Migratory schwannoma of the cauda equina with a change in radicular pattern: illustrative case.

BACKGROUND: Intradural spinal tumors are an uncommon entity with a variety of pathologies and symptom patterns. Few cases reports in the literature have described tumor migration within the spinal canal. OBSERVATIONS: A 38-year-old male presented with bilateral upper lumbar radicular symptoms of anterior thigh pain, with an enhancing tumor of the cauda equina initially located at L1-2. He declined surgery initially, and at a follow-up 3 years later, his symptoms were unchanged but the tumor was now located at T12-L1. He again declined surgery, but 3 months later, he had a significant change in his pain distribution, which was now along his posterolateral right leg to his foot with associated dorsiflexion and extensor hallicus longus weakness. At this time, the tumor had migrated to L2-3. He underwent laminectomy and tumor resection with resolution of his radicular symptoms and improvement in his strength back to baseline by the 1-month follow-up. Pathology was consistent with a World Health Organization grade I schwannoma. LESSONS: Migratory schwannoma is a rare entity but should be considered when radicular symptoms acutely change in the setting of a known intradural tumor. Repeat imaging should be performed to avoid wrong-level surgery. Intraoperative imaging can also be used for tumor localization.

Anticoagulant Medications and Operative Subdural Hematomas: A Retrospective Cohort Study Evaluating Reoperation Rates.

BACKGROUND: Anticoagulant therapy is common and complicates the operative management of acute and mixed-density subdural hematomas (SDHs). The risk of reoperation inferred by anticoagulant (AC) medication and the ability of reversal agents to reduce hemorrhagic complications in patients presenting with AC-associated SDHs are not fully understood. METHODS: Data were collected for 288 consecutive patients treated with craniotomy or craniectomy for evacuation of an acute or mixed-density SDH between 2012 and 2017 at 2 academic institutions. Primary end points were reoperation within 30 days and functional outcome at discharge. Groups were compared based on AC use. Logistic regression models were used to identify predictors of reoperation and functional outcome at discharge. RESULTS: Forty-six patients on ACs and 242 with no AC history were analyzed. All patients on AC underwent AC reversal before hematoma evacuation. Reoperation rates between groups were not significantly different (10.9% vs. 12.4%; P = 1.00); however, time to reoperation was significantly shorter in those on ACs (0.8 ± 1.1 days vs. 6.8 ± 10.4 days; P = 0.04). Aspirin use was independently associated with the need for reoperation (odds ratio, 3.05; confidence interval, 1.30-7.19; P = 0.01). Patients taking ACs were significantly older, had more medical comorbidities and were more likely to have a higher modified Rankin Scale score at discharge. CONCLUSIONS: Anticoagulant use was not associated with an increased reoperation rate, suggesting that reversal of AC may have eliminated the hemorrhagic risk conferred by these medications. Patients on ACs were significantly older, harbored more medical comorbidities, and had a worse functional outcome at discharge.

Antiplatelet Medication and Operative Subdural Hematomas: A Retrospective Cohort Study Evaluating Reoperation Rates.

BACKGROUND: Antiplatelet therapy is common and complicates the operative management of subdural hematomas (SDH). The risk of reoperation inferred by antiplatelet medication and the ability of platelet transfusion to reduce hemorrhagic complications in patients presenting with antiplatelet associated SDHs are poorly defined. METHODS: We performed a retrospective review of consecutive patients treated with craniotomy or craniectomy for evacuation of an acute or mixed-density SDH between 2012 and 2017 at 2 academic institutions. Exclusion criteria included anticoagulant therapy, thrombocytopenia, and/or international normalized ratio >1.3. Clinical and radiographic data were collected; primary endpoint was reoperation within 30 days. Logistic regression models were used to identify predictors of reoperation. RESULTS: A total of 195 patients were included: 86 patients on antiplatelet medication and 109 with no antithrombotic history. Overall, 24 (12.3%) of patients required a reoperation. Reoperation rate in patients on antiplatelet medication was not significantly different than those not on antithrombotics (14.0% vs. 11.0%, P = 0.53). Patients taking antiplatelet medication were significantly older, more likely to have medical comorbidities, and more likely to receive preoperative platelet transfusion (36.0% vs. 3.7%, P < 0.001). Of patients taking antiplatelet medications, there was no difference in reoperation rate between those patients receiving preoperative platelet transfusion and those not receiving transfusion (16.1% vs. 12.7%, P = 0.75). CONCLUSIONS: Antiplatelet medication was not a significant predictor of reoperation following evacuation of an acute or mixed-density SDH. In patients on antiplatelet medication, preoperative platelet transfusion did not reduce reoperation rates.

The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury.

OBJECT: Mild traumatic brain injury (mTBI), as defined by Glasgow Coma Scale (GCS) score of 13 or higher, is a common problem in the United States and worldwide, estimated to affect more than 1 million patients yearly. When associated with intracranial hemorrhage, it is a common reason for neurosurgical consultation and transfer to tertiary care centers. The authors set out to investigate the clinical implications of subarachnoid hemorrhage (SAH) and/or intraparenchymal hemorrhage (IPH) associated with mTBI in hopes of standardization of mTBI clinical care and optimization of resource allocation. METHODS: The authors performed a retrospective review of 500 consecutively treated patients with mTBI and SAH and/or IPH admitted to a Level I trauma center in Alabama between May 2003 and May 2013. They performed a review of medical records to confirm the diagnosis, determine neurological condition at admission, and assess for episodes of neurological decline or brain injury-related complications including altered mental status, seizures, and hyponatremia. RESULTS: Of the 500 patients for whom data were reviewed, 304 (60.8%) were male and 196 (39.2%) were female. Average age was 46.3 years. Overall, 63 patients (12.6%) had isolated IPH, 411 (82.2%) had isolated SAH, and 26 (5.2%) had radiographic evidence of both IPH and SAH. One hundred forty-five patients (29%) were transferred an average distance of 64.5 miles. The authors identified no patients who experienced neurological worsening during their hospital course. Two patients experienced hyponatremia that required treatment with sodium supplementation. CONCLUSIONS: Patients with the constellation of SAH and/or IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to tertiary referral centers.

Neurosurgical injuries resulting from the 2011 tornados in Alabama: the experience at the University of Alabama at Birmingham Medical Center.

OBJECT: The April 27, 2011, tornados that affected the southeastern US resulted in 248 deaths in the state of Alabama. The University of Alabama at Birmingham (UAB) Medical Center, the largest Level I trauma center in the state, triaged and treated a large number of individuals who suffered traumatic injuries during these events, including those requiring neurosurgical assessment and treatment. METHODS: A retrospective review of all adult patients triaged at UAB Medical Center during the April 27, 2011, tornados was conducted. Those patients who were diagnosed with and treated for neurosurgical injuries were included in this cohort. RESULTS: The Division of Neurosurgery at UAB Medical Center received 37 consultations in the 36 hours following the tornado disaster. An additional patient presented 6 days later, having suffered a lumbar spine fracture that ultimately required operative intervention. Twenty-seven patients (73%) suffered injuries as a direct result of the tornados. Twenty-three (85%) of these 27 patients experienced spine and spinal cord injuries. Four patients (15%) suffered intracranial injuries and 2 patients (7%) suffered combined intracranial and spinal injuries. The spinal fractures that were evaluated and treated were predominantly thoracic (43.5%) and lumbar (43.5%). The neurosurgery service performed 14 spinal fusions, 1 ventriculostomy, 2 halo placements, 1 diagnostic angiogram, 1 endovascular embolectomy, and 1 wound debridement and lavage. Twenty-two patients (81.5%) were neurologically intact at discharge and all but 4 had 1 year of follow-up. Three patients had persistent deficits from spinal cord injuries and there was 1 death in a patient with multisystem injuries in whom no procedures were performed. Two patients experienced postoperative complications in the form of 1 wound infection and 1 stroke. CONCLUSIONS: The April 27, 2011, tornados in Alabama produced significant neurosurgical injuries that primarily involved the spine. There were a disproportionate number of patients with thoracolumbar fractures, a finding possibly due to the county medical examiner's postmortem findings that demonstrated a high prevalence of fatal cervical spine and traumatic brain injuries. The UAB experience can be used to aid other institutions in preparing for the appropriate allotment of resources in the event of a similar natural disaster.