Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers.

BACKGROUND AND OBJECTIVES: Central cord syndrome (CCS) is expected to become the most common traumatic spinal cord injury, yet its optimal management remains unclear. This study aimed to evaluate variability in nonoperative vs operative treatment for CCS between trauma centers in the American College of Surgeons Trauma Quality Improvement Program, identify patient- and hospital-level factors associated with treatment, and determine the association of treatment with outcomes. METHODS: Adults with CCS were identified from the Trauma Quality Improvement Program database (2014-2016). Mixed-effects modeling with a random intercept for trauma centers was used to examine the adjusted association of patient- and hospital-level variables with nonoperative treatment. The random-effects output of the model assessed the risk-adjusted variability in nonoperative treatment across centers. Outlier hospitals were identified, and the median odds ratio was calculated. The adjusted effect of nonoperative treatment on mortality, morbidity, and hospital length of stay (LOS) was examined at the patient and hospital level by mixed-effects regression. RESULTS: Three thousand, nine hundred twenty-eight patients across 255 centers were eligible; of these, 1523 (38.8%) were treated nonoperatively. Older age, noncommercial insurance (odds ratio [OR] 1.26, 95% CI 1.08-1.48, P = .004), absence of fracture (OR 0.58, 95% CI 0.49-0.68, P < .001), severe head injury (OR 1.41, 95% CI 1.09-1.82, P = .008), and comatose presentation (1.82, 95% CI 1.15-2.89, P = .011) were associated with nonoperative treatment. Twenty-eight hospitals were outliers, and the median odds ratio was 2.02. Patients receiving nonoperative treatment had shorter LOS (mean difference -4.65 days). Nonoperative treatment was associated with lesser in-hospital morbidity (OR 0.49, 95% CI 0.37-0.63, P < .001) at the patient level. There was no difference in mortality. CONCLUSION: Operative decision-making for CCS is influenced by patient factors. There remains substantial variability between trauma centers not explained by case-mix differences. Nonoperative treatment was associated with shorter hospital LOS and lesser inpatient morbidity.

Isolated Traumatic Subarachnoid Hemorrhage: An Evaluation of Critical Care Unit Admission Practices and Outcomes From a North American Perspective.

OBJECTIVES: Traumatic subarachnoid hemorrhage is a common radiographic finding associated with traumatic brain injury. The objective of this investigation is to evaluate the association between hospital-level ICU admission practices and clinically important outcomes for patients with isolated traumatic subarachnoid hemorrhage and mild clinical traumatic brain injury. DESIGN: Multicenter observational cohort. SETTING: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program spanning January 2012 to March 2014. PATIENTS: A total of 14,146 subjects, 16 years old and older, admitted to 215 trauma centers with isolated traumatic subarachnoid hemorrhage and Glasgow Coma Scale score 13 or greater. Patients with concurrent intracranial injuries, severe injury to other body regions, or tests positive for alcohol or illicit substances were excluded. INTERVENTION: ICU admission. MEASUREMENTS AND MAIN RESULTS: The primary outcome was need for neurosurgical intervention, defined as insertion of an intracranial monitor/drain or craniectomy/craniotomy. Secondary outcomes describing the clinical course included hospital discharge disposition, in-hospital mortality, and length of stay. Admission to ICU was common within the cohort (44.6%), yet the need for neurosurgical intervention was rare (0.24%). Variability was high between centers and remained so after adjusting for differences in case-mix and hospital-level characteristics (median odds ratio, 4.1). No significant differences in neurosurgical interventions, mortality, or discharge disposition to home under self-care were observed between groups of the highest and lowest ICU admitting hospitals. However, those in highest admitting group "stayed" in hospital 1.13 (95% CI, 1.07-1.20; p < 0.001) times that of the lowest admitting group. CONCLUSIONS: Critical care admission for mild traumatic brain injury patients with isolated traumatic subarachnoid hemorrhage is frequent and highly variable despite low probability of requiring neurosurgical intervention. Reevaluation of hospital-level practices may represent an opportunity for resource optimization when managing patients with mild clinical traumatic brain injury and associated isolated traumatic subarachnoid hemorrhage.

Spinal intraoperative three-dimensional navigation: correlation between clinical and absolute engineering accuracy.

BACKGROUND CONTEXT: Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. PURPOSE: This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. DESIGN/SETTING: This is a retrospective review of a prospectively collected cohort. PATIENT SAMPLE: We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. OUTCOME MEASURES: Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). METHODS: We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. RESULTS: Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. CONCLUSIONS: Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.

A multicenter registry of hydrocephalus following coil embolization of unruptured aneurysms: which patients are at risk and why it occurs.

INTRODUCTION: Unexplained post-procedural events such as cerebral edema, inflammation, aseptic meningitis and hydrocephalus have been reported following unruptured cerebral aneurysm coiling. However, understanding of the etiology for these occurrences is limited due to their rare occurrence. A multicenter registry was developed to investigate further the occurrence of these events. METHOD: This registry consisted of a retrospective analysis of unruptured aneurysms treated with hydrocoil that evolved to develop focal cerebral edema, inflammation, aseptic meningitis, or ventricular enlargement/hydrocephalus following uncomplicated coil embolization. Data points included pre, intra, and postoperative imaging, patient demographics, aneurysm demographics, procedural details such as coils used, medications administered, and intraprocedural complications, and all post-procedure follow-up including clinical status of the patients and all adverse events. RESULTS: Twenty-five patients (26 aneurysm coiling procedures) were found at 12 centers over an 8-year period. The mean aneurysm size was 13.7 mm. The average time from treatment to onset of symptoms was 8.5 months (2 weeks to 30 months, median 6 months). Delayed hydrocephalus was the most common clinical presentation. Six of the 25 patients were asymptomatic and did not require treatment. CONCLUSION: Patients undergoing endovascular coiling may be at risk of developing delayed complications, which may or may not be symptomatic. This risk appeared low and was restricted mostly to larger aneurysms. These events can be difficult to detect due to delayed presentation.

Vertebral compression fracture (VCF) after spine stereotactic body radiation therapy (SBRT): analysis of predictive factors.

PURPOSE: Vertebral compression fractures (VCFs) are increasingly observed after spine stereotactic body radiation therapy (SBRT). The aim of this study was to determine the risk of VCF after spine SBRT and identify clinical and dosimetric factors predictive for VCF. The analysis incorporated the recently described Spinal Instability Neoplastic Score (SINS) criteria. METHODS AND MATERIALS: The primary endpoint of this study was the development of a de novo VCF (ie, new endplate fracture or collapse deformity) or fracture progression based on an existing fracture at the site of treatment after SBRT. We retrospectively scored 167 spinal segments in 90 patients treated with spine SBRT according to each of the 6 SINS criteria. We also evaluated the presence of paraspinal extension, prior radiation, various dosimetric parameters including dose per fraction (≥20 Gy vs <20 Gy), age, and histology. RESULTS: The median follow-up was 7.4 months. We identified 19 fractures (11%): 12 de novo fractures (63%) and 7 cases of fracture progression (37%). The mean time to fracture after SBRT was 3.3 months (range, 0.5-21.6 months). The 1-year fracture-free probability was 87.3%. Multivariate analysis confirmed that alignment (P=.0003), lytic lesions (P=.007), lung (P=.03) and hepatocellular (P<.0001) primary histologies, and dose per fraction of 20 Gy or greater (P=.004) were significant predictors of VCF. CONCLUSIONS: The presence of kyphotic/scoliotic deformity and the presence of lytic tumor were the only predictive factors of VCF based on the original 6 SINS criteria. We also report that patients with lung and hepatocellular tumors and treatment with SBRT of 20 Gy or greater in a single fraction are at a higher risk of VCF.

Endovascular therapy of hypoglossal canal AVFs presenting with orbital symptoms.

OBJECTIVE: Dural arteriovenous fistulae (DAVF) of the hypoglossal canal region are rare lesions. We describe three cases of DAVF of the hypoglossal canal presenting with ocular symptoms and discuss the endovascular management options. METHODS: Three consecutive patients with DAVF of the hypoglossal canal region presented with proptosis, chemosis and disturbances of extra-ocular mobility. Each patient was treated using a different endovascular approach, based on variations of the vascular access. RESULTS: The cases and treatments are reviewed, with a literature review on the subject. Endovascular treatment, transvenous or trans-arterial was curative in all cases. CONCLUSION: DAVF of the hypoglossal canal region can present with ocular manifestations very similar to DAVF of the cavernous sinus or carotid-cavernous fistulas. Endovascular treatment is usually feasible and effective, but an understanding of the vascular anatomy and pathophysiology of the disease are of utmost importance when planning the approach.

Intraoperative biplanar rotational angiography during neurovascular surgery. Technical note.

OBJECT: The purpose of this study was to evaluate the authors' initial experience with the integration of high-resolution rotational and biplanar angiography during neurovascular operative procedures. METHODS: Eight patients with intracerebral arteriovenous malformations (AVMs) and aneurysms underwent surgical treatment of their lesions in a combined endovascular surgical suite. After initial head positioning, preoperative biplane and rotational angiography was performed. Resection of the AVM or clipping of the aneurysm was then performed. Further biplane and rotational 3D angiograms were obtained intraoperatively to confirm satisfactory treatment. RESULTS: One small residual AVM identified intraoperatively necessitated further resection. One aneurysm was clipped during endovascular inflation of an intracarotid balloon for temporary proximal control. The completeness of treatment was confirmed on intraoperative 3D rotational angiography in all cases, and there were no procedure-related complications. CONCLUSIONS: Intraoperative rotational angiography performed in an integrated biplane angiography/surgery suite is a safe and useful adjunct to surgery and may enable combining endovascular and surgical procedures for the treatment of complex vascular lesions.

Overview of the current role of endovascular and surgical treatment in spinal dural arteriovenous fistulas.

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

Repeated meningitis as a delayed complication of scoliosis surgery.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of very delayed repeated meningitis after surgical treatment of scoliosis. SUMMARY OF BACKGROUND DATA: Delayed infection after spine surgery is a well-reported phenomenon, presenting usually with local wound symptoms and back pain. The occurrence of meningitis after spinal instrumentation is reported but not common. Delayed repeated episodes of meningitis after surgical treatment of scoliosis have never been reported. CASE REPORT: We report a case of a 44-year-old gentleman, submitted to surgical treatment of scoliosis years ago, who presented with repeated episodes of meningitis due to the formation of an abnormal communication between an infected cyst in the bone cavity where the rods were located and the intradural space in the lumbar spine. Computerized tomography and magnetic resonance imaging revealed the presence of a bone cyst with thickened layering, and surgical exploration revealed the communication between this cystic cavity and the intradural space. After surgical closure of the dural space and cleaning of the cyst, the patient responded well to antibiotic therapy and was free of new episodes of meningitis up to the last follow-up, 1 year after the surgical treatment. Clinical diagnosis of delayed postoperative infection in spine surgery may be difficult if no wound signs are present. Clinical symptoms vary and may include increased back pain, wound redness, swelling and drainage, elevated erythrocyte sedimentation rate and white blood count, fever, and malaise. CONCLUSIONS: Delayed meningitis can be a late complication of spinal instrumentation for scoliosis. A high index of suspicion is necessary.

Pituitary adenoma associated with intraventricular meningioma: case report.

Although rare, the association of intracranial meningiomas and pituitary adenomas has been reported. Intraventricular meningiomas are unusual, and meningiomas located in the fourth ventricle are even more so. We report a patient who harbored a prolactin-secreting pituitary adenoma and a fourth ventricle meningioma who was treated with surgical resection of the latter and medical treatment for the former. To our knowledge, this is the first report of such an unusual association.

Symptomatic non-atherosclerotic bilateral extracranial vertebral artery occlusion treated with extracranial to intracranial bypass: case report.

Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25% of all ischemic strokes, and the vast majority of the cases are related to atherosclerotic stenosis of the vertebral and/or basilar arteries. Acute ischemia can also occur in the setting of vertebral artery dissection, traumatic or spontaneous. Recently, blunt trauma has been increasingly recognized as a cause for craniocervical artery injury. The management options for both traumatic and atherosclerotic lesions of the posterior fossa are still under debate. We present a case of a delayed onset of hemodynamic ischemic symptoms due to bilateral vertebral artery occlusion probably related to remote trauma to the head and neck in a 55-year-old-man treated successfully with extracranial to intracranial bypass.

Symptomatic non-atherosclerotic bilateral extracranial vertebral artery occlusion treated with extracranial to intracranial bypass: case report / Oclusão sintomática não-aterosclerótica da artéria vertebral extracraniana tratada com bypass: relato de caso

Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25 percent of all ischemic strokes, and the vast majority of the cases are related to atherosclerotic stenosis of the vertebral and/or basilar arteries. Acute ischemia can also occur in the setting of vertebral artery dissection, traumatic or spontaneous. Recently, blunt trauma has been increasingly recognized as a cause for craniocervical artery injury. The management options for both traumatic and atherosclerotic lesions of the posterior fossa are still under debate. We present a case of a delayed onset of hemodynamic ischemic symptoms due to bilateral vertebral artery occlusion probably related to remote trauma to the head and neck in a 55-year-old-man treated successfully with extracranial to intracranial bypass.

Acidentes vasculares cerebrais (AVC) isquêmicos no sistema vertebro-basilar não são frequentes. Representam cerca de 25 por cento dos AVCs isquêmicos, e a maioria é relacionada com aterosclerose das artérias vertebrais e/ou basilar. Isquemia aguda pode também ser resultado de dissecções da artéria vertebral, traumáticas ou espontâneas. Recentemente, traumatismos fechados têm sido cada vez mais reconhecidos como causa de lesão das artérias craniocervicais, podendo ou não resultar em sintomas isquêmicos. O tratamento para estas lesões, sejam traumáticas ou ateroscleróticas, ainda é motivo de debate. Relatamos o caso de um homem de 55 anos com sintomas isquêmicos, hemodinâmicos, tardios, devido a oclusão bilateral das artérias vertebrais, provavelmente relacionada a lesão traumática das artérias vertebrais, tratada com sucesso com bypass extra-intracraniano.

Cavernous malformations of the brainstem in infants. Report of two cases and review of the literature.

Cavernous malformations of the brainstem (CMB) occur less commonly in children than in adults. Their appearance is even rarer in infants, with only five cases reported in the literature. The authors report two additional cases in which giant CMBs were diagnosed in two infants, one when the patient was 1 month old and the other when the patient was 15 months old. A median suboccipital approach in one patient and a pterional-orbitozygomatic approach in the other were used to obtain complete resection of the malformations. Excellent outcomes were achieved in both children. A review of the literature is also presented. It seems that CMBs in infants usually follow a progressive course of growth and associated neurological deterioration. Patients with symptomatic lesions abutting the pial surface should undergo surgical treatment with the goal of cure. An increase may be expected in the number of CMBs diagnosed in children as a result of regular screening of relatives with the familial form of the disease. Nevertheless, due to the small confines of the brainstem, incidental or asymptomatic CMB should still be extraordinary. In the case of such a rare occurrence, conservative treatment should be advocated.

Chronic subdural hematoma of the posterior fossa associated with cerebellar hemorrhage: report of rare disease with MRI findings.

Chronic subdural hematoma of the posterior fossa is an uncommon entity, and spontaneous lesions are very rarely described, occurring mostly during anticoagulation therapy. The association of the posterior fossa chronic subdural hematoma with spontaneous parenchymal hemorrhage without anticoagulation therapy was never related in the literature, to our knowledge. We describe a case of a 64 year-old woman who suffered a spontaneous cerebellar hemorrhage, treated conservatively, and presented 1 month later with a chronic subdural posterior fossa hematoma.

Unruptured intracranial aneurysms: natural history and management decisions.

Aneurysmal subarachnoid hemorrhage (SAH) carries a grim prognosis, with high mortality and morbidity rates. The mortality rate in the first 30 days postrupture is estimated to be in the range of 40 to 50%, and almost half of the survivors will be left with a neurological deficit. Unlike patients with aneurysmal SAH, those with unruptured intracranial aneurysms usually experience no neurological deficit, and their treatment is prophylactic, aiming to reduce the risk of future bleeding and its consequences. The risk of rupture therefore assumes special importance when making decisions regarding which patient or aneurysm to treat. In previous reports the risk of bleeding for unruptured aneurysms has been stated as approximately 2% per year. The retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) reported very low annual bleeding rates (0.05-1%) and high surgical morbidity and mortality rates (8-18%), prompting discussion in which the benefits of prophylactic treatment in the majority of these lesions were questioned. Prospective data from the second part of the ISUIA recently included rupture rates ranging from 0 to 10% per year. The aim of this paper was to review the evidence that is currently available for neurosurgeons to use when making decisions regarding patients who would benefit from treatment of an unruptured intracranial aneurysm.