Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach.

OBJECTIVE: To describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach. METHODS: This was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent. RESULTS: Thirty-five patients were included in this series. The patients' mean age was 33 years (range 11-71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3-65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus. CONCLUSION: Traumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Perforating Brain Injury By a Rusty Steel Bar.

A perforating head injury is a type of an injury wherein the projectile passes entirely through the cranium leaving both entrance and exit wounds. It is considered less prevalent than other kinds of head trauma such as closed or penetrating head injuries carry a worse prognosis among other varieties of head injuries. Having unique mechanism and pathophysiology it is considered a significant challenge for the practicing neurosurgeon mandating high precaution and novel approach to minimize further damage. Here, we presented a case of a 5-year-old boy who suffered from perforating brain injury by a fallen rusty steel bar.

Pharmacokinetics of colistin in cerebrospinal fluid after intraventricular administration alone in intracranial infections.

The aim of this study was to investigate the pharmacokinetics of colistin in cerebrospinal fluid (CSF) after intraventricular (IVT) administration of colistin methanesulfonate (CMS) for central nervous system (CNS) infections caused by multidrug-resistant Gram-negative bacteria. Ten patients with CNS infection were treated with CMS (active substance colistin equivalent to 100 000 units, every 24 h) by IVT administration. After 3 days of treatment, the concentration of colistin in the CSF was determined by selective ultra-performance liquid chromatography (UPLC) at 2, 4, 6, 8, 12 and 24 h after CMS administration. A pharmacokinetic analysis was performed using Phoenix WinNonlin. Following IVT administration of CMS, the estimated colistin apparent CSF half-life (t1/2) was 10.46 ± 6.98 h, the average peak colistin concentration (Cmax) was 16.95 ± 7.39 µg/mL and the average time to peak concentration (Tmax) was 4.6 ± 0.97 h. The measured trough concentration (Cmin; colistin concentration in CSF at 24 h after administration of CMS) was 1.12-8.33 µg/mL and the average Cmin was 2.91 ± 2.11 µg/mL. CSF concentrations of colistin were above the minimum inhibitory concentration (MIC) of 0.5 µg/mL at 24 h after IVT administration in all patients. Microbiological cure was observed in all patients. In conclusion, this is the first study of colistin pharmacokinetics in CSF after IVT administration alone in patients with CNS infection. It provides essential data for designing relatively safe and effective CMS dosing regimens.

A retrospective study on outcomes following posterior fossa decompression with dural splitting surgery in patients with Chiari type I malformation.

BACKGROUND: Chiari type I malformation (CM I) is a congenital defect of the skull base and brain. Posterior fossa decompression alone or with duraplasty and partial resection of cerebellar tonsils is a standard approach. The effectiveness of other approaches such as the dural splitting technique is still under the study. OBJECTIVE: To study and compare the outcome following a dural splitting surgery with the duraplasty group. METHOD: 184 patients that received dural splitting surgery and 39 patients that received duraplasty surgery were identified. The outcome of the individual procedure in terms of symptoms, pre- and postoperative presence of syrinx, operation time, hospital admission period, and Chicago Chiari Outcome Scale (CCOS) were analyzed and compared. RESULTS: The observed values in terms of symptomatic relief between the two groups were similar Pearson's chi-square test was 0.677 with p=0.411. Independent samples Mann-Whitney U test to analyze CCOS score showed p = 0.249 at Z = 1.152. The average postoperative period in days was less in PFDDS group 9.25 days, the average admission period in days for the group was less in PFDDS group 14.23 days with p < 0.0005. Fisher's exact test showed the Syrinx disappearance rate was better in the PFDDS group. The average duration for surgery was less on the PFDDS group. CONCLUSION: Our study showed that more optimal results were obtained in terms of syrinx resolution as well as shorter operation time and postoperative stay among the PFDDS group. Both procedures are equally effective in terms of CCOS score.

[The diagnosis and surgical management for intramedullary spinal cord cavernous angioma].

OBJECTIVE: The clinical diagnosis and surgical management of intramedullary spinal cord cavernous angioma were discussed. METHOD: Total 19 patients with intramedullary cavernous angioma were analyzed retrospectively on the clinical manifestation, radiographic feature, diagnosis and differentiation, surgical technique and caution. Of all the 19 patients, averaging 38.7 years old, 14 were male and 5 were female. Nine patients were followed. RESULT: All the 19 patients pathologically diagnosed with spinal cord cavernous angioma got good surgical results, besides one patient showed loss of proprioception. Nine patients were followed up and all demonstrated improvement on neurological function. CONCLUSION: The clinical symptom of most of the patients with spinal cord cavernous angioma presented mildly at onset, but deteriorated gradually because of repeated prehemorrhage. Since the lesion showed some characteristic in MRI, MRI examination was regarded as an important diagnostic tool. Dissection should be done between the tumor and the gliosis during the surgical procedure, special attention should be paid to avoiding tumor residual. It was not necessary to aggressively evacuate the hematoma derived from tumor hemorrhage, which extended along the central canal up and down, except obvious occupied syndrome exited.

Outcome Following the Treatment of Ventriculitis Caused by Multi/Extensive Drug Resistance Gram Negative Bacilli; Acinetobacter baumannii and Klebsiella pneumonia.

Introduction: CNS ventriculitis is a serious complication following an intracranial insult that demands immediate treatment with broad-spectrum antibiotics in a critical care setting. Infections due to multi/extensive drug resistance (MDR/XDR) microorganisms are very challenging, which may demand an additional approach to the ongoing practice; intravenous and intraventricular administration of antibiotics. Aim: To study the efficacy and safety of thorough ventricular irrigation followed by daily intraventricular antibiotic administration in patients with MDR/XDR ventriculitis. Materials and Methods: A retrospective analysis was done on 19 inpatients with ventriculitis caused by Acinetobacter baumannii (AB) or Klebsiella pneumonia (KP), at Shanghai Tenth People's Hospital from January 2016 to October 2017. We reviewed our experience; the role of thorough ventricular irrigation with Colistin mixed normal saline, followed by intraventricular Colistin therapy. Treatment outcomes were evaluated based on the clinical symptoms, Cerebro-Spinal Fluid (CSF) culture, laboratory findings and complications. Results: A total of 19 patients were included (15 males and 4 females), with a mean age in years of 51, which ranged from 18-67. Fourteen patients had Acinetobacter baumannii (AB) and 5 had Klebsiella pneumoniae (KP). The average CSF sterilization period following ventricular irrigation and intraventricular Colistin was 6 days. Sixteen patients (84%) were cured, and 3 patients (15%) died during the course of the treatment. Conclusion: In addition to Intraventricular Colistin, thorough ventricular irrigation could increase the cure rate up to 84% in patients suffering from MDR/XDR CNS ventriculitis.

[Diagnosis and treatment of spinal cord hemangioblastoma].

OBJECTIVE: To study the diagnosis and treatment of spinal cord hemangioblastoma. METHOD: The clinical data of 42 patients with spinal cord hemangioblastoma who were operated on between 1997 and 2005 were analyzed. RESULT: Spinal cord hemangioblastoma mostly showed space occupying lesions with clear boundary and Dd-DTPA homogenous enhancement by MRI. All the 42 patients underwent complete excision. 27 patients showed improvement of their symptoms, the 6 patients failed to show any change, and neurological deficits were aggravated in the 5 patients. CONCLUSION: MRI and DSA are helpful in qualitative and localized diagnoses of the spinal cord hemangioblastoma. Surgical outcomes are favorable.

Negative-Pressure Hydrocephalus: A Case Report on Successful Treatment Under Intracranial Pressure Monitoring with Bilateral Ventriculoperitoneal Shunts.

BACKGROUND: Negative-pressure hydrocephalus (NegPH), a very rare condition of unknown etiology and optimal treatment, usually presents postneurosurgery with clinical and imaging features of hydrocephalus, but with negative cerebrospinal fluid pressure. CASE DESCRIPTION: We describe a NegPH case of -3 mm Hg intracranial pressure that was successfully treated to achieve 5 mm Hg under continuous intracranial pressure monitoring with horizontal positioning, head down and legs elevated to 10°-15°, neck wrapping for controlled venous drainage, chest and abdomen bandages, infusion of 5% dextrose fluid to lower plasma osmolarity (Na+, 130-135 mmol/L), daily cerebrospinal fluid drainage >200 mL, and arterial blood gas partial pressure of carbon dioxide >40 mm Hg.

KLF4 Knockdown Attenuates TBI-Induced Neuronal Damage through p53 and JAK-STAT3 Signaling.

AIMS: Traumatic brain injury (TBI) is induced by complex primary and secondary mechanisms that give rise to cell death, inflammation, and neurological dysfunction. Understanding the mechanisms that drive neurological damage as well as those that promote repair can guide the development of therapeutic drugs for TBI. Kruppel-like factor 4 (KLF4) has been reported to negatively regulate axon regeneration of injured retinal ganglion cells (RGCs) through inhibition of JAK-STAT3 signaling. However, the role of KLF4 in TBI remains unreported. Reactive oxygen species (ROS)-induced neuronal death is a pathophysiological hallmark of TBI. METHODS: In this study, we used H2 O2 -treated RGCs in vitro and the optic nerve crush model in vivo to simulate neuronal damage in TBI. The function of KLF4 in RGC survival and axon regeneration in these models was investigated. In addition, the effects of KLF4 knockdown on neuronal damage after a brain impact that mimics moderate TBI were studied. RESULTS: The results show that H2 O2 induces p53-dependent apoptosis of RGCs in vitro through upregulation of KLF4. Additionally, KLF4 knockdown in vivo significantly enhances CNTF-induced axon regeneration of RGCs after optic nerve crush, and more importantly, prevents neuronal damage after a moderate brain impact in rats. Our Western blot analysis and immunoprecipitation assay results indicate that these effects of KLF4 knockdown are mediated by the p53 and JAK-STAT3 pathways. CONCLUSION: These findings provide evidence that KLF4 plays an important role in the pathophysiology of TBI. Blocking KLF4 may be a potential therapeutic strategy for the treatment of TBI, either alone or in combination with agents that target complementary mechanisms.

Anatomical studies on the temporal bridging veins with Dextroscope and its application in tumor surgery across the middle and posterior fossa.

OBJECTIVE: To evaluate the application of virtual reality technology in neurosurgical anatomy we compared the virtual three-dimensional (3D) microanatomy of the temporal bridging veins as part of the resection of tumors across the petrosal crest in 25 patients against the actual microanatomy of the temporal bridging veins on 20 cadaveric head sets. PATIENTS AND METHODS: The experiment was carried out by two groups of data: a virtual group made of 25 clinical cases and a physical body group made of 20 cadaveric head sets. In the physical body group, the temporal bridging veins on the cadaveric heads were examined under the microscope from the number of their tributaries to termination and measure the distance between emptying point on sinus of labbé vein and sigmoid transverse sinus. In the virtual group, the dissection of the temporal bridging veins was simulated on Dextroscope. We compared the anatomical features of temporal bridging veins in two groups. Virtual reality technology was used in the planning of 25 cases for which the anatomy of temporal bridging veins needed to be studied carefully by the neurosurgical team. RESULTS: Four basic configurations of veins were found: venous lakes running in the tentorium before emptying the sinuses 17.5% (7 hemispheres), candelabra of veins uniting to form one large drainage 40% (16 hemispheres), single independent draining veins 20% (8 hemispheres) and multiple independent draining veins 22.5% (9 hemispheres) in physical body group, venous lake16% (8 hemispheres), candelabra of veins uniting to form one large drainage 42% (21 hemispheres), single independent draining veins 18% (9 hemispheres) and multiple independent draining veins 24% (12 hemispheres) in virtual group. 213 tributaries (85 drainage to labbé veins) and 87 terminations of temporal bridging veins were found in cadaveric heads, whereas 167 tributaries (80 to labbé veins) and 81 terminations of temporal bridging veins were found in the virtual group. The distribution of anatomical terminations of temporal bridging veins were divided into three groups: transverse area 52.87% (46) tentorium area 24.13% (21) and petrosal area 23.10% (20) in physical body group, whereas 54.35% (50) 23.91% (22) and 21.74% (20) in virtual group, respectively. The proportion of fore-placed type veins of labbé is 7.69% in physical body group and 8.33% in virtual group (P>0.05). The distance from the emptying point of the labbé veins to the sigmoid transverse point in the virtual group was 18.75 ± 1.95 mm, in the physical body group was 20.12 ± 2.51 mm (P>0.05). The anatomical features of labbé veins found during the operation of the 25 patients with tumors extended from middle fossa to posterior fossa and were identical to what was seen in presurgical planning. CONCLUSIONS: Virtual reality technology can accurately simulate the anatomical feature of the temporal bridging veins which facilitates the planning of individual operations in neurosurgery.

Microsurgical excision of the craniocervical neurenteric cysts by the far-lateral transcondylar approach: case report and review of the literature.

Neurenteric cysts in the anterior craniocervical junction (CCJ) region can be found in extremely rare cases. We report one case with craniocervical neurenteric cyst that was excised by the far-lateral transcondylar (FLT) approach. A 43-year-old man presented with a history of recurrent episodes of mild neck pain and dysesthesia in his bilateral hands of 2 years' duration with rapid deterioration 3 weeks prior to admission. Magnetic resonance imaging (MRI) of the CCJ region revealed a well-defined intradural cystic lesion located ventral from the pontomedullary junction to C1 vertebra with medulla and C1 cord compression. This patient underwent total excision of the lesion via the FLT approach without any postoperative neurological deficits, and the histopathologic diagnosis was neurenteric cyst. Follow-up MRI has revealed no evidence of recurrence. The clinical features, imaging studies, and surgical approach options involved in resecting craniocervical neurenteric cysts are discussed, along with a review of the literature.