Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report.

PURPOSE: Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION: An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION: TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Neurorehabilitation Through Synergistic Man-Machine Interfaces Promoting Dormant Neuroplasticity in Spinal Cord Injury: Protocol for a Nonrandomized Controlled Trial.

BACKGROUND: Spinal cord injury (SCI) constitutes a major sociomedical problem, impacting approximately 0.32-0.64 million people each year worldwide; particularly, it impacts young individuals, causing long-term, often irreversible disability. While effective rehabilitation of patients with SCI remains a significant challenge, novel neural engineering technologies have emerged to target and promote dormant neuroplasticity in the central nervous system. OBJECTIVE: This study aims to develop, pilot test, and optimize a platform based on multiple immersive man-machine interfaces offering rich feedback, including (1) visual motor imagery training under high-density electroencephalographic recording, (2) mountable robotic arms controlled with a wireless brain-computer interface (BCI), (3) a body-machine interface (BMI) consisting of wearable robotics jacket and gloves in combination with a serious game (SG) application, and (4) an augmented reality module. The platform will be used to validate a self-paced neurorehabilitation intervention and to study cortical activity in chronic complete and incomplete SCI at the cervical spine. METHODS: A 3-phase pilot study (clinical trial) was designed to evaluate the NeuroSuitUp platform, including patients with chronic cervical SCI with complete and incomplete injury aged over 14 years and age-/sex-matched healthy participants. Outcome measures include BCI control and performance in the BMI-SG module, as well as improvement of functional independence, while also monitoring neuropsychological parameters such as kinesthetic imagery, motivation, self-esteem, depression and anxiety, mental effort, discomfort, and perception of robotics. Participant enrollment into the main clinical trial is estimated to begin in January 2023 and end by December 2023. RESULTS: A preliminary analysis of collected data during pilot testing of BMI-SG by healthy participants showed that the platform was easy to use, caused no discomfort, and the robotics were perceived positively by the participants. Analysis of results from the main clinical trial will begin as recruitment progresses and findings from the complete analysis of results are expected in early 2024. CONCLUSIONS: Chronic SCI is characterized by irreversible disability impacting functional independence. NeuroSuitUp could provide a valuable complementary platform for training in immersive rehabilitation methods to promote dormant neural plasticity. TRIAL REGISTRATION: ClinicalTrials.gov NCT05465486; https://clinicaltrials.gov/ct2/show/NCT05465486. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/41152.

Tissue Engineering of Human Intervertebral Disc: A Concise Review.

Intervertebral disc (IVD) represents a structure of crucial structural and functional importance for human spine. Pathology of IVD institutes a frequently encountered condition in current clinical practice. Degenerative disc disease (DDD), the principal clinical representative of IVD pathology, constitutes an increasingly diagnosed spinal disorder associated with substantial morbidity and mortality in recent years. Despite the considerable incidence and socioeconomic burden of DDD, existing treatment modalities including conservative and surgical methods have been demonstrated to provide a limited therapeutic effect, being not capable of interrupting or reversing natural progress of underlying disease. These limitations underline the requirement for development of novel, innovative, and more effective therapeutic strategies for DDD management. Within this literature framework, compromised IVD replacement with a viable IVD construct manufactured with tissue-engineering (TE) methods has been recommended as a promising therapeutic strategy for DDD. Existing preliminary preclinical data demonstrate that proper combination of cells from various sources, different scaffold materials, and appropriate signaling molecules renders manufacturing of whole-IVD tissue-engineered constructs a technically feasible process. The aim of this narrative review was to critically summarize current published evidence regarding particular aspects of IVD-TE, primarily emphasizing in providing researchers in this field with practicable knowledge to enhance clinical translatability of their research and informing clinical practitioners about the features and capabilities of innovative TE science in the field of IVD-TE. Impact Statement Human intervertebral disc (IVD) pathology represents an extremely frequent condition in current clinical practice. Given the considerable limitations of available treatment options, deployment of novel and groundbreaking therapeutic modalities constitutes a rather urgent need. Tissue engineering of entire human IVD, a technically feasible process within laboratory framework, is theoretically capable of overcoming limitations that characterize currently applied therapeutic measures. Optimization of laboratory manufacturing techniques in conjunction with more diligent in vivo evaluation of tissue-engineered constructs are expected to lay the foundations for clinical trials initiation.

Syringomyelia resolution after anterior cervical discectomy: A case report and literature review.

BACKGROUND: Syringomyelia is rarely associated with cervical disc herniations and/or spinal stenosis. CASE DESCRIPTION: A 62-year-old male presented with a 4-month history of right brachial pain and hyposensitivity in the C5 distribution. The cervical magnetic resonance (MR) imaging scan revealed a C5-C6 right anterolateral disc herniation with syringomyelia extending from C5-C6 to T1. Following a C5-C6 anterior cervical discectomy and fusion (ACDF), the patient's symptoms resolved. The 3-month postoperative MR documented total resolution of the syrinx. Notably, due to residual neuropathic pain, the patient required a subdural spinal cord stimulator which was placed without any complications. CONCLUSION: Syringomyelia rarely occurs in conjunction with cervical disc disease and stenosis, and even more infrequently resolves following an ACDF. Future research should focus on the etiology of syrinx formation in these patients and should explore their response to various treatment modalities.

Gross total resection of intracisternal accessory nerve schwannomas using a familiar midline suboccipital subtonsilar approach.

BACKGROUND: Intracisternal Accessory Nerve Schwannomas (ANS) constitute a rare clinical entity with only a few cases reported so far. Their symptoms are usually due to brainstem compression and not manifested until they render of great size. Secondary neuropathy and muscle atrophy are other late signs. The hitherto reported literature advocates a suboccipital craniotomy as a suitable approach. In most of the cases the spinal root was the location tumor arose from. Gross total resection was possible to be carried out in most cases with only sporadic tolerable postoperative deficits reported. CASE DESCRIPTION: We hereby present three cases of patients with intracisternal ANS treated in the same fashion. Two patients were male and one female. Two patients complained of mainly chronic headaches and neck pain, whereas in the third patient the lesion was found incidentally. Only one patient suffered post-operatively cerebrospinal fluid leakage and wound healing complication, which was treated with revision surgery and administration of antibiotics. None of the patients had postoperative neurological deficits. Furthermore, we conducted a review of the relevant literature where we noted that there is no consensus yet with regards to the appropriate surgical approach. CONCLUSIONS: Based on relevant anatomical studies, we advocate that suboccipital subtonsilar approach provides a wide corridor to the area of lesion allowing complete and safe resection of intracisternal ANS. We thus support that, in most cases, the neurosurgeon should consider using this familiar approach for treating this rare lesion.

Lasting bilateral mydriasis after traumatic brain injury may not always be a lost case.

BACKGROUND: Lasting bilateral mydriasis and absence of pupillary light reflex following severe traumatic brain injury (TBI) are considered signs of irreversible brainstem damage and have been strongly associated with poor outcome. CASE DESCRIPTION: A young female patient presented with severe TBI, contusions, and diffuse brain edema. She was initially treated medically, but developed delayed secondary refractory intracranial hypertension and bilaterally dilated, non-reactive pupils for 12 h. Wide decompressive craniectomy and dural incisions were performed. The patient presented gradual improvement in her clinical condition [Glasgow Coma Scale (GCS) 13/15]. Delayed recurring infections lead to the patient's death due to sepsis after 3 months. CONCLUSION: In light of recent studies, lasting bilateral mydriasis may not always be considered a decisive factor for non-escalation of treatment, as variability among TBI patients and outcomes has been demonstrated. Wide decompressive craniectomy is viable for controlling refractory intracranial hypertension in hemodynamically stable patients.

Anterolateral meningioma of the foramen magnum and high cervical spine presenting intradural and extradural growth in a child: case report and literature review.

PURPOSE: We report a rare case of anterolateral meningioma of the foramen magnum (FMM) and high cervical spine presenting both intradural and extradural growth in a 7.5-year-old boy. We also performed a review of the relevant peer-reviewed literature. METHODS: The patient presented with progressive tetraparesis and gait instability. Neuroimaging revealed an anterolateral tumor of the foramen magnum, C1 and C2 cervical spine level. The patient was treated in two stages: During the first operation, the extradural part was resected while the intradural part was removed in a second operation. Following the second operation, the patient showed almost complete neurological recovery as a result of cervical spinal cord and brainstem decompression but was complicated with cerebrospinal fluid leakage and infection by Acinetobacter. He sustained two further operations for dural sealing and external ventricular drainage and was treated with intraventricular administration of antibiotics. RESULTS: Histopathology of the tumor confirmed a meningotheliomatous meningioma. At the 6-month post-op follow-up examination, the patient exhibited complete neurological recovery and no radiological tumor recurrence. To the authors' best knowledge, we report the third case of sporadic pediatric meningioma of the foramen magnum and high cervical compartments with an extradural growth. CONCLUSIONS: Accurate pre-operative estimation of possible extradural growth is crucial towards surgical planning and sufficient treatment. Treatment of choice is total resection in a single operating session to avoid re-operations and increased risk of complications. If not possible, a re-operation should always attempt to secure the desired result.

Repair of Temporal Bone Encephalocele following Canal Wall Down Mastoidectomy.

We report a rare case of a temporal bone encephalocele after a canal wall down mastoidectomy performed to treat chronic otitis media with cholesteatoma. The patient was treated successfully via an intracranial approach. An enhanced layer-by-layer repair of the encephalocele and skull base deficit was achieved from intradurally to extradurally, using temporalis fascia, nasal septum cartilage, and artificial dural graft. After a 22-month follow-up period the patient remains symptom free and no recurrence is noted.

Spontaneous spinal epidural hematoma secondary to extradural arteriovenous malformation in a child: a case-based update.

INTRODUCTION: The aim of this study was to report a rare pediatric case of spontaneous spinal epidural hematoma (SSEH) mimicking Guillain-Barré syndrome (GBS), secondary to an epidural arteriovenous malformation (AVM). Furthermore, a case-based update and insight into the entity is attempted. METHODS: An 8-year-old male presented with progressing severe lower limb weakness and no traumatic history. Presentation was mimicking GBS with ascending symptoms. Magnetic resonance (MR) scan revealed a dorsal epidural mass, extending from C6-C7 to T2, compressing the spinal cord. Emergency laminoplasties and surgical evacuation of the hematoma were performed. An up-to-date review of reported SSEH cases in children was conducted, with emphasis on underlying vascular malformations (epidural AVMs in particular). Pathogenesis, predisposing factors, imaging, diagnosis, treatment and outcome are discussed. RESULTS: The hematoma was successfully evacuated. A vascular membrane on the dura was peeled off and sent for histopathology. There was no evidence of intradural vascular penetration. The patient improved postoperatively and was able to walk with support 7 months later. Histology revealed closely packed thin-walled angiomatous structures with wide lumens (filled with red blood cells) with walls composed of collagen and smooth muscle fibers, findings consistent with AVM. CONCLUSIONS: Non-traumatic SSEH is rare in the pediatric population. Although vascular malformations are suspected, they are extremely rarely identified histopathologically. This case represents one of the very few reports of pediatric SSEH caused by a histologically proven, purely epidural AVM. High index of clinical suspicion and low threshold for MR can lead to timely diagnosis and prompt treatment with good functional outcome.

Pilomyxoid astrocytoma of the cervical spinal cord in a child with rapid progression into glioblastoma: case report and literature review.

INTRODUCTION: Pilomyxoid astrocytoma (PMA) is a recently described glial tumor with similarities to pilocytic astrocytomas, yet with distinct histopathological characteristics and a more aggressive behavior. It occurs predominantly in the hypothalamic/chiasmatic region. Only four patients with spinal cord PMA have been reported in the pediatric population. The 2007 WHO Working Group recognized PMA as a new variant and recommended an assignment to WHO grade II. OBJECTIVE: The purpose of this paper was to report a rare location, address the aggressive behavior and rapid progression, and based on the specific patient, to review the literature and discuss current treatment strategies. CASE PRESENTATION: A 12-year-old girl presented with motor and sensory deficits of the left side as well as gait disturbance. Imaging revealed an intramedullary tumor extending from C2 to C7. The patient improved impressively after surgical resection. Histopathological findings were consistent with PMA. Three months later, the patient presented with rapid neurological deterioration. Histopathology after the second operation was consistent with glioblastoma. The outcome was fatal 12 months after initial diagnosis, despite adjuvant therapy. CONCLUSIONS: This is the fifth pediatric spinal cord PMA in literature. Furthermore, it is the only documented patient with rapid recurrence and progression within 3 months into a glioblastoma. The question of a sampling error affecting initial pathology is raised. Based on contemporary literature data, we discuss the further treatment options, as there are no guidelines yet. Efforts towards registries should be encouraged, as the documentation of PMA might lead to more evidence based treatment strategies.

A light and electron microscopic study of the limb long bones perichondral ossification in the quail embryo (Coturnix coturnix japonica).

The perichondral ossification of the limb long bones in the quail embryo is investigated, in this study, by means of light and electron microscopy. Longitudinal sections of the humerus, radius, ulna, femur, tibia and fibula stained with haematoxylin-eosin were examined by the light microscope. Ultrathin cross sections were selected for the electron microscope as well. Light microscopic analysis showed that the ossification began at the same time in the long bones of the wing and leg. At the embryonic day 6, all the cartilaginous rudiments consisted of three zones. The central zone composed of hypertrophic chondrocytes, a second zone on either side of the central zone, which consisted of flattened cells and a third zone, which represented the epiphyseal region. A thin sheath of osteoid and a bi-layered perichondrium-periosteum surrounded the central zone of the cartilaginous rudiments of the long bones. The perichondrium consisted of a layer of osteoblasts, in contact with the cartilage, and a layer of fibroblasts. At the embryonic day 7, the thickness of the calcified osteoid ring increased and a vasculature appeared between the layer of osteoblasts and the layer of fibroblasts. At the embryonic day 8, a second sheath of periosteal bone began to be formed. Concurrently, vascular and perivascular elements began to invade the cartilage. The ossification spread towards the distal ends of both the diaphysis. At the electron microscopic level, the osteoblasts of the perichondium showed cytoplasmatic characteristics of cells involved in protein synthesis. The perichondral ossification is the first hallmark of the osteogenesis in the long bones. The observations reported above, are in accordance with previous studies in the chick embryo.

Bone morphogenetic protein expression in newborn rat kidneys after prenatal exposure to radiofrequency radiation.

Effects of nonthermal radiofrequency radiation (RFR) of the global system of mobile communication (GSM) cellular phones have been as yet mostly studied at the molecular level in the context of cellular stress and proliferation, as well as neurotransmitter production and localization. In this study, a simulation model was designed for the exposure of pregnant rats to pulsed GSM-like RFR (9.4 GHz), based on the different resonant frequencies of man and rat. The power density applied was 5 microW/cm2, in order to avoid thermal electromagnetic effects as much as possible. Pregnant rats were exposed to RFR during days 1-3 postcoitum (p.c.) (embryogenesis, pre-implantation) and days 4-7 p.c. (early organogenesis, peri-implantation). Relative expression and localization of bone morphogenetic proteins (BMP) and their receptors (BMPR), members of a molecular family currently considered as major endocrine and autocrine morphogens and known to be involved in renal development, were investigated in newborn kidneys from RFR exposed and sham irradiated (control) rats. Semi-quantitative duplex RT-PCR for BMP-4, -7, BMPR-IA, -IB, and -II showed increased BMP-4 and BMPR-IA, and decreased BMPR-II relative expression in newborn kidneys. These changes were statistically significant for BMP-4, BMPR-IA, and -II after exposure on days 1-3 p.c. (P <.001 each), and for BMP-4 and BMPR-IA after exposure on days 4-7 p.c. (P <.001 and P =.005, respectively). Immunohistochemistry and in situ hybridization (ISH) showed aberrant expression and localization of these molecules at the histological level. Our findings suggest that GSM-like RFR interferes with gene expression during early gestation and results in aberrations of BMP expression in the newborn. These molecular changes do not appear to affect renal organogenesis and may reflect a delay in the development of this organ. The differences of relative BMP expression after different time periods of exposure indicate the importance of timing for GSM-like RFR effects on embryonic development.