Electroconvulsive Therapy in Patients With Cerebral Aneurysms.

ABSTRACT: Subarachnoid hemorrhage due to cerebral aneurysm rupture is a devastating event with a high mortality and significant morbidity. The safety of patients undergoing electroconvulsive therapy (ECT) in the presence of an aneurysm is not clear and is a cause of anxiety for both health care workers and patients. The present article collated the available evidence related to ECT in the presence of an aneurysm and found that there were no case reports where ECT directly led to the rupture of an aneurysm, although 1 case reported a rupture of an aneurysm between sessions of ECT. The epidemiology of cerebral aneurysms is discussed, as are key clinical considerations related to the care of patients with aneurysms who require ECT.

Aerospace Implications of Key Neurological Conditions.

INTRODUCTION: The neurological impact (or lack thereof) of certain medical histories and imaging findings is important to understand in the context of air and spaceflight. There are a number of neurological conditions that, if present in pilots and astronauts, carry variable (and sometimes adverse) functional implications for safety and overall mission success. In this systematic overview, the authors will refer to the relevant clinical and radiological features of brain tumors and vascular anomalies, cerebral edema and intracranial hypertension, concussion and the traumatic brain injury (TBI) spectrum, hematomas, cerebrospinal fluid circulation anomalies including hydrocephalus and sequestrations, spinal degenerative changes, and cerebral ischemia and demyelination. It is notable that these last two conditions have recently been reported to be a complication in some people with coronavirus disease 2019 (COVID-19). A paradigm for practical neurological workup of symptomatic pilots and astronauts will be discussed, as will the controversial notion of pre-emptive radiological screening (vs. not screening) in asymptomatic or clinically occult situations. The concepts of medical surveillance in the setting of known or diagnosed pathologies, and expert panel review and simulator and flight checks in complex neurological cases, are also elaborated on in this paper. We believe this overview will contribute toward the enhancement of a broad understanding of neurological conditions, their clinical workup, and their precautionary management in the setting of aviation and aerospace.Khurana VG, Jithoo R, Barnett M. Aerospace implications of key neurological conditions. Aerosp Med Hum Perform. 2021; 92(2):113119.

Escalating Mean Arterial Pressure in Severe Traumatic Brain Injury: A Prospective, Observational Study.

To investigate cerebral autoregulatory status in patients with severe traumatic brain injury (TBI), guidelines now suggest active manipulation of mean arterial pressure (MAP). There is a paucity of data, however, describing the effect on intracranial pressure (ICP) when MAP is raised. Consecutive patients with TBI requiring ICP monitoring were enrolled from November 2019 to April 2020. The MAP and ICP were recorded continuously, and clinical annotations were made whenever intravenous vasopressors were commenced or adjusted to defend cerebral perfusion pressure (CPP) targets. A significant change in MAP burden was defined as MAP >100min.mm Hg over 15 min. The primary outcome was the change in ICP burden over the same 15-min period. Bedside and clinical parameters were then compared between these groups. Twenty-eight patients were enrolled, providing 212 clinical events, of which 60 were deemed significant. Over the first 15 min, 65% were associated with a net negative ICP burden. A greater reduction in ICP burden was observed with events occurring in patients without a history of hypotension at scene (p = 0.016), after three days post-injury (p = 0.0018), and where the pressure-reactivity index (PRx) was <0.25 (p = 0.0005) or the ICP amplitude to CPP correlation coefficient (RAC) was <-0.10 (p = 0.0036) at the initiation of vasopressor changes. The ICP burden in the first 15 min was highly correlated with the next 15-min period. In patients with severe TBI requiring ICP monitoring, increasing MAP to pursue a CPP target was followed by a net negative ICP burden in approximately two-thirds of events. These data suggest a MAP challenge may be a useful adjunct in managing intracranial hypertension.

Brown-Sequard syndrome associated with Horner's syndrome following a penetrating drill bit injury to the cervical spine.

We report a 41-year-old male who presented with a partial Brown-Sequard syndrome and Horner's syndrome following a penetrating drill bit injury to his mid cervical spine. As the injury was not a complete hemisection of the spinal cord, the patient presented with ipsilateral motor deficit and hyperesthesia and diminished contralateral fine touch sensation; however, proprioception, vibration and temperature were all initially intact. A cervical CT and MRI scan showed a damaged spinal cord at the C5/6 level with posterior cord compression secondary to haematoma. A decompressive laminectomy and evacuation of the haematoma was performed. Over the following 5 days the patient's right-sided motor deficit improved daily; however, he developed a contralateral deficit to pain and temperature upon wakening from the operation which did not resolve. The right-sided Horner's syndrome also persisted.

Use of Idarucizumab for dabigatran reversal: Emergency department experience in two cases with subdural haematoma.

INTRODUCTION: Idarucizumab is the first effective humanized monoclonal antibody fragment developed specifically as a reversal agent for dabigatran, a Direct Oral Anticoagulant. Despite recent trials demonstrating reversal of clinically relevant bleeding, there is a paucity of data on use outside the trial setting. This manuscript describes the use of Idarucizumab to reverse dabigatran in two patients presenting to the emergency department of a major tertiary hospital with acute traumatic subdural haematomas (SDH). METHODS: Patients were identified through retrospective review of medication dispensing systems and electronic medical records. RESULTS: Two cases of Idarucizumab use were identified. Case 1 was of a 63-year-old male who presented following a motorcycle crash. Case 2 was of a 77-year-old male who presented with a 3-week history of ataxia and recurrent falls. Both patients were taking dabigatran for atrial fibrillation (AF). CT Brain revealed acute SDH with clinical indications for urgent surgical evacuation. Serum dabigatran levels were obtained on arrival in the emergency department with levels of 155 ng/ml and 110 ng/ml (reference range 117-275 ng/ml). Idarucizumab for dabigatran reversal was commenced; Case 1 received 5 g Idarucizumab as an intravenous bolus dose, while Case 2 received 5 g Idarucizumab as two 2.5 g intravenous infusions. Serum dabigatran levels for Cases 1 and 2 were 0 ng/ml at 75 min and 340 min post Idarucizumab administration respectively. Both patients proceeded to craniotomy with evacuation of the SDH. There was no extension of the SDH in either case. Anticoagulation was withheld until outpatient clinic review, and both patients transferred for rehabilitation prior to discharge home. CONCLUSION: Idarucizumab was clinically effective for reversing dabigatran, resulting in undetectable serum levels, and should be considered in patients presenting to hospital with clinically significant bleeding associated with dabigatran therapy.

Cryptococcal meningitis causing obstructive hydrocephalus in a patient on fingolimod.

Cryptococcosis is a recognised opportunistic infection in immunocompromised patients. The long-term adverse effect profile of fingolimod, an immunomodulating agent approved for use in multiple sclerosis in 2010, is only just emerging. We report the first case to our knowledge of a patient presenting with obstructive hydrocephalus secondary to cryptococcal meningitis in the setting of fingolimod therapy. Extensive posterior fossa leptomeningeal inflammation with associated cerebellar oedema resulted in effacement of the fourth ventricle and obstructive hydrocephalus requiring urgent ventriculostomy. Induction, consolidative and maintenance antifungal therapy was prescribed and subsequent conversion to a ventriculoperitoneal shunt was successful in relieving the patient's ventriculomegaly. Awareness of these rare, novel and life-threatening complications of fingolimod-associated immunocompromise is critical as the use of such drugs is expected to rise.

Idiopathic Spinal Subarachnoid Hemorrhage: A Case Report and Review of the Literature.

Study Design Case report. Objective Spinal subarachnoid hemorrhage (SSAH) makes up less than 1.5% of all the cases of subarachnoid hemorrhage. Most cases of spontaneous SSAH occur in association with coagulopathy, lumbar punctures, or minor trauma. Idiopathic SSAH is extremely rare with only 17 cases published. Idiopathic SSAH presents a diagnostic dilemma, and the appropriate investigations and treatment remain a matter of controversy. We report a case of idiopathic SSAH and a review of the literature regarding its clinical presentation, diagnosis, and treatment. Methods A 73-year-old woman presented to the emergency department after spontaneously developing severe right leg and lower back pain while bending over to vomit. After a review of the patient's history and examination, the magnetic resonance imaging (MRI) of the thoracolumbar spine revealed T1 hyperintensity and T2 hypointensity, a diffusion-restricted collection at the T11-T12 level, and a posterior collection from L3 to S1 producing a mild displacement of the thecal sac. Results The patient was taken for an L5 laminectomy. Intraoperatively, rust-colored, xanthochromic fluid was drained from the subarachnoid space, confirming SSAH. The thecal sac was decompressed. The cultures and Gram stains were negative. Computer tomography (CT) and CT angiography of the brain were normal. She recovered postoperatively with resolution of the pain and no further episodes of hemorrhage after 2 years of follow-up. Repeat thoracolumbar MRI, selective spinal angiogram, and six-vessel cerebral angiogram did not reveal pathology. Conclusion We suggest a clinical algorithm to aid in the diagnosis and management of such patients.

Spontaneous spinal epidural haematoma in a geriatric patient on aspirin.

Spontaneous spinal epidural haematoma (SSEH) is a rare cause of spinal cord compression in adults, especially in the elderly. We report an independent 88-year-old female, on aspirin only for chronic atrial fibrillation, who presented with a 12-hour history of acute lumbar back pain, urinary incontinence and progressive bilateral lower limb paresis. Examination revealed saddle anaesthesia and reduced anal tone. Urgent spinal MRI demonstrated an epidural haematoma extending from T7 to L5. The patient made a poor initial post-operative recovery, but four months later had begun to mobilise independently after intensive physiotherapy. The case highlights the significance of clinical suspicion, especially in those patients on anti-platelet therapy, rapid spinal radiography and emergent decompressive surgery in SSEH patients, as well as the importance of ongoing rehabilitation in restoring neurological function.

A patient with delayed traumatic cervical spinal epidural haematoma presenting with hemiparesis.

Delayed presentation of spinal epidural haematoma post-trauma is rare, and portends a significant management challenge for clinicians. A 57-year-old female presented 1 week after motor vehicle accident with a 24-hour history of progressive interscapular pain and right-sided hemiparesis. Urgent spinal MRI demonstrated an extensive epidural haematoma extending from C3 to T2. The patient made an excellent post-operative neurological recovery. The importance of clinical suspicion is highlighted, especially in patients presenting with unilateral neurological deficits, as well as expeditious spinal radiography (including CT scans) and emergent surgical treatment in achieving positive clinical outcomes.

Spinal cord compression as the initial presentation of acute biphenotypic leukaemia.

Acute biphenotypic leukaemia (BAL) is an uncommon haematological malignancy with features of myeloid and lymphoid origin and poor overall prognosis. We report a 68-year-old man who presented with rapidly progressive upper thoracic spinal cord compression secondary to an extradural lesion. A T2-3 decompressive laminectomy with tumour excision was performed. Histopathology confirmed the diagnosis of acute biphenotypic (B/myeloid) leukaemia. The patient had only minor post-operative improvement in pyramidal lower limb weakness. He succumbed to the disease three months post-diagnosis after failing induction chemotherapy. While central nervous system involvement with acute leukaemia is well recognised, this is the first reported patient with spinal cord compression secondary to this leukaemia subtype.

Sacral ganglioneuroma in a 19-year-old woman.

Ganglioneuroma is a rare benign neural crest tumour, located usually in the posterior mediastinum and retroperitoneum. It tends to acquire significant size before symptoms or clinical signs become apparent. We report a 19-year-old female who underwent excision of a pelvisacral ganglioneuroma via a Pfannenstiel incision, after an abdominopelvic CT scan for investigation of left iliac fossa pain and menorrhagia detected a pelvic mass. This report highlights the importance of complete surgical excision of these lesions and the collaboration of multiple surgical units in managing these often large, variably located tumours.