Preventing Muscle Atrophy Following Strokes: A Reappraisal

Muscle atrophy leading to muscle weakness accounts for major cause of disabilities among stroke survivors. It amounts to compromised gait and prevails to viscous cycle of diminished physical capacities and compromised participation in rehabilitative tasks. There is predisposition to recurrent strokes due to added risk of developing metabolic syndrome. Therefore, beyond the shadow of doubt, there is ripple effect of rehabilitation and thereby muscle protection in these subsets of patients. Herein, we highlight upon the newer insights with regard to preventing muscle atrophy following strokes.

Foot soft tissue myopericytoma: Case-report and review

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Myopericytoma is a rare tumor of deep soft tissues.

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Small tumefying at the level of the plantar region, between the 2nd and 3rd toe of the right foot.

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Neoformation of 0.6 cm in diameter, well circumscribed, capsulated and with free resection margins.

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The immunohistochemical profile was consistent for positive alpha-actin and negative desmine.

Introduction

Myopericytoma is a rare tumor of deep soft tissues, originating from pericytes and characterized by numerous thin walled blood vessels.

Case report

We report a case of myopericytoma found at the level of the second toe of the right foot.

A patient came to the Endocrinology Surgery Department of Catania Polyclinic because of a presence of a small swelling in the plantar region, between the 2nd and 3rd toe of the right foot. At the anatomopathological examination, the escalated lesion showed a neoformation of 0.6 cm in diameter, well circumscribed, capsulated, with myopericytoma diagnosis.

Discussion

Its histopathological appearance is similar to myofibromatic lesions from glomic and angiomyoma tumors. It is a rare tumor that affects all ages with a peak after 50 years 3. The most frequent localization is at the lower extremities, particularly in soft subcutaneous tissues, but can rarely occur in other sites.

Conclusion

At the anatomopathological evaluation, the immunohistochemical examination for the correct formulation of the diagnosis is essential and an adequate surgical excision is important.

Giant cystic pheochromocytoma

A 56-year-old healthy woman presents with 2-year history of symptoms classic for pheochromocytoma. Evaluation revealed one of the largest cystic pheochromocytomas reported but without any metastatic disease. After achieving medical management of her symptoms, surgical removal was performed successfully and without any complications intraoperatively. Pathology of the mass confirmed the diagnosis. The patient had complete resolution of her symptoms thereafter.

Prospective observational research on the clinical profile and outcome analysis among a cohort of patients sustaining traumatic cervical spine and cord injury in a peripheral tertiary spine care centre in Nepal

Background: In developing nations like Nepal, spinal cord injury has multispectral consequences for both the patient and their family members. It has the tendency to cripple and handicap the patients, and burn out their caretakers, both physically and mentally. Furthermore, the centralization of health care with only a handful of dedicated rehabilitation centers throughout Nepal further places patients into disarray. This study was carried out as a pilot study to determine the modes of injury, age groups affected, clinical profiles and patterns of injury sustained, as well as the efficacy of managing a subset of patients, who have sustained cervical spine and cord injuries. Methods: This was a prospective cohort study comprising of 163 patients enrolled over a period of three years that were managed in the spine unit of College of Medical Sciences, Bharatpur, Nepal. Results: Road traffic accidents were implicated in 51% of these patients. 65% of them were in the age group of 30-39 years. Traumatic subluxation occurred in 73 patients with maximum involvement of the C4/5 region (28.76%). Good outcome was seen in patients with ASIA 'C' and 'D' with 55% of patients showed improvement from 'C' to 'D' and 95% of patients showed improvement from 'D' to 'E' at 1 year follow up. The overall mortality in the patients undergoing operative interventions was only 1.98%. Conclusions: The prevalence of cervical spine injuries in the outreach area is still significant. The outcome of managing these patients, even in the context of a resource limited setup in a spine unit outside the capital city of a developing nation, can be as equally as effective and efficient compared to the outcome from a well-equipped and dedicated spine unit elsewhere.

Primary dural diffuse large B cell lymphoma mimicking parafalcine meningioma

A 58-year-old immunocompetent woman presented with complaints of recent onset recurrent generalised tonic-clonic seizures and left hemiparesis. On MRI a dural-based heterogeneously enhancing mass was seen along the falx cerebri mimicking parafalcine meningioma, causing brain parenchymal compression and vasogenic oedema in the right frontal and parietal lobes. The tumour was completely excised and on subsequent investigation it was diagnosed as diffuse large B cell type primary dural lymphoma. Chemotherapy with CHOP (cyclophosphamide, hydroxyl doxorubicin, vincristine and prednisone) regimen was started; however, the patient later died from episodes of acute pulmonary thromboembolism, aspiration pneumonia and septic shock.

Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging

BACKGROUND

Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking.

METHODS

We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience.

RESULTS

Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping.

CONCLUSIONS

We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.

Traumatic spondyloptosis of the cervical spine: A case report and discussion of worldwide treatment trends

Background:

Cervical spondyloptosis is defined as the dislocation of the spinal column most often caused by trauma. Due to compression or transection of the spinal cord, severe neurological deficits are common. Here, we review the literature and report a case of traumatic C5–6 spondyloptosis that was successfully treated using an anterior-only surgical approach.

Methods:

The patient presented with quadriplegia and absent sensation distal to the C5 dermatome following a rollover motor vehicle accident. The preoperative American Spinal Injury Association Impairment Scale was A. Computed tomography of the cervical spine revealed C5–6 spondyloptosis, lamina fractures on the right side at the C3–4 level, and widened facet joint on the right side at C6–7.

Results:

The patient underwent cervical traction and anterior cervical discectomy and fusion at the C5–6, C6–7 levels; no 360° fusion was warranted. Six months postoperatively, the patient remained quadriplegic below the C5 level.

Conclusion:

Presently, no consensus is present regarding the best treatment for spondyloptosis. Worldwide, the 360° approach is the most commonly used (45%), followed by anterior-only surgery (31%) and posterior-only surgery (25%). The surgical choice depends upon patient-specific features but markedly varies among geographical regions.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma

OBJECTIVE

Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score.

METHODS

Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome.

RESULTS

Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels.

CONCLUSIONS

The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

Case Report: Sciatic nerve schwannoma - a rare cause of sciatica

Herein we report a rare case of a sciatic nerve schwannoma causing sciatica in a 69-year-old female. Sciatic nerve schwannoma is a rare entity. It should always be considered as a possible cause of sciatica in patients that present with symptoms of sciatica with no prolapsed disc in the lumbar spine and a negative crossed straight leg raise test. Timely diagnosis and complete excision of the lesion leads to complete resolution of the symptoms of such patients.

Traumatic high-grade spondylolisthesis at C7-T1 with no neurological deficits: Case series, literature review, and biomechanical implications

Traumatic high-grade spondylolisthesis in subaxial cervical spine is frequently associated with acute spinal cord injury and quadriparesis. There have been rare cases where such pathology demonstrates minimal to no neurological deficits. Assessment of the underlying biomechanics may provide insight into the mechanism of injury and associated neurological preservation. Patient 1 is a 63-year-old female presenting after a motor vehicle collision with significant right arm pain without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, associated with a locked facet on the left at C6/7 and a locked facet on the right at C7/T1, with a fracture of the left C7 pedicle and right C7 lamina. Patient 2 is a 60-year-old male presenting after a bicycle collision with transient bilateral upper extremity paresthesias without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, with fractures of bilateral C7 pedicles, C7/T1 facets, and C7 lamina. Patient 3 is a 36-year-old male presenting after a motor vehicle collision with diffuse tingling sensation throughout all extremities. His neurological examination was nonfocal. Imaging demonstrated a grade 4 spondylolithesis at C7/T1, associated with bilateral C7/T1 locked facets. From literature, most cases were noted to be dislocations resulting from fractures of the posterior elements. A minority of cases has been found to involve facet dislocations without fractures. Further biomechanical studies are needed to understand the underlying mechanisms.

Treatment of chronic traumatic C7-T1 grade III spondylolisthesis with mild neurological deficit: case report

Traumatic cervical severe spondylolisthesis is a rare and severe lesion which is typically associated with a spinal cord injury. Nevertheless, it occasionally has a pauci-symptomatic course which may delay its diagnosis. The authors report an exceptional case of a 33-year-old woman who had mild spasticity in her lower limbs and neck pain 9 months after a traffic accident. The computed tomographic scan and magnetic resonance image revealed C7-T1 grade III spondylolisthesis and spinal cord signal change. The initial cervical traction did not obtain a spinal realignment. An anterior-posterior approach was performed to achieve a correct spinal fusion. After 18 months of follow-up care, the patient's symptoms improved significantly and she began to lead a normal life again. The case underlines the importance of performing a correct initial diagnostic workup upon a patient. This would improve surgical management by avoiding a worsening of the initial neurological deficit during the realignment maneuvers in the chronic grade III, IV or V spondylolisthesis.

Traumatic Cervical Spondyloptosis of the Subaxial Cervical Spine: A Case Series with a Literature Review and a New Classification

Study Design

This is a retrospective study on patients with traumatic subaxial cervical spondyloptosis and includes a review of the available literature regarding the management of this injury.

Purpose

This study aimed to assess the biomechanics and varied clinical presentations of this rare but devastating injury.

Overview of Literature

This is a case series of three patients and a review of the available literature on subaxial cervical spondyloptosis. Traumatic cervical spondyloptosis of the subaxial spine is rare, with varied clinical presentations.

Methods

The management of cervical subaxial spondyloptosis represents a challenge to all spine care specialists, and there is a paucity of literature on the best methods for managing this condition. Our experience includes three such patients who visited our tertiary trauma center. This article explains the diverse clinical features of the injury as well as the management of these patients and includes a review of the available literature.

Results

Subaxial cervical spondyloptosis is a devastating injury with diverse clinical features. We present a classification of these fractures based on clinical presentation and magnetic resonance imaging results, which can help in decision-making regarding the management of such patients.

Conclusions

This article may help physicians assess this injury in an evidence-based manner and also elucidates the management strategies available for such patients.

Traumatic Anterior Cerebral Artery Pseudoaneurysmal Epistaxis

BACKGROUND

Pseudoaneurysmal epistaxis is a rare but emergent condition. We report a case of traumatic anterior cerebral artery pseudoaneurysmal epistaxis and review the published literature.

CASE DESCRIPTION

A 49-year-old man sustained severe head trauma. He was diagnosed with multiple skull bone fractures, left subdural hematoma, subarachnoid hemorrhage, pneumocephalus, and right frontal hematoma. Subdural hematoma evacuation was done at a local hospital. In the following months, he experienced repeated epistaxis that required nasal packing to stop the bleeding. Digital subtraction angiography showed an anterior cerebral artery pseudoaneurysm protruding into the posterior ethmoid sinus. Embolization of the aneurysm was performed with microcoils, and the parent artery was occluded by thrombosis. The patient presented 1 month later with another epistaxis episode. Digital subtraction angiography showed recanalization of the parent artery and recurrence of the aneurysm. The parent artery was occluded for the second time with coils and Onyx embolic agent.

CONCLUSIONS

Pseudoaneurysmal epistaxis is rare, and this is the first report of an anterior cerebral artery pseudoaneurysm that manifested with epistaxis. Endovascular intervention has become the first choice of treatment for this disease. The high recurrence rate is the main disadvantage of endovascular intervention. Aneurysm trapping with bypass surgery is another treatment option.

Cisternostomy for Management of Intracranial Hypertension in Severe Traumatic Brain Injury; Case Report and Literature Review

Main goal in the management of patients with severe traumatic brain injury (TBI) is control of intracranial pressure (ICP). Decompressive craniectomy is an accepted technique for control of refractory intracranial hypertension in patients with severe TBI. Because of high complication rate after decompressive craniectomy, new techniques such as basal cisternostomy have developed. We herein report a case of severe TBI in a 13-year-old boy treated by cisternostomy. The patient was admitted following a motor vehicle accident. Brain CT scan showed diffuse brain edema, left frontal contusion and posterior interhemispheric subdural hematoma. The patient underwent ICP monitoring. Subsequently, with 26 mmHg mean-value of ICP, he was treated surgically by cisternostomy technique. A progressive improvement of the neurological conditions in the following hours. After 5 days the boy was discharged and in the 3-months follow-up he was completely recovered. Cisternostomy could be an appropriate alternative to decompressive craniectomy for management of intracranial hypertension in patietns with sever TBI.

Traumatic spondyloptosis at the cervico-thoracic junction without neurological deficits

Background:

There have been rare cases of traumatic cervical spondyloptosis without neurological compromise. We report another case and provide a review of the literature, with a focus on appropriate management.

Case Description:

A 60-year-old male rode his bicycle into a stationary semi-truck. He reported initial bilateral upper extremity paresthesias that resolved. Imaging demonstrated C7 on T1 spondyloptosis. Traction did not achieve reduction and a halo was applied. Subsequently, he underwent posterior decompression C6-T1, reduction via bilateral complete facetectomies at C7, and fixation from C4 to T2 fixation. Afterward, an anterior C7-T1 fixation occurred, where exposure was performed through a midline sternotomy. Postoperatively, he woke up with baseline motor and sensory examination in his extremities. He did exhibit voice hoarseness due to paralysis of the left vocal cords. He was discharged home 3 days after surgery. At 6 months follow-up, there was a progressive improvement of the left vocal cords to slight paresis; dynamic X-rays demonstrated no instability with good fusion progression.

Conclusion:

Traumatic cervical spondyloptosis without neurological compromise is a rare and challenging scenario. There is a concern for neurologic compromise with preoperative traction, but if specific posterior elements are fractured, the spinal canal may be wide enough where the concern for disc migration is minimal. For patients who have not been reduced preoperatively, a posterior approach with initial decompression to widen the canal, before reduction, appears safe. This scheme may avoid an initial anterior approach for decompression, necessitating a 3-stage procedure if circumferential stabilization is pursued.