History Of Meningitis Research Articles

Pituitary function in children following infectious diseases of the central nervous system

Recent studies in adults suggest that pituitary deficiencies develop in a considerable proportion of patients who recover from infectious meningitis. The aim of this study was to evaluate pituitary function of children with a history of meningitis. Seventy-nine children were admitted to the Safra Children's Hospital due to meningitis between 2007 and 2010. Twenty-four families were lost for follow-up, 55 were interviewed by phone and 14 (9 males) participated in the study. Evaluation included medical history, physical examination, auxological measurements and basal levels of TSH, fT4, cortisol and IGF1. Children with abnormal results were followed for a year and dynamic testing was performed when indicated. Mean age at time of infectious meningitis was 3.8 ± 5.4 years (range 0.03-15.8), and at clinical evaluation 6.4 ± 6.4 (range 1.2-20). The interval between the acute event and evaluation was 2.7 ± 1.2 years. Thyroid function tests and basal cortisol levels were normal for all children. Three children had low IGF1 levels; however over a year of follow-up two of them had normal height and growth velocity, making growth hormone deficiency unlikely. One child had low height SDS, but exhibited a normal response to a growth hormone stimulation test. Pituitary dysfunction with overt clinical symptoms is not a frequent consequence of acute meningitis in children. Follow-up of growth and puberty of children post-meningitis by the primary care physician is probably sufficient. Invasive assessments should be reserved for selected cases where there is slow growth or other clinical suspicion of hypopituitarism.

Spontaneous Tegmen Defect and Semicircular Canal Dehiscence

To describe the clinical and radiologic features of associated spontaneous tegmen defects (STDs) with semicircular canal dehiscences (SCCDs) and to postulate a novel etiopathogenic hypothesis of these pathologic conditions. Medical records of all patients with surgically confirmed STD between 2001 and May 2010 were reviewed. We excluded all secondary tegmen defects. Clinical, audiological, and radiologic data were analyzed. Twenty-three patients matched the inclusion criteria. Semicircular canal dehiscence was associated to STD in 13 patients. Of these patients, 12 (95%) had protruding superior semicircular canals in the middle cranial fossa versus only 3 (30%) of 10 patients for the nondehiscent cases. Twenty-two patients complained of hearing loss. Cerebrospinal fluid leak was found in 13 patients. Four patients had history of meningitis. Vestibular symptoms were present in 8 patients. This is the largest series of reported coexistence of STD and SCCD in the literature. Protrusion of the superior semicircular canal in the middle cranial fossa is probably an additional factor underlying STD and SCCD etiopathogeny. Semicircular canal dehiscence should always be looked for when STD is present.

Prevalence of Metabolic Syndrome in Very Low Birth Weight Infants at 2 Years of Age

Background: There is no study showing the prevalence of MS in preterm in early childhood. Objective: To assess the prevalence of MS in children with birthweight < 1500 grams at two years of age and identify perinatal or early childhood factors associated with occurrence of MS. Design/Methods: A cross sectional study with two years of age children that attended a preterm follow up clinic. Criteria for MS diagnosis were three or more of: waist circumference ≥90th percentile, fasting glucose ≥100mg/dl, triglycerides ≥110mg/dL, HDL cholesterol ≥40 mg/dl and blood pressure ≥90th percentile. Results: 235 preterm children with very low birth weight were discharged to outpatient care. Of these, 9.4% failed the follow up. Of the 212 evaluated children, 32(15.1%) had MS. Maternal preeclampsia, gestational diabetes, sex, gestational age, SGA, early and late sepsis, BPD, TPN in the first 24 hours of life, NEC, IVH and PVL, PDA, diet at discharge and during the first year of life, income and maternal education were similar between groups. Maternal urinary tract infection or chorioamnionitis showed a higher prevalence of MS (p = 0.032). Neonatal meningitis presented more MS (p = 0.003). Using Poisson regression, the history of meningitis was the only variable related to the presence of MS (p=0.06). Conclusions: MS is already present in very low birth weight preterm at 2 years. Maternal peripartum infection probably leads to an increase in fetal cortisol, programming MS. Severity of infection, such as neonatal meningitis, appears to be an additional risk factor.

Longitudinal Risk of Meningitis After Cochlear Implantation Associated With the Use of the Positioner

In 2002, the electrode combined with positioner was identified as a significant risk factor for postimplantation meningitis and was voluntarily discontinued by the manufacturer. The ongoing risk of meningitis with passage of time with the positioner remains unknown. The objective of this study was to determine the current risk of meningitis in patients implanted with the positioner. Data regarding the date of implantation, report of meningitis, and presence or absence of risk factors for meningitis (otitis media, inner ear malformation) were obtained from the clinical database maintained by the manufacturer. There were 8,329 devices implanted that may have used a positioner, yielding a cumulative postimplantation time of 74,976 patient-years. The incidence of meningitis during the 3-year spans of 1999 to 2001, 2002 to 2004, 2005 to 2007, and 2008 to 2010 was 33, 40, 11, and 2, respectively; the risk of meningitis in cases per patient-years has decreased significantly from 0.0044 at its peak in 2001 to 0.0011 in 2010. Only a single case of positioner-related meningitis 96 months or longer after implantation has been reported. More than 40% of children had otitis media within 1 week of developing meningitis; less than 10% had a history of meningitis or inner ear malformation. The risk of meningitis with the use of positioner is highest within the first 24 months after implantation and is frequently associated with otitis media. The risk of meningitis more than 96 months after implantation is significantly reduced. Thus, the prophylactic removal of the positioner is not recommended in patients who underwent implantation more than 8 years ago.

Fatal Drip: Sinusitis and Meningitis

MRI brain coronal view of left superior ethmoid cell defect.A 48-year-old woman presented to the emergency department complaining of a five- to six-week history of persistent nasal drip, with fever and intermittent headaches for one month. She described a throbbing occipital headache radiating to the periorbital area bilaterally. She had been treated with several different antibiotics in the preceding four months for a presumptive diagnosis of sinusitis. Symptoms improved while on the medication, but then would quickly return once the antibiotic course was finished. At presentation, the patient had a temperature of 102.0°F, and her skin was flushed and hot to the touch. She appeared uncomfortable, lying on the stretcher holding her head. Nasal congestion with surrounding erythema and clear rhinorrhea were noted. Her tympanic membranes were normal bilaterally, and her pharynx appeared normal with no tonsillar hypertrophy or exudate. Her neck was supple with no tender lymphadenopathy. Her heart maintained normal rhythm and rate, and her lungs were clear to auscultation bilaterally. She was neurologically intact. The rest of her physical exam was unremarkable. Laboratory studies demonstrated a leukocytosis of 23.6 × 103/mcL with 89% segmented neutrophils and 6% lymphocytes. Besides an elevated alkaline phosphatase at 158, the rest of her laboratory evaluation and a CT scan of her brain were unremarkable. A lumbar puncture was attempted but unsuccessful. Ceftriaxone 2 g was given, and the patient was admitted for an MRI and fluoroscopic-guided lumbar puncture. An MRI of the brain subsequently demonstrated a left superior ethmoid cell defect causing CSF leakage through the ethmoid sinuses. (Photo.) CSF analysis was suggestive of bacterial meningitis, but no organisms were found. She was transferred to a tertiary care facility where she was successfully treated with endoscopic endonasal repair without recurrence of symptoms. Cerebrospinal fluid (CSF) fistulas can occur from traumatic and atraumatic causes. Although the occurrence of a CSF fistula is rare, traumatic causes are the most common etiology, occurring in 70 to 80 percent of cases. CSF fistulas can also occur from eroding tumors, congenital defects, ENT infections, or increased intracranial pressures such as those with pseudotumor cerebri. In any of these cases, there is a destruction or breakdown of the bony architecture resulting in a defect of the cribriform plate. Immediate action is necessary to prevent ascending meningitis, which occurs in a third of patients with CSF leaks. Whatever the cause of a CSF leak, patients most commonly present with unilateral clear rhinorrhea, which can easily be confused for allergic rhinitis. The fluid may be tested for beta-2 transferrin to confirm the CSF leak. The second most common presentation is active meningitis or a history of meningitis. Defects are most commonly in the sphenoid sinus and the ethmoid roof. Management depends on etiology. If due to traumatic events, patients who present with small fistulas may be treated conservatively with head elevation, bed rest, and antibiotics. For those who do not respond to conservative management or who have large or nontraumatic fistulas, immediate surgical repair is needed. IV acetazolamide is given for those with pseudotumor cerebri to attempt to decrease intracranial pressure. A VP shunt is placed for those who present with recurring leaks or who do not respond appropriately to diuretics. The etiology of this patient's CSF leak still remains uncertain. There was no recent trauma to suggest that a physical defect occurred. Cases of CSF leaks have been known to occur 20 years after a traumatic head injury, however, and this patient admitted to such an event 22 years previously. According to the patient, past CT scans and MRIs of the brain were negative, although small fistulas may be missed by radiological studies. Our patient was also obese, and admitted to occasional headaches, which may also suggest pseudotumor cerebri as a cause. Our patient also had a history of sinus infections for more than four months, which also could be the source of the defect. Unfortunately, the mystery remains on whether the leak was present prior to the sinusitis causing similar symptoms. One thing, however, is certain. The multiple courses of antibiotic regimens that she received saved her life. The authors are from the emergency medicine residency at Good Samaritan Hospital Medical Center in West Islip, NY.

Veno‐Venous Extracorporeal Membrane Oxygenation as a Bridge to and Support for Pulmonary Thromboendarterectomy in Misdiagnosed Chronic Thromboembolic Pulmonary Hypertension

Diagnostic delay in patients suffering massive pulmonary embolism (PE) on chronic thromboembolic pulmonary hypertension (CTEPH) has inevitably fatal consequences. Indications to pulmonary thromboendarterectomy (PTE) and extracorporeal membrane oxygenation (ECMO) are limited by severe comorbid conditions, some of which, as neurologic disease, absolutely contraindicate these procedures. We reported the clinical course of a severely diseased patient with a history of meningitis, psychosis and epilepsy, experiencing acute massive pulmonary embolism complicated by acute respiratory failure, successfully treated by ECMO and PTE. A 51-year-old woman with massive PE complicating a misdiagnosed CTEPH needed mechanical ventilation because of acute respiratory insufficiency. Thoracic computed tomography (CT) scan demonstrated PE, and brain CT showed multiple cerebral and cerebellar ischemic lesions. Veno-venous ECMO assistance was instituted despite CT imaging. She recovered from acute respiratory insufficiency by means of veno-venous ECMO. Weaning from ECMO was however impossible until surgical exploration demonstrated an underlying chronic CTEPH, which was successfully addressed by PTE, switching the ECMO system to a standard cardiopulmonary bypass. Postoperative course was uneventful and the patient was discharged home in healthy condition. Despite the fact that the cost-effective ratio should always be considered in advanced life support, expanding the commonly accepted selection criteria for expensive procedures might be advisable in selected acute life-threatening cases, in view of the possibility to unexpectedly save lives.

Syringomyelia Due to Thoracic Spinal Stenosis With Ossified Ligamentum Flavum -Case Report-

A 50-year-old male presented with back pain and numbness of the lower extremities persisting for 10 years. He had played volleyball for a long period until recently. He had no history of meningitis or traumatic injury. Magnetic resonance imaging revealed a syringomyelia located in the region from T8 to T9 without contrast enhancement or Chiari malformations. Computed tomography showed T9-10 spinal stenosis caused by the right enlarged ossified yellow ligament. Decompressive laminectomy was performed and the ossified ligament removed. Due to the finding of arachnoid thickening and adhesions during the intradural operation, shunting was also performed. Postoperatively, the neuroimaging and clinical findings improved. Syringomyelia is often associated with Chiari malformations, trauma, spinal tumor, hemorrhaging, and meningitis. We suggest that repeated minor mechanical damage caused by physical exercise in addition to long-standing compression of the spinal cord due to spinal spondylosis could induce severe arachnoid fibrotic change similar to adhesive arachnoiditis, which may be one of the main triggers of syringomyelia. Extradural decompressive surgery is considered to be the initial treatment for syringomyelia associated with spinal spondylosis.

Combined Electric and Acoustic Stimulation: Successful Treatment Option for Partial Deafness

Combined Electric and Acoustic Stimulation: Successful Treatment Option for Partial Deafness

Current Status of Bacterial Meningitis After Cochlear Implantation

Meningitis after cochlear implantation continues to be a concern. Recent studies and anecdotal reports support the belief that intracochlear trauma, lack of appropriate immunizations, and a previously used dual-component electrode predispose patients to a higher rate of contracting meningitis. In addition, a history of meningitis, cochlear dysplasia, and certain variations of surgical technique such as the cochleostomy, very young age, immunocompromise, and the presence of neural prostheses such as shunts, are all potentially predisposing factors. Because many of these factors are beyond our control, there is likely to be an inevitable baseline incidence of meningitis, perhaps related to the underlying deafness, but by controlling other factors, we can hope to minimize the incidence. Despite the efforts of multiple individuals and organizations, there continue to be new cases of meningitis, including a small number of fatalities, each year. There is recent evidence that a sizeable percentage of children with implants have not been vaccinated as suggested by governmental agencies, otolaryngologic societies, implant manufacturers, and many cochlear implant centers. Clearly, efforts must be made to ensure age-appropriate vaccination for all cochlear implant recipients.

Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus

Spontaneous meningoencephaloceles of the lateral sphenoid sinus are rare lesions that are hypothesized to result from persistence of the lateral craniopharyngeal canal. Prior reports of the management of this lesion have been limited by its relative rarity. The objective of this paper is to report the theoretical etiology, surgical technique, and outcomes in patients undergoing endoscopic repair of spontaneous meningoencephalocele of the sphenoid sinus. The authors conducted a retrospective review of a multiinstitutional series of 13 cases involving patients who underwent endoscopic repair of spontaneous meningoencephalocele of the lateral sphenoid sinus. The surgical technique and pathophysiological considerations are discussed. The clinical manifestations included CSF rhinorrhea (85%), chronic headache (77%), and a history of meningitis (15%). The endoscopic approaches to the lateral sphenoid sinus were transnasal (39%), transpterygoid (23%), and transethmoid (39%). Two patients (8%) had postoperative CSF leaks, one of which closed spontaneously and one of which required revision endoscopic closure. All patients were free of leak at most recent follow-up. One patient experienced postoperative meningitis in the early postoperative period. Endoscopic endonasal closure is an effective modality in the treatment of spontaneous meningoencephaloceles of the lateral sphenoid sinus. If the sphenoid sinus has extensive lateral pneumatization, adequate exposure may require a transpterygoid approach.

The Elephant in the Room

The conclusion reached by Wilder et al. 1that exposure to multiple anesthetics is a significant risk factor in the development of learning difficulties is a headline-grabbing statement with far-reaching consequences for all providers of children's services. However, we believe there has been an insufficient attempt to draw attention to the elephant in the room: that children who require multiple operations usually have significant medical diagnoses, and/or syndromes with associated morbidities, that in turn are associated with a higher incidence of learning disorders than the general population has. Though this information on diagnoses is essential to interpret the data, it is only accessible on-line, and there is no information at all on the actual surgical procedures involved. Further analysis of the on-line data reveals that 22 of the 45 patients with multiple exposure to anesthesia have severe comorbidity or congenital anomalies that are frequently associated with learning difficulties. It should come as no surprise that children with cerebral palsy, Sturge–Weber syndrome, a history of meningitis, or cleft lip and palate have a higher incidence of learning difficulties than the general population.2Of the remaining 23 patients, 13 have serous otitis media. Even such isolated “minor” conditions are known to be associated with an increased incidence of educational delay.3An attempt has been made to adjust statistically for neonatal factors but not for the effect of comorbidity. Though the inability to adjust for comorbidity is referred to in the text, we believe this omission is so significant that it invalidates any conclusion from this study. We are therefore afraid that this study does not contribute sensibly to the important discussion about potential anesthetic neurotoxicity in the immature human brain.*Birmingham Children's Hospital, Birmingham, United Kingdom. kcthies@hotmail.com

Delayed Diagnosis of Common Variable Immunodeficiency

Source: Urshel S, Kayikci L, Wintergerst U, et al. Common variable immunodeficiency disorders in children: delayed diagnosis despite typical clinical presentation. J Pediatr. 2009;154(6):888–894; doi:10.1016/j.jpeds.2008.12.020To characterize the clinical presentation of children with early-onset common variable immunodeficiency (CVID), investigators from Munich, Germany, surveyed patients and reviewed their medical records. To identify study participants, the investigators screened data collected between 1990 and 2004 by the immunology laboratory and the immunodeficiency clinic of a tertiary care center. Study patients had IgG and IgM levels or IgA levels reduced more than two standard deviations (SD) from mean values, evidence of impaired increase of specific antibody titers after vaccination, and recurrent infections. Those with other primary immunodeficiency disorders were excluded.A total of 32 patients with early-onset CVID were analyzed. Among the 32 study patients, 17 were female. The median age at diagnosis was 10.4 years. Most patients had a history of chronic or recurrent infections including bronchitis (88%), pneumonia (78%), sinusitis (78%), otitis media (69%), fungal infections (47%), and various gastrointestinal, skin, oral, and parasitic infections (3%–10%). Eight study children had a history of meningitis and five had culture-proven sepsis. Other clinical manifestations included allergy or allergy-like symptoms (38%); autoimmune diseases were found in 31% of study patients, including hemolytic anemia, thrombocytopenia, arthritis, vasculitis, gluten-sensitive enteropathy, diabetes mellitus, vitiligo, and psoriasis.Overall, 80% of the patients underwent surgical procedures before the diagnosis of CVID was made. Nearly half of the patients had findings suggestive of immunologic disease such as diffuse lymphadenopathy or splenomegaly. Four patients (13%) subsequently developed lymphomas; all survived following chemotherapy. Nine affected children (28%) showed significant growth retardation; of these nine, all had a history of recurrent bronchitis, seven had a history of recurrent pneumonia, and five had a history of allergies and/or diarrhea.At the time of diagnosis, all subjects had serum IgG levels 2 SD or more below the mean; IgM concentrations were reduced in 30 of 32. IgA concentrations were normal in one patient and below detection in 15 of 32. Reduced serum levels of all three immunoglobulin classes were found in 29 of 32 patients. The median duration between symptoms and the definitive diagnosis was 5.8±4.2 years.The authors conclude that CVID’s effects on growth and development are unique to pediatrics but the symptoms and disorders of CVID in children are comparable to the manifestations in adults. Marked delay of diagnosis may be due to the overlap with common pediatric disorders along with lack of familiarity with CVID in children.Dr Nimmagadda has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.CVID is second only to selective IgA deficiency among humoral immunodeficiencies and is thought to have a prevalence of 1:10,000 to 1:50,000. It affects males and females equally.1 CVID is part of a group of genetic disorders that results primarily in hypogammaglobulinemia or failure of antibody production. Patients typically present with recurrent infections, particularly of the respiratory tract, although gastrointestinal disease, autoimmune and inflammatory features, and lymphoma are frequent. Onset of symptoms can occur at any age, although there are peaks in the first and third decades of life. In about 10–20% of patients, other family members are affected.1Over the past few decades, studies on the cells of the immune system in patients with CVID have revealed a spectrum of lymphocyte abnormalities.2 Most patients appear to have normal numbers of B-lymphocytes, but they fail to undergo normal maturation into plasma cells capable of making the different types of immunoglobulins and antibodies. Other patients lack enough function from helper T-lymphocytes necessary for a normal antibody response. A third group of patients have excessive numbers of cytotoxic T-lymphocytes, although the role of these cells in the disease is unclear.The current study highlights the importance of clinical awareness of CVID in younger patients and the frequency of diagnostic delay. CVID usually presents in children as recurrent respiratory infections such as bronchitis, pneumonia, and otitis media, which are managed by primary care physicians until the frequency increases or a sentinel event occurs, prompting further investigation. CVID is under-recognized and underdiagnosed, with an average diagnostic delay of four to seven years from onset of symptoms. These delays in diagnosis often result in long-term sequelae, most commonly bronchiectasis and chronic sinusitis. This permanent damage is responsible for most of the chronic ill health and mortality associated with CVID.3,4The treatment of CVID is similar to that of other disorders characterized by low levels of serum immunoglobulins. In the absence of a significant T-lymphocyte defect or organ damage, immunoglobulin replacement therapy almost always brings improvement of symptoms. Thus, early recognition and diagnosis is critical to optimize the long-term outcome of these patients.

Venous Stroke Can Be the Unusual Clinical Presentation of an Arising Naso-Ethmoidal Encephalo-Meningocele in Adulthood

Trans-ethmoidal encephalo-meningocele is an extremely rare event among the adult population. It mainly affects young people who have previously reported a head injury. Even though early treatment is mandatory to avoid septic complications, the diagnosis is usually late because of the misleading symptomatology. We describe the unusual clinical history of an adult patient with a giant trans-ethmoidal encephalo-meningocele. A 61-year-old woman presented progressively more intense headache and rhinorrhea. No trauma was reported. We learned that she had a history of misunderstood spontaneous rhinorrhea beginning two years before, followed one year later by a lateral sinus thrombosis which worsened the cerebrospinal fluid leakage. Some months after stroke a new cerebral magnetic resonance scan revealed a giant trans-ethmoidal encephalo-meningocele. The brain herniation was surgically removed by a subfrontal intradural approach through a frontal craniotomy. Even rare, giant naso-ethmoidal encephalo-meningocele has to be considered in adult patients presenting with rhinorrhea even without a history of meningitis or neurological defects. Venous stroke can affect patients in whom prolonged CSF leakage occurs because of misunderstood cerebrospinal fistula. These patients must be monitored after stroke for the possible onset of an encephalo-meningocele.

Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years

Objective Endoscopic repair of cerebrospinal fluid (CSF) leaks has become a routine approach. This study describes endoscopic closure of a large series over 21 years, focusing on management, surgical technique, and long-term outcomes. Study Design Chart review. Subjects and Methods CSF leak patients treated by the senior author and at the University of Pennsylvania from 1987 to 2008. The data included body mass index (BMI), etiology, defect location, graft material, presence of encephalocele, lumbar drain, history of meningitis, intracranial pressure, recurrence, and follow-up. Results A total of 193 cases were identified. Follow-up ranging from 1 month to 9 years (mean 21 months) was available on 166 patients. The etiology was spontaneous in 77 patients (40%), traumatic in 109 (56%), and congenital in 7 (4%). The average BMI of spontaneous CSF leak patients (35) was greater ( P < 0.001) than both traumatic (30) and congenital patients (23). Defects were most commonly located in the sphenoid (n = 62, 32%) and ethmoid (n = 60, 31%) The initial success rate was 91 percent (n = 176) and overall success rate was 98 percent (n = 190). Conclusion The overall success rate (98%) and low morbidity in this large series support endoscopic approach as standard of care for CSF leak closure.

耳性髄液漏を伴った髄膜炎を発症した内耳奇形合併成人例

We report a 46-year-old man with bacterial meningitis and left cerebrospinal fluid (CSF) otorrhea associated with inner ear malformation (common cavity type). Left tympanotomy showed granulation over the stapes and water-like otorrhea, and the stapes was separated from the thickened incus long arm. A partial defect was present in the stapes foot plate, and removal of the stapes led to pronounced leakage of CSF. We therefore packed the vestibule with fascia and small pieces of auricular cartilage tightly and then positioned the cap of the vestibule with fascia and fibrin glue. He has remained well and free from meningitic symptoms for two years after the operation. Our case indicates that the occlusion of the vestibule with fascia and auricular cartilage should be considered even in cases without a history of meningitis.

Can intraoperative assessment of endoscopic third ventriculostomy predict success?

In the article that follows, Greenfield et al. have identified and investigated an intuitive observation that many surgeons doing endoscopic third ventriculostomy (ETV) have made. There seem to be patients in whom one can predict a successful outcome; the ventricles are pristine, the floor of the third ventricle is thin, it balloons up when perforated, and one has a clear view of the basilar artery in a widely patent subarachnoid space. By contrast there are other patients in whom there is scarring, a thickened floor of the third ventricle that is relatively immobile after perforation, scarred membranes below the floor, and so on, where failure seems to follow. These authors have attempted to quantify these observations, in a retrospective fashion, to develop a prediction model of these intraoperative findings, perhaps so that surgeons could immediately resort to an alternative treatment (such as ventriculoperitoneal shunt placement) if it looked like the chances of success were small. The authors’ findings match their intuition: there do appear to be clinical and surgical features that predict success. Although they plan to follow this study with a prospective study, how convinced can we be with their current model, and what might they include in their prospective study? There is a specific method for this type of model generation and testing to which the authors have followed to some extent. One first needs a group of patients with the clinical problem at hand who undergo the treatment of interest and experience an outcome. One is immediately aware that this report is from a “quaternary” referral center, particularly devoted to management of intracranial neoplasms, and this patient population might be different from other centers. Their determination of success or failure was the requirement for a subsequent cerebrospinal fluid (CSF) diversion. This is a convenient, often used outcome, but it is potentially problematic in this type of analysis because it depends on the decision making of the surgeon, usually the one performing the first procedure. If the treating surgeon had preconceived notions of what intraoperative factors may lead to failure, it could affect his or her decision-making process on who requires an additional procedure (and thus in whom it would fail), fulfilling the prophesy and acting as a form of bias. There are methods for defining CSF diversion failure at least for shunts, which can be blindly adjudicated, reducing this bias, and probably something the authors should do for ETV for their next study. Second, one needs factors that might have been previously reported or suspected to lead to success or failure. This is perhaps the most vital process in developing clinical prediction rules. The authors effectively used previous literature and clinical expert opinion to generate the potential predictors for study; however, the opinions were limited to a single institution. There is an emerging field in clinical epidemiology of quantitative methods, such as Delphic panels, which would significantly expand the scope of opinions and evaluate them in a more scientific manner. These factors should also be stringently defined, particularly if they are to be used across centers. The authors analyze 2 preoperative factors: 1) patient age < 2 years and 2) documented intraventricular hemorrhage (IVH), a history of meningitis, or a shunt infection. This second factor is really a group of factors that might all be envisioned to create some arachnoid or ventricular scarring. These factors are, however, not strictly speaking separate etiologies; IVH is different from meningitis, not all shunt infections have meningitis, and so on. Similarly for intraoperative findings under “abnormal anatomy” they group intraventricular scarring and intraventricular synechiae (probably the same process), but also leptomeningeal tumor dissemination, which is intuitively quite different. Normally the effect of each individual factor is analyzed separately, and they are only grouped for statistically valid reasons. The authors may have grouped these factors to stay within the confines of their statistical power. For this analysis they would require ~ 10 failures per factor to be analyzed. With 35 failures, the number of factors they J Neurosurg Pediatrics 2 295 297

Endoscopic Closure of CSF Rhinorrhea: 193 cases in 21 years

Objective Over the past 2 decades, endoscopic repair of cerebrospinal fluid (CSF) leaks has become a routine treatment. The goal of this study is to describe endoscopic closure of a large series of traumatic and spontaneous CSF leaks over a 21-year period, focusing on perioperative management, surgical technique, and long-term outcomes. Methods Retrospective chart review of CSF leak patients treated by the senior author and at the Hospital of the University of Pennsylvania from 1987 to 2008. The data analyzed included BMI, etiology, defect location, graft material, presence of encephalocele, use of lumbar drain, history of meningitis, evidence of intracranial hypertension, recurrence rates, and follow-up. Results 193 cases were identified. Follow-up ranging from 1 month to 9 years (mean 20 months) was available on 166 patients. The etiology was spontaneous in 77 patients (40%), traumatic in 109 (56%), and congenital in 7 patients (4%). The average BMI of spontaneous CSF leak patients (35) was significantly greater (p&lt;0.001) than both traumatic (30) and congenital patients (23). Defects were most commonly located in the sphenoid sinus (n = 62, 32%) and the ethmoid roof (n = 60, 31%). The initial success rate was 88% (n = 170) and the overall success rate was 98% (n = 190). 45 patients (23%) had a history of meningitis, and 4 patients (2%) developed meningitis after repair. Conclusions The overall success rate (98%) and low incidence of morbidity in this large series strongly support the endoscopic approach as standard of care for CSF leak closure.

Surgical Factors in Pediatric Cochlear Implantation and Their Early Effects on Electrode Activation and Functional Outcomes

To assess the impact of surgical factors on electrode status and early communication outcomes in young children in the first 2 years of cochlear implantation. Prospective multicenter cohort study. Six tertiary referral centers. Children 5 years or younger before implantation with normal nonverbal intelligence. Cochlear implant operations in 209 ears of 188 children. Percent active channels, auditory behavior as measured by the Infant Toddler Meaningful Auditory Integration Scale/Meaningful Auditory Integration Scale and Reynell receptive language scores. Stable insertion of the full electrode array was accomplished in 96.2% of ears. At least 75% of electrode channels were active in 88% of ears. Electrode deactivation had a significant negative effect on Infant Toddler Meaningful Auditory Integration Scale/Meaningful Auditory Integration Scale scores at 24 months but no effect on receptive language scores. Significantly fewer active electrodes were associated with a history of meningitis. Surgical complications requiring additional hospitalization and/or revision surgery occurred in 6.7% of patients but had no measurable effect on the development of auditory behavior within the first 2 years. Negative, although insignificant, associations were observed between the need for perioperative revision of the device and 1) the percent of active electrodes and 2) the receptive language level at 2-year follow-up. Activation of the entire electrode array is associated with better early auditory outcomes. Decrements in the number of active electrodes and lower gains of receptive language after manipulation of the newly implanted device were not statistically significant but may be clinically relevant, underscoring the importance of surgical technique and the effective placement of the electrode array.

Risk of Meningitis with Cerebrospinal Fluid Rhinorrhea

The annual risk of meningitis in unrepaired fistulas is widely quoted to be approximately 10% per annum. Our aim was to review our experience with cerebrospinal fluid (CSF) leaks and to calculate the overall risk and the annual incidence of meningitis, and to correlate our findings with the causation and the effect of operative intervention in a subgroup of patients who had a history of meningitis. We prospectively collected data on all patients referred with a CSF leak to our tertiary referral center over a 12-year period between 1994 and 2006. We had a follow-up rate of 91%. One hundred eleven patients had a proven leak on endoscopy, beta-2 transferrin, imaging, and/or fluorescein lumbar puncture. The accumulated duration of an active CSF leak in the cohort was 190 years. The total number of episodes of meningitis was 57 in 21 patients, giving an overall risk of developing meningitis of 19%, with an overall incidence of 0.3 episodes per year. There was a progressive reduction in the incidence of meningitis with time, and most episodes occurred within the first year following the onset of the CSF leak. However, the risk persisted as long as the CSF leak was active. The overall risk of meningitis in patients with persistent CSF rhinorrhea was 19%. The annual incidence of meningitis was 0.3 episodes per year, with most episodes occurring within the first year following the onset of the leak. Endoscopic closure is the treatment of choice in most CSF leaks; if successful, it reduces the risk of meningitis.

Presurgical evaluation in refractory epilepsy secondary to meningitis or encephalitis: bilateral memory deficits often preclude surgery

We investigated the clinical features and surgical outcome of 17 patients with refractory epilepsy secondary to CNS infection who were referred to a tertiary center for presurgical evaluation. Six patients had a history of meningitis and 11 patients had a history of encephalitis. Median age at infection was three years (40 days-40 years). Time to seizure onset was shorter in the encephalitis group (median of 0.9 years versus 5.9 years in the meningitis group). MRI showed unilateral mesial temporal sclerosis (MTS) in all but one patient with meningitis (5/6). MRI in the encephalitis group showed unilateral MTS (four patients), bilateral MTS (three), porencephalic cysts (one) or no significant findings (three). Seizure semiology, following analysis of 127 seizures, included automotor seizures, complex motor/hypermotor seizures, dialeptic seizures and bilateral asymmetric tonic seizures. Neuropsychological assessment in patients with MTS frequently showed bilateral memory impairment (7 out of 12 MTS-patients), even in 4 patients with unilateral MTS, precluding epilepsy surgery. Six patients (two meningitis and four encephalitis patients) underwent a temporal lobe resection. All patients are either seizure-free (Class 1a) or are having only auras after surgery. One patient from the meningitis group underwent functional hemispherectomy and he is also seizure-free. In our series, MTS was the most common finding in refractory epilepsy after CNS infections. Bilateral memory deficits were often encountered in patients with MTS, even when unilateral, these deficits being a limiting factor for surgery. Good surgical outcome can be expected in selected patients with unilateral MTS and congruent memory deficits.