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Open access

Improved psychotic symptoms following resection of amygdalar low-grade glioma: illustrative case

John P. Andrews, Thomas A. Wozny, John K. Yue, and Doris D. Wang

BACKGROUND

Epilepsy-associated psychoses are poorly understood, and management is focused on treating epilepsy. Chronic, interictal psychosis that persists despite seizure control is typically treated with antipsychotics. Whether resection of a mesial temporal lobe lesion may improve interictal psychotic symptoms that persist despite seizure control remains unknown.

OBSERVATIONS

In a 52-year-old man with well-controlled epilepsy and persistent comorbid psychosis, brain magnetic resonance imaging (MRI) revealed an infiltrative, intraaxial, T2 fluid-attenuated inversion recovery intense mass of the left amygdala. The patient received an amygdalectomy for oncological diagnosis and surgical treatment of a presumed low-grade glioma. Pathology was ganglioglioma, World Health Organization grade I. Postoperatively, the patient reported immediate resolution of auditory hallucinations. Patient has remained seizure-free on 2 antiepileptic drugs and no antipsychotic pharmacotherapy and reported lasting improvement in his psychotic symptoms.

LESSONS

This report discusses improvement of psychosis symptoms after resection of an amygdalar glioma, independent of seizure outcome. This case supports a role of the amygdala in psychopathology and suggests that low-grade gliomas of the limbic system may represent, at minimum, partially reversible etiology of psychotic symptoms.

Open access

Paraparesis caused by intradural thoracic spinal granuloma secondary to organizing hematoma: illustrative case

John K. Yue, Young M. Lee, Daniel Quintana, Alexander A. Aabedi, Nishanth Krishnan, Thomas A. Wozny, John P. Andrews, and Michael C. Huang

BACKGROUND

Spinal granulomas form from infectious or noninfectious inflammatory processes and are rarely present intradurally. Intradural granulomas secondary to hematoma are unreported in the literature and present diagnostic and management challenges.

OBSERVATIONS

A 70-year-old man receiving aspirin presented with encephalopathy, subacute malaise, and right lower extremity weakness and was diagnosed with polysubstance withdrawal and refractory hypertension requiring extended treatment. Seven days after admission, he reported increased bilateral lower extremity (BLE) weakness. Magnetic resonance imaging showed T2–3 and T7–8 masses abutting the pia, with spinal cord compression at T2–3. He was transferred to the authors’ institution, and work-up showed no vascular shunting or malignancy. He underwent T2–3 laminectomies for biopsy/resection. A firm, xanthochromic mass was resected en bloc. Pathology showed organizing hematoma without infection, vascular malformation, or malignancy. Subsequent coagulopathy work-up was unremarkable. His BLE strength significantly improved, and he declined resection of the inferior mass. He completed physical therapy and was cleared for placement in a skilled nursing facility.

LESSONS

Spinal granulomas can mimic vascular lesions and malignancy. The authors present the first report of paraparesis caused by intradural granuloma secondary to organizing hematoma, preceded by severe refractory hypertension. Tissue diagnosis is critical, and resection is curative. These findings can inform the vigilant clinician for expeditious treatment.

Open access

Short segment rib resection to mitigate risk of pleural violation during retropleural lateral thoracic interbody fusion

Bo Li, Gregory A. Kuzmik, Saman Shabani, Nitin Agarwal, Alysha Jamieson, Thomas Wozny, Simon Ammanuel, Praveen V. Mummaneni, and Dean Chou

It can be difficult to avoid violating the pleura during the retropleural approach to the thoracolumbar spine. In this video, the authors resect a short segment of rib to allow more room for pleural dissection during a minimally invasive (MIS) lateral retropleural approach. After a lateral MIS skin incision, the rib is dissected and removed, clearly identifying the retropleural space. The curvature of the rib can then be followed, decreasing the risk of pleural violation. The pleura can then be mobilized ventrally until the spine is accessed. Managing the diaphragm is also illustrated by separating the fibers without a traditional cut through the muscle.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID21138

Free access

Decision tree–based machine learning analysis of intraoperative vasopressor use to optimize neurological improvement in acute spinal cord injury

Nitin Agarwal, Alexander A. Aabedi, Abel Torres-Espin, Austin Chou, Thomas A. Wozny, Praveen V. Mummaneni, John F. Burke, Adam R. Ferguson, Nikos Kyritsis, Sanjay S. Dhall, Philip R. Weinstein, Xuan Duong-Fernandez, Jonathan Pan, Vineeta Singh, Debra D. Hemmerle, Jason F. Talbott, William D. Whetstone, Jacqueline C. Bresnahan, Geoffrey T. Manley, Michael S. Beattie, and Anthony M. DiGiorgio

OBJECTIVE

Previous work has shown that maintaining mean arterial pressures (MAPs) between 76 and 104 mm Hg intraoperatively is associated with improved neurological function at discharge in patients with acute spinal cord injury (SCI). However, whether temporary fluctuations in MAPs outside of this range can be tolerated without impairment of recovery is unknown. This retrospective study builds on previous work by implementing machine learning to derive clinically actionable thresholds for intraoperative MAP management guided by neurological outcomes.

METHODS

Seventy-four surgically treated patients were retrospectively analyzed as part of a longitudinal study assessing outcomes following SCI. Each patient underwent intraoperative hemodynamic monitoring with recordings at 5-minute intervals for a cumulative 28,594 minutes, resulting in 5718 unique data points for each parameter. The type of vasopressor used, dose, drug-related complications, average intraoperative MAP, and time spent in an extreme MAP range (< 76 mm Hg or > 104 mm Hg) were collected. Outcomes were evaluated by measuring the change in American Spinal Injury Association Impairment Scale (AIS) grade over the course of acute hospitalization. Features most predictive of an improvement in AIS grade were determined statistically by generating random forests with 10,000 iterations. Recursive partitioning was used to establish clinically intuitive thresholds for the top features.

RESULTS

At discharge, a significant improvement in AIS grade was noted by an average of 0.71 levels (p = 0.002). The hemodynamic parameters most important in predicting improvement were the amount of time intraoperative MAPs were in extreme ranges and the average intraoperative MAP. Patients with average intraoperative MAPs between 80 and 96 mm Hg throughout surgery had improved AIS grades at discharge. All patients with average intraoperative MAP > 96.3 mm Hg had no improvement. A threshold of 93 minutes spent in an extreme MAP range was identified after which the chance of neurological improvement significantly declined. Finally, the use of dopamine as compared to norepinephrine was associated with higher rates of significant cardiovascular complications (50% vs 25%, p < 0.001).

CONCLUSIONS

An average intraoperative MAP value between 80 and 96 mm Hg was associated with improved outcome, corroborating previous results and supporting the clinical verifiability of the model. Additionally, an accumulated time of 93 minutes or longer outside of the MAP range of 76–104 mm Hg is associated with worse neurological function at discharge among patients undergoing emergency surgical intervention for acute SCI.

Restricted access

Oral Presentations 2016 AANS Annual Scientific Meeting Chicago, IL • April 30–May 4, 2016

Published online April 1, 2016; DOI: 10.3171/2016.4.JNS.AANS2016abstracts