Spontaneous Intracranial and Lumbar Subdural Hematoma Presenting as Vaginal Pain.

BACKGROUND: Spontaneous spinal and intracranial subdural hematomas are rarely reported, especially occurring simultaneously. Anticoagulation use has been associated with spontaneous hemorrhages. Prompt diagnosis is required to prevent permanent neurological sequelae. In this case report, we describe a spontaneous spinal and intracranial subdural hematoma in a woman taking warfarin and initially presenting with severe vaginal pain. CASE REPORT: A 42-year-old woman who had a history of mechanical valve replacement and was therefore taking warfarin, came to an emergency department for relief of severe vaginal pain. Mild concurrent lumbar pain increased concern about spinal pathology, so magnetic resonance imaging of her spine was performed. It revealed a subdural hematoma extending from L1-S1 with arachnoiditis, which suggested intracranial pathology, though the patient had no complaint of a headache. Computed tomography of her brain demonstrated a large right subdural hemorrhage with midline shift. Subsequent imaging revealed no aneurysm or source of the intracranial bleeding. We concluded that the patient experienced spontaneous anticoagulation-related intracranial hemorrhage resulting in lumbar subdural hematoma and arachnoiditis with referred vaginal pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pelvic, vaginal, or perineal pain may be the presenting symptom in patients with lower spinal pathology. It is important to consider causes other than gynecological ones in the differential diagnosis of these patients, as well as to be cognizant of the relationship between spinal and intracranial subdural hemorrhages. In patients with back pain or radiating lumbar pain, especially coupled with neurological effects, clinicians should consider spinal subdural hemorrhage and arachnoiditis to expedite imaging studies and treatment of these rare entities.

Treatment of a Recurrent Neuroma Within Nerve Allograft With Autologous Nerve Reconstruction.

BACKGROUND: The purpose of this case report is to describe the findings of a neuroma within an allograft, highlight the unique opportunity to evaluate the allograft (following human engraftment) ex vivo histologically, to reinforce an effective treatment strategy, and review outcomes in peripheral nerve surgery regarding gap defect distance. METHOD: A 55-year-old, right hand dominant man suffered a workplace injury 37 years ago resulting in lacerations and crush injury of the palm and lacerations of the left index finger requiring multiple neuroma excisions and eventual ray amputation. In an attempt to address stump neuroma pain and restore sensation of the radial digital nerve of the middle finger, which was lost after the ray amputation, a neuroma was resected and reconstructed with a 45-mm bioabsorbable allograft (AxoGen, Inc, Alachua, Florida). After the inciting injury in 1977, the patient initially presented to our clinic in 2013 with return of pain at the palm and numbness along the distribution of the common digital nerve and radial nerve of the middle finger prompting surgical exploration. A recurrent common digital nerve neuroma was identified at the proximal aspect of the allograft measuring 20 mm and was resected along with the remaining allograft. RESULTS: A 50-mm reversed superficial peroneal interpositional nerve graft was used for reconstruction resulting in progressive resolution of pain. On 6-month follow-up, the patient regained indiscriminate sensation with moving 2-point discrimination at the pulp of the middle finger with improved grasp function. CONCLUSION: In the setting of recalcitrant neuromas and intractable pain following multiple neuroma excisions, allografts may be suboptimal in reconstruction of larger gap defects. Autologous reconstruction with porcine submucosa extracellular matrix, as in this case, can avoid tethering, local ischemia, and nerve traction to optimize outcomes.

Social stress and CRF-dopamine interactions in the VTA: role in long-term escalation of cocaine self-administration.

The nature of neuroadaptations in the genesis of escalated cocaine taking remains a topic of considerable interest. Intermittent social defeat stress induces both locomotor and dopaminergic cross-sensitization to cocaine, as well as escalated cocaine self-administration. The current study examines the role of corticotropin releasing factor receptor subtypes 1 and 2 (CRFR1, CRFR2) within the ventral tegmental area (VTA) during social defeat stress. This study investigated whether injecting either a CRFR1 or CRFR2 antagonist directly into the VTA before each social defeat would prevent the development of later (1) locomotor sensitization, (2) dopaminergic sensitization, and (3) escalated cocaine self-administration in rats. CRFR1 antagonist CP376395 (50 or 500 ng/side), CRFR2 antagonist Astressin2-B (100 or 1000 ng/side), or vehicle (aCSF) was microinjected into the VTA 20 min before social defeat stress (or handling) on days 1, 4, 7, and 10. Ten days later, rats were injected with cocaine (10 mg/kg, i.p.) and assessed for either locomotor sensitization, measured by walking activity, or dopaminergic sensitization, measured by extracellular dopamine (DA) in the nucleus accumbens shell (NAcSh) through in vivo microdialysis. Locomotor sensitization testing was followed by intravenous cocaine self-administration. Intra-VTA antagonism of CRFR1, but not CRFR2, inhibited the induction of locomotor cross-sensitization to cocaine, whereas both prevented dopaminergic cross-sensitization and escalated cocaine self-administration during a 24 h "binge." This may suggest dissociation between locomotor sensitization and cocaine taking. These data also suggest that interactions between CRF and VTA DA neurons projecting to the NAcSh are essential for the development of dopaminergic cross-sensitization to cocaine.