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Letter to the Editor. Early decompressive craniectomy and limited tract debridement: a proven strategy?

Jonathan E. Martin

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Introduction. Military neurosurgery

Randy S. Bell, Chris J. Neal, and Randall McCafferty

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Treatment of third ventricular choroid plexus papilloma in an infant with embolization alone

Case report

Joshua J. Wind, Randy S. Bell, William O. Bank, and John S. Myseros

The authors present the case of a 3-month-old boy with a third ventricular tumor consistent with a choroid plexus papilloma. This child presented with macrocephaly, irritability, inability to roll over, and vomiting. He was found to have an enlarged head circumference, a full and tense fontanel, splayed sutures, and forced downward gaze. Imaging revealed severe ventriculomegaly and a brightly enhancing third ventricular lesion consistent with papilloma. Treatment planning included placement of a ventriculoperitoneal shunt to treat hydrocephalus and to allow the child to grow prior to resection. Due to the vascular nature of these tumors and the age of this child, the tumor was embolized with a plan for eventual resection; however, embolization resulted in involution and total regression of the tumor. There is no residual disease at last follow-up of 16 months. In this specific scenario of a choroid plexus papilloma in an infant, when operative intervention may be technically difficult and associated with significant morbidity, embolization with close observation may be a valid treatment option. If used, the patient would need to be closely followed for evidence of residual or recurrent disease, which would require operative intervention.

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The changing landscape of military medical malpractice: from the Feres Doctrine to present

Callum D. Dewar, Jason H. Boulter, Brian P. Curry, Dana M. Bowers, and Randy S. Bell

Medical malpractice suits within the military have historically been limited by the Feres Doctrine, a legal precedent arising from a Supreme Court decision in 1950, which stated that active-duty personnel cannot bring suit for malpractice against either the United States government or military healthcare providers. This precedent has increasingly become a focus of discussion and reform as multiple cases claiming malpractice have been dismissed. Recently, however, the National Defense Authorization Act of 2020 initiated the first change to this precedent by creating an administrative body with the sole purpose of evaluating and settling claims of medical malpractice within the military’s $50 billion healthcare system. This article seeks to present the legal history related to military malpractice and the Feres Doctrine as well as discuss the potential future implications that may arise as the Feres Doctrine is modified for the first time in 70 years.

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Eosinophilic meningitis after implantation of a rifampin and minocycline–impregnated ventriculostomy catheter in a child

Case report

Randy S. Bell, Alexander H. Vo, Patrick B. Cooper, Carrie L. Schmitt, and Michael K. Rosner

✓ Eosinophilic meningitis has been defined as meningitis in which a total cerebrospinal fluid (CSF) sample is found to have more than 10 eosinophils per millimeter or is composed of greater than 10% eosinophils. The differential diagnosis is broad and the clinical presentation, lacking an internalized CSF diversion system, is often nonspecific. With respect to patients with shunt systems, a positive correlation exists between CSF eosinophilia and eventual shunt failure requiring revision. In this paper the authors present the highest reported level of CSF eosinophilia in conjunction with a rifampin and minocycline–impregnated ventriculostomy catheter recently approved by the Food and Drug Administration.

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Letter to the Editor: Bibliometric profiles for US neurosurgical residency programs

Randy S. Bell and Chris J. Neal

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Neurological sequelae from brachiocephalic vein stenosis

Report of 2 cases

David W. Herzig, Andrew B. Stemer, Randy S. Bell, Ai-Hsi Liu, Rocco A. Armonda, and William O. Bank

Stenosis of central veins (brachiocephalic vein [BCV] and superior vena cava) occurs in 30% of hemodialysis patients, rarely producing intracranial pathology. The authors present the first cases of BCV stenosis causing perimesencephalic subarachnoid hemorrhage and myoclonic epilepsy.

In the first case, a 73-year-old man on hemodialysis presented with headache and blurry vision, and was admitted with presumed idiopathic intracranial hypertension after negative CT studies and confirmatory lumbar puncture. The patient mildly improved until hospital Day 3, when he experienced a seizure; emergency CT scans showed perimesencephalic subarachnoid hemorrhage. Cerebral angiography failed to find any vascular abnormality, but demonstrated venous congestion. A fistulogram found left BCV occlusion with jugular reflux. The occlusion could not be reopened percutaneously and required open fistula ligation. Postoperatively, symptoms resolved and the patient remained intact at 7-month follow-up.

In the second case, a 67-year-old woman on hemodialysis presented with right arm weakness and myoclonic jerks. Admission MRI revealed subcortical edema and a possible dural arteriovenous fistula. Cerebral angiography showed venous engorgement, but no vascular malformation. A fistulogram found left BCV stenosis with jugular reflux, which was immediately reversed with angioplasty and stent placement. Postprocedure the patient was seizure free, and her strength improved. Seven months later the patient presented in myoclonic status epilepticus, and a fistulogram revealed stent occlusion. Angioplasty successfully reopened the stent and she returned to baseline; she was seizure free at 4-month follow-up.

Central venous stenosis is common with hemodialysis, but rarely presents with neurological findings. Prompt recognition and endovascular intervention can restore normal venous drainage and resolve symptoms.

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Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury

R. Michael Meyer, M. Benjamin Larkin, Nicholas S. Szuflita, Chris J. Neal, Jeffrey M. Tomlin, Rocco A. Armonda, Jeffrey A. Bailey, and Randy S. Bell

OBJECTIVE

Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE.

METHODS

The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients.

RESULTS

Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant.

CONCLUSIONS

Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.

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The evolution of the treatment of traumatic cerebrovascular injury during wartime

A review

Randy S. Bell, Robert D. Ecker, Meryl A. Severson III, John E. Wanebo, Benjamin Crandall, and Rocco A. Armonda

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.

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Cranioplasty complications following wartime decompressive craniectomy

Frederick L. Stephens, Correy M. Mossop, Randy S. Bell, Teodoro Tigno Jr., Michael K. Rosner, Anand Kumar, Leon E. Moores, and Rocco A. Armonda

Object

In support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF-A), military neurosurgeons in the combat theater are faced with the daunting task of stabilizing patients in such a way as to prevent irreversible neurological injury from cerebral edema while simultaneously allowing for prolonged transport stateside (5000–7000 miles). It is in this setting that decompressive craniectomy has become a mainstay of far-forward neurosurgical management of traumatic brain injury (TBI).

As such, institutional experience with cranioplasty at the Walter Reed Army Medical Center (WRAMC) and the National Naval Medical Center (NNMC) has expanded concomitantly. Battlefield blast explosions create cavitary injury zones that often extend beyond the border of the exposed surface wound, and this situation has created unique reconstruction challenges not often seen in civilian TBI. The loss of both soft-tissue and skull base support along with the need for cranial vault reconstruction requires a multidisciplinary approach involving neurosurgery, plastics, oral-maxillofacial surgery, and ophthalmology. With this situation in mind, the authors of this paper endeavored to review the cranial reconstruction complications encountered in these combat-related injuries.

Methods

A retrospective database review was conducted for all soldiers injured in OIF and OEF-A who had undergone decompressive craniectomy with subsequent cranioplasty between April 2002 and October 2008 at the WRAMC and NNMC. During this time, both facilities received a total of 408 OIF/OEF-A patients with severe head injuries; 188 of these patients underwent decompressive craniectomies in the theater before transfer to the US. Criteria for inclusion in this study consisted of either a closed or a penetrating head injury sustained in combat operations, resulting in the performance of a decompressive craniectomy and subsequent cranioplasty at either the WRAMC or NNMC. Excluded from the study were patients for whom primary demographic data could not be verified. Demographic data, indications for craniectomy, as well as preoperative, intraoperative, and postoperative parameters following cranioplasty, were recorded. Perioperative and postoperative complications were also recorded.

Results

One hundred eight patients (male/female ratio 107:1) met the inclusion criteria for this study, 93 with a penetrating head injury and 15 with a closed head injury. Explosive blast injury was the predominant mechanism of injury, occurring in 72 patients (67%). The average time that elapsed between injury and cranioplasty was 190 days (range 7–546 days). An overall complication rate of 24% was identified. The prevalence of perioperative infection (12%), seizure (7.4%), and extraaxial hematoma formation (7.4%) was noted. Twelve patients (11%) required prosthetic removal because of either extraaxial hematoma formation or infection. Eight of the 13 cases of infection involved cranioplasties performed between 90 and 270 days from the date of injury (p = 0.06).

Conclusions

This study represents the largest to date in which cranioplasty and its complications have been evaluated in a trauma population that underwent decompressive craniectomy. The overall complication rate of 24% is consistent with rates reported in the literature (16–34%); however, the perioperative infection rate of 12% is higher than the rates reported in other studies. This difference is likely related to aspects of the initial injury pattern—such as skull base injury, orbitofacial fractures, sinus injuries, persistent fluid collection, and CSF leakage—which can predispose these patients to infection.