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Open access

Diffuse symptomatic pneumocephalus after biportal endoscopic spinal surgery: illustrative case

Chien-Tung Yang, Cheng-Di Chiu, and Chih-Ying Wu

BACKGROUND

Percutaneous endoscopic lumbar decompression is gaining attention as a minimally invasive surgery. Here, the authors report a rare complication of pneumocephalus caused by vacuum drain after biportal endoscopic spinal surgery (BESS) for lumbar stenosis.

OBSERVATIONS

A 79-year-old woman with spinal stenosis over the L4–5 level received BESS. No visible dural tear was encountered during surgery, and a vacuum drain was placed after surgery. Approximately 150 mL of cerebrospinal fluid was drained on postoperative day 1. Simultaneously, symptoms of intracranial hypotension were noted. Brain computed tomography (CT) revealed pneumocephalus. The patient was advised to have bed rest and hydration, and her symptoms improved subsequently. Follow-up brain CT indicated the resolution of pneumocephalus.

LESSONS

Pneumocephalus after endoscopic lumbar surgery is rare. Dural tear, high rate of normal saline irrigation, and vacuum drain placement are the associated risk factors.

In Journal of Neurosurgery: Case Lessons Volume 3 (2022): Issue 26 (Jun 2022)

Open access

Giant anterior sacral meningocele associated with hydroureteronephrosis and renal injury: illustrative case

Lucas Loiola, Vinícius M. Henriques, Carlos A. S. Moreira, Vinícius Gregório, Fernando A. Vasconcelos, Alexandre M. Schmidt, and Fernando Guedes

BACKGROUND

Anterior sacral meningocele (ASM) is a defect in the closure of the neural tube. Patients can be asymptomatic or present with genitourinary, neurological, reproductive, or colorectal dysfunction. Magnetic resonance imaging (MRI) is the gold standard test because it can assess communication between the spinal subarachnoid space and the lesion and identify other abnormalities. Surgical correction is the definitive treatment because untreated cases have a mortality rate of more than 30%.

OBSERVATIONS

A 24-year-old woman with Marfan syndrome presented with polyuria, recurrent urinary tract infections, and renal injury for 3 months along with a globose abdomen, with a palpable mass in the middle and lower third of the abdomen that was massive on percussion. MRI showed an ASM consisting of two cystic lesions measuring 15.4 × 14.3 × 15.8 and 6.7 × 6.1 × 5.9 cm, respectively, compressing the distal third of the right ureter and causing a hydroureteronephrosis. Drainage and ligature of the cystic lesion were performed. The urinary outcome was excellent, with full recovery after surgery.

LESSONS

ASM should be suspected in all abdominal masses with progressive symptoms in the setting of Marfan syndrome. Computed tomography and MRI are important to investigate genitourinary anomalies or other types of dysraphism to guide the best surgical approach.

In Journal of Neurosurgery: Case Lessons Volume 3 (2022): Issue 26 (Jun 2022)

Open access

Multimodal monitoring to guide neurosurgical intervention in high-grade aneurysmal subarachnoid hemorrhage: illustrative case

Bradley Kolb, Daniel Wolfson, Ivan Da Silva, and Stephan A. Munich

BACKGROUND

Multimodal monitoring to guide medical intervention in high-grade aneurysmal subarachnoid hemorrhage (aSAH) is well described. Multimodal monitoring to guide surgical intervention in high-grade aSAH has been less studied.

OBSERVATIONS

Intracranial pressure (ICP), brain lactate to pyruvate ratio (L/P ratio), and brain parenchymal oxygen tension (pO2) were used as surrogates for clinical status in a comatose man after high-grade aSAH. Acute changes in ICP, L/P ratio, and pO2 were used to identify brain injury from both malignant cerebral edema and delayed cerebral ischemia, respectively, and decompressive hemicraniectomy with clot evacuation and intraarterial nimodipine were used to treat these conditions. The patient showed marked improvement in multimodal parameters following each intervention and eventually recovered to a modified Rankin score of 2.

LESSONS

In patients with a limited neurological examination due to severe acute brain injury in the setting of aSAH, multimodal monitoring can be used to guide surgical treatment. With prompt, aggressive, maximal medical and surgical interventions, otherwise healthy individuals may retain the capacity for close to full recovery from seemingly catastrophic aSAH.

In Journal of Neurosurgery: Case Lessons Volume 3 (2022): Issue 26 (Jun 2022)

Open access

Pediatric skull fracture with injury and thrombosis of the superior sagittal sinus: illustrative case

Douglas M. Zoerner, Taylor Reardon, and Brandon A. Miller

BACKGROUND

Cerebral venous sinus thrombosis (VST) is a complication of head injury and can be secondary to sinus compression by depressed skull fractures. Fracture elevation is a treatment option for VST secondary to extrinsic compression, but conservative management may also be effective. Venous sinuses can also be lacerated from skull fractures, resulting in epidural or subdural hematomas. The authors presented a case of sagittal sinus injury and thrombosis from a depressed skull fracture that caused a subgaleal hematoma. The injury was successfully managed conservatively.

OBSERVATIONS

A 14-year-old boy presented after a head injury with a diastatic, depressed parietal bone fracture. Computed tomography venogram showed disruption and occlusion of the superior sagittal sinus with a subgaleal hematoma in continuity with the injured sagittal sinus. Because of concern for hemorrhage if tamponade on the sinus was removed, the patient was treated nonsurgically. At follow-up, the sinus had recanalized and the fracture had healed.

LESSONS

Skull fractures with underlying sinus thrombosis can be managed conservatively with good outcome. Careful assessment for venous sinus injury should be made before undertaking fracture elevation to relieve sinus compression.

In Journal of Neurosurgery: Case Lessons Volume 3 (2022): Issue 26 (Jun 2022)

Open access

Primary spinal infections in patients with solid organ transplant: a systematic literature review and illustrative case

Matthew J. Hatter, Ryan S. Beyer, Gaston Camino-Willhuber, Austin Franklin, Nolan J. Brown, Sohaib Hashmi, Michael Oh, Nitin Bhatia, and Yu-Po Lee

BACKGROUND

Primary spinal infections (PSIs) are a group of uncommon but serious infectious diseases considered more prevalent and aggressive among patients with chronic immunocompromised states. Association of PSI and solid organ transplant has not been systematically analyzed. The authors performed a systematic review analyzing clinical presentation and mortality of patients with PSI in the setting of solid organ transplant.

OBSERVATIONS

PSIs in patients with immunosuppressive therapy, such as those with solid organ transplant, may behave differently in terms of epidemiology, clinical presentation, and outcomes compared with nonimmunosuppressed patients. Overall PSI in solid organ transplant patients is associated with a high rate of neurological compromise, postoperative complications, and mortality.

LESSONS

Accurate diagnosis and appropriate treatment of PSI require a multidisciplinary effort. Localized pain is the most frequently reported symptom associated with PSI. As opposed to PSI in patients without transplant, inflammatory and infectious markers such as white blood cells and C-reactive protein are often not elevated. Furthermore, the causative microorganism profile varies significantly when compared to pyogenic spinal infection in patients without transplant. Aspergillus species was responsible for spondylodiscitis in transplant patients in more than 50% of cases, and the incidence of Aspergillus infection is projected to rise in the coming years.

In Journal of Neurosurgery: Case Lessons Volume 3 (2022): Issue 26 (Jun 2022)

Restricted access

Effects of prior concussion on symptom severity and recovery time in acute youth concussion

James Mooney, James Pate, Ian Cummins, M. Chandler McLeod, and Sara Gould

OBJECTIVE

Many studies have identified factors associated with increased symptom burden and prolonged recovery after pediatric and adolescent concussion. Few have systematically examined the effects of prior concussion on these outcomes in patients with concussion due to any mechanism. An improved understanding of the short- and long-term effects of a multiple concussion history will improve counseling and management of this subgroup of patients.

METHODS

A retrospective review of adolescent and young adult acute concussion patients presenting to the multidisciplinary concussion clinic between 2018 and 2019 was conducted at a single center. Patient demographic data, medical history including prior concussion, initial symptom severity score (SSS), injury mechanisms, and recovery times were collected. Univariate and multivariable analyses were conducted to identify associations of history of prior concussion and patient and injury characteristics with symptom score and recovery time.

RESULTS

A total of 266 patients with an average age of 15.4 years (age range 13–27 years) were included. Prior concussion was reported in 35% of patients. The number of prior concussions per patient was not significantly associated with presenting symptom severity, recovery time, or recovery within 28 days. Male sex and sports-related concussion (SRC) were associated with lower presenting SSS and shorter recovery time on univariate but not multivariable analysis. However, compared to non–sport concussion mechanisms, SRC was associated with 2.3 times higher odds of recovery within 28 days (p = 0.04). A history of psychiatric disorders was associated with higher SSS in univariate analysis and longer recovery time in univariate and multivariable analyses. Multivariable log-linear regression also demonstrated 5 times lower odds of recovery within 28 days for those with a psychiatric history.

CONCLUSIONS

The results of this study demonstrated that an increasing number of prior concussions was associated with a trend toward higher presenting SSS after youth acute concussion but did not show a significant association with recovery time or delayed (> 28 days) recovery. Presence of psychiatric history was found to be significantly associated with longer recovery and lower odds of early (≤ 28 days) recovery. Future prospective, long-term, and systematic study is necessary to determine the optimal counseling and management of adolescent and young adult patients with a history of multiple concussions.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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ICP, CPP, and PRx in traumatic brain injury and aneurysmal subarachnoid hemorrhage: association of insult intensity and duration with clinical outcome

Teodor Svedung Wettervik, Anders Hånell, Timothy Howells, Elisabeth Ronne Engström, Anders Lewén, and Per Enblad

OBJECTIVE

The primary aim of this study was to determine the combined effect of insult intensity and duration of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and pressure reactivity index (PRx) on outcome measured with the Glasgow Outcome Scale–Extended (GOS-E) in patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

This observational study included all TBI and aSAH patients treated in the neurointensive care unit in Uppsala, Sweden, 2008–2018, with at least 24 hours of ICP monitoring during the first 10 days following injury and available long-term clinical outcome data. ICP, CPP, and PRx insults were visualized as 2D plots to highlight the effects of both insult intensity and duration on patient outcome.

RESULTS

Of 950 included patients, 436 were TBI and 514 aSAH patients. The TBI patients were younger, more often male, and exhibited worse neurological status at admission, but recovered more favorably than the aSAH patients. There was a transition from good to poor outcome with ICP above 15–20 mm Hg in both TBI and aSAH. The two diagnoses had opposite CPP patterns. In TBI patients, CPP episodes at or below 80 mm Hg were generally favorable, whereas CPP episodes above 80 mm Hg were favorable in the aSAH patients. In the TBI patients there was a transition from good to poor outcome when PRx exceeded zero, but no evident transition was found in the aSAH cohort.

CONCLUSIONS

The insult intensity and duration plots formulated in this study illustrate the similarities and differences between TBI and aSAH patients. In particular, aSAH patients may benefit from much higher CPP targets than TBI patients.

In Journal of Neurosurgery Publish Before Print

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Intratumoral hemorrhage in vestibular schwannomas after stereotactic radiosurgery

Othman Bin-Alamer, David Fogg, Zhishuo Wei, James Duehr, Arka N. Mallela, Ajay Niranjan, L. Dade Lunsford, and Hussam Abou-Al-Shaar

OBJECTIVE

Vestibular schwannomas (VSs) are benign tumors of the cerebellopontine angle that are typically managed with stereotactic radiosurgery (SRS). Intratumoral hemorrhage (ITH) of VSs is a rare occurrence that results in worsening vestibular and new cranial nerve deficits. Few reports have described the management and outcomes of this entity after SRS. To further delineate the incidence and impact of this event, the authors performed a retrospective review of their VS SRS patients at a single center.

METHODS

Between 1987 and 2022, 2058 patients with VSs underwent Gamma Knife radiosurgery (GKRS) at the University of Pittsburgh Medical Center. The authors performed a review of the prospectively maintained VS database at their center to identify patients with ITH. The presentation, management, and clinical and imaging outcomes of the patients are reported.

RESULTS

A total of 1902 VS patients had sufficient clinical and imaging follow-up data. Five Koos grade III (n = 1) and IV (n = 4) VS patients developed ITH after GKRS, resulting in a cumulative incidence rate of 0.26%. The age at presentation ranged from 62 to 79 years, and 3 patients were male. The time from VS diagnosis to GKRS ranged from 1 to 13 months, and the time from GKRS to ITH ranged from 2 to 130 months. Three patients had bleeding risk factors. One patient required urgent surgical intervention due to the ITH volume, while the other 4 patients were initially observed. Three patients remained stable and required no delayed intervention; 1 patient required delayed resection because of symptom progression and hemorrhagic expansion. Histopathological analysis revealed multiple fragments of S-100–positive cells, hemorrhage, and hemosiderin-laden macrophages. At last follow-up, 4 patients had clinically improved and 1 patient remained stable.

CONCLUSIONS

ITH after VS radiosurgery is a rare phenomenon with a cumulative incidence rate of 0.26% in this series. Patient-tailored management in the form of observation or resection is based on patient presentation, acuity, and ITH size.

In Journal of Neurosurgery Publish Before Print

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Long-term health-related quality of life in patients with ruptured arteriovenous malformations treated in childhood

Elias Oulasvirta, Anni Pohjola, Päivi Koroknay-Pál, Ahmad Hafez, Risto Roine, Harri Sintonen, and Aki Laakso

OBJECTIVE

The aim of this study was to reveal the long-term health-related quality of life (HRQOL), educational level, and impact on occupation in 55 patients who experienced ruptured brain arteriovenous malformations (AVMs) that were treated during childhood.

METHODS

In 2016, questionnaires including the 15D instrument were sent to all living patients older than 18 years (n = 432) in the Helsinki AVM database. The cohort was further specified to include only patients with ruptured AVMs who were younger than 20 years at the time of diagnosis (n = 55). Educational level was compared with the age-matched general population of Finland. The mean 15D scores were calculated for independent variables (Spetzler-Ponce classification, admission age, symptomatic epilepsy, and multiple bleeding episodes) and tested using the independent-samples t-test or ANCOVA. Linear regression was used to create a multivariate model. Bonferroni correction was used with multiple comparisons.

RESULTS

The mean follow-up time from diagnosis to survey was 24.2 (SD 14.7) years. The difference in the mean 15D scores between Spetzler-Ponce classes did not reach statistical significance. The youngest age group (< 10 years at the time of diagnosis) performed less well on the dimension of usual activities than the older patients. Symptomatic epilepsy significantly reduced the long-term HRQOL. Multiple hemorrhages significantly reduced the scores on three dimensions: mobility, speech, and sexual activity. In the regression model, symptomatic epilepsy was the only significant predictor for a lower 15D score. The educational level of the cohort was for the most part comparable to that of the general population in the same age group. AVM was the reason for early retirement in 11% of the patients, while lowered performance because of the AVM was reported by 37% of the patients.

CONCLUSIONS

Patients with ruptured AVMs treated in childhood can live an independent and meaningful life, even in the case of the highest-grade lesions. Symptomatic epilepsy significantly reduced the long-term HRQOL, highlighting the need for continuing support for these patients.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Lumbar stenosis due to wild-type transthyretin amyloid–induced thickening of the ligamentum flavum: a separate etiology from degeneration of intervertebral discs?

Andy Y. Wang, Matthew Kanter, Michelle Olmos, Ellen D. McPhail, Mina G. Safain, James Kryzanski, Knarik Arkun, and Ron I. Riesenburger

OBJECTIVE

Wild-type transthyretin amyloid (ATTRwt) is deposited in the ligamentum flavum (LF) of a subset of patients with spinal stenosis who undergo decompressive surgery, although its role in the pathophysiology of spinal stenosis is unknown. It has been theorized that degeneration of intervertebral discs causes increased mechanical stress and inflammatory/degenerative cascades and ultimately leads to LF fibrosis. If ATTRwt deposits contribute to LF thickening and spinal stenosis through a different pathway, then patients with ATTRwt may have less severe disc degeneration than those without it. In this study, the authors compared the severity of disc degeneration between patients with lumbar stenosis with and without amyloid in their LF to test whether ATTRwt is a unique contributor to LF thickening and spinal stenosis.

METHODS

Of 324 consecutive patients between 2018 and 2019 who underwent decompression surgery for spinal stenosis and had LF samples sent for pathological analysis, 31 harboring ATTRwt were compared with 88 controls. Patient medical records were retrospectively reviewed for demographic and surgical information. Disc degeneration was assessed on preoperative T2-weighted MR images with the modified Pfirrmann grading system at every lumbar disc level.

RESULTS

Baseline characteristics were similar between the groups, except for a statistically significant increase in age in the ATTRwt group. The crude unadjusted comparisons between the groups trended toward a less severe disc degeneration in the ATTRwt group, although this difference was not statistically significant. A multivariable linear mixed-effects model was created to adjust for the effects of age and to isolate the influence of ATTRwt, the presence of an operation at the level, and the specific disc level (between L1 and S1). This model revealed that ATTRwt, the presence of an operation, and the specific level each had significant effects on modified Pfirrmann scores.

CONCLUSIONS

Less severe disc degeneration was noted in patients with degenerative spinal stenosis harboring ATTRwt compared with those without amyloid. This finding suggests that ATTRwt deposition may play a separate role in LF thickening from that played by disc degeneration. Future studies should aim to elucidate this potentially novel pathophysiological pathway, which may uncover an exciting potential for the development of amyloid-targeted therapies that may help slow the development of spinal stenosis.

In Journal of Neurosurgery: Spine Publish Before Print