J Neurosurg 77:476-477, 1992
Retromastoid cisternal Ommaya reservoir for intrathecal therapy of coccidioidomycosis meningitis Technical note CHARLES J. WROBEL,M.D., AND JOHN F. ALKSNE, M.D. Division of Neurosurgery, University of California, San Diego, California
~" A method is described that simplifiesplacement of an Ommaya reservoir for chronic access to the basilar cisterns. This technique is useful in treating coccidioidomycosisand other fungal meningitides. KEY WORDS
"
eoceidioidomycosis
OCCIDIOIDOMYCOSISmeningitis is a chronic fungal infection that produces dense cisternal arachnoiditis and attendant cranial neuropathies, hydrocephalus, and vascular occlusions. At present, the only effective therapy is intrathecal amphotericin B administered for a period ranging from months to years. Lumbar injections of amphotericin B may cause severe arachnoiditis resulting in inadequate treatment of the basilar cisterns. Percutaneous puncture of the cisterna magna is uncomfortable to the patient and considerable morbidity may be produced by inadvertent vascular injury. Some investigators have resorted to injectable shunt systems bearing on/off valves and ventricular Ommaya reservoirs. However, ventriculitis per se seldom occurs in coccidioidal infection of the central nervous system, and ventricular delivery systems may not provide adequate drug levels in the basilar cisterns. Midline suboccipital cisterna magna reservoirs have been employed to overcome these problems. Suboccipital Ommaya reservoirs require considerable dissection to insert, are difficult to palpate for routine access, and often fail owing to neck flexion and extension. Placement of a retromastoid Ommaya reservoir is a simple alternative, providing chronic access for therapy directed at the basal cisterns.
C
9
shunt
9
meningitis
performed as it is for procedures to correct hemifacial spasm. 3 The dura is opened in a cruciate fashion and cerebrospinal fluid is evacuated. Under magnification, the cerebellum is elevated slightly at its inferior lateral margin and arachnoidal adhesions about the lowest cranial nerves are lysed. A 5-cm ventricular catheter is
Technique
The patient is maintained in a lateral position with the head turned 20* toward the floor to facilitate gravity retraction of the cerebellum. A reverse question-mark retroauricular flap is fashioned and a small craniectomy 476
FIG. 1. Illustration showing placement of a retromastoid Ommaya reservoir and eisterna magna catheter. A partialthickness craniectomy aids in the proper seating of the reservoir. The dark broken line shows the retroauricular flap. J. Neurosurg. / Volume 77/September, 1992
Retromastoid cisternal Ommaya reservoir passed retrograde to the cisterna magna under direct vision. The catheter is secured to a 2.5-cm side-port flat-bottomed Ommaya reservoir.* The reservoir is anchored to the pericranium so that it resides over bone within the semicircular curve of the flap (Fig. 1). A partial-thickness craniectomy performed with an air drill may also be employed to seat the reservoir. Watertight dural, muscle, and fascial closure completes the procedure. Staged bilateral reservoir procedures are employed in refractory patients with significant sequestration of cerebrospinal fluid demonstrated by radionuelide cisternography. Comment
Chronic meningitis is the most serious complication of disseminated coccidioidomycosis. Particularly severe reactive arachnoiditis occurs and has a predilection for the posterior fossa and upper cervical subarachnoid * Ommaya reservoir, Model NL 850-1272, manufactured by Heyer-Schulte Corp., Goleta, California.
J. Neurosurg. / Volume 77/September, 1992
space. Morbidity and mortality are related to uncontrollable hydrocephalus, progressive bulbar palsies, and brachial amyotrophy.: Intrathecal therapy may be facilitated by placement of a retromastoid Ommaya reservoir. The procedure is straightforward and we have experienced no complications related to it. References
1. Bouza E, Dreyer JS, Hewitt WL, et al: Coccidioidal meningitis. An analysis of thirty-one cases and review of the literature. Medicine 60:139-172, 198 l 2. Einstein HE: Coccidioidomycosis of the central nervous system. Adv Neural 6:101-105, 1974 3. Yeh HS, Tew JM Jr, Ramirez RM: Microsurgical treatment of intractable hemifacial spasm. Neurosurgery 9: 383-386, 1981 Manuscript received October 1, 1991. Accepted in final form March 4, 1992. Address reprint requests to: Charles J. Wrobel, M.D., Division of Neurosurgery, University of California, San Diego, 225 Dickinson Street, San Diego, California 92103.
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Retromastoid cisternal Ommaya reservoir for intrathecal therapy of coccidioidomycosis meningitis Technical note CHARLES J. WROBEL,M.D., AND JOHN F. ALKSNE, M.D. Division of Neurosurgery, University of California, San Diego, California
~" A method is described that simplifiesplacement of an Ommaya reservoir for chronic access to the basilar cisterns. This technique is useful in treating coccidioidomycosisand other fungal meningitides. KEY WORDS
"
eoceidioidomycosis
OCCIDIOIDOMYCOSISmeningitis is a chronic fungal infection that produces dense cisternal arachnoiditis and attendant cranial neuropathies, hydrocephalus, and vascular occlusions. At present, the only effective therapy is intrathecal amphotericin B administered for a period ranging from months to years. Lumbar injections of amphotericin B may cause severe arachnoiditis resulting in inadequate treatment of the basilar cisterns. Percutaneous puncture of the cisterna magna is uncomfortable to the patient and considerable morbidity may be produced by inadvertent vascular injury. Some investigators have resorted to injectable shunt systems bearing on/off valves and ventricular Ommaya reservoirs. However, ventriculitis per se seldom occurs in coccidioidal infection of the central nervous system, and ventricular delivery systems may not provide adequate drug levels in the basilar cisterns. Midline suboccipital cisterna magna reservoirs have been employed to overcome these problems. Suboccipital Ommaya reservoirs require considerable dissection to insert, are difficult to palpate for routine access, and often fail owing to neck flexion and extension. Placement of a retromastoid Ommaya reservoir is a simple alternative, providing chronic access for therapy directed at the basal cisterns.
C
9
shunt
9
meningitis
performed as it is for procedures to correct hemifacial spasm. 3 The dura is opened in a cruciate fashion and cerebrospinal fluid is evacuated. Under magnification, the cerebellum is elevated slightly at its inferior lateral margin and arachnoidal adhesions about the lowest cranial nerves are lysed. A 5-cm ventricular catheter is
Technique
The patient is maintained in a lateral position with the head turned 20* toward the floor to facilitate gravity retraction of the cerebellum. A reverse question-mark retroauricular flap is fashioned and a small craniectomy 476
FIG. 1. Illustration showing placement of a retromastoid Ommaya reservoir and eisterna magna catheter. A partialthickness craniectomy aids in the proper seating of the reservoir. The dark broken line shows the retroauricular flap. J. Neurosurg. / Volume 77/September, 1992
Retromastoid cisternal Ommaya reservoir passed retrograde to the cisterna magna under direct vision. The catheter is secured to a 2.5-cm side-port flat-bottomed Ommaya reservoir.* The reservoir is anchored to the pericranium so that it resides over bone within the semicircular curve of the flap (Fig. 1). A partial-thickness craniectomy performed with an air drill may also be employed to seat the reservoir. Watertight dural, muscle, and fascial closure completes the procedure. Staged bilateral reservoir procedures are employed in refractory patients with significant sequestration of cerebrospinal fluid demonstrated by radionuelide cisternography. Comment
Chronic meningitis is the most serious complication of disseminated coccidioidomycosis. Particularly severe reactive arachnoiditis occurs and has a predilection for the posterior fossa and upper cervical subarachnoid * Ommaya reservoir, Model NL 850-1272, manufactured by Heyer-Schulte Corp., Goleta, California.
J. Neurosurg. / Volume 77/September, 1992
space. Morbidity and mortality are related to uncontrollable hydrocephalus, progressive bulbar palsies, and brachial amyotrophy.: Intrathecal therapy may be facilitated by placement of a retromastoid Ommaya reservoir. The procedure is straightforward and we have experienced no complications related to it. References
1. Bouza E, Dreyer JS, Hewitt WL, et al: Coccidioidal meningitis. An analysis of thirty-one cases and review of the literature. Medicine 60:139-172, 198 l 2. Einstein HE: Coccidioidomycosis of the central nervous system. Adv Neural 6:101-105, 1974 3. Yeh HS, Tew JM Jr, Ramirez RM: Microsurgical treatment of intractable hemifacial spasm. Neurosurgery 9: 383-386, 1981 Manuscript received October 1, 1991. Accepted in final form March 4, 1992. Address reprint requests to: Charles J. Wrobel, M.D., Division of Neurosurgery, University of California, San Diego, 225 Dickinson Street, San Diego, California 92103.
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