Diabetes insipidus-an extremely rare complication from replacement of an external ventricular drain.

Insertion of an external ventricular drain (EVD) is one of the most common and most important lifesaving procedures encountered in the neurologic intensive care unit, but often done by the junior members of the team. A good number of complications may follow the insertion of EVD. In the available literature, only one case was reported with the placement of EVD in suprasellar cistern. There is no report of insertion or replacement of an EVD in the sella. Diabetes insipidus (DI) is also an unheard of complication of EVD. Here, we report a case where a patient with subarachnoid haemorrhage (SAH) with acute hydrocephalus needed CSF diversion and had an EVD, during replacement of which through the same tract, the new EVD went into the sellar floor and she developed diabetes insipidus (DI) eventually. The catheter was pulled out and the DI settled. DI may occur as a consequence of SAH. The rationale behind reporting this case is to differentiate the cause of DI; as following insertion of EVD in a patient of SAH, the development of DI should raise the suspicion of misplaced EVD, should not be left as a consequence of SAH and appropriate imaging should be obtained. To prevent this happening, preoperative verification of CT, image-guided insertion, measurement of the length of the tubing and careful anchorage of EVD to surrounding tissue are necessary.

Evaluation of computed tomography artefacts of carbon-fiber and titanium implants in patients with spinal oligometastatic disease undergoing stereotactic ablative radiotherapy.

This study evaluated artefacts on computed tomography (CT) images using Hounsfield units (HU) in patients with spinal oligometastatic disease who received carbon-fiber (CF; n = 11) or titanium (n = 11) spine implants and underwent stereotactic ablative radiotherapy (SABR). Pre- and postoperative HU were measured at the vertebral body, pedicle, and spinal cord at three different levels: the lower instrumented vertebra, the level of metastatic spinal cord compression, and an uninvolved level. Areas measured at each level were delicately matched pre- and postoperatively. Significant differences in HU were observed at the vertebral body, the pedicle, and the spinal cord at the lowest instrumented vertebra level for both CF and titanium (average increase 1.54-fold and 5.11-fold respectively). At the metastatic spinal cord compression level, a trend towards a higher HU-increase was observed in titanium compared with CF treated patients (average increase 2.51-fold and 1.43-fold respectively). The relatively high postoperative HU-increase after insertion of titanium implants indicated CT artefacts, while the relatively low HU-increase of CF implants was not associated with artefacts. Less CT artefacts could facilitate an easier contouring phase in radiotherapy planning. In addition, we propose a CT artefact grading system based on postoperative HU-increase. This system could serve as a valuable tool in future research to assess if less CT artefacts lead to time savings during radiotherapy treatment planning and, potentially, to better tumoricidal effects and less adverse effects if particle therapy would be administered.

Surgical management of scalp arterio-venous malformation and scalp venous malformation: An experience of eleven cases.

AIMS: Scalp arterio-venous malformation (AVM) and scalp venous malformation (SVM) are rare conditions that usually need surgical treatment. Here, we have reported our experience of the surgical management of such lesions with a short review of the literature. MATERIALS AND METHODS: In this prospective study, 11 patients with scalp AVM and SVM, who underwent surgical excision of lesion in our hospital from 2006 to 2012, were included. All suspected high-flow AVM were investigated with the selective internal and external carotid digital subtraction angiogram (DSA) ± computed tomography (CT) scan of brain with CT angiogram or magnetic resonance imaging (MRI) of brain with MR angiogram, and all suspected low-flow vascular malformation (VM) was investigated with MRI of brain + MR angiogram. Eight were high-flow and three were low-flow VM. RESULTS: All lesions were successfully excised. Scalp cosmetic aspects were acceptable in all cases. There was no major post-operative complication or recurrence till last follow-up. CONCLUSIONS: With preoperative appropriate surgical planning, scalp AVM and SVM can be excised without major complication.

Novel Surgical Treatment of Recurrent CSF Leak by Temporoparietal Temporalis Myofascial Flap: A Series of 6 Cases.

BACKGROUND: With the advent of modern endoscopes and a better anatomic understanding of the skull base, the indications of endonasal approaches are increasing. These procedures may be complicated by high rates of postoperative cerebrospinal fluid (CSF) leak, and reconstruction of the defect remains challenging. In the anterior skull base, vascularized grafts have been reported as superior in preventing CSF leakage and infection. The Hadad-Bassagasteguy flap, being a pedicled flap, is our first line flap to reconstruct the skull base. When we were not successful with this flap, we resorted to different flaps. OBJECTIVE: We modified the originally described temporoparietal fascial flap by Fortes et al and applied clinically. The objective of this paper is to briefly describe the modification of the flap and to review the clinical outcome. METHODS: From 2014 to 2018, in 6 cases of CSF leak with the appropriate indication, we used the temporoparietal myofascial flap repair that is a modification of the temporoparietal fascial flap by Fortes et al. We took all the 6 patients in our study and followed them up. RESULTS: All of the 6 repairs were successful, and no CSF leak was found just after the operation in 6- to 48-month follow-up. CONCLUSION: We recommend our modified novel temporoparietal myofascial flap as a very good option in case of failed cases of postoperative CSF leak.

Bony reconstruction by reposition of bony chips in suboccipital craniectomy.

In suboccipital craniectomy where the bone is not repositioned, there may be a significant cosmetic defect due to lack of skull bone in the suboccipital region. It may accompanied by sensory symptoms, including pain. To prevent any cosmetic defect and sensory symptoms we repositioned the bone chips at the craniectomy site in 42 suboccipital craniectomies before the closure of the scalp. At a mean follow-up of 22 months (range: 5-44 months), two patients complained of mild discomfort in the healed wound or of occasional local pain. One patient complained of mild itching at the site. In two patients, bone chips were accumulated at the lower part of the suboccipital craniectomy and failed to form a uniform bone cover at the operated site. In one patient, all bone chips were reabsorbed and there was no bone at the operated site. There was pseudomeningocele formation in one patient. In the rest of the cases there was satisfactory bone coverage at the operated site, both clinically and radiologically. The wound sites were aesthetically acceptable in 40 cases. Our study suggests that in the majority of cases where suboccipital craniotomy is not possible or not done, repositioning of the bone chips at the craniectomy site is associated with satisfactory aesthetic and functional outcome and formation of bone coverage at the operated site.

Clinical Characteristics and Diagnostic Challenges of COVID-19: An Update From the Global Perspective.

Clinical characteristics are essential for the correct diagnosis of diseases. The current review aimed to summarize the global clinical characteristics of the COVID-19 patients systematically and identify their diagnostic challenges to help the medical practitioners properly diagnose and for better management of COVID-19 patients. We conducted a systematic search in PubMed, Web of Science, Scopus, Science Direct, and Google Scholar databases for original articles containing clinical information of COVID-19 published up to 7th May 2020. Two researchers independently searched the databases to extract eligible articles. A total of 34 studies from 8 different countries with 10889 case-patients were included for clinical characteristics. The most common clinical symptoms were cough 59.6, fever 46.9, fatigue 27.8, and dyspnea 20.23%. The prominent laboratory findings were lymphocytopenia 55.9, elevated levels of CRP 61.9, aspartate aminotransferase 53.3, LDH 40.8, ESR 72.99, serum ferritin 63, IL-6 52, and prothrombin time 35.47%, and decreased levels of platelets 17.26, eosinophils 59.0, hemoglobin 29, and albumin 38.4%. CT scan of the chest showed an abnormality in 93.50% cases with bilateral lungs 71.1%, ground-glass opacity 48%, lesion in lungs 78.3%, and enlargement of lymph node 50.7%. Common comorbidities were hypertension, diabetes, obesity, and cardiovascular diseases. The estimated median incubation period was 5.36 days, and the overall case fatality rate was 16.9% (Global case fatality outside China was 22.24%: USA 21.24%, Italy 25.61%, and others 0%; whereas the case fatality inside the Hubei Province of China was found to be 11.71%). Global features on the clinical characteristics of COVID-19 obtained from laboratory tests and CT scan results will provide useful information to the physicians to diagnose the disease and for better management of the patients as well as to address the diagnostic challenges to control the infection.

Use of Pulsed Radiofrequency Energy Device (PEAK Plasmablade) in Neuromodulation Implant Revisions.

BACKGROUND: Battery replacement or revision surgery for neuromodulation implants is conventionally performed using sharp dissection. Meticulous dissection within thick scar tissue is vital to avoid damage to surrounding lead(s), which could result in more extensive revision surgery. Traditional electrosurgery devices are contraindicated as the emitted energy can be transferred to the hardware, resulting in implant or tissue damage with severe consequent complications. OBJECTIVE: We report our experience and potential applications of a novel, pulsed monopolar radiofrequency energy device (PEAK PlasmaBlade, Medtronic PLC, Minneapolis, Minnesota, USA), which facilitates dissection around implants without the risk of damaging or transmitting energy through the system. METHODS: We conducted a 2-center retrospective study to review the indications, safety, and efficacy of the PlasmaBlade in 57 cases requiring either neuromodulation system replacement or revision. Deep brain stimulator (DBS) battery replacements were undertaken in 45 cases, 8 vagal nerve stimulator battery revisions, 2 intrathecal baclofen system revision, 1 DBS extension revision, and 1 DBS scar revision around the cranial portion of the lead. RESULTS: All cases proceeded without adverse event or damage to lead/generator and with a subjective and objective impression of significant time savings. Average operating times for battery replacements were reduced from 37 to 26 minutes (P = 0.015). CONCLUSION: In our experience, the PlasmaBlade is safe to use in revising/replacing neuromodulation implants. We observed no damage or transmission of energy to the implants or leads; additional advantages of the system include reduced operating times, less damage to surrounding tissue, and the potential to facilitate revision procedures in awake patients under local anesthesia.

Abdominal schwannoma in a case of neurofibromatosis type 2: A report of a rare combination.

Neurofibromatosis-2 (NF2) is an autosomal-dominant disease, which is characterized by vestibular schwannomas (VSs) (acoustic neurinoma) as well as tumours of the peripheral and central nervous system, demonstrating a variety of expression. A 12-year-old girl presented to us with headache and ataxia for four months. We examined and found a lump in the right side of her abdomen. On magnetic resonance imaging (MRI) of brain, a bilateral VS at the cerebellopontine (CP) angle was detected, and on computerized tomography (CT) scan and ultrasonography of her abdomen a large retroperitoneal schwannoma was revealed in the right side of her abdomen. At first, the right-sided CP angle tumour and two months later, the left-sided lesion was operated. After some days, she became mute and incontinent, and was found to have hydrocephalus on CT scan. We introduced a ventriculoperitoneal shunt. Then we operated the abdominal lump, which was histologically proven as schwannoma. The association of these three tumours is rare and untiring surgical approaches made her better. The patient recovered well except bilateral mild facial and vestibulocochlear deficit.