Pseudomonas aeruginosa nosocomial meningitis following spinal anesthesia - still a significant treatment dilemma.

Background: Infections of central nervous system after spinal anesthesia nowadays are a rarity; however, their presence might be of concern. Case Description: We report the case of lateral ventricular empyema treated unsuccessfully with parenteral antibiotic therapy, with the clinical signs of a persisting meningitis. After several lumbar taps suggesting an infection, Pseudomonas aeruginosa was isolated and a brain magnetic resonance imaging find out the collection in the left horn of the lateral ventricle. An intrathecal/intraventricular antibiotic therapy with colistin proved highly effective combined with an extra ventricular drainage to deal with the hydrocephaly. Conclusion: Clinicians should take into account even uncommon infectious agents while facing the picture of a meningitis otherwise nonresponsive to empiric or standard therapy.

Intracranial hypotension as a unique complication of the rupture of an anterior sacral meningocele into a recurrent pilonidal cyst.

BACKGROUND: Intracranial hypotension (IH) is an underdiagnosed, but important cause of new-onset, daily persistent headache, especially among the young- and middle-aged population. It results from a cerebrospinal fluid (CSF) leak with subsequent lowered CSF pressure. CASE DESCRIPTION: A 37-year-old female presented to the emergency department with sudden onset severe headaches. Two years earlier, she had undergone surgery for resection of a pilonidal cyst (PC). The night before admission, she had watery discharge from the recurrent PC and severe diffuse positional headaches associated with photophobia and neck pain. The head computed tomography showed pneumocephalus in the posterior fossa and a spine magnetic resonance imaging revealed an anterior sacral meningocele (ASM) in close contact with the recurrent PC. A final diagnosis was made of headaches due to IH. The leakage site was the rupture of the ASM in the PC. The surgical repair of the ASM was achieved suturing two overlapping dural flaps. There was no more CSF leakage from the PC and the headaches disappeared. CONCLUSION: This is a unique case of IH due to the rupture of an ASM into a recurrent PC. The association of an ASM and PC, at the best of our knowledge, is unique. Moreover, the fistulation of the ASM to the PC is exceptional. ASM can be successfully closed with a posterior approach, using two overlapping dural flaps.

Early reappearance of disappeared ruptured small aneurysm with concomitant vertebral artery dissection.

Thrombosis of a previously ruptured intracranial aneurysm is a frequent event and it most commonly occurs in large or giant aneurysms. We present a dynamic short-term follow-up and management of thrombosis in a ruptured small posterior inferior cerebellar artery aneurysm with concomitant vertebral artery dissection (VAD). Clinical and radiological follow-up findings and reviewed literature on thrombosis of small ruptured aneurysms are the focus of this presentation. Early reappearance of a disappeared ruptured small cerebral aneurysm with a concomitant VAD may be attributed to the controlled ovarian hyperstimulation phase of in vitro fertilization and prolonged use of oral contraceptive pills.

An unusual complication of atrial fibrillation ablation: case report.

The authors report a complication of catheter ablation that, to their knowledge, has never been previously reported. A 63-year-old man had undergone successful transvenous catheter thermoablation for atrial fibrillation. The patient remained well until 3 days prior to further admission when he noticed itching in the right frontal area of his scalp. On palpating his scalp, he discovered a metallic body projecting out of it and he proceeded to extract 20 cm of wire from his head. The following day a progressive left hemiplegia developed, and the patient experienced a deteriorating level of consciousness. A CT scan of the brain showed a right frontotemporal intraparenchymal hemorrhage and revealed a metallic structure in the middle of the hematoma. The hematoma was evacuated and a decompressive craniotomy was performed. The guidewire was identified, but it was only possible to extract part of it. It was covered by fibrous tissue, secondary to inflammatory reaction. To the authors' knowledge, this is the first report of guidewire-induced brain hemorrhage. The guidewire apparently had not been removed and had spontaneously migrated from the heart to the brain and beyond to the scalp where it then exited the patient's head. The patient had been well before he attempted to pull out the wire. Earlier identification of the iatrogenic complication of a retained guidewire might have prevented the fatal outcome in this case.

Glioblastoma after AVM radiosurgery. Case report and review of the literature.

BACKGROUND: Stereotactic radiosurgery (SRS) is considered to be a relatively safe procedure in cerebral arteriovenous malformation management. There are very few reported cases of SRS-associated/induced malignancies. METHODS: We show the case of a 21-year-old female who presented with a 21-mm(3) ruptured AVM in the right mesial frontocallosal region. Embolization and/or radiosurgery was proposed. She preferred radiosurgery. The AVM was treated with CyberKnife(®) SRS. RESULTS: She presented behavior changes 6 years after SRS. MRI showed a right subcortical frontal lesion with increased perfusion, more consistent with high-grade glioma. The lesion's center was within the irradiated region of the previous SRS, having received an estimated radiation dose of 4 Gy. Pathological examination noted a hypercellular tumor showing astrocytic tumor cells with moderate pleomorphism in a fibrillary background, endothelial proliferation, and tumor necrosis surrounded by perinecrotic pseudopalisades. Numerous mitotic figures were seen. The appearances were those of glioblastoma, WHO grade IV, with neuronal differentiation. SRS-associated/-induced GBM after treatment of a large AM is exceptional. SRS-associated/-induced malignancies are mostly GBMs and occur on average after a latency of 9.4 years, within very low-dose peripheral regions as well as the full-dose regions; 33.3 % of patients were under 20 years at the time of SRS, and in 66 % the lesion treated was a vascular pathology. CONCLUSION: Although it is unlikely that the risk of radiation-induced cancer will change the current standard of practice, patients must be warned of this potential possibility before treatment.

Insights on the natural history and pathogenesis of multilevel discal cysts.

Discal cysts are rare lesions and uncommon causes of low back pain and radiculopathy. Despite growing evidence regarding the clinical, pathological and radiological presentation of these lesions, we do not yet have a detailed understanding of their natural history, etiology or pathogenesis. To our knowledge this is the first report of multiple and multilevel discal cysts, and possible mechanisms of pathogenesis are proposed.