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Biomedical subjects

Hal S Meltzer

Publications and source records attributed to Hal S Meltzer.

18 recordsLinked to original sources
PubMed2006

Emotional and psychological impact of delayed craniosynostosis repair.

INTRODUCTION: Among children with craniosynostosis, there exists an interesting dynamic involving parents' preconceptions of craniosynostosis and its repair, influenced in large part by differing cultural perspectives. In a time in which we are understanding how critical a child's early formative years are in influencing his/her emotional and psychological development, the authors describe one medical aspect involved in that dynamic process. MATERIALS AND METHODS: The authors reviewed their cumulative experience at the Children's Hospital San Diego between January 2000 and June 2004 and identified nine children with significant craniofacial deformities and, for one reason or another, had delayed surgical repair. DISCUSSION: The authors have found that by age 6, parents will often bring their children back to their physician and insist on surgical correction. The significant motivating factor in most of these cases stems from teasing by classmates with respect to head shape. In this manuscript, we report and discuss some of the emotional and psychological issues associated with delayed craniosynostosis repair. Often times, these issues are overlooked or underemphasized in the overall surgical care of such patients.

Adaptation, Psychological↗
PubMed2006

The pathophysiologic mechanism of cerebellar mutism.

OBJECTIVE: Cerebellar mutism (CM) is a postoperative complication of mainly pediatric posterior fossa surgery. Multiple theories exist for explaining this phenomenon. We have made an attempt to further understand this entity given a particularly interesting case as it relates to multiple pathophysiologic pathways. METHODS: We have reviewed the details surrounding a particularly interesting case of CM. A retrospective analysis of this patient's clinical history and recovery is described. An extensive literature review has been performed in conjunction with an attempt to help elucidate details and a better understanding of CM. RESULTS: A thorough analysis of existing theories as to the pathophysiologic mechanism of CM has been performed as it relates to the details of this particular case. A case is described in which a child exhibiting CM abruptly improved and made a relatively quick recovery after the triggering of the melodic speech pathway by way of watching and beginning to sing along with a video. It appears that this incident involving a familiar song catalyzed various speech pathways, which apparently were in some state of shock. This phenomenon seems to be a temporary entity involving not only the mechanical coordination of speech production, but also the initiation of speech itself. CONCLUSIONS: Evidence exists for a pathophysiologic pathway for speech by way of coordinating phonation and articulation. In addition, there seems to exist a pathway by which the initiation of speech may be altered or halted by posterior fossa pathology, namely, vermian or dentate nuclear injury. In particular to this case, we found that the incidental appreciation of other forms of speech, melodic in this instance, may be the key to help stimulate and accelerate the recovery from CM.

Acoustic Stimulation↗
PubMed2006

Robotic virtual endoscopy: development of a multidirectional rigid endoscope.

INTRODUCTION: The use of neuroendoscopy has increased in the past 20 years. Despite an increase in the number of indications for use, novel adjuncts and modifications to existing endoscopes remain all but nonexistent. We introduce a robotic virtual endoscope with applications for neurosurgery that could serve as a novel step in the evolution of future endoscopic technologies. METHODS: Over the past 8 years, we have worked on the construction of a prototype endoscope with three degrees of freedom that was designed to allow for enhanced safety while maximizing the benefits of virtual field rendition and robotic control. We have developed a prototype to examine a cerebral ventricular model in vitro that functions via either a direct video- or computer-based interface. RESULTS: Assessment of viewing angulation with robotic feedback has verified the accuracy of the prototype. Models support the ability of the endoscope to localize regions identified via a software interface. CONCLUSION: The endoscope is a rigid virtual robotic endoscope that provides complete visual coverage of a three-dimensional space by controlling an adjustable viewing direction with three degrees of freedom.

Endoscopes↗
PubMed2005

Surgical correction of metopic synostosis.

BACKGROUND: Premature closure of the metopic suture results in deformation of the anterior portion of the calvarium, which can vary from mild to severe. In mild forms, there is only prominent ridging of the metopic suture; more severe forms result in a marked narrowing of the frontal and temporal regions that in turn affects the supraorbital rims and produces hypotelorism. METHODS: The authors retrospectively reviewed 39 consecutive cases of metopic synostosis treated over a 12-year period. RESULTS: The average age at referral was 5 months, with surgery performed at an average age of 7.5 months. Fifteen infants had other congenital anomalies, with eight having synostosis of other sutures. Follow-up ranged from 7 months to 6 years, with an average of 29 months. In three mild cases, burring of the metopic ridge was performed with excellent aesthetic results in all cases. The other 36 patients had significant deformity of the supraorbital ridges and temporal regions, with obvious hypotelorism for over 50% of the time. In these cases, the patients underwent craniofacial reconstruction to normalize their appearance. In addition, the lateral aspect of the sphenoid ridges, including the orbital roof and lateral orbital wall to the infraorbital fissure, was removed to free the cranial base. The average blood loss was under 400 ml and the average hospital stay was 3.6 days. Results were considered good to excellent in all except three cases, which had recurrence of a prominent metopic ridge; two required a second operation after 6 months for burring of this ridge, whereas the third was treated conservatively with an orthotic headband. CONCLUSION: Mild forms of metopic synostosis can be successfully treated with burring of the metopic ridge alone. Severe forms require craniofacial reconstruction and may be associated with other congenital abnormalities, additional synostosis, and developmental delay. In all cases, the operative procedure must be tailored to the nature and severity of the deformity.

Child↗
PubMed2005

Gel-based surgical preparation resulting in an operating room fire during a neurosurgical procedure: case report.

Despite general reports of fires in the operating room, those during neurosurgical procedures are rare. The most significant contributor to perioperative fires is excess oxygenation. The consideration of novel gel-based surgical preparation solutions as potential fuel sources should be included in the literature. Given the significant patient risk and legal ramifications of surgical fires, education regarding operating room fires and the potential for prevention and treatment is requisite. The authors describe the case of an 18-month-old girl who, while undergoing a resection of a right retroauricular scalp mass, suffered partial thickness bums as a result of the ignition of surgical preparation solution following the use of monopolar electrocautery.

Administration, Topical↗
PubMed2004

Initial experience with antibiotic-impregnated silicone catheters for shunting of cerebrospinal fluid in children.

INTRODUCTION: Infection is a major complication of cerebrospinal fluid (CSF) shunting procedures. Recently, rifampin-impregnated and clindamycin-impregnated silicone catheters have been developed in an attempt to prevent and/or reduce the incidence of shunt infections. In vitro and in vivo animal studies have shown their efficacy in reducing bacterial colonization of catheters. However, these shunts are yet to be evaluated in clinical trials and their safety and efficacy in preventing shunt infections is unknown. METHODS: Between April 2002 and April 2003, 31 children (age range 6 months to 17 years, mean 4.5 years) underwent implantation of an antibiotic-impregnated silicone catheter for CSF diversion. All surgeries were performed by a single neurosurgeon (HSM) at a single medical center. The Codman Hakim Bactiseal silicone catheter was used in all children. Thirty-two catheters were implanted in 31 children. All children have been followed since surgery (for an average of 19 months). For comparison, the previous 46 standard implanted shunts over a similar period of time were reviewed (average follow-up 31 months). RESULTS: Of the 32 implanted catheters, 11 involved placement of a new complete shunt system, 8 were distal revisions, and 13 were proximal/ventricular revisions. There were fewer early and late complications than in the standard shunt group (12.5 and 18.8% vs. 23.9 and 34.8%). There was no local reaction from implantation of the catheters. One child contaminated his distal catheter by disrupting his abdominal incision. None of the other patients have developed any evidence of shunt infection to date. CONCLUSION: Rifampin-impregnated and clindamycin-impregnated silicone catheters appear to be safe and well tolerated in children. Preliminary results suggest a low incidence of shunt infection. Longer follow-up and a larger number of patients are needed to more accurately assess the efficacy of these catheters compared with traditional silicone catheters.

Adolescent↗
PubMed2004

Management of pilocytic astrocytoma with diffuse leptomeningeal spread: two cases and review of the literature.

INTRODUCTION: Leptomeningeal dissemination of juvenile pilocytic astrocytoma (JPA) is a rare event. We report two children with disseminated JPAs treated with a chemotherapeutic agent, temozolomide, after progression of the disease despite surgery, traditional chemotherapy, and/or radiation therapy. CASE REPORTS: Patient 1 presented with hydrocephalus and progressive lower extremity weakness, and was found to have a suprasellar mass as well as extensive spinal disease. Ventriculoperitoneal shunting, decompressive laminectomy with spinal tumor debulking, and chemotherapy with carboplatin and vincristine were initially employed. However, disease progressed and craniospinal irradiation and temozolomide were used. Patient 1 remains in a fair condition today, 2 years later. Patient 2 presented at 8 months of age with failure to thrive. Imaging revealed a cystic lesion in the hypothalamic region with extensive subarachnoid metastatic disease to the spine. Biopsy was performed followed by chemotherapy with vincristine, cyclohexylchloroethylnitrosourea (CCNU), 6-TG, and procarbazine. Due to the continued progression of the disease, cytoreductive surgery was performed and her chemotherapeutic regimen was switched to temozolomide. Two years after initial presentation patient 2 is clinically much improved with stable residual disease. DISCUSSION: We review the literature and discuss treatment strategies for this challenging disease.

Antineoplastic Agents, Alkylating↗
PubMed2004

Craniofacial reconstruction with a fast resorbing polymer: a 6- to 12-month clinical follow-up review.

OBJECT: Resorbable polymer implants have become a compelling option in the treatment of acquired and congenital craniofacial deformities. In particular, the resorbable polylactide and polyglycolide polymers have demonstrated excellent safety profiles in multiple in vitro, animal, and clinical studies and are currently being used in a wide variety of craniofacial applications. In pediatric craniofacial reconstruction a desirable attribute of fixation is early resorption, which may limit the duration of any effect on cranial growth. In this paper the authors discuss the biomaterial properties of a fast resorbing polymer (FRP) and the clinical results in a series of patients who participated in a 6- to 12-month study. METHODS: The authors performed craniofacial reconstruction by using FRP implants in 29 patients beginning in August 2002. All patients experienced maintenance of stable bone fixation followed by bone healing. Cosmetic results were rated satisfactory or excellent, except for one unsatisfactory cosmetic result caused by disease progression. CONCLUSIONS: Results of this study support the effectiveness of an FRP implant in a variety of craniofacial surgical procedures including craniosynostoses, fibrous dysplasia, cranial defects, and encephaloceles.

Absorbable Implants↗
PubMed2004

Fronto-orbital and cranial osteotomies with resorbable fixation using an endoscopic approach.

Over the past 3 years the authors have used modified minimally invasive endoscopic techniques in the surgical correction of craniosynostosis. For selected patients, these techniques offer an alternative to traditional techniques, minimizing postoperative morbidity and the need for cranial banding. Long-term follow-up will be needed to assess the ultimate efficacy of these techniques. Traditional techniques for repair of craniosynostosis have historically had a record of excellent aesthetic results with acceptable morbidity. Ultimately, each patient is best served by a customized plan, developed and implemented by a multidisciplinary team capable of the full range of techniques.

Absorbable Implants↗
PubMed2004

Bacterial adhesion to surfactant-modified silicone surfaces.

OBJECTIVE: Ventricular shunt infections are a major contributor to morbidity in patients being treated for hydrocephalus. The majority of these infections are from Staphylococcus epidermidis. Prevention of bacterial adhesion to the silicone surface of a ventricular catheter could decrease shunt infections. We studied the effectiveness of a surfactant and/or 2% iodine prewash on preventing bacterial adhesion to Silastic catheter material. METHODS: In a laboratory setting, various concentrations of a surfactant, Poloxamer-188 (P188), and a bactericidal agent, iodine, were compared against a control solution in their ability to prevent bacterial adhesion of S. epidermidis to a silicone surface. Silicone wafers were soaked for 1 hour in the test solution, then inoculated and incubated with S. epidermidis for 24 hours. Bacterial counts were then obtained and compared. RESULTS: The most effective method tested in this study was 20% P188, which allowed only 3.02% bacterial adhesion compared with 22.2% bacterial adhesion in the control (P < 0.001). P188 at a 10% concentration or 20% mixed with iodine had the next most effective inhibition. Of the germicidal solutions, a 5-ppm solution of iodine was the most effective. The most ineffective method tested was 2 ppm iodine, which allowed 13.2% bacterial adhesion. CONCLUSION: Use of a surfactant and/or a germicidal will provide some protection against bacteria attaching to silicone surfaces before they are surgically implanted. The use of a surfactant soak of 20% P188 or iodine at a concentration of 5 ppm before inoculation with S. epidermidis significantly decreased the bacterial adhesion to silicone wafers. This finding has relevance to clinical practice because it highlights a simple step undertaken before implanting a ventricular catheter that could reduce the adhesion rate of the most common contaminant of these catheters. This step may become an important factor in decreasing infection rates in shunt-dependent patients.

Anti-Infective Agents, Local↗
PubMed2004

Vertebral body granuloma of the cervical region after pencil injury.

OBJECTIVE AND IMPORTANCE: Granuloma formation has been reported as a rare complication of pencil lead injury. Insufficient data exist regarding pencil lead injuries of the cervical spine. We present the findings in an 18-year-old male patient with secondary granuloma formation after a penetrating transoral pencil injury. We suggest that imaging characteristics and a detailed history will assist with the diagnosis of such lesions. CLINICAL PRESENTATION AND INTERVENTION: The patient was an 18-year-old man who presented with cervical pain. His history included falling as a child while having a pencil in his mouth. T2-weighted imaging studies documented a 1- x 1-cm enhancing lesion posterior to the vertebral body at the C3 level. The patient underwent a C3 vertebrectomy, and specimens were notable for infection, pencil lead, and granuloma formation. CONCLUSION: In the evaluation of a potential granuloma or mass lesion of the cervical spine in a child or adolescent, the differential diagnosis may include a neoplasm. Although computed tomography is an ideal tool to detect foreign objects, including pencil leads, only awareness of the potential for pencil lead injuries and that pencil lead fragments may remain unrecognized on computed tomographic scans will assist the physician in diagnosing such injuries.

Adolescent↗
PubMed2004

Leptomeningeal cyst development after endoscopic craniosynostosis repair: case report.

OBJECTIVE AND IMPORTANCE: Endoscopically assisted (minimally invasive) craniosynostosis repair has been suggested as an alternative to traditional open craniosynostosis repair. Advocates of this approach assert advantages, including decreased blood loss, operative time, and hospital stay, while providing esthetic results and safety comparable with traditional open craniosynostosis repair. The difficulties inherent in endoscopic visualization may result in complications, however, that could temper enthusiasm for this procedure. The authors report a child in whom a leptomeningeal cyst developed after performance of endoscopic craniosynostosis repair, presumably from an iatrogenic dural laceration. CLINICAL PRESENTATION: A 5-month-old girl with sagittal synostosis underwent endoscopically assisted craniosynostosis repair. By report, the procedure was uneventful and the initial results were acceptable. The authors performed a chart review of their own experience with both endoscopically assisted craniosynostosis repair and traditional open repair. INTERVENTION: Five months after surgery, a pulsating forehead mass developed. Neuroimaging confirmed the diagnosis of a leptomeningeal cyst. The child was referred to our pediatric neurosurgery practice for operative repair. At the time of surgery, a dural defect lying directly under a previous osteotomy site was identified. After uneventful repair and follow-up of more than 1 year, the child is well and is without the development of a clinical seizure disorder or recurrence of her leptomeningeal cyst. CONCLUSION: Unrecognized dural injury combined with an overlying osteotomy in an infant can result in the development of a leptomeningeal cyst. Care must be taken at the time of endoscopic extradural surgery to recognize any inadvertent dural tears and to perform a direct repair at the time of the initial occurrence. Facility with and use of an appropriate endoscope is essential to the safe performance of minimally invasive craniosynostosis surgery.

Arachnoid Cysts↗
PubMed2004

Hypothalamic ganglioglioma treated by temporal lobectomy. Case report and review of the literature.

The authors report the case of a hypothalamic ganglioglioma with left-sided temporal lobe extension in an 8-year-old girl who presented with seizures. Other cases of ganglioglioma involving the hypothalamus have been reported in the literature; however, this site of origin is exceedingly rare and worthy of report. Treatment involved medial temporal lobectomy with the hypothalamic component of the tumor remaining untouched. The patient recovered postoperatively with no neurological deficits and was seizure free at 12 months. Neither radio- nor chemotherapy was recommended because of the tumor histology, location, and the patient's age. The authors recommend follow up and surgical treatment for possible tumor recurrence. The prognosis for hypothalamic ganglioglioma is unknown.

Anterior Temporal Lobectomy↗
PubMed2004

Hydrocephalus in children with middle fossa arachnoid cysts.

OBJECT: The optimal management of children with middle fossa arachnoid cysts (MFACs) remains controversial. In this study the authors evaluated the relationship between two preoperative variables, hydrocephalus and nonspecific macrocephaly, in children undergoing fenestration of temporal arachnoid cysts and hydrocephalus-related shunt placement. METHODS: During a 16-year period, 40 children (30 boys and 10 girls) underwent treatment of MFACs. All but one patient experienced either worsening symptoms or progressive serial imaging-documented cyst enlargement. Hydrocephalus was present in six patients and nonspecific macrocephaly in another nine. The mean age at surgery was 66 months (range 1-201 months, median 36 months), and the mean follow-up duration was 54 months (range 6-83 months, median 39 months). All patients presenting with hydrocephalus required placement of a ventriculoperitoneal (VP) shunt as well as cyst fenestration, regardless of which procedure was performed first. Five patients with macroencephaly undergoing initial fenestration required subsequent VP shunt insertion. Complications of cerebrospinal fluid (CSF) diversion were typical. CONCLUSIONS: Patients with hydrocephalus or macrocephaly are likely to require VP shunt placement in addition to cyst fenestration. Children with nonspecific macrocephaly may harbor a latent derangement of CSF circulation.

Adolescent↗
PubMed2003

Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature.

OBJECTIVE AND IMPORTANCE: Neonatal subgaleal hematomas (SGHs) are infrequent but underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock can cause death in 20 to 60% of newborn infants. We report the first two known patients with extracranial cerebral compression caused by SGH. Also, the surgical evacuation of neonatal SGH has not been described previously. CLINICAL PRESENTATION: One patient was a full-term boy who was delivered via vacuum extraction after an uncomplicated pregnancy. Within a few hours, he developed an expanding fluid collection of the scalp and disseminated intravascular coagulation and shock requiring intubation, inotropic support, and blood transfusions. His head circumference grew from 33 cm at birth to 42 cm. He became progressively lethargic and developed posturing movements. Computed tomography of the head revealed a massive SGH causing gross overlapping of the cranial sutures and diffuse cerebral edema. The other patient was a full-term boy delivered via cesarean section after an unsuccessful attempt at vacuum extraction and forceps delivery. The initial head circumference was 34 cm. Within a few hours, he developed an expanding fluid collection of the scalp and became progressively lethargic with posturing. Magnetic resonance imaging of the head revealed a massive SGH with cranial compromise and diffuse cerebral edema. INTERVENTION: Both children had radiographic features indicative of elevated intracranial pressure as well as neurological decompensation. The first patient was taken to the operating room, and the hematoma was evacuated through a small scalp incision. Initially, approximately 150 ml of blood was removed, and a Jackson-Pratt drain diverted another 200 ml of blood during the next 2 days. The infant made a good recovery. In the second case, the patient remained too unstable for operative intervention and died. CONCLUSION: Extracranial cerebral compression represents another way by which neonatal SGH may jeopardize the infant's life. Management consists of measures to correct hypovolemic shock and disseminated intravascular coagulation, as well as surgical intervention to control elevated intracranial pressure.

Adolescent↗
PubMed2003

Improvement of aggressive and antisocial behavior after resection of temporal lobe tumors.

Seizures associated with temporal lobe tumors may rarely manifest as episodic aggressive behavior. We describe 2 cases involving pediatric patients who presented with histories of unusually aggressive and antisocial behavior. Magnetic resonance imaging identified right mesial temporal lobe masses in both patients. After craniotomy for tumor removal, both patients were seizure-free and had marked reductions in their aggressive behavior. Tumors in the temporal lobe may be associated with behavioral problems, including aggression and rage attacks, which can be alleviated with surgical intervention. It is important to distinguish this subgroup of pediatric patients from those with alternative diagnoses such as attention-deficit/hyperactivity disorder or oppositional defiant disorder.

Adolescent↗
PubMed2002

Pediatric acute hemorrhagic leukoencephalitis: report of a surviving patient and review.

Acute hemorrhagic leukoencephalitis (AHLE) is a rare, fulminant CNS demyelinating condition usually diagnosed at autopsy. We report the clinical, laboratory, radiographic, and pathologic features of the first nonfatal case of pediatric AHLE confirmed by brain biopsy. Pathologic diagnosis of this condition may be critical to exclude more-common processes and to expedite the decision to administer high-dose corticosteroid therapy, which is potentially lifesaving.

Anti-Inflammatory Agents↗