Multisystem thromboembolism in a COVID-19 patient: a case report.

Hypercoagulability has been found in patients diagnosed with the novel coronavirus 19 (COVID-19) and has been identified as a major cause of morbidity and mortality. Herein, we report the challenge in managing a patient presenting with a 5 day history of COVID-19 diagnosis, complicated by deep venous thrombosis, pulmonary embolism and ischemic stroke in the setting of atrial septal aneurysm, presumed patent foramen ovale and paradoxical embolism, identified to have clots in transit on echocardiogram. The application of anticoagulation was felt to be high risk. The patient was transferred to a tertiary facility where the patient underwent thrombus aspiration and was eventually complicated by hemorrhagic conversion of the stroke.

Guillain-Barré Syndrome After a Gunshot Wound to the Thoracic Spine.

BACKGROUND: Guillain-Barré syndrome (GBS) is a rare but well-documented cause of paralysis, often occurring after infection. Few cases have been reported in association with spinal cord injury (SCI), which masks the characteristic ascending paralysis. To our knowledge, this is the first reported case of confirmed GBS during the clinical course of thoracic paraplegia due to a gunshot wound (GSW). CASE DESCRIPTION: A 23-year-old male presented with a GSW to the right axilla that lodged in the spinal canal at the level of T4, causing right hemothorax and American Spinal Injury Association A paraplegia. He had full strength in bilateral upper extremities until 2 weeks after the injury, at which time he developed progressive weakness in the arms with associated paresthesias and dyspnea. Within 5 days, he was intubated and nearly quadriplegic. Cerebrospinal fluid analysis and electromyography led to a diagnosis of GBS. He was treated with plasmapheresis and experienced rapid and marked recovery in respiratory and upper extremity motor function. CONCLUSIONS: The differential diagnosis for new-onset weakness in patients with GSW-induced SCI is complicated by the inability to obtain magnetic resonance imaging. This unique case of GBS in a patient with T4 paraplegia highlights the importance of obtaining a thorough history and using diagnostic tools to explore possibilities beyond surgery.

Neurosurgical Outcomes of Isolated Hemorrhagic Mild Traumatic Brain Injury.

Introduction Mild traumatic brain injury (TBI) is common but its management is variable. Objectives To describe the acute natural history of isolated hemorrhagic mild TBI. Methods This was a single-center, retrospective chart review of 661 patients. Inclusion criteria were consecutive patients with hemorrhagic mild TBI. Exclusion criteria were any other acute traumatic injury and significant comorbidities. Variables recorded included neurosurgical intervention and timing, mortality, emergency room disposition, intensive care unit (ICU) length of stay (LOS), discharge disposition, repeat computed tomography head (CTH) indications and results, neurologic exam, age, sex, Glasgow Coma Scale (GCS) score, and hemorrhage type. Results Overall intervention and unexpected delayed intervention rates were 9.4% and 1.5%, respectively. The mortality rate was 2.4%. A 10-year age increase had 26% greater odds of intervention (95% CI, 9.6-45%; P<.001) and 53% greater odds of mortality (95% CI, 11-110%; P=.009). A one-point GCS increase had 49% lower odds of intervention (95% CI, 25-66%; P<.001) and 50% lower odds of mortality (95% CI, 1-75%; P=.047). Subdural and epidural hemorrhages were more likely to require intervention (P=.02). ICU admission was associated with discharge to an acute care facility (OR, 2.9; 95% CI, 1.4-6.0; P=.003). Neurologic exam changes were associated with a worsened CTH scan (OR, 12.3; 95% CI, 7.0-21.4; P<.001) and intervention (OR, 15.1; 95% CI, 8.4-27.2; P<.001). Conclusions Isolated hemorrhagic mild TBI patients are at a low, but not clinically insignificant, risk of intervention and mortality.

Very High Blood Alcohol Concentration and Fatal Hemorrhage in Acute Subdural Hematoma.

INTRODUCTION: Alcohol intoxication is often present concurrently with traumatic brain injury (TBI). Recent studies have looked at the effect alcohol has on TBI and on coagulopathy. Typically, cases reviewed in the current literature report only on the effects of modest alcohol intoxication. CASE DESCRIPTION: A 43-year-old male presented to the trauma center after a fall, with rapidly deteriorating mental status. Computed tomography of the head demonstrated a 1.9-cm acute subdural hematoma. Of note, classical coagulation studies were normal, but blood ethanol level was high, 436 mg/dL. Postoperatively, the patient suffered an intracerebral hemorrhage requiring emergent return to the operating room, where a large volume of unclotted blood and clinical coagulopathy was encountered. DISCUSSION: We review the literature pertaining to coagulopathy in the context of TBI and ethanol intoxication. This case is a cautionary tale of a phenomenon of unmeasured coagulopathy in the face of severe alcohol intoxication manifested by intraoperative coagulopathy with new postoperative hemorrhage. Although routine preoperative testing indicated normal clotting function, a thromboelastogram demonstrated delayed clot formation. The protective effects of alcohol are well described; however, we believe that there is a population of patients with severe acute intoxication who have coagulopathy that may go undetected by routine preoperative screening. CONCLUSIONS: Caution should be exercised when taking care of patients with very high levels of alcohol because physiologic derangements may be unpredictable. Additional research is needed for patients with very high levels of alcohol intoxication and the effect it may have on coagulation.

Volumetry in the Assessment of Pituitary Adenoma Resection: Endoscopy versus Microscopy.

Background Assessment of the extent of resection after surgical resection of pituitary adenomas is most commonly reported in terms of the presence or absence of residual tumor. A quantitative comparison of volumetric resection between endonasal endoscopy (EE) and microsurgery (MS) has rarely been done. Methods A retrospective analysis was performed on a consecutive series of 154 patients with pituitary adenomas treated by the same surgeon at a single institution. We employed volumetric analysis pre- and postoperatively on two cohorts of pituitary adenoma patients treated through MS ( n = 37) versus EE approach ( n = 117). Results Volumetric analysis revealed a higher incidence of complete resection (64.4 vs. 56.8%) and mean volume reduction in the EE cohort (92.7 vs. 88.4%), although not significant. Recurrence rates were significantly lower in the EE group (7.7% vs 24.3%, p = 0.015). Subgroup analysis identified that patients with preoperative tumor volumes >1 mL were less likely to recur through EE (7.8 vs. MS: 29.6%; p = 0.0063). A higher incidence of complete resection was also noted in patients with favorable Knosp grades (0-1) (EE: 87.8 vs. MS: 63.2%; p = 0.036). Postoperative complication rates were not significantly different between both techniques. Conclusion Both microscopy and endoscopy are well-tolerated, effective approaches in the treatment of pituitary adenomas. Our series demonstrated that EE may be superior to MS in preventing tumor recurrence and achieving a complete resection in certain subsets of patients. EE provides a slight advantage in tumor control outcomes that may justify the paradigm shift to pure endoscopy at our center.

Transdural approach to resection of retro-odontoid cysts in elderly patients: report of 3 cases.

Retro-odontoid cysts that arise from the tectorial membrane are uncommon lesions that can occur in elderly patients. They arise secondary to degenerative changes, including calcium pyrophosphate deposition within the ligaments. Surgical treatment is indicated when these lesions result in intractable pain, instability, and/or myelopathy. Several surgical techniques to treat this condition exist, but the optimal approach in elderly patients with comorbidities remains controversial. Here, the authors present a case series of 3 patients who underwent successful resection of a retro-odontoid lesion performed through a transdural approach. The patients were 70, 81, and 74 years old and presented with symptoms of cervical myelopathy. In consideration of their advanced age and the location of their lesion, resection via a posterior approach was considered. A 1- to 2-cm suboccipital craniectomy and C-1 and partial C-2 laminectomy were performed. These lesions could not be accessed via an extradural posterolateral approach, and so a transdural approach was performed. In the first 2 patients, a preexisting deformity prompted an instrumented fusion. In the third patient, only a lesion resection was performed. In each case, the dural opening was made using a paramedian ipsilateral-sided incision, and the lesion was resected through an incision in the anterior dura mater. Only the posterior dura was closed primarily. MR imaging evidence of excellent spinal cord decompression was evident in follow-up examinations. Transdural resection of retro-odontoid cysts is a viable option for treating asymmetrical ventral extradural cysts. Results from this case series suggest that such an approach is safe and feasible and can provide an alternative to open or endoscopic anterior transpharyngeal approaches.

Combined Use of Intraoperative Indocyanine Green and Dynamic Angiography in Rotational Vertebral Artery Occlusion.

Rotational vertebral artery occlusion (RVAO) is a well-documented surgically amenable cause of vertebrobasilar insufficiency. Traditionally, patients have been imaged using dynamic rotational angiography. We report a case of RVAO in which intraoperative indocyanine green angiography (ICGA) was used to confirm adequate surgical decompression of the VA. A 57-year-old female who presented with multiple episodes of syncope provoked by turning her head to the right. Rotational dynamic angiography revealed a dominant right VA that became occluded at the level of C5/6 with head rotation to the right. The patient underwent successful surgical decompression of the VA via an anterior cervical approach. ICGA demonstrated VA patency with head rotation. This was further confirmed by intraoperative dynamic catheter angiography. To the best of our knowledge, we present the first use of ICG combined with intra-operative dynamic rotational angiography to document the adequacy surgical decompression of the VA in a patient with RVAO.

Etiology and Treatment Modalities of Occipital Artery Aneurysms.

BACKGROUND: Aneurysms of the external carotid artery represent approximately 2% of cervical carotid aneurysms, with the majority being traumatic pseudoaneurysms. Given the paucity of literature available for guidance, the diagnosis, treatment, and follow-up of such lesions are completely individualized. CASE DESCRIPTION: We report an 83-year-old woman with an 8-week history of headache in the occipital region, transient episode of gait disturbance, and pulsatile tinnitus on the right. She had no history of trauma, surgery, autoimmune disease, or infection. Physical examination revealed a pulsatile mass tender to palpation in the right occipital scalp. The mass was surgically excised, and histopathological diagnosis of a true aneurysm was made. Postoperatively, the patient's symptoms resolved; however, 1 month after the procedure, she developed occipital neuralgia, which was successfully treated with a percutaneous nerve block. CONCLUSIONS: To the best of our knowledge, this is the second reported case of a true aneurysm of the occipital artery in a patient with no history of trauma. The clinical examination, diagnosis, and treatment are discussed and the literature is reviewed for previously reported cases.

Transischiorectal fossa approach for resection of pudendal nerve schwannoma: case report.

Pudendal nerve schwannomas are very rare, with only two cases reported in the English-language literature. The surgical approaches described in these two case reports are the transgluteal approach and the laparoscopic approach. The authors present the case of a patient with progressive pelvic pain radiating ipsilaterally into her groin, vagina, and rectum, who was subsequently found to have a pudendal schwannoma. The authors used a transischiorectal fossa approach and intraoperative electrophysiological monitoring and successfully excised the tumor. This approach has the advantage of direct access to Alcock's canal with minimal disruption of the pelvic muscles and ligaments. The patient experienced complete relief of her pelvic pain after the procedure.

Long-term angiographic results of endovascularly "cured" intracranial dural arteriovenous fistulas.

OBJECTIVE: Dural arteriovenous fistulas (DAVFs) are complex lesions consisting of abnormal connections between meningeal arteries and dural venous sinuses and/or cerebral veins. The goal of treatment is surgical or endovascular occlusion of the fistula or fistulous nidus or at least the disconnection of the feeding vessels and the draining veins. Delayed angiographic data on previously embolized dural fistulas is lacking. The authors report their experience and the long-term angiographic results with embolization of intracranial DAVF using Onyx. METHODS: All cases of DAVF treated primarily with Onyx at the authors' institution from 2006 to 2013 were retrospectively reviewed. Patient demographics, fistula characteristics, embolization details, and angiographic follow-up were analyzed. RESULTS: Fifty-eight patients with DAVFs were treated during the study period. Twenty-two patients were treated with open surgery with or without prior embolization. Thirty-six patients were treated with embolization alone, of whom 26 underwent an attempt at curative embolization and are the subject of this review. All but 2 of these patients were treated in a single session. Angiographic "cure" was achieved in all cases following treatment. Follow-up angiography was performed in 21 patients at a mean of 14 months after treatment (range 2-39 months). Asymptomatic angiographic recurrence of the fistula was evident in 3 of the 21 patients (14.3%). On reviewing the procedural angiograms of the cases in which the DAVFs recurred, it was observed that the Onyx cast did not reach the venous portion in 1 case, whereas it did reach the vein in the other 2 cases. CONCLUSIONS: Recurrence following initial angiographic cure of DAVF is not uncommon. Incomplete penetration of the embolic material into the proximal portion of the venous outlet may lead to delayed recurrence. Long-term angiographic follow-up is highly recommended.

Infarct growth despite full reperfusion in endovascular therapy for acute ischemic stroke.

AIM: To explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT). METHODS: We retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008-2013/2010-2013). Sixty patients selected by MRI or CT perfusion presenting within <24 h of onset with modified Thrombolysis In Cerebral Infarction (mTICI) grade 3 or 2c reperfusion were included. Significant infarct growth (SIG) was defined as infarct expansion >11.6 mL. RESULTS: Mean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG. CONCLUSIONS: Despite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion.

Covered Stents for the Prevention and Treatment of Carotid Blowout Syndrome.

BACKGROUND: Carotid blowout syndrome (CBS) is a life-threatening emergency resulting from compromise of the carotid artery caused by malignancy in the head and neck. OBJECTIVE: To report our experience with covered stents for the prevention or treatment of carotid blowout syndrome secondary to head and neck cancer to ascertain the safety and efficacy of this technique. METHODS: We reviewed the characteristics and outcome of all patients who underwent covered stent placement in the extracranial carotid artery in the setting of head and neck malignancy between 2006 and 2013 at the University of Miami. Patient demographics, presenting symptoms, devices used, perioperative complications, imaging, and follow-up data were reviewed. RESULTS: Seventeen carotids in 15 patients, whose ages ranged from 20 to 84 years (mean, 70.4 years), were treated with 20 covered nitinol (Viabahn Endoprosthesis, Gore, Flagstaff, Arizona) stents. Three patients were treated acutely for bleeding from carotid blowout, and 12 were treated prophylactically for threatened carotid blowout. All patients were given periprocedural dual antiplatelet therapy. No thromboembolic or ischemic complications were noted. Hemorrhage after treatment occurred in 4 patients. In 2 patients, the hemorrhage was from a source not covered by the stent. CONCLUSION: The use of covered stents is a simple, safe, and effective method for treating or preventing carotid blowout syndrome in patients with head and neck malignancy. Carotid artery reconstruction with covered stents may minimize the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

Carotid siphon calcification impact on revascularization and outcome in stroke intervention.

OBJECTIVE: The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. The authors sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention. METHODS: All anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012 were reviewed. Clinical and radiographic data were collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale). RESULTS: One-hundred seventeen patients met inclusion criteria. The mean age was 65.4±15.6 years and 36% were male. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho=0.883, p<0.001). The mean Calcium Extent Score was 1.5±1.3, Calcium Thickness Score 1.3±1.0 and total CSC Score 2.8±2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores. CONCLUSION: Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion.

Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors using Onyx.

OBJECT: The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.). METHODS: The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded. RESULTS: Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction). CONCLUSION: Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization.

Acellular dermal allograft for sellar repair after transsphenoidal approach to pituitary adenomas.

Objectives Our practice has transitioned from using fat autograft to acellular dermal matrix (AlloDerm, LifeCell Corp, Woodlands, Texas, USA). We present the largest series to our knowledge of AlloDerm for sellar floor repair after transsphenoidal approach to pituitary adenoma and compare rates of postoperative cerebrospinal fluid (CSF) leak with an earlier cohort of patients whose CSF leaks were repaired with fat autograft. Design This is a retrospective cohort study comparing sellar repair with fat autograft versus inlay Alloderm between the years 2003 and 2012. The primary end point was postoperative CSF leak. Results A total of 429 patients (368 primary; 83 revision operations) without intraoperative lumbar drainage were included. A total of 18 postoperative CSF leaks were observed (3.9%). Intraoperative CSF leak occurred in 160 cases (35.5%). Among this subset of patients with intraoperative CSF leak, 95 underwent repair with AlloDerm and 46 underwent repair with fat autograft, with postoperative CSF leak rates of 8.4% and 15.2%, respectively (p = 0.34, chi-square test); 19 patients underwent repair with other techniques or no repair at all, with postoperative leak rate of 0%. Conclusions AlloDerm is an effective alternative to fat autograft in cases of low-flow CSF leak following transsphenoidal resection of pituitary adenoma.