Minimally Invasive Bilateral Decompressive Lumbar Laminectomy with Unilateral Approach Among Obese versus Nonobese Patients.

OBJECTIVE: Decompressive lumbar laminectomy (DLL) is a common procedure for lumbar stenosis. A unilateral approach, unlike the traditional open approach, spares the posterior elements to mitigate the risk of iatrogenic instability associated with a DLL. Various minimally invasive techniques have been described but little attention has been aimed toward this specific microsurgical approach, particularly regarding obese patients. We aimed to compare operative details, perioperative outcomes, and complication profiles between obese and nonobese patients. METHODS: One hundred and ninety-four patients who underwent bilateral laminectomy with a unilateral approach by the study surgeon from July 2013 to June 2018 were included. Of these patients, 105 were classified as obese, with body mass index (BMI) ≥30.0 kg/m2, and 89 were nonobese, with BMI <30.0 kg/m2. The obese and nonobese groups were compared; operative time, blood loss, and complications were assessed. RESULTS: Operative time was nonsignificantly increased in the obese group (177 vs. 166 minutes; P = 0.21) and estimated blood loss was nonsignificantly lower (91 mL vs. 97 mL; P = 1.00) in the obese group. Durotomy rates (3 [2.9%] obese vs. 2 [2.2%] nonobese; P = 0.789) and postoperative wound drainage rates (4 [3.8%] obese vs. 2 [3.8%] nonobese; P = 0.92) did not significantly differ between the 2 groups. Length of stay was significantly longer in the obese group (1.5 vs. 1.0 days; P = 0.0005). CONCLUSIONS: Compared with the nonobese group, the obese group had significantly longer length of hospitalization, as well as nonsignificantly increased length of operation and decreased blood loss. The 2 groups had similar perioperative complication rates.

Engagement of a State Medical Society to Promote Uniform Hospital Policies on Determination of Brain Death.

There is a need for the neuroscience community to advocate for uniformity in the determination of brain death/death by neurologic criteria (BD/DNC). Engagement with state medical societies is one example of this type of advocacy. After determining that her hospital policy on determination of BD/DNC was unclear and inconsistent with accepted standards, the principal author submitted a resolution to the Illinois State Medical Society (ISMS) in an attempt to encourage consistency in institutional policies on the determination of BD/DNC across the state. ISMS ultimately approved a resolution on this topic, but it has some shortcomings, so its impact is unclear. Nonetheless, other neuroscience clinicians are encouraged to engage with their state medical societies to advocate for uniformity in the determination of BD/DNC.

Pediatric pineal region masses: a single-center experience over 25 years.

PURPOSE: Pineal region tumors (PRT) represent less than 1% of brain neoplasms. The rare and heterogeneous nature of these tumors is reflected in the variety of treatment modalities employed. METHODS: A single-center retrospective review of all pediatric patients with pineal region tumors between November 1996 and June 2021 was performed. Fifty-six cases of pineal tumors were reviewed for age and symptoms upon presentation, diagnostic methods, imaging characteristics, histological classification, treatment modalities, recurrence, and mortality rates. RESULTS: The average age at diagnosis was 11.3 years. The majority of patients were male (82.1%) and Caucasian (73.2%). The most common presenting symptoms were headache (n = 38, 67.9%) and visual problems (n = 34, 60.7%). Hydrocephalus was present in 49 patients (87.5%). Germinoma (n = 20, 35.7%) and non-germinomatous germ cell tumor (NGGCT) (n = 17, 30.4%) were the most common tumors. Chemotherapy was employed for 54 patients (96.4%), radiation for 49 (87.5%), and surgical resection for 14 (25.0%). The average duration of treatment was 5.9 months. Progression-free survival was 74.4% at 5 years and 72.0% at 10 years. Overall survival was 85.7% at 5 years and 77.1% at 10 years. CONCLUSION: Treatment of pineal region tumors must be targeted to each patient based on presentation, subtype, presence of hydrocephalus, and extent of disease. Upfront surgical resection is usually not indicated. As advances in oncological care proceed, treatment modalities may continue to improve in efficacy.

Postoperative general medical ward admission following Chiari malformation decompression.

OBJECTIVE: Prior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients. METHODS: After a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications. RESULTS: PICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit. CONCLUSIONS: Medically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.

Minimally invasive bilateral decompressive lumbar laminectomy with unilateral approach: patient series.

BACKGROUND: Minimally invasive bilateral decompressive lumbar laminectomy with a unilateral approach is a less destructive procedure compared to the traditional open bilateral laminectomy. The objective of this study is to report the authors' experience with this technique. The first 26 cases performed using the unilateral approach for bilateral decompression are described. Baseline characteristics, operative time, blood loss, and intraoperative complications were collected retrospectively. No specific surgical equipment is needed for this technique. OBSERVATIONS: Twenty-six patients and a total of 40 lumbar levels were treated. Mean operative time was 82 minutes per level and mean estimated blood loss was 40.4 mL per level. Mean length of hospitalization was 1.65 days. Cerebrospinal fluid leak occurred in 1 of 26 (3.85%) cases. LESSONS: Although improved stabilization needs to be proven in future long-term studies to clearly show a decrease in need for fusion, the initial experience with a unilateral approach is positive and continued use in minimally invasive spine surgery seems promising.

Glioblastoma 20 years after a nail gun trauma: A risk factor?

A 48-year-old man presented with headaches and confusion. Imaging demonstrated a right frontal glioblastoma multiforme (GBM), twenty years after a nail gun injury to the same region. GBM in the same location as a previous injury points toward possible causation from the trauma in the development of a high-grade glioma.

Nonmissile penetrating head injury with a wooden table leg: An illustrative case.

Penetrating head injuries are relatively uncommon and require a unique approach. This report highlights a previously unreported mechanism of injury with a table leg and the steps required to evaluate and promptly treat the patient.

Antiplatelet Therapy for Stent-Assisted Coil of Ruptured Middle Cerebral Artery Bifurcation Aneurysm: Is There a Right Answer?

A variety of modalities exist for treatment of cerebral aneurysms. Stent-assisted coiling is an effective option but poses a challenge regarding antiplatelet therapy. No consensus exists among neuroendovascular surgeons regarding preferred agent, dose, and timing to balance the risk of thromboembolism and hemorrhage. This is especially true in the setting of aneurysmal subarachnoid hemorrhage. We present a 66-year-old female with history of thrombocytopenia and nonalcoholic cirrhosis who presented with severe headache. Head CT demonstrated a right temporal lobe intraparenchymal hemorrhage with sylvian fissure subarachnoid hemorrhage. Cerebral angiogram showed a 1.5mm x 1.5mm right middle cerebral artery (MCA) bifurcation aneurysm. The patient underwent Y-stent coiling from the right M1 into the right M2 superior division and the right M1 into the right M2 inferior division, with a 1mm x 1cm coil. Given the patient's thrombocytopenia, only aspirin monotherapy was administered peri-procedural. Shortly thereafter, the patient developed left hemiparesis. Computed tomography angiogram (CTA) demonstrated thrombus within the stent. Thrombectomy was performed with thrombolysis in cerebral infarction (TICI) 3 revascularization and improvement to neurologic baseline. However, that evening she became acutely hypotensive, unresponsive, and ultimately expired due to hemorrhagic cause. Antiaggregate therapy among neuroendovascular procedures is debated with no clear standard of care. This case highlights the difficult decisions that must be made to balance the risks associated with the use of antiplatelets with ruptured aneurysms.

Management Strategies and Outcomes of Hemorrhagic Traumatic Brain Injury on Oral Anticoagulants.

INTRODUCTION: Traumatic brain injury (TBI) is common, and the frequency of patients taking oral anticoagulants is increasing. However the optimal initial triage, management, and long term care plans of hemorrhagic TBI patients taking oral anticoagulants is not clear. OBJECTIVES: To determine the usage pattern of reversal agents for hemorrhagic TBI patients taking oral anticoagulants, and examine their characteristics and outcomes as compared to hemorrhagic TBI patients not taking these medications. METHODS: This was a single-center, retrospective, observational study. Included were adults with trauma categorization and traumatic intracranial hemorrhage (ICH) between April 1, 2017 and December 31, 2019. Patient age, type of ICH, initial Glasgow Coma Scale (GCS) score, oral anticoagulant prescribed pre-injury, anticoagulation reversal agent given, and hospital discharge disposition were recorded. RESULTS: For the entire sample size (n=111), the mean age and GCS were 71.6 years old and 13.8, respectively. Compared to patients not taking oral anticoagulants, patients taking oral anticoagulants were older (76.7 years old versus 69.1; p<0.01), had similar GCS scores (13.7 versus 13.9; p=0.69), had fewer subarachnoid hemorrhages (18.9% versus 37.8%; p=0.04), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had similar incidence of mortality (13.5% versus 6.7%; p=0.30). A total of 14/37 (37.8%) patients taking oral anticoagulants received reversal agents in the emergency department. Compared to patients taking oral anticoagulants and not given reversal agents, patients taking oral anticoagulants and given reversal agents had similar ages (78.8 years old versus 75.4; p=0.41), had similar GCS scores (12.9 versus 14.1; p=0.17), had similar ICH types (all p=1.0), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had higher incidence of mortality (28.6% versus 4.2%; p=0.05). CONCLUSIONS: This limited data set did not show improved outcomes by giving reversal agents to hemorrhagic TBI patients taking oral anticoagulants. However, until more robust data is available, judicious use of reversal agents in this high-risk patient population should remain common practice.

Spontaneous Migration of a Ventriculoperitoneal Shunt into the Venous System: A Multidisciplinary Approach.

Ventriculoperitoneal shunt catheter migration is a rare but documented complication. The exact mechanism of this occurrence is not well understood. We report the case of an 81-year-old male who initially presented with symptoms consistent with normal pressure hydrocephalus. A ventriculoperitoneal shunt was placed uneventfully. Four months later, the patient presented complaining of a persistent headache despite multiple adjustments in the shunt setting. Shunt series radiographs demonstrated the distal catheter passing through the superior vena cava and looping into the right cardiac atrium and ventricle. Catheter retrieval was attempted from a proximal retroauricular incision but required a combination of snare technique by interventional radiology and, ultimately, surgical venotomy by a cardiothoracic surgeon. The distal catheter was replaced in the abdomen, and the patient had no further complications. This case is the first of its kind reported in the literature that includes a treatment team comprising neurosurgery, interventional radiology, and cardiothoracic surgery. We highlight the importance of a multidisciplinary approach to best address the migrated catheter.

Multidisciplinary Management of Low-velocity Nonmissile Penetrating Head Injuries.

Introduction Penetrating head injuries (PHIs) can have diverse presentations and mechanisms; therefore, treatment methods have not been clearly outlined. Vascular injury is common and foreign body removal is often required. We present three cases to illustrate low-velocity nonmissile penetrating head injuries (NPHIs) and discuss a multidisciplinary approach. Methods We present a case series from our institution that illustrates the importance of multidisciplinary treatment of these injuries. All injuries are low- velocity NPHIs with separate mechanisms and anatomical locations. Results Multidisciplinary management involving neurosurgery, otolaryngology, and neuroendovascular surgery is represented in our case series with all patients having good clinical outcomes. Our first case is a 34-year-old male who presented neurologically intact after a stabbing in the left temporal region with concerns for external carotid artery injury and maxillary sinus injury. Our second case is a 37-year-old male who presented with a self-inflicted nail gun injury that penetrated the right temporal bone, right temporal lobe, bilateral sphenoid sinus, and left petrous carotid canal with concerns of petrous internal carotid injury. Our third case is a 31-year-old male who presented after an accidental nail gun injury that penetrated through the oral cavity, hard palate, and left sphenoid sinus and ending in the left cavernous sinus with concerns of cavernous internal carotid injury. Conclusion  Careful consideration must be taken when evaluating low-velocity NPHIs. Particular attention must be given when an associated vascular injury is suspected. Our case series highlights the importance of a multidisciplinary approach in achieving good clinical outcomes in PHIs.

Guillain-Barré Syndrome After a Gunshot Wound to the Thoracic Spine.

BACKGROUND: Guillain-Barré syndrome (GBS) is a rare but well-documented cause of paralysis, often occurring after infection. Few cases have been reported in association with spinal cord injury (SCI), which masks the characteristic ascending paralysis. To our knowledge, this is the first reported case of confirmed GBS during the clinical course of thoracic paraplegia due to a gunshot wound (GSW). CASE DESCRIPTION: A 23-year-old male presented with a GSW to the right axilla that lodged in the spinal canal at the level of T4, causing right hemothorax and American Spinal Injury Association A paraplegia. He had full strength in bilateral upper extremities until 2 weeks after the injury, at which time he developed progressive weakness in the arms with associated paresthesias and dyspnea. Within 5 days, he was intubated and nearly quadriplegic. Cerebrospinal fluid analysis and electromyography led to a diagnosis of GBS. He was treated with plasmapheresis and experienced rapid and marked recovery in respiratory and upper extremity motor function. CONCLUSIONS: The differential diagnosis for new-onset weakness in patients with GSW-induced SCI is complicated by the inability to obtain magnetic resonance imaging. This unique case of GBS in a patient with T4 paraplegia highlights the importance of obtaining a thorough history and using diagnostic tools to explore possibilities beyond surgery.

From Toothpick to Intraparenychmal Otogenic Pneumocephalus: A Case Report.

BACKGROUND: Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax. CASE DESCRIPTION: An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects. CONCLUSIONS: Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.

Long-term Survival in a Patient with Butterfly Glioblastoma: A Case Report.

Butterfly glioblastoma (bGBM) is a malignant glioma that crosses the corpus callous with bilateral cerebral hemisphere involvement. Literature reports are scarce and highlight a dismal prognosis with limited successful treatment options. We describe a patient who survived more than five years from the initial diagnosis. A 44-year-old woman presented to the emergency room for evaluation one day after a motor vehicle collision at the insistence of her husband, with four weeks of confusion, behavioral changes, and increased fatigue. Magnetic resonance imaging (MRI) of the brain revealed an enhancing, heterogeneous mass with significant necrosis, centered in the septum pellucidum and corpus callosum with intraventricular extension. She underwent a stereotactic biopsy of the lesion. Pathology was consistent with glioblastoma, WHO grade IV. She underwent standard radiation treatment and adjuvant temozolomide, demonstrating a near-complete disappearance of the tumor on imaging for the subsequent two years. Upon recurrence, she underwent additional chemotherapy with limited response. A repeat biopsy was positive for a BRAF mutation and she was treated with lomustine. After two cycles, she developed thrombocytopenia and shortly after elected to discontinue treatment. She succumbed to the progression of disease five years and two months after the initial presentation. bGBMs are uncommon and highly aggressive brain tumors. A tailored treatment protocol may improve survival. This case marks an unusually long survival of a patient with bGBM and may prompt further research to better understand the behavior of these tumors and how to improve treatment response and survival.

Endovascular Management of Uncontrollable Orbital Hemorrhage Secondary to Blast Injury.

Blast injuries to the face frequently involve vascular injury and have been reported in association with vehicles, including compressed air hoses and car battery explosions. While related to high-pressure releases, we present the first case of a car tire inflation resulting in tire explosion causing uncontrollable orbital hemorrhage, ocular damage, and the first case of endovascular intervention resulting in resolution of hemorrhage. A 63-year-old male presented after a tire explosion with evisceration of the right eye and uncontrollable hemorrhage from the orbit. CT demonstrated multiple maxillofacial fractures. Due to persistent hemorrhage, he was taken for emergent endovascular evaluation. On the angiogram, there was noted to be active extravasation from the right meningo-ophthalmic artery. Onyx® embolization of the right meningo-ophthalmic artery was performed with no further hemorrhage. Due to the severity of the injury, ophthalmology was unable to preserve vision in the eye. Arterial hemorrhages are traditionally managed with surgical exploration. However, endovascular management may be of particular utility in vascular injuries to the head and neck region. We highlight the importance of endovascular intervention to treat uncontrollable hemorrhage from orbit.

Ventral Herniation of the Cervical Cord After Single-Level Corpectomy.

BACKGROUND: Spinal cord herniation in the cervical spine is an exceptionally rare occurrence. It is most often cited in association with surgery and almost exclusively with a posterior approach. Herniation with an anterior approach has been reported in 3 cases after multilevel corpectomy, all of which involved herniation through a dural defect sustained during surgery. CASE DESCRIPTION: A 49-year-old man presented to the emergency room with generalized fatigue. He had a previous anterior C5 corpectomy and posterior cervical fusion from C2-T4 performed 17 years prior for a cervical kyphotic deformity that developed after a laminectomy. Magnetic resonance imaging of the cervical spine demonstrated a significant ventral cord herniation into the C5 ventral corpectomy site. The patient underwent a C4-6 vertebral corpectomy with C3-7 anterior reconstruction, fusion, and instrumentation with successful reduction and anatomic realignment of the spinal cord herniation. CONCLUSIONS: We present a case of cervical cord herniation that occurred into the ventral corpectomy site without obvious dural defect. We hypothesize that cerebral spinal pulsations over time degraded the corpectomy site and ultimately promoted herniation of the spinal cord. Here, we discuss the successful surgical management of this unique pathology and discuss a relevant review of the literature.

Epithelioid glioblastoma presenting as aphasia in a young adult with ovarian cancer: A case report.

Our patient's clinical history and preoperative radiographic evaluation suggested central nervous system (CNS) metastatic disease. Ultimately, final pathology revealed epithelioid glioblastoma (eGBM), a newly classified CNS primary tumor. This reinforces the importance of direct tissue sampling and including eGBM on the differential for young patients with histories of systemic cancer presenting with new CNS lesions.