Baclofen Toxicity Mimicking Brain Death: A Case Report of a Pediatric Patient.

BACKGROUND: Baclofen is commonly used in both pediatric and adult patients to treat spasticity secondary to spinal cord and cerebral pathology. A broad range of symptoms and severity of baclofen toxicity have been described. However, to our knowledge, there are no reports to date of baclofen toxicity mimicking brain death in pediatric patients. OBJECTIVE: We reviewed the presentation, clinical course, diagnostic studies including imaging and electroencephalography, and outcome of a patient with transient coma and loss of brainstem reflexes mimicking brain death secondary to baclofen toxicity. METHODS: During a baclofen pump refill, a 12-year-old boy with cerebral palsy had inadvertent injection of 12,000 µg of baclofen into the pocket around his pump. Within an hour, he presented with acute altered mental status that rapidly progressed to a comatose state with absent brainstem reflexes. RESULTS: After appropriate management, the patient returned to his neurological baseline by hospital day 3. DISCUSSION: We reviewed the literature for varying presentations of baclofen toxicity and associated electroencephalography findings, mechanism of overdose, and different management options. In this case, the mechanism of baclofen toxicity was suspected to be secondary to extravasation from the pump pocket and subsequent systemic absorption. CONCLUSIONS: Patients with baclofen toxicity may have a dramatic presentation and an initial examination mimicking brain death. Given its rarity, this clinical entity may not be readily recognized, and there is potential for misinterpretation of diagnosis and prognosis. It is important for physicians to be familiar with this clinical scenario to avoid false declaration of brain death.

Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review.

BACKGROUND: Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy. METHODS: PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection. RESULTS: The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques. CONCLUSIONS: Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.

A novel integrative healing services approach for neurosurgery inpatients: Preliminary experiences and cost calculations.

BACKGROUND: Neurosurgery inpatients are oftentimes critically ill, and face significant stress, post-operative pain, and/or emotional distress. As a result, the use of non-pharmacologic, alternative therapies as adjuncts in surgical care may benefit this patient population. Hospital economics related to integrative services may also provide additional incentive to providing alternative therapies. This study characterizes and evaluates how Integrative Healing Services (IHS) affects patient pain levels and length of stay. We also performed a literature review to examine national trends in inpatient integrative healing. METHODS: An IHS team (e.g. acupuncture, healing touch, music therapy, pet therapy, and counseling) was incorporated into the treatment regimen of neurosurgery inpatients (with >4days of stay) with chronic or intractable pain, stress or depression, and/or patients intolerant to or who failed physical or occupational therapy. RESULTS: 34 charts were retrospectively reviewed, with 17 patients receiving IHS (11 cranial and 6 spine cases), and 17 age and gender matched controls receiving routine care (11 cranial and 6 spine patients). Overall, 71% (12/17) of patients had a reduction in pain medication consumption, with 55% (6/11) of cranial and 100% (6/6) of spine patients reporting a reduction compared to baseline. The average pre-treatment pain-scale score was 5.5 out of 10 across all patients, while the average post-treatment pain-scale score was 3 out of 10 (p<0.01). 59% of patients had improved mobility. The average length of stay in the IHS group was 12.6days, and 19.6days in the routine care group (range 4-45) (p<0.01). CONCLUSIONS: IHS intervention may be an effective option for treating pain and decreasing hospital length of stay. National trends support the use of integrative healing and will likely continue to increase as further studies are performed.

Intracranial Myeloid Sarcoma Metastasis Mimicking Acute Subdural Hematoma.

Myeloid sarcoma, a rare consequence of myeloproliferative disorders, is rarely seen in the central nervous system, most commonly in the pediatric population. Although there are a handful of case reports detailing initial presentation of CNS myeloid sarcoma in the adult population, we have been unable to find any reports of CNS myeloid sarcoma presenting as a large mass lesion in a herniating patient. Here, we present the case of a patient transferred to our facility for a very large subdural hematoma. Based on imaging characteristics, it was felt to be a spontaneous hematoma secondary to coagulopathy. No coagulopathy was found. Interestingly, he did have a history of acute myeloid leukemia (AML) diagnosed 2 months previously, and intraoperatively he was found to have a confluent white mass invading both the subdural and subarachnoid spaces. There was minimal associated hemorrhage and final pathology showed myeloid sarcoma. This is the first report we are aware of in which CNS myeloid sarcoma presented as a subdural metastasis and also the first report in which we are aware of this etiology causing a herniation syndrome secondary to mass effect.

Membranectomy in Chronic Subdural Hematoma: Meta-Analysis.

OBJECTIVE: Initial management strategies of chronic subdural hematoma (cSDH) are controversial and range from bedside twist-drill or burr-hole drainage to craniotomy with membranectomy (CWM). We aim to 1) perform a meta-analysis of the available data on the outcomes of CWM for treatment of cSDH in published English-language literature and 2) evaluate collective outcomes of CWM with respect to morbidity, mortality, and recurrence rates. METHODS: A search of English-language literature performed in PubMed, Ovid, and Cochrane databases using key words ("subdural hematoma" or "chronic subdural hematoma") and ("membrane" or "membranectomy") from inception to December 2016 was conducted. Studies reporting outcomes of CWM in cSDH were included. Mortality, morbidity, follow-up duration, and recurrence rate data were extracted and analyzed. Pooled estimates and confidence intervals (CIs) were calculated for all outcomes using a random-effects model. RESULTS: Of 301 articles found, 17 articles containing 5369 patients met our eligibility criteria. Mean follow-up duration ranged from 1-30.8 months. Collective mean mortality and morbidity rates were 3.7% and 6.9%, respectively (95% CI 2-5.4% and 2.1-11.6%; P < 0.001 and P = 0.004). The collective mean recurrence rate was 7.6% (95% CI: 5%-10.2%; P < 0.001). CONCLUSIONS: Clinical data on outcomes of CWM in cSDH are limited to single institutional analyses, with considerable variation in recurrence rates and follow-up time. The rates we reported are comparable with the 5% mortality and 3%-12% morbidity rates and lower than the 10%-21% recurrence rate in the literature for burr holes or craniotomy without membranectomy. This meta-analysis provides an in-depth analysis of available data and reviews reported outcomes.