scholarly journals Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems

2018 ◽  
Vol 45 (4) ◽  
pp. E2 ◽  
Author(s):  
Michael C. Dewan ◽  
Justin Onen ◽  
Hansen Bow ◽  
Peter Ssenyonga ◽  
Charles Howard ◽  
...  
Keyword(s):  
Spina Bifida ◽  
Comprehensive Evaluation ◽  
Pediatric Neurosurgery ◽  
High Volume ◽  
High Yield ◽  
Third Ventriculostomy ◽  
Subspecialty Training ◽  
Home Institution ◽  
Ventriculoperitoneal Shunting ◽  
Unnecessary Death

There is inadequate pediatric neurosurgical training to meet the growing burden of disease in low- and middle-income countries (LMIC). Subspecialty expertise in the management of hydrocephalus and spina bifida—two of the most common pediatric neurosurgical conditions—offers a high-yield opportunity to mitigate morbidity and avoid unnecessary death. The CURE Hydrocephalus and Spina Bifida (CHSB) fellowship offers an intensive subspecialty training program designed to equip surgeons from LMIC with the state-of-the-art surgical skills and equipment to most effectively manage common neurosurgical conditions of childhood. Prospective fellows and their home institution undergo a comprehensive evaluation before being accepted for the 8-week training period held at CURE Children’s Hospital of Uganda (CCHU) in Mbale, Uganda. The fellowship combines anatomy review, treatment paradigms, a flexible endoscopic simulation lab, daily ward and ICU rounds, radiology rounds, and clinic exposure. The cornerstone of the fellowship is the unique operative experience that includes a high volume of endoscopic third ventriculostomy with choroid plexus cauterization, myelomeningocele closure, and ventriculoperitoneal shunting, among many other procedures performed at CCHU. Upon completion, fellows return to their home institution to establish or rejuvenate a robust pediatric practice as part of a worldwide network of CHSB trainees committed to the care of underserved children. To date, the fellowship has graduated 33 surgeons from 20 different LMIC who are independently performing thousands of hydrocephalus and spina bifida operations each year.

scholarly journals Illustrated dynamic stories behind pediatric neurosurgery

2019 ◽  
Vol 10 ◽  
pp. 178
Author(s):  
Voramol Rochanaroon ◽  
Danil A. Kozyrev ◽  
Jonathan Roth ◽  
Shlomi Constantini
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Surgical Techniques ◽  
Pediatric Neurosurgery ◽  
Third Ventriculostomy ◽  
Practical Application ◽  
Sequential Order ◽  
Anatomical Features ◽  
Surgical Trainees ◽  
Ventriculoperitoneal Shunting ◽  
Strip Craniectomy

Background: The aim of this paper is to provide a depiction of the surgical technique and dynamic story behind the procedures in pediatric neurosurgery. Methods: Five standard common pediatric neurosurgeries: endoscopic third ventriculostomy, fronto-orbital advancement for metopic and coronal craniosynostoses, posterior fossa craniotomy, strip craniectomy for sagittal craniosynostosis, and ventriculoperitoneal shunting were chosen to be exampled in illustrations. Results: Surgical techniques were depicted in a step-by-step fashion with comic-like style of images. Illustrations enable to highlight specific surgical and anatomical features and also convey surgical procedures in a sequential order from beginning to end as if it is a story. Conclusion: Surgical illustrations may serve as an educational tool with potentially instructional value for practical application, especially for surgical trainees.

Prospective surveillance of complications in a pediatric neurosurgery unit

2010 ◽  
Vol 5 (6) ◽  
pp. 544-548 ◽  
Author(s):  
James M. Drake ◽  
Jay Riva-Cambrin ◽  
Andrew Jea ◽  
Kurtis Auguste ◽  
Mandeep Tamber ◽  
...  
Keyword(s):  
External Ventricular Drain ◽  
Pediatric Neurosurgery ◽  
Shunt Infection ◽  
Shunt Revision ◽  
Third Ventriculostomy ◽  
Neurosurgical Procedures ◽  
Csf Leakage ◽  
Second Procedure ◽  
Shunt Infections ◽  
Csf Leaks

Object Complications of specific pediatric neurosurgical procedures are well recognized. However, focused surveillance on a specific neurosurgical unit, for all procedures, may lead to better understanding of the most important complications, and allow targeted strategies for quality improvement. Methods The authors prospectively recorded the morbidity and mortality events at a large pediatric neurosurgical unit over a 2-year period. Morbidity was defined as any significant adverse outcome or death (for obstructive shunt failure, within 30 days). Multiple and unrelated complications in the same patient were recorded as separate events. Results There were 1082 surgical procedures performed during the evaluation period. One hundred seventy-seven complications (16.4%) occurred in 147 patients. By procedure, the most common complications occurred in vascular surgery (41.7%) and brain tumor surgery (27.9%). The most common complications were CSF leakage (31 cases), a new neurological deficit (27 cases), early shunt or endoscopic third ventriculostomy obstruction (27 cases), and shunt infection (24 cases). Meningitis occurred in 19 cases: in 58% of shunt infections, 13% of CSF leaks, and 10% of wound infections. Sixty-four percent of adverse events required a second procedure, most commonly an external ventricular drain placement or shunt revision. Conclusions Complications in pediatric neurosurgical procedures are common, result in significant morbidity, and more than half the time require a repeat surgical procedure. Targeted strategies to prevent common complications, such as shunt infections or CSF leaks, might significantly reduce this burden.

scholarly journals Fetal surgery for spina bifida aperta

2018 ◽  
Vol 103 (6) ◽  
pp. F589-F595 ◽  
Author(s):  
Luc Joyeux ◽  
Enrico Danzer ◽  
Alan W Flake ◽  
Jan Deprest
Keyword(s):  
Spina Bifida ◽  
Prolonged Exposure ◽  
Controlled Trial ◽  
Fetal Surgery ◽  
Neurological Deficits ◽  
Cerebrospinal Fluid Leakage ◽  
Essential Information ◽  
Ventriculoperitoneal Shunting ◽  
Spina Bifida Aperta ◽  
Randomised Controlled

Spina bifida aperta (SBA) is one of the most common congenital malformations. It can cause severe lifelong physical and neurodevelopmental disabilities. Experimental and clinical studies have shown that the neurological deficits associated with SBA are not simply caused by incomplete neurulation at the level of the lesion. Additional damage is caused by prolonged exposure of the spinal cord and nerves to the intrauterine environment and a suction gradient due to cerebrospinal fluid leakage, leading to progressive downward displacement of the hindbrain. This natural history can be reversed by prenatal repair. A randomised controlled trial demonstrated that mid-gestational maternal-fetal surgery for SBA decreases the need for ventriculoperitoneal shunting and hindbrain herniation at 12 months and improves neurological motor function at 30 months of age. This came at the price of maternal and fetal risks, the most relevant ones being increased prematurity and a persistent uterine corporeal scar. Recently minimally invasive fetal approaches have been introduced clinically yet they lack extensive experimental or clinical trials. We aim to provide clinicians with the essential information necessary to counsel SBA parents as the basis for considering referral of selected patients to expert fetal surgery centres. We review the reported clinical outcomes and discuss recent developments of potentially less invasive fetal SBA approaches.

Advanced Turbine Technology Applications Project (ATTAP): Overview, and Ceramic Component Technology Status

1991 ◽  
Author(s):  
Philip J. Haley
Keyword(s):  
High Speed ◽  
High Volume ◽  
Department Of Energy ◽  
High Yield ◽  
Design System ◽  
Ceramic Component ◽  
Forming Process ◽  
Technology Applications ◽  
Ceramic Components ◽  
Monolithic Ceramics

The automotive gas turbine’s (AGT) significant potential payoffs in fuel economy, emissions, and alternate fuels usage continue to motivate development activities worldwide. The U.S. Department of Energy-sponsored, NASA-managed Advanced Turbine Technology Applications Project (ATTAP) focuses on developing critical AGT structural ceramic component technologies. The area of greatest challenge is that of cost-effective, near-net-shape, high-volume, high-yield manufacturing processes. Process physics modeling and Taguchi analyses are affording substantial progress, and new processes are being explored. Laboratory characterization is building a shared materials data base among Allison, Garrett, Government labs, and ceramic manufacturers. General Motors (GM) has logged over 700 test hours with ceramic components in hot gasifier rigs during ATTAP. A key ATTAP milestone was addressed by successfully demonstrating full goal temperature and speed (2500°F rotor inlet at 100% shaft speed) with ceramic components. Fast-fracture ceramic component design tools are well correlated. Although time-dependent data and mechanistic models exist, a validated design system for such phenomena does not, and is a pressing need. Damage tolerance and impact resistance have been substantially addressed through tailored component designs, tougher monolithic ceramics, and increased ceramic strengths. Ceramic turbine rotors are now continuing to run after various substantial impacts, and after chipping damage. Ceramic-ceramic and ceramic-metal interfacing is being addressed by minimizing components’ joints, and by other DOE-sponsored work on joining models, processes, and materials. The extruded regenerator disk is a continuing goal which requires both forming process and materials technology development. Controlling turbine tip clearances and tolerating tip rubs are key technologies. GM has demonstrated clearance control schemes, as well as rotor survivability to high speed/temperature tip rubs. Several noteworthy ceramic materials reflect the rapid progress over the past decade of monolithic ceramics, especially the Si3N4 family. GM forecasts achieving ATTAP engine cyclic durability goals.

Endoscopic Third Ventriculostomy in Pediatric Patients: The Canadian Experience

Neurosurgery ◽  
2007 ◽  
Vol 60 (5) ◽  
pp. 881-886 ◽  
Author(s):  
James M. Drake
Keyword(s):  
Pediatric Patients ◽  
Endoscopic Third Ventriculostomy ◽  
Cox Model ◽  
Pediatric Neurosurgery ◽  
Third Ventriculostomy ◽  
Time To Failure ◽  
Success Rates ◽  
Accurate Analysis ◽  
Young Infants ◽  
Small Series

Abstract OBJECTIVE Reports from relatively small series of pediatric patients predominantly from single centers have hampered accurate analysis of outcome from endoscopic third ventriculostomy. We combined patients from nine pediatric neurosurgery centers across Canada to obtain a better estimate of outcome and identify factors affecting success of the procedure. METHODS Databases were recoded for uniformity. Failure of the procedure was defined as any subsequent operation or death resulting from hydrocephalus. Time to failure was analyzed by Kaplan-Meier estimate and Cox proportional hazard analysis. RESULTS During a 15-year period (1989–2004), 368 patients underwent the procedure. The average age was 6.5 years, and 57% were male. Aqueduct stenosis and tumors were the most common etiology, comprising 34 and 29%, respectively. Twenty-two percent of the patients had been previously shunted. The 1- and 5-year success rates were 65 and 52%, respectively. Factors included in the Cox model were age, sex, etiology of hydrocephalus, previous surgery, center volume, and surgeon volume. By multivariate analysis, only age had a significant effect on outcome, with younger patients failing at higher rates, particularly neonates and infants. CONCLUSION Based on data from multiple Canadian centers, age seems to be the primary determinant of outcome in endoscopic third ventriculostomy in pediatric patients. Failure rates are particularly high in neonates and young infants; thus, the role of this procedure in this age group should be carefully considered.

scholarly journals Shunt malfunction and endoscopy

2021 ◽  
Vol 3 (1(January-April)) ◽  
pp. e792021
Author(s):  
Bermans Iskandar ◽  
Ricardo de Amoreira Gepp
Keyword(s):  
Obstructive Hydrocephalus ◽  
Pediatric Neurosurgery ◽  
Shunt Malfunction ◽  
Surrounding Tissue ◽  
Shunt Revision ◽  
Third Ventriculostomy ◽  
Ventricular Catheter ◽  
Ventricular Wall ◽  
Optimal Position ◽  
Slit Ventricle Syndrome

Objective:   Hydrocephalus is the most common neurological disease in pediatric neurosurgery.(1) The CSF shunts remains as the most common treatment choice for nonobstructive hydrocephalus worldwide, but shunt complications still the most common neurosurgical problem, especially in pediatric neurosurgery. Endoscopy and shunts are the way to treat hydrocephalus. Especially third ventriculostomy is the most effective treatment to obstructive hydrocephalus but shunt still the most important way to treat.(2, 3) Shunt malfunction is frequent and after so many years this is very important problem to the patients. Ventricular problem due to obstruction is responsible up to 72% of shunt problems.(4) The Shunt Trial Study showed that the overall shunt survival was 62% at 1 year, 52% at 2 years, 46% at 3 years, 41% at 4 years. The survival curves for the 3 differents valves were similar to those from the original trial and did not show a survival advantage for any particular valve.(5, 6) We still don´t have one perfect solution to hydrocephalus and shunt malfunction. The major author described his experience in use endoscopy to evaluate and treat shunt malfunction and one new approach and way to evaluate this problem.   Results/Discussion: The literature review was performed, and we found 84 articles when we used the keywords. Endoscopy has been one important way to treat and solve shunt problems. In obstructive hydrocephalus third ventriculostomy is the best way to treat these patients.(1-3) The major author first described goals of endoscopy. First goal is safe catheter removal in surgical review, avoiding bleeding when removing catheter addressing all the adhesions on catheter. Second goal is put in optimal position the new catheter with pure endoscopy view or using neuronavigation systems that could help the endoscope system.(7, 8)   Optimal new catheter placement and optimal long-term catheter survival are especially important because most of the problems are due to ventricular problems. These good placements could avoid loculations and ventricular collapse with ependymal problems. Avoid new catheter malpositiitioning, you can use the endoscope to follow the old tract to insert the new catheter in one good position avoiding choroid plexus. Another situation is when you have small ventricles especially in slit ventricle syndrome.   The major author has been studied some causes to ventricular catheter obstruction. He noticed after some surgical reviews some ventricular ependymal inside catheter. Ventricular ependymal protrusions inside the catheter could cause intermittent occlusion.(8) Some endoscope views showed these protrusion and ependymal changes after intermittent increase and decrease of ventricular pressure. These protrusions correspond to catheter holes a secondary to suction. These protrusions could stuck in the holes in chronicle suction.(8) The major author reported one endoscopic evidence of overdrainage-related ventricular tissue protrusions that cause partial or complete obstruction of the ventricular catheter. He did a retrospective review in fifty patients underwent 83 endoscopic shunt revision procedures that revealed in-growth of ventricular wall tissue into the catheter tip orifices (ependymal bands), producing partial, complete, or intermittent shunt obstructions. Endoscopic ventricular explorations revealed ependymal bands at various stages of development, which appear to form secondarily to siphoning.(8) How to minimize this overshunting? Anti siphon systems could help and decrease proximal shunt malfunction in some complex patients. The other problem is ventricular bleeding. The use of endoscope has been important tool to remove ventricular catheters, when you could see the adhesions.(9) The use the endoscope could be particularly important to open loculations and cysts avoiding ventricular entrapment. Patients with ventricular cysts could need more than one catheter. The use of endoscopy to fenestrate the cyst could keep the patient with one catheter or without any shunt system.(10, 11)   Conclusion: Shunt malfunction has a lot of possible causes, but a probably ventricular catheter problem is the most common situation. Choose appropriate endoscope rigid or flexible for each case could help to treat and avoid some of ventricular. Endoscopy could be one important tool to help the surgeon to understand and solve this dangerous situation to the patient. Ventricular wall protrusions are a significant cause of proximal shunt obstruction, and they appear to be caused by siphoning of surrounding tissue into the ventricular catheter orifices.

scholarly journals Intraventricular bone dust migration after neuroendoscopy: report of 2 cases

2018 ◽  
Vol 22 (5) ◽  
pp. 578-583
Author(s):  
Tarek Y. El Ahmadieh ◽  
Cody B. Wolfe ◽  
Joyce Koueik ◽  
Bradley E. Weprin ◽  
Bermans J. Iskandar ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Pediatric Neurosurgery ◽  
Colloid Cyst ◽  
Burr Hole ◽  
Third Ventriculostomy ◽  
Dural Defect ◽  
Bone Fragment ◽  
Csf Leakage ◽  
Bone Fragments ◽  
External Trauma

Neuroendoscopy has demonstrated safety and efficacy in the treatment of a host of pediatric neurosurgical pathologies. With the increase in its applicability, several associated complications have been described in the literature. A common practice in pediatric neurosurgery is the use of Gelfoam sponge pledget in the burr hole, followed by bone fragments and dust (obtained from the created burr hole), to cover the dural defect. This technique is used to enhance burr hole sealing and potentially prevent CSF leakage from the surgical site. Reports on intracranial bone dust migration associated with this technique are scarce. The authors report 2 cases of intracranial migration of bone fragments after an endoscopic third ventriculostomy and an endoscopic colloid cyst resection. The bone fragment migration was thought to be caused by negative pressure from a lumbar puncture in one case and external trauma to the head in the other. As endoscopy becomes more widely used, it is important to be aware of this potential complication that may in some cases require an intervention. A review of the cases reported in the literature is provided and a technique is suggested to help prevent this complication.

PP65 Coordinated Implementation And Evaluation Of Promising Stroke Therapy

2018 ◽  
Vol 34 (S1) ◽  
pp. 91-92
Author(s):  
Laurie Lambert ◽  
Leila Azzi ◽  
François Désy ◽  
Anabèle Brière ◽  
Lucy Boothroyd ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Real World ◽  
New Technologies ◽  
Comprehensive Evaluation ◽  
High Volume ◽  
Evaluation Framework ◽  
Disruptive Technology ◽  
Expert Committee ◽  
Processes Of Care ◽  
Real World Evidence

Introduction:One important objective at the Institut d'excellence en santé et en services sociaux (INESSS) is to guide the implementation of promising new technologies into Québec's healthcare system. A comprehensive evaluation framework was recently developed that takes into account the dynamic and iterative nature of the life cycle of such technologies. This framework is presently being used to inform the decision-making process concerning use of thrombectomy for ischemic stroke.Methods:A field evaluation has been undertaken since April 2016 in all four of Québec's specialized tertiary stroke centers. This real-world evidence is communicated regularly to the clinical teams as well as decision-makers. A systematic literature surveillance is also ongoing, with results being shared amongst clinical experts on our interdisciplinary advisory committee. On the basis of the generated evidence from these sources, recommendations to optimize structures, processes of care and clinical outcomes will be developed, in collaboration with the interdisciplinary committee.Results:Thrombectomy has been shown to be safe and effective for treating ischemic stroke in the randomized trial setting in high-volume, expert centers. Real-world evidence from Québec indicates increasing use of this new technology but with wide variation across health regions. Observed times to treatment appear favorable for patients admitted directly to tertiary centers, but inter-hospital transfer is associated with important increases in delays from first door to thrombectomy. The documentation of 90-day outcomes is problematic, especially for patients transferred out of tertiary stroke centers prior to discharge. Uncertainties raised in the literature include patient selection criteria and optimal processes of care during prehospital and inter-hospital phases of the patient's trajectory.Conclusions:The ongoing comprehensive evaluation of thrombectomy for ischemic stroke in Québec is a concrete example of how the use of an innovative, disruptive technology can be optimized. We acknowledge the contribution of the members of the clinical expert committee.

Hydrothorax Due to Ventriculopleural Shunting in a Child with Spina Bifida on Chronic Dialysis: Third Ventriculostomy as an Alternative of Cerebrospinal Diversion

2005 ◽  
Vol 37 (3) ◽  
pp. 571-574 ◽  
Author(s):  
Jose Grunberg ◽  
Anabella Rébori ◽  
María Cristina Verocay ◽  
Virginia Ramela ◽  
Ricardo Alberti ◽  
...  
Keyword(s):  
Spina Bifida ◽  
Chronic Dialysis ◽  
Third Ventriculostomy
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