1st NeuroSurgery Appointment

First appointment in Neurosurgery with Dr. Bruce Kaufman, Medical Director of Pediatric Neurosurgery at Children’s Hospital of Wisconsin. He is Board Certified in Pediatric Neurological Surgery.

Wednesday, September 1, 2010.
Also met with Dr. Chris Peske, PA (Physicians Assistant)
Revised copy Sept. 8, 2010

1)    Ryan weighed 20 lbs. 15 oz.  

2)    Dr. Peske stated he read Ryan’s medical records.  He examined Ryan and took a brief history.   He asked questions about Ryan’s medical history, his birth, developmental milestones, demeanor, etc. 

3)    Dr. Kaufman then joined the appointment and showed the pictures comparing the first MRI (taken Sept. 18, 2009) and the second MRI (taken July 20, 2010).  He said Dr. Jacobson’s  (the neurologist) impression was Chiari I malformation after reviewing the recent MRI, so that is why Ryan was referred to neurosurgery. 

4)    Dr. Kaufman said children can have a bigger head size due to: big head size in the family or increasing fluid in the brain.  He said Ryan’s head was somewhat bigger but not huge.  He said he had to decipher if it is hydrocephalus or not.  Dr. Kaufman said he did not know if he had this increase fluid during infancy as there was no record of MRI at birth or soon after.  He suggested we check the early medical records to see if a bigger head or increased fluid in the brain was mentioned in the notes. 

5)    Dr. Kaufman showed us the comparison of the first and second MRI.  The first MRI (2009) showed some increased size of ventricles in the brain and some increased fluid but not significant.  The second MRI (2010) showed a) increased fluid in the lateral ventricles, b) part of the cerebellum was protruding into the spinal canal, c) increased fluid behind the cerebellum, and d) a fluid filled cyst in the back of the brain.  He said he was very concerned about the increase of fluid build up between the first and second MRI.  There is a blocking or narrowing of the passageway for the cerebrospinal fluid causing increased intracranial pressure.  Dr. Kaufman said that sometimes this fluid buildup causes physical symptoms and sometimes it doesn’t.  He stated that with Chiari malformation, the brain stem and/or cerebellum are longer than normal and protrude down into the spinal cord/canal thus narrowing the passageway and disrupting  normal flow of cerebrospinal fluid.  Dr. Kaufman stated he will be cleaning out this passageway of debris, bone or other matter in this canal.  Some of the symptoms of Chiari malformation include headaches, choking, gagging, etc.  

6)    Dr. Kaufman said with increased cerebrospinal fluid in the brain, treatment is a) use of a shunt to divert increasing fluid in the brain to other parts of the body where it can be absorbed  or b) performing  a decompression (to release pressure) to open up passageways so the cerebrospinal fluid can flow normally throughout the brain and spinal cord. 

7)    His recommendation was to do a Chiari I Decompression before considering  a shunt, to help decrease fluid in the brain and to open up passageway for normal flow.  The incision would be in the back of the skull, above the neck.  It would also help drain the fluid filled cyst, opening up a  passageway through the arachnoid membrane (the arachnoid membrane encloses the brain and spinal cord).  He said the risks of the procedure would be: infection (administering  antibiotics post surgery) and blood clots (check with Dr. Peske if anti-clotting meds will be given). 

8)    We asked him about the first MRI. If that did not show an excessive build-up of fluid, then what caused the hypotonia and developmental delays during Ryan’s first year of life?  He could not speculate because there was no MRI after birth. He said sometimes there is Intraventricular hemorrhages (IVH) (bleeding within the ventricles of the brain) – sometimes a complication with premature births.  But the bleeding would not show up on the MRI’s now, so this cause is strictly speculative at this time.   Review early medical records to  see if this was mentioned or any tests were performed to check for IVH after Ryan’s birth.   

9)    Dr. Kaufman’s diagnosis is: Obstructive Hydrocephalus (there is an obstruction in the flow of cerebrospinal fluid within the ventricular system of the brain, causing the ventricles to expand in size and a build up of fluid in a cyst).  He does surgery on Monday, Tuesday, Wednesday, and Thursday.  They will call you with a date.  It will require 5-7 days in the hospital with the first day in ICU.  Dr. Kaufman will be the Attending Physician, with help of PA’s and residents, but he will be throughout the procedure.  There will be about a 5-6 hour timeframe from pre-op to recovery –  (1 to 1 ½ hours in pre-op, 1-2 hours in surgery, 45 minutes to close, and then recovery time).  Dr. Peske said that if you have any questions before surgery, you should call him.   Call him to get an approximate timeframe of when Ryan could return to daycare, inquire about the level of home and medical care needed post surgery, and when Dr. Kaufman would want to see him for a follow-up appointment. 


Terms:

Cerebellum – the part of the brain that coordinates movement, muscle tone, and controls balance. 

 Ventricles – the 4 cavities of the brain filled with cerebrospinal fluid  (2 lateral, 3rd ventricle, and the 4th ventricle).  

 Cerebrospinal Fluid (CSF)  – a water cushion protecting the brain and spinal cord from physical impact.  CSF is made up of mostly water with a few trace proteins and nutrients that are needed for the nourishment and normal function of the brain. CSF circulates around the brain and spinal cord, protecting them from injury and trauma.   

Three membranes surround the spinal cord and brain: a) the dura mater – the outermost membrane, b) the arachnoid –the middle layer –  a thin transparent membrane; the sub-arachnoid space contains CSF, and c) the pia mater – the inner most layer closely surrounding the spinal cord and brain. 

Obstructive Hydrocephalus – there is an obstruction in the flow of cerebrospinal fluid within the ventricular system of the brain, causing the ventricles to expand in size and a build up of fluid in a cyst.

Pictures of Ryan within a week or two from the time he went into surgery.

He spends LOTS of time on his stomach and forearms.

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