Neurosurgery and Medical Management of Severe Head Injury.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. In the austere or hostile environment, the challenges to deliver care to this patient population are magnified. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

Improving awareness of nonanesthesia-related malignant hyperthermia presentations: a tale of two brothers.

A 30-year-old man developed unexplained rhabdomyolysis, persistently increased creatine kinase and severe debilitating muscle cramps. After a nondiagnostic neurologic evaluation, he was referred for a muscle biopsy, to include histology/histochemistry, a myoglobinuria panel, and a caffeine halothane contracture test. Only the caffeine halothane contracture test was positive, and a subsequent ryanodine receptor type 1 gene evaluation revealed a mutation functionally causative for malignant hyperthermia. His identical twin brother, who was suffering from similar complaints, was found to share the same mutation. They each require oral dantrolene therapy to control symptoms, despite difficulty in identifying health care providers familiar with treating this disorder.

Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts.

BACKGROUND CONTEXT: The most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures. PURPOSE: To report our institutional experience in the management of low lumbar burst fractures. STUDY DESIGN: Retrospective review. METHODS: We performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up. RESULTS: Thirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3-L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12-L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits. CONCLUSION: Low lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.

Transcranial Doppler ultrasonography identifies symptomatic cavum septum pellucidum cyst: case report.

OBJECTIVE: Cavum Septum Pellucidum (CSP) cysts are considered normal anatomic variants, comprising as many as 15% of the adult and 85% of pediatric populations. On rare occasions, the cavum can obstruct CSF outflow from the lateral ventricles causing elevated intracranial pressure (ICP) and headaches. The purpose of this paper is to present a challenging case of new onset symptomatic CSP in a previously healthy adult male without papilledema and elevated ICP detected by transcranial Doppler (TCD) ultrasonography. CLINICAL PRESENTATION: A previously healthy 44 year-old man presented to the neurology service with debilitating positional headaches that were mitigated solely by recumbent positioning. A magnetic resonance imaging scan (MRI) of the brain revealed a cavum septum pellucidum. A lumbar puncture was performed and revealed normal ICP. No papilledema was evident on fundoscopic examination. A CSF flow study revealed normal dye opacification pattern without evidence of CSF leak. INTERVENTION: Without other clinical indicators of high ICP, but a history suspicious for symptomatic CSP, TCD study was performed and revealed abnormally low cerebral blood flow velocities (CBFV's) and significantly elevated pulsatility indices (PI's) for patient's age indicative of high ICP. Endoscopic fenestration of the septum pellucidum was performed improving the patient's headaches and normalization of the PI's and CBFV's to normal (p<0.01). CONCLUSIONS: Symptomatic CSP is a difficult diagnosis to make based on existing diagnostic paradigm. TCD in the absence of other objective confirmatory studies, can aid in the diagnosis and provide information about the success of fenestration of the cavum septum.

Abuse pattern of gestational toluene exposure alters behavior in rats in a "waiting-for-reward" task.

Toluene abuse during pregnancy is a world-wide public health concern although the neurobehavioral teratogenic effects of toluene at the high concentrations and binge-like exposure patterns typical of abuse remain understudied. We assessed the effects of binge prenatal toluene exposure on behavior reflective of impulsivity in rat offspring using a "waiting-for-reward" operant task. Timed-pregnant Sprague-Dawley rats were exposed for 15 min, twice daily, from gestational day (GD) 8 through GD20 to either air, 8000 ppm, 12,000 ppm or 16,000 ppm toluene in a static exposure system. At postnatal day 60, male and female offspring were trained to stable lever pressing in a standard fixed-ratio 50 (FR50) paradigm. A wait requirement was then introduced such that after each FR completion, a "free" pellet was delivered at increasing time intervals (2 s, 4 s, 6 s, etc.) until the rat pressed another lever which reinstated the FR50 component ("FR Reset"). A pattern of increased FR Resets and fewer total pellets received overall and during the wait component is interpretable as "impulsivity." The "wait" component assessment was repeated after the rats had been injected with varying doses of amphetamine. Consistent with our hypotheses, repeated binge prenatal toluene exposure appeared to increase impulsivity based upon decreases in the total number of free pellets received and mean waiting time. However, a toluene dose-dependent decrease in the number of FR Resets and in response rates under all conditions indicated there was a general impairment in performance in rats exposed prenatally to higher doses of toluene. Also, prenatal exposure to 12,000 ppm and 16,000 ppm toluene resulted in a hyposensitivity to the stimulatory effects of the amphetamine challenge in male rats. For female rats, amphetamine further interfered with performance on the task. These results suggest that acute binge prenatal toluene exposure alters performance in this task but the results are not consistent with increased impulsivity or impaired behavioral inhibition. These outcomes in young adult rats also suggest that there may be long-term behavioral deficits due to prenatal toluene exposure.

Subependymoma revisited: clinicopathological evaluation of 83 cases.

OBJECT: Subependymomas are rare ependymal neoplasms. To date, a large clinicopathologic study of these benign neoplasms treated with modern neurosurgical techniques has not been reported. METHODS: Eighty-three cases of subependymoma were retrieved from the files of the Armed Forces Institute of Pathology. Clinicopathological features were reviewed; chromogenic in situ hybridization analysis for chromosome 22 was performed (n = 8), and patient follow-up was obtained (n = 34). Overall, the patients included 68 males and 15 females, 1.5 to 85 years of age (mean, 51.0 years). Twenty-seven cases were discovered at autopsy and the remaining were surgical specimens (n = 56). Tumors arose in the posterior fossa (n = 43), lateral ventricles (n = 37), spinal cord (2) and only one arose in the temporal horn. Tumors ranged in size from 2.0 mm to 60 mm in greatest dimension (mean, 23.0 mm). Eighteen-percent (15/83) of subependymomas exhibited a mixed histologic pattern; that is, subependymoma together with another glial tumor. The most common mixture (13/15) was subependymoma and ependymoma. Surgical excision was used in all symptomatic patients; 10 patients received radiation. Four patients developed a recurrence due to incomplete excision. All patients were without evidence of disease at the last follow-up: alive (n = 28) or dead (n = 8). CONCLUSIONS: Age is the only variable found to be significantly associated with survival. Currently, surgical methods result in an excellent long-term clinical outcome. Subependymomas do not appear to be associated with NF2 mutations.

Gamma knife radiosurgery in the management of malignant melanoma brain metastases.

OBJECTIVE: Radiosurgery is increasingly used to manage malignant melanoma brain metastases. We reviewed our series of patients who underwent radiosurgery for melanoma brain metastases to assess clinical outcomes and identify prognostic factors for survival and cerebral disease control. METHODS: Two hundred forty-four patients had radiosurgery for the management of 754 metastatic tumors. A mean of 2.6 tumors were irradiated per procedure. The median tumor volume was 4.4 cm3. The median margin and maximum doses used were 18 and 32 Gy, respectively. RESULTS: The median survival was 5.3 months after radiosurgery (mean, 10 mo; range, 0.2-114.3 mo). Patients survived a median of 7.8 months (mean, 13.4 mo) from the diagnosis of brain metastases and 44.9 months (mean, 69 mo) after the diagnosis of the primary tumor. Survival was better in patients with controlled systemic disease (12.7 mo), single brain metastasis (6.8 mo), and a Karnofsky performance score of 90 or 100% (6.3 mo). Sustained local control was achieved in 86.2% of tumors. Increased tumor volume and previous evidence of hemorrhage increased the risk of local failure. Multiple lesions and failure to provide systemic immunotherapy were predictors for the occurrence of new brain metastases, which developed in 41.7% of the patients. Symptomatic radiation changes occurred in 6.6% of the patients. Overall, 71.4% of the patients improved or remained clinically stable. Brain disease was the cause of death in 40.5% of the patients, usually from the development of new metastases. CONCLUSION: Gamma knife radiosurgery for malignant melanoma brain metastases is safe and effective and provides a high rate of durable local control. Improved survival can be achieved in patients with single metastasis, controlled systemic disease, and a high Karnofsky performance score.

Eosinophilic meningitis after implantation of a rifampin and minocycline-impregnated ventriculostomy catheter in a child. Case report.

Eosinophilic meningitis has been defined as meningitis in which a total cerebrospinal fluid (CSF) sample is found to have more than 10 eosinophils per millimeter or is composed of greater than 10% eosinophils. The differential diagnosis is broad and the clinical presentation, lacking an internalized CSF diversion system, is often nonspecific. With respect to patients with shunt systems, a positive correlation exists between CSF eosinophilia and eventual shunt failure requiring revision. In this paper the authors present the highest reported level of CSF eosinophilia in conjunction with a rifampin and minocycline-impregnated ventriculostomy catheter recently approved by the Food and Drug Administration.

Rare giant cell ependymoma in an octogenarian. Case report and review of the literature.

Ependymomas are glial tumors that occur most often in children. In adults, ependymomas most often appear in the spinal cord. The World Health Organization recognizes several rare ependymoma subtypes, including the giant cell ependymoma of the terminal filum. The authors describe an unusual case of a posterior fossa giant cell ependymoma in an 89-year-old man presenting with vertigo and disequilibrium. Only seven cases of this tumor have been reported in the literature to date. The authors discuss the clinical presentation, radiological findings, pathological considerations, and surgical intervention in this patient and review the relevant literature.

Combined anterior-posterior fusion with laterally placed threaded interbody cages and pedicle screws for Scheuermann kyphosis. Case report and review of the literature.

The authors report their preferred method for correcting Scheuermann disease via a combined anterior-posterior approach; their procedure is associated with a lower morbidity rate than the standard approach. Twenty-month followup examination demonstrated excellent maintenance of correction. The results satisfied the requirements to function without restriction in a vigorous military environment.