Normal perfusion pressure breakthrough phenomenon: what still remains unknown.

We report two cases of normal perfusion pressure breakthrough phenomenon after total brain arteriovenous malformation removal. Hereby, we demonstrate that not only autoregulation impairment in the ipsilateral hemisphere occurs but also contralateral remote vessels response does. Such findings may be observed at 2-4 weeks and may resolve after 1-3 months.

Protective effect of rifampicin and clindamycin impregnated devices against Staphylococcus spp. infection after cerebrospinal fluid diversion procedures.

BACKGROUND: Infection is a major complication of cerebrospinal fluid shunting procedures. The present report assesses the efficacy of such catheters in both shunts and external ventricular drains (EVDs) against infection and particularly against Staphylococcus spp. infection. METHODS: All shunt and EVD procedures performed by means of antibiotic-impregnated catheters (AICs) and non-AICs during the period of study were registered. In cases of shunt procedures, a minimal follow-up of 90 days was considered, as well as de novo insertion and catheter revisions. Single valve revisions were not included. In cases of EVD procedures, those catheters removed before the fifth post-insertion day were not included. A total of 119 cerebrospinal fluid shunting procedures performed with AICs were studied in comparison with 112 procedures performed by means of non-AICs. RESULTS: Antibiotic-impregnated catheters were associated with a significant decrease in both overall and staphylococcal infection (p = 0.030 and p = 0.045, respectively). The number needed to treat for AICs was 8 to prevent one infection and 14 to prevent one staphylococcal infection. When comparing with shunts, the use of EVDs was associated with a 37-fold increased likelihood of infection. CONCLUSIONS: Antibiotic-impregnated catheters are a safe and helpful tool to reduce CSF shunting device-related infections.

A historical analysis of severe head injury.

Severe head injury (SHI) is a significant health, social and economic concern rendering a worldwide health problem. This retrospective study was designed to describe the features and outcomes of patients with SHI treated in a single neurosurgical unit (Hospital "12 de Octubre", Madrid, Spain) over a period approaching 13 years. The subjects enrolled were 895 patients (15 years or older) with non-missile SHI treated over the period January 1987 to August 1999, in whom a computerised tomography scan had been performed within the first 6 h of injury. We considered epidemiological, clinical, analytical, radiological and therapeutic data along with final patient outcomes. The overall mortality rate was 46.8% (419 patients). Of these 419 deaths, 177 (42.2%) occurred within the first 48 h of injury rendering an early death rate of 19.8% (177/895 patients). Despite overall mortality showing a clear decreasing trend by the end of the 1990s, proportions of early deaths (within the first 48 h of injury) dramatically rose in the last 3 years of the study. As a whole, an unfavourable outcome was recorded in 62.6% (560 patients). Despite continued efforts to improve the outcome of patients with SHI, the results of our study are pessimistic in that high mortality and unfavourable outcome rates were recorded in this large series of patients. Although overall mortality has diminished over the years, the number of early deaths has increased.

Intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa.

Dural arteriovenous malformations of the middle cranial fossa are very rare. Venous drainage flows either through superficial leptomeningeal veins or through the sphenoparietal, sphenopetrous and/or sphenobasilar sinuses. They often have an aggressive course and therefore poor outcome. It is essential to analyse and understand the angioarchitecture of the dural arteriovenous malformations in order to select and plan the correct treatments. We describe an exceptional case of intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa. To our knowledge, this is the first case report of such characteristics described in the literature.

Penetrating brain injury by drill bit.

Non-missile low velocity penetrating brain injuries are unusual among civilian population. They show specific characteristics different from missile wounds. In this paper we describe a rare case of self-inflicted penetrating head trauma by electric drill. We document neuroimaging studies and review the management concerning this pathology. To our knowledge, this is the first case of intracranial retained drill bit with such radiological findings reported in the literature. An 80-year-old male with no previous psychiatric disorder presented at our hospital after suffering an accident while working with an electric drill. Physical examination revealed right lower extremity plegia and three penetrating scalp wounds to the left parasagittal region. Skull X-ray and computed tomography demonstrated an intracranial metallic foreign body located in the left parietal lobe and an intraparenchymal hematoma with no mass effect close to the foreign body. The patient was taken to the operating room to remove the drill bit fragment. Antibiotic and antiseizure prophylaxis were administered. Postoperative computed tomography confirmed no residual metallic fragments and functional recovery was excellent. After psychiatric assessment, suicide attempt was confirmed and antidepressive therapy was then started. On follow-up, no complication was documented. It is essential to exclude penetrating brain trauma whenever a scalp wound is noticed in order to provide proper treatment and prevention care. The permanent neurological deficit in low velocity injuries is related to the degree and location of the primary injury. It also depends on an early diagnosis and treatment and the absence of delayed complications.

Retropharyngeal pseudomeningocele formation as a traumatic atlanto-occipital dislocation complication: case report and review.

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation is a rare complication, with only five cases described in the literature. It develops when a traumatic dural tear occurs allowing cerebrospinal fluid outflow, and it often appears associated with hydrocephalus. We present a case of a 29-year-old female who suffered a motor vehicle accident causing severe brain trauma and spinal cord injury. At hospital arrival the patient scored three points in the Glasgow Coma Scale. Admission computed tomography of the head and neck demonstrated subarachnoid hemorrhage and atlanto-occipital dislocation. Three weeks later, when impossibility to disconnect her from mechanical ventilation was noticed, a magnetic resonance imaging of the neck showed a large retropharyngeal pseudomeningocele. No radiological evidence of hydrocephalus was documented. Given the poor neurological status of the patient, with spastic quadriplegia and disability to breathe spontaneously due to bulbar-medullar injury, no invasive measure was performed to treat the pseudomeningocele. Retropharyngeal pseudomeningocele after atlanto-occipital dislocation should be managed by means of radiological brain study in order to assess for the presence of hydrocephalus, since these two pathologies often appear associated. If allowed by neurological condition of the patient, shunting procedures such as ventriculo-peritoneal or lumbo-peritoneal shunt placement may be helpful for the treatment of the pseudomeningocele, regardless of craniocervical junction management.

[Effect of antibiotic-impregnated catheters on the incidence of infection after cerebrospinal fluid shunting]. / Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo.

BACKGROUND AND OBJECTIVE: Infection is a major complication after cerebrospinal fluid (CSF) shunt systems insertion. Antibiotic-impregnated (AI) catheters seem to reduce infection rate in clinical practice. The objective of this study was to determine if the use of AI catheters reduces Staphylococcus spp. infection rate, as it is the most commonly isolated organism. PATIENTS AND METHOD: Authors retrospectively reviewed all patients who underwent rifampin-impregnated and clindamycin-impregnated catheters at our hospital. These included external ventricular catheters (inserted from January 2006 to January 2007) and internalized shunts (inserted from January 2004 to January 2007). They also reviewed patients who underwent insertion of non-impregnated external catheters and internalized shunts during the same periods. Overall infection rate, Staphylococcus spp. infection rate and gram negative bacilli infection rate were compared in both groups by means of chi2 test. RESULTS: Sixty-five procedures with AI catheters and 66 procedures with non-AI catheters were performed. Overall infection rate as well as Staphylococcus spp. infection rate were significantly lower in the AI catheters cohort (p = 0.046 and p = 0.029, respectively), without increasing gram negative bacilli infections. CONCLUSIONS: The use of rifampin and clindamycin-impregnated catheters is a useful tool to reduce Staphylococcus spp. infections after CSF shunting procedures. However, future clinical trials are required to confirm these results.

[Risk factors for cerebrospinal fluid shunt infection]. / Factores de riesgo de infección en procedimientos de derivación de líquido cefalorraquídeo.

BACKGROUND AND OBJECTIVE: Shunt-related infection is a major complication. The effort to face up to this problem has focused on therapy, analysis of risk factors and primary prevention. The aim of this study is to identify risk factors for cerebrospinal fluid shunt infection. MATERIAL AND METHOD: We retrospectively reviewed all patients who underwent shunt placement at our hospital during the period of study. Procedures followed for less than 90 days were excluded. One hundred and nineteen procedures were included in the final analysis. RESULTS: Infection rate per procedure was 8.4%. Previous cerebrospinal fluid infection, previous shunt and complete substitution of the shunt were identified as risk factors for infection in the univariate analysis. However, a multivariate analysis confirmed that previous cerebrospinal fluid infection was the only independent risk factor for shunt-related infection (p=0.011). CONCLUSION: Previous cerebrospinal fluid infection is an independent risk factor for shunt-related infection. Other factors such as age, gender, etiology of hydrocephalus, previous shunt or complete substitution of the shunt were not associated with increased risk of infection.

Do antibiotic-impregnated catheters prevent infection in CSF diversion procedures? Review of the literature.

SUMMARY: Cerebrospinal fluid shunting devices are foreign bodies internally or externally placed in a patient with the aim of improving the prognosis. Device-related infection is the most serious complication. Its importance arises from the high frequency of occurrence and the consequences that it implies in terms of morbidity and mortality. As a result, the presence of these two factors increases significantly hospital costs. Among many primary prevention measures investigated, one of those that has gained in importance over the last years is the use of antibiotic-impregnated catheters. Although their experimental development dates back to the 1970s, experience in clinical practice has not been settled until the last decade. This is the reason why only 22 studies on the usefulness of AICs in CSF shunting procedures in clinical practice have been published in the literature since their commercialization. Although experience with antibiotic-impregnated shunts continues growing, practice with antibiotic-impregnated external ventricular drains is much shorter. The present study reviews and analyses the different investigations performed in order to determine the efficacy of antibiotic-impregnated shunts and external ventricular drains with the aim of reducing device-related infectious complications. The results suggest that AICs reduce device-related infection as well as hospital costs. However, evidence is not enough to state categorical conclusions, and further large, prospective, randomized and double-blind studies must be performed in order to confirm these results and the efficacy of other antibiotic-impregnated devices. Further economic evaluation is required to confirm the benefit in terms of cost-effectiveness as well.

Dural cavernous haemangioma of the anterior cranial fossa.

Extra-axial cavernous haem angiomas are uncommon lesions histologically identical to cavernomas in other locations. However, their radiological features and clinical behaviour may differ. They are frequently misdiagnosed preoperatively, as they often mimic other tumours. We describe a patient suffering from loss of the sense of smell, due to a cavernous haemangioma implanted in the dura mater of the anterior cranial fossa close to the olfactory bulb. To our knowledge, this is the first patient reported with such a lesion.

Intradural extramedullary spinal ependymoma: a benign pathology?

STUDY DESIGN: Spinal ependymoma is a benign central nervous system tumor described as an intramedullary lesion more frequently located at the conus medullaris. It has been described exceptionally in the literature as an intradural extramedullary tumor. OBJECTIVE: Presentation of an extremelly rare location and evolution of extremedullary ependymoma and discussion of its probable origin, differential diagnosis, treatment options, and follow-up. SUMMARY OF BACKGROUND DATA: This case demonstrates an unusual location of a benign ependymal tumor in the extramedullary space with a total resection, which recurred in a lower level with a malignant transformation with the same extramedullary location. METHODS: The authors present the case of a 47-year-old woman with a subacute spinal cord dysfunction and an intradural extramedullary D2-D3 tumor mimicking meningioma or neurinoma. At surgery, an encapsulated intradural extramedullary mass was found, but neither dural attachment nor medullary infiltration was present. RESULTS: After complete resection, anatomic-pathologic studies confirmed that the lesion was a benign classic ependymoma. Good neurologic outcome was achieved, and no residual tumor was present at magnetic resonance imaging (MRI) control performed at 3 and 9 months later. One year after surgery, a new intradural extramedullary tumor was found at the D4 level without recurrence at D2. The patient was operated on again, but at this time the histologic study showed an anaplastic ependymoma with a proliferation index of 25% measured by Ki-67. Whole central nervous system radiotherapy was performed. CONCLUSION: All of the previously reported cases of spinal intradural extramedullary ependymomas carried out a benign course. The case we are reporting is the first one in which malignant transformation occurred. This tumor should be taken into account in the differential diagnosis of intradural extramedullary lesions. Moreover, close follow-up is recommended for this unusual location of ependymomas.

Factores de riesgo de infección en procedimientos de derivación de líquido cefalorraquídeo / Risk factors for cerebrospinal fluid shunt infection

Fundamento y objetivo: La infección es una de las complicaciones más serias tras la implantación de una derivación permanente de líquido cefalorraquídeo (LCR). El esfuerzo para solucionar este problema se ha centrado en su tratamiento, identificar posibles factores de riesgo y la prevención primaria. El objetivo de este trabajo es identificar factores de riesgo de infección en pacientes portadores de derivaciones de LCR en nuestro medio. Material y método: Se identificaron retrospectivamente los pacientes sometidos a la implantación de una derivación permanente de LCR en nuestro centro durante el período de estudio considerado. Se excluyeron aquellos procedimientos cuyo seguimiento fue inferior a 90 días. Ciento diecinueve procedimientos fueron incluidos en el análisis final.Resultados: El 8,4% de los procedimientos se infectaron. En el análisis univariable el antecedente de infección del LCR en los 6 meses previos a la implantación de la derivación, el antecedente de derivación previa y la sustitución completa de la derivación se asociaron a mayor riesgo de infección. Tras el análisis multivariable, el antecedente de infección del LCR en los 6 meses anteriores a la implantación de la derivación fue el único factor de riesgo independiente identificado (p=0,011). Conclusión: El antecedente de infección del LCR en los 6 meses anteriores a la implantación de una derivación permanente es un factor de riesgo de infección independiente en nuestro medio. La edad, el sexo, la etiología de la hidrocefalia, el antecedente de derivación previa o el tipo de cirugía realizado no se asociaron a un riesgo incrementado de infección (AU)

Background and objective: Shunt-related infection is a major complication. The effort to face up to this problem has focused on therapy, analysis of risk factors and primary prevention. The aim of this study is to identify risk factors for cerebrospinal fluid shunt infection.Material and method: We retrospectively reviewed all patients who underwent shunt placement at our hospital during the period of study. Procedures followed for less than 90 days were excluded. One hundred and nineteen procedures were included in the final analysis. Results: Infection rate per procedure was 8.4%. Previous cerebrospinal fluid infection, previous shunt andcomplete substitution of the shunt were identified as risk factors for infection in the univariate analysis.However, a multivariate analysis confirmed that previous cerebrospinal fluid infection was the only independent risk factor for shunt-related infection (p = 0.011).Conclusion: Previous cerebrospinal fluid infection is an independent risk factor for shunt-relatedinfection. Other factors such as age, gender, etiology of hydrocephalus, previous shunt or completesubstitution of the shunt were not associated with increased risk of infection (AU)

Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo / Effect of antibiotic-impregnated catheters on the incidence of infection after cerebrospinal fluid shunting

FUNDAMENTO Y OBJETIVO: La infección es una de las principales complicaciones asociadas a la colocaciónde sistemas de derivación de líquido cefalorraquídeo (LCR). La utilización de catéteres impregnados con antibiótico (IA) parece disminuir la tasa de infección posquirúrgica en la práctica clínica. El objetivo de este trabajo ha sido determinar si el uso de sistemas IA reduce el riesgo de infección posquirúrgica por Staphylococcus spp., principal agente de infección.PACIENTES Y MÉTODO: Se identificó retrospectivamente a todos los pacientes a quienes se habían implantado catéteres impregnados con rifampicina y clindamicina en nuestro centro, incluidos catéteres externos (desde enero de 2006 hasta enero de 2007) y sistemas de derivación interna (desde enero de 2004 hasta enero de 2007), y a aquellos a quienes se habían implantado catéteres externos y sistemas de derivación interna sin IA durante los mismos períodos de tiempo. Mediante la prueba de la 2 se analizó y comparó el porcentaje de infección global, por Staphylococcus spp. y por bacilos gramnegativos en ambas cohortes.RESULTADOS: Se registraron 65 procedimientos con catéteres IA y 66 procedimientos con catéteresno impregnados. Tanto el porcentaje de infección global como el porcentaje de infección por Staphylococcus spp. fueron significativamente menores en el grupo con catéteres IA (p = 0,046 y p = 0,029, respectivamente), sin que se observara un aumento significativo de las infecciones por bacilos gramnegativos.CONCLUSIONES: El uso de sistemas de derivación de LCR impregnados con rifampicina y clindamicina parece una herramienta útil para reducir la aparición de complicaciones infecciosas posquirúrgicas por Staphylococcus spp. Deben llevarse a cabo estudios prospectivos, aleatorizados y doble ciego para confirmar estos resultados

BACKGROUND AND OBJECTIVE: Infection is a major complication after cerebrospinal fluid (CSF)shunt systems insertion. Antibiotic-impregnated (AI) catheters seem to reduce infection rate inclinical practice. The objective of this study was to determine if the use of AI catheters reducesStaphylococcus spp. infection rate, as it is the most commonly isolated organism.PATIENTS AND METHOD: Authors retrospectively reviewed all patients who underwent rifampin-impregnatedand clindamycin-impregnated catheters at our hospital. These included external ventricular catheters (inserted from January 2006 to January 2007) and internalized shunts (inserted from January 2004 to January 2007). They also reviewed patients who underwent insertionof non-impregnated external catheters and internalized shunts during the same periods. Overall infection rate, Staphylococcus spp. infection rate and gram negative bacilli infection rate were compared in both groups by means of 2 test.RESULTS: Sixty-five procedures with AI catheters and 66 procedures with non-AI catheters were performed. Overall infection rate as well as Staphylococcus spp. infection rate were significantly lower in the AI catheters cohort (p = 0.046 and p = 0.029, respectively), without increasing gram negative bacilli infections.CONCLUSIONS: The use of rifampin and clindamycin-impregnated catheters is a useful tool to reduceStaphylococcus spp. infections after CSF shunting procedures. However, future clinical trials are required to confirm these results

Comentario al trabajo, Empiema epidural espinal. Análisis de 14 casos de M. Gelabert-González y cols / No disponible

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