Referred Shoulder Pain Due to the Positioning of the Ventriculoperitoneal Shunt: A Case Report and Literature Review of an Unusual Complication.

We present the case of an 18-year-old male with a ventriculoperitoneal (VP) shunt for hydrocephalus who experienced right shoulder pain. The patient was thoroughly investigated for gastrointestinal disease, including abdominal ultrasound and upper endoscopy, which revealed no abnormalities that could explain his symptoms. X-ray imaging subsequently revealed that the shunt's distal peritoneal tubing was positioned in a supra-hepatic subdiaphragmatic location. Surgical shortening and repositioning of the peritoneal tubing successfully alleviated the patient's shoulder pain. A review of the literature uncovered four articles, comprising a total of six patients, who exhibited similar symptoms of shoulder pain linked to their VP shunts. Given the rarity of this complication, it can be easily overlooked or misdiagnosed. It is crucial for physicians to consider this possibility when evaluating patients with VP shunts who present with shoulder pain to ensure prompt and effective treatment.

Cranioplasty Outcomes from a Tertiary Hospital in a Developing Country.

BACKGROUND: Decompressive craniectomy (DC) is a surgical procedure to treat refractory increase in intracranial pressure. DC is frequently succeeded by cranioplasty (CP), a reconstructive procedure to protect the underlying brain and maintain cerebrospinal fluid flow dynamics. However, complications such as seizures, fluid collections, infections, and hydrocephalus can arise from CP. Our aim is to investigate these complications and their possible risk factors and to discuss whether early or late CP has any effect on the outcome. MATERIALS AND METHODS: A single-center retrospective cohort study was performed, including patients who underwent CP after DC between January 2014 and January 2022. Relevant information was collected such as demographics, type of brain injury, materials used in CP, timing between DC and CP, and postoperative complications. Ultimately, 63 patients were included in our study. We also compared the complication rate between patients who underwent late CP after DC (>90 days) against patients who underwent early CP (<90 days). RESULTS: Most patients were male (78%). The sample median age was 29 years, with pediatric patients, accounting for 36% of the samples. Overall complication rate was 57% and they were seizure/epilepsy in 50% of the patients, fluid collection (28%), infections (25%), posttraumatic hydrocephalus (17%), and bone defect/resorption (3%). Twenty-two percent of patients with complications required reoperation and underwent a second CP. The median (interquartile range) duration between the craniotomy and the CP was 56 (27-102) days, with an early (≤3 months) percentage of 68%. We found no significant difference between early (≤3 months) and late (>3 months) CP regarding complication rates. CONCLUSION: Despite CP being a simple procedure, it has a considerable rate of complications. Therefore, it is important that surgeons possess adequate knowledge about such complications to navigate these challenges more effectively.

Résumé Contexte:La craniectomie décompressive (DC) est une intervention chirurgicale destinée à traiter l'augmentation réfractaire de la pression intracrânienne. La DC est fréquemment remplacée par une cranioplastie (CP), une procédure reconstructive visant à protéger le cerveau sous-jacent et à maintenir la dynamique du flux du liquide céphalo-rachidien. Cependant, des complications telles que des convulsions, des collections de liquides, des infections et une hydrocéphalie peuvent survenir en raison de la CP. Notre objectif est d'étudier ces complications et leurs facteurs de risque possibles et de discuter si une CP précoce ou tardive a un effet sur le résultat.Matériels et méthodes:Une étude de cohorte rétrospective monocentrique a été réalisée, incluant des patients ayant subi une PC après une DC entre janvier 2014 et janvier 2022. Des informations pertinentes ont été collectées telles que les données démographiques, le type de lésion cérébrale, les matériaux utilisés dans la PC, le timing entre la DC et CP et complications postopératoires. Au final, 63 patients ont été inclus dans notre étude. Nous avons également comparé le taux de complications entre les patients ayant subi une CP tardive après une DC (> 90 jours) et ceux ayant subi une CP précoce (<90 jours).Résultats:La plupart des patients étaient des hommes (78 %). L'âge médian de l'échantillon était de 29 ans, les patients pédiatriques représentant 36 % des échantillons. Le taux global de complications était de 57 % et il s'agissait de convulsions/épilepsie chez 50 % des patients, d'accumulation de liquide (28 %), d'infections (25 %), d'hydrocéphalie post-traumatique (17 %) et de défauts/résorptions osseuses (3 %). Vingt­deux pour cent des patients présentant des complications ont dû être réopérés et ont subi une deuxième CP. La durée médiane (intervalle interquartile) entre la craniotomie et la CP était de 56 (27 à 102) jours, avec un pourcentage précoce (≤ 3 mois) de 68 %. Nous n'avons trouvé aucune différence significative entre la PC précoce (≤ 3 mois) et tardive (> 3 mois) en ce qui concerne les taux de complications.Conclusion:Bien que la CP soit une procédure simple, elle entraîne un taux de complications considérable. Il est donc important que les chirurgiens possèdent des connaissances adéquates sur ces complications pour relever ces défis plus efficacement.

Long term clinical and radiological outcomes following surgical treatment of symptomatic cranial arachnoid cyst: A population based consecutive cohort study.

OBJECTIVE: Symptomatic intracranial arachnoid cysts are treated mainly through surgical resection, endoscopic fenestration, or by implanting cystoperitoneal (CP) shunt. However, the use of a specific technique remains controversial. The purpose of this study is to discuss these surgical modalities in symptomatic patients with intracranial arachnoid cysts (ACs) and investigate which has better outcomes and less complications by comparing variable preoperative and postoperative parameters. METHODS: An analysis of thirty-nine symptomatic patients who underwent intracranial arachnoid cyst surgery in the department of neurosurgery between 2009 and 2023 was performed. Patients were retrospectively compared based on age group, gender, anatomical location, laterality, type of intervention, clinical and volumetric changes, postoperative complications and outcome. RESULTS: Of the 39 patients, 20 patients (51.28 %) received CP shunt. Eleven patients (28.2 %) underwent endoscopic fenestration, and 8 patients (20.5 %) had surgical resection. The age at the time of first operation ranged from 1 month to 59.9 years (mean age: 16.8 years), and the pediatric patients were 25 (64.1 %). The most common initial symptom was headache which was observed in 19 patients (48.7 %), followed by seizure in 12 patients (30.8 %), vomiting in 11 patients (28.2 %), visual dysfunction in 8 patients (20.5 %), drowsiness in 8 patients (20.5 %), visual symptoms in 8 patients (20.5 %), cognitive impairment in 4 patients (10.3 %), focal neurological deficits in 3 patients (7.7 %), and cranial nerve involvement in 1 patient (2.6 %). 24 patients (61.5 %) showed improvement while in 15 patients (38.5 %) the symptoms persisted or worsened. Postoperatively, patients were followed up for an average of one year. The highest improvement rate was noted in endoscopic fenestration with 9 improved patients (81.8 %), followed by surgical resection with 5 symptom-free patients (62.5 %). The worst outcomes were seen in cystoperitoneal shunt with only half of the patients were relieved (50 %). Complications developed in 2 patients (25 %) who underwent surgical resection, 5 patients (45.5 %) who had endoscopic fenestration, and 13 patients (65 %) who had cystoperitoneal shunting. CONCLUSION: Endoscopic fenestration has the highest improvement rate, the lowest serious complications along with being the least invasive technique. These features make it the optimal modality in treatment of ACs. Surgical resection or cystoperitoneal shunt can be considered as secondary techniques when patients report unchanged or worsening symptoms.

Operative versus non-operative management of posterior fossa epidural hematoma: A systematic review and meta-analysis.

BACKGROUND: Posterior fossa epidural hematoma (PFEDH) is rare, occurring in less than 3% of head injuries. It can be managed either operatively or non-operatively. Management guidelines date from 2006, without recent updates providing class III evidence. METHOD: We searched PubMed and other databases for English language observational studies up to 2021 that compared the two treatment approaches for PFEDH and. RESULTS: Twenty-four of the 350 references, for involving 874 patients, met the study criteria. Conservative management showed higher GOS 5 scores and lower mortality. GCS 13-15 patients were more prevalent in the conservative group. Surgical cases often involved ventriculomegaly/compression, hydrocephalus or contusion. CONCLUSION: The study shed light on surgical versus conservative PFEDH management, although evidence is sparse. Generally, conservative methods showed better initial outcomes, and should be preferred. However, respect of individual patient traits and Brain Trauma Foundation guidelines is crucial: conservative management may not suit all cases. To enhance the evidence base, RCTs are important for optimal PFEDH management. Bridging this gap can substantially improve patient outcomes and clinical decision-making, emphasizing the need to consider both the available evidence and patient-specific factors for effective guidance.

Effectiveness of Anodal otDCS Following with Anodal tDCS Rather than tDCS Alone for Increasing of Relative Power of Intrinsic Matched EEG Bands in Rat Brains.

BACKGROUND: This study sought to determine whether (1) evidence is available of interactions between anodal tDCS and oscillated tDCS stimulation patterns to increase the power of endogenous brain oscillations and (2) the frequency matching the applied anodal otDCS's frequency and the brain's dominant intrinsic frequency influence power shifting during stimulation pattern sessions by both anodal DCS and anodal oscillated DCS. METHOD: Rats received different anodal tDCS and otDCS stimulation patterns using 8.5 Hz and 13 Hz state-related dominant intrinsic frequencies of anodal otDCS. The rats were divided into groups with specific stimulation patterns: group A: tDCS-otDCS (8.5 Hz)-otDCS (13 Hz); group B: otDCS (8.5 Hz)-tDCS-otDCS (13 Hz); group C: otDCS (13 Hz)-tDCS-otDCS (8.5 Hz). Acute relative power changes (i.e., following 10 min stimulation sessions) in six frequency bands-delta (1.5-4 Hz), theta (4-7 Hz), alpha-1 (7-10 Hz), alpha-2 (10-12 Hz), beta-1 (12-15 Hz) and beta-2 (15-20 Hz)-were compared using three factors and repeated ANOVA measurement. RESULTS: For each stimulation, tDCS increased theta power band and, above bands alpha and beta, a drop in delta power was observed. Anodal otDCS had a mild increasing power effect in both matched intrinsic and delta bands. In group pattern stimulations, increased power of endogenous frequencies matched exogenous otDCS frequencies-8.5 Hz or 13 Hz-with more potent effects in upper bands. The power was markedly more potent with the otDCS-tDCS stimulation pattern than the tDCS-otDCS pattern. SIGNIFICANCE: The findings suggest that the otDCS-tDCS pattern stimulation increased the power in matched intrinsic oscillations and, significantly, in the above bands in an ascending order. We provide evidence for the successful corporation between otDCS (as frequency-matched guidance) and tDCS (as a power generator) rather than tDCS alone when stimulating a desired brain intrinsic band (herein, tES specificity).

An in Depth Look Into Intracranial Abscesses and Empyemas: a Ten-year Experience in a Single Institute.

Background: As the incidence of intracranial infections increase due to diagnostic procedures improvement, more real-life data is needed to reach a more solid informed management approach. Objective: This study aims to describe and analyse clinical features of intracranial abscesses patients treated at a tertiary hospital in North Jordan during a 10-year period. Methods: We retrospectively identified 37 patients treated at King Abdullah University Hospital (KAUH) from 2011 to 2020 in Irbid, North Jordan. Treatment consisted of either aspiration, open craniotomy excision (OCE) or conservative therapy. Extracted variables included demographic data such (age, gender), clinical presentation, lab findings, radiological findings as well as management plan. Retrieved data was compared between the patients who underwent a single operation and those who underwent reoperation after the initial procedure. Results: Thirty-seven patients with 55 intracerebral abscesses were identified, 29 of whom had intraparenchymal brain abscesses, 4 patients had epidural empyema, and 4 had subdural empyema. The mean age was 28.8 (± 20.7) years, with a male predominance (78.4%). Sixteen patients underwent open craniotomy excision (OCE), 14 patients were treated by aspiration and 7 patients were treated conservatively. When comparing the single operation and the reoperation groups, there was no statistically significant difference across variables. Conclusion: Our study presents valuable insight from a tertiary hospital in north Jordan on intracranial abscesses and empyemas. Our findings confirm that good recovery can be established after aspiration or OCE in the majority of patients. Similar results were obtained when comparing the SOP and the ROP groups.

Management of chronic subdural hematoma: A study from Jordan.

Objectives: Chronic subdural hematoma (CSDH) is a common condition encountered in neurosurgical practice. Few studies have reported the characteristics of CSDH patients in the Middle Eastern population. We describe the clinical presentation, surgical management, radiological findings, and post-operative outcomes in our hospital. Methods: We performed a retrospective cohort study in King Abdullah University Hospital, Northern Jordan, between 2009 and 2019. Data were extracted from patients' medical records and analyzed in patients treated with burr hole drainage (BHD). Univariate analysis was performed to identify correlations with age, laterality, and recurrence. Results: A total of 172 CSDH patients were identified, of whom 128 (74.4%) were treated surgically. The mean age of patients treated with BHD (n = 108) was 60.9 years with a male-to-female ratio of 2.38:1. Headache was the most common presenting symptom (64.81%) and was significant in patients aged 41-64 years (p = 0.004), whereas muscle weakness and unsteady gait were significant in patients ≥ 65 years (p = 0.004 and p = 0.033, respectively). A higher pre-operative maximum thickness was associated with bilateral presentation (p = 0.001), whereas a higher pre-operative midline shift was associated with unilateral presentation (p = 0.027). Regarding CSDH recurrence, only a preoperative midline shift was significant (p = 0.021). Conclusion: Clinical presentation was affected by age, as patients < 65 years commonly presented with headaches, whereas those ≥ 65 years presented with limb weakness, speech impairment, unsteady gait, and altered consciousness. BHD was the most utilized surgical option with low mortality and complication rates. Recurrence was only associated with a pre-operative midline shift.

Paraparesis As a Rare First Presentation Of Primary Hyperparathyroidism-Related Brown Tumor in The Thoracic Spine: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Brown tumor (BT) is defined as osteolytic lesion of an underlying state of hyperparathyroidism. Hyperparathyroidism will activate osteoclasts which initiate active bone resorption foci of lytic-cysts with hemosiderin depositions that pigment it with its characteristic brown pathologic gross appearance. Devastating fractures and injuries can occur to affected bones and surrounding tissue that require emergent intervention and correction. CASE PRESENTATION: We present a case of a medically free 31-year-old female patient, who presented complaining of unsteadiness and progressive lower limbs weakness over 40 days of duration. Subsequent lab tests showed elevated PTH levels, along with 3.5 × 1.8 cm heterogeneous soft tissue mass involving the right pedicle on T7 level compressing the corresponding level of the spinal cord. Surgical management aimed to decompress the spinal cord and to obtain a biopsy for histopathologic examination which revealed a brown tumor. Neck ultrasound and Sestamibi scan indicated the presence of hyperactive and hyperplastic parathyroid tissue most suggestive of parathyroid adenoma. CLINICAL DISCUSSION: Various presentations of Brown Tumor depend on the bone affected, despite the rarity of spinal involvement, yet expanding tumors can manifest either with back pain, radicular pain, paresthesia, weakness, paralysis, or incontinence. The highest incidence rates of spinal brown tumors affect adults over the age of 40. Management goals are to decompress the neuronal tissue emergently and to prevent further bony lytic deterioration. CONCLUSION: The objective of this study is to provide an overview of primary hyperparathyroidism-related spinal brown tumors, presentation, and summary of previously reported similar cases in the literature.

Primary cervical glioblastoma multiforme as a presentation of constitutional mismatch repair deficiency: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Primary Glioblastoma Multiforme(GBM) of cervical spinal cord represent an extremely rare type of tumors in the pediatric age group. Constitutional mismatch repair deficiency (CMMRD) patients are known to develop uni- or multiple synchronous-high grade gliomas in the brain. CASE PRESENTATION: The authors report a 23 month old child presented with bilateral upper limb weakness for 7 days with imaging evidence of intramedullary mass lesion that extends from the level of the C3 to C7. The patient underwent excisional biopsy from C3 to C7 and laminoplasty. Immunohistology confirmed primary cervical GBM. CLINICAL DISCUSSION: Constitutional mismatch repair deficiency is cancer tendent syndrome associated with broad spectrum of malignancies. Screening for CMMRD is not a daily practice in oncology and thus prevalence might be underestimated. To authors' knowledge, no prior primary cervical GBM in CMMRD syndrome. CONCLUSION: This report highlights the challenges of CMMRD polymorphic presentations, diagnosis, complications, management and surveillance.

Rare Presentation of Morganella morganii Microorganism as Epidural and Subdural Empyema / Apresentação rara de Morganella morganii Microrganismo como Empiema Epidural e Subdural

Background Morganella morganii is a gram-negative bacterium that rarely infects the central nervous system (CNS). Few reports described such an infection in the CNS. We present a case of extremely invasive M. morganii infection in the CNS. In addition, we performed a literature review of M. morganii infection in the CNS. Case report A 53-year-old male was admitted to the hospital due to fever, general weakness, and left-sided facial muscle twitching. He had a history of diabetes mellitus, hypertension, brain tumor, and epilepsy. Multiple left frontal scalp ulcers were revealed. In addition, a computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed a left side epidural abscess and subdural empyema. Moreover, the patient had left frontal bone osteomyelitis. The next day, the patient underwent craniectomy, was transferred to the intensive care unit and started an empirical antibiotic course. Morganella morganii was identified from the infected scalp ulcers. On the 13th day, the patient passed away due to uncontrolled status epilepticus. Conclusion M. morganii can cause isolated or multiple types of CNS infections, including brain abscess, meningitis, and subdural empyema. The mortality rate may differ according to age and to the use of surgical evacuation.

Introdução Morganella morganii é uma bactéria gram-negativa que raramente infecta o sistema nervoso central (SNC). Poucos relatos descreveram tal infecção no SNC. Apresentamos um caso de infecção extremamente invasiva por M. morganii no SNC. Além disso, realizamos uma revisão da literatura sobre a infecção por M. morganii no SNC. Relato de caso Um homem de 53 anos foi admitido no hospital devido a febre, fraqueza geral e espasmos da musculatura facial do lado esquerdo. Ele tinha história de diabetes mellitus, hipertensão, tumor cerebral e epilepsia. Múltiplas úlceras no couro cabeludo frontal esquerdo foram reveladas. Além disso, uma tomografia computadorizada (TC) e uma ressonância magnética (RM) revelaram um abscesso epidural do lado esquerdo e empiema subdural. Além disso, o paciente apresentava osteomielite do osso frontal esquerdo. No dia seguinte, o paciente foi submetido à craniectomia, foi transferido para a unidade de terapia intensiva e iniciou curso empírico de antibiótico. Morganella morganii foi identificada a partir das úlceras do couro cabeludo infectadas. No 13° dia, o paciente faleceu devido a estado de mal epiléptico não controlado. Conclusão M. morganii pode causar tipos isolados ou múltiplos de infecções do SNC, incluindo abscesso cerebral, meningite e empiema subdural. A taxa de mortalidade pode diferir de acordo com a idade e com o uso da evacuação cirúrgica.

Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5- C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, whichmay be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.