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1.
Cureus ; 12(9): e10508, 2020 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-33094049

RESUMO

INTRODUCTION: Traumatic brain injury (TBI) is common, and the frequency of patients taking oral anticoagulants is increasing. However the optimal initial triage, management, and long term care plans of hemorrhagic TBI patients taking oral anticoagulants is not clear. OBJECTIVES: To determine the usage pattern of reversal agents for hemorrhagic TBI patients taking oral anticoagulants, and examine their characteristics and outcomes as compared to hemorrhagic TBI patients not taking these medications. METHODS: This was a single-center, retrospective, observational study. Included were adults with trauma categorization and traumatic intracranial hemorrhage (ICH) between April 1, 2017 and December 31, 2019. Patient age, type of ICH, initial Glasgow Coma Scale (GCS) score, oral anticoagulant prescribed pre-injury, anticoagulation reversal agent given, and hospital discharge disposition were recorded. RESULTS: For the entire sample size (n=111), the mean age and GCS were 71.6 years old and 13.8, respectively. Compared to patients not taking oral anticoagulants, patients taking oral anticoagulants were older (76.7 years old versus 69.1; p<0.01), had similar GCS scores (13.7 versus 13.9; p=0.69), had fewer subarachnoid hemorrhages (18.9% versus 37.8%; p=0.04), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had similar incidence of mortality (13.5% versus 6.7%; p=0.30). A total of 14/37 (37.8%) patients taking oral anticoagulants received reversal agents in the emergency department. Compared to patients taking oral anticoagulants and not given reversal agents, patients taking oral anticoagulants and given reversal agents had similar ages (78.8 years old versus 75.4; p=0.41), had similar GCS scores (12.9 versus 14.1; p=0.17), had similar ICH types (all p=1.0), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had higher incidence of mortality (28.6% versus 4.2%; p=0.05). CONCLUSIONS: This limited data set did not show improved outcomes by giving reversal agents to hemorrhagic TBI patients taking oral anticoagulants. However, until more robust data is available, judicious use of reversal agents in this high-risk patient population should remain common practice.

2.
Cureus ; 12(4): e7779, 2020 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-32455085

RESUMO

Ventriculoperitoneal shunt catheter migration is a rare but documented complication. The exact mechanism of this occurrence is not well understood. We report the case of an 81-year-old male who initially presented with symptoms consistent with normal pressure hydrocephalus. A ventriculoperitoneal shunt was placed uneventfully. Four months later, the patient presented complaining of a persistent headache despite multiple adjustments in the shunt setting. Shunt series radiographs demonstrated the distal catheter passing through the superior vena cava and looping into the right cardiac atrium and ventricle. Catheter retrieval was attempted from a proximal retroauricular incision but required a combination of snare technique by interventional radiology and, ultimately, surgical venotomy by a cardiothoracic surgeon. The distal catheter was replaced in the abdomen, and the patient had no further complications. This case is the first of its kind reported in the literature that includes a treatment team comprising neurosurgery, interventional radiology, and cardiothoracic surgery. We highlight the importance of a multidisciplinary approach to best address the migrated catheter.

3.
Cureus ; 12(3): e7388, 2020 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-32337115

RESUMO

Introduction Penetrating head injuries (PHIs) can have diverse presentations and mechanisms; therefore, treatment methods have not been clearly outlined. Vascular injury is common and foreign body removal is often required. We present three cases to illustrate low-velocity nonmissile penetrating head injuries (NPHIs) and discuss a multidisciplinary approach. Methods We present a case series from our institution that illustrates the importance of multidisciplinary treatment of these injuries. All injuries are low- velocity NPHIs with separate mechanisms and anatomical locations. Results Multidisciplinary management involving neurosurgery, otolaryngology, and neuroendovascular surgery is represented in our case series with all patients having good clinical outcomes. Our first case is a 34-year-old male who presented neurologically intact after a stabbing in the left temporal region with concerns for external carotid artery injury and maxillary sinus injury. Our second case is a 37-year-old male who presented with a self-inflicted nail gun injury that penetrated the right temporal bone, right temporal lobe, bilateral sphenoid sinus, and left petrous carotid canal with concerns of petrous internal carotid injury. Our third case is a 31-year-old male who presented after an accidental nail gun injury that penetrated through the oral cavity, hard palate, and left sphenoid sinus and ending in the left cavernous sinus with concerns of cavernous internal carotid injury. Conclusion  Careful consideration must be taken when evaluating low-velocity NPHIs. Particular attention must be given when an associated vascular injury is suspected. Our case series highlights the importance of a multidisciplinary approach in achieving good clinical outcomes in PHIs.

4.
World Neurosurg ; 139: 175-178, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32311568

RESUMO

BACKGROUND: Guillain-Barré syndrome (GBS) is a rare but well-documented cause of paralysis, often occurring after infection. Few cases have been reported in association with spinal cord injury (SCI), which masks the characteristic ascending paralysis. To our knowledge, this is the first reported case of confirmed GBS during the clinical course of thoracic paraplegia due to a gunshot wound (GSW). CASE DESCRIPTION: A 23-year-old male presented with a GSW to the right axilla that lodged in the spinal canal at the level of T4, causing right hemothorax and American Spinal Injury Association A paraplegia. He had full strength in bilateral upper extremities until 2 weeks after the injury, at which time he developed progressive weakness in the arms with associated paresthesias and dyspnea. Within 5 days, he was intubated and nearly quadriplegic. Cerebrospinal fluid analysis and electromyography led to a diagnosis of GBS. He was treated with plasmapheresis and experienced rapid and marked recovery in respiratory and upper extremity motor function. CONCLUSIONS: The differential diagnosis for new-onset weakness in patients with GSW-induced SCI is complicated by the inability to obtain magnetic resonance imaging. This unique case of GBS in a patient with T4 paraplegia highlights the importance of obtaining a thorough history and using diagnostic tools to explore possibilities beyond surgery.


Assuntos
Síndrome de Guillain-Barré/complicações , Paraplegia/etiologia , Traumatismos da Medula Espinal/complicações , Vértebras Torácicas/lesões , Ferimentos por Arma de Fogo/complicações , Eletromiografia , Síndrome de Guillain-Barré/líquido cefalorraquidiano , Síndrome de Guillain-Barré/diagnóstico , Síndrome de Guillain-Barré/terapia , Humanos , Masculino , Plasmaferese , Canal Vertebral , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/etiologia , Tomografia Computadorizada por Raios X , Adulto Jovem
5.
Cureus ; 12(2): e6914, 2020 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-32190469

RESUMO

Butterfly glioblastoma (bGBM) is a malignant glioma that crosses the corpus callous with bilateral cerebral hemisphere involvement. Literature reports are scarce and highlight a dismal prognosis with limited successful treatment options. We describe a patient who survived more than five years from the initial diagnosis. A 44-year-old woman presented to the emergency room for evaluation one day after a motor vehicle collision at the insistence of her husband, with four weeks of confusion, behavioral changes, and increased fatigue. Magnetic resonance imaging (MRI) of the brain revealed an enhancing, heterogeneous mass with significant necrosis, centered in the septum pellucidum and corpus callosum with intraventricular extension. She underwent a stereotactic biopsy of the lesion. Pathology was consistent with glioblastoma, WHO grade IV. She underwent standard radiation treatment and adjuvant temozolomide, demonstrating a near-complete disappearance of the tumor on imaging for the subsequent two years. Upon recurrence, she underwent additional chemotherapy with limited response. A repeat biopsy was positive for a BRAF mutation and she was treated with lomustine. After two cycles, she developed thrombocytopenia and shortly after elected to discontinue treatment. She succumbed to the progression of disease five years and two months after the initial presentation. bGBMs are uncommon and highly aggressive brain tumors. A tailored treatment protocol may improve survival. This case marks an unusually long survival of a patient with bGBM and may prompt further research to better understand the behavior of these tumors and how to improve treatment response and survival.

6.
World Neurosurg ; 138: 253-256, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32194265

RESUMO

BACKGROUND: Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax. CASE DESCRIPTION: An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects. CONCLUSIONS: Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.


Assuntos
Pneumocefalia/etiologia , Pneumocefalia/cirurgia , Membrana Timpânica/lesões , Idoso de 80 Anos ou mais , Dispositivos para o Cuidado Bucal Domiciliar , Feminino , Humanos , Pneumocefalia/diagnóstico por imagem
7.
Cureus ; 12(1): e6713, 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-32104636

RESUMO

Blast injuries to the face frequently involve vascular injury and have been reported in association with vehicles, including compressed air hoses and car battery explosions. While related to high-pressure releases, we present the first case of a car tire inflation resulting in tire explosion causing uncontrollable orbital hemorrhage, ocular damage, and the first case of endovascular intervention resulting in resolution of hemorrhage. A 63-year-old male presented after a tire explosion with evisceration of the right eye and uncontrollable hemorrhage from the orbit. CT demonstrated multiple maxillofacial fractures. Due to persistent hemorrhage, he was taken for emergent endovascular evaluation. On the angiogram, there was noted to be active extravasation from the right meningo-ophthalmic artery. Onyx® embolization of the right meningo-ophthalmic artery was performed with no further hemorrhage. Due to the severity of the injury, ophthalmology was unable to preserve vision in the eye. Arterial hemorrhages are traditionally managed with surgical exploration. However, endovascular management may be of particular utility in vascular injuries to the head and neck region. We highlight the importance of endovascular intervention to treat uncontrollable hemorrhage from orbit.

8.
World Neurosurg ; 136: 12-16, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31917311

RESUMO

BACKGROUND: Spinal cord herniation in the cervical spine is an exceptionally rare occurrence. It is most often cited in association with surgery and almost exclusively with a posterior approach. Herniation with an anterior approach has been reported in 3 cases after multilevel corpectomy, all of which involved herniation through a dural defect sustained during surgery. CASE DESCRIPTION: A 49-year-old man presented to the emergency room with generalized fatigue. He had a previous anterior C5 corpectomy and posterior cervical fusion from C2-T4 performed 17 years prior for a cervical kyphotic deformity that developed after a laminectomy. Magnetic resonance imaging of the cervical spine demonstrated a significant ventral cord herniation into the C5 ventral corpectomy site. The patient underwent a C4-6 vertebral corpectomy with C3-7 anterior reconstruction, fusion, and instrumentation with successful reduction and anatomic realignment of the spinal cord herniation. CONCLUSIONS: We present a case of cervical cord herniation that occurred into the ventral corpectomy site without obvious dural defect. We hypothesize that cerebral spinal pulsations over time degraded the corpectomy site and ultimately promoted herniation of the spinal cord. Here, we discuss the successful surgical management of this unique pathology and discuss a relevant review of the literature.


Assuntos
Vértebras Cervicais/cirurgia , Dura-Máter , Hérnia Ventral/etiologia , Doenças da Medula Espinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia
9.
Clin Case Rep ; 7(4): 821-825, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30997093

RESUMO

Our patient's clinical history and preoperative radiographic evaluation suggested central nervous system (CNS) metastatic disease. Ultimately, final pathology revealed epithelioid glioblastoma (eGBM), a newly classified CNS primary tumor. This reinforces the importance of direct tissue sampling and including eGBM on the differential for young patients with histories of systemic cancer presenting with new CNS lesions.

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