Delayed presentation of traumatic supra- and infratentorial extradural hematoma: illustrative case.

BACKGROUND: Supra- and infratentorial epidural hematomas (SIEDHs) are a rare subtype of epidural hematoma (EDH), showing expanding bleeding on both sides of the tentorium, and account for <2% of EDHs (Aji, Apriawan, and Bajamal, 2018). These lesions can typically expand and decompensate quickly, making immediate diagnosis and surgical intervention crucial. OBSERVATIONS: The authors' patient presented >48 hours from a blunt trauma to the right side of the head with progressive vomiting and bruising behind the right ear. He had a Glasgow Coma Scale score of 15 on arrival. Head computed tomography showed an SIEDH measuring approximately 3 cm, and, given the hematoma's size and mass effect, the patient was taken emergently to the operating room for decompression, where the source of bleeding was noted to be an emissary vein from the transverse sinus. The linear parietooccipital fracture was mended with mesh cranioplasty. Patient imaging and follow-up showed an excellent recovery. LESSONS: Although SIEDH is rare, patients can present in a delayed fashion and be neurologically intact. The threshold to obtain imaging to rule out delayed hemorrhage should be low in any patient with a history of trauma in the region of a dural venous sinus.

Discontinuation of Levetiracetam and Valproic Acid Due to Adverse Effects in Early Post-traumatic Seizure Prophylaxis.

INTRODUCTION: Levetiracetam (LEV) and valproic acid (VPA) are two anti-epileptic drugs (AEDs) routinely used for post-traumatic seizure (PTS) prophylaxis at our institution. In our practice, VPA is used for its beneficial effects on behavioral agitation and headaches, but it is also associated with abnormal liver function tests (LFTs). Both medications may be associated with thrombocytopenia. There is less literature comparing the adverse effect profiles and discontinuation rates of LEV and VPA in the context of PTS prophylaxis. We conducted a quality improvement (QI) analysis to determine the safety of LEV and VPA for traumatic brain injury (TBI) patients at our institution. In particular, our QI analysis involved calculating the rates of discontinuation or change of drug regimen due to the adverse effects. METHODS: Our QI analysis focused on patients treated for TBI at our institution during a six-year period. We recorded the AED used and if the AED was discontinued or switched due to thrombocytopenia, behavioral agitation, headaches, or elevated LFTs (including elevated aspartate aminotransferase or alanine aminotransferase values). We also recorded the incidence of early PTS, defined as seizures within seven days of the TBI. RESULTS: Our QI analysis included patients with a mean age of approximately 49 years with nearly 75% males. The mean Glasgow Coma Scale (GCS) score was 12.88, with 73.11% of patients having a mild GCS. The three leading injury mechanisms were fall, assault, and motor vehicle collision. The three leading types of TBI were traumatic subarachnoid hemorrhage, subdural hematoma, and cerebral contusion. Among patients with no prior history of seizures, we found an early PTS incidence of 7.28%. For patients administered LEV and VPA, 0.11% (1/898) and 3.85% (4/104) had the medication discontinued or changed because of thrombocytopenia (p < 0.001), respectively. For patients on LEV, 4.01% (36/898) and 1.78% (16/898) had the medication discontinued or changed because of behavioral agitation and headaches, respectively. For patients on VPA, 2.88% (3/104) had the medication discontinued or changed because of hepatotoxicity. In total, 5.90% versus 6.73% (p > 0.5) of patients on LEV and VPA, respectively, had their medication regimens changed due to the adverse effects. CONCLUSIONS: The incidence of early PTS in our patients is within the range of what has been reported in the literature. The rate of discontinuation of LEV and VPA on account of adverse events is low in the context of PTS prophylaxis. Both medications had similar overall rates of discontinuation. VPA was discontinued more frequently than LEV due to thrombocytopenia, but discontinuation was not common in either case. LEV is associated with behavioral agitation and headaches, which makes VPA a desirable alternative for patients suffering from these symptoms.

Delayed Traumatic Intracerebral Hematoma: A Pathophysiological Classification and Literature Review.

Delayed traumatic intracerebral hematoma (DTICH) is a relatively common occurrence after a traumatic brain injury (TBI). Several case series have been performed to study DTICH, many of which offer different definitions of DTICH. Some definitions involve a delayed progression of an existing hemorrhage, and others involve a de novo intracerebral hematoma that was not evident on the initial trauma evaluation. We propose a classification system for DTICH that accounts for the subtleties in the clinical manifestation and pathophysiology of the different types of DTICH, with the ultimate goal of providing strategies to prevent and manage DTICH. Based on the senior author's clinical experience, we generated a classification system for DTICH, and each type of DTICH was illustrated with a case. We defined type 1A (case 1A), the classic presentation of DTICH as predominantly characterized in the literature, as an intracerebral hematoma unseen on initial computed tomography imaging that typically develops five days to one week following blunt or penetrating head trauma. We defined type 1B (case 1B) as a hematoma that forms after at least one week following trauma in areas of the brain initially hemorrhage-free. We defined type 2 (case 2) as a hematoma that develops rapidly following a surgical evacuation of a different hematoma. We defined type 3 (case 3) as a hematoma that develops after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal. A literature review was performed using select terms on PubMed to find articles related to DTICH, excluding articles describing DTICH from an underlying vascular injury. After performing the literature review and screening articles by title and/or abstract, a total of 79 articles were found to meet the inclusion and exclusion criteria. We recorded which type of DTICH from our classification system best correlated with the articles in our literature review. Taken together with results from the literature, the proposed classification system is based on the senior author's clinical experience. Overall, DTICH is a relatively common occurrence after head trauma, and our pathophysiologic classification has the potential to help outline future studies to recognize and prevent the development of DTICH.

Long-term Outcome of Globus Pallidus Internus Stimulation for Pisa Syndrome.

Pisa syndrome, defined as dystonia leading to lateral flexion of the spine, is an increasingly recognized complicating factor in the treatment of Parkinson's disease (PD). Symptoms may persist despite medical therapy, or medical therapy may not be tolerated due to adverse effects. Here, we demonstrate the long-term efficacy of deep brain stimulation (DBS) at the globus pallidus internus (GPi) for the treatment of Pisa syndrome. One patient with Pisa syndrome and Parkinson disease underwent bilateral GPi DBS with computed tomography (CT)-and microelectrode-based guidance. Follow-up with neurosurgery and neurology was done over a four-year period. The patient's axial deformity decreased from approximately 45 to 25 degrees, and he reported significant relief from back pain. Bilateral GPi DBS is a safe and effective option for Pisa syndrome in patients with PD.

Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy.

INTRODUCTION: There is continued interest in identifying factors that predict a favorable outcome after endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (ACLVO). We compared the predictive values of 2 different scoring systems for evaluating venous collateral circulation. METHODS: A retrospective review of patients who underwent EVT for ACLVO at a single institution was performed. Those who underwent preprocedural computed tomography angiography (CTA) were selected. The Cortical Vein Opacification Score (COVES) and Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) score were calculated from each patient's CTA. Our primary outcome of interest was the Modified Rankin Scale (mRS) score at 90 days. RESULTS: A total of 103 patients were included in the study (average age = 68.3 years, median National Institutes of Health Stroke Scale = 15). The mean time to reperfusion was 6.4 hours and Thrombolysis in Cerebral Infarction 2B or 3 reperfusion was achieved in 77.7% of cases. An unfavorable COVES score was significantly associated with an unfavorable (mRS 3-6) outcome (adjusted odds ratio [aOR]: 3.06; 95% confidence interval [CI] 1.15-8.13, P = .025), while an unfavorable PRECISE score was not (aOR: 1.02; 95% CI .37-2.80, P = .966). Based on the Receiver Operating Characteristic analysis, the COVES score had a sensitivity of 68.1%, specificity of 71.4%, and area under the curve (AUC) of .77. The PRECISE score had a sensitivity of 68.9%, specificity of 70.7%, and the AUC of .73. CONCLUSIONS: The COVES score, but not the PRECISE score, is associated with functional outcomes at 90 days after EVT for ACLVO.

Academic Genealogy of Neurosurgery via Department Chair.

BACKGROUND: An academic genealogy describes mentoring relationships in an academic discipline. In this study, we outline an academic genealogy of neurosurgery department chairs in the United States beginning with the founding members of the field. METHODS: The biographic information provided by the Society for Neurological Surgery provided the basis for our genealogy. We also performed a literature review with PubMed using the term neurosurgery department history. Our data was manually uploaded to an online database called Academic Tree. Within this platform, mentor and trainee relationships were indicated to produce an academic genealogy. RESULTS: Our search yielded a total of 377 chairs and 368 mentoring relationships across 98 neurosurgery departments. The largest family tree in our academic genealogy was that of Harvey Cushing, with 177 department chairs. Harvey Cushing was also the individual who trained the most number of department chairs (22). The institution that trained the most department chairs was Brigham and Women's Hospital (26). Only 23.6% of department chairs completed residency training at the same institution where they became chair. CONCLUSIONS: The academic genealogy in this study allows for any neurosurgeon trained in the United States to put his or her training into historical context. It also provides a reference for bibliographic research to quantitatively describe the influence of individuals and institutions on the field.

Intradural Extramedullary Thoracic Cavernoma in a Man with Familial Multiple Cavernomas.

Intradural extramedullary cavernomas are rare vascular malformations of the spine. Of the 40 previously described cases, four involved the upper thoracic spine and one was associated with familial multiple cavernoma syndrome. We report the case of a 55-year-old man with familial multiple cavernomas presenting with thoracic radiculopathy and back pain due to a T3-T4 intradural extramedullary cavernoma compressing the spinal cord and dorsal nerve rootlets. Vascular malformations of the thoracic spine are a rare cause of atypical chest pain that should be considered in an individual with familial multiple cavernoma syndrome.

Single and staged laser interstitial thermal therapy ablation for cortical tubers causing refractory epilepsy in pediatric patients.

OBJECTIVE Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a novel, minimally invasive treatment for the surgical treatment of epilepsy. In this paper, the authors report on clinical outcomes for a series of pediatric patients with tuberous sclerosis complex (TSC) and medication-refractory epileptogenic cortical tubers. METHODS A retrospective chart review was performed at SUNY Upstate Golisano Children's Hospital in Syracuse, New York. The authors included all cases involving pediatric patients (< 18 years) who underwent MRgLITT for ablation of epileptogenic cortical tubers between February 2013 and November 2015. RESULTS Seven patients with cortical tubers were treated (4 female and 3 male). The patients' average age was 6.6 years (range 2-17 years). Two patients had a single procedure, and 5 patients had staged procedures. The mean time between procedures in the staged cases was 6 months. All of the patients had a meaningful reduction in seizure frequency as reported by Engel and ILAE seizure outcome classifications, and most (71.4%) of the patients experienced a reduction in AED burden. Three of the 4 patients who presented with neuropsychiatric symptoms had some improvement in these domains after laser ablation. No perioperative complications were noted. The mean duration of follow-up was 19.3 months (range 4-49 months). CONCLUSIONS Laser ablation represents a minimally invasive alternative to resective epilepsy surgery and is an effective treatment for refractory epilepsy due to cortical tubers.

The Effect of Keppra Prophylaxis on the Incidence of Early Onset, Post-traumatic Brain Injury Seizures.

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of long-term disability. Early onset post-traumatic seizures (PTS) after traumatic injury to the brain is a strong predictor of adverse outcomes in these patients. Our study investigates the role of Keppra in early PTS prophylaxis compared to no treatment, taking into account risk factors including injury severity, seizure history, and anti-epileptic drug (AED) use. METHODS: This was a retrospective cohort study based on patient chart data from January 2013 to January 2017 at a level one trauma center in the United States. A t-test was performed with P<0.05 as significant; we utilized a 95% confidence interval (CI) for our findings. Subgroup analysis was performed, with respect to the Glasgow Coma Scale (GCS) score (Group A: Mild GCS=13-15, Keppra N=135, Non-Keppra N=122; Group B: Moderate GCS=9-12, Keppra N=23, Non-Keppra N=19; Group C: Severe GCS= <8, Keppra N=69, Non-Keppra=35). RESULTS: Of 403 patients included in the study, 227 were given Keppra. Demographics between treatment groups were similar. Whole cohort analysis confirmed six patients with PTS, and no significant difference between groups (Keppra N=3, Non-Keppra N=3, OR=0.77, P=0.75, 95% CI=(0.154-3.87)). Subgroup analysis revealed reduction in seizure incidence in Keppra groups A (OR=0.18, P=0.27, 95% CI=(0.008-3.80)) and B (OR=0.82, P=0.92, 95% CI=(0.015-43.7)), but this reduction was not statistically significant. Those with the severe TBI in group C accounted for the majority of seizures (n=4, OR=1.52, P=0.71, 95% CI=(0.15-15.4)).  Conclusion: Patients with more severe TBI suffered a higher incidence of early-onset post-traumatic seizures. Data of the cohort as a whole revealed a trend towards a lower seizure incidence in patients who were treated with Keppra prophylaxis. Despite this trend, the decrease in seizure incidence did not reach statistical significance.

First-line management of chronic subdural hematoma with the subdural evacuating port system: Institutional experience and predictors of outcomes.

Chronic subdural hematoma (cSDH) is a common condition that disproportionately affects older patients. Given the greater risks of general anesthesia in this population, interest has turned towards less invasive surgical approaches such as the subdural evacuating port system (SEPS; Medtronic, Inc., Minneapolis, MN). There is a relative dearth of information about the outcomes following this procedure. Here, we present our institution's experience with SEPS and analyze factors associated with the outcomes. Using a prospectively maintained institutional database, we retrospectively identified all patients who presented with cSDH and received first line therapy with SEPS. Pre- and post-operative clinical and radiographic data was obtained from the electronic health record. Outcomes included success or failure, Modified Rankin Scale (mRS) at discharge, length of stay (LOS), and discharge disposition. A total of 126 patients met the inclusion criteria (36 females and 90 males; mean age of 71.6 years). None of the pre-procedural clinical or radiographic variables were associated with the likelihood of a successful outcome. Increasing age was associated with non-routine hospital discharge (p = 0.003), and lower presenting GCS was associated with longer hospital stay (p = 0.005). Greater thickness of the cSDH was associated with a lower likelihood of having a favorable outcome (mRS ≥ 3; p = 0.003). SEPS is an effective first-line therapy for cSDH. Variables previously reported to limit the effectiveness of the technique (presence of septations, mixed density collections) were not associated with treatment failure.

The Impact of Aneurysm Location on Incidence and Etiology of Hyponatremia Following Subarachnoid Hemorrhage.

BACKGROUND: Hyponatremia is the most common electrolyte abnormality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting (CSW) are the most common etiologies. Whether or not the location of the ruptured aneurysm is associated with the etiology of hyponatremia is unknown. We sought to determine whether or not the incidence of SIADH and CSW after aSAH differed based on aneurysm location. METHODS: Retrospective analysis of 335 consecutive patients who presented with aSAH at a single institution was performed. Patients were included if they developed hyponatremia before postbleed day 14. Electronic health records were reviewed to obtain data regarding aneurysm location, treatment, etiology of hyponatremia, and modified Rankin Scale score at hospital discharge. RESULTS: Inclusion criteria were met by 114 patients. There were 67 (59%) anterior circulation aneurysms and 47 (41%) posterior circulation aneurysms. Of patients, 85 (75%) had hyponatremia owing to SIADH, 14 (12%) had CSW, and 15 (13%) did not fit either etiology. SIADH was more common than CSW in anterior circulation aneurysms (90%) compared with posterior circulation aneurysms (75%). This trended toward, but did not reach, statistical significance (P = 0.08). More severe Hunt and Hess grades were associated with the development of CSW rather than SIADH (P = 0.002). CONCLUSIONS: SIADH is much more common than CSW in patients with aSAH. Anterior circulation aneurysms may be associated with a higher rate of SIADH than posterior circulation aneurysms.