino , Metagenoma , ARN Ribosómico 16S , Manejo de Especímenes/veterinariaRESUMEN
A single-blind, randomized, controlled trial was done to compare the results of carpal tunnel release using classic incision, short incision, or endoscopic technique. In total, 90 consecutive cases were included. Follow-up was 24 weeks. We found a significantly shorter sick leave in the endoscopic group. No significant differences in pain, paraesthesiae, range of motion, pillar pain, and grip strength could be found at 24 weeks of follow-up, although intermediate significant differences were seen, especially in grip strength, in favour of endoscopic technique. No major advantage to using a short incision could be found. There were no serious complications in either group. The results indicate that the endoscopic procedure is safe and has the benefit of faster rehabilitation and return to work.
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Síndrome del Túnel Carpiano/cirugía , Descompresión Quirúrgica , Endoscopía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fuerza de la Mano , Humanos , Masculino , Persona de Mediana Edad , Parestesia/epidemiología , Rango del Movimiento Articular , Reinserción al Trabajo , Ausencia por Enfermedad , Método Simple Ciego , Escala Visual Analógica , Adulto JovenAsunto(s)
Hemangioma/diagnóstico , Neoplasias Cutáneas/diagnóstico , Niño , Preescolar , Diagnóstico Diferencial , Humanos , Masculino , MusloRESUMEN
OBJECTIVE: Questions of recurrence and inadequacy of follow-up length persist regarding endoscopic treatment of colloid cysts. In this retrospective review, we report our long-term follow-up during a 13-year period in 35 patients who underwent endoscopic resection of colloid cysts. METHODS: The 19 males and 16 females (age range 14 to 58 years, mean 35.9 years) who had symptomatic colloid cysts that ranged in size from 5 mm to 4 cm underwent endoscopic resection in the period from 1991 to 2004. RESULTS: Of 2 patients who developed recurrences at 5.9 years and 4.3 years (1 and 6 mm, respectively) both remain asymptomatic. The rate of late asymptomatic recurrence in this series is 6.3%. Three endoscopic resections were converted to an open craniotomy. Three operative complications occurred (i.e., introducer tract hemorrhage, thalamic stroke secondary to thermal injury, epidural hematoma that required evacuation). Four patients noted minimal short-term memory loss without interference in daily living. Of 3 patients with shunts preoperatively, all have no evidence of hydrocephalus after shunt removal. Two patients have asymptomatic ventriculomegaly. Prophylactic anticonvulsants were not prescribed and no seizures were reported. No infections were recorded with antibiotic administration preoperatively, and 24 hours postoperatively. CONCLUSIONS: Our series represents the longest follow-up (mean of 7.8 years) of colloid cysts after endoscopic resection. We now use this technique as the first line of treatment for colloid cysts. The risk of recurrence is minimal with gross total resection and/or coagulation of the cyst wall.
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Quistes del Sistema Nervioso Central/cirugía , Neoplasias del Ventrículo Cerebral/cirugía , Endoscopía/estadística & datos numéricos , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Tercer Ventrículo/cirugía , Adolescente , Adulto , Quistes del Sistema Nervioso Central/patología , Quistes del Sistema Nervioso Central/fisiopatología , Neoplasias del Ventrículo Cerebral/patología , Neoplasias del Ventrículo Cerebral/fisiopatología , Craneotomía/normas , Craneotomía/estadística & datos numéricos , Endoscopía/efectos adversos , Endoscopía/métodos , Femenino , Hematoma Epidural Craneal/etiología , Hematoma Epidural Craneal/patología , Hematoma Epidural Craneal/fisiopatología , Humanos , Hidrocefalia/etiología , Hidrocefalia/prevención & control , Hidrocefalia/cirugía , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/patología , Hemorragias Intracraneales/fisiopatología , Masculino , Trastornos de la Memoria/etiología , Trastornos de la Memoria/fisiopatología , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/métodos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/fisiopatología , Recurrencia , Estudios Retrospectivos , Enfermedades Talámicas/etiología , Enfermedades Talámicas/patología , Enfermedades Talámicas/fisiopatología , Tercer Ventrículo/patología , Tercer Ventrículo/fisiopatología , Tiempo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Major sources of morbidity and mortality in patients with tuberous sclerosis who develop subependymal giant cell astrocytomas (SEGAs) relate to tumor growth and resultant hydrocephalus. We describe a modification of a specialized minimal access resection technique in which an operative corridor is formed with balloon dilation over the course of a week prior to tumor resection. METHODS: Three patients with tuberous sclerosis who had an enlarging SEGA and concomitant hydrocephalus underwent surgical resection with this modified technique. A frontal craniotomy was performed and the optimal trajectory for tumor resection was confirmed by image guidance. After initial insertion of the deflated balloon into the ventricle and removal of the peel-away sheath, inflation of the balloon with a 1-mL saline injection sealed the tract. Additional 1-mL saline injections were continued during the next week until the balloon reached a 15-mm diameter, thus creating the operative corridor. One week after the first operation, the balloon was deflated and removed, and the patient underwent tumor resection via the newly formed operative corridor. RESULTS: Three patients with tuberous sclerosis underwent gross total resections of SEGAs and experienced subsequent resolution of ventricular dilation. Postoperative imaging confirmed minimal cortical disruption. CONCLUSIONS: Use of balloon dilation for the gradual formation of an operative corridor eliminated the need for additional retraction during SEGA resection, potentially decreasing injury to the surrounding neural tissue. In our three patients, the dilation tract retained its integrity during the operation and had sealed completely on postoperative imaging.
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Astrocitoma/cirugía , Neoplasias Encefálicas/cirugía , Cateterismo/métodos , Craneotomía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Esclerosis Tuberosa/cirugía , Adolescente , Astrocitoma/etiología , Neoplasias Encefálicas/etiología , Niño , Preescolar , Femenino , Humanos , Hidrocefalia/prevención & control , Masculino , Procedimientos Neuroquirúrgicos/métodos , Tomografía Computarizada por Rayos X , Esclerosis Tuberosa/complicacionesRESUMEN
OBJECTIVE: To assess the clinical and economic consequences of different diagnostic strategies in newborns with suspected occult spinal dysraphism. METHODS: A decision-analytic model was constructed to project the cost and health outcomes of magnetic resonance imaging (MRI), ultrasound (US), plain radiographs, and no imaging in newborns with suspected occult spinal dysraphism. Morbidity and mortality rates of early versus late diagnosis of dysraphism and the sensitivity and specificity of MRI, US, and plain radiographs were obtained from the literature. Cost estimates were obtained from a hospital cost accounting database and from the Medicaid fee schedule. RESULTS: We found that the choice of imaging strategy depends on the underlying risk of occult spinal dysraphism. In low-risk children with intergluteal dimple or newborns of diabetic mothers (pretest probability: 0.3%-0.34%), US was the most effective strategy with an incremental cost-effectiveness ratio of $55 100 per quality-adjusted life year gained. For children with lumbosacral dimples, who have a higher pretest probability of 3.8%, US was less costly and more effective than the other 3 strategies considered. In intermediate-risk newborns with low anorectal malformation (pretest probability: 27%), US was more effective and less costly than radiographs and no imaging. However, MRI was more effective than US at an incremental cost-effectiveness of $1000 per quality-adjusted life year gained. In the high-risk group that included high anorectal malformation, cloacal malformation, and exstrophy (pretest probability: 44%-46%), MRI was actually cost-saving when compared with the other diagnostic strategies. For the intermediate-risk group, we found our analysis to be sensitive to the costs and diagnostic performances (sensitivity and specificity) of MRI and US. Lower MRI cost or greater MRI diagnostic performance improved the cost-effectiveness of the MRI strategy, whereas lower US cost or greater US diagnostic performance worsened the cost-effectiveness of the MRI strategy. Therefore, individual or institutional expertise with a specific diagnostic modality (MRI versus US) may influence the optimal diagnostic strategy. CONCLUSIONS: In newborns with suspected occult dysraphism, appropriate selection of patients and diagnostic strategy may increase quality-adjusted life expectancy and decrease cost of medical work-up.
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Diagnóstico por Imagen/economía , Tamizaje Neonatal/economía , Disrafia Espinal/diagnóstico , Disrafia Espinal/economía , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Humanos , Recién Nacido , Imagen por Resonancia Magnética/economía , Morbilidad , Pronóstico , Años de Vida Ajustados por Calidad de Vida , Radiografía/economía , Riesgo , Sensibilidad y Especificidad , Disrafia Espinal/cirugía , Ultrasonografía/economíaRESUMEN
BACKGROUND AND PURPOSE: Macrocrania is a common pediatric clinical condition affecting up to 5% of the population. The purpose of this study was to determine clinical and imaging predictors that are useful in the differentiation of disorders requiring surgical treatment from those that can be treated medically in children with macrocrania. METHODS: In a 3-year 7-month retrospective study, 88 patients (median age, 8 months; interquartile range, 5--13 months) with macrocrania and no known underlying neurologic disorder underwent imaging of the brain (sonography, n = 36; CT, n = 31; MR imaging = 21). The study was conducted in a pediatric tertiary care referral center. Clinical and imaging data were correlated to final diagnosis by means of logistic regression and receiver operating characteristic curves. RESULTS: Sixteen (18%) of the patients had disorders requiring surgery: communicating hydrocephalus, n = 7; noncommunicating hydrocephalus, n = 3; hemorrhagic subdural collections, n = 3; neoplasm, n = 1; encysted cavum septi pellucidi, n = 1; and vein of Galen malformation, n = 1. Clinical predictors of disorders requiring surgery included vomiting (P =.007), labor instrumentation (P =.026), developmental delay (P =.008), and abnormal neurologic findings (P =.028). Imaging predictors of disorders requiring surgery included a focal space-occupying lesion (P <.0001) and moderate-to-severe ventriculomegaly (P <.0001). The diagnostic sensitivity of the combination of independent clinical and imaging predictors was higher than that of independent clinical predictors alone, being 100% (95% confidence interval = 96.9%, 100%) and 93.8% (95% confidence interval = 88.7%, 98.8%), respectively. A trend indicated that the area under the receiver operating characteristic curve for clinical plus imaging findings (0.95) was greater than that for clinical findings alone (0.85) (P =.09). An increase in the number of clinical and imaging predictors was highly correlated with an increased risk of a disorder requiring surgery (P <.0001). CONCLUSION: Baseline neuroimaging is indicated for children with macrocrania because the combination of clinical and imaging predictors has the best diagnostic performance in determining the need for surgical versus nonsurgical management.
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Cráneo/patología , Encefalopatías/diagnóstico , Encefalopatías/patología , Encefalopatías/cirugía , Cefalometría , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/patología , Hemorragia Cerebral/cirugía , Estudios de Cohortes , Diagnóstico por Imagen , Femenino , Predicción , Humanos , Hidrocefalia/diagnóstico , Hidrocefalia/patología , Hidrocefalia/cirugía , Lactante , Masculino , Análisis Multivariante , Estudios RetrospectivosRESUMEN
To investigate the consumption of alcohol among emergency room patients, we included 395 patients above 18 years old entering the emergency room during a period of ten days. The patients completed a questionnaire about alcohol consumption, smoking habits and medication. In our investigation 56% of the men and 25% of the women had a daily consumption above the limits recommended by the Ministry of Health (three drinks daily for men and two for women), while 41% men and 14% women consumed at least five drinks daily or 35 per week. Trauma seen in male patients with high alcohol consumption was characterised by excessive damage to the head, trauma of the lower limb and blows from an object, person or an animal. The alcoholic women were characterised by excessive chemical injuries, incisions and stab wounds, and trauma of the upper limb. In conclusion a surprisingly large amount of emergency room patients can be defined as alcohol abusers and drinking is found to be associated with excessive damage.
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Consumo de Bebidas Alcohólicas/efectos adversos , Trastornos Relacionados con Alcohol/epidemiología , Intoxicación Alcohólica/epidemiología , Alcoholismo/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Adulto , Trastornos Relacionados con Alcohol/complicaciones , Intoxicación Alcohólica/complicaciones , Alcoholismo/complicaciones , Dinamarca/epidemiología , Femenino , Humanos , Consentimiento Informado , Masculino , Encuestas y Cuestionarios , Violencia , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/etiologíaRESUMEN
The association between sudden death and cervicomedullary compression in infants with achondroplasia has been well described. Prospective clinical and imaging evaluations have been recommended to identify those infants with achondroplasia who are at risk of dying suddenly from respiratory arrest secondary to unrecognized cervicomedullary compression. Since 1988, we have prospectively evaluated 11 infants (average age 13 weeks) with achondroplasia who were asymptomatic for cervicomedullary compression on initial clinical evaluation. Craniocervical magnetic resonance imaging (MRI) findings included narrowing of the foramen magnum, effacement of the subarachnoid spaces at the cervicomedullary junction, abnormal intrinsic cord signal intensity and mild to moderate ventriculomegaly. Two patients with severe cord compression underwent immediate decompression. Two patients developed opisthotonic posturing within 3 months of evaluation and underwent foramen magnum decompression, including suboccipital craniectomy and atlantal laminectomy. Surgery in all cases revealed forward extension of the squamous portion of the occipital bone, thickened posterior rim of the foramen magnum and a dense fibrotic epidural band. There were no complications from surgery. Seven patients did not require surgery and were followed closely. All 11 patients remain asymptomatic at follow-up (mean 4.6 years; range 16 months to 7.3 years), and no patient has required a diversionary shunt procedure. The results of this prospective study confirm that early clinical and MRI evaluations are necessary to determine whether infants with achondroplasia have cervicomedullary compression. With early recognition, an immediate decompression can be performed safely to avoid serious complications associated with cervicomedullary compression, including sudden death.
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Acondroplasia/cirugía , Compresión de la Médula Espinal/cirugía , Acondroplasia/complicaciones , Acondroplasia/mortalidad , Acondroplasia/patología , Vértebras Cervicales/patología , Muerte Súbita/etiología , Femenino , Humanos , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Hueso Occipital/anomalías , Hueso Occipital/cirugía , Estudios Prospectivos , Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/patologíaRESUMEN
Despite various attempts at prevention, injury in downhill skiing continues to be a worrisome recreational problem. The purpose of this study was to test the effect of an instructional ski video on the behaviour and injuries of 763 downhill skiers. They were enrolled in two study groups, based on whether or not an instructional video had been shown in their bus on the way to a skiing resort. The video focussed on information regarding how to get started in downhill skiing and injury prevention. The outcome parameters, behaviour (binding test and adjustment), injury risk, type and consequence, were registered on the return trip 8 days later by a questionnaire. In the intervention group all outcome parameters changed significantly. The binding test was performed by 86% in the intervention group and by only 59% in the control group (P < 0.05). Adjustment of the bindings was done by 22% in the intervention group vs 14% in the control group. Regarding injury risk, 205 injuries were seen in 158 persons (20.7%) which is 26 injured skiers per 1000 skier-days and 33.6 injuries per 1000 skier-days. In the intervention group 16% of all skiers were injured vs 23% in the control group, yielding a reduction in injury risk of 30% (P < 0.05). Injuries caused by falls were seen in 12.6% in the intervention group vs 16.2% in the control group (P < 0.05). Injuries caused by collision were seen in 6% of the intervention group vs 12% in the control group (P < 0.05). The overall mean injury risk was 16 injuries per 1000 falls. Knee injuries made up 32.6% of the total. For inexperienced skiers the knee injury risk was significantly lower if the bindings had been tested (P < 0.05). Therefore, an instructional ski video can change the behaviour of downhill skiers and reduce the injury risk and consequences significantly.
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Educación en Salud/métodos , Esquí/lesiones , Grabación en Video , Adolescente , Adulto , Femenino , Humanos , Traumatismos de la Rodilla/prevención & control , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Encuestas y Cuestionarios , Heridas y Lesiones/prevención & controlRESUMEN
PURPOSE: We describe imaging features that are clues to the diagnosis of atretic cephaloceles and discuss clinical findings and a possible mechanism by which these lesions develop. METHODS: Eight children (five girls and three boys) ranging in age from 1 day to 3 years 4 months with midline subscalp lesions underwent radiologic examination with CT or MR imaging. In all cases, the lesions were surgically excised and subjected to pathologic examination. Imaging studies and medical records were reviewed retrospectively. RESULTS: Six of eight children had vertical embryonic positioning of the straight sinus with a prominent superior cerebellar cistern. A "spinning-top" configuration of the tentorial incisura, a "cigar-shaped" CSF tract within the interhemispheric fissure, fenestration of the superior sagittal sinus, and "peaking" of the tentorium were associated findings helpful in making this diagnosis. Two of the eight children had findings indistinguishable from focal dermoid, six were developmentally normal, one had mild motor delay, and one died at the age of 3 years. Pathologic examination revealed glial, meningeal (arachnoid), fibrous, and dermal elements. CONCLUSION: Characteristic findings on MR images and CT scans provide clues to the diagnosis of atretic cephalocele. However, even in the presence of abnormal imaging findings, these children may be developmentally normal.
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Encefalocele/diagnóstico , Imagen por Resonancia Magnética , Lóbulo Parietal/diagnóstico por imagen , Lóbulo Parietal/patología , Tomografía Computarizada por Rayos X , Cerebelo/anomalías , Cerebelo/diagnóstico por imagen , Cerebelo/patología , Preescolar , Senos Craneales/embriología , Encefalocele/embriología , Encefalocele/cirugía , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Lóbulo Parietal/cirugía , Estudios RetrospectivosRESUMEN
OBJECT: Radiation is a common treatment modality for pediatric brain tumors. The authors present a retrospective review of six children who developed cerebral cavernous malformations after they underwent radiation treatment for central nervous system (CNS) neoplasia and propose two possible models to explain the formation of cavernous malformations. METHODS: Three boys, aged 13, 9, and 17 years, suffered intracerebral hemorrhages from cerebral cavernous malformations 87, 94, and 120 months, respectively, after they received whole-brain radiation therapy (WBRT) for acute lymphocytic leukemia. A 10-year-old girl and a 19-year-old man developed temporal lobe cavernous malformations 46 and 48 months, respectively, after they received radiation therapy for posterior fossa astrocytomas. A 12-year-old girl developed a temporal lobe cavernous malformation 45 months after WBRT was administered for a medulloblastoma. In all of these cases the cavernous malformation appeared in the irradiated field, was not known to be present prior to radiation therapy, and developed after a latency period following treatment. The incidence of cavernous malformations in these patients suggests that children who undergo radiation therapy of the brain may have an increased risk of hemorrhage. CONCLUSIONS: Two possible models may explain the formation of cavernous malformations following brain radiation in these patients. First, the cavernous malformations may form de novo in response to the radiation. Second, the cavernous malformations may have been present, but radiographically occult, at the time of radiation therapy and may have hemorrhaged in response to the radiation. The authors conclude that cavernous malformations may develop after brain radiation and propose a possible mechanism for this formation.
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Neoplasias Encefálicas/radioterapia , Seno Cavernoso/efectos de la radiación , Malformaciones Arteriovenosas Intracraneales/etiología , Adolescente , Astrocitoma/radioterapia , Seno Cavernoso/patología , Niño , Preescolar , Femenino , Humanos , Malformaciones Arteriovenosas Intracraneales/patología , Imagen por Resonancia Magnética , Masculino , Meduloblastoma/radioterapia , Leucemia-Linfoma Linfoblástico de Células Precursoras/radioterapia , Radioterapia Adyuvante/efectos adversosRESUMEN
The surgical treatment of transsphenoidal cephaloceles in children is controversial. Reduction and repair via a transcranial approach are associated with high postoperative rates of morbidity, mortality, and hypothalamic dysfunction. In this study, four patients, aged 3 to 35 months at surgery, underwent successful transpalatal repair of two encephaloceles and two meningoceles. Two patients presented with nasal obstruction in infancy, one presented with unexplained meningitis, and in one patient the lesion was found incidentally during evaluation for seizures. Two children had median cleft face syndrome, another had an associated Arnold-Chiari type I malformation, and the fourth had no other cranial abnormalities. All patients underwent preoperative evaluation including magnetic resonance (MR) imaging. Auditory, ophthalmological, genetic, endocrinological, or other evaluation was undertaken as indicated. Lesions were approached through the median raphe of the hard and soft palates. All cephaloceles were easily visualized and dissected after division of the nasal palatal mucosa. The dural sac and its contents were reduced by surface coagulation after division and dissection of the overlying mucosa. Once reduced, the bone defect was obliterated in three of four patients. The dura was not opened and anomalous neural elements were not resected. At follow-up evaluation, all patients demonstrated resolution of preoperative symptoms without evidence of infection or lasting morbidity. Follow-up MR imaging showed reduction in all cases. The authors conclude that this transpalatal approach is safe and reliable for the treatment of transsphenoidal cephaloceles in young children.
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Encefalocele/cirugía , Procedimientos Neuroquirúrgicos/métodos , Hueso Paladar/cirugía , Seno Esfenoidal/anomalías , Seno Esfenoidal/cirugía , Preescolar , Encefalocele/diagnóstico , Encefalocele/fisiopatología , Femenino , Humanos , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Resultado del TratamientoRESUMEN
Chronic hematomas are a common problem during infancy and usually occur as the consequence of trauma. They tend to enlarge and are often managed successfully with repeated subdural taps. In patients with collections that fail to respond to percutaneous drainage, the choice of operative management, including burr hole evacuation, shunting, or craniotomy, remains controversial. A new technique, called endoscopic washout, was successfully used in 7 children under the age of 2 years who presented with irritability, vomiting, seizures, and rapid head growth. Preoperative computerized tomography (CT) scans demonstrated enlarging, bilateral, chronic subdural collections; these failed to respond to repeated percutaneous taps over 10 days. With the patient positioned supine, bilateral linear incisions were made anterior to the coronal suture in the midpupillary lines and burr holes were placed. After the dura and outer membrane were opened and coagulated with bipolar cautery, a 4-mm steerable fiberscope was introduced into the subdural space to visualize the collections, evacuate any residual clot, and continuously irrigate the space with lactated Ringer's solution warmed to physiologic temperature. No bridging vessels or synechiae were violated; nitrous oxide and hyperventilation were discontinued before removing the fiberscope. The subdural space was irrigated again prior to closure. At follow-up (range 18 months to 8 years), CT scans showed reexpansion of the brain and no reaccumulation of the hematomas. We conclude that the endoscopic washout is a safe, uncomplicated treatment for chronic subdural hematomas in infants; is more effective than treatment with conventional burr holes alone, and eliminates the need for shunting or craniotomy.
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Endoscopios , Hematoma Subdural/cirugía , Trepanación/instrumentación , Enfermedad Crónica , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/etiología , Humanos , Lactante , Masculino , Recurrencia , Irrigación Terapéutica/instrumentación , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Neoplasias del Ventrículo Cerebral/cirugía , Endoscopía , Ependimoma/cirugía , Anciano , Biopsia , Neoplasias del Ventrículo Cerebral/complicaciones , Neoplasias del Ventrículo Cerebral/diagnóstico , Ependimoma/complicaciones , Ependimoma/diagnóstico , Humanos , Imagen por Resonancia Magnética , Masculino , Inducción de RemisiónRESUMEN
Loculated hydrocephalus remains a difficult neurosurgical problem and endoscopes designed to navigate through the ventricular system provide a new option for treatment. The authors review their experience, during the period March 1990 to June 1993, using a steerable fiberscope in 34 cases of loculated hydrocephalus to evaluate the efficacy of endoscopic cyst fenestration. The goals of treatment were to control hydrocephalus, simplify preexisting shunt systems, and reduce operative morbidity. Endoscopic cyst fenestrations reduced the shunt revision rate from 3.04 per year prior to endoscopy to 0.25 per year after the procedure, during a follow-up period ranging from 8 to 45 months, mean 26 months. However, eight patients (23.5%) required 14 repeat operations to control loculated hydrocephalus. After endoscopy, patients with multiloculated hydrocephalus had a nearly fivefold increased risk (relative risk 4.85) for shunt malfunction and more than a twofold increased risk (relative risk 2.43) for cyst recurrence versus patients with uniloculated hydrocephalus. Similarly, six (50%) of 12 patients shunted prior to endoscopy required a repeat endoscopic procedure (relative risk 5.56). Although repeat endoscopic procedures may be required to control hydrocephalus, endoscopic cyst fenestration avoided placement of a shunt in seven (33%) of 21 patients with uniloculated hydrocephalus. One patient, encountered early in the authors' experience, required a craniotomy for fenestration of multiple ventricular cysts. Endoscopic complications included cerebrospinal fluid leakage in one case and ventriculitis in another. The authors conclude that endoscopic treatment of loculated hydrocephalus is a safe, minimally invasive technique that should be considered as the initial treatment option.
Asunto(s)
Endoscopía/métodos , Hidrocefalia/terapia , Técnicas Estereotáxicas , Adolescente , Adulto , Anciano , Encefalopatías/complicaciones , Encefalopatías/cirugía , Ventrículos Cerebrales/cirugía , Derivaciones del Líquido Cefalorraquídeo , Niño , Preescolar , Quistes/complicaciones , Quistes/cirugía , Endoscopía/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/etiología , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Reoperación , Tomografía Computarizada por Rayos XRESUMEN
It is still not determined which is the best surgical option for third ventricle colloid cysts. Since 1990, the authors have used a steerable fiberscope to remove colloid cysts in seven patients and have performed microsurgery via a transcallosal approach in eight patients. The two techniques were compared for operating time, length of hospital stay, incidence of complications, recurrence, and hydrocephalus, and days spent recuperating before return to work to determine if endoscopic removal of colloid cysts is a safe and effective alternative to microsurgery. Statistical analysis was adjusted for age, sex, and presenting symptoms. Microsurgical cases averaged 206 minutes of operating time whereas endoscopic cases averaged 127 minutes (p = 0.01). For combined days spent in the intensive care unit and on the ward, the patients averaged 9.5 days after microsurgery and 4 days after endoscopy (p = 0.05). Postoperative complications occurred in five of eight patients after microsurgery and in one of seven patients after endoscopy (p = 0.09); complications were transient and primarily related to short-term memory loss. In all patients, preoperative symptoms resolved and the cysts have not recurred. Postoperatively, one patient required a ventriculoperitoneal shunt after microsurgery but all patients were shunt-independent after endoscopy. Patients returned to work an average of 59 days after discharge following microsurgery compared with an average of 26 days after endoscopy (p = 0.05). Compared with transcallosal microsurgery for the removal of colloid cysts, these preliminary results show that a steerable endoscope reduced operating time and that patients spent fewer days in the hospital and returned to work sooner after endoscopy.
Asunto(s)
Ventrículos Cerebrales/cirugía , Cuerpo Calloso/cirugía , Quistes/cirugía , Endoscopía , Microcirugia , Adolescente , Adulto , Anciano , Encefalopatías/cirugía , Cuidados Críticos , Endoscopía/efectos adversos , Endoscopía/métodos , Femenino , Humanos , Hidrocefalia/etiología , Incidencia , Coagulación con Láser , Tiempo de Internación , Masculino , Trastornos de la Memoria/etiología , Memoria a Corto Plazo , Microcirugia/efectos adversos , Microcirugia/métodos , Persona de Mediana Edad , Alta del Paciente , Recurrencia , Factores de TiempoRESUMEN
The role of hemispherectomy in treating holohemispheric hemimegaloencephaly, a unilateral brain malformation, is still not well defined. The authors describe the cases of five infants presenting with intractable seizures, progressive neurological deficits, and severe developmental delay. Electroencephalography (EEG) showed generalized polyspikes from the megaloencephalic hemisphere and progressive slowing on the opposite side in all children; contralateral seizure spikes occurred in three children. Three of the five children underwent hemispherectomy for intractable seizures before 2 years of age, after which the seizures subsided completely in two children and improved remarkably in the third. Preoperative Wada testing proved useful in evaluating pharmacologically the effect of hemispherectomy on contralateral polyspikes. Postoperative EEG revealed the absence of polyspikes in the operated hemisphere and decreased slowing on the contralateral side. Psychomotor development in the surgically treated infants exceeded that of the children not undergoing hemispherectomy. Of the two children treated medically, one died at 4 years of age in status epilepticus and the other (now 5 years old) has frequent seizures and severe developmental delay. Based on these results, hemispherectomy appears to be a useful procedure for controlling seizures and improving psychomotor development in children with hemimegaloencephaly involving the entire hemisphere. Surgery in infancy can prevent or minimize seizure foci and encephalopathic changes that may develop in the contralateral hemisphere. Staging the procedure and exercising meticulous hemostasis make surgery relatively safe in infants who otherwise may have significant blood loss associated with increased blood flow to the megaloencephalic hemisphere.