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1.
Oper Neurosurg (Hagerstown) ; 20(3): 310-316, 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33372226

RESUMO

BACKGROUND: Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time. OBJECTIVE: To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study. METHODS: We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018. RESULTS: The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3). CONCLUSION: Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

2.
World Neurosurg ; 2020 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-33065350

RESUMO

OBJECTIVE: To determine the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on operative case volume in 8 U.S. neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period. METHODS: A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January through April 2020. Cases were grouped as elective cranial, elective spine, and nonelective emergent cases. Programs were surveyed regarding residents' perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data were analyzed for individual programs and pooled across programs. RESULTS: Across programs, the 2019 monthly mean ± SD case volume was 211 ± 82; 2020 mean ± SD case volumes for January, February, March, and April were 228 ± 93, 214 ± 84, 180 ± 73, and 107 ± 45. Compared with 2019, March and April 2020 mean cases declined 15% (P = 0.003) and 49% (P = 0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents required COVID-19 testing; however, to our knowledge, only 1 resident from the participating programs tested positive. CONCLUSIONS: This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the COVID-19 pandemic on residents' operative case volumes, identify deficiencies, and develop plans to mitigate any effects.

3.
Interdiscip Neurosurg ; 22: 100878, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32837915

RESUMO

COVID-19 patients are increasingly understood to develop multisystem manifestations, including neurologic involvement. We report the case of a 42-year old COVID-19 positive patient with a fatal intracerebral hemorrhage (ICH). The patient presented with fever and dyspnea, requiring intubation due to medical complications. After prolonged sedation and anticoagulation, the patient suddenly developed bilaterally fixed and dilated pupils, caused by a right-sided intracranial hemorrhage with uncal herniation. The course of this case illustrates the delicate balance between hypercoagulability and coagulation factor depletion; especially in the intubated and sedated patient, in whom regular neurological assessments are impeded. As we expand our understanding of the neurological ramifications of COVID-19, clinicians need to be increasingly aware of the precarious coagulation balance.

4.
Neurocrit Care ; 32(2): 400-406, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31556001

RESUMO

OBJECTIVE: The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous catheters (CVC) in the neuroscience intensive care unit (NSICU). METHODS: This study was carried out in a 32-bed NSICU in a large academic hospital in the USA from July 2015 until January 2017. Patients admitted requiring central venous access were randomly assigned to have a PICC or CVC inserted. Complications were recorded and compared. The primary outcome was all complications as well as combined numbers of large vein thrombosis, central-line-associated blood stream infections, and insertional trauma. Outcomes were compared using the Fisher's exact test, logistic regression, or unpaired T tests, as appropriate. RESULTS: One hundred and fifty-two patients were enrolled; 72 were randomized to the PICC arm and 80 to the CVC arm. There were no crossovers, withdrawals, nor losses to follow-up. The study was stopped at the second pre-planned interim analysis for futility. The combined number of large vein thrombosis, central-line-associated blood stream infection, and insertional trauma was 4/72 in the PICC arm and 1/80 in the CVC group (OR 4.6 (95% CI 0.5-42.6) p = 0.14). The number of all complications in the PICC arm was 14/72 compared to 10/80 in the CVC arm (OR 1.7 (95% CI 0.7-4.1) p = 0.24). CONCLUSIONS: PICCs and CVCs have similar numbers of complications when placed in patients admitted to the NSICU.

5.
Childs Nerv Syst ; 34(11): 2187-2194, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30187183

RESUMO

INTRODUCTION: Case reports, case series, and case control studies have looked at the incidence of complete nerve transection in the setting of fracture and the need for surgical exploration dating back to the 1920s. We present two cases of nerve laceration accompanying traumatic fracture with a thorough review of the literature. METHODS: We used the following search terms: "ulnar nerve" OR "sciatic nerve" AND "laceration" OR "transection" AND "fracture." Results were reviewed and included for discussion if they specifically reported ulnar or sciatic nerve laceration accompanying traumatic fracture. RESULTS: Our search yielded 15 papers reporting a total of 10 ulnar nerve lacerations and nine sciatic nerve lacerations. We present two additional cases. The first is a patient with a humerus fracture and complete ulnar nerve transection. The second case is a patient who suffered a femur fracture and complete transection of the sciatic nerve. CONCLUSION: Nerve laceration accompanying traumatic fracture is rare. We review the reported cases of nerve laceration and present two cases treated at our institution. Though uncommon, nerve laceration should be considered in the setting of traumatic fracture with neurological injury, particularly open fractures.


Assuntos
Fraturas do Fêmur/complicações , Fraturas do Úmero/complicações , Nervo Isquiático/lesões , Nervo Ulnar/lesões , Adolescente , Criança , Feminino , Humanos , Masculino
6.
World Neurosurg ; 115: e53-e58, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29621608

RESUMO

BACKGROUND: Numerous studies have examined the impact of initiating an external ventricular drain (EVD) placement and handling protocol on the infection rate dating back to the early 2000s. METHODS: We report a quantitative systematic review of the published literature, described our own protocol (including a mandatory checklist), and present our single institution experience. Search terms "external ventricular drain protocol" or "external ventricular drain placement protocol" or "preventing infections in external ventricular drains" or "external ventricular drain infections" were entered into standard search engines in a systematic fashion. Articles were reviewed and graded independently for class of evidence. There were 10 relevant class IV articles and no discrepancies among article ratings (i.e., κ = 1). The published evidence was reviewed and evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: Our meta-analysis revealed a statistically significant drop in rates of EVD infection after initiation of the protocol, although the overall quality of the body of evidence according to the GRADE criteria was "very poor". Preimplementation and postimplementation infection rates were collected and analyzed in combination with the results from our literature review. The EVD infection rate in our institution was 12% in the 8 months before protocol initiation (January 2015 to August 2015), and dropped to 0% in the 7 months after initiation. CONCLUSIONS: Although the quality of the literature supporting EVD placement protocols is poor, all published studies show a consistent and substantial benefit, and this effect was recapitulated in our own meta-analysis-based prospective EVD protocol experience.


Assuntos
Cateteres de Demora/tendências , Infecção Hospitalar/prevenção & controle , Drenagem/tendências , Contaminação de Equipamentos/prevenção & controle , Ventriculostomia/tendências , Cateteres de Demora/efeitos adversos , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/etiologia , Drenagem/efeitos adversos , Humanos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ventriculostomia/efeitos adversos
7.
Surg Clin North Am ; 97(6): 1237-1253, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29132507

RESUMO

Traumatic brain injury remains a serious public health problem, causing death and disability for millions. In order to maximize outcomes in the face of a complex injury to a complex organ, a variety of advanced neuromonitoring techniques may be used to guide surgical and medical decision-making. Because of the heterogeneity of injury types and the plethora of treatment confounders present in this patient population, the scientific study of specific interventions is challenging. This challenge highlights the need for a firm understanding of the anatomy and pathophysiology of brain injuries when making clinical decisions in the intensive care unit.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Adolescente , Corticosteroides/uso terapêutico , Adulto , Lesões Encefálicas Traumáticas/diagnóstico , Infecções Bacterianas do Sistema Nervoso Central/prevenção & controle , Criança , Pré-Escolar , Cuidados Críticos/métodos , Descompressão Cirúrgica/métodos , Diuréticos Osmóticos/uso terapêutico , Escala de Coma de Glasgow , Humanos , Lactente , Pessoa de Meia-Idade , Neuroimagem/métodos , Exame Neurológico/métodos , Exame Físico/métodos , Convulsões/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Adulto Jovem
8.
Cureus ; 8(11): e857, 2016 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-27917325

RESUMO

We report the case of a 41-year-old female with neurofibromatosis Type 1 (NF1) who developed a rosette-forming glioneuronal tumor (RGNT) in the tectal plate. This tumor was diagnosed in 2002 when the patient presented with obstructive hydrocephalus, which was subsequently treated with a ventriculoperitoneal shunt and then an endoscopic third ventriculostomy. Initially thought to be a pilocytic astrocytoma, it was followed with serial magnetic resonance imaging (MRI) until tumor progression and development of a large fourth ventricular cystic component prompted resection via suboccipital craniotomy. Histological examination demonstrated an RGNT, a WHO Grade 1 tumor, with neurocytic rosettes, perivascular pseudorosettes, and elements resembling a pilocytic astrocytoma. Initially, the patient did well after her craniotomy, but postoperative complications set in that eventually led to her death. In this case report, we describe a relatively rare tumor that, despite its benign nature, leads to frequent complications and deficits due to its surgically challenging location. Along with previously reported examples, this cases raises the possibility of a causal relationship between NF1 and RGNT.

9.
Cureus ; 8(11): e876, 2016 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-28003940

RESUMO

Undifferentiated pleomorphic sarcoma is a histologic diagnosis based on cell morphology. These tumors are found throughout the body. They are rarely found in the central nervous system and almost never occur as a primary intraventricular tumor. We present the unusual case of a 68-year-old woman with an intraventricular undifferentiated pleomorphic sarcoma. We go on to discuss the clinical presentation, radiographic characteristics, and management paradigm for these rare lesions. Our patient presented with acute confusion, inability to balance a checkbook, and gait imbalance. CT and MRI demonstrated a 4 x 3.6 x 3.6 cm enhancing lesion in the left lateral ventricle abutting the foramen of Monro. Pathology revealed an undifferentiated pleomorphic sarcoma.

10.
Cureus ; 8(10): e833, 2016 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-27904815

RESUMO

Obtaining intravascular access in the neonatal intensive care unit (NICU) is not only critical but also technically challenging. Malposition of the catheter tip is a known and well-documented complication. Specifically, peripherally inserted central venous catheter (PICC) line insertion into the ascending lumbar vein can lead to neurological dysfunction and, in some cases, even death. We present the first reported case of pneumorrhachis (PR) following PICC line insertion into the ascending lumbar vein. Our patient presented with lower extremity weakness and imaging confirmed the presence of air within the spinal canal. After conservative treatment, the strength deficit resolved and subsequent imaging revealed resolution of the air within the spinal canal. Insertion of central venous catheters into the ascending lumbar vein is a well-documented complication that can lead to neurologic injury and even death. This should be considered in the evaluation of any neonate presenting with an abnormal neurological examination or unexplained change in exam after line insertion.

11.
Cureus ; 8(10): e838, 2016 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-27900232

RESUMO

Pituitary macroadenomas are the most common suprasellar lesions in adults and are typically managed surgically through transsphenoidal resection when symptomatic. Due to their close proximity to the optic chiasm, pituitary macroadenomas often present with signs of bitemporal hemianopsia. Alternatively, these tumors can cause mass effect, thus presenting with signs of elevated intracranial pressure or can present with signs and symptoms of endocrine dysfunction. Here, we discuss a 55-year-old male diagnosed with a non-functioning pituitary macroadenoma (NFPA) based on cranial imaging, ophthalmologic exam, and endocrine evaluation. Following diagnosis, the patient was scheduled for transsphenoidal hypophysectomy. On magnetic resonance imaging (MRI) done three and half months later for surgical planning, the tumor had almost completely regressed and only residual pituitary tissue was noted. We describe the presentation and clinical course of the patient, summarize chief differential diagnoses, and discuss potential managements of these conditions.

12.
Childs Nerv Syst ; 32(6): 1033-8, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27083568

RESUMO

INTRODUCTION: Case reports, case series and case control studies have looked at the use of phrenic nerve stimulators in the setting of high spinal cord injuries and central hypoventilation syndromes dating back to the 1980s. We evaluated the evidence related to this topic by performing a systematic review of the published literature. METHODS: Search terms "phrenic nerve stimulation," "phrenic nerve and spinal cord injury," and "phrenic nerve and central hypoventilation" were entered into standard search engines in a systematic fashion. Articles were reviewed by two study authors and graded independently for class of evidence according to published guidelines. The published evidence was reviewed, and the overall body of evidence was evaluated using the grading of recommendations, assesment, development and evaluations (GRADE) criteria Balshem et al. (J Clin Epidemiol 64:401-406, 2011). RESULTS: Our initial search yielded 420 articles. There were no class I, II, or III studies. There were 18 relevant class IV articles. There were no discrepancies among article ratings (i.e., kappa = 1). A meta-analysis could not be performed due to the low quality of the available evidence. The overall quality of the body of evidence was evaluated using GRADE criteria and fell within the "very poor" category. CONCLUSION: The quality of the published literature for phrenic nerve stimulation is poor. Our review of the literature suggests that phrenic nerve stimulation is a safe and effective option for decreasing ventilator dependence in high spinal cord injuries and central hypoventilation; however, we are left with critical questions that provide crucial directions for future studies.


Assuntos
Terapia por Estimulação Elétrica/métodos , Hipoventilação/terapia , Nervo Frênico/fisiologia , Traumatismos da Medula Espinal/terapia , Vértebras Cervicais , Bases de Dados Bibliográficas/estatística & dados numéricos , Humanos
13.
Cureus ; 8(2): e498, 2016 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-27014532

RESUMO

BACKGROUND: Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD. METHODS: Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria. RESULTS: Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was "very low." CONCLUSIONS: The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

15.
Spinal Cord Ser Cases ; 2: 16013, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28053757

RESUMO

Autonomic dysreflexia (AD) following spinal cord injury can lead to a physiologic state where there is unopposed sympathetic tone and subsequent hypertension, bradycardia, hyperhidrosis and anxiety. It is known to be triggered by nociceptive stimuli below the level of injury-most commonly constipation and bladder retention. We present a case of a C6-7 tetraplegic who developed AD 20 years after his injury with the unusual trigger of positional spinal instability due to osteomyelitis and discitis. The patient's clinical course began when he was diagnosed with L2-3 and L3-4 osteomyelitis, discitis and myositis of the bilateral paraspinous muscles. The infection did not respond well to an attempted course of medical management and degenerated into an unstable spinal segment. This instability in the vertebral column led to positional AD with symptom onset in extension (lying supine) and relieved with flexion (patient sitting up and bending forward). Once the trigger for his AD was determined, he was successfully treated with spinal fusion to stabilize the mobile segment and further antibiotic treatment. He had complete resolution of his AD after surgery and eradication of his infection.

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