Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review.

BACKGROUND: Neurologic complications are common complications encountered by patients with left ventricular assist devices (LVADs). This single-center retrospective study aims to identify the incidence and risk factors of neurologic complications and interventions in patients supported with LVADs and define the associated anticoagulation management. METHODS: Between August 2009 and August 2017, 244 patients underwent LVAD implantation. Twenty-one patients were excluded for having neurologic complications before LVAD placement or for having previously undergone heart transplantation. RESULTS: Fifty-six patients (25%) suffered 61 complications, and 11 (19.6%) died as a result. Gender, type of LVAD, or chronic medical comorbidities evaluated did not contribute to a difference in complication rate; in contrast, length of LVAD implantation was directly related to risk of neurologic complication. Eleven patients (19.6%) underwent 13 surgical interventions including 5 mechanical thrombectomies. Anticoagulation was reversed in 16 patients and held without complication. Anticoagulation was not held for ischemic complications, and no clinically significant hemorrhagic transformation occurred. Intravenous tissue plasminogen activator was also successfully administered to 3 patients without complication. CONCLUSIONS: Neurologic complications were observed in 25% of patients supported with LVADs, of which 20% required neurosurgical intervention. Anticoagulation can be safely withheld in patients with hemorrhagic complications. Patients with ischemic complications can continue to be anticoagulated with no significant risk of hemorrhagic transformation. Length of LVAD implantation was directly related to the risk of neurologic complication. Finally, our study adds to existing literature that mechanical thrombectomy and even intravenous tissue plasminogen activator are options for LVAD patients with ischemic complications.

Multiple extraspinal recurrences of ependymoma 13 years after spinal cordectomy: case report.

Ependymomas of the spinal cord remain confined to the CNS and vary in presentation, depending on WHO grade. Higher-grade lesions usually cannot be surgically removed due to their infiltrative growth pattern. Spinal cordectomy has been proposed as a rescue treatment to improve survival in patients with high-grade as well as recurrent lesions. This report details an instructive and unique case of long-term follow-up of a patient who underwent cordectomy from T-4 through S-5 for what was initially diagnosed as a high-grade glial neoplasm of the spinal cord in 1993. The patient lived symptom free for 13 years after spinal cord resection and then presented with numerous bilateral extraspinal (intraabdominal and intrathoracic) tumors, which eventually led to her death 15 years after the cordectomy. In this case, spinal cordectomy was effective in preventing the ascending spread of the neoplasm, but ultimately not effective in preventing recurrence in the plicated distal dural sac.

De Novo Spinal Dural Arteriovenous Fistula in a Patient with a Lipomyelomeningocele: Case Report.

BACKGROUND: Spinal dural arteriovenous fistula (AVF), the most common type of spinal vascular malformation, tends to manifest as progressive myelopathy over several years. Spinal dural AVFs are considered an acquired lesion and, in contrast to spinal arteriovenous malformations, are not often associated with other anomalies. The presence of a spinal dural AVF in the setting of a lipomyelomeningocele and tethered cord is extremely rare. Both lesions tend to cause similar symptoms, and patients with concomitant lesions generally require surgical intervention for both. CASE DESCRIPTION: A 57-year-old female with lifelong urinary incontinence and mild weakness in the left lower extremity presented with progressive worsening of left lower extremity weakness as well as worsening bowel and bladder incontinence. Magnetic resonance imaging (MRI) performed 4 years before our evaluation revealed a lipomyelomeningocele and a tethered cord; a new MRI demonstrated a new additional finding of flow voids suspicious of an underlying vascular malformation. Diagnostic angiography revealed a dural AVF fed by a left lateral sacral artery. Onyx embolization of the dural AVF was performed, and the patient improved steadily postoperatively without the need for surgically addressing the tethered cord. CONCLUSION: In this case report, we present evidence of de novo development of a spinal dural AVF associated with a lipomyelomeningocele. In addition, this is the second documented patient in the literature with a lipomyelomeningocele and concomitant dural AVF who did not undergo detethering of the cord as part of treatment.

Acute Management of Moderate-Severe Traumatic Brain Injury.

Traumatic brain injury (TBI) continues to be a major public health problem. Proposed treatments have not withstood testing in clinical trials because of failure to account for different types of TBI and other weaknesses in trial design. Management goals continue to be prevention and prompt treatment of secondary insults (hypotension, hypoxia, and other physiologic derangements). This goal is best accomplished by careful attention to airway, breathing, circulation, and basic principles of intensive care unit management. Attempts to intervene prophylactically to prevent intracranial hypertension or other complications have not been beneficial and may even have deleterious effects.