The Awake Craniotomy: A Patient's Experience and A Literature Review.

We present a case report and a literature review of the awake craniotomy procedure for mass resection, with emphasis on the historical aspects, anatomical and surgical considerations, and, uniquely, a patient's experience undergoing this procedure. This procedure is a safe and effective method for lesion resection when working in and around eloquent brain. We have described our process of guiding a patient through an awake craniotomy procedure and detailed the patient's experience in this study. We also conducted a systematic literature review of studies involving awake craniotomy over three years, 2018-2021. Lastly, we compared the methodology used by our institution and the current mostly used methods within the neurosurgical community. Several studies were identified using PubMed and Google Scholar. Awake craniotomy is a safe and effective method of achieving a high rate of resection of lesions located in and around the eloquent cortex with a low degree of postoperative neurological deficit.

Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index.

Background Traumatic brain injury (TBI) has a complex pathophysiology that has historically been poorly understood. New evidence on the pathophysiology, molecular biology, and diagnostic studies involved in TBI have shed new light on optimizing rehabilitation and recovery. The goal of this study was to assess the effect of osteopathic manipulative treatment (OMT) on peripheral and central glial lymphatics in patients with severe TBI, brain edema, and elevated intracranial pressure (ICP) by measuring changes in several parameters regularly used in management. Methodology This was a retrospective study at a level II trauma center that occurred in 2018. The study enrolled patients with TBI, increased ICP, or brain edema who had an external ventricular drain placed. Patients previously underwent a 51-minute treatment with OMT with an established protocol. Patients received 51 minutes of OMT to the head, neck, and peripheral lymphatics. The ICP, cerebrospinal fluid (CSF) drainage, optic nerve sheath diameter (ONSD) measured by ultrasonography, and Neurological Pupil Index (NPi) measured by pupillometer were recorded before, during, and after receiving OMT. Results A total of 11 patients were included in the study, and 21 points of data were collected from the patients meeting inclusion criteria who received OMT. There was a mean decrease in the ONSD of 0.62 mm from 6.24 mm to 5.62 mm (P = 0.0001). The mean increase in NPi was 0.18 (P = 0.01). The mean decrease in ICP was 3.33 mmHg (P= 0.0001). There was a significant decrease in CSF output after treatment (P = 0.0001). Each measurement of ICP, ONSD, and NPi demonstrated a decrease in overall CSF volume and pressure after OMT compared to CSF output and ICP prior to OMT. Conclusions This study demonstrates that OMT may help optimize glial lymphatic clearance of CSF and improve brain edema, interstitial waste product removal, NPi, ICP, CSF volume, and ONSD. A holistic approach including OMT may be considered to enhance management in TBI patients. As TBI is a spectrum of disease, utilizing similar techniques may be considered for all forms of TBI including concussions and other diseases with brain edema. The results of this study can better inform future trials to specifically study the effectiveness of OMT in post-concussive treatment and in those with mild-to-moderate TBI.

A Reassessment of Weaning Parameters in Patients With Spontaneous Intracerebral Hemorrhage.

Background and purpose Patients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted. Results All trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI. Conclusion The RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.

Toxic Leukoencephalopathy due to Inhalational Heroin Abuse.

Heroin-induced spongiform leukoencephalopathy (HSLE) is a rare condition that is strongly associated with heroin vapor inhalation which has become a popular method among heroin addicts because it poses a less immediate danger to the user and makes the drug much easier to use. We present a case of a 22-year-old male who presented with dysarthria and cerebellar symptoms starting, after 3 months of heroin inhalation. Diagnosis was confirmed to be HSLE after extensive diagnostic testing. HSLE is a rare complication of which the pathogenesis is poorly understood. Clinical history and characteristic findings on magnetic resonance imaging (diffuse, symmetric T2-hyperintensity, and diffusion restriction in frontal, parietal, occipital lobs, basal ganglia, and superior cerebellum) are diagnostic; however, care should be taken to exclude other etiologies. Treatment is primarily supportive; however, there is anecdotal evidence that coenzyme Q10 may be of benefit. The growing number of victims of the opioid crisis requires that physicians be aware of and counsel patients on the devastating neurological complications that can occur with abuse of these drugs.

A noninvasive method for the estimation of increased intracranial pressure in patients with severe traumatic brain injury using optic nerve sheath diameter measured on computed tomography head.

BACKGROUND: Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission. METHODS: Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18-90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors. RESULTS: A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD ≥6.0 mm + Marshall score ≥3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP ≥20 mmHg during hospitalization. CONCLUSION: Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

Efficacy of Trauma Catheter and Mushroom Tip Catheter in Evacuation of Chronic Subdural Hematoma and Complications of Drain Placement.

Objective The aim of this study was to assess the efficacy and complications of trauma catheter versus mushroom tip catheter placement in the evacuation of chronic subdural hematoma via twist drill craniostomy with closed system drainage. Background Chronic subdural hematoma (cSDH) is one of the most frequent neurosurgical pathologies in patients >70 years of age with an estimated incidence of 8.2 per 100,000 people per year. The most common risk factors for cSDH are advanced age, alcohol abuse, seizures, cerebrospinal fluid (CSF) shunts, coagulopathies, blood thinners, and patients at risk for falling. Twist drill craniostomy can be performed at the bedside under local anesthesia, making it an attractive treatment option, especially in poly-morbid patients who are poor surgical candidates. A closed drainage system is placed at the time of surgery to allow continuous drainage and promote postoperative brain expansion. Despite the increasing prevalence, limited literature exists to guide surgical management, particularly in terms of drain management and selection of catheter.  Methods This is a retrospective review of 205 patients from January 2007 to May 2017 at two-level high volume centers for the evaluation and treatment of cSDH. Inclusion criteria include patients >18 years of age with the radiographic presence of a subdural hematoma for greater than three weeks. All patients were managed with either a trauma catheter or mushroom tip catheter. All patients received computed tomography (CT) of the head without contrast prior to subdural drain placement and within 24 hours after subdural drain removal. Exclusion criteria include patients <18 years of age and patients with depressed skull fractures, vascular malformations, subdural empyema, subdural hygroma, or who initially underwent open craniotomy or burr-hole craniotomy. Results Drain efficiency in evacuating the cSDH was assessed using both radiographic and clinical markers. Analysis of 205 patients treated by twist drill craniostomy and the subsequent closed system drainage utilizing either the mushroom tip catheter or trauma catheter revealed that neither catheter was superior in producing a statistically significant change in the maximum thickness of the cSDH (p = 0.35) and midline shift (p = 0.45). Furthermore, when assessing patients clinically via utilization of the Glasgow Coma Scale (GCS), both the trauma catheter and the mushroom catheter did not show a statistically significant difference in improving GCS after the evacuation of the cSDH (p = 0.35). Neither catheter was associated with an increased incidence of hemorrhage with drain placement requiring open surgery (p = 0.12), need for additional drain placement (p = 0.13) or decline in GCS with intervention (p = 0.065). Conclusion Analysis of the 205 patients treated by twist drill craniostomy with closed system drainage for the evacuation of chronic subdural hematoma utilizing either the mushroom tip or trauma catheters revealed that neither catheter was statistically significant in radiographic or clinical improvement in evacuating cSDH. Furthermore, neither catheter was found to be associated with an increased complication risk.

Novel Method of Non-contact Remote Measurement of Neuronal Electrical Activity.

Measuring the electrical potential of a neuron cell currently requires direct contact with the cell surface. This method requires invasive probing and is limited by the deflection of electricity from baseline. From a clinical perspective, the electrical potential of the brain's surface can only be measured to a depth of one centimeter using an electroencephalogram (EEG), however, it cannot measure much deeper structures. In this trial, we attempt a novel method to remotely record the electromagnetic field (EMF) of action potential provoked from hippocampal neurons without contact. A bipolar stimulating electrode was placed in contact with the CA1 region of viable hippocampal slice from donor mice. The specimen was bathed in artifical cerebrospinal fluid (aCSF) to simulate in vivo conditions. This setup was then placed into a magnetic shielded tube. Very low-frequency EMF sensors were used to obtain recordings. The impedance of the aCSF and hippocampal slice were measured after each stimulation individually and in combination. An electromagnetic signal was detected in three out of four scenarios: (a) aCSF alone with electrical stimulus without a hippocampal slice, (b) Hippocampal slice in aCSF without electrical stimulus and, (c) Hippocampal slice in aCSF with an electric stimulus applied. Therefore, our trial suggests that EMFs from neuronal tissue can be recorded through non-invasive non-contact sensors.

A rare case of Brown-Sequard syndrome caused by traumatic cervical epidural hematoma.

BACKGROUND: Brown-Sequard syndrome (BSS) is a well-known entity that is most commonly caused by a penetrating injury to the spinal cord (e.g., stab wound or gunshot wound). It is characterized by an ipsilateral weakness (damage to corticospinal tracts) and contralateral loss of pain and temperature two levels below the lesion (damage to lateral spinothalamic tracts). Although, rarely non-penetrating injuries, tumors, disc herniations, infections, autoimmune diseases, and epidural hematomas (non-penetrating trauma and spontaneous) have contributed to BSS syndromes, there are only four cases of BSS in the literature attributed to traumatic spinal epidural hematomas. Here, we add an additional case involving a 59-year-old male. CASE DESCRIPTION: A 59-year-old male presented with a Brown-Sequard syndrome (BSS) after a motor vehicle accident. The magnetic resonance imaging (MRI) demonstrated a cervical epidural hematoma at the C7-T1 level. Following a T1 laminectomy and C6-T1 fusion, his neurological deficit markedly improved. Within six postoperative months, he regained full motor function. CONCLUSION: For this patient and others with a traumatic cervical epidural hematoma (C7T1) resulting in a BSS, early decompression (within 48 hours) should result in marked postoperative neurological improvement.