| Ethical concerns in fertility preservation in the young Nalini Mahajan The Onco Fertility Journal 2018 1(2):59-60 |
| Breast cancer and Fertility Part 2- Pregnancy Associated Breast Cancer Nalini Mahajan The Onco Fertility Journal 2018 1(2):61-70 Pregnancy-associated breast cancer (PABC) refers to breast cancer (BC) diagnosed during pregnancy or within the first postpartum year. The increasing incidence follows the increase in age at first childbirth. Diagnostic delay due to physiological breast changes of pregnancy leads to the tumor being diagnosed at a more advanced stage. Since the termination of pregnancy does not alter the course of disease, patients can be offered BC management during pregnancy with a good outcome. Chemotherapy (CT) can be given safely during the second and third trimester of pregnancy. In the first trimester, the option of surgery is available while during puerperium, radiotherapy can be safely administered in addition to CT. Prognosis is related to the stage and grade of the tumor. Neonatal outcomes are reassuring. This article gives an overview of the diagnosis, management, and prognosis of PABC. |
| Fertility preservation network in Asia: Current status and issues of fertility preservation network in Japan Yasushi Takai The Onco Fertility Journal 2018 1(2):71-73 Fertility preservation (FP)/oncofertility is a crucial facet of cancer supportive care. The publication of FP guidelines is becoming increasingly prevalent in Japan. However, the viability of the guidelines is predicted on a well-developed FP network comprising of cancer hospitals, assisted reproductive technology (ART) hospitals/clinics, and oncofertility center, and the quality of the FP network in Japan varies greatly based on the region. Oncofertility care availability is influenced by the sustainability of each network and public financial support which may be facilitated by oncofertility registry system which recently launched in Japan. |
| Comparison of ovarian reserve and response to gonadotropin stimulation in fertile and infertile Indian women based on ovarian reserve markers, anti-Mullerian hormone and antral follicle count Jasneet Kaur, Nalini Mahajan The Onco Fertility Journal 2018 1(2):74-80 Background: Poor ovarian response to gonadotropin (GT) stimulation during assisted reproductive technology cycles is often encountered in infertile women and is considered to be a cause of their infertility. Poor ovarian response is mostly a result of a low ovarian reserve (OR), implying that there may be an earlier depletion of the oocyte pool in infertile women. Aim of the Study: To evaluate whether infertile Indian women below the age of 35 years have an earlier depletion of their OR and a lower ovarian response to GT in comparison to age-matched fertile controls. Materials and Methodology: A total of 146 women undergoing in vitro fertilization-intracytoplasmic sperm injection at our fertility center between March 2017 and August 2017 were prospectively enrolled in this study. Anti-Mullerian hormone and antral follicle count (AMH and AFC) assessment was done for women enrolled in the study in the early follicular phase. Flexible GnRH antagonist protocol was followed. Age, AMH, AFC, body mass index, and response to ovarian stimulation (OS) were compared between the fertile and infertile groups. We also sought to determine which among these had the best prediction for ovarian response to controlled OS. Statistical Analysis: Chi-square test was used for comparisons between study groups with respect to percentages. P < 0.05 was considered to be statistically significant. Results: When adjusted for the differences in the demographic variables, we found no difference in the AMH (P = 0.298) and AFC (P = 0.302) between the fertile and infertile women. In addition, there was no difference in the ovarian response; the mean number of oocytes retrieved was 15.8 ± 7.5 in the fertile group and 14.3 ± 7.5 in the infertile group (P = 0.510). AMH had the strongest correlation with the number of oocytes retrieved (r = 2.11) in comparison to AFC (r = 0.08) and age (r = −0.45) Conclusion: There is no difference in OR and response in fertile and infertile Indian having similar demographics and basal characteristics. |
| Intrauterine autologous platelet-rich plasma therapy to improve implantation rates in patients undergoing frozen embryo transfer: A pilot study Anju Madhavan, Padmaja Naidu, Kum Kum Rani, Jasneet Kaur, Nalini Mahajan The Onco Fertility Journal 2018 1(2):81-85 Background: Successful implantation is a well-orchestrated event requiring the presence of a healthy embryo, a receptive endometrium, appropriate embryo endometrial cross-talk, and adequate maternal immune protection. Despite advances in assisted reproductive technology, there are insignificant improvements in the implantation and pregnancy rates. Intrauterine infusion of platelet-rich plasma (PRP) might improve implantation rates through its paracrine effects by recruiting growth factors and cytokines that favor decidualization and implantation. Objectives: The objective of the study is to study whether intrauterine PRP improves implantation rates in patients undergoing frozen embryo transfer (FET). Subjects and Methods: In this retrospective study, we collected data of patients who underwent FET in Mother and Child Hospital for 11 months from January 2018 to November 2018. We screened data of 98 patients who had at least one previous failed FET and underwent subsequent FET. The patients were divided into a study and control group. The study group received Intrauterine PRP before FET, while the control group did not. All patients underwent the same hormone replacement therapy regimen for endometrial preparation. Main Outcome Measure: The main outcomes studied were the implantation rates and clinical pregnancy rates (CPR) after embryo transfer. Results: Patient demographics such as mean age, body mass index, and anti-mullerian hormone of both groups were comparable. Overall, the CPR was 42.8% in the control group and 47.6% in the intervention group, and the difference was not statistically significant. Conclusion: Intrauterine PRP does not increase the implantation rates/CPR significantly in patients who have had one previous FET failure. |
| Strategies for fertility preservation in young patients with cancer Devika Gunasheela, Jyothi Menon, N Ashwin The Onco Fertility Journal 2018 1(2):86-88 Advances in cancer therapy have given a chance for patients suffering from cancers to have a productive life. Future effects of chemotherapy or radiotherapy or fertility should be discussed with all cancer patients who have reproductive potential. Fertility preservation stratergies for females include oocyte or embryo preservation, cortical tissue cryopreservation, ovarian transportation. Fertility preservation stratergies for male involve cryopreservation of semen. Fertility preservation in cancer patients should be approached with a multidisciplinary setting. |
| Fertility preservation in testicular seminoma Madhuri Patil, Priyanka Reddy The Onco Fertility Journal 2018 1(2):89-95 Testicular cancer is the most common solid malignancy affecting males between the ages of 15 and 35, although it accounts for only 1% of all cancers in men. Germ cell tumors (GCTs) account for 95% of testicular cancers. Two broad categories of testicular tumors have been described, one pure seminoma (no nonseminomatous elements present) and the other is nonseminomatous GCTs. It is one the most curable neoplasm with 5 years survival rate of 98%–99% when diagnosed at an early stage. We present here one such case of metastatic seminoma, where the semen was cryopreserved for fertility preservation. Although the sample was oligoasthenospermic, a successful pregnancy and live birth was obtained with intrauterine insemination of the frozen sample in an controlled ovarian stimulation cycle. Testicular tumors can impair fertility after treatment in majority of patients. Fertility preservation methods such as semen freezing, sperm freezing using epididymal or testicular sperm extraction (TESE) or testicular tissue freezing provides hope for those who wish to father a child latter. |
| Fertility preservation in a premenarcheal female with sickle cell anemia Sonu Balhara Ahlawat, Sarabpreet Singh The Onco Fertility Journal 2018 1(2):96-98 The objective of the study was fertility preservation in a premenarcheal female with sickle cell anemia (SCA) using controlled ovarian hyperstimulation and oocyte preservation. The study design was a case report. The study was conducted at the reproductive medicine unit of a tertiary care private hospital. A 15-year-old premenarcheal female with Tanner stage 3 breast development and Tanner stage 1 pubic hair diagnosed with SCA, referred by a medical oncologist for fertility preservation before undergoing chemotherapy and bone marrow transplant. The interventions were evaluation of ovarian reserve, ovarian stimulation (OS), transvaginal oocyte aspiration, and oocyte cryopreservation (OC). The main outcome measure was cryopreservation of mature oocytes before the antineoplastic therapy. Controlled ovarian hyperstimulation allowed for cryopreservation of ten mature oocytes before the start of the patient's gonadotoxic treatment. OS and OC can be successfully performed in premenarcheal/peripubertal SCA patients before undergoing chemotherapy, thus providing a viable option for fertility preservation. |
| A case report on severe ovarian hyperstimulation syndrome in a pregnancy with torsion of bilateral enlarged ovaries with acute abdomen Sankar Kumar Das, Priyanka Roy The Onco Fertility Journal 2018 1(2):99-102 Ovarian hyperstimulation syndrome is a complication of fertility treatment, which uses pharmacological ovarian stimulation to increase the number of oocytes and therefore embryos available during assisted reproductive technology. Ovarian hyperstimulation syndrome is invariably associated with increased volume of ovaries which is itself a threat to undergo torsion, and it may cause an additional threat requiring prompt surgical intervention in many situations. Simple release of torsion, sacrificing the devitalized ovarian tissue in part and complete can have effect in continuation of pregnancy; and something like this happened in our case. The patient, 29-year-old, a known case of polycystic ovary syndrome (PCOS), conceived through ovulation induction; came with an episode of acute pain abdomen with abdominal distension toward the later part of her first trimester. Ultrasonography was done. Bilateral enlarged ovaries of around 23 cm × 11.8 cm each were seen meeting at the pouch of Douglas with ascites. It was a case of ovarian hyperstimulation syndrome, more specifically, a case of late ovarian hyperstimulation syndrome. Serum E2 level was 3263 pg/ml. Laparotomy was then done. Intraperitoneally bilateral ovarian torsion was seen with areas of necrosis. The right oophorectomy was done, while on the left side some portion of normal ovarian tissue was preserved. Following the operation, her symptoms were improved. The pregnancy continued uneventfully. Exposure of ovaries to human chorionic gonadotropin or luteinizing hormone following controlled ovarian stimulation by follicle-stimulating hormone underlies most cases of ovarian hyperstimulation syndrome. The risk of ovarian hyperstimulation syndrome is smaller when using gonadotropin-releasing hormone antagonist (GnRH) antagonist protocol instead of GnRH agonist protocol for suppression of ovulation during ovarian hyperstimulation. To avoid ovarian hyperstimulation syndrome, the best trigger is GnRH agonists. In PCOS patients, metformin is an important aid in reducing ovarian hyperstimulation syndrome. |
| Beware of bleomycin toxicity: Fertility preservation for dysgerminoma Ashraf M Ali, Paapa Dasari The Onco Fertility Journal 2018 1(2):103-106 An 18-year-old female who underwent fertility preservation surgery for dysgerminoma Stage IIa received adjuvant chemotherapy and bleomycin, etoposide and cisplatin of four cycles. She presented with cough and breathlessness after 45 days of the last cycle of chemotherapy. She was tachypneic and had decreased SpO2 and was managed by supportive therapy. Her X-ray chest revealed bilateral ground-glass nodular opacity and computed tomography thorax showed evidence of pulmonary fibrosis in the form of intra- and inter-lobular septal fibrosis with surrounding ground-glass opacity. She ultimately died after 5 days of admission due to respiratory failure. Her body weight was 37 kg and she received standard dose of bleomycin and the cumulative dose was 360 U. Bleomycin dose recommendation is not per kg bodyweight, and the complication of pulmonary fibrosis could have been prevented if the dosage schedule as per bodyweight (0.25–0.5 U/kg) is advocated. |
Παρασκευή 22 Φεβρουαρίου 2019
The Onco Fertility Journal (Onco Fertil J)
Πέμπτη 21 Φεβρουαρίου 2019
Clinical Infectious Diseases
| The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study Abstract Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown.Methods This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015–September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship.Results There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003).Conclusions Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing. | ||||||||||||||||||
| Prevalence, Predictors, and Successful Treatment Outcomes of Xpert MTB/RIF–identified Rifampicin-resistant Tuberculosis in Post-conflict Eastern Democratic Republic of the Congo, 2012–2017: A Retrospective Province-Wide Cohort Study Abstract Background Multidrug-resistant tuberculosis (MDR-TB) jeopardizes global TB control. The prevalence and predictors of Rifampicin-resistant (RR) TB, a proxy for MDR-TB, and the treatment outcomes with standard and shortened regimens have not been assessed in post-conflict regions, such as the South Kivu province in the eastern Democratic Republic of the Congo (DRC). We aimed to fill this knowledge gap and to inform the DRC National TB Program.Methods of adults and children evaluated for pulmonary TB by sputum smear microscopy and Xpert MTB/RIF (Xpert) from February 2012 to June 2017. Multivariable logistic regression, Kaplan–Meier estimates, and multivariable Cox regression were used to assess independent predictors of RR-TB and treatment failure/death.Results Of 1535 patients Xpert-positive for TB, 11% had RR-TB. Independent predictors of RR-TB were a positive sputum smear (adjusted odds ratio [aOR] 2.42, 95% confidence interval [CI] 1.63–3.59), retreatment of TB (aOR 4.92, 95% CI 2.31–10.45), and one or more prior TB episodes (aOR 1.77 per episode, 95% CI 1.01–3.10). Over 45% of RR-TB patients had no prior TB history or treatment. The median time from Xpert diagnosis to RR-TB treatment initiation was 12 days (interquartile range 3–60.2). Cures were achieved in 30/36 (83%) and 84/114 (74%) of patients on 9- vs 20/24-month MDR-TB regimens, respectively (P = .06). Predictors of treatment failure/death were the absence of directly observed therapy (DOT; adjusted hazard ratio [aHR] 2.77, 95% CI 1.2–6.66) and any serious adverse drug event (aHR 4.28, 95% CI 1.88–9.71).Conclusions Favorable RR-TB cure rates are achievable in this post-conflict setting with a high RR-TB prevalence. An expanded Xpert scale-up; the prompt initiation of shorter, safer, highly effective MDR-TB regimens; and treatment adherence support are critically needed to optimize outcomes.
|
| Hepatitis C Guidance 2018 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection Abstract Recognizing the importance of timely guidance regarding the rapidly evolving field of hepatitis C management, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) developed a web-based process for the expeditious formulation and dissemination of evidence-based recommendations. Launched in 2014, the hepatitis C virus (HCV) guidance website undergoes periodic updates as necessitated by availability of new therapeutic agents and/or research data. A major update was released electronically in September 2017, prompted primarily by approval of new direct-acting antiviral agents and expansion of the guidance's scope. This update summarizes the latest release of the HCV guidance and focuses on new or amended recommendations since the previous September 2015 print publication. The recommendations herein were developed by volunteer hepatology and infectious disease experts representing AASLD and IDSA and have been peer reviewed and approved by each society's governing board. |
Pneumocephalus and pneumoventricle
| CASE REPORT | |
|
Delayed pneumoventricle following endonasal cerebrospinal fluid rhinorrhea repair with thecoperitoneal shunt
Shyam Sundar Krishnan, Adarsh Manuel, Madabhushi Chakravarthy Vasudevan
Department of Neurosurgery, Achanta Lakshmipathi Neurosurgical Centre, Voluntary Health Services Hospital, Chennai, Tamil Nadu, India
| Date of Web Publication | 21-Feb-2019 |
     |
Correspondence Address:
Dr. Shyam Sundar Krishnan
Department of Neurosurgery, Achantha Lakshmipathy Neurosurgical Centre, Voluntary Health Services, TTTI Post, Taramani, Chennai - 600 113, Tamil Nadu
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ajns.AJNS_224_18
| Abstract |
Pneumocephalus and pneumoventricle are well-documented in neurosurgical practice. Although both are common posttraumatic sequelae, iatrogenic causes are also well recognized. Iatrogenic causes may be seen after intracranial surgical procedures or cerebrospinal fluid (CSF) diversion procedures. Small amount of pneumoventricle postshunt procedure is usually a self-limiting condition. Rarely, the patient may develop tension pneumoventricle which requires emergency intervention. The occurrence of delayed tension pneumoventricle/pneumatocele following surgery for CSF rhinorrhea with CSF diversion procedures is very rare. We report one case of late presentation of delayed tension pneumoventricle with temporal pneumatocele in a patient who underwent transnasal endoscopic repair of CSF fistula followed by thecoperitoneal shunt. This condition is potentially lethal that requires prompt recognition and surgical treatment.
Keywords: Cerebrospinal fluid rhinorrhea, pneumatocele, pneumocephalus, tension pneumoventricle, thecoperitoneal shunt
| How to cite this article: Krishnan SS, Manuel A, Vasudevan MC. Delayed pneumoventricle following endonasal cerebrospinal fluid rhinorrhea repair with thecoperitoneal shunt. Asian J Neurosurg 2019;14:325-8 |
| How to cite this URL: Krishnan SS, Manuel A, Vasudevan MC. Delayed pneumoventricle following endonasal cerebrospinal fluid rhinorrhea repair with thecoperitoneal shunt. Asian J Neurosurg [serial online] 2019 [cited 2019 Feb 21];14:325-8. Available from: http://www.asianjns.org/text.asp?2019/14/1/325/250010 |
| Introduction |  |
The occurrence of pneumoventricle as a delayed complication of cerebrospinal fluid (CSF), rhinorrhea repair with thecoperitoneal shunt is a rare presentation. Tension pneumocephalus is a known and common entity as compared to tension pneumoventricle. The presence of pneumatocele in the temporal lobe in association with the above condition makes it a unique clinical presentation.
| Case Report | |
This 48-year-old female presented with complaints of CSF rhinorrhea since 2 months. There was no history or clinical finding suggestive of trauma or meningitis. Her neurological examination otherwise was unremarkable. Computed tomography (CT) face/skull base followed by magnetic resonance imaging (MRI) brain and diagnostic nasal endoscopy were done which showed the defect in the cribriform plate and left a lateral wall of the sphenoid sinus [Figure 1]. Lumbar puncture done showed the CSF opening pressure of 35 cm of water and no evidence of infection.
 | Figure 1: Magnetic resonance images of the patient showing cerebrospinal fluid fistula in cribriform plate (short arrow) and lateral wall of sphenoid sinus (long arrow) and computed tomography paranasal sinuses bone window showing defect (long arrow) in the sphenoid bone with cerebrospinal fluid filling into the left sphenoid sinus (long arrow) Click here to view |
She underwent transnasal endoscopic repair of CSF fistula along with placement of thecoperitoneal shunt with no anti-siphon device. The bath-plug technique was used to seal the defects by introducing a fat plug with a specifically secured vicryl suture into the intradural space, followed by applying traction on the suture to seal the defect much like a bathplug seals a bath. Rectus abdominis fascia graft was harvested from the same abdominal wound used for shunt placement. The defect was further reinforced by fascia, fat and surgical, and fibrin sealant. It was decided to place thecoperitoneal shunt as the CSF opening pressure was very high to prevent the recurrent CSF leak. Postoperatively, she was symptom-free and discharged to home.
After 1 month, she presented with memory disturbances, multiple episodes of vomiting and headache. There was no recurrence of CSF rhinorrhea or postnasal drip. MRI brain showed pneumoventricle with right temporal pneumatocele [Figure 2]. Diagnostic endoscopy was done which showed dislodged fascia graft. She underwent emergency repacking of the CSF fistula with the removal of thecoperitoneal shunt and aspiration of pneumoventricle underwater seal which was under high pressure. Fasica graft was repositioned to cover the defect after sealing it with fat using the bath-plug technique as in the previous surgery. Fat and fascia packing was reinforced with a pedicled Hadad flap and fibrin sealant. She improved in her symptoms postoperatively. Postoperative CT brain showed good resolution of pneumoventricle with reduced size of ventricular system [Figure 3]. She remained symptom free at 6-month follow-up.
 | Figure 2: Magnetic resonance imaging brain showing pneumatocele (long arrow) in the right temporal lobe and pneumoventricle (short arrow) Click here to view |
 | Figure 3: Postoperative computed tomography brain showing good resolution of tension pneumoventricle and right temporal pneumatocele Click here to view |
| Discussion | |
Pneumocephalus is defined as the presence of air in the intracranial compartment due to communication between intracranial and extracranial compartments.[1],[2],[3] Tension pneumocephalus is a rarer form of pneumocephalus in which the air is under high pressure.[1],[2],[4],[5],[6],[7]Pneumocephalus occur most commonly in head injuries.[1],[2],[3] Intra- and post-operative pneumocephalus/pneumoventricle is well-documented, especially, in sitting position surgeries, nitrous oxide anesthesia, and CSF diversion surgeries.[1],[2],[3] Other conditions causing pneumocephalus are CNS infections caused by gas-producing organisms, congenital neurenteric cysts, and postradiotherapy for nasopharyngeal carcinoma.[1],[2],[4],[5],[6],[7] Small amounts of pneumoventricle alone are common after shunt surgeries, ventricular tumor surgeries.[1],[2],[3],[8] Sometimes, wound breakdown following the shunt surgeries may cause influx of air peritubally and cause pneumoventricle.[9] Delayed tension pneumoventricle is an extremely rare complication and <50 cases have been described in the literature.[1]Pneumocephalus/pneumoventricle is usually benign which does not require any treatment, and it decreases at a rate of 25% per week.[4],[9],[10],[11],[12]
Two different mechanisms have been proposed in the development of delayed tension pneumoventricle/pneumocephalus.[1],[2],[3],[13],[14]
- Dandy's theory of ball valve mechanism: one-way ball valve mechanism causing air to flow into the skull through dural defect where the exit is prevented by brain or meninges sealing the leak site
- Horowitz inverted soda-bottle effect: negative pressure develops inside the cranial cavity as a result of excessive loss of CSF. This drop in intracranial pressure (ICP) causes air to flow from the extra to the intracranial space across the pressure gradient.
In our case, the patient presented with spontaneous CSF rhinorrhea and was treated by endoscopic skull base defect repair with thecoperitoneal shunt placement. CSF rhinorrhea can be due to traumatic or nontraumatic causes. Traumatic can be either due to head injuries causing skull base fractures or due to iatrogenic causes. Spontaneous leaks could be associated with or without raised ICP. High-pressure leaks could account up to 45% of the nontraumatic CSF rhinorrhea.[15] Sustained increase in ICP causes bony erosion and creation of an osteodural defect in pneumatized parts of the skull base such as cribriform plate, craniopharyngeal canal, sella, and spheno-occipital synchondrosis leading to CSF leak.[7],[15] CSF leaks in these cases have been postulated to represent a manifestation of benign intracranial hypertension or pseudotumor cerebri.[16],[17],[18],[19] In our case also CSF leak was associated with raised ICP with no evidence of trauma or infection. This could be an underlying benign ICP with or without congenital defect.
Normal pressure leaks represent 55% of the nontraumatic cases of the CSF rhinorrhea.[20],[21] It is hypothesized that the spontaneous leak is due to point erosions in the skull base which occur in normal person as a result of physiologic alterations in CSF pressure with transient increase in ICP up to 80 mm of water lasting for few seconds.[15] Other nontraumatic causes of CSF leak include congenital skull base defects, erosion of the skull base by tumors, infection, mucocele, and following radiation.
CSF diversion in patients with long-standing raised ICP may result in the pneumoventricle by air aspiration through a preexisting congenital or iatrogenic skull base erosion/fistula.[3] These fistulous sites/erosion points are plugged by scarred meninges or gliotic brain which open up due to a drop in ICP causing inward flow of air. This air is prevented from escaping by temporarily resealing of meningeal cicatrix and this cycle repeatedly happens, resulting in tension pneumoventricle (ball valve mechanism). Shunts by their siphon effect can create significant negative ICP drop which ranges from −30 to −155 mm of water, and sometimes as low as −440 mm of water.[2],[5] Pneumatocele is located close to the site of fistulae and more common in the temporal lobe. In our case also there might have been a sustained negative pressure caused by the thecoperitoneal shunt without anti-siphon device.
Pneumoventricle presents usually with symptoms and signs of raised ICP such as a recurrent headache with vomiting, impairment of consciousness, seizures, memory disturbances, and gait disturbance. Sometimes, patients present with acute or chronic meningitis. Intracranial splashing sounds called "bruit hydroaerique" are characteristic in some patients. Similarly, our patient also presented with memory disturbances and cognitive impairment during the second presentation.
The delay from CSF shunting to the development of pneumocephalus may vary from a week up to 5 years.[7],[22] The usage of high-pressure shunts and antisiphon devices have been recommended by some authors to prevent this complication.[1],[2],[23] Our routine policy is to place Chhabra standard adult thecoperitoneal shunt with no anti-siphon device. However, anti-siphon device has advantages of preventing over-drainage of CSF, and the reservoir gives access to check the patency of the shunt system. We have seen an increased risk of shunt obstruction with anti-siphon device. We had 42 cases who underwent Lumbar-peritoneal (LP) shunts without anti-siphon device in the past 5 years and none of them presented with shunt obstruction or shunt-related morbidity other than shunt migration (five patients) and abdominal pseudocyst (two patients). Programmable shunt provides the benefit of adjusting the pressure setting according to the ventricular pressure. We routinely do not use programmable LP shunts as ours is a resource-limited center with most of the patients coming from low-socioeconomic strata.
Prevention of infection, treatment of raised ICP, aspiration of pneumoventricle, closure of fistula, and removal of shunt tube are the keys to successful management of tension pneumoventricle secondary to CSF fistula.[23] Broad-spectrum antibiotics are used after shunt removal, but its prophylactic usage is debated.[1],[5],[23] Removal of the shunt tube relieves the sustained negative pressure which may cause recurrent pneumoventricle/pneumocephalus. Postshunt removal a temporary CSF diversion is preferred by some authors, especially, if the infection is doubted clinically or confirmed.[1],[2],[23]
In our case, as there was dislodgement of fat-fascia graft, repacking was done followed by aspiration of pneumoventricle underwater seal and thecoperitoneal shunt was removed. We feel the tension pneumoventricle caused air to dissect into the right temporal lobe region under pressure forming the temporal pneumatocele. The shunt was removed to alleviate negative pressure gradient as it was nonprogrammable shunt with no anti-siphon device. The patient had complete resolution of symptoms after the procedure. This makes us think that we should probably reconsider the usage of anti-siphon device and also a pedicled flap to repair the skull base defects. A programmable valve may be the best choice in financially affordable patients. In patients with normal/moderately high ICP (25 cm of water), a temporary lumbar drain can be considered for few days until the defects heal thus preventing the recurrent CSF leaks.
| Conclusion | |
Although it is a rare entity, tension pneumoventricle should be considered in patients who have undergone CSF diversion procedures along with anterior skull base repair. Sometimes, it can occur as a delayed complication which may lead to acute neurological deterioration and sudden death. Hence, prompt diagnosis is necessary for timely intervention and prevention.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| Figures |
[Figure 1], [Figure 2], [Figure 3]
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