Ventriculolumbar perfusion and inhalational anesthesia with sevoflurane in an accidental intrathecal injection of tranexamic acid: unreported treatment options

2021 ◽  
pp. rapm-2021-102498
Author(s):  
Sergej Godec ◽  
Michael Jozef Gradisek ◽  
Tomislav Mirkovic ◽  
Primoz Gradisek
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Tranexamic Acid ◽  
Treatment Options ◽  
Intrathecal Injection ◽  
Combined Treatment ◽  
Neurological Status ◽  
Trauma Patients ◽  
Multiple Receptors ◽  
Inhalational Sedation

BackgroundTranexamic acid (TXA) decreases hemorrhage-related mortality in trauma patients and is increasingly being used during obstetric and orthopedic surgeries. Inadvertent intrathecal injection of TXA is a rare, potentially lethal event leading to dose-dependent cardiotoxicity and neurotoxicity. TXA enhances neuronal excitation by antagonizing inhibitory γ-aminobutyric acid type A and glycine receptors. Until now, mechanistic-based pharmacological treatments targeting multiple central nervous system receptors have been advocated for use in such cases, with no data on intrathecal TXA elimination techniques.Case presentationA patient scheduled for hip surgery accidentally received 350 mg of intrathecal TXA instead of levobupivacaine. The clinical picture progressed from spinal segmental myoclonus to generalized convulsions and malignant arrhythmias. The treatment consisted of ventriculolumbar perfusion with normal saline at a rate of 50 mL/hour starting 5 hours after TXA administration and inhalational sedation with sevoflurane, in addition to drugs acting on multiple receptors at different central nervous system levels. Over 2 months the neurological status improved, although it was not complete.ConclusionsFor the first time, the feasibility and possible clinical efficacy of combined treatment with ventriculolumbar perfusion and inhalational sedation with sevoflurane were demonstrated. A referral to a neurosurgical facility is recommended in patients with acute TXA-induced neurotoxicity and cardiotoxicity.

scholarly journals CENTRAL NERVOUS SYSTEM INVOLVEMENT IN ADULT ACUTE LYMPHOBLASTIC LEUKEMIA: DIAGNOSTIC TOOLS, PROPHYLAXIS AND THERAPY

2014 ◽  
Vol 6 (1) ◽  
pp. e2014075 ◽  
Author(s):  
Maria Ilaria Del Principe ◽  
Luca Maurillo ◽  
Francesco Buccisano ◽  
Giuseppe Sconocchia ◽  
Mariagiovanna Cefalo ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Acute Lymphoblastic Leukemia ◽  
Lymphoblastic Leukemia ◽  
Intrathecal Injection ◽  
False Negative ◽  
Diagnostic Tools ◽  
Positive Finding ◽  
Cns Involvement ◽  
Hematopoietic Stem

In adult patients with acute lymphoblastic leukemia (ALL), Central Nervous System (CNS) involvement is associated with a very poor prognosis. The diagnostic assessment of this condition relies on the use of neuroradiology, conventional cytology (CC) and flow cytometry (FCM). Among these approaches, which is the gold standard it is still a matter of debate. Neuroradiology and CC have a limited sensitivity with a higher rate of false negative results. FCM demonstrated a superior sensitivity over CC, particularly when low levels of CNS infiltrating cells are present. Although prospective studies of large series of patients are still awaited, a positive finding by FCM appears to anticipate an adverse outcome even if CC shows no infiltration. Current strategies for adult ALL CNS-directed prophylaxis or therapy involve systemic and intrathecal chemotherapy and radiation therapy. Actually, early and frequent intrathecal injection of cytostatic combined with systemic chemotherapy is the most effective strategy to reduce the frequency of CNS involvement. In patients with CNS overt ALL, at diagnosis or upon relapse, allogenic hematopoietic stem cell transplantation might be considered. This review will discuss risk factors, diagnostic techniques for identification of CNS infiltration and modalities of prophylaxis and therapy to manage it. 

Central Nervous System Disease in Acute Lymphoblastic Leukemia: Prophylaxis and Treatment

Hematology ◽  
2006 ◽  
Vol 2006 (1) ◽  
pp. 142-146 ◽  
Author(s):  
Ching-Hon Pui
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Acute Lymphoblastic Leukemia ◽  
Lymphoblastic Leukemia ◽  
Treatment Options ◽  
Central Nervous System Disease ◽  
Cranial Irradiation ◽  
Childhood All ◽  
Excellent Outcome ◽  
Cns Relapse

Abstract Improved treatment for acute lymphoblastic leukemia (ALL) has virtually eliminated testicular relapse. However, the control of central nervous system (CNS) leukemia remains a therapeutic challenge in childhood ALL, partly because of the late complications arising from cranial irradiation. In most current pediatric protocols, cranial irradiation (12 to 18 Gy) is given to 5% to 25% of patients—those with T-cell ALL, overt CNS disease (CNS3 status) or high-risk cytogenetics. CNS control is a less urgent concern in adults with ALL, in whom systemic relapse remains the major problem. With current approaches, approximately 2% to 10% of patients can be expected to develop CNS relapse. Children with B-cell precursor ALL who have a late CNS relapse (after an initial remission of 18 months or more) and did not receive cranial irradiation have an excellent outcome after retrieval therapy, with a 5-year event-free survival (EFS) rate approaching that in newly diagnosed patients. Innovative treatment options are needed for children who develop CNS relapses after a short initial remission or after receiving cranial irradiation, and in any adults with CNS leukemia at diagnosis or relapse.

scholarly journals Disseminated Mycobacterium Tuberculosis Infection with Central Nervous System Involvement and Ponchet’s Disease

2018 ◽  
Vol 3 (2) ◽  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Mycobacterium Tuberculosis ◽  
Brain Mri ◽  
Central Nervous System Infection ◽  
Central Nervous System Involvement ◽  
Neurological Status ◽  
Left Knee ◽  
Mycobacterium Tuberculosis Infection ◽  
Cns Tuberculosis

Background: Diagnosing central nervous system (CNS) tuberculosis is challenging because of its rarity, indolent course, and insensitive microbiological diagnosis. The mortality of the disease is high even with prompt initiation of appropriate therapy. Case report: A 36-year-old male from Pakistan with no past medical history was brought to the hospital with fever (39o C) and altered behavior since 2 weeks. He was confused, with nuchal rigidity, an enlarged right cervical lymph node and swelling of the left knee and ankle. The first brain CT was normal. Lumbar puncture revealed lymphocytic pleocytosis with elevated protein and low glucose. He was started on ceftriaxone, ampicillin and acyclovir pending further cerebrospinal fluid (CSF) analysis. CSF acid-fast staining, tuberculin skin test, CSF PCR for mycobacterium tuberculosis, testing for HIV, Cryptococcus and syphilis were all negative. Due to the patient’s worsening neurological status, a brain MRI was performed revealing worsening hydrocephalus, leptomeningeal enhancement and brain edema, findings consistent with tuberculous central nervous system infection. A ventriculostomy was placed and he was started on anti-tuberculosis therapy and adjunctive prednisone. The diagnosis of tuberculosis was later confirmed from culture of the CSF. Synovial fluid analysis revealed 30 leukocytes/ul, with negative cultures (suggesting Poncet’s disease). Despite improvement of the level of conscience, neurological improvement was otherwise limited, and the patient died 4 months later after repeated in-hospital infections. Discussion: Considering the morbidity and mortality of CNS tuberculosis empirical initiation of therapy is important when the clinical suspicion is high.

scholarly journals CENTRAL NERVOUS SYSTEM RELAPSE OF MULTIPLE MYELOMA

2019 ◽  
Vol 5 (1) ◽  
Author(s):  
Maria Qubtia ◽  
Muhammad Umer Nasir ◽  
Memoona Mian ◽  
Abdul Hameed
Keyword(s):  
Central Nervous System ◽  
Multiple Myeloma ◽  
Nervous System ◽  
Initial Response ◽  
Complete Response ◽  
Neurological Status ◽  
Best Supportive Care ◽  
High Dose ◽  
Central Nervous System Relapse ◽  
Dismal Prognosis

Multiple myeloma (MM) is a plasma cell disorder primarily involving bone marrow. Extramedullary involvement is less common, with central nervous system (CNS) myelomatosis being a rare entity and such presentation carries extremely dismal prognosis. We present case of a 40 years old male with MM who was initially treated with 6 cycles of Cyclophosphamide, Thalidomide and Dexamethasone resulting in complete response. 2 years later he presented with CNS myelomatosis and scrotal involvement and was initially treated with Bortezomib and dexamethasone, cranial irradiation and intrathecal Methorexate, Cytarabine, Hydrocortisone (TRIO IT), along with radical orchiectomy and testicular radiation during the course of treatment. However, after initial response his disease showed clinical and radiological progression after 4 months of therapy. He was switched to high dose Methotrexate (HD-MTX) with TRIOITand later Lenalidamide and dexamethasone (Len/dex) was added to the above regimen. He continued to show good clinical response but his cytology remained persistently positive, therefore, HD-MTX was discontinued in the later course of treatment. Subsequently he was started on best supportive care only, when his neurological status deteriorated further. He survived almost 9 months after a diagnosis of CNS myelomatosis. Patients with multiple myeloma, presenting with neurological symptoms should always be investigated for the possibility of CNS MM. CNS relapse is a fatal disease with poor prognosis. Recommended treatment must include a systemic anti-MM regimen that crosses the BBB (ideally Immunomodulatory drugs (IMiDs) IMiDs-dexamethasone based therapy), CNS irradiation and intrathecal chemotherapy.Key words: Multiple myeloma, central nervous system myelomatosis, therapy

scholarly journals Primary intradural neuroendocrine tumour of spine: a rare pathology

2018 ◽  
Vol 5 (4) ◽  
pp. 1567 ◽  
Author(s):  
Vipin K. Gupta ◽  
Archit Latawa ◽  
Gagan Kalra ◽  
Bishan D. Radotra
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Case Report ◽  
Lumbar Spine ◽  
Neuroendocrine Tumour ◽  
Primary Tumour ◽  
Symptomatic Relief ◽  
Treatment Options

Neuroendocrine tumour in central nervous system is a very rare pathology. We hereby report a primary intradural neuroendocrine tumour, second to the only other case reported in literature till now as per the best of our knowledge. The tumour was completely intradural, spanning across five segments in the lumbar spine and no primary tumour could be detected elsewhere in body. The patient underwent surgery followed by radiotherapy and showed symptomatic relief.  This case report focusses on compiling the available literature on spinal carcinoids (both primary and metastatic) and discussing the relevant investigations and available treatment options for the same.

scholarly journals High-dose methotrexate-based regimens with or without vincristine for the treatment of primary central nervous system lymphoma

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Tracelyn Freeman ◽  
Carlo S Legasto ◽  
M Alexandra Schickli ◽  
Eric M McLaughlin ◽  
Pierre Giglio ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Treatment Options ◽  
Group Versus ◽  
Central Nervous System Lymphoma ◽  
Progression Free Survival ◽  
Adverse Event Rate ◽  
High Dose ◽  
High Dose Methotrexate ◽  
Dose Methotrexate

Abstract Background Primary central nervous system lymphoma (PCNSL) is a rare malignancy with few treatment options. One regimen used for induction is rituximab, high-dose methotrexate (HD-MTX), procarbazine, and vincristine (R-MPV). A common institutional practice is removing vincristine (VCR) from this regimen due to its poor CNS penetration and associated toxicities. The aim of this study was to evaluate how the omission of VCR from HD-MTX-based induction impacted clinical outcomes. Methods In a retrospective review, patients with PCNSL who received HD-MTX-based induction therapy between January 1, 2010 and May 31, 2018 were evaluated. Patients were stratified according to treatment into 2 groups, VCR-containing therapy versus no VCR. The primary endpoint was complete response (CR) rate following the completion of induction chemotherapy. Secondary endpoints included progression-free survival (PFS), overall survival (OS), and adverse event rate. Results Twenty-nine patients were included: 16 patients in the VCR group and 13 in the non-VCR group. A CR was achieved in 7 (44%) and 5 (38%) (odds ratio [OR] = 1.24; 95% confidence interval [CI]: 0.28–5.53) patients, respectively. Median OS was 85.3 (95% CI: 20.2–85.3) versus 67.1 months (95% CI: 10.5–NR) and median PFS was 60.7 (95% CI: 9.4–NR) versus 23.7 months (95% CI: 4.7–NR) in the VCR group versus non-VCR group, respectively. The incidence of any grade peripheral neuropathy was higher in the VCR group. Conclusions CR rate, OS, and PFS were similar between groups regardless of VCR inclusion. Adverse events were higher in the VCR group. Larger studies are required to further evaluate the efficacy of VCR in PCNSL induction regimens.

To the treatment of nervous diseases by parenteral administration of milk

1926 ◽  
Vol 22 (5-6) ◽  
pp. 748-749
Author(s):  
G. Pervushin
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Peripheral Nerves ◽  
Combined Treatment ◽  
Full Recovery ◽  
Parenteral Administration ◽  
The Central Nervous System

Prof. VV Korelin (Psycho-Neur. Jur., 1926, issue I), having applied this treatment at 23 patients, observed full recovery in 8 cases, syphilis of the central nervous system, at combined treatment with mercury, - 4 sl., Inflammation of peripheral nerves - 3 sl. And epidemic meningitis - 1 sl.); further, in 3 cases this treatment gave improvement, and in others remained without result.

Treatment Of Non-Hodgkin’s Lymphoma With Secondary Central Nervous System Involvement: Encouraging Response Rates Using CNS-Penetrating Idaram Chemotherapy

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 4367-4367
Author(s):  
Paul M Maciocia ◽  
Mohsin Badat ◽  
Simon Cheesman ◽  
Jonathan Lambert ◽  
Martin Pule ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Stem Cell ◽  
Poor Prognosis ◽  
Intrathecal Injection ◽  
Response Rates ◽  
Refractory Disease ◽  
Cns Involvement ◽  
Grade 3 ◽  
New Diagnosis

Abstract Introduction Non-Hodgkin’s lymphomas with secondary involvement of the central nervous system (CNS) typically carry a poor prognosis. There is limited data in the literature regarding the optimal therapy for these patients. IDARAM is a cytotoxic regimen which penetrates the CNS. It has demonstrated efficacy in early studies in secondary CNS lymphoma [Moreton et al, Cancer Chemother Pharmacol (2004) 53: 324–8]. We present here the largest series of patients with secondary CNS involvement treated with IDARAM+/- rituximab at University College Hospital London between June 2005 and January 2013. Methods Thirty-eight patients were treated with 1-4 cycles of IDARAM, consisting of methotrexate 12.5mg by intrathecal injection day 1; idarubicin daily 10mg/m2 IV days 1 and 2; dexamethasone 100mg daily IV infusions of 12h duration days 1-3; cytosine arabinoside daily 1000mg/m2 IV over 1 hour days 1 and 2; and methotrexate 2000mg/m2 IV over 2 hours day 3. CSF was analysed for lymphomatous involvement by flow cytometry on D1. Patients with a clear CSF from the outset only received one intrathecal injection on day 1 of cycle 1. Most patients with B-cell lymphoma additionally received 1-2 doses of rituximab 375 mg/m2 IV on day 1 (+/- day 8) of each cycle. Results Baseline characteristics are presented in table 1. 16/38 (42%) patients had secondary CNS involvement at the time of initial diagnosis of NHL or within 2 months (‘New Diagnosis’). 22/38 (58%) had refractory (CNS involvement diagnosed in latter part of therapy or within 3 months of completion of primary therapy) or relapsed (CNS involvement diagnosed at relapse - either combined with a systemic relapse or isolated to CNS) disease. 84 cycles of IDARAM were delivered to 38 patients. Patients received a median of 2 cycles. 20/37 responded (overall response rate (ORR) = 54%) with 12/37 (32%) achieving a complete response and 8/37 (22%) a partial response (PR). Median progression-free survival (PFS) was 6.8 months and overall survival (OS) was 27.5 months. In patients with a ‘New’ diagnosis ORR was 10/15 (67%) CR 7/15 (47%), PR 3/15 (20%), median PFS was 48 months, median OS has not been reached (see figure 1). Neither age nor performance score predicted outcome in these patients. Grade 3 or 4 haematological toxicity was observed in 100% of cycles. Non-haematological grade 3 or 4 toxicities included infection 81%, stomatitis 11.3%, diarrhoea 4.3%, other 6.5%. 4/84 (5%) of cycles were complicated by ITU stay and treatment-related mortality was 2/38 (5%). 8 (21%) of patients received consolidation radiotherapy (4 patients in CR, 4 in PR), 4 patients (10%) received salvage radiotherapy for disease refractory to IDARAM, and 3 patients (8%) received palliative radiotherapy. 8 patients (20%) received an autologous stem cell transplant; 6 (75%) as consolidation and 2 (25%) for disease relapsing after IDARAM. Conditioning was with TBI in 6 (75%) and LEAM/ BEAM in 2 (25%). 2 patients received reduced-intensity conditioned allogeneic stem cell transplants from HLA-matched unrelated donors: one for primary refractory disease and one for relapsed disease after autograft in 1st CR. Of 10 newly diagnosed patients achieving CR/PR with IDARAM, 5/5 who received consolidation autograft, and 4/5 who did not, remain alive (median follow-up 30 months). 1 patient in each group has relapsed. Conclusions IDARAM +/- R is a well-tolerated regime with encouraging response rates in patients with poor prognosis lymphoma. The short duration of survival of patients with relapsed or refractory disease indicates the urgent need to identify efficacious new treatments for these patients. Patients in whom CNS involvement is detected early in the disease course fare reasonably well, including older patients and those with a poor performance status. Disclosures: No relevant conflicts of interest to declare.

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