Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

OBJECTIVE: The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. METHODS: A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). RESULTS: Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. CONCLUSIONS: With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Cocaine-induced encephalocele: case report and literature review.

BACKGROUND AND IMPORTANCE: The abuse of cocaine can lead to significant destruction of midline craniofacial structures. This process occurs secondary to myriad mechanisms, including ischemic necrosis, irritation by chemical adulterants, and direct trauma during its administration. Coupled with a prolonged chronic infection of intranasal and anterior skull base regions, an encephalocele can be formed. We report a case of an encephalocele secondary to cocaine use and its associated complications. CLINICAL PRESENTATION: A 56-year-old man presented with altered mental status and cerebritis secondary to the presence of an intranasal encephalocele. On computed tomography, extensive destruction of the anterior cranial fossa was observed. The patient had a 30-year history of intranasal cocaine abuse, and his urine tested positive for the presence of cocaine on admission. The patient was treated with intravenous antibiotics and underwent a repair of his cranial defect and resection of the encephalocele. The patient made a good recovery after treatment. CONCLUSION: Alternative causes of an encephalocele, including trauma, surgery, and congenital malformation, were ruled out in this patient. Histopathological analysis of the necrotic tissue and the absence of renal or pulmonary disease also indicated that the patient did not suffer from Wegener granulomatosis, a known cause of spontaneous intranasal lesions. To the best of our knowledge, this is the first report of an encephalocele likely induced solely by cocaine abuse.

Spinal Kaposi sarcoma presenting without cutaneous manifestations. Case report.

Kaposi sarcoma (KS) is one of the most common tumors in patients with human immunodeficiency virus (HIV), which characteristically presents with cutaneous lesions. The authors report a rare case of spinal KS with no cutaneous manifestation in a 32-year-old man with the acquired immunodeficiency syndrome who presented with abdominal pain. A computed tomography scan revealed incidental lesions in his lumbar spine, and additional imaging studies revealed numerous lesions in the lumbosacral spine and pelvis. An open biopsy was performed, and histopathological examination of the lesion confirmed the diagnosis of KS. At the time of presentation, the patient had no skin lesion or any other manifestation indicative of KS. The authors suggest that in HIV-positive patients who present with spinal lesions, KS should be included in the differential diagnosis.

History of instrumentation for stabilization of the subaxial cervical spine.

In the past several decades methods have been developed to stabilize the subaxial cervical spine both posteriorly and anteriorly. Methods of posterior stabilization have progressed from interspinous wiring, through facet wiring and sublaminar wiring, to the lateral mass screws with plates and rods that are in use today. Plates for anterior stabilization have evolved from rigid plates requiring bicortical screws through those used with unicortical locking screws, to dynamic load-sharing plates used with variable angle screws. The original description of spinous process wiring was published by Hadra in 1891. In 1942 Rogers described the interspinous wiring method used for trauma-induced cervical instability, which was modified by Bohlman in 1985 (triple wiring technique). Luque rods with sublaminar wires were introduced in the late 1970s to address multilevel and occipitocervical instability. Facet wiring was developed in 1977 by Callahan to address the problem of stabilization when laminae are not present. Wiring remained the method used until Roy-Camille introduced the lateral mass screw-plate construct in the 1980s. The first plate for anterior stabilization was designed by Orozco and Llovet in 1970 and was later refined by Caspar; this was a rigid plate with bicortical screws. Morscher devised unicortical locking screws in the 1980s. The latest concept of dynamic load-sharing plates with variable angle screws was developed in 2000. In this article historical landmarks in surgical methods for the stabilization of the subaxial cervical spine are reviewed.

Communication between malignant glioma cells and vascular endothelial cells through gap junctions.

OBJECT: Extensive invasion and angiogenesis are hallmark features of malignant gliomas. Communication between malignant glioma cells and surrounding astrocytes occurs, resulting in transformation of the astrocytic phenotype. In the present study, the authors examined whether malignant glioma cells and vascular endothelial cells (VECs) communicate through the formation of gap junctions and whether this communication influences angiogenesis. METHODS: Connexin43 (Cx43), a gap junction protein expressed in glioma cells, was identified in human umbilical VECs (HUVECs). Immunocytochemical staining for Cx43 demonstrated immunoreactive plaques at areas of cell-cell contact among HUVECs as well as between HUVECs and Cx43-expressing malignant glioma cells. Dye transfer, performed using the gap junction-permeable dye dicarboxy-dichlorofluorescein diacetate (CDCF), among these cocultures indicated that these were functional communications. Calcium signaling also occurred from malignant glioma cells to HUVECs. Tube formation by HUVECs cocultured with Cx43-transfected T98G malignant glioma cells (T98G-Cx43 cells) or with U87MG malignant glioma cells, which naturally express Cx43, was significantly increased compared with tube formation by HUVECs alone. The difference in tube formation by HUVECs cocultured with empty vector-transfected T98G glioma cells (T98G-mock cells) or with Cx43-deficient U373MG malignant glioma cells and tube formation by HUVECs alone was not statistically significant. Furthermore, the concentration of vascular endothelial growth factor (VEGF), an angiogenic factor important for the induction of angiogenesis and blood vessel formation, was significantly higher in medium harvested from cultures of T98G-Cx43 cells than in that harvested from cultures of control T98G-mock cells. Human malignant glioma U87MG cells also secreted increased concentrations of VEGF as compared with HUVECs alone. Nevertheless, there was no statistically significant difference in tube formation by HUVECs cultured in medium conditioned by either Cx43-expressing or Cx43-deficient glioma cells, suggesting that the direct gap junction communication between glioma cells and HUVECs may play a much more significant role than the increased VEGF secretion in vascular tube formation in this assay. CONCLUSIONS: These results indicate that functional gap junction formation between human malignant glioma cells and VECs occurs. This communication appears to influence tumor angiogenesis. Targeting gap junction signaling may offer a potential mechanism for therapy in patients with these tumors.