Treatment strategy for the tumor cyst of the medulla in an eloquent area: a case report and review of the literature

This is a clinical case of a 24-year-old woman with the unrescetable cystic tumor of the medulla because of eloquent area involved and severe neurological symptoms caused by the recurrent cystic component. The patient underwent emptying the cyst twice previously by means of safe entry zone myelotomy. Later there was a recurrence of the cyst with a significant neurological and oweral deterioration which is typical for such neoplasms. Recurrent cystic mass-effect was resolved with the help of newly designed device implanted. It provided simultaneous stable cisternal drainage and an opportunity for active aspiration via Ommaya reservoir.

Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports

Background: Some complications associated with cisternal drainage have been reported; however, there are few reports on direct vascular injury caused by cisternal drain. We experienced two rare cases of thalamic infarction caused by cisternal drain placement during open clipping for a ruptured anterior communicating artery (AcomA) aneurysm through an anterior interhemispheric approach. Case Description: Two cases of ruptured AcomA aneurysm were treated by surgical clipping through an anterior interhemispheric approach, and then a cisternal drain was inserted from opticocarotid space toward prepontine cistern. Postoperatively, the magnetic resonance imaging showed unilateral anterior-medial thalamic infarction in both two cases. By reviewing the postoperative computed tomography and digital subtraction angiography, it was suspected that the cisternal drain, which was inserted slightly deep, obstructed the P1 perforator because of an anatomical variation involving a lowered basilar bifurcation and caused postoperative unilateral paramedian thalamic infarction. Conclusion: To avoid these complications, neurosurgeons should consider the potential for P1 perforator injury related to cisternal drain placement.

Prevention of cerebral vasospasm and delayed cerebral ischemia in patients with massive aneurysmal subarachnoid hemorrhage

The study objective is to evaluate the effectiveness and the safety of different cerebrospinal fluid drainage methods and intrathecal fibrinolytic therapy in the prevention of cerebral vasospasm and improving outcomes in patients with massive subarachnoid hemorrhage. Materials and methods. The study was performed on 86 patients with massive aneurismal subarachnoid hemorrhage (Hijdra score >15) who had clipping surgery within 72 h after symptoms onset. We used lumbal drainage in 12 patients (group 1), combined lumbal and cisternal drainage in 24 patients (group 2), lumbal and cisternal drainage with intrathecal fibrinolytic therapy with recombinant staphylokinase in 25 patients (group 3); control group (group 4) included 25 patients with similar clinical and instrumental data. Results. Incidence of unfavorable outcome and symptomatic cerebral vasospasm was 83 and 83 %, respectively (in group 1), 36.8 and 47.4 % (in group 2), 9.1 and 9.1 % (in group 3), 76 and 60 % (in group 4). Conclusion. The proposed intrathecal fibrinolytic therapy with recombinant staphylokinase may be effective and safe to reduce the severity of cerebral vasospasm, improve clinical outcome and lower frequency of normal pressure hydrocephalus after aneurysm rupture.

Role of Cisternal Drainage in Patients with Traumatic Brain Injury Undergoing Decompressive Craniectomy

The effect of decompressive craniectomy (DC) on survival and functional outcome in traumatic brain injuries (TBI) is far from satisfactory. Additional modalities including cisternal drainage (CD) that provides good control of refractory intracranial pressure (ICP) intraoperatively need careful scrutiny. Two centre retrospective superiority study with one centre offering only standard decompressive craniectomy (DC) i.e. Group 1 and the other centre supplementing cisternal drainage (CD) to standard DC i.e. Group 2 was conducted. Consecutive patients with traumatic brain injury with signs of brain herniation or CT scan showing mass lesion or diffuse brain edema or midline shift or with GCS less than 9 or rapid fall in GCS over 2 points with persistently raised ICP of 25 mmHg over 15 minutes between August 2012 and July 2017 were included. The primary outcome was rating on Glasgow Outcome Scale (GOS) at 6 months post operatively, with GOS (1-3) categorized as ‘Unfavorable’ and GOS (4,5) as ‘Favorable’. Patients either received DC alone (Group 1=73 patients, 48.7%) or DC with CD (Group 2=77 patients, 51.3%). 107 (71.3%) severe, 36 (24%) moderate, and 7 (4.7%) mild head injuries cases received 72 unilateral and 78 bilateral DC. GOS 1 was observed in 32 DC only group (43.8%) and 22 DC plus CD group (28.6%) (p=0.052), an absolute risk reduction of 15.2% was found. Outcome (favorable sun favorable) against all strata of head injury severity, predominant radiological feature, laterality of surgery, and patient characteristics across the two groups were statistically not significant, however the groups were statistically significantly different on age and GCS at presentation (p=0.016 & 0.034 consecutively). Distinct survival benefit in patients with traumatic brain injury receiving cisternal drainage during decompressive craniectomy did not translate to better functional outcome.

RELATION BETWEEN CHANGE IN Ca AND Mg LEVELS OF CEREBROSPINAL FLUID AFTER SUBARACHNOID HEMORRHAGE AND THE OCCURRENCE OF VASOSPASM

Cerebral vasospasm is a characteristic complication after subarachnoid hemorrhage (SAH), and the onset of vasospasm is a very important factor to decide the patient's outcome. Though various causal factors have been proposed for cerebral vasospasm after SAH, none of them explain the whole pathomechanism of vasospasm. To evaluate the role of trace elements in vasospasm, we have examined the sequential change in element concentration in the cerebrospinal fluid (CSF) after SAH by PIXE, and have investigated the relation between trace elements and vasospasm. We obtained the CSF samples from cisternal drainage of 17 patients with SAH who underwent radical surgery within 48 hours from the onset. The drainage was placed into basal cisterns at the end of the operation. Three sampling times (3-5, 7-9 and 12-14 days from the onset) were scheduled, because vasospasm is likely to occur from day 4 through day 14 after the onset. Cerebral angiograms were performed to classify vasospasm on day 1 and 7 after the onset. We measured 29 elements in the CSF and focused on Ca and Mg levels in this study, since Ca -influx into the smooth muscle cells is a principal mechanism of muscle contraction, and the competition between Ca and Mg is closely related to the muscle contraction. We found a significantly lower levels of Mg in the CSF of patients with vasospasm on days 7-9 after the onset. These results suggest that Mg in the CSF possibly ameliorate vasoconstriction due to Ca in the pathomechanism of vasospasm.