A case report of lobular intradural extramedullary capillary hemangioma in a 14-year-old patient: resection and reconstruction.

Background: Intradural, extramedullary capillary hemangiomas of the cauda equina are exceedingly rare malformations arising from the endothelial cells of the nervous system vasculature. Roughly 20 cases have been reported in the literature, with the youngest and only pediatric case being in a 17-year-old patient. We report the youngest case of intradural extramedullary capillary hemangioma of the cauda equina in a 14-year-old patient. Case Description: A 14-year-old female presented with two-month history of low back pain with bilateral leg pain and numbness. Magnetic resonance imaging (MRI) revealed an L2 well-defined homogenous contrast-enhancing intradural, extramedullary mass causing severe spinal canal stenosis. Patient underwent laminoplasty for resection of an intradural tumor. Intraoperative hemostasis was readily achieved via early identification and coagulation of the predominate feeding vessel. Postoperatively, the patient awoke with no deficits and resolved leg pain. A 3-month postoperative MRI revealed no tumor recurrence and fully healed lamina. Conclusions: Given the benign nature, the operative goal is complete excision of the tumor without damage to surrounding neural structures. Postoperatively the goal is relief of pain and improvement in neurologic function. To our knowledge we report the first case in which laminoplasty is utilized for the treatment of this pathology in a pediatric patient. Evidence for laminoplasty in this patient population is sparse and future studies are still needed. In any case, reconstruction of the surgical site in a manner that returns the patient's normal anatomy should be strongly considered especially in younger patients.

Factors Associated With Morbidity and Retreatment After Surgical Management of Nonacute Subdural Hematomas in Elderly Patients.

Background Preoperative identification of clinical, radiographic, and surgery-specific factors associated with nonacute subdural hematomas (SDHs) may enable clinicians to optimize the efficacy of the initial surgical intervention, improve outcomes, and decrease rates of surgical recurrence. Methods The authors identified patients aged ≥65 years who underwent surgical treatment of chronic, subacute, or mixed-density SDH at a level-1 trauma hospital over a ten-year period (2010-2019). Pre-and postoperative clinical, radiographic, and surgery-specific data were collected. Predictors of surgical recurrence as well as morbidity, mortality, and discharge disposition were analyzed. Results There were 268 nonacute SDHs treated surgically; 46 were chronic, 19 were subacute, and 203 were mixed density. Of these, 179 were treated with burr hole(s), 62 with miniature craniotomy, and 27 via a large craniotomy and removal of subdural membranes. Statin use was protective (OR 0.22; 95% CI 0.08, 0.60) against recurrence requiring reoperation. Preoperative use of antithrombotic agents was not significantly associated with increased recurrence requiring reoperation. Smaller preoperative hematoma thickness was associated with significantly lower mortality risk, whereas mixed-density hematomas, patient age, change in thickness after surgery, density, and presence of cisternal effacement were significantly associated with discharge disposition. Hematoma type was also associated with hospital and intensive care length of stay. Conclusions Our experience suggests that, in elderly patients, premorbid statin usage is associated with lower recurrence rates and preoperative antithrombotic use does not affect recurrence when appropriately reversed before surgery. Patient age, preoperative thickness, and hematoma type contribute to postoperative outcomes such as discharge disposition and length of stay.

Intracranial Epstein-Barr virus-associated smooth muscle tumor with superimposed cryptococcal infection: A case report.

RATIONALE: Epstein-Barr virus-associated smooth muscle tumors (EBV-SMT) are rare, virally-induced malignancies that occur almost exclusively in immunocompromised individuals. We report a very rare case of a dura-based EBV-SMT with superimposed local cryptococcal infection. PATIENT CONCERNS: An adult male with a history of untreated acquired immunodeficiency syndrome presented to our hospital with worsening headaches, diarrhea, and diffuse myalgias. DIAGNOSES: Blood cultures were positive for methicillin-resistant Staphylococcus aureus and Cryptococcus neoformans serum antigen. Magnetic resonance imaging revealed 2 adjacent enhancing masses in the right temporal lobe, perilesional edema, and mass effect of the right lateral ventricle. Histological examination and immunohistochemical stains of the surgical specimen were consistent with EBV-SMT. Cryptococcus organisms were identified within the neoplasm. INTERVENTIONS: The patient underwent complete tumor resection, received an extended course of amphotericin and flucytosine, and was restarted on antiretroviral therapy. OUTCOMES: The patient was discharged from the hospital with no focal neurological deficits. LESSONS: Epstein-Barr virus associated smooth muscle tumors are rare malignancies that occur in immunocompromised patients. Prognosis is largely dependent on immune reconstitution and treatment of concomitant infections.

Remote Development of Symptomatic Intracranial Cavernous Malformation After Stereotactic Radiosurgery.

Cavernous hemangiomas, or cavernomas, are vascular malformations that affect about 0.1-0.5% of the population and usually result from sporadic or familial mutations of genes involved with endothelial cell junctions. They are histologically described as dilated vascular clusters, and they may occur in various areas of the body. Cavernomas of the central nervous system can generate localizing symptoms, including focal neurological defects, headaches, seizures, and hemorrhage. Radiation-induced cavernomas (RICs) have been described in the literature since 1994 and have been more frequently described in children. Although there has been speculation about the pathophysiology of RICs, no consensus exists in the literature, and pathological evaluation of RICs remains sparsely reported. We present the case of a 63-year-old patient who underwent stereotactic radiosurgery for treatment of an intracranial arteriovenous malformation (AVM) and subsequently developed a symptomatic RIC seven years later that required microresection. Clinicians should exercise diligence when monitoring patients with a history of intracranial radiation because of growing evidence supporting cavernomas as potential late-stage sequelae.

Surface Area of Decompressive Craniectomy Predicts Bone Flap Failure after Autologous Cranioplasty: A Radiographic Cohort Study.

Skull bone graft failure is a potential complication of autologous cranioplasty after decompressive craniectomy (DC). Our objective was to investigate the association of graft size with subsequent bone graft failure after autologous cranioplasty. This single-center retrospective cohort study included patients age ≥18 years who underwent primary autologous cranioplasty between 2010 and 2017. The primary outcome was bone flap failure requiring graft removal. Demographic, clinical, and radiographic factors were recorded; three-dimensional (3D) reconstructive imaging was used to perform accurate measurements. Univariate and multi-variate regression analysis were performed to identify risk factors for the primary outcome. Of the 131 patients who underwent primary autologous cranioplasty, 25 (19.0%) underwent removal of the graft after identification of bone flap necrosis on computed tomography (CT); 16 (64%) of these were culture positive. The mean surface area of craniectomy defect was 128.5 cm2 for patients with bone necrosis and 114.9 cm2 for those without bone necrosis. Linear regression analysis demonstrated that size of craniectomy defect was independently associated with subsequent bone flap failure; logistic regression analysis demonstrated a defect area >125 cm2 was independently associated with failure (odds ratio [OR] 3.29; confidence interval [CI]: 0.249-2.135). Patient- and operation-specific variables were not significant predictors of bone necrosis. Our results showed that increased size of antecedent DC is an independent risk factor for bone flap failure after autologous cranioplasty. Given these findings, clinicians should consider the increased potential of bone flap failure after autologous cranioplasty among patients whose initial DC was >125 cm2.

Endoscopy-assisted early correction of single-suture metopic craniosynostosis: a 19-year experience.

In BriefThe long-term results of treating infants with metopic craniosynostosis by using endoscopic, minimally invasive techniques are reported. The impetus arose from the lack of consistent and favorable outcomes associated with calvarial vault remodeling techniques and from the very traumatic and invasive nature of these procedures. The results presented show excellent and consistent long-term outcomes that are superior to traditional methods and are associated with minimal trauma, blood loss, and anesthetic exposure, and with short surgical times.

Case of Lumbar Schwannoma Presenting with Isolated Signs and Symptoms of Intracranial Hypertension.

BACKGROUND: Hydrocephalus and intracranial hypertension are rare signs of spinal tumors when presenting in isolation, particularly with benign tumors. CASE DESCRIPTION: Herein reported is a case of a 53-year-old woman who presented with headache, blurry vision, communicating hydrocephalus, and intracranial hypertension. No primary intracranial pathology was identified, and there were no clinical signs or symptoms of intraspinal pathology. Lumbar puncture revealed elevated opening pressure, cerebrospinal fluid protein, and suspected tumor cells in the cerebrospinal fluid, thus prompting spinal imaging. A primary lumbar schwannoma was subsequently determined to underlie her symptoms, which resolved with tumor resection. CONCLUSIONS: Clinical suspicion of spinal pathology should be maintained in patients with unexplained intracranial hypertension, even in the absence of localizing signs of spinal pathology.

Correction: The impact of tackle football injuries on the American healthcare system with a neurological focus.

[This corrects the article DOI: 10.1371/journal.pone.0195827.].

The impact of tackle football injuries on the American healthcare system with a neurological focus.

BACKGROUND: Recent interest in the study of concussion and other neurological injuries has heightened awareness of the medical implications of American tackle football injuries amongst the public. OBJECTIVE: Using the National Emergency Department Sample (NEDS) and the National Inpatient Sample (NIS), the largest publicly available all-payer emergency department and inpatient healthcare databases in the United States, we sought to describe the impact of tackle football injuries on the American healthcare system by delineating injuries, specifically neurological in nature, suffered as a consequence of tackle football between 2010 and 2013. METHODS: The NEDS and NIS databases were queried to collect data on all patients presented to the emergency department (ED) and/or were admitted to hospitals with an ICD code for injuries related to American tackle football between the years 2010 and 2013. Subsequently those with football-related neurological injuries were abstracted using ICD codes for concussion, skull/face injury, intracranial injury, spine injury, and spinal cord injury (SCI). Patient demographics, length of hospital stay (LOS), cost and charge data, neurosurgical interventions, hospital type, and disposition were collected and analyzed. RESULTS: A total of 819,000 patients presented to EDs for evaluation of injuries secondary to American tackle football between 2010 and 2013, with 1.13% having injuries requiring inpatient admission (average length of stay 2.4 days). 80.4% of the ED visits were from the pediatric population. Of note, a statistically significant increase in the number of pediatric concussions over time was demonstrated (OR = 1.1, 95% CI 1.1 to 1.2). Patients were more likely to be admitted to trauma centers, teaching hospitals, the south or west regions, or with private insurance. There were 471 spinal cord injuries and 1,908 total spine injuries. Ten patients died during the study time period. The combined ED and inpatient charges were $1.35 billion. CONCLUSION: Injuries related to tackle football are a frequent cause of emergency room visits, specifically in the pediatric population, but severe acute trauma requiring inpatient admission or operative interventions are rare. Continued investigation in the long-term health impact of football related concussion and other repetitive lower impact trauma is warranted.

Bone flap salvage in acute surgical site infection after craniotomy for tumor resection.

Craniotomy surgical site infections are an inherent risk and dreaded complication for the elective brain tumor patient. Sequelae can include delays in resumption in adjuvant treatments for multiple surgeries if staged cranioplasty is pursued. Here, the authors review their experience in operative debridement of surgical site infections with single-stage reimplantation of the salvaged craniotomy bone flap. A prospectively maintained database of a single surgeon's neuro-oncology patients from 2009 to 2017 (JRF) was queried to identify 11 patients with surgical site infection after craniotomy for tumor resection. All patients underwent a protocol of aggressive operative debridement including drilling the bone edges and intraoperative flap sterilization with single-stage reimplantation, followed by tailored-antibiotic therapy. Ten of the 11 patients with frankly contaminated bone flaps from surgical site infection were able to be salvaged in a single-stage procedure. Five of these patients underwent adjuvant chemotherapy and/or radiation without secondary complication. There was one treatment failure in a delayed fashion which required additional surgery for craniectomy; however, this occurred after adjuvant treatment was administered. Surgical debridement and bone flap salvage is safe and cost-effective in managing acute surgical site infections after craniotomy for tumors. Additionally, this practice is likely beneficial in expediting the resumption of cancer therapy.

Surgical evacuation of acute subdural hematoma in octogenarians: a ten-year experience from a single trauma center.

BACKGROUND: Elderly patients presenting with an acute subdural hematoma (aSDH) have historically had unfavorable outcomes. METHODS: We retrospectively reviewed patient records from 2005 through 2015 that were ≥80 years of age and underwent surgical evacuation of aSDH. RESULTS: Thirty-four patients met inclusion criteria, with a mean age of 84 years (range 80-91). Glascow Outcome Scale (GOS) of 4-5 was deemed a good outcome and a GOS 1-3 was deemed to be a poor outcome. Six patients had good outcome at last follow up and 27 patients had poor outcome. Patients with a higher presenting Glascow Coma Scale (GCS) trended towards better outcome [(good: mean 13.1, median 14.5, IQR 12.5-15) vs. (poor: mean 9.6, median 10, IQR 6-14) p = 0.06]. Patients with a higher in-hospital post-operative GCS score had significantly better overall outcome than patients who left the hospital with a lower GCS score [(good: mean 14.5, median 14.5, IQR 14-15) vs. (poor: mean 8.4, median 9, IQR 4-11) p = 0.001]. Patients with a good outcome had a median aSDH thickness of 17mm (IQR 12.75-19.75) while patients with a poor outcome had a median thickness of 20mm (IQR 16-24.5); p = 0.17. In addition, patients with a good outcome had a median midline shift of 10mm (IQR 6-12.5), while patients with a poor outcome had a median midline shift of 14mm (IQR 10-20); p = 0.07. CONCLUSIONS: The prognosis for elderly patients with large aSDH remains poor, but a subset of patients can benefit from surgical intervention.

Primary atypical teratoid rhabdoid tumor in the adult spine.

BACKGROUND: Atypical teratoid/rhabdoid tumor (ATRT) is a highly aggressive tumor of the central nervous system (WHO grade IV), which is most frequently found intracranially in young children and infants. Only three prior cases of primary ATRT involving the adult spine were found following a literature review, and the average survival for these patients was only 20 postoperative months. CASE DESCRIPTION: A 43 year-old female presented with an acute exacerbation of chronic neck pain. While awaiting magnetic resonance (MR) studies of the cervical spine, she was found pulseless in her room. Although cardiopulmonary resuscitation was successful, she was found to be quadriplegic. The subsequent cervical MR imaging revealed a C1-3 intradural, extramedullary ventrolateral mass, markedly compressing the upper cervical spinal cord. Following successful surgical resection of the lesion, which proved pathologically to be an ATRT, she was treated with a full course of fractionated radiation therapy. Over the successive 6-month period, her neurological examination continued to improve to 4-/5 functional strength in her upper extremities, however, remained with 2/5 nonfunctional strength in her legs. CONCLUSIONS: ATRT involving the adult spine are rare and may often be misdiagnosed. This study points out that aggressive surgery followed by radiation therapy may improve outcome.

Implant compositions for the unidirectional delivery of drugs to the brain.

The overall objective of this study was to design and characterize the properties of a bioadhesive trilayer sustained-release implant device for the unidirectional local delivery of anticancer compounds to the brain following the removal of glioblastoma multiforme tumors. Using acetaminophen as a model drug compound, we compressed trilayer wafers that contained (i) a bioadhesive layer, (ii) a drug layer that contained a lipid and a pore-forming hydrophilic polymer, and (iii) a third layer comprising a lipid substance. To maintain a unidirectional pathway of drug release from these trilayer wafers, the edges and the surface lipophilic layer were coated with molten wax followed by cooling of the wafer. These wafers were subsequently heat cured to promote interlayer adhesion in the device. Polyethylene oxide was utilized both as the bioadhesive layer and the pore-forming hydrophilic polymer. Glyceryl behenate was employed as the lipid. The drug release properties of the trilayer wafer were a function of (i) the molecular weight and concentration of polyethylene oxide in the drug-containing lipid layer, (ii) the presence of the bioadhesive layer on the wafer, and (iii) the lipid coating applied to the top and sides of the delivery system. The unidirectional release of the drug occurred from the device through the bioadhesive layer, and zero-order release kinetics resulted over a 10-day period after a 3-day lag time. During this period, <10% of the drug had been released from the wafer. All of the drug was released by 21 days.

Temporopolar bridging veins during anteromedial temporal strip placement: a case report on complication avoidance†.

INTRODUCTION: Surgery for temporal lobe epilepsy is proven to be beneficial in the treatment of medically refractory temporal lobe epilepsy. Subdural electrode strips are commonly passed in a blind fashion, allowing additional EEG coverage without requiring larger exposure. However, this increases risk of complication, specifically through vascular injury. CASE REPORT: We present a case of a 22-year-old male with medically refractory epilepsy. During passage of an anterior medial temporal strip electrode, resistance was encountered despite multiple attempts and redirection. This strip was abandoned. During the subsequent resection operation, a large temporopolar bridging vein complex was noted and photographed precisely where we encountered resistance. CONCLUSION: Although much frequently less encountered than paramedian subdural strips, anterior medial temporal strip subdural electrodes may indeed injure large bridging veins. As subdural strips are passed where bony exposure is minimal, potential disastrous complications may arise if extreme caution is not used.

Functional Hemispherectomy for Refractory Status Epilepticus in 2 Adults.

BACKGROUND: Status epilepticus (SE) is a medical emergency, as deleterious long-term effects are well known. Medically induced burst suppression is often required if first-line and second-line treatments fail. Surgical intervention can be considered in some patients after prolonged treatment failure of medically induced coma. Multiple surgical options for terminating SE have been demonstrated in the literature, with only 2 reports including hemispherectomy in adults. CASE DESCRIPTION: We present 2 cases of adults with refractory SE who failed more conservative medical/surgical treatment but responded to functional hemispherectomy. Pertinent electroencephalography and imaging findings are discussed. In addition, all previously published pediatric and adult cases are briefly reviewed. CONCLUSIONS: Functional hemispherectomy can be considered in patients, including adults, with super-refractory SE and diffuse hemispheric onset. We report acceptable outcomes and quality of life in our 2 patients.

Intracerebral fibroma: a case report and review of the literature.

Intracerebral fibromas are among the most rare neoplasms found in the central nervous system. Ten previously reported cases have been documented in the literature including only two reported cases since 1985. As a result, little is known about these uncommon intracerebral fibrous tumors. We report a case of an intracerebral fibroma without dural or leptomeningeal attachment, discuss the pertinent diagnostic findings and briefly review all prior reports of this entity.

Pseudomyogenic hemangioendothelioma (epithelioid sarcoma-like hemangioendothelioma, fibroma-like variant of epithelioid sarcoma) of the thoracic spine.

PURPOSE: Pseudomyogenic hemangioendothelioma is a soft tissue tumor found in young adults, predominantly males. The tumor has been reported in various locations in the body, including the head, neck, chest wall, abdominal wall, genital region, and extremities. Until now, there has been no indication of occurrence in the spine. METHODS: A 25-year-old male presented with spinal cord compression, due to an extradural tumor involving the third and fourth thoracic vertebrae with extension into the right pleural cavity. RESULTS: Histopathologic examination revealed a pseudomyogenic hemangioendothelioma, also described as epithelioid sarcoma-like hemangioendothelioma, or fibroma-like variant of epithelioid sarcoma. CONCLUSION: We describe the first occurrence of pseudomyogenic hemangioendothelioma in the thoracic spine. According to previous reports based on other locations, the tumor has an indolent clinical course with a small risk of metastasis, therefore complete macroscopic excision is the treatment of choice. Local recurrence may occur even with complete surgical resection, requiring close follow-up; adjuvant therapy is warranted.