455 A Case of An Unusual Penetrating Brain Injury

Abstract Introduction Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident. Case Presentation 45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring. Discussion It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).

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Traumatic Cerrebral Fungus: Experience From an Institution in North East India

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_10_17 ◽

2017 ◽

Vol 08 (S 01) ◽

pp. S37-S43

Author(s):

Binoy Kumar Singh ◽

Abinash Dutta ◽

Shameem Ahmed ◽

Zakir Hussain ◽

Rajib Hazarika ◽

...

Keyword(s):

Head Injury ◽

Brain Parenchyma ◽

Csf Leak ◽

Mortality And Morbidity ◽

Patients Âgés ◽

North East India ◽

North East ◽

Brain Parenchymal ◽

Gcs Score ◽

Parenchymal Injury

ABSTRACTBackground: Traumatic brain fungus is manifestation of neglected head injury. Although rare it is not uncommon. The patients are usually intact with good Glasgow coma (GCS) score inspite of complex injuries and exposed brain parenchyma but morbidity and mortality is very high with time if no proper and timely management is offered. There is very less study on traumatic brain fungus with no defined management protocols. So an attempt was made to explain in details the surgical strategies and other management techniques in patients with traumatic brain fungus. Aims: To study and evaluate the pattern of causation, clinical presentations, modalities of management of traumatic brain fungus and outcome after treatment. Methods: All patients with fungus cerebri, admitted to our centre from January 2012 to December 2015 were studied prospectively. All the patients were examined clinically and triaged urgently for surgery. CT head was done in all patients to look for any brain parenchymal injury. All patients were managed surgically. Outcome was assessed as per the Glassgow Outcome Score. Results: Total 10 patients were included in the study. 8 were men and 2 women. The patients' ages ranged from 3-48 years (mean 31.6 years). The interval between initial injury and protrusion ranged from 3 days to 6 days (mean 4.1 days). Mean GCS at the time of presentation was 13.2.60% of the patients (n =6) sustained moderate head injury. (GCS-9-13). Size of the fungus ranged from 5cm×3cm to 8cm×10cm. Conclusion: Early and proper local wound treatment prevents fungus formation. Pre-emptive antibiotics, AEDs and cerebral decongestants are recommended. Loose water-tight duroplasty prevents CSF leak. But mortality and morbidity can be reduced significantly if brain fungus is managed properly by applying basic surgical principles and antibiotic protocols combined with newer surgical modalities.

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Cerebral Proliferative Angiopathy: Case Report

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1642604 ◽

2018 ◽

Vol 37 (02) ◽

pp. 131-133 ◽

Cited By ~ 1

Author(s):

Luana Gatto ◽

Rodrigo Brisson ◽

Zeferino Demartini ◽

Gelson Koppe ◽

Carlos Rocha

Keyword(s):

Case Report ◽

Endovascular Procedures ◽

Brain Parenchyma ◽

Neurological Deficits ◽

Motor Deficit ◽

Brain Arteriovenous Malformation ◽

Cerebral Vascular Disease ◽

Functional Brain ◽

History Of ◽

Over Time

AbstractProliferative angiopathy (PA) is a rare cerebral vascular disease in which anomalous vessels continually recruit additional feeder arteries, amid a functional brain parenchyma. We report the case of a young woman with progressive history of headache, motor deficit, seizures and drowsiness. She received a misdiagnosis of brain arteriovenous malformation (AVM) and evolved with dysarthria and cognitive decline after an unsuccessful embolization performed at another institution. We opted for conservative treatment with periodic control by imaging tests. Proliferative angiopathy differs in natural history, prognosis, histopathology and treatment of the usual AVMs. Endovascular procedures aggravate the neurological deficits, which are usually progressive and tend to worsen over time.

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Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

Neurosurgical FOCUS ◽

10.3171/2019.8.focus19543 ◽

2019 ◽

Vol 47 (5) ◽

pp. E10

Author(s):

Kunal Varshneya ◽

Adrian J. Rodrigues ◽

Zachary A. Medress ◽

Martin N. Stienen ◽

Gerald A. Grant ◽

...

Keyword(s):

Pediatric Patients ◽

Pediatric Population ◽

Skull Fracture ◽

Neurological Deficits ◽

Csf Leak ◽

Skull Fractures ◽

Pediatric Head Trauma ◽

Cerebrospinal Fluid Leaks ◽

Neurosurgical Intervention ◽

Csf Leaks

OBJECTIVESkull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.METHODSThe authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.RESULTSThe authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).CONCLUSIONSThe authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

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Tension pneumocephalus with cerebrospinal fluid rhinorrhoea in a post craniotomy patient

Acute Medicine Journal ◽

10.52964/amja.0258 ◽

2010 ◽

Vol 9 (1) ◽

pp. 13-14

Author(s):

Nicholas H Smallwood ◽

◽

Sreenivasan Shiva ◽

Keyword(s):

Cerebrospinal Fluid ◽

Clinical Features ◽

Frontal Sinus ◽

Surgical Intervention ◽

Csf Leak ◽

Dural Tear ◽

Tension Pneumocephalus ◽

Neurological Signs ◽

Important Complication ◽

Csf Rhinorrhoea

Tension pneumocephalus is an uncommon but important complication of neurosurgery, often requiring urgent surgical intervention. It should be considered in any patient presenting with neurological symptoms after recent craniotomy, particularly if they also have clinical features consistent with cerebrospinal fluid (CSF) leak. We describe a patient who presented four weeks post-craniotomy with fluctuating neurological signs and CSF rhinorrhoea, who made a full recovery following repair of a frontal sinus defect and dural tear.

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Application of a new hydrogel dural sealant that reduces epidural adhesion formation: evaluation in a large animal laminectomy model

Journal of Neurosurgery Spine ◽

10.3171/2009.10.spine09537 ◽

2010 ◽

Vol 12 (4) ◽

pp. 381-390 ◽

Cited By ~ 19

Author(s):

Mark C. Preul ◽

Patrick K. Campbell ◽

David S. Garlick ◽

Robert F. Spetzler

Keyword(s):

Polyethylene Glycol ◽

Valsalva Maneuver ◽

Adhesion Formation ◽

Tissue Response ◽

Neurological Deficits ◽

Csf Leak ◽

Large Animal ◽

Adhesion Barrier ◽

Csf Leakage ◽

Epidural Adhesion

Object The aim of this study was to evaluate the application and effects of a novel, nonswelling, polyethylene glycol-based hydrogel adhesion barrier and sealant in a canine laminectomy model of CSF leakage and adhesion formation. Methods After full-width L-2 and L-5 laminectomies, 1-cm midline durotomies were created and sutured closed, except for the last 1–2 mm on the cranial end to create spontaneous CSF leakage. All 5 control animals received no further treatment. Experimental animals received hydrogel at both durotomy sites via either the Dual Liquid applicator (5 animals) or MicroMyst gas-assisted sprayer (5 animals). Sealing of the CSF leak was confirmed by Valsalva maneuver. At 2 months, 2 animals from each group were killed to evaluate dural healing and epidural adhesion formation. The remaining animals were similarly evaluated 4 months after surgery. One animal died at 66 days due to a cause unrelated to hydrogel treatment. Results In hydrogel-treated animals, all leaking durotomies were sealed intraoperatively. All animals recovered uneventfully. There were no treatment-related health effects. MicroMyst hydrogel application was more controlled, slower, and significantly less thick (p = 0.0094) than Dual Liquid application. All 5 control animals developed subcutaneous CSF accumulations under the incision within days of surgery, compared with only 1 of 10 hydrogel-treated animals (p = 0.002). At 2 and 4 months, control laminectomy sites showed extensive, dense epidural adhesions blending with neodura, compared with hydrogel-treated sites (p < 0.0001 and p = 0.0234, respectively). At 2 months in hydrogel-treated animals, gel filled the epidural space and no epidural adhesions were noted (p < 0.0001 relative to controls). At 4 months, the hydrogel was absorbed. The hydrogel space was filled with scant, loosely organized connective tissue. Conclusions Hydrogel prevented CSF leakage and mitigated epidural scarring without affecting healing of the dura or laminectomy site. The safety profile of the hydrogel appears favorable due to its synthetic composition, polyethylene glycol chemistry, minimal local tissue response, and lack of neurological deficits. Controlled application of such hydrogel materials may reduce the incidence of postoperative leaks, prevent adhesion formation and thus improve recovery from spinal surgery, and improve identification of tissue planes for reoperations.

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Long-term surgical outcomes following transsphenoidal surgery in patients with Rathke’s cleft cysts

Journal of Neurosurgery ◽

10.3171/2017.11.jns171498 ◽

2019 ◽

Vol 130 (3) ◽

pp. 831-837 ◽

Cited By ~ 7

Author(s):

Michelle Lin ◽

Michelle A. Wedemeyer ◽

Daniel Bradley ◽

Daniel A. Donoho ◽

Vance L. Fredrickson ◽

...

Keyword(s):

Transsphenoidal Approach ◽

Neurological Deficits ◽

Csf Leak ◽

Rathke's Cleft Cysts ◽

The Mean ◽

Rathke's Cleft ◽

Cyst Fenestration ◽

Csf Leaks

OBJECTIVERathke’s cleft cysts (RCCs) are benign epithelial lesions of the sellar region typically treated via a transsphenoidal approach with cyst fenestration and drainage. At present, there is limited evidence to guide patient selection for operative treatment. Furthermore, there is minimal literature describing factors contributing to cyst recurrence.METHODSThe authors conducted a retrospective analysis of 109 consecutive cases of pathology-confirmed RCCs treated via a transsphenoidal approach at a single center from 1995 to 2016. The majority of cases (86.2%) involved cyst fenestration, drainage, and partial wall resection. Long-term outcomes were analyzed.RESULTSA total of 109 surgeries in 100 patients were included, with a mean follow-up duration of 67 months (range 3–220 months). The mean patient age was 44.6 years (range 12–82 years), and 73% were women. The mean maximal cyst diameter was 14.7 mm. Eighty-eight cases (80.7%) were primary operations, and 21 (19.3%) were reoperations. Intraoperative CSF leak repair was performed in 53% of cases and was more common in reoperation cases (71% vs 48%, p < 0.001). There were no new neurological deficits or perioperative deaths. Two patients (1.8%) developed postoperative CSF leaks. Transient diabetes insipidus (DI) developed in 24 cases (22%) and permanent DI developed in 6 (5.5%). Seven cases (6.4%) developed delayed postoperative hyponatremia. Of the 66 patients with preoperative headache, 27 (44.3%) of 61 reported postoperative improvement and 31 (50.8%) reported no change. Of 31 patients with preoperative vision loss, 13 (48.1%) reported subjective improvement and 12 (44.4%) reported unchanged vision. Initial postoperative MRI showed a residual cyst in 25% of cases and no evidence of RCC in 75% of cases. Imaging revealed evidence of RCC recurrence or progression in 29 cases (26.6%), with an average latency of 28.8 months. Of these, only 10 (9.2% of the total 109 cases) were symptomatic and underwent reoperation.CONCLUSIONSTranssphenoidal fenestration and drainage of RCCs is a safe and effective intervention for symptomatic lesions, with many patients experiencing improvement of headaches and vision. RCCs show an appreciable (although usually asymptomatic) recurrence rate, thereby mandating serial follow-up. Despite this, full RCC excision is typically not recommended due to risk of hypopituitarism, DI, and CSF leaks.

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Lack of mitochondrial ferritin aggravated neurological deficits via enhancing oxidative stress in a traumatic brain injury murine model

Bioscience Reports ◽

10.1042/bsr20170942 ◽

2017 ◽

Vol 37 (6) ◽

Cited By ~ 9

Author(s):

Ligang Wang ◽

Libo Wang ◽

Zhibo Dai ◽

Pei Wu ◽

Huaizhang Shi ◽

...

Keyword(s):

Oxidative Stress ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Knockout Mice ◽

Brain Injuries ◽

Brain Infarction ◽

Neurological Deficits ◽

Important Correlation ◽

The Brain ◽

And Oxidative Stress

Oxidative stress has been strongly implicated in the pathogenesis of traumatic brain injury (TBI). Mitochondrial ferritin (Ftmt) is reported to be closely related to oxidative stress. However, whether Ftmt is involved in TBI-induced oxidative stress and neurological deficits remains unknown. In the present study, the controlled cortical impact model was established in wild-type and Ftmt knockout mice as a TBI model. The Ftmt expression, oxidative stress, neurological deficits, and brain injury were measured. We found that Ftmt expression was gradually decreased from 3 to 14 days post-TBI, while oxidative stress was gradually increased, as evidenced by reduced GSH and superoxide dismutase levels and elevated malondialdehyde and nitric oxide levels. Interestingly, the extent of reduced Ftmt expression in the brain was linearly correlated with oxidative stress. Knockout of Ftmt significantly exacerbated TBI-induced oxidative stress, intracerebral hemorrhage, brain infarction, edema, neurological severity score, memory impairment, and neurological deficits. However, all these effects in Ftmt knockout mice were markedly mitigated by pharmacological inhibition of oxidative stress using an antioxidant, N-acetylcysteine. Taken together, these results reveal an important correlation between Ftmt and oxidative stress after TBI. Ftmt deficiency aggravates TBI-induced brain injuries and neurological deficits, which at least partially through increasing oxidative stress levels. Our data suggest that Ftmt may be a promising molecular target for the treatment of TBI.

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The supraorbital eyebrow approach in children: clinical outcomes, cosmetic results, and complications

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.10.peds1430 ◽

2015 ◽

Vol 15 (1) ◽

pp. 12-19 ◽

Cited By ~ 12

Author(s):

Brian J. Dlouhy ◽

Michael P. Chae ◽

Charles Teo

Keyword(s):

Frontal Sinus ◽

Medial Temporal Lobe ◽

Skin Incision ◽

Senior Author ◽

Csf Leak ◽

Cosmetic Results ◽

Working Space ◽

Operative Outcomes ◽

Endoscopic Assistance ◽

A Minor

OBJECT The supraorbital eyebrow approach utilizes an eyebrow skin incision to fashion a supraorbital craniotomy for exposure of the subfrontal corridor. This provides anterolateral access to surgical lesions in the anterior cranial fossa, parasellar regions, brainstem, and medial temporal lobe. With use of the endoscope, further areas can be accessed. This approach has been applied effectively in adults, but questions remain about its use in children—specifically with regard to adequate working space, effectiveness for achieving the desired results, cosmesis, and complications. METHODS The authors conducted a retrospective review of more than 450 cases involving patients of all ages who had undergone a supraorbital eyebrow approach performed by the senior author (C.T.) from 1995 to 2013. Only cases involving patients younger than 18 years with a minimum follow-up of 6 weeks were included in this study. All inpatient and outpatient records were retrospectively reviewed and clinical/operative outcomes, cosmetic results, and complications were recorded. In the present article, the authors briefly describe the surgical approach and highlight any differences in applying it in children. RESULTS Fifty-four pediatric patients who had undergone a supraorbital eyebrow approach met inclusion criteria. The pathological conditions consisted mostly of tumors or other resectable lesions. In a total of 51 resectable lesions, 44 surgeries resulted in a gross-total (100%) resection and 7 cases resulted in subtotal (50%–99%) resection. The endoscope assisted and expanded visualization or provided access to areas not reached by standard microscopic visualization in all cases. Cosmetic outcomes were excellent. In all cases, the incisional scar was barely visible at 6 weeks. In 3 cases a minor bone defect was observed on the forehead. Given the small size of the frontal sinus in children, no frontal sinus breaches occurred. Additionally, no CSF leak or wound infection was identified. CONCLUSIONS The supraorbital eyebrow approach is extremely effective in achieving desired results in properly selected cases in patients of all pediatric age ranges, from infants to teenagers. There is sufficient working space for the endoscope and all instruments, allowing for endoscopic assistance and bimanual surgical technique. Cosmetic results are excellent, and complications related to the approach are minimal.

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Rapid development of an intranidal aneurysm with perifocal brain edema in an unruptured cerebral arteriovenous malformation

Journal of Neurosurgery ◽

10.3171/jns.2002.97.6.1436 ◽

2002 ◽

Vol 97 (6) ◽

pp. 1436-1440 ◽

Cited By ~ 8

Author(s):

Atsuya Akabane ◽

Hidefumi Jokura ◽

Kuniaki Ogasawara ◽

Kou Takahashi ◽

Kazuyuki Sugai ◽

...

Keyword(s):

Mr Imaging ◽

Arteriovenous Malformation ◽

Brain Edema ◽

Rapid Development ◽

Brain Parenchyma ◽

Neurological Deficits ◽

High Signal ◽

Surgical Removal ◽

Content Type ◽

Signal Void

✓ The authors present the case of a 22-year-old man with an unruptured arteriovenous malformation (AVM) in which an intranidal aneurysm had grown in the course of 3 months and was complicated by perifocal brain edema. A left parietal AVM was incidentally diagnosed on magnetic resonance (MR) imaging. No aneurysms were noted on cerebral angiograms obtained simultaneously. Three months later, T2-weighted MR imaging revealed perifocal brain edema (increased signal intensity in the brain parenchyma adjacent to the nidus). An aneurysm-like signal void was demonstrated in the center of the high-signal area, but no previous hemorrhages could be detected. Angiographic studies revealed an intranidal aneurysm 4 mm in diameter projecting anterolaterally from the nidus. Surgical removal was performed without incident, and no neurological deficits or postoperative complications were observed. An MR image obtained 2 weeks postsurgery revealed complete resolution of the perifocal brain edema. To the authors' knowledge, this is the first reported case of an unruptured AVM in which an intranidal aneurysm with perifocal brain edema developed rapidly (within a few months).

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Therapeutic Effects of Systemic Administration of the Novel RANKL-Modified Peptide, MHP1, for Ischemic Stroke in Mice

BioMed Research International ◽

10.1155/2018/4637084 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 2

Author(s):

Munehisa Shimamura ◽

Hironori Nakagami ◽

Hideo Shimizu ◽

Kouji Wakayama ◽

Tomohiro Kawano ◽

...

Keyword(s):

Ischemic Stroke ◽

Infarct Volume ◽

Brain Parenchyma ◽

Neurological Deficits ◽

Therapeutic Effects ◽

Inhibitory Effects ◽

Continuous Administration ◽

Anti Inflammatory ◽

Rank Signaling ◽

Continuous Injection

Microglial healing peptide 1, “MHP1”, is a newly developed synthetic peptide composed of the DE and a part of the EF loop of the receptor activator of nuclear factor-кB (NFκB) ligand (RANKL). Our previous report demonstrated that MHP1 significantly inhibits Toll-like receptor (TLR) 2- and 4-induced inflammation in microglia/macrophages through RANK signaling without osteoclast activation. However, its inhibitory effects on ischemic stroke when administered intravenously have not been clarified. First, we examined whether MHP1 could penetrate the brain parenchyma. Intravenous injection of FITC-conjugated MHP1 demonstrated that MHP1 could cross the blood-brain-barrier in peri-infarct regions, but not in intact regions. Because MHP1 in the parenchyma was reduced at 60 minutes after injection, we speculated that continuous injection was necessary to achieve the therapeutic effects. To check the possible deactivation of MHP1 by continuous injection, the anti-inflammatory effects were checked in MG6 cells after incubation in 37°C for 24 hours. Although the inhibitory effects for IL6 and TNFα were reduced compared to nonincubated MHP1, its anti-inflammatory efficacy remained, indicating that continuous administration with pump was possible. The single and successive continuous administration of MHP1 starting from 4 or 6 hours after cerebral ischemia successfully reduced infarct volume and prevented the exacerbation of neurological deficits with reduced activation of microglia/macrophages and inflammatory cytokines. Different from recombinant RANKL, MHP1 did not activate osteoclasts in the paralytic arm. Although further modification of MHP1 is necessary for stabilization, the MHP1 could be a novel agent for the treatment ischemic stroke.

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