Intraventricular haemorrhage due to re-ruptured arteriovenous malformation cleared with tissue plasminogen activator administered through a pre-existing ventriculoperitoneal shunt.

In the context in intraventricular haemorrhage (IVH), intrathecal thrombolytic agents administered in conjunction with extraventricular drainage have been demonstrated to clear larger volumes of blood and reduce mortality rates. However, patients with arteriovenous malformations (AVM) have been mostly excluded from clinical trials. We describe a patient with hydrocephalus secondary to a ruptured AVM who was treated via external ventriculostomy, which was subsequently converted to a ventriculoperitoneal shunt (VPS). Eight months later, the AVM re-ruptured, causing IVH and rendering the patient comatose. Taking into consideration the patient's poor outlook, a single dose of intraventricular tissue plasminogen activator (t-PA) was administered through the shunt reservoir. The shunt maintained its function and the patient's condition ultimately improved. This impressive case demonstrates the utility of t-PA administered through an existing VPS in the setting of IVH due to ruptured AVM, highlighting its lifesaving potential in the appropriate patient and overall decrease in the cost of care by mitigating the need for shunt revision.

Review and analysis of modern lumbar spinal fusion techniques.

PURPOSE: A variety of different lumbar spinal fusion techniques have been developed. In this study, we review published medical literature highlighting the differences between lumbar interbody fusion techniques with regard to their surgical technique, clinical outcomes, and complications. MATERIALS AND METHODS: PubMed, ScienceDirect, and Google Scholar searches were performed for studies published between January 1990 to April 2018 reporting spinal fusion surgery clinical outcomes of at least one fusion technique. Clinical outcomes were extracted and pooled by surgical technique. Chi-squared analyses and Fisher Exact Tests were used to determine differences in rates between groups. RESULTS: PLIF had the highest rate of successful fusion (97% [155/159]) and the lowest rate of complications (4% [6/131]). A chi square analysis revealed a significant difference in fusion success in PLIF compared to PLF (84% [278/330], p < .001). PLIF also had significantly fewer complications compared to PSF (14.7% [251/1709], p = .001), PLF (13.4% [47/351], p = .008), ALIF (14.2% [22/155], p = .008), and LIC (13.9% [47/339], p = .005). Additionally, there were significant differences in the rate of successful fusion when comparing lateral interbody cage (LIC) techniques (p = .041), which include OLIF (100% [63/63]), DLIF (92% [24/26]), and XLIF (87% [67/77]). LIC techniques overall had higher fusion success rates (93.0% [154/166] compared to PLF (p = .01), but a higher rate of complications (14% [47/339]) compared to PLIF (p = .005) and TLIF (6% [17/259], p = .005). CONCLUSIONS: Overall, PLF and XLIF have the lowest fusion success rates, and OLIF demonstrated a trend of higher fusion rates among LIC. Techniques that utilized interbody fusion tended to increase the rate of fusion. While interbody fusion techniques offer higher rates of fusion, complication rates also tend to rise with the increase in complexity of the surgical technique, as with OLIF which notably has the highest fusion rate and complication rate.

Atlanto-occipital Dissociation in the Setting of Relatively Normal Radiologic Findings.

BACKGROUND: Craniocervical junction (CCJ) dislocations are often fatal. Atlanto-occipital dissociation can be challenging to diagnose, especially in patients who present with absent or subtle radiologic signs. CASE DESCRIPTION: A neurologically intact 37-year-old patient presented to the hospital following a high-speed motor vehicle accident. Initial computed tomography scans showed normal CCJ anatomy, but magnetic resonance imaging (MRI) of the CCJ was performed to further evaluate perimesencephalic subarachnoid hemorrhage. MRI revealed partial disruption of the anterior atlantoaxial membrane and tectorial membrane as well as complete disruption of the posterior atlanto-occipital membrane, ligamentum flavum, and apical ligament, signifying atlanto-occipital dissociation. Halo spinal immobilization was performed in preparation for stabilization with posterior occipitocervical fusion; however, the CCJ distracted widely during surgery owing to the accident-related dislocation, signifying an unstable fracture. Posterolateral fusion was performed, and the distraction injury was corrected via posterior surgical instrumentation. CONCLUSIONS: Normal occiput-C1 craniometric parameters in the setting of unexplained perimesencephalic subarachnoid hemorrhage does not eliminate the possibility of missed or delayed diagnosis of traumatic atlanto-occipital dissociation injuries. Cervical MRI without contrast should be considered in patients with vertebral artery dissection or perimesencephalic subarachnoid hemorrhage after a blunt injury with neck pain. When MRI shows evidence of disruption of ≥2 atlanto-occipital ligaments, surgical stabilization should be considered, as these are clinically very unstable injuries.

Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage.

BACKGROUND: Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage. OBJECTIVE: To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm. METHODS: Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons. RESULTS: A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01). CONCLUSION: No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.

The ABCs of accurate volumetric measurement of cerebral hematoma.

BACKGROUND AND PURPOSE: Both initial hematoma volume and hematoma growth are independent predictors of clinical outcomes and mortality among intracerebral hemorrhage patients. The purpose of this study was to evaluate the accuracy of different computed tomography image acquisition protocols and hematoma volume measurement techniques. METHODS: We used plastic and cadaveric phantoms to determine the accuracy of different volumetric measurement techniques. We performed both axial and spiral computed tomography scans with 0.75-, 1.5-, 3.0-, and 4.5-mm-thick transverse sections (with no gap). Different measurement techniques (planimetry, ABC/2, and 3D rendering) and different window width/level settings (I, 150/50 versus II, 587/-321) were used to assess generated errors in volumetric calculations. RESULTS: Both axial and spiral computed tomography scans yielded similar percent errors for different slice thicknesses and different measurement techniques. Comparison of different measurement techniques revealed a significant difference in measurement error only from the ABC/2 method as compared with 3D-rendering measurements (P<0.0001). The overall measurement error according to the ABC/2 method was further increased by approximately 8% for irregularly shaped hematomas (P=0.0004). A significant percent difference in measurement error was observed between window width/levels I and II for both planimetry (mean difference across all thicknesses, 1.91 ± 3.78, P=0.004) and Analyze software (mean difference across all thicknesses, 6.92 ± 7.29, P<0.0001) methods. CONCLUSIONS: A better understanding of the limitations that may affect measurement of hematoma volume is crucial in the assessment of hematoma volume, which is considered an independent marker of clinical outcome.