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Open access

Continuous direct intraarterial treatment of meningitis-induced vasospasm in a pediatric patient: illustrative case

Aubrey C Rogers, Aditya D Goyal, and Alexandra R Paul

BACKGROUND

Bacterial meningitis–induced ischemic stroke continues to cause significant long-term complications in pediatric patients. The authors present a case of severe right internal carotid artery terminus and M1 segment vasospasm in a 9-year-old with an infected cholesteatoma, which was refractory to multiple intraarterial treatments with verapamil and milrinone. This is the first report of continuous intraarterial antispasmodic treatment in a pediatric patient as well as the first report of continuous treatment in an awake and extubated patient.

OBSERVATIONS

Arterial narrowing was successfully treated by continuous direct intraarterial administration of both a calcium channel blocker (verapamil) and a phosphodiesterase-3 inhibitor (milrinone). The patient recovered remarkably well and was discharged home with no neurological deficit (National Institutes of Health Stroke Scale score 0) and ambulatory without assistance after 22 days. The authors report a promising outcome of this technique performed in a pediatric patient.

LESSONS

This represents a novel treatment option for the prevention of stroke in pediatric bacterial meningitis. Continuous, direct intraarterial administration of antispasmodic medications can successfully prevent long-term neurological deficit in pediatric meningitis-associated vasospasm. The described method has the potential to significantly improve outcomes in severe pediatric meningitis-associated vasospasm.

Open access

Coronavirus disease 2019–associated persistent cough and Chiari malformation type I resulting in acute respiratory failure: illustrative case

Anthony J Piscopo, Nahom Teferi, Anthony Marincovich, Meron Challa, and Brian J Dlouhy

BACKGROUND

Chiari malformation type I (CM-I) is the herniation of cerebellar tonsils through the foramen magnum, potentially resulting in the obstruction of cerebrospinal fluid flow and brainstem compression. Sleep-disordered breathing (SDB) is common in patients with CM-I, and symptomatic exacerbations have been described after Valsalva-inducing stressors. Acute decompensation in the setting of coronavirus disease 2019 (COVID-19) has not been described.

OBSERVATIONS

After violent coughing episodes associated with COVID-19 infection, a 44-year-old female developed several months of Valsalva-induced occipital headaches, episodic bulbar symptoms, and worsening SDB, which led to acute respiratory failure requiring mechanical ventilation. Imaging demonstrated 12 mm of cerebellar tonsillar descent below the foramen magnum, dorsal brainstem compression, and syringobulbia within the dorsal medulla. She underwent posterior fossa and intradural decompression with near-complete resolution of her symptoms 6 months postoperatively.

LESSONS

Although CM-I can remain asymptomatic, Valsalva-inducing stressors, including COVID-19 infection, can initiate or acutely exacerbate symptoms, placing patients at risk for CM-I–associated brainstem dysfunction and, in rare cases, acute respiratory failure. Worsening Valsalva maneuvers can contribute to further cerebellar tonsil impaction, brainstem compression, syringomyelia/syringobulbia, and worsening CM-I intradural pathology. Ventilator support and timely decompressive surgery are paramount, as brainstem compression can reduce central respiratory drive, placing patients at risk for coma, neurological deficits, and/or death.

Open access

Magnetic resonance imaging–derived relative cerebral blood volume characteristics in a case of pathologically confirmed neurocysticercosis: illustrative case

Nada E Botros, David Polinger-Hyman, Ryan T Beck, Christopher Kleefisch, E. Kelly S Mrachek, Jennifer Connelly, Kathleen M Schmainda, and Max O Krucoff

BACKGROUND

Neurocysticercosis (NCC) is a parasitic infection of the brain caused by ingesting water or food contaminated with tapeworm eggs. When it presents as a solitary mass, differentiation from a primary brain tumor on imaging can be difficult. Magnetic resonance imaging (MRI)-derived relative cerebral blood volume (rCBV) is a newer imaging technique used to identify areas of neovascularization in tumors, which may advance the differential diagnosis.

OBSERVATIONS

A 25-year-old male presented after a seizure. Computed tomography (CT) and MRI demonstrated a partially enhancing lesion with microcalcifications and vasogenic edema. Follow-up rCBV assessment demonstrated mild hyperperfusion and/or small vessels at the lesional margins consistent with either an intermediate grade glioma or infection. Given the radiological equipoise, surgical accessibility, and differential diagnosis including primary neoplasm, metastatic disease, NCC, and abscess, resection was pursued. The calcified mass was excised en bloc and was confirmed as larval-stage NCC.

LESSONS

CT or MRI may not always provide sufficient information to distinguish NCC from brain tumors. Although reports have suggested that rCBV may aid in identifying NCC, here the authors describe a case of pathologically confirmed NCC in which preoperative, qualitative, standardized rCBV findings raised concern for a primary neoplasm. This case documents the first standardized rCBV values reported in a pathologically confirmed case of NCC in the United States.

Open access

Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case

Vincent Hagel, Felix Dymel, Stephan Werle, Vera Barrera, and Mazda Farshad

BACKGROUND

Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches.

OBSERVATIONS

The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage.

LESSONS

The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

Open access

Abnormal magnetic resonance imaging signal in the burr hole and the identification of the intracranial infection of a deep brain stimulation device: illustrative case

Ryota Sasaki, Hidehiro Hirabayashi, and Ichiro Nakagawa

BACKGROUND

Device infection is a critical postoperative complication in deep brain stimulation (DBS). However, intracranial infections are rare and lack specific findings, which lead to a challenging diagnosis.

OBSERVATIONS

A 59-year-old female with generalized dystonia underwent bilateral globus pallidus internus and subthalamic nucleus (STN) DBS device implantation. One year earlier, a left STN-DBS extension wire disconnection was observed and replaced. The patient presented to our department because of tenderness along the extension wire that had persisted for 1 month. Magnetic resonance imaging (MRI) of the head indicated abnormal signals around the lead of the left STN and burr hole. Intraoperatively, the authors observed pus and infected granulation tissue in the burr holes. After device removal, antibiotics were administered, and the patient successfully progressed without complications. Moreover, the abnormal MRI signal disappeared.

LESSONS

A characteristic abnormal MRI signal within the burr hole in DBS may suggest early infection even in the absence of other inflammatory findings. Clinicians should ensure that MRI is not limited to intracranial findings but extends beyond the extracranial space.

Open access

Pediatric brainstem abscess successfully treated with stereotactic aspiration: illustrative case

Nahom Teferi, Ajmain Chowdhury, Sarah Lee, Meron Challa, Lukasz Weiner, Sarah Auerbach, Mahil Rao, and Brian J. Dlouhy

BACKGROUND

Pediatric brainstem abscesses are rare entities that account for 1% of all brain abscesses and, when diagnosed, constitute a neurosurgical emergency.

OBSERVATIONS

A previously healthy 11-year-old male presented with several days of worsening headache, confusion, and ataxia. Brain magnetic resonance imaging (MRI) revealed a midbrain and pons lesion. The patient subsequently had a rapid neurological decline with loss of consciousness and brainstem function. Follow-up MRI revealed significant enlargement of the brainstem lesion with extension into the pons, midbrain, and thalamus, with greater concerns for an abscess rather than a tumor or an inflammatory process. He was taken for an emergent stereotactic aspiration of the abscess, and broad-spectrum antibiotics were initiated. He had neurological improvement, which subsequently declined 5 days later with brain MRI revealing an increase in the brainstem abscess, which required a second stereotactic aspiration. After rehabilitation, he made a significant neurological recovery.

LESSONS

Pediatric brainstem abscesses are rare pathologies, and a high index of suspicion is needed in patients presenting with a brainstem lesion mimicking tumor but with rapid neurological decline despite no other evidence of infection or infectious/inflammatory markers. Stereotactic aspiration is required for large lesions to target the antibiotic treatment and as an adjunct to broad-spectrum antibiotics.

Open access

Pediatric intracranial tuberculoma: illustrative case

Eva Liu, Pramath Kakodkar, Henry Pan, Amy Zhou, Patrick Toyota, Amit Rahul Persad, Kristen Marciniuk, Chunjie Wang, Roland Nikolaus Auer, Stephen Sanche, Aleksander Vitali, and Julia Radic

BACKGROUND

Tuberculosis is an airborne disease caused by Mycobacterium tuberculosis. Intracranial tuberculoma is a rare complication of extrapulmonary tuberculosis due to hematogenous spread to subpial and subependymal regions. Intracranial tuberculoma can occur with or without meningitis.

OBSERVATIONS

A 3-year-old male who had recently emigrated from Sudan presented to the emergency department with right-sided seizures lasting 30 minutes, which were aborted with levetiracetam and midazolam. Head computed tomography revealed a multilobulated left supratentorial mass with solid and cystic components and measuring 8.0 × 4.8 × 6.5 cm. The patient had successful resection of the mass, which was positive for M. tuberculosis. He was started on rifampin, isoniazid, pyrazinamide, ethambutol, and fluoroquinolone and was discharged home in stable condition.

LESSONS

A literature review on pediatric intracranial tuberculoma was performed, which included 48 studies (n = 49). The mean age was 8.8 ± 5.4 years with a slight female predilection (59%). Predominant solitary tuberculomas (63%) were preferentially managed with both resection and antituberculosis therapy (ATT), whereas multifocal tuberculomas were preferentially managed with ATT. Intracranial tuberculoma is a rare but treatable cause of space-occupying lesions in children. Clinicians should maintain a high level of suspicion in patients from endemic regions and involve the infectious disease service early.

Open access

Pedicle subtraction metallectomy with complex posterior reconstruction for fixed cervicothoracic kyphosis: illustrative case

Harman Chopra, José Manuel Orenday-Barraza, Alexander E. Braley, Alfredo Guiroy, Olivia E. Gilbert, and Michael A. Galgano

BACKGROUND

Iatrogenic cervical deformity is a devastating complication that can result from a well-intended operation but a poor understanding of the individual biomechanics of a patient’s spine. Patient factors, such as bone fragility, high T1 slope, and undiagnosed myopathies often play a role in perpetuating a deformity despite an otherwise successful surgery. This imbalance can lead to significant morbidity and a decreased quality of life.

OBSERVATIONS

A 55-year-old male presented to the authors’ clinic with a chin-to-chest deformity and cervical myelopathy. He previously had an anterior C2–T2 fixation and a posterior C1–T6 instrumented fusion. He subsequently developed screw pullout at multiple levels, so the original surgeon removed all of the posterior hardware. The T1 cage (original corpectomy) severely subsided into the body of T2, generating an angular kyphosis that eventually developed a rigid osseous circumferential union at the cervicothoracic junction with severe cord compression. An anterior approach was not feasible; therefore, a 3-column osteotomy/fusion in the upper thoracic spine was planned whereby 1 of the T2 screws would need to be removed from a posterior approach for the reduction to take place.

LESSONS

This case highlights the devastating effect of a hardware complication leading to a fixed cervical spine deformity and the complex decision making involved to safely correct the challenging deformity and restore function.

Open access

Intratumoral abscess complicating a postradiation-induced World Health Organization grade II meningioma: illustrative case

Katherine Callahan, Isidora Beach, Sadie Casale, John DeWitt, and Bruce Tranmer

BACKGROUND

Cerebral meningiomas and brain abscesses are common independently, but intrameningioma abscesses rarely occur, with only 15 cases in the literature. These abscesses most frequently develop in patients with a known source of bacteremia; only one case of intrameningioma abscess without a known source of infection has been reported previously.

OBSERVATIONS

This is the second reported case of an intrameningioma abscess without a clear source of infection, occurring in a 70-year-old female with a history of transsphenoidal craniopharyngioma resection and radiation many years prior. She presented with severe fatigue and altered mental status initially ascribed to adrenal insufficiency, and magnetic resonance imaging showed a new heterogeneously enhancing left temporal mass with surrounding edema. After urgent tumor resection, pathology demonstrated a World Health Organization grade II meningioma (radiation induced). After a course of steroids and intravenous nafcillin, the patient recovered without neurological deficits.

LESSONS

The natural history of intrameningioma abscesses is not fully understood. These uncommon lesions can form secondary to hematogenous spread facilitated by meningiomas’ robust vascularization, typically in patients with bacteremia. Even when no significant source of infection is identified, the differential diagnosis of intrameningioma abscess should be considered because this pathology can be rapidly progressive, even fatal, but is treatable if recognized promptly.

Open access

Rathke’s cleft cyst presenting with recurrent aseptic meningitis and inflammatory apoplexy: illustrative case

Roger Murayi, Megh M. Trivedi, Joao Paulo Almeida, Gabrielle Yeaney, Carlos Isada, and Varun R. Kshettry

BACKGROUND

Rathke’s cleft cyst (RCC) is a benign sellar/suprasellar lesion often discovered incidentally. Rarely, symptomatic cases can present with headache and may exhibit concomitant aseptic meningitis or apoplexy. The authors describe a patient with an RCC presenting with recurring episodes of aseptic meningitis and ultimately inflammatory-type apoplexy.

OBSERVATIONS

A 30-year-old female presented with three episodes of intractable headaches over 2 months. Each episode’s clinical picture was consistent with meningitis though cerebrospinal fluid cultures, and viral tests remained negative. Imaging demonstrated a sellar lesion, initially thought to be coincidental. On the third presentation, there was rapid interval growth of the lesion, adjacent cerebritis, and new endocrinopathy. Resection was then performed via an endoscopic endonasal approach. Pathology showed an RCC with acute and chronic inflammation and no evidence of hemorrhage. Cultures were negative for organisms. The patient received several weeks of antibiotic treatment with the resolution of all symptoms and no recurrence.

LESSONS

Recurrent aseptic meningitis with apoplexy-like symptoms is a rare presentation of RCC. The authors propose the term inflammatory apoplexy to describe such a presentation without evidence of abscess, necrosis, or hemorrhage. The mechanism is unclear although may be due to intermittent microleakage of cyst contents into the subarachnoid space.