A swine model of intracellular cerebral edema - Cerebral physiology and intracranial compliance.

Cerebral edema leading to elevated intracranial pressure (ICP) is a fundamental concern after severe traumatic brain injury (TBI), stroke, and severe acute hyponatremia. We describe a swine model of water intoxication and its cerebral histological and physiological sequela. We studied female swine weighing 35-45 kg. Four serum sodium intervals were designated: baseline, mild, moderate, and severe hyponatremia attained by infusing hypotonic saline. Intracranial fluid injections were performed to assess intracranial compliance. At baseline and following water intoxication wedge biopsy was obtained for pathological examination and electron microscopy. We studied 8 swine and found an increase in ICP that was strongly related to the decrease in serum sodium level. Mean ICP rose from a baseline of 6 ±â€¯2 to 28 ±â€¯6 mm Hg during severe hyponatremia, while cerebral perfusion pressure (CPP) decreased from 72 ±â€¯10 to 46 ±â€¯11 mm Hg. Brain tissue oxygen tension (PbtO2) decreased from 18.4 ±â€¯8.9 to 5.3 ±â€¯3.0 mm Hg. Electron microscopy demonstrated intracellular edema and astrocytic foot process swelling following water intoxication. With severe hyponatremia, 2 cc intracranial fluid injection resulted in progressively greater ICP dose, indicating a worsening intracranial compliance. Our model leads to graded and sustained elevation of ICP, lower CPP, and decreased PbtO2, all of which cross clinically relevant thresholds. Intracranial compliance worsens with increased cerebral swelling. This model may serve as a platform to study which therapeutic interventions best improve the cerebral physiological profile in the face of severe brain edema.

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.

OBJECTIVE: To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture. METHODS: We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014. RESULTS: A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis. CONCLUSIONS: This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Vertebral artery pseudoaneurysms secondary to blunt trauma: Endovascular management by means of neurostents and flow diverters.

Extracranial vertebral pseudoaneurysms that develop following blunt trauma to the cervical area may have a benign course; however, embolic or ischemic stroke and progressive pseudoaneurysm enlargement may occur. We review the presentation and endovascular management of pseudoaneurysms of the cervical vertebral artery (VA) due to blunt trauma in nine patients (eight male, mean age 27years). Pseudoaneurysms occurred in dominant vessels in seven patients and coexisted with segmental narrowing in six. We favored endovascular intervention during the acute phase only in cases with significant narrowing of a dominant VA, especially when anticoagulation was contraindicated. Four patients were treated during the acute stage (contraindication to anticoagulation, mass effect, severely injured dominant VA/impending stroke); five during the chronic phase (pseudoaneurysm growth, ischemic stroke on aspirin prophylaxis, patient preference). Reconstructive techniques were favored over deliberate endovascular occlusion when dominant vessels were involved. Arterial reconstruction was performed in eight of nine patients using a flow-diverter implant (5 patients), stent-assisted coiling (1), overlapping stent implant (1), or implantation of a balloon-expandable stent (1). Deliberate VA occlusion with coils was performed in one of nine patients due to suboptimal expansion of the stented artery after flow-diverter implant. No neurological complications occurred during follow-up. All cases treated by reconstructive techniques showed complete, persistent pseudoaneurysm occlusion and full arterial patency. Endovascular therapy of traumatic VA pseudoaneurysms using neurostents and flow-diverters resulted in occlusion of the pseudoaneurysms, preservation of the parent vessel, and no periprocedural or delayed clinical complications, supporting the feasibility and safety of the approach.

Supraciliary keyhole craniotomy for anterior frontal lesions in children.

Treatment for anterior frontal space occupying lesions such as epidural hematoma, vascular malformations or brain tumors, have typically involved invasive craniotomies. This method often requires large incisions with wide exposure and may be associated with high morbidity rates. The basis for the "keyhole" method is that a minimally invasive craniotomy is often sufficient for exposing large areas deep in tissue, and may limit exposure and decrease surgically related morbidity while enabling adequate removal and decompression. The supraciliary method includes a cut above the eyebrow and a small craniotomy to uncover the base of the frontal lobe and the orbital roof. We demonstrate our experience with this method. We identified children who were operated via the supraciliary approach between January 2009 and December 2013, and gathered their pre- and post-operative clinical and radiological statistics. Fourteen patients were identified. Pathologies included tumors, abscesses and epidural hematomas. Nine were operated due to epidural hematoma, two due to tumors, two due to brain abscesses, and one for anterior encephalocele. No significant peri-operative or post-operative complications were observed. Long-term follow-up shows that the surgical scars were nearly invisible. The supraciliary approach is a safe, effective and elegant technique for treating lesions in the anterior skull base. The method should be weighed alongside traditional methods on a case-by-case basis.

Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction.

Randomized controlled trials have demonstrated the efficacy of decompressive craniectomy in substantially decreasing mortality and improving functional outcome in middle cerebral artery infarction. The role of intracranial pressure (ICP) monitoring following decompressive craniectomy for stroke has not been well studied. We present a retrospective review of our experience with postoperative ICP monitoring in 12 stroke patients who underwent decompressive craniectomy. All elevations of ICP above a 20 mm Hg threshold were noted. ICP was recorded for 1417 hours during which 68 ICP elevations were seen. Nine out of 12 patients had events of raised ICP, including eight with more than three elevations. A total of 81 interventions were employed to treat elevated ICP; 71 were effective in reducing ICP below the 20 mm Hg threshold. The most frequent intervention was cerebrospinal fluid drainage via an external ventricular drain, which was effective in 85.4% of cases. Eleven out of 12 patients survived (92%) and attained a median modified Rankin Scale score of 4 (interquartile range 4-5) at a mean 15 month follow-up. In our experience, elevated ICP may commonly occur following decompressive craniectomy for stroke. Monitoring ICP influenced postoperative management and standard measures for reducing ICP were usually effective in the current series.

Tumefactive demyelination following in vitro fertilization (IVF).

Tumefactive demyelination (TD) is a solitary cerebral demyelinating lesion clinically and radiologically mimicking brain tumors. It can occur in isolation or may be rarely associated with other demyelinating diseases. The underlying pathogenic mechanisms are unknown. We present the first report of TD following in-vitro fertilization (IVF) in a 36-year-old healthy woman who developed subacute right hemiparesis shortly after a scheduled IVF cycle. Evaluation revealed left hemispheric space-occupying lesion pathologically diagnosed as TD. Treatment with intravenous methylprednisolone promptly resulted in a clinical and radiological improvement maintained thereafter. This report confirms and expands the spectrum of inflammatory demyelinating conditions associated with IVF and suggests possible hormonal influence in the development of TD.

Polyetheretherketone implants for the repair of large cranial defects: a 3-center experience.

BACKGROUND: Calvarial reconstruction of large cranial defects following decompressive surgery is challenging. Autologous bone cannot always be used due to infection, fragmentation, bone resorption, and other causes. Polyetheretherketone (PEEK) is a synthetic material that has many advantages in cranial-repair surgery, including strength, stiffness, durability, and inertness. OBJECTIVE: To describe our experience with custom-made PEEK implants for the repair of large cranial defects in 3 institutions: San Francisco General Hospital, Hadassah-Hebrew University Hospital, and the National Neuroscience Institute, Singapore. METHODS: A preoperative high-resolution computed tomography scan was obtained for each patient for design of the PEEK implant. Cranioplasty was performed via standard technique with the use of self-tapping titanium screws and miniplates. RESULTS: Between 2006 and 2012, 66 cranioplasties with PEEK implants were performed in 65 patients (46 men, 19 women, mean age 35 ± 14 years) for repair of large cranial defects. There were 5 infections of implants and 1 wound breakdown requiring removal of the implant (infection and surgical removal rates of 7.6% and 9.1%, respectively). Two patients required drainage of postoperative hematoma (overall surgical complication rate, 12.7%). Nonsurgical complications in 5 patients included seizures, nonoperative collection, and cerebrospinal fluid rhinorrhea that resolved spontaneously. Overall median patient or family satisfaction with the cranioplasty and aesthetic result was good, 4 on a scale of 5. Temporal wasting was the main aesthetic concern. CONCLUSION: Custom-designed PEEK implants are a good option for patients with large cranial defects. The rate of complications is comparable to other implants or autologous bone. Given the large size of these defects, the aesthetic results are good.

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease.

BACKGROUND AND PURPOSE: Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures. MATERIALS AND METHODS: Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5-L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1-3 months after stenting. RESULTS: Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8-10), falling to 2.0 immediately postop (range 1-6, P  =  0.000) and 0 at all subsequent follow-up (P ≤ 0.012). Mean preoperative vertical height loss was 25.8% (range 0-84.0%) versus a postoperative mean of 18.0% (range 0-66.0%, P  =  0.000). Median pre- and postoperative kyphotic angle improved from 8.3° (range 0.2°-54.0°) to 7.1° (range 0.2°-25.0°, P  =  0.000). Wilcoxon signed rank test or student's t-test was used for comparisons. CONCLUSIONS: Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.

Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older.

OBJECTIVES: We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process. METHODS: We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan-Meier and Cox regression analysis. RESULTS: Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65-87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1-14). All patients regained ambulation. Overall, mean survival was 320 days (range 19-798) and mean ambulation was 302 days (range 18-747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302-747); 14 patients had died (67%) at a mean of 251 days (range 19-798), with a mean ambulation of 223 days (range 18-730). DISCUSSION: With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.

Spinal meningioma becoming symptomatic in the third trimester of pregnancy.

We report a rare case of a spinal meningioma leading to symptoms of spinal cord compression starting in the third trimester of gestation in a 32-year-old woman. Neurological symptoms, which continued to progress after the patient had given birth, were assumed to be sequelae of pregnancy and delivery, leading to a 6 month delay in diagnosis and treatment. Fortunately a gross total resection was achieved at surgery and the patient recovered fully, without permanent consequences. Associated symptoms of spinal cord compression may be falsely attributed to pregnancy, both by the pregnant women and her treating physician. A high index of suspicion and thorough history and physical examination to identify red flags should be performed in patients with neurological symptoms.

Superficial siderosis of the central nervous system due to chronic hemorrhage from a giant invasive prolactinoma.

Superficial siderosis of the central nervous system (CNS) is a rare disorder caused by deposition of hemosiderin in neuronal tissue in the subpial layer of the CNS due to slow subarachnoid or intraventricular hemorrhage. The most common neurologic manifestations include progressive gait ataxia, sensorineural hearing loss, and corticospinal tract signs. We present a case of superficial siderosis in a 43-year-old man who presented to the Emergency Department with sudden onset bilateral visual deterioration and a loss of consciousness. A hemorrhagic giant prolactinoma was diagnosed based on brain CT scan, T1-weighted MRI, and an endocrine blood examination. Susceptibility-weighted non-contrast MRI showed pathognomonic signs of superficial siderosis in the form of a hypointensity rim surrounding the brainstem, cerebellar fissures, and cranial nerves VII and VIII. This report demonstrates that superficial siderosis can be caused by pituitary apoplexy.

Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections.

BACKGROUND: Traumatic internal carotid artery dissection (CAD) has a potentially grave outcome. Anticoagulant therapy may be ineffective or contraindicated; surgery impractical. We present our experience with endovascular stenting in CAD patients. METHODS: From 2004 to 2011, 23 patients with angiographically proven traumatic CAD underwent endovascular stent-assisted arterial reconstruction based on clinical and radiographic criteria: contraindication or failure of anticoagulation, evidence of impending ischemic stroke, or need for urgent intracranial revascularization. Dissections were graded based on degree of stenosis and extent of injury. RESULTS: Seventeen patients (73.9%) presented with stroke or transient ischemic attack. Carotid revascularization was achieved with one (11 patients, 48%) or multiple stents (12 patients, 52%); distal protection was used rarely (three patients, 13%). No complications were directly attributed to stenting. Mean dissection-related stenosis improved from 72% ± 28.87% to 4% ± 8.29%. At a mean clinical follow-up of 28.7 months ± 31.9 months, 16 patients (69.6%) improved, six (26.1%) remained stable, and one (4.3%) had died secondary to multiple traumatic injuries. At long-term follow-up, no patient had a transient ischemic attack or stroke or presented evidence of de novo in-stent stenosis or stent thrombosis. There were no neurologic sequelae after partial or total discontinuation of antiplatelet therapy in seven patients undergoing trauma-related surgeries. CONCLUSIONS: Selected cases of traumatic CAD can be safely managed by endovascular stent-assisted angioplasty. Procedural complications are infrequent; the need for postprocedure antiplatelet therapy is a concern. Early detection is essential to avoid stroke. Stenting restores the integrity of the vessel lumen immediately, efficiently prevents the occurrence or recurrence of ischemic events, and avoids the need of long-term anticoagulation.

Intradural extramedullary hemangiopericytoma of the thoracic spine infiltrating a nerve root: a case report and literature review.

STUDY DESIGN: Review the presentation and diagnosis of an intradural extramedullary hemangiopericytoma of the thoracic spine. OBJECTIVE: To present a rare case of intradural, subpial hemangiopericytoma in the thoracic spine, with a brief overview of the literature. SUMMARY OF BACKGROUND DATA: Spinal intradural extramedullary hemangiopericytoma is rare entity that radiographically mimics nerve-sheath tumors. These lesions are typically diagnosed at surgery performed due to suspicion of tumor. METHODS: A 20-year-old man who presented with back pain, leg weakness, and sphincter incontinence. MR imaging demonstrated an intradural extramedullary lesion at the T9-T10 level that was isointense on T1- and T2-weighted images and homogeneously enhancing after administration of gadolinium, with cystic components seen on T2-weighted images. The preoperative diagnosis was meningioma or schwannoma. RESULTS: At surgery, the lesion was bluish and completely subpial, with apparent nerve root invasion. Pathological examination revealed a neoplasm adjacent to a nerve root with possible focal infiltration. Abundant reticulin fibers and widened, branching vascular channels imparting a staghorn appearance were seen. Up to five mitotic figures were counted in one high-power field. On immunostaining, the neoplastic cells were diffusely immunoreactive for CD99 and immunonegative for EMA, CD34, and S-100 protein. The pathological diagnosis was consistent with anaplastic hemangiopericytoma, WHO grade III. CONCLUSION: This is the ninth report of spinal intradural hemangiopericytoma. The location of the neoplasm supports the hypothesis that hemangiopericytoma may arise from the spinal pial capillaries.

Radiation-induced meningioma.

The long-term or delayed side effects of irradiation on neural tissue are now known to include the induction of new central nervous system neoplasms. However, during the first half of the 20th century, human neural tissue was generally considered relatively resistant to the carcinogenic and other ill effects of ionizing radiation. As a result, exposure to relatively high doses of x-rays from diagnostic examinations and therapeutic treatment was common. In the present article the authors review the literature relating to radiation-induced meningiomas (RIMs). Emphasis is placed on meningiomas resulting from childhood treatment for primary brain tumor or tinea capitis, exposure to dental x-rays, and exposure to atomic explosions in Hiroshima and Nagasaki. The incidence and natural history of RIMs following exposure to high- and low-dose radiation is presented, including latency, multiplicity, histopathological features, and recurrence rates. The authors review the typical presentation of patients with RIMs and discuss unique aspects of the surgical management of these tumors compared with sporadic meningioma, based on their clinical experience in treating these lesions.

Clinical review: the Israeli experience: conventional terrorism and critical care.

Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.

Nocardial cerebral abscess: report of three cases and review of the current neurosurgical management.

Nocardia asteroides cerebral abscesses are rare but challenging intracranial lesions. Early diagnosis, institution of appropriate antimicrobial therapy, lack of underlying systemic disease and limited intracranial disease are recognized factors leading to good outcome. However, the optimal treatment approach has not been established and nocardial brain abscesses have been managed either conservatively, with steroetactic aspirations or with open craniotomy and enucleation. We present three cases of Nocardia asteroides cerebral abscesses cured only after neurosurgical enucleation, and discuss the current management alternatives and conclude that a more aggressive approach than that currently preferred for this entity may be more effective.