Upper Thoracic Spine (D2-D3) Fracture With Unilateral Lock Facets Without Associated Neurological Deficits: Case Report & Literature Review.

Introduction: Upper thoracic spine fractures are rare as compared to other spine segments due to anatomical landmarks. If they occur, they are usually associated with paraplegia or any other neurological dysfunction. We report upper thoracic fracture without neurological dysfunction which is a rare entity along with its radiological imaging, and management plan. Case Description: Forty-years old male presented after RTA. CT spine showed T2 vertebral body fracture with dislocation/locking of the right T2-T3 facet joint. The patient underwent surgical fixation and was neurologically intact. Conclusion: Upper thoracic spine fracture is a rare entity due to its anatomical location. And sometimes it is missed as well. Proper imaging should be considered if there is high suspicion and early surgery is warranted to prevent permanent damage.

Role of albumin-induced volume expansion therapy for cerebral vasospasm in aneurysmal subarachnoid hemorrhage: A systematic review.

Objectives: This study reviews the effect of albumin-induced volume expansion therapy on symptomatic vasospasm and clinical outcome in aneurysmal subarachnoid hemorrhage (aSAH). Materials and Methods: Computer searches carried out from the Scopus, Medline, Embase, Web of Science, the Cochrane Library, and Internet documents; hand searching of medical journals; and review of reference lists. Randomized controlled trials (RCT) and observational studies (OSs) comparing albumin therapy in combination or alone with crystalloid therapy for the treatment of cerebral vasospasm in aSAH were included in the study. Risk-of-bias assessment was conducted using ROB2.0 and ROBINS-I tools for RCTs and Oss, respectively. Results: Out of a total of 1078 searches, one RCT (published in two articles) and one observational (retrospective) study were included for final analysis. In RCT, albumin was used for volume expansion therapy with a baseline crystalloid regime and comparison made between hypervolemic and normovolemic groups and it showed no beneficial effects on symptomatic vasospasm and clinical outcomes based on the Glasgow outcome scale. Furthermore, the use of albumin showed a tendency for sodium retention with lowering of glomerular filtration rate, limiting the amount of total fluid required for targeted central venous pressure values, and thereby avoiding fluid overload manifestations. The retrospective study results between albumin versus non-albumin groups (crystalloids only) supported improved outcomes in the former group with lower in-hospital mortality. Cardiorespiratory complications were equivocal in RCT and increased in non-albumin group in the retrospective study. Risk-of-bias assessment analyses revealed "some concerns" in RCT and "serious" limitation in OS due to its retrospective design. Conclusion: Albumin-induced volume expansion therapy for cerebral vasospasm does not have substantiative evidence to improve cerebral vasospasm and clinical outcomes in aSAH. Studies with well-designed RCTs are required to compare the use of albumin for volume expansion therapy versus standard fluid management using crystalloids to mitigate the scarcity of published data.

Onyx Embolization of Distal Middle Cerebral Artery Aneurysm in a Patient with Nontraumatic Subdural Hematoma.

Distal cortical middle cerebral artery (MCA) aneurysm is a rare entity. Despite the challenging procedure, the role of endovascular treatment is emerging due to its safety and efficacy in obliterating the microaneurysm. We report a 25-year-old male, who presented with a history of dizziness and headache for almost 2 weeks. Computed tomography scan showed a right front parietal subdural hematoma (SDH). We could not identify any underlying defining etiology of SDH neither head injury nor coagulopathy disorder. Therefore, diagnostic cerebral angiogram was performed, which showed a microaneurysm in the distal right MCA cortical branch. Hence, complete obliteration of this microaneurysm was performed using Onyx for endovascular embolization. Therefore, this case report demonstrates the efficacy of this modality in the treatment of microaneurysms with SDH.

Cerebral schistosomiasis: Case series from Qatar.

Schistosomiasis is the third most widespread devastating parasitic disease worldwide and has a high mortality burden. Neuroschistosomiasis is one of the rare and most severe clinical presentations of the disease. It is caused by granuloma formation around eggs that lodge in the central nervous system, with Schistosoma japonicum usually causing most reported cerebral disease. Three unusual presentations of schistosomiasis in Qatar are described herein. The three patients were young males who presented with seizures and tumor-like lesions on brain imaging. The diagnosis was confirmed by biopsy, which showed necrotizing granulomas containing Schistosoma eggs. These cases raise awareness of neuroschistosomiasis as a potential cause of tumor-like brain lesions in migrants and returning travelers from endemic areas.

Baseline Occlusion Angiographic Appearance on Mechanical Thrombectomy Suggests Underlying Etiology and Outcome.

Background: Etiology of a large vessel occlusion is relevant in the management of acute ischemic stroke patients and often difficult to determine in the acute phase. Aims: We aim to investigate whether the angiographic appearance of the occlusion is related to its etiology and outcome. Materials and Methods: Patients without cervical carotid occlusions who underwent mechanical thrombectomy in our center from April 2015 to September 2018 were studied. Demographics, clinical and radiological variables and outcome measures, including etiological classification of stroke, were collected. Underlying intracranial atherosclerosis was estimated according to the presence of stenosis after recanalization. Patients were assigned to groups based on the appearance of the occlusion observed in the first angiogram as "tapered" or "non-tapered." Differences were searched amongst them. Results: 131 patients met inclusion criteria. 31 (23.6%) were "tapered" and 100 (76.3%) non-tapered. Tapered presented lower mean baseline NIHSS (10.3 ± 6.2 vs. 16.1 ± 7.2; p < 0.001), smaller acute infarct cores as CTP CBV ASPECTS (8.6 ± 1.6 vs. 7.2 ± 2.4; p = 0.003), higher proportion of instant re-occlusions (26.7 vs. 8.2%; p = 0.025), fewer complete recanalization (45.2 vs. 71.0%; p = 0.028), and more persistent occlusions (37.5 vs. 10.6%; p = 0.011) on follow up MRA. There were no differences in reperfusion rates (83.9 vs. 84.0%; p = 0.986) nor in good long term functional outcome (50.0 vs. 51.1%; p = 0.921). Intracranial atherosclerosis etiology was more common in tapered than in non-tapered occlusions (54.8 vs. 18.0%; p < 0.001). Conclusion: The angiographic appearance of an occlusion in mechanical thrombectomy patients may determine its etiology, predict likelihood of successful recanalization, and risk of reocclusion.

The Role of Decompressive Craniectomy in Traumatic Brain Injury: A Systematic Review and Meta-analysis.

The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case-control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75-1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40-0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26-0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.

Balloon Angioplasty for In-Stent Restenosis Resulting in Carotid Stent Fracture: Literature Review of Stent-in-Stent Technique as a Viable Therapeutic Option.

BACKGROUND: Carotid stent fractures are rare, and multiple etiologies have been proposed to explain their occurrence. We describe a patient with an internal carotid artery (ICA) stent who developed in-stent restenosis. We performed balloon angioplasty to address in-stent restenosis, but he developed a carotid stent fracture after the procedure. To our knowledge, balloon angioplasty has not been reported to cause stent fractures. CASE DESCRIPTION: A 72-year-old man underwent stent placement for symptomatic left ICA stenosis with residual stenosis of 55% after stent placement. He presented with transient ischemic attacks 2 months later, and work-up revealed in-stent restenosis of the left ICA. Given prior complete occlusion of right ICA and right vertebral artery and narrowing of left vertebral artery ostium, satisfactory balloon (5 × 40 mm) angioplasty was carried out. After balloon angioplasty, x-ray showed a new stent fracture, which was initially missed on immediate postoperative imaging. He presented 9 months later with symptoms of compromised cerebral perfusion. Work-up revealed the previously missed stent fracture causing blood flow changes. Peak systolic velocity in the left ICA was 383 cm/second. He underwent left ICA repeat stent placement via a stent-in-stent technique for symptomatic severe left ICA stenosis of 70% with 40% residual stenosis after new stent deployment. CONCLUSIONS: Balloon angioplasty to address in-stent restenosis can secondarily cause stent fractures. We provide evidence of successful management of stent fracture with recurrent in-stent stenosis by repeat stent placement via a stent-in-stent technique.

Air embolism related to removal of Mayfield head pins.

Venous air embolism (VAE) may be fatal and frequently carries high neurologic, respiratory, and cardiovascular morbidity. Its occurrence during anesthesia is challenging to the anesthesiologists in terms of early discovery and management. VAE during neurosurgical procedures especially in the sitting position is well known and usually prepared for it; however, VAE might happen unexpectedly as in this patient's case. A young patient underwent an exploratory pterional craniotomy for recollection of subdural hematoma and head pins were used to stabilize the head. The surgery and anesthesia were uneventful; however, he developed a sudden cardiovascular collapse at the end of surgery and immediately after removal of the Mayfield pins.