Successful Endovascular Treatment of a Traumatic Cervical Arteriovenous Fistula After a Carotid Paraganglioma Resection: A Case Report.

Traumatic cervical arteriovenous fistulas are rare, accounting for only 4% of all arteriovenous fistulas. They can be caused by penetrating, or rarely, blunt trauma, resulting in high-pressure arterial blood draining directly into a vein, decreasing distal perfusion. They are seldom reported as a complication of a carotid paraganglioma surgical resection. Historically, arteriovenous fistulas were treated initially conservatively, after that, surgically; nowadays, endovascular treatment, when feasible, is the preferred method as it offers advantages over surgery. This case report describes a rare traumatic cervical arteriovenous fistula that developed after a carotid paraganglioma resection and was successfully treated using coils and Onyx embolic agent via endovascular embolization. After successful embolization, the patient had a smooth recovery and remained stable. In conclusion, vascular injury seems to be the only constant in all acquired cervical arteriovenous fistulas independent of the trauma mechanism; and endovascular treatment, when feasible, is preferred over surgery as it offers superior advantages.

Weighing the Risk Profile of Cervical Spine MRI in Evaluating Pediatric Cervical Spine Injuries.

OBJECTIVE: Screening for cervical spine injury after blunt trauma is common, but there remains varied practice patterns and clinical uncertainty regarding adequate radiographic evaluation. An oft-cited downside of MRI is the added risk compared to CT in the pediatric population; however, these specific risks have not yet been reported. This study examines the risks of cervical spine MRI in pediatric trauma patients in the context of what value MRI adds. METHODS: This was a retrospective observational study of all pediatric blunt trauma patients who were evaluated with a cervical spine MRI over a 4-year period at a level 1 pediatric trauma center. Clinical and radiographic data were abstracted, as well as anesthesia requirements and MRI-related major adverse events. CT and MRI results were compared for their ability to detect clinically unstable injuries - those requiring halo or surgery. RESULTS: There was one major adverse event related to MRI among the 269 patients who underwent cervical spine MRI - a rate of 0.37%. While 55% of children had an airway and anesthesia for MRI, only 57% of these airways were newly placed for the MRI. None of the 85 patients newly intubated for MRI developed aspiration pneumonitis or ventilator-associated pneumonia, and no patients had a significant neurologic event while at MRI. Another area of the body was imaged concurrently with the cervical spine MRI in 64% of patients and 83% of MRIs were performed within 48 h. CT and MRI were both 100% sensitive for injuries requiring halo or operative intervention. Eighty-three patients had an MRI performed after a negative CT, 11% (9/83) of these patients had a clinically stable injury detected on subsequent MRI, and none of these patients presented for delayed cervical spine complications. CONCLUSIONS: Overall, the safety profile of MRI in this setting is excellent and less than one-third of patients need new airway and anesthesia solely for MRI. In this clinical scenario, MRIs can happen relatively quickly and many patients require another body part to be imaged concurrently anyway. MRI and CT were both 100% sensitive for clinically unstable injuries. In the appropriate patients, MRI remains a safe and radiation-free alternative to CT.

Evaluation and Management of Symptomatic Vasospasm following Endoscopic Endonasal Resection of Pediatric Adamantinomatous Craniopharyngioma.

BACKGROUND: Cerebral vasospasm is a well-described pathology following subarachnoid hemorrhage and trauma in children; however, very few cases have been published following craniopharyngioma resection in children. Those that were published were associated with significant morbidity or mortality at hospital discharge. Case Summary. Here, we report the challenging clinical course of a pediatric patient who developed delayed cerebral vasospasm following craniopharyngioma resection. It was first noted on postoperative day 13. The patient was managed with induced hypertension, hypervolemia, and intra-arterial vasodilator therapy (nicardipine). This patient made a full recovery without new focal deficits at hospital discharge. CONCLUSION: In contrast to previously reported similar pediatric cases, this patient with cerebral vasospasm after craniopharyngioma resection made a full recovery without new focal neurologic deficits. To our knowledge, this is the first occurrence of a patient with this clinical course.

Meet in the middle: a technique for resecting nasocranial dermoids-technical note and review of the literature.

INTRODUCTION: Nasal dermoids with intracranial extension are benign lesions that can have life-threatening consequences, as a nasal punctum may serve as a portal of entry for infection into the central nervous system. The surgical management of these lesions can be challenging, as the extracranial and intracranial cysts and sinus tract must be resected to prevent recurrence, and the surgery must be carried out with an acceptable esthetic result. TECHNIQUE: The authors present a technique for the resection of nasocranial dermoids that eliminates the need to remove and replace the frontonasal segment. Working through a small frontal craniotomy enables the surgeon to drill out the sinus tract through the foramen cecum and inferiorly into the nose. This exposure eliminates the need to enter the frontal sinus, if it is present. CONCLUSION: The extracranial punctum and tract are resected from below in a minimally invasive fashion that permits removal of the lesion without a disfiguring scar.

Treatment-refractory Escherichia coli subdural empyema caused by infection of a chronic subdural hematoma in an infant.

INTRODUCTION: Subdural empyema (SDE) is a neurosurgical emergency that is typically treated with surgical drainage, either by burr hole or by craniotomy. Escherichia coli is an uncommon cause of SDE and is associated with infection of a pre-existing subdural hematoma. CASE REPORT: We report the case of an otherwise healthy, immunocompetent 4-month-old infant girl with an E. coli-infected subdural hematoma. The infection persisted despite aggressive neurosurgical treatment that included drainage of the subdural space through burr holes and, subsequently, a wide craniotomy was performed. Ultimately, after 30 days, the SDE resolved with good neurological outcome. A review of prior literature indicates that infected subdural hematomas (including those caused by E. coli) are typically less aggressive and respond to burr hole drainage. CONCLUSION: We illustrate the fulminant progression of the SDE in the face of neurosurgical treatment. Our experience suggests lowering the threshold for wide craniotomy in these incompletely understood cases.

Diffuse vasospasm after transcortical temporal lobectomy for intractable epilepsy.

Cerebral delayed ischemia due to arterial vasospasm is a rare complication following epilepsy surgery. Here we report the third known case and first of diffuse vasospasm. A 48-year-old woman underwent a transcortical anterior left temporal lobectomy. Eleven days later, she had new-onset expressive aphasia with narrowing of the anterior, middle, and posterior cerebral arteries, and increased velocities via transcranial Doppler. She was treated with fluids, nimodipine, and permissive hypertension. At 6 months, her speech was near baseline. Cerebral vasospasm may represent a rare cause of morbidity after anterior temporal lobectomy; a literature review on the subject is presented.

Middle cerebral artery aneurysm rupture in a neonate with interrupted aortic arch: case report.

INTRODUCTION: Arterial cerebral aneurysms in the neonatal population are rare, and while the association of interrupted aortic arch and intracranial aneurysm has been reported in the adult and pediatric population (three cases each), to date, it has not been reported in the neonate. CASE REPORT: We report the case of a 26-day-old girl who presented with a generalized seizure 2 weeks after undergoing congenital heart surgery. Head CT revealed diffuse SAH with a 1.7 × 2.9-cm frontal intra-parenchymal hematoma with subdural extension producing 3 mm of midline shift. CTA evidenced a 2-mm left MCA bifurcation aneurysm, and the patient was taken to the operating room for clipping. Twenty-four-hour post-operative head CT showed ventriculomegaly and an EVD was placed. It was removed 4 days later without the need for permanent CSF diversion, and after this, her hospital stay was uneventful and she was discharged home. At 25 months of age, she was meeting developmental milestones. At this time, she underwent further heart surgery and expired shortly thereafter due to cardiomyopathy. CONCLUSION: Here, we report the successful treatment of a ruptured neonatal aneurysm, and the first known case associated with interrupted aortic arch. Given the time and presentation, this patient likely illustrates the role of hemodynamic factors in the rupture of neonatal aneurysms. In reviewing all of the reported cases of neonatal aneurysms, promptly securing the aneurysm by either open clipping, parent vessel occlusion, or endovascular coiling is strongly preferable to no surgical intervention.

Iatrogenic Intradiploic Epidermoid Cyst Following Strip Craniectomy for Sagittal Craniosynostosis.

INTRODUCTION: The increased incidence and success of strip craniectomy with postoperative helmet therapy in the treatment of sagittal craniosynostosis has been documented by multiple centers throughout the country and world. The authors report a child with a postoperative implantation intradiploic epidermoid cyst following a strip craniectomy, a complication, that to our knowledge, has not been reported. METHODS: This clinical report involves a 3-year-old boy with a scaphocephalic appearance who was transferred to our center following an interstate adoption. He underwent a strip craniectomy with helmet therapy in infancy. On presentation to our facility the chief complaint was a scaphocephalic appearance. Preop computed tomography scans showed areas of bone gaps along the sagittal suture. RESULTS: The child was brought to the operating room for a mid-vault expansion. At surgery, a large intradiploic epidermoid cyst was noted on the posterior aspect of the area of the sagittal suture, immediately beneath to posterior incision for the strip craniectomy. The cyst extended through the inner table of the skull and necessitated split cranial grafts to aid in the reconstruction. CONCLUSION: The authors present a patient with an iatrogenic intradiploic epidermoid cyst of the posterior skull following strip craniectomy, which has not been previously been described in association with strip craniectomy. This patient underlies the importance of a strong working relationship between craniofacial surgery and neurosurgery.

The maxillary artery and its variants: an anatomical study with neurosurgical applications.

BACKGROUND: The maxillary artery (MA) has gained attention in neurosurgery particularly in cerebral revascularization techniques, intracranial endonasal approaches and endovascular procedures. OBJECTIVES: To describe and illustrate the anatomy of the MA and its neurosurgical importance in a detailed manner. METHODS: Six cadaveric heads (12 MAs) were injected with latex. The arteries and surrounding structures were dissected and studied using microsurgical techniques. The dimensions, course and branching patterns of the MA were recollected. In addition, 20 three-dimensional reconstruction CT head and neck angiograms (3D CTAs) of actual patients were correlated with the cadaveric findings. RESULTS: The MA can be divided in three segments: mandibular, pterygoid and pterygopalatine. Medial and lateral trunk variants regarding its course around the lateral pterygoid muscle can be found. The different branching patterns of the MA have a direct correlation with the course of its main trunk at the base of the skull. Branching and trunk variants on one side do not predict the findings on the contralateral side. CONCLUSION: In this study the highly variable course, branching patterns and relations of the MA are illustrated and described in human cadaveric heads and 3D CTAs. MA 3D CTA with bone reconstruction can be useful preoperatively for the identification of the medial or lateral course variants of this artery, particularly its pterygoid segment, which should be taken into account when considering the MA as a donor vessel for an EC-IC bypass.

Complicaciones clínicas de un electrodo Sprint Fidelis / Clinical complications with the Sprint Fidelis electrode

Se presenta el caso de un paciente que ingresa a nuestro servicio presentando terapias inapropiadas e infección del bolsillo, posterior al implante de un desfibrilador automático implantable con un electrodo Sprint Fidelis 6949 en estado de alerta del fabricante...

A case of a patient who was admitted to our department with inappropriate therapies and infection of the pocket, after implantation of an implantable defibrillator with a Sprint Fidelis 6949 electrode on alert of the manufacturer...

Pharmacologic management of isolated low high-density lipoprotein syndrome.

High-density lipoprotein (HDL) cholesterol is a heterogeneous group of lipoproteins exhibiting a variety of properties like prostacyclin production stimulation, decrease in platelet aggregation, endothelial cell apoptosis inhibition, and low-density lipoprotein oxidation blockade. Epidemiologic studies have shown an inverse relation between HDL cholesterol levels and cardiovascular risk. Low HDL cholesterol is associated with increased risk for myocardial infarction, stroke, sudden death, peripheral artery disease, and postangioplasty restenosis. In contrast, high HDL levels are associated with longevity and protection against atherosclerotic disease development. Given the evolving epidemic of obesity, diabetes mellitus, and metabolic syndrome, the prevalence of low HDL will continue to rise. In the United States, low HDL is present in 35% of men, 15% of women, and approximately 63% of patients with coronary artery disease. Data extracted from the Framingham study highlight that 1-mg increase in HDL levels decreases by 2% to 3% the risk of cardiovascular disease. There is no doubt regarding clinical importance about isolated low HDL, but relatively few clinicians consider a direct therapeutic intervention of this dyslipidemia. In this sense, lifestyle measures should be the first-line strategy to manage low HDL levels. On the other hand, pharmacologic options include niacin, fibrates, and statins. Fibrates appear to reduce risk preferentially in patients with low HDL with metabolic syndrome, whereas statins reduce risk across all levels of HDL. Torcetrapib, a cholesteryl esters transfer protein inhibitor, represented a hope to raise this lipoprotein; however, all clinical trials on this drug had ceased after ILLUMINATE, RADIANCE and ERASE trials had recorded an increase in mortality, rates of myocardial infarction, angina, and heart failure. In the near future, drugs as beta-glucans, Apo-A1 mimetic peptides, and ACAT inhibitors, are the new promises to treat this condition.