A New Scoring System for Prediction of Underlying Vascular Pathology in Patients with Intracerebral Hemorrhage: The Modified Secondary Intracerebral Hemorrhage Score.

BACKGROUND: Secondary intracerebral hemorrhage (SICH) score is used to predict risk of intracranial hemorrhage (ICH) associated vascular lesions. However, it has low clinical utility in identifying patients without need for neurovascular imaging. This study aims to develop a modified scoring system to capture patients with low risk of underlying vascular pathology, thereby decreasing need for vascular imaging and its associated morbidity. METHODS: A retrospective analysis of 994 patients with atraumatic ICH over 8 years was conducted, excluding known underlying pathology, subarachnoid hemorrhage, or lack of vascular imaging. Using a multivariate logistic regression model, independent predictors of vascular pathology were identified and utilized toward developing a modified Secondary Intracerebral Hemorrhage (mSICH) score. RESULTS: Of 575 patients identified, 60 (10.4%) had underlying vascular etiology. Statistically significant predictors of vascular pathology included age; female sex; admission systolic blood pressure <160 mm Hg; locations other than basal ganglia, thalamus, pons, or midbrain; presence of high-risk imaging features; and proximity to large vessel-containing cisterns. The mSICH score correlated with an increasing incidence of vascular pathology [0-1 (0%), 9 (4.3%), 12 (9.7%), 21 (40.4%), 6 (33.3%), 8 (88.9%), and 4 (100%)] and had a significantly higher number of patients receiving scores with 0% incidence of vascular lesions compared with the SICH score [159 (27.6%) versus 12 (2.1%); P < 0.001)]. CONCLUSIONS: The mSICH score can more accurately predict risk of underlying vascular pathology of ICH and identify patients with lowest risk of vascular pathology. This may minimize the cost and associated risks of invasive cerebrovascular imaging.

Adult Chiari I Malformations: An Analysis of Surgical Risk Factors and Complications Using an International Database.

BACKGROUND: Chiari I malformations are common in adults and a frequent procedure in neurosurgical practice. Despite several studies, there is no consensus about the indications or surgical technique for this common condition. Increasing emphasis on value-based care has emphasized reduction of readmissions and reoperations and is particularly relevant in Chiari, which has traditionally been associated with a high complication rate. OBJECTIVE: To provide a contemporary surgical profile of risk factors and complications for Chiari I malformations in adults. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day outcomes after surgery for Chiari I malformations in adults between 2005 and 2016. Demographics, clinical risk factors, and postoperative events were analyzed, along with reoperation and readmission reasons. RESULTS: A total of 672 adult patients were identified in the cohort, with a female predominance (80%). The overall cohort readmission rate was 9.3%, and 6.8% of patients returned to the operating room. Obesity (45.7%) was predictive of both readmission and reoperation risk. Male sex and American Society of Anesthesiologists class were predictive for reoperations. The most common reason for reoperation was cerebrospinal fluid leak, which was responsible for nearly two thirds of reoperations and 4% of the cohort. CONCLUSIONS: Surgery for Chiari in adults is common and carries a definitive risk profile, including rates of readmission and reoperation higher than other common neurosurgical procedures. This cohort provides a representative sample of contemporary neurosurgical outcomes in surgery for Chiari I malformations.

Intramedullary Thoracic Spine Astrocytoma Presenting as Hydrocephalus in an Infant: A Case Report.

We present the case of an intramedullary spinal cord tumor from C7 to T4, classified as a WHO grade I pilocytic astrocytoma, manifesting solely with isolated, acute hydrocephalus and a normal neurological exam in a 5-month-old infant. We discuss the common presenting symptoms of spinal cord tumors in the pediatric population and possible anatomical explanations for this unique presentation and offer recommendations for the management of isolated hydrocephalus in an infant.

Surgical Repair of Iatrogenic Transverse-Sigmoid Sinus Laceration with a Dural Flap During Skull Base Tumor Surgery: A Technical Case Report.

BACKGROUND: Injury to cerebral venous sinuses during craniotomy procedures can cause significant blood loss or venous air embolism, potentially leading to serious morbidity or mortality. When iatrogenic sinus injuries occur, it is essential to promptly obtain hemostasis and repair the sinus defect. CASE DESCRIPTION: We report on a 43-year-old woman that sustained a transverse-sigmoid sinus injury during a retrosigmoid craniotomy for resection of a cerebellopontine angle meningioma. Sinus repair was performed using a reflected dural flap with excellent outcome. CONCLUSIONS: The use of a reflected dural flap for closure of a widely torn sinus proved to be an effective and straightforward sinus repair strategy, with postoperative imaging demonstrating persistent patency of the sinus. The described technique may be a useful addition to any neurosurgeon's armamentarium and should be considered during cases of complex sinus injuries.

Spinal epidural abscess in a patient with piriformis pyomyositis.

BACKGROUND: Spinal epidural abscess resulting from piriformis pyomyositis is extremely rare. Such condition can result in serious morbidity and mortality if not addressed in a timely manner. CASE DESCRIPTION: The authors describe the case of a 19-year-old male presenting with a 2-week history of fever, low back pain, and nuchal rigidity. When found to have radiographic evidence of a right piriformis pyomyositis, he was transferred to our institution for further evaluation. Because he demonstrated rapid deterioration, cervical, thoracic, and lumbar magnetic resonance imaging scans were emergently performed. They revealed an extensive posterior spinal epidural abscess causing symptomatic spinal cord compression extending from C2 to the sacrum. He underwent emergent decompression and abscess evacuation through a dorsal midline approach. Postoperatively, he markedly improved. Upon discharge, the patient regained 5/5 strength in both upper and lower extremities. Cultures from the epidural abscess grew methicillin-sensitive Staphylococcus aureus warranting a 6-week course of intravenous nafcillin. CONCLUSION: A 19-year-old male presented with a holospinal epidural abscess (C2 to sacrum) originating from piriformis pyomyositis. The multilevel cord abscess was emergently decompressed, leading to a marked restoration of neurological function.