Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome

2019 ◽  
Vol 131 (6) ◽  
pp. 1920-1925
Author(s):  
Daniel A. Tonetti ◽  
William J. Ares ◽  
David O. Okonkwo ◽  
Paul A. Gardner
Keyword(s):  
Neurological Deterioration ◽  
Neurological Deficits ◽  
Motor Deficits ◽  
Study Cohort ◽  
Venous Infarction ◽  
Nonsurgical Management ◽  
Subdural Hematomas ◽  
Poor Outcomes ◽  
Contemporary Management

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

scholarly journals Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

2021 ◽  
Vol 10 (19) ◽  
pp. 4436
Author(s):  
Andrey Petrov ◽  
Arkady Ivanov ◽  
Larisa Rozhchenko ◽  
Anna Petrova ◽  
Pervinder Bhogal ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Complete Resolution ◽  
Middle Meningeal Artery ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Embolic Agent ◽  
Ethylene Vinyl Alcohol ◽  
Arteriovenous Fistulas ◽  
Subdural Hematomas

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

Radiographic clearance of chronic subdural hematomas after middle meningeal artery embolization

2021 ◽  
pp. neurintsurg-2021-018073
Author(s):  
Joshua S Catapano ◽  
Andrew F Ducruet ◽  
Visish M Srinivasan ◽  
Kavelin Rumalla ◽  
Candice L Nguyen ◽  
...  
Keyword(s):  
Complete Resolution ◽  
Patient Characteristics ◽  
Middle Meningeal Artery ◽  
Multivariable Logistic Regression Analysis ◽  
Study Cohort ◽  
Subdural Hematomas ◽  
Improved Outcomes ◽  
Rapid Clearance ◽  
Meningeal Artery

BackgroundFew reports discuss variables associated with improved outcomes after middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDHs). We analyzed radiographic evidence of cSDH clearance after MMA embolization to elucidate optimal techniques, hematoma clearance rates, and suitable length of follow-up.MethodsPatients who underwent MMA embolization for cSDH from January 1, 2018 through December 31, 2020 were analyzed. Patient characteristics, demographics, and technical procedural details were examined. Outcomes for cSDHs analyzed included complete or near-complete resolution at 30, 90, and 180 days following embolization. A multivariable logistic regression analysis identified variables predictive of rapid clearance and resolution of hematomas at 90 days.ResultsThe study cohort comprised 66 patients with 84 treated cSDHs. The mean (SD) cSDH size differed significantly at 30-day (8.8 (4.3) mm), 90-day (3.4 (3.0) mm), and 180-day (1.0 (1.7) mm) follow-up (p<0.001). More cSDHs had complete or near-complete resolution at 180 days (92%, 67/73) than at 90 (63%, 45/72) and 30 days (18%, 15/84) post-embolization (p<0.001). Only distal embolysate penetration was independently associated with rapid clearance (OR 3.9, 95% CI 1.4 to 11.1; p=0.01) and resolution of cSDHs at 90 days (OR 5.0, 95% CI 1.7 to 14.6; p=0.003).ConclusionAlthough 63% of cSDHs with MMA embolization had complete or near-complete resolution by 90 days post-procedure, 92% reached this stage by 180 days. Therefore, 90-day follow-up may be insufficient to determine the effectiveness of MMA embolization for cSDHs, particularly compared with surgical evacuation alone. Also, distal MMA penetration may be associated with more rapid hematoma clearance.

Cervical spine injury from gunshot wounds

2014 ◽  
Vol 21 (3) ◽  
pp. 442-449 ◽  
Author(s):  
Narlin Beaty ◽  
Justin Slavin ◽  
Cara Diaz ◽  
Kyle Zeleznick ◽  
David Ibrahimi ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Neurological Deficit ◽  
Neurological Outcome ◽  
Treatment Algorithm ◽  
Gunshot Wounds ◽  
Neurological Deterioration ◽  
Neurological Deficits ◽  
Cervical Instability ◽  
Cord Injury

Object Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. Methods A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. Results Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients underwent decompression alone for neurological deterioration and persistent compressive injury, both of whom experienced marked neurological recovery. Follow-up was obtained in 92% of cases. Three patients undergoing stabilization converted at least 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and the remaining operative cases experienced small ASIA motor score improvement. Eighteen patients underwent inpatient MRI. No patient suffered complications or neurological deterioration related to retained metal. Three of 28 patients presenting with AIS Grade A improved to Grade B. For those 12 patients with incomplete injury, 1 improved from AIS Grade C to D, and 3 improved from Grade D to E. Conclusions Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.

A Case Series of Surgically Treated Spinal Dumbbell Tumors of Critical Parent Nerve Roots: To Cut or Not to Cut?

2020 ◽  
Author(s):  
Vicki Marie Butenschoen ◽  
Nikolaus Kögl ◽  
Bernhard Meyer ◽  
Claudius Thomé ◽  
Maria Wostrack
Keyword(s):  
Motor Function ◽  
Nerve Root ◽  
Tumor Resection ◽  
Case Series ◽  
Neurological Deficits ◽  
Motor Deficits ◽  
Nerve Roots ◽  
Dumbbell Tumor ◽  
Lumbar Level

Abstract BACKGROUND Dumbbell tumors present challenging cases, with either an incomplete tumor resection or a need to sacrifice nerve roots. Published literature suggests encouraging neurological outcomes after nerve root amputation. OBJECTIVE To determine the incidence of postoperative neurological deficits after amputating the parent nerve root. METHODS A retrospective consecutive analysis of all patients treated for dumbbell nerve sheet tumors with a reported amputation of the functional relevant parent nerve roots C5-Th1 and L3-S1. RESULTS Among 21 evaluated patients, minor postoperative neurological motor function deterioration occurred in 4 patients (19%). Most patients recovered to the preoperative level at the follow-up examination, and only one patient retained a new Medical Research Council (MRC) scale of 4/5 for deltoid weakness. The majority of tumors were resected at the lumbar level (nerve root L3: 28.6%, L5: 19%). Gross total resection was achieved in 90.5% of patients. Neuropathic pain was reported in one third of the patients during the long-term follow-up. CONCLUSION Amputating critical parent nerve roots during the dumbbell tumor resections seems to result in a low incidence of postoperative motor deficits and may offer an acceptable sacrifice in otherwise only incompletely resectable dumbbell tumors. The cross-innervation of neighboring nerve roots and its, probably, per-se-reduced functionality may be a possible mechanism for maintaining motor function.

scholarly journals Minimally Invasive Endoscopy Versus Craniotomy for Acute Subdural Hematomas: A Retrospective Matched Cohort Study

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Enzo Fortuny ◽  
Nicolas K Khattar ◽  
Kevin John ◽  
Esther Bak ◽  
Shawn W Adams ◽  
...  
Keyword(s):  
Cohort Study ◽  
Minimally Invasive ◽  
Brain Injuries ◽  
Study Cohort ◽  
Matched Cohort ◽  
Hematoma Volume ◽  
Matched Cohort Study ◽  
Subdural Hematomas ◽  
Baseline Characteristics

Abstract INTRODUCTION Acute subdural hematomas (aSDH) are one of the most commonly encountered neurosurgical conditions, occurring in approximately 10% to 20% of all traumatic brain injuries, and they represent a significant cause of morbidity and mortality. The aim of this retrospective matched cohort study is to compare the outcomes of minimally invasive endoscopy vs craniotomy for evacuation of aSDH. METHODS We retrospectively analyzed seven consecutive patients who underwent endoscopic aSDH evacuation at our institution from April 2015 to July 2018. We matched those with respect to age, sex, and hematoma volume using propensity match scoring and included seven patients who underwent craniotomies contemporaneously. We then compared the outcomes of the two matched cohorts. RESULTS The study cohort comprised seven aSDH patients in each of the matched endoscopy and craniotomy cohorts. The baseline characteristics were comparable between the endoscopy vs craniotomy cohorts, with respect to age (median 50 [21-91] vs 66 [24-78] yr; P = .71), baseline modified Rankin Scale (mRS; median 1 [0-2] vs 2 [0-2]; P = .15), preoperative hematoma volume (median 51.5 [12.1-91.6] vs 28.9 [9-87] cm3; P = .317), maximum preoperative hematoma thickness (mean 11.7 [SD 7.7, 1-27] mm vs 14.9 [SD 3.8, 11-23] mm; P = .052) and amount of midline shift (mean 9.28 [SD 3.35, 6-16] vs 10.28 [SD 5.18, 3-19] mm; P = .74). Significant differences were observed in the baseline GCS at presentation (median 15 [13-15] vs 7 [4-14]; P = .005), The postoperative outcomes were similar between the endoscopy versus craniotomy cohorts, with respect to degree of hematoma evacuation (median 88% [84.8-95.9] vs 90% [85.2-99.2]; P = .654), and follow-up mRS (median 2 [0-6] vs 4 [1-6]; P = .118). No immediate postoperative surgical complications occurred in either cohort. CONCLUSION In this preliminary analysis, endoscopic aSDH evacuation afforded adequate evacuation and comparable outcomes to craniotomy. Endoscopy could represent a reasonable alternative to conventional surgery for carefully selected aSDH patients with coagulopathies or extensive medical comorbidities.

Treatment of Chiari type I malformation in patients with and without syringomyelia: a consecutive series of 66 cases

2001 ◽  
Vol 11 (1) ◽  
pp. 1-9 ◽  
Author(s):  
Juan C. Alzate ◽  
Karl F. Kothbauer ◽  
George I. Jallo ◽  
Fred J. Epstein
Keyword(s):  
Chiari I Malformation ◽  
Neurological Deficits ◽  
Motor Deficits ◽  
Consecutive Series ◽  
Spinal Cord Tissue ◽  
Type I ◽  
Excellent Outcome ◽  
Dural Graft ◽  
Chiari I

Object The authors describe the results of performing a standard posterior craniovertebral decompression and placement, if indicated, of a syringosubarachnoid shunt for the treatment of patients with Chiari I malformation with and without syringomyelia. Methods This is a retrospectively analyzed consecutive series of 66 patients (mean patient age 15 years, range 1–53 years). The uniform posterior craniovertebral decompression consisted of a small suboccipital craniectomy, a C-1 laminectomy, microsurgical reduction of the cerebellar tonsils, and dural closure with a synthetic dural graft to increase the cerebrospinal fluid space at the craniocervical junction. The presence of a large syrinx, with significant thinning of the spinal cord tissue and obliteration of the spinal subarachnoid space, particularly when combined with syrinx-related symptoms, was an indication for the placement of a syringosubarachnoid shunt. In 32 patients Chiari I malformation alone was present, and 34 in patients it was present in combination with syringomyelia. Clinical findings included pain, neurological deficits, and spinal deformity. The presence of syringomyelia was significantly associated with the presence of scoliosis (odds ratio 74.4 [95% confidence interval 8.894–622.4]). All patients underwent a posterior craniovertebral decompression procedure. In 22 of the 34 patients with syringomyelia a syringosubarachnoid shunt was also placed. The mean follow-up period was 24 months (range 3–95 months). Excellent outcome was achieved in 54 patients (82%) and good outcome in 12 (18%). In no patient were symptoms unchanged or worse at follow-up examination, including four patients who initially required a second operation for persistent syringomyelia. Pain was more likely to resolve than sensory and motor deficits after decompressive surgery. Radiological examination revealed normalization of tonsillar position in all patients. The syrinx had disappeared in 15 cases, was decreased in size in 17, and remained unchanged in two. Conclusions Posterior craniovertebral decompression and selective placement of a syringosubarachnoid shunt in patients with Chiari I malformation and syringomyelia is an effective and safe treatment. Primary placement of a shunt in the presence of a sufficiently large syrinx appears to be beneficial. The question of if and when to place a shunt, however, requires further, preferably prospective, investigation.

AAC Supports for Individuals With Rett Syndrome Across the Lifespan

2015 ◽  
Vol 24 (3) ◽  
pp. 74-85
Author(s):  
Sandra M. Grether
Keyword(s):  
Rett Syndrome ◽  
Communication Skills ◽  
Preliminary Analysis ◽  
Multidisciplinary Approach ◽  
Motor Deficits ◽  
Complex Profile ◽  
Communication Behaviors ◽  
The Individual

Individuals with Rett syndrome (RS) present with a complex profile. They benefit from a multidisciplinary approach for diagnosis, treatment, and follow-up. In our clinic, the Communication Matrix © (Rowland, 1990/1996/2004) is used to collect data about the communication skills and modalities used by those with RS across the lifespan. Preliminary analysis of this data supports the expected changes in communication behaviors as the individual with RS ages and motor deficits have a greater impact.

Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (2) ◽  
pp. V7
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Cleavage Plane ◽  
Foramen Magnum ◽  
Senior Author ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Sitting Position ◽  
Brainstem Cavernoma ◽  
Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

SKIN MELANOMA INCIDENCE IN WORKERS OCUPATIONALLY EXPOSED TO IONIZING RADIATION OVER A PROLONGED PERIOD

2019 ◽  
Vol 65 (3) ◽  
pp. 441-446
Author(s):  
Valentina Rybkina ◽  
Tamara Azizova ◽  
Yevgeniya Grigoreva
Keyword(s):  
Ionizing Radiation ◽  
Gamma Rays ◽  
Disease Risk ◽  
Incidence Rates ◽  
Study Cohort ◽  
Calendar Period ◽  
Skin Melanoma ◽  
Melanoma Incidence ◽  
Occupationally Exposed

Purpose of the study. The study is aimed to investigate skin melanoma incidence in workers occupationally exposed to radiation over a prolonged period. Materials and methods. Skin melanoma incidence was studied in a cohort of workers first employed at nuclear facility Mayak Production Association (PA) between 1948 and 1982 who had been followed up till 31.12.2013 (22,377 individuals). Mean cumulative doses from external gamma-rays over the whole follow-up period were 0.54±0.001 Sv in males and 0.44±0.002 Sv in females. Incident rates for skin melanoma were analyzed by sex, attained age, calendar period of diagnostics and radiation dose using worldwide standard and the direct standardization technique. Results. 60 skin melanoma cases (37 in males and 23 in females) were registered in the study cohort over the whole follow-up period. The standardized skin melanoma incident rate was 8.51±1.46 in males and 8.78±2.27 in females per 100000 workers revealing statistically higher rates compared to corresponding rates for general populations of the Russian Federation, Urals Federal District and Chelyabinsk region. Skin melanoma incidence was significantly increased in the period of 1994 - 2013 as compared to the period of 1974 - 1993. Skin melanoma incidence excess in females was greater than that for males. Skin melanoma incidence increment in females was mostly driven by modifications of disease occurrence risk while in males it was driven by a combined effect of age pattern modifications in the study cohort and increase of disease risk. Conclusions. Skin melanoma incidence rates in the cohort of workers occupationally exposed to ionizing radiation over a prolonged period were associated with sex and attained age workers and the calendar period of diagnostics. No significant association of skin melanoma incidence with dose from external gamma-rays was observed. A significantly increasing trend was observed for skin melanoma incidence by the end of the follow-up in both males and females.

scholarly journals Adenosine-induced Asystole during AVM Embolization

2021 ◽  
Author(s):  
V. Hellstern ◽  
P. Bhogal ◽  
M. Aguilar Pérez ◽  
M. Alfter ◽  
A. Kemmling ◽  
...  
Keyword(s):  
Demographic Data ◽  
Clinical Results ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Residual Shunt ◽  
Grade 5 ◽  
Martin Grade ◽  
Grade 3 ◽  
Brain Avms

Abstract Background Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. Material and Methods We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. Results We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). Conclusion Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

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