Stories about: Department of Neurosurgery

One-time hydrocephalus operation, alternative to shunting, brings good outcomes for babies

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infant hydrocephalus archival photos
(Flickr/Wikimedia Commons)

Hydrocephalus, literally “water on the brain,” is an abnormal build-up of cerebrospinal fluid in the brain cavities known as ventricles. In infants, it can be congenital (it often accompanies spina bifida, for example), or it can be caused by brain hemorrhage or infection. The usual treatment is surgery to implant a shunt, which drains the excess fluid into the abdomen, relieving pressure on the brain.

But over time, shunts nearly always fail, requiring emergency neurosurgery to repair or replace them. But emergency neurosurgery is not something that’s readily available outside of metropolitan areas. Untreated, hydrocephalus causes progressive brain damage and usually death.

What if a one-time operation could treat hydrocephalus permanently? In today’s New England Journal of Medicine, a randomized trial shows good results with a minimally invasive, relatively inexpensive shunt alternative called endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). …

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Shunt-flushing device for hydrocephalus gets FDA clearance; could help patients avoid extra surgery

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A new shunt-flushing device flushes out shunt blockages noninvasively.
Brain shunts frequently clog up, requiring surgical repair or replacement. A new device flushes out the blockages with the press of a button. (Wikimedia/Adobe Images)

Children with hydrocephalus often have shunts implanted to drain the excess cerebrospinal fluid that builds up inside their brain. Unfortunately, shunts have a tendency to plug up. This potentially life-threatening event necessitates emergency surgery to correct or replace the shunt.

“If you have a shunt, you are always worried about what might happen in the future,” says Joseph Madsen, MD, a neurosurgeon at Boston Children’s Hospital. “Close to half of shunts will have a revision within the first year of implantation. About 80 percent will require a revision within 10 years.”

Last week, the FDA cleared a device originally conceived by Madsen that can potentially flush out a clogged shunt noninvasively, avoiding the need for surgery in both children and adults. The neurosurgeon or other trained healthcare professional could simply press a button at the back of the patient’s head, just under the skin, in an office setting, Madsen says. …

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Robot-enhanced neurosurgery for nimbler seizure mapping

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implanting electrodes for seizure monitoring, with robotic assistance
Scellig Stone and Joseph Madsen in surgery with the robot.

Head shaved, a little boy rests on the operating table, deep under anesthesia. His parents have brought him to Boston Children’s Hospital in hopes of determining the cause of his seizures. Now, neurosurgeons Scellig Stone, MD, PhD, Joseph Madsen, MD, and their colleagues in the Epilepsy Center are performing a procedure designed to monitor seizure activity in the 3-year-old’s brain.

But as the team members crowd around the table, they’re not alone. With the push of a button, a large robotic arm rotates and lowers right next to the boy’s head, helping the physicians pinpoint the precise location to drill. “This is a real game-changer,” murmurs one of the clinicians observing the surgery. “It’s going to transform the way we practice.” …

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Training neurosurgeons in a rare hydrocephalus procedure, with a little help from Hollywood

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ETV trainer

A 4-year-old has a progressively enlarging head and loss of developmental milestones: a clear case of hydrocephalus. He undergoes a minimally invasive endoscopic third ventriculostomy (ETV) to drain off the trapped cerebrospinal fluid.

This requires puncturing the floor of the brain’s third ventricle (fluid-filled cavity) with an endoscope — while avoiding a lethal tear in the basilar artery, which lies perilously close.

There are no good neurosurgical training models for this rare and scary operation.

“We semi-blindly poke a hole through the ventricle floor,” says Benjamin Warf, MD, director of Neonatal and Congenital Anomaly Neurosurgery at Boston Children’s Hospital. “To make the technique safer and to be able to train more people, it would be very helpful to make that hole in a way that’s less anxiety-provoking.” …

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Looking between seizures to map seizures’ origins

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seizure mapping

When epilepsy can’t be controlled with drugs, neurosurgery is sometimes curative, if the seizures are coming from discrete brain tissue that can be safely removed.

Finding these diseased areas, however, can require invasive surgery to place grids of electrodes on the brain’s surface. That’s followed by long-term, 24-hour EEG monitoring — typically for a week — until a seizure happens. Neurosurgeons then use this data to map a surgical path. But to actually remove the diseased tissue, a second operation is needed.

That’s enough to deter many families from epilepsy surgery. But what if seizure origins could be mapped without having to actually observe a seizure?

Joseph Madsen, MD, director of Epilepsy Surgery at Boston Children’s Hospital, and Eun-Hyoung Park, PhD, a computational biophysicist in the Department of Neurosurgery, think they have a way to do that — with an algorithm originally used for economic forecasting.  …

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