Traumatic acute epidural hematoma caused by injury of the diploic channels

Background: Traumatic acute epidural hematomas (EDHs) commonly develop by rupture of the meningeal arteries. EDH caused by an injury of the diploic channel (DC) has not been reported. Case Description: A 21-year-old man suffered a head injury while falling off the skateboard. At presentation, the patient was drowsy but did not exhibit any focal neurological deficits. Cranial computed tomography (CT) revealed a biconvex intracranial hematoma with 18-mm thickness in the high parietal region and a linear fracture that involved both the outer and inner tables and passed above the hematoma. A well-developed and large DC was observed near the hematoma. Patient’s consciousness level decreased at 12 h after admission with considerable growth of the hematoma. A frontoparietal craniotomy revealed an EDH. The dura mater and the meningeal arteries underneath the hematoma were intact. The medial bone cut caused brisk bleeds from the large DC. Postoperative CT revealed the cut of the DC and other finer DCs exhibiting air density and lying near the fracture. Based on these findings, we assumed that the EDH was developed by an injury of the DCs. Conclusion: Traumatic EDH can develop by an injury of the DCs. Careful observation of patient’s neurological status and precise interpretation of neuroimages is important to identify venous EDHs.

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Craniotomy for Fenestration of Multiloculated Hydrocephalus in Pediatric Patients

Operative Neurosurgery ◽

10.1227/01.neu.0000163489.75279.8c ◽

2005 ◽

Vol 57 (suppl_1) ◽

pp. 100-106 ◽

Cited By ~ 10

Author(s):

David I. Sandberg ◽

J. Gordon McComb ◽

Mark D. Krieger

Keyword(s):

Pediatric Patients ◽

Neurological Status ◽

Neurological Deficits ◽

Ventricular Catheter ◽

Shunt System ◽

Neurological Outcomes ◽

Multiloculated Hydrocephalus ◽

Before And After ◽

Posterior Parietal ◽

Ventricular Catheters

Abstract OBJECTIVE: To assess the treatment of progressive multiloculated hydrocephalus by craniotomy for microsurgical fenestration of cerebrospinal fluid (CSF) compartments to minimize the number of ventricular catheters. METHODS: We studied 33 pediatric patients who underwent craniotomies for fenestration of progressive multiloculated hydrocephalus between 1989 and 2003. In 20 of 33 patients, hydrocephalus was attributed to intraventricular hemorrhage associated with prematurity. Twenty-three of 33 patients had previous central nervous system infections. Craniotomy was typically performed via a posterior parietal approach. Communication between bilateral supratentorial loculated compartments and posterior fossa compartments was achieved. Surgical and neurological outcomes were assessed. RESULTS: Fenestration of loculated CSF spaces was performed successfully in all patients. No new neurological deficits were noted after surgery, and no patients required intraoperative blood transfusions. CSF infections within 3 months after surgery occurred in 4 of 33 patients. Over a median follow-up period of 3.7 years (range, 1.5 mo to 8.7 yr), 19 of 33 patients required additional fenestration procedures. The number of repeat fenestration procedures ranged from one to six, and a total of 47 additional fenestrations were performed in these 19 patients. The majority of patients (n = 25) ultimately required shunt systems with only one ventricular catheter. The neurological status of these patients was extremely poor both before and after surgery. Twenty-nine of 33 patients were severely delayed, and four were mildly delayed. CONCLUSION: Fenestration of multiloculated CSF compartments can enable most patients to function with a single ventricular catheter shunt system. Neurological status remains poor in this patient population.

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Intracranial hematoma following ruptured anterior communicating artery aneurysms: risk factors, outcome, and prognostic factors after management of coiling first

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017506 ◽

2021 ◽

pp. neurintsurg-2021-017506

Author(s):

Heng Ni ◽

Lin-Bo Zhao ◽

Sheng Liu ◽

Zhen-Yu Jia ◽

Yue-Zhou Cao ◽

...

Keyword(s):

Risk Factors ◽

Prognostic Factors ◽

Neurological Status ◽

External Ventricular Drainage ◽

Anterior Communicating Artery ◽

Intracranial Hematoma ◽

Factors Associated ◽

Independent Variable ◽

Logistic Regressions ◽

Significant Factors

BackgroundTo determine the risk factors for intracranial hematoma (ICH) development following ruptured anterior communicating artery (AcomA) aneurysms and to determine prognostic factors associated with unfavorable outcomes after coiling first.MethodsFrom March 2014 to February 2020, 235 patients with ruptured AcomA aneurysms underwent endovascular treatment in our department. The clinical and radiographic conditions were collected retrospectively. Modified Rankin Scale (mRS) scores of ≤ 2 were accepted as favorable outcomes. Univariate and multivariate logistic regressions were performed to identify significant factors contributing to the incidence of ICHs and to unfavorable outcomes.ResultsOf these 235 patients, 68 had additional ICHs. A posterior orientation of ruptured AcomA aneurysms was the independent variable associated with the incidence of ICHs (OR 3.675; p<0.001). Furthermore, having preoperative Hunt–Hess grades Ⅳ–Ⅴ was an independent variable associated with unfavorable outcomes for ICH patients (OR 80.000; p<0.001). Among the 68 patients with ICHs, 40% (27/68) had Hunt–Hess grades IV–V. Four percent of patients (3/68) underwent surgical hematoma evacuation after the coiling procedure and 15% of the patients (10/68) underwent external ventricular drainage. A favorable outcome was achieved in 72% (49/68) of patients with ruptured AcomA aneurysms. The mortality rate was 21% (14/68) at 6 months.ConclusionA posterior orientation of ruptured AcomA aneurysms was associated with the incidence of ICHs. Coiling first with surgical management if necessary seems to be an acceptable treatment for ruptured AcomA aneurysms with ICHs. The clinical outcome was associated with the clinical neurological status on admission.

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Continuous Incremental Heavy Halo Traction Combined with Posterior-only Approach for Severe Cervical Kyphosis with Neurofibromatosis-1.

10.21203/rs.2.15877/v1 ◽

2019 ◽

Author(s):

Chaofeng Guo ◽

Hongqi Zhang ◽

Zhenhai Zhou ◽

Jinyang Liu ◽

Ang Deng

Keyword(s):

Posterior Instrumentation ◽

Neurological Status ◽

Neurofibromatosis 1 ◽

Neurological Deficits ◽

Cervical Kyphosis ◽

Kyphosis Correction ◽

Halo Traction ◽

Key Words Neurofibromatosis ◽

Correction Result

Abstract Background Surgical management of cervical kyphosis in patients with NF-1 is a challenging task. Presently, anterior-only (AO), posterior-only (PO) and combined anterior-posterior (AP) spinal fusion are common surgical strategies. However, the choice of surgical strategy and application of Halo traction remain controversial. Few studies have shown and recommended posterior-only approach for cervical kyphosis correction in patients with NF-1. The aim of this study is to evaluate the safety and the effectiveness of Continuous-Incremental-Heavy Halo Traction (CIH-HT) combined with posterior-only approach for treatment of cervical kyphosis with NF-1. Methods 19 patients with severe cervical kyphosis due to NF-1 were reviewed retrospectively between January 2010 and April 2017. All the cases underwent CIH-HT combined with posterior instrumentation and fusion surgery. Correction result, neurologic status and complications were analyzed. Results In this study, cervical kyphosis Cobb angle decreased from initial 63.0 ± 21.0 degrees to postoperative 10.8 ± 4.0 degrees(P＜0.01),with total correction rate of 92%, which consist of 44% from CIH-HT and 48% from surgical correction. JOA scores were improved from preoperative 13.6±1.6 to postoperative 16.0±1.0(P＜0.01). Neurological status was also improved. There was no correction loss and the neurological status was stable in mean 3.7 years follow-up. The incidence of complications was 36.8% (7/19). Six patients underwent local complications and one patient underwent a second surgery. Conclusion CIH-HT combined PO approach is safe and effective method for cervical kyphosis correction in patients with NF-1. A satisfied correction result, and successful bone fusion can be achieved via this procedure, even improvement of neurological deficits can also be obtained. Our study suggested that CIH-HT combined PO approach is another consideration for cervical kyphosis correction in patients with NF-1. Key words : Neurofibromatosis-1; Cervical kyphosis; Continuous-Incremental-Heavy Halo Traction; posterior-only approach;

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Postoperative ischemic changes following brain metastasis resection as measured by diffusion-weighted magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/2013.9.jns13596 ◽

2013 ◽

Vol 119 (6) ◽

pp. 1395-1400 ◽

Cited By ~ 17

Author(s):

Jens Gempt ◽

Julia Gerhardt ◽

Vivien Toth ◽

Stefanie Hüttinger ◽

Yu-Mi Ryang ◽

...

Keyword(s):

Brain Metastasis ◽

Brain Metastases ◽

Neurological Deficit ◽

Karnofsky Performance Status ◽

Performance Status ◽

Neurological Status ◽

Neurological Deficits ◽

Brain Irradiation ◽

Diffusion Weighted ◽

The Mean

Object Brain metastases occur in 10% to 40% of patients harboring cancer. In cases of neurosurgical metastasis resection, all postoperative neurological deterioration should be avoided. Reasons for postoperative deficits can be direct tissue damage due to resection, hemorrhage, venous congestive infarcts, or arterial ischemic events leading to tissue infarction. The aim of this study was to evaluate whether postoperative ischemic infarctions occur in surgery for brain metastasis and to determine their influence on new postoperative neurological deficits. Methods Patients who underwent resection of brain metastases and had preoperative and early postoperative (within 48 hours) MRI scans, including diffusion-weighted imaging sequences and apparent diffusion coefficient maps, between January 2009 and May 2012 were included in this study. Clinical and histopathological data (histopathological results, pre- and postoperative neurological status, and previous tumor-specific therapy) were recorded. Results One hundred twenty-two patients (56 male, 66 female) who underwent resection of brain metastases were included. The patients' mean age was 60 years (range 21–89 years). The mean time span from initial tumor diagnosis to resection of brain metastasis was 44 months (range 0–338 months). The mean preoperative Karnofsky Performance Status was 80% (exact mean 76% ± 17% [SD]), and the mean postoperative value was 80% (exact mean 78% ± 17%). Twelve (9.8%) of the 122 patients had postoperative permanent worsening of a neurological deficit or a new permanent neurological deficit; 44 (36.1%) of the 122 patients had postoperative ischemic lesions. When comparing patients with and without previous brain irradiation, 53.8% of patients with previous brain irradiation had ischemic lesions on postoperative imaging compared with 31.3% of patients without previous brain irradiation (p = 0.033). There was a significant association between ischemia and postoperative neurological status deterioration (transient or permanent); 13 (29.5%) of 44 patients with ischemic lesions had deterioration of their neurological status compared with 7 (9%) of the 78 patients who did not have ischemic lesions (p = 0.003). Conclusions This study demonstrates a high prevalence of vascular incidents in patients undergoing resection for metastatic brain disease. Patients harboring postoperative ischemic lesions detected by MRI have a higher rate of neurological deficits (transient or permanent). Patients who had previous irradiation therapy are at higher risk of developing postoperative ischemic lesions. A large number of postoperative neurological deficits are caused by ischemic incidents.

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Spinal meningiomas: Clinical and therapeutic tonsiderations

Open Medicine ◽

10.2478/s11536-008-0045-7 ◽

2008 ◽

Vol 3 (3) ◽

pp. 322-326

Author(s):

Johannes Schröder ◽

Bernhard Fischer ◽

Stefan Palkovic ◽

Hansdetlef Wassmann

Keyword(s):

Spinal Canal ◽

Thoracolumbar Spine ◽

Cauda Equina ◽

Complete Removal ◽

Neurological Status ◽

Neurological Deficits ◽

Before And After ◽

Patient Will ◽

Spinal Meningiomas ◽

The Mean

AbstractMeningiomas of the spinal canal are rare, in contrast to their cranial counterparts. This study reports on the dominant features of spinal meningiomas before and after treatment. We treated 30 patients (23 female) with meningiomas of the spinal canal from 1992 to 2003. The mean age was 68 (range: 43–91). Upon admission, 26 patients presented with a marked neurological deficit (11 paraparesis, 9 motor weakness, 4 myelopathic ataxia, 1 quadriplegia, and 1 cauda equina syndrome). Two patients had sensory deficits, and two had pain only. The distribution of the tumors was as follows: 8 cases were cranio-cervical, 1 case was cervical, 6 cases were at the cervico-thoracic junction, 9 cases were of the thoracic spine, 5 cases were of the thoracolumbar spine, and 1 case was of the lumbar spine. Five cases also had intracranial manifestations. The mean interval between the onset of the first symptoms and treatment was 12 months. All cases were treated via (hemi)-laminectomy for complete removal of the tumor and occasionally via duraplasty. After a mean follow-up of 3 years, symptoms had improved by 3 points (on a 5-point scale) in 3 cases, by 2 points in 7 cases, and by 1 point in 12 cases; 7 cases were unchanged, and 1 case had worsened by 1 point. We observed 3 local recurrences. One case developed manifestations at a different site. Spinal meningiomas are often diagnosed late, after they have already caused major neurological deficits. Nevertheless, owing to their benign character, the outcome is favorable when treated appropriately. The outcome depends above all on the initial neurological status. The worse the deficit is, the less probable it is that the patient will recover neurologically.

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Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care

Journal of Neurosurgery ◽

10.3171/jns.1995.82.1.0048 ◽

1995 ◽

Vol 82 (1) ◽

pp. 48-50 ◽

Cited By ~ 104

Author(s):

William A. S. Taylor ◽

Nicholas W. M. Thomas ◽

Julia A. Wellings ◽

B. Anthony Bell

Keyword(s):

Intensive Care ◽

Posterior Fossa ◽

Stereotactic Biopsy ◽

Neurological Status ◽

Posterior Fossa Surgery ◽

Intracranial Hematoma ◽

Content Type ◽

Postoperative Hematoma ◽

Neurosurgical Patients ◽

Neurosurgical Intensive Care

✓ This study records the incidence and timing of postoperative hematomas in neurosurgical patients and analyzes the best use of neurosurgical intensive care. In 2305 patients undergoing freehand or stereotactic biopsy, elective or emergency craniotomy, or posterior fossa surgery, 50 (2.2%) developed a hematoma. Clinical deterioration as a result of postoperative hematoma occurred within 6 hours of surgery in 44 patients and more than 24 hours after surgery in six patients. Although patients undergoing posterior fossa surgery or emergency craniotomy warrant longer periods of intensive-care observation, patients having elective supratentorial operations can safely be transferred to a neurosurgical ward for observation, provided they have regained their preoperative neurological status by 6 hours postsurgery.

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Effects of profound hypotension on cerebral blood flow during surgery for intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/jns.1981.55.6.0857 ◽

1981 ◽

Vol 55 (6) ◽

pp. 857-864 ◽

Cited By ~ 76

Author(s):

J. Keith Farrar ◽

Francis W. Gamache ◽

Gary G. Ferguson ◽

John Barker ◽

George P. Varkey ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Neurological Status ◽

Neurological Deficits ◽

Arterial Spasm ◽

Arterial Blood ◽

Flow Disturbances ◽

Group I ◽

Increased Risk ◽

Profound Hypotension

✓ The progression of changes in cerebral blood flow (CBF) and neurological status were measured in 12 patients in whom profound hypotension (mean arterial blood pressure (MABP): 30 to 40 mm Hg) was used during intracranial aneurysm surgery. Nine patients (Group I) showed autoregulation of CBF to an MABP of 40 to 50 mm Hg during surgery. None of these patients had arterial spasm preoperatively. Postoperatively, mild flow disturbances were noted at the site of retraction. Three Group I patients developed arterial spasm postoperatively, but there was no associated neurological deterioration. The remaining three patients (Group II) had impaired autoregulation during surgery, and CBF decreased by 35% to 65% at an MABP of 50 mm Hg. Two of these patients had angiography immediately before surgery, and both showed moderate to severe arterial spasm. Relatively severe flow disturbances were noted postoperatively at the site of retraction, and two patients developed ischemic deficits of late onset. Brain retractor pressure and the degree and duration of hypotension were equivalent in the two patient groups. There was no correlation between intraoperative reductions in CBF (to as low as 20 ml/100 gm/min in the unretracted hemisphere) and immediate postoperative neurological deficits. The use of halothane and mannitol and the relatively short duration of the flow reductions were suggested as factors contributing to the protection from ischemia that was observed. Arterial spasm was found to produce hemodynamic instability and reduced CBF, although neurological status was unaffected in the majority of patients. Patients with impaired autoregulation during surgery were at increased risk of delayed ischemic complications postoperatively, and showed characteristic flow disturbances at all three stages of their clinical course.

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Treatment of patients with glioma during the COVID-19 pandemic: what we learned and what we take home for the future

Neurosurgical FOCUS ◽

10.3171/2020.9.focus20704 ◽

2020 ◽

Vol 49 (6) ◽

pp. E10

Author(s):

Federico Pessina ◽

Pierina Navarria ◽

Luisa Bellu ◽

Elena Clerici ◽

Letterio Salvatore Politi ◽

...

Keyword(s):

Performance Status ◽

Imaging Study ◽

High Grade Glioma ◽

Neurological Status ◽

Chest Ct ◽

Neurological Deficits ◽

Cancer Center ◽

Nasopharyngeal Swab ◽

Newly Diagnosed ◽

Effective Manner

OBJECTIVECoronavirus disease 2019 (COVID-19) has changed the way in which cancer is treated. Patients with high-grade glioma (HGG) are believed to be in a vulnerable category. The aim of this study was to describe the experience of a hub cancer center and the measures that were put in place for treatment of patients with newly diagnosed and recurrent glioma.METHODSTo prevent in-hospital contagion and preserve the safety of health professionals and patients, specific protocols and strict regulations were introduced. Physical distancing, use of surgical masks, and diligent hand hygiene were adopted. Each case was discussed in a multidisciplinary board meeting before treatment. All patient candidates for surgical procedures were tested for SARS-CoV-2 with a nasopharyngeal swab and a chest CT scan. Indications for surgery were the radiological suspicion of HGG in patients with a good performance status and/or the rapid and progressive occurrence of neurological deficits. Adjuvant treatments were performed only in cases of HGG. This therapy consisted of conventional fractional radiotherapy (RT; 60 Gy/30 fractions) with concomitant and adjuvant temozolomide chemotherapy (TMZCHT) in younger patients; in elderly patients, a short course of RT was employed (40.5 Gy/15 fractions). For recurrent HGG, treatments were assessed after a careful evaluation of the patient’s general condition, neurological status, and risk of early impairment in neurological status if not treated. During simulation CT for the RT plan, each patient underwent a chest CT study. In cases in which an imaging study was suspicious for COVID-19 pneumonia, the patient was immediately isolated and rapidly underwent nasopharyngeal swab testing.RESULTSBetween March 1 and April 30, 2020, 23 HGGs were treated, and these cases are included in the present evaluation. Fifteen patients harboring newly diagnosed glioblastoma (GBM) underwent resection followed by a regimen of chemotherapy and RT, and 3 patients with newly diagnosed anaplastic oligodendroglioma underwent surgery followed by adjuvant RT. Five patients were treated for recurrent GBM, and they received surgery plus adjuvant RT. One patient in whom the simulation CT study was suspicious for COVID pneumonia was tested with a nasopharyngeal swab, which proved positive for SARS-CoV-2 infection. No patients contracted COVID-19 during hospitalization for surgery or during RT treatment. Corticosteroid therapy was administered to all patients beginning on the 1st day of RT.CONCLUSIONSThe authors’ experience during the COVID-19 pandemic showed that patients with HGG can be treated in the most effective manner without a compromise in safety. Careful selection criteria and a multidisciplinary evaluation are pivotal to assessing the optimal therapeutic strategy.

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Abstract T P72: Baseline Variables Have Little Influence on Early Change in Neurological Status (ΔNIHSS) After Acute Ischemic Stroke: Basis For a Genetic Study

Stroke ◽

10.1161/str.46.suppl_1.tp72 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Laura Heitsch ◽

Carlos Cruchaga ◽

Naim Khoury ◽

Rebecca Weisenhan ◽

Ford L Andria ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Neurological Status ◽

Neurological Recovery ◽

Neurological Deficits ◽

Dramatic Improvement ◽

Scale Scores ◽

Multivariable Regression ◽

Jewish Hospital ◽

The Difference

Introduction: Neurological deficits can be highly unstable within the first 24 hours after acute ischemic stroke (AIS), with some patients showing dramatic improvement while others rapidly deteriorate. We are interested in genetic influences on early neurological recovery/deterioration. Here, we characterize NIHSS changes within the first 24 hours after stoke onset (ΔNIHSS) in a large cohort to determine baseline clinical variables that influence this outcome measure. Methods: AIS patients presenting to two sites (Barnes-Jewish Hospital, St Louis and Vall D’Hebron Hospital Barcelona) between 2008-2013 were prospectively enrolled. Baseline NIHSS was collected within 6 hours and again at 24 hours after symptom onset. ΔNIHSS was calculated as the difference in these stroke scale scores. Demographics, baseline comorbidities and medications, as well as acute treatment variables were recorded for each subject. Stepwise multivariable regression (SAS) was used to determine variables that significantly influence ΔNIHSS. Results: There were 954 patients enrolled (St Louis = 433, Barcelona = 521). Table 1 demonstrates the frequencies and means (SD) of the baseline variables. ΔNIHSS follows a normal distribution (figure). All baseline variables listed in table 1 were analyzed for influence on ΔNIHSS. Only baseline NIHSS (R2 = 0.0597, p<0.0001), baseline glucose (R2 = 0.0176, p=<0.0001,) and age (R2 = 0.0106, p=0.0011) independently influenced ΔNIHSS, accounting for only 8.79% of the variance. Conclusion: Baseline variables (NIHSS, glucose and age) modestly influence early neurological recovery/deterioration. However, 91% of ΔNIHSS variability remains unexplained, suggesting that other factors such as genetics, could play an important role in early outcomes following AIS. A GWAS of ΔNIHSS is currently underway.

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Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique

Journal of Neurosurgery Spine ◽

10.3171/2013.8.spine121160 ◽

2013 ◽

Vol 19 (5) ◽

pp. 595-599 ◽

Cited By ~ 1

Author(s):

Pooya Javidan ◽

Nima Kabirian ◽

Gregory M. Mundis ◽

Behrooz A. Akbarnia

Keyword(s):

Neurological Complication ◽

Posterior Spinal Fusion ◽

Neurological Status ◽

Neurological Deficits ◽

Preoperative Risk ◽

Preoperative Risk Assessment ◽

Rod System ◽

Proximal Extension ◽

Junctional Kyphosis

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

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