Search PubMed⌕ Search

Biomedical subjects

Hugh J L Garton

Publications and source records attributed to Hugh J L Garton.

9 recordsLinked to original sources
PubMed2006

Papilledema in the assessment of ventriculomegaly.

To determine whether ventriculomegaly is associated with ongoing increased intracranial pressure (ICP), physicians often rely on corroborative imaging features such as altered periependymal signal, distortion of ventricular shape, subarachnoid space flattening, and an increase in ventricular size over time. In 2 patients with new headache and altered mental status, symptoms and ventriculomegaly were dismissed as long-standing and not reflective of current ICP elevation. In the first patient, ICP was considered normal because there were no corroborative imaging features of elevated ICP. In the second patient, ICP was considered normal because ventricular size was stable over a 1-year period. The diagnosis of ICP elevation was finally made by ICP monitoring after papilledema was recognized. Ventriculoperitoneal shunting rapidly resolved the papilledema and markedly improved mentation. Brain imaging may often be an unreliable guide to the presence of elevated ICP. In such patients, the finding of papilledema is a critical determinant of management.

Adult↗
PubMed2006

Occult tethered cord syndrome: a survey of practice patterns.

OBJECT: Tethered cord syndrome (TCS) is associated with a number of congenital anomalies involving early development of the spinal cord. These include myelomeningocele, spinal cord lipoma, low-lying conus medullaris, and a fibrofatty terminal filum. Occult TCS occurs in patients when clinical features indicate a TCS but the typical anatomical abnormalities are lacking. It is controversial whether surgical release of the terminal filum leads to clinical improvement in a patient who does not have a previously identified anatomical abnormality. To assess the clinical standard used by practicing pediatric neurosurgeons, a practice survey was conducted at the 2004 Annual Meeting of the Joint Section for Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. METHODS: The survey examined clinical decision making for a same-case scenario with differing appearance on imaging studies. There was a clear consensus regarding diagnosis and treatment in the patient with symptoms, a low-lying conus medullaris, and a fatty terminal filum. The vast majority of respondents (85%) favored surgical untethering for this patient. A majority of respondents (67%) also favored treatment for the patient having symptoms and a fatty terminal filum. There was, however, significant disagreement regarding the diagnosis and treatment of disease in one patient with symptoms and an inconclusive magnetic resonance imaging study. Some respondents clearly favored surgery, whereas others believed that this patient did not meet the diagnostic criteria for TCS. CONCLUSIONS: The results of this survey support the development of a randomized clinical trial to address the benefit of surgery for occult TCS.

Cauda Equina↗
PubMed2006

Management of shunt infections: a multicenter pilot study.

OBJECT: Approximately 10% of cerebrospinal fluid (CSF) shunt operations are associated with infection and require removal or externalization of the shunt, in-hospital treatment with antibiotic agents, and insertion of a new shunt. In a previous survey, the authors identified substantial variation in the duration of antibiotic therapy as well as the duration of hospital stay. The present multicenter pilot study was undertaken to evaluate current strategies in the treatment of shunt infection. METHODS: Patients were enrolled in the study if they had a successful treatment of a CSF shunt infection proved by culture of a CSF specimen. Details of their care and the incidence of culture-proved reinfection were recorded. Seventy patients from 10 centers were followed up for 1 year after their CSF shunt infection. The initial management of the infection was shunt externalization in 17 patients, shunt removal and external ventricular drain insertion in 50, and antibiotic treatment alone in three. Reinfection occurred in 18 patients (26%). Twelve of the 18 reinfections were caused by the same organism and six were due to new organisms. The treatment time varied from 4 to 47 days, with a mean of 17.4 days for those who later experienced a reinfection compared with 16.2 days for those who did not. The most common organism (Staphylococcus epidermidis, 34 patients) was associated with a reinfection rate of 29% and a mean treatment time of 12.8 days for those who suffered reinfection and 12.5 days for those who did not. CONCLUSIONS: Reinfection after treatment of a CSF shunt infection is alarmingly common. According to the data available, the incidence of reinfection does not appear to be related to the duration of antibiotic therapy.

Adolescent↗
PubMed2004

Hydrocephalus.

Hydrocephalus is not an exotic condition in general pediatric practice. A general pediatrician might expect to serve two to five children with CSF shunts. This article reviews posthemorrhagic hydrocephalus in detail.

Cerebrospinal Fluid Shunts↗
PubMed2004

Cerebrospinal fluid diversion procedures.

Cerebrospinal fluid (CSF) diversion procedures remain the principal method of treatment of hydrocephalus and an important option in treating idiopathic intracranial hypertension. Recent advances in CSF shunt hardware offer some promise in reducing the rate of complications. Third ventriculostomy has become an increasingly practiced alternative to conventional shunting in an ever-widening patient population. Long-term follow-up studies have identified complications of lumboperitoneal shunt placement. Advances in surgical navigation suggest that ventriculoperitoneal shunting may be a viable alternative in patients with idiopathic intracranial hypertension.

Cerebrospinal Fluid Shunts↗
PubMed2004

Risk of infection with prolonged ventricular catheterization.

OBJECTIVE: The relationship between extended ventricular catheterization and infection remains controversial. Although studies have substantiated an increasing infection rate with prolonged catheterization, there has been less agreement on whether this trend continues beyond 10 days. Our study reviews the daily infection rate of 595 patients, 213 of whom underwent more than 10 days of catheterization. METHODS: All patients who underwent ventricular monitoring in the neurological intensive care unit from 1995 to 2003 at the University of Michigan Health System were reviewed retrospectively. Infection was defined as a positive cerebrospinal fluid culture. Life-table analysis was used to calculate daily hazard (infection) rates. Patient age, sex, diagnosis, catheter exchanges, location of patient during catheter insertion, and cerebrospinal fluid leak were evaluated as risk factors for infection. RESULTS: The average patient age was 51.3 years, and 51.3% were male. Duration of catheterization averaged 8.6 days. The overall infection rate was 8.6%. Daily infection rates increased from the onset of catheter insertion but reached a plateau after Day 4, with subsequent rates ranging predominantly between 1 and 2%, even with extended catheterization beyond 10 days. Only ventricular catheters that had been placed at other institutions significantly affected the infection rate. CONCLUSION: A relationship between duration of catheterization and infection seems to be present. However, this relationship is not linear. There is an extremely low daily infection rate that rises over the initial 4 days but then remains relatively constant even with prolonged catheter use. Clinical decisions to continue ventricular catheterization should reflect this low daily risk of infection, which does not seem to increase with extended catheter use.

Adolescent↗
PubMed2004

Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature.

Migration of distal ventriculoperitoneal shunt tubing is known to occur in a wide of variety of locations. The authors report an unusual complication involving a previously confirmed intraperitoneal shunt catheter that migrated into the heart and pulmonary vasculature. Radiographic evidence suggested that this occurred secondary to cannulation of a segment of the external jugular vein with a shunt trochar during tunneling of the distal catheter. This is the sixth reported case of a peritoneal shunt tube migrating proximally into the heart. The authors review the literature regarding migration of distal tubing into the heart and pulmonary artery. Based on imaging studies obtained in the present case, the authors posit that the mechanism for this unusual type of shunt migration is inadvertent penetration of either the internal or external jugular vein during the initial tunneling procedure. Negative intrathoracic pressure and slow venous flow then draws the catheter out of the peritoneum and into the vasculature. The distal catheter then migrates into the right side of the heart and pulmonary artery. Diagnosis and management of this type of complication is discussed.

Adolescent↗
PubMed2002

A cost-effectiveness analysis of endoscopic third ventriculostomy.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) is currently the principal alternative to cerebrospinal fluid shunt placement in the management of pediatric hydrocephalus. Cost-effectiveness analysis can help determine the optimal strategy for integrating these different approaches. METHODS: All patients (n = 28) who underwent ETV at British Columbia's Children's Hospital between 1989 and 1998 were matched for age, pathogenesis, and number of previous shunt procedures, with patients treated with cerebrospinal fluid shunts. To perform a cost-effectiveness analysis, hydrocephalus-related resource consumption and outcome (determined as the number of hydrocephalus treatment-free days during follow-up) were then retrospectively identified. Cost data were linked to resource use to provide a total cost for all resources used. Costs and outcomes were discounted annually at 5% by standard economic analysis methods. RESULTS: Twenty-four of 28 ETV patients had obstructive hydrocephalus. Over equivalent follow-up periods (median, 35 mo), the ETV success rate (defined by need for reoperation) was 54%. One hydrocephalus-related death and one hemiparesis occurred in the ETV group. No permanent procedure-related morbidity or mortality was seen in the shunt group. The cost/effect ratios for the two groups were similar. The additional incremental resource use by the shunt group included six readmissions and eight reoperations. ETV mean costs per patient were $10,570 +/- $7628, versus $10,922 +/- $8722 for the shunt group (Canadian dollars for the year 2000). Costs accrued more quickly for the shunt group as time passed. The additional incremental outcome benefit to the endoscopy group was 86 treatment-free days (3.07 d per patient [95% confidence interval, -7.56 to 13.70 d]). Neither of these differences was statistically significant. CONCLUSION: In this matched cohort, ETV was not significantly less costly or more effective over a median 35 months of follow-up, with a 54% initial ETV success rate, even before the additional morbidity and mortality encountered were taken into account. The time course for the accrued costs suggests that a larger cohort, longer follow-up, or higher success rates are needed to demonstrate the cost-effectiveness of this therapy.

Adolescent↗