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Open access

Posterior communicating artery injury and symptomatic vasospasm after high-energy blunt head injury: illustrative case

Nidal B. Omar, Gustavo Chagoya, Dario Marotta, Galal Elsayed, and Mark R. Harrigan

BACKGROUND

Most of the published literature pertaining to blunt traumatic cerebrovascular injury (BCVI) is focused on extracranial arterial injury. Studies of intracranial arterial injury are relatively uncommon.

OBSERVATIONS

The clinical course of a patient who sustained an injury to the right posterior communicating artery followed by infarction due to vasospasm after severe traumatic brain injury is presented, along with a focused literature review.

LESSONS

Intracranial BCVI is uncommon, and this report may serve to raise awareness of BCVI management and the importance of recognizing symptomatic vasospasm due to BCVI.

Open access

Lead toxicity due to retained intracranial bullet fragments: illustrative case

Daniel M. Aaronson, Ahmed J. Awad, and Hirad S. Hedayat

BACKGROUND

Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors’ knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments.

OBSERVATIONS

The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms.

LESSONS

Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Open access

Transorbital penetrating head injury with a favorable outcome: illustrative case

Laura-Nanna Lohkamp, Stephanie Holowka, Elysa Widjaja, Arbelle Manicat-Emo, and James T. Rutka

BACKGROUND

Transorbital penetrating head injuries (PHIs) are uncommon but can lead to substantial deficits, depending on intracranial involvement and the neuroanatomical structures affected. Complete recovery after such injuries is rare.

OBSERVATIONS

A 7-year-old boy sustained a PHI when he fell onto a garden spike while climbing a fence. Initial imaging showed an orbital roof fracture, focal subarachnoid hemorrhage, and an intraparenchymal hemorrhage in the right frontal lobe with associated linear tract extending to the contralateral superior temporal gyrus. Relevant neuroanatomical structures, including the anterior cerebral arteries (ACAs) and the basal ganglia, were spared. This is in keeping with superior transorbital PHI caused by a garden spike, which had transgressed the skull entering from the right superior orbit. Clinically, he experienced some transient right-sided weakness and mild speech disturbance. Some questionable vasospasm of the ACAs observed on interim magnetic resonance imaging was absent in a repeat imaging study, followed by an unremarkable radiographic follow-up at 6 months after injury. At 18 months after injury, he is neurologically intact without deficit.

LESSONS

Most PHIs bear serious lifelong consequences, but here was a case of a deep, penetrating object that managed to avoid all significant neuroanatomical pathways, leading to complete recovery in follow-up.

Open access

Cerebrospinal fluid fistula as a complication of reverse transcriptase–polymerase chain reaction collection for the detection of coronavirus disease 2019: illustrative cases

Lucca B. Palavani, Camila V. F. Andrade, Renato A. Andrade, Egmond Alves, Marcio Falchi Barros, and João F. Barbieri

BACKGROUND

The most used method to detect coronavirus disease 2019 during the pandemic is reverse transcriptase–polymerase chain reaction with nasal swab. Despite being highly effective, the test does not leave the patient risk-free and can lead to serious complications. These can be traumatic nasal cerebrospinal fluid (CSF) fistula and its consequences, such as meningitis.

OBSERVATIONS

In this article, the authors present 4 case reports and a literature review. The following MeSH terms in the research were used: “CSF leak case report and covid 19.” Six results were found and after searching the references and keywords 16 articles were identified. By using them, the authors tried to clarify the etiology of the fistula, its influences, and complications.

LESSONS

The authors conclude that professionals must receive training, since CSF fistula originates from technical failure and lack of anatomical knowledge. The diagnosis cannot be neglected because it can bring complications to the patient’s health.

Open access

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Maxwell Gruber, Nate Klingele, Christy Monson, and Eric A. Sribnick

BACKGROUND

After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home.

OBSERVATIONS

Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection.

LESSONS

In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

Open access

Ocular needlefish injury with cavernous sinus thrombosis and carotid-cavernous fistula: illustrative case

Anahita Malvea, Armaan K. Malhotra, Ann Schmitz, Whitney Parker, Leeor Yefet, Prakash Muthusami, James T. Rutka, and Peter Dirks

BACKGROUND

The Belonidae family of fish has been implicated in various penetrating injuries; to date, however, there have been limited reports of brain injury due to this species.

OBSERVATIONS

The authors present the case of a young patient who suffered an ocular penetrating injury from a needlefish with a resultant cavernous sinus thrombosis and concomitant carotid-cavernous fistula. This case highlights the interdisciplinary management of this rare condition through a strategy of anticoagulation titration to the endpoint of fistula closure.

LESSONS

Through this report the importance of a high index of suspicion for neurovascular injury and fistula formation in penetrating ocular injuries is highlighted as well as the importance of interdisciplinary management of patients with such injuries and their sequelae.

Open access

Severe hyperglycorrhachia and status epilepticus after endoscopic aqueductoplasty: illustrative case

Anand A. Dharia, Ahmad Masri, Jay F. Rilinger, and Christian B. Kaufman

BACKGROUND

While hypoglycorrhachia is observed and managed frequently, there are few reports in the literature of clinically significant hyperglycorrhachia after neurosurgery. Understanding the effects and management of severe hyperglycorrhachia is important to the neurosurgeon and neurocritical care teams who care for patients in these rare scenarios.

OBSERVATIONS

The authors present the case of a 3-month-old male with congenital hydrocephalus who faced profound hyperglycorrhachia and status epilepticus after an endoscopic aqueductoplasty using an irrigant composed of lactated Ringer’s solution with dextrose 5% in water. A multidisciplinary approach was developed to monitor and treat the patient’s seizures and cerebrospinal fluid (CSF) osmolytes.

LESSONS

This case provides several learning opportunities for understanding CSF physiology, pathogenesis of common brain injuries related to osmotic shifts and inflammatory states, as well as clinical management of hyperglycorrhachia. It also reiterates the significance of meticulous intraoperative assessment to avoid preventable medical errors.

Open access

Delayed presentation of traumatic supra- and infratentorial extradural hematoma: illustrative case

Sami Pathak, Danielle McAuliffe, Robert Ziechmann, Rohan Gupta, and Philip Villanueva

BACKGROUND

Supra- and infratentorial epidural hematomas (SIEDHs) are a rare subtype of epidural hematoma (EDH), showing expanding bleeding on both sides of the tentorium, and account for <2% of EDHs (Aji, Apriawan, and Bajamal, 2018). These lesions can typically expand and decompensate quickly, making immediate diagnosis and surgical intervention crucial.

OBSERVATIONS

The authors’ patient presented >48 hours from a blunt trauma to the right side of the head with progressive vomiting and bruising behind the right ear. He had a Glasgow Coma Scale score of 15 on arrival. Head computed tomography showed an SIEDH measuring approximately 3 cm, and, given the hematoma’s size and mass effect, the patient was taken emergently to the operating room for decompression, where the source of bleeding was noted to be an emissary vein from the transverse sinus. The linear parietooccipital fracture was mended with mesh cranioplasty. Patient imaging and follow-up showed an excellent recovery.

LESSONS

Although SIEDH is rare, patients can present in a delayed fashion and be neurologically intact. The threshold to obtain imaging to rule out delayed hemorrhage should be low in any patient with a history of trauma in the region of a dural venous sinus.

Open access

Can we build better? Challenges with geospatial and financial accessibility in the Caribbean. Illustrative case

Ellianne J dos Santos Rubio, Chrystal Calderon, Annegien Boeykens, and Kee B Park

BACKGROUND

Within the Caribbean, Curaçao provides a neurosurgical hub to other Dutch Caribbean islands. At times, the inefficiency of neurosurgical referrals leads to unsatisfactory patient outcomes in true emergency cases.

OBSERVATIONS

This article reports an illustrative case of a patient in need of emergency neurosurgical care, who was referred to a tertiary health institution in Curaçao. This case highlights the challenges of timely neurosurgical referrals within the Dutch Caribbean.

LESSONS

Highlighting this case may provide a foundation for further discussions that may improve neurosurgical care and access. Limiting long-distance surgical referrals in the acute care setting will aid in saving lives.

Open access

Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases

Evan Courville, Joshua Marquez, Michael Homma, Michael Conley, Georgios P Skandalakis, Peter Shin, James Botros, and Christian Ricks

BACKGROUND

This report describes the use of a novel approach to address acute sinking skin flap syndrome (SSFS), a postcraniectomy complication arising from brain dysfunction beneath the skull defect. The authors present a case series of two patients, emphasizing the prospective application of an external plaster cast in tandem with a vacuum-assisted closure (VAC) device (wound VAC) to promptly reposition the scalp and relieve brain compression.

OBSERVATIONS

Following intervention, one patient showed immediate neurological improvement, with complete resolution of symptoms within hours. Conversely, the second patient developed nonconvulsive status epilepticus. Computed tomography scans postintervention validated the successful scalp repositioning and mass effect resolution in both instances. This temporary approach proved successful in one patient with moderate symptoms, serving as a bridge to cranioplasty.

LESSONS

The integration of an external plaster cast and wound VAC offers a cost-effective and prompt solution for patients with acute SSFS pending cranioplasty. Appropriate patient selection and heightened caution for those with severe symptoms should be exercised.