Fixed, Dilated, and Conversing—Unreactive Pupil With Preserved Consciousness Indicating Acutely Rising Intracranial Pressure due to Traumatic Intraparenchymal Contusions: Case Report and Review of the Literature

Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). He described complete loss of vision and could not identify objects or count fingers. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. Corneal reflexes were intact bilaterally. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. His pupil became reactive 5 hours after surgery. While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.

Abstract 17116: Recurrent Atrial Myxomas As A Presenting Feature Of Carney Complex

Case Presentation: A 24-year-old man with a history of adrenal insufficiency on hydrocortisone presented to the hospital after losing consciousness in a swimming pool and was found to have an acute MCA stroke. PMHx was significant for left atrial myxoma status post resection 3 years ago, known L frontal brain, L adrenal, and testicular masses status post-resection. His father had a history of resected left atrial mass. Cardiology was consulted for a L atrial mass on the bedside echocardiogram upon initial emergency evaluation, during which the patient was placed on mechanical ventilation with stable vitals. The cardiovascular exam revealed a midsternal scar but was otherwise normal. Pulses were 2+ bilaterally on the upper and lower extremities. The skin was noted to have multiple hyperpigmented macules resembling cafe-au lait spots. The patient underwent mechanical thrombectomy with thrombolysis for his large MCA occlusion. His postoperative course was complicated by a worsening neuro exam in the setting of mid-line shift for which he had undergone decompressive hemicraniectomy. His adrenal insufficiency was managed by endocrinology. A TTE was significant for a L atrial mass measuring 4.8 cm attached to the interatrial septum with a stalk. A CT scan identified 2 discrete hypodensities of 8 mm and 3.8 cm which were thought to be the cardioembolic source for the stroke. An abdominal CT revealed a recurrent L adrenal neoplasm with absent R adrenal gland post resection of neoplasm. Conservative cardiac management was elected in the setting of a worsening neuroprognosis with follow-up post neurologic insult. Discussion: Considering the constellation of neoplastic and cutaneous findings, this was diagnosed as a case of Carney complex. This case identifies recurrent myxoma as a unique feature of Carney complex, ruling out other differentials such as neurofibromatosis and MEN syndrome. It highlights the importance of screening to prevent embolic stroke from recurrent myxomas.

A review on covid-19 and acute ischemic stroke, malignant cerebral edema & decompressive hemicraniectomy: A perfect storm; tackling this crisis by understanding it

Since the world was hit by novel coronavirus pandemic, so many challenges for all healthcare providers have been arisen. It is safe to say that no specialty was singled out in the matter of different complication from this viscous covid-19 situation and neurologists and neurosurgeon were no different. There are some studied reporting neurological complication associated with coronavirus infections but when it comes to life threatening and acute neurological complications such as strokes and malignant cerebral edema the data is scant. Here we are going to review the possible pathophysiology of this phenomenon, the relationship between covid-19 and acute ischemic stroke and malignant cerebral edema by taking a closer look at current data regarding this matter. Keywords: covid-19; acute ischemic stroke; malignant cerebral edema; covid-19 associated neurological complications. Abbreviations: DHC: Decompressive Hemicraniectomy; ELVO: Emergent Large Vessel Occlusion; MCE: Malignant Cerebral Edema.

Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency

Purpose Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. Methods Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. Results Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6–5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. Conclusions Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.

Blunt Cerebrovascular Injury with Severe Head Injury

Blunt Cerebrovascular Injury (BCVI) are rare and comprises of less than 1% of total head injury in our tertiary neurocenter. This leads to significant morbidity and mortality of patient. This case report is to focus on the BCVI with head injury. Because of rarity of this disease, there’s no treatment guidelines. However whatever the treatment we have is based on the experience of the surgeons/physician our case came to our Emergency Room with alleged history of lying along the road side in pool of blood .He was evaluated in peripheral hospital and he was later transferred to our center. Patient on evaluation was found to have transaction of Right ICA just distal to right Common carotid artery bifurcation. There was associated fracture of spinous process C5, C6. Probable mechanism of injury was sudden hyperextension of neck. Patient presented with delayed stroke following BCVI. He was managed with Right Decompressive hemicraniectomy and anticoagulation therapy was started for Right ICA injury. Thus early diagnosis and treatment of Blunt Cerebrovascular injury is essential in traumatic brain injury patients with risk factors for BCVI for definitive treatment of vascular injury with either stenting or surgery and thereby limiting morbidity and mortality of the patient.

Case Report: Takotsubo Cardiomyopathy After Traumatic Brain Injury

Introduction: Takotsubo cardiomyopathy (TCM) or “stress cardiomyopathy” is an uncommon condition characterized by transient cardiac dysfunction with left ventricular apical ballooning in an appropriate clinical context. TCM has been observed in a variety of acute neurological conditions most prominently in patients with aneurysmal subarachnoid hemorrhage and status epilepticus. TCM has only been reported infrequently in association with traumatic brain injury (TBI). Herein we present a patient who developed TCM 3 days after hospital admission with severe TBI.Case Presentation: A 30-year-old male presented to the hospital with an acute subdural hematoma, anisocoria, declining consciousness and CT evidence of uncal herniation after being found down in a hotel room. The patient was taken emergently to the operating room for decompressive hemicraniectomy and hematoma evacuation. On the post-trauma day (PTD) 3, the patient developed acute dyspnea with increased oxygen requirements that improved with diuresis. On PTD 4, nursing staff noted T waive inversions (TWI) on the bedside monitor prompting an electrocardiogram (ECG) that showed a prolonged QTc interval and worsening TWI in leads I, II, aVL, and V2-6. Troponin I level was mildly elevated at 0.63ng/mL. Transthoracic echocardiography (TTE) was subsequently performed and showed a low ejection fraction (EF 26%) with apical hypokinesis and basal hyperkinesis, consistent with TCM. A diagnosis of TCM was confirmed by Cardiology consultation and he was started on a beta-blocker and an ACE inhibitor. Follow-up TTE on PTD 20 showed a normal left ventricular EF.Conclusion: While rarely reported in patients with TBI, TCM developed in an otherwise healthy young male following severe TBI necessitating decompressive hemicraniectomy. TTE should be considered in patients with TBI who have cardio-pulmonary symptoms or unexplained ECG abnormalities.