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Antuña Ramos A, Mayordomo-Colunga J, Blanco Lago R, Álvarez Vega MA. Decompressive craniectomy in the acute fulminant cerebral edema. NEUROCIRUGIA (ENGLISH EDITION) 2024:S2529-8496(24)00047-9. [PMID: 39074658 DOI: 10.1016/j.neucie.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/28/2024] [Accepted: 07/06/2024] [Indexed: 07/31/2024]
Abstract
Acute fulminant cerebral edema is a type of rapidly progressive encephalitis that occurs in children and is associated with significant morbidity and mortality. We present a clinical case with seizures, rapid neurological deterioration and the early appearance of cerebral herniation signs. Although the radiological tests were initially normal and there are no established parameters that predict the evolution of encephalitis to a rapidly progressive subtype, the clinical evolution forced to consider the decompressive craniectomy due to the lack of response to the medical management of the cerebral edema. It may be necessary take a brain biopsy to confirm the etiology of the encephalitis origin of acute fulminant cerebral edema. The objective of surgery should be not only to increase survival, but also to reduce subsequent neurological sequelae.
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Affiliation(s)
- Aida Antuña Ramos
- Departamento de Neurocirugía, Hospital Universitario Central de Asturias, Asturias, Spain
| | - Juan Mayordomo-Colunga
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Asturias, Spain
| | - Raquel Blanco Lago
- AGC Pediatría, Neuropediatria, Hospital Universitario Central de Asturias, Asturias, Spain
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Schröder I, Güresir E, Vatter H, Soehle M. Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases. Acta Neurochir (Wien) 2024; 166:283. [PMID: 38969875 PMCID: PMC11226498 DOI: 10.1007/s00701-024-06170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/12/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes. METHODS We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale. RESULTS A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age. CONCLUSIONS Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.
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Affiliation(s)
- Isabelle Schröder
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Martin Soehle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Konar SK, Dinesh YS, Shukla D, Nadeem M, Sadashiva N, S LT, Deora H, Singh GJ, Shanbhag NC. Decompressive craniectomy in children: indications and outcome from a tertiary centre. Childs Nerv Syst 2024:10.1007/s00381-024-06513-6. [PMID: 38953913 DOI: 10.1007/s00381-024-06513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION The role of decompressive craniectomy (DC) is as a rescue therapy for the treatment of intracranial hypertension. The indications for the DC are variable. METHODS The clinical details, imaging, operative findings and follow-up data of children less than or equal to 18 years of age were reviewed for more information on the children who underwent DC in the last 5 years. RESULTS During the study period, a total of 128 children underwent DC. The trauma cases were 66, and the non-trauma cases were 62. The common indication for DC was pure acute subdural hematoma 33 (50%), followed by contusion 10 (15%) in the trauma group, and in non-trauma, arterial infarction in 20 (32%) and cerebral venous thrombosis in 17 (27%). Hemicraniectomy was done in 114 (89%), and bifrontal craniectomy was done in 7 (5.4%) cases. The median duration follow-up was 7 months in non-trauma and 6 months in trauma. GCS was less than 8, the motor score was less than 3, and pupillary asymmetry, hypotension and basal cistern effacement were factors related to an unfavourable outcome in the non-trauma group. In regression analysis, only a motor score of less than three was associated with the non-trauma group. Age less than 10 years, GCS less than 8, motor score less than three and preoperative infarction were the predictive factors in univariate analysis, and only GCS less than 8 was the predictive factor for unfavourable factors in regression analysis in the trauma group. CONCLUSION The DC is performed as a lifesaving procedure. The unfavourable outcome is slightly higher in non-trauma cases compared to trauma cases. However, the mortality rate is high in trauma cases.
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Affiliation(s)
- Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Y S Dinesh
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Mohammed Nadeem
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Lingaraju T S
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Gyani Jail Singh
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
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4
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Angelini C, Zangrossi P, Mantovani G, Cavallo MA, De Bonis P, Scerrati A. The effect of antiplatelet and anticoagulant therapies on clinical outcome of patients undergoing decompressive craniectomy: a systematic review. Front Neurol 2024; 15:1336760. [PMID: 38385039 PMCID: PMC10879343 DOI: 10.3389/fneur.2024.1336760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Objective This systematic review aims to investigate a potential correlation between the administration of antiplatelets (APs) or anticoagulants (ACs) and perioperative complications, with a particular focus on hemorrhagic events, in patients undergoing decompressive craniectomy (DC). Additionally, the secondary objective is to assess the neurological outcomes in patients undergoing DC while taking APs/ACs, comparing them to patients not on APs/ACs. Methods The study utilized PubMed and Science Direct as primary online medical databases for the systematic review. Articles underwent screening based on title, abstract, and full-text review. Four studies meeting the inclusion criteria were selected for comprehensive analysis. Results Our findings suggest that the administration of APs/ACs in patients undergoing DC does not significantly impact functional outcomes. Notably, the occurrence of rebleeding within 6 months and other complications, including infections, appears to be less frequent in patients taking APs compared to those not taking APs/ACs. Conclusion Literature-derived data on the association between APs/ACs and DC presented considerable heterogeneity and insufficient volume for robust statistical analysis. Consequently, a definitive conclusion regarding the influence of suspending or continuing these therapies on complications and clinical outcomes cannot be confidently reached at present. To address this, a large-scale prospective study is warranted to gather substantial and precise data, facilitating a nuanced understanding of how to balance the risks and benefits associated with antiplatelet and anticoagulant agents in the context of decompressive craniectomy.
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Affiliation(s)
- Chiara Angelini
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pietro Zangrossi
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Minimally Invasive Neurosurgery Unit, Ferrara University Hospital, Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Monteiro S, Teixeira B, Fraga C, Dias A, Cardoso AL, Meireles D, Sarmento A, Ferreira PR, Silva J, Garrido C, Gonçalves S. Acute Fulminant Cerebral Edema in a Child With Suspected Meningoencephalitis. Cureus 2023; 15:e45339. [PMID: 37849589 PMCID: PMC10577669 DOI: 10.7759/cureus.45339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/19/2023] Open
Abstract
Acute fulminant cerebral edema (AFCE) is a recently identified encephalitis type associated with significant morbimortality. Described as rare, limited data exists on its early detection and treatment. This paper describes a case of AFCE that progressed to unresponsive intracranial hypertension. A previously healthy four-year-old boy presented with fever, myalgias, and neurological symptoms. Diagnostic assessments showed cerebrospinal fluid abnormalities, and despite medical interventions, his condition deteriorated rapidly and developed severe cerebral edema and herniation within 24 hours. A decompressive craniectomy was attempted to decrease intracranial pressure, without success. This case emphasizes the urgency of early AFCE recognition and effective management strategies given its severe prognosis, aiming to improve understanding and spur further research.
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Affiliation(s)
- Sara Monteiro
- Paediatric Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Beatriz Teixeira
- Paediatric Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Carolina Fraga
- Paediatric Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Andreia Dias
- Paediatric Department, Centro Hospitalar De Trás-Os-Montes E Alto Douro, Vila Real, PRT
| | - Ana Lúcia Cardoso
- Paediatric Intensive Care Unit, Neonatology and Pediatrics Intensive Care Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Daniel Meireles
- Paediatric Intensive Care Unit, Neonatology and Pediatrics Intensive Care Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Alzira Sarmento
- Paediatric Intensive Care Unit, Neonatology and Pediatrics Intensive Care Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Paula Regina Ferreira
- Paediatric Intensive Care Unit, Neonatology and Pediatrics Intensive Care Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - João Silva
- Neurosurgery Department, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Cristina Garrido
- Paediatric Neurology Unit, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Sara Gonçalves
- Paediatric Intensive Care Unit, Neonatology and Pediatrics Intensive Care Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário de Santo António, Porto, PRT
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Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View. Diseases 2023; 11:diseases11010022. [PMID: 36810536 PMCID: PMC9944486 DOI: 10.3390/diseases11010022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.
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7
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Bhave VM, Bernstock JD, Carlson JM, Kappel AD, Torio EF, Chen JA, Essayed WI, Gawelek KL, DiToro DF, Izzy S, Cosgrove GR. Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature. Neurosurgery 2023; 92:915-933. [PMID: 36700784 DOI: 10.1227/neu.0000000000002334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Herpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases. OBJECTIVE To systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct. METHODS We performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases. RESULTS Surgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement. CONCLUSION Surgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.
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Affiliation(s)
| | - Joshua D Bernstock
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julia M Carlson
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ari D Kappel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Erickson F Torio
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Chen
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara L Gawelek
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel F DiToro
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Evaluation of the Fitting Accuracy of CAD/CAM-Manufactured Patient-Specific Implants for the Reconstruction of Cranial Defects-A Retrospective Study. J Clin Med 2022; 11:jcm11072045. [PMID: 35407653 PMCID: PMC9000016 DOI: 10.3390/jcm11072045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
Cranioplasties show overall high complication rates of up to 45.3%. Risk factors potentially associated with the occurrence of postoperative complications are frequently discussed in existing research. The present study examines the positioning of 39 patient-specific implants (PSI) made from polyetheretherketone (PEEK) and retrospectively investigates the relationship between the fitting accuracy and incidence of postoperative complications. To analyze the fitting accuracy of the implants pre- and post-operatively, STL files were created and superimposed in a 3D coordinate system, and the deviations were graphically displayed and evaluated along with the postoperative complications. On average, 95.17% (SD = 9.42) of the measurements between planned and surgically achieved implant position were within the defined tolerance range. In cases with lower accordance, an increased occurrence of complications could not be demonstrated. The overall postoperative complication rate was 64.1%. The fitting of the PEEK-PSI was highly satisfactory. There were predominantly minor deviations of the achieved compared to the planned implant positions; however, estimations were within the defined tolerance range. Despite the overall high accuracy of fitting, a considerable complication rate was found. To optimize the surgical outcome, the focus should instead be directed towards the investigation of other risk factors.
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9
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Insights from experience in the treatment of tick-borne bacterial coinfections with tick-borne encephalitis. ANNUAL REPORTS IN MEDICINAL CHEMISTRY 2022. [DOI: 10.1016/bs.armc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Loesch-Biffar AM, Junker A, Linn J, Thon N, Heck S, Ottomeyer C, Straube A, Pfister HW. Case Report: Minimal Neurological Deficit of Two Adult Patients With Weston-Hurst Syndrome Due to Early Craniectomy: Case Series and Review of Literature on Craniectomy. Front Neurol 2021; 12:673611. [PMID: 34531810 PMCID: PMC8438150 DOI: 10.3389/fneur.2021.673611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: We describe two new cases of acute hemorrhagic leucoencephalitis (AHLE), who survived with minimal sequelae due to early measures against increased intracranial pressure, particularly craniotomy. The recently published literature review on treatment and outcome of AHLE was further examined for the effect of craniotomy. Methods: We present two cases from our institution. The outcome of 44 cases from the literature was defined either as good (no deficit, minimal deficit/no daily help) or poor outcome (severe deficit/disabled, death). Patients with purely infratentorial lesions (n = 9) were excluded. Fisher's exact test was applied. Results: Two cases are presented: A 43-year-old woman with rapidly progressive aphasia and right hemiparesis due to a huge left frontal white matter lesion with rim contrast enhancement. Pathology was consistent with AHLE. The second case was a 56-year-old woman with rapidly progressive aphasia and right hemiparesis. Cranial MRI showed a huge left temporo-occipital white matter lesion with typical morphology for AHLE. Both patients received craniotomy within the first 24 h and consequent immunosuppressive-immunomodulatory treatment and survived with minimal deficits. Out of 35 supratentorial reported AHLE cases, seven patients received decompressive craniotomy. Comparing all supratentorial cases, patients who received craniotomy were more likely to have a good outcome (71 vs. 29%). Conclusion: Due to early control of the intracranial pressure, particularly due to early craniotomy; diagnosis per biopsy; and immediate start of immunosuppressive-immunomodulatory therapies (cortisone pulse, plasma exchanges), both patients survived with minimal sequelae. Craniotomy plays an important role and should be considered early on in patients with probable AHLE.
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Affiliation(s)
- Anna Mira Loesch-Biffar
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Junker
- Institute of Neuropathology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Jennifer Linn
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Caroline Ottomeyer
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Hans Walter Pfister
- Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
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11
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Non-traumatic pediatric intracranial hypertension: key points for different etiologies, diagnosis, and treatment. Acta Neurol Belg 2021; 121:823-836. [PMID: 33829371 DOI: 10.1007/s13760-021-01626-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/02/2021] [Indexed: 12/30/2022]
Abstract
Intracranial hypertension can be an acute life-threatening event or slowly deteriorating condition, leading to a gradual loss of neurological function. The diagnosis should be taken in a timely fashioned process, which mandates expedite measures to save brain function and sometimes life. An optimal management strategy is selected according to the causative etiology with a core treatment paradigm that can be utilized in various etiologies. Distinct etiologies are intracranial bleeds caused by traumatic brain injury, spontaneous intracranial hemorrhage (e.g., neonatal intraventricular hemorrhage), or the rare pediatric hemorrhagic stroke. The other primary pediatric etiologies for elevated intracranial pressure are intracranial mass (e.g., brain tumor) and hydrocephalus related. Other unique etiologies in the pediatric population are related to congenital diseases, infectious diseases, metabolic or endocrine crisis, and idiopathic intracranial pressure. One of the main goals of treatment is to alleviate the growing pressure and prevent the secondary injury to brain parenchyma due to inadequate blood perfusion and eventually inadequate parenchymal oxygenation and metabolic state. Previous literature discussed essential characteristics of the treatment paradigm derived mainly from pediatric brain traumatic injuries' treatment methodology. Yet, many of these etiologies are not related to trauma; thus, the general treatment methodology must be tailored carefully for each patient. This review focuses on the different possible non-traumatic etiologies that can lead to intracranial hypertension with the relevant modification of each etiology's treatment paradigm based on the current literature.
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12
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Babaei A, Shatizadeh Malekshahi S, Pirbonyeh N, Moattari A. Prevalence and clinical manifestations of herpes simplex virus infection among suspected patients of herpes simplex encephalitis in Shiraz, Iran. Virusdisease 2021; 32:266-271. [PMID: 34350317 DOI: 10.1007/s13337-021-00680-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/05/2021] [Indexed: 11/29/2022] Open
Abstract
Encephalitis has infectious and noninfectious etiology. Among infectious agents, viruses are the main causes of encephalitis; Herpes simplex virus (HSV) is known as the most common causative agent of viral encephalitis. In this current cross-sectional investigation, we aimed to assess the prevalence of HSV in the cerebrospinal fluid (CSF) specimens of Herpes Simplex Encephalitis (HSE) suspected patients and also determining the clinical symptoms and laboratory findings of this viral complication. Two hundred consecutive HSE suspected patients with clinical diagnosis of encephalitis were included in the study and then the presence of HSV DNA in their CSF was applied by Polymerase Chain Reaction (PCR) assay. Molecular detection of two hundred (117 males with mean age: 43 years, 83 females with mean age: 39 years) CSF samples showed that 22 (11.11%) cases were positive for HSV infection. 15(68.18%) of the positive samples were more than 50 years old, however, there was no significant correlation between age distribution, gender and HSE clinical manifestations. Fever (91%), headache (72.7%), seizer (59%), and weakness (59%) were the most common symptoms in positive patients and also mortality rate was (18.18%). CSF laboratory abnormalities of HSE cases were as follows; lymphocytic pleocytosis 19 (86.3%), leukocytosis 19 (86.3%), elevated protein level 16 (72.7%), and hypoglycorrhachia 3(13.6%). Screening of HSE suspected patients is crucial in the treatment of patients and reduce the mobility and morbidity of patients. Qualitative PCR as an available method in most developing countries could be a reliable method to monitor consecutive HSE suspected patients.
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Affiliation(s)
- Abouzar Babaei
- Department of Bacteriology and Virology, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | | | - Neda Pirbonyeh
- Department of Bacteriology and Virology, Shiraz University of Medical Sciences, Shiraz, Iran.,Burn and Wound Healing Research Center, Microbiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afagh Moattari
- Department of Bacteriology and Virology, Shiraz University of Medical Sciences, Shiraz, Iran
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13
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Invasive neuromonitoring and neurological intensive care unit management in life-threatening central nervous system infections. Curr Opin Neurol 2021; 34:447-455. [PMID: 33935217 DOI: 10.1097/wco.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients with infectious diseases of the central nervous system (CNS) commonly require treatment in the intensive care unit (ICU). In a subset of patients with a life-threatening course, a more aggressive and invasive management is required. Treatment relies on the expertise of the intensivists as most recommendations are currently not based on a high level of evidence. RECENT FINDINGS Published data suggest that an invasive brain-focused management should be considered in life-threatening CNS infections. Brain resuscitation by adequate control of intracranial pressure (ICP) and optimization of cerebral perfusion, oxygen and glucose delivery supports the idea of personalized medicine. Recent advances in monitoring techniques help to guide clinicians to improve neurocritical care management in these patients with severe disease. Robust data on the long-term effect of decompressive craniectomy and targeted temperature management are lacking, however, these interventions can be life-saving in individual patients in the setting of a potentially fatal situation such as refractory elevated ICP. SUMMARY Advances in the neurocritical care management and progress in monitoring techniques in specialized neuro-ICUs may help to preserve brain function and prevent a deleterious cascade of secondary brain damage in life-threatening CNS infections.
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Abstract
Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.
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15
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Hardy D, Gentile CP, Beslow LA, Santi M, Agarwal S. Acute Fulminant Cerebral Edema: A Case Series at a Large Pediatric Tertiary Center. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1724099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractAcute fulminant cerebral edema is a poorly understood but serious neurologic condition resulting in profound neurologic disability or mortality. Here we presented a case series of four children that presented to our institution with new neurologic dysfunction and neuroimaging evidence of cerebral edema. Ages ranged from 2 to 7 years with the most common presenting features being altered mental status, vomiting, and/or seizure. Two patients had normal head computed tomography, but follow-up imaging performed within 15 hours demonstrated fulminant edema. One patient was positive for influenza, and one had neuropathology consistent with acute hemorrhagic leukoencephalitis. Two had no identified cause. Treatments included broad-spectrum antibiotics and acyclovir, hyperosmolar agents, intravenous steroids, and decompressive craniectomy. Only one patient survived. Acute encephalopathy complicated by fulminant cerebral edema is a rapidly evolving and often fatal neurologic condition. Early identification with neuroimaging and intervention may improve outcomes. Repeat neuroimaging should be considered if initial imaging is normal but there is persistent or progressive unexplained encephalopathy. Further studies are required to determine optimal diagnostic and management strategies.
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Affiliation(s)
- Duriel Hardy
- Division of Child Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Carlyn Patterson Gentile
- Division of Child Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Lauren A. Beslow
- Division of Child Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Mariarita Santi
- Department of Anatomic Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sonika Agarwal
- Division of Child Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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16
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Tamura G, Inagaki T. Prognostic Factors for Pediatric Acute Encephalopathy Associated with Severe Brain Edema. Pediatr Neurosurg 2021; 56:221-228. [PMID: 33827101 DOI: 10.1159/000515037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute encephalopathy is a life-threatening brain dysfunction in children, often associated with a preceding infection and diffuse noninflammatory brain edema. At present, the role of decompressive craniectomy (DC) over the swollen area of the brain is unclear. The risk factors for predicting clinical deterioration also need clarification. METHODS A retrospective study of pediatric patients admitted between 2015 and 2019 with acute cerebral encephalopathy was carried out. Patients were classified according to: (1) the preceding pathogens, (2) the syndromic classification, and (3) the extent of brain edema. The syndromic classification is a relatively new classification of acute encephalopathy proposed in 2016 and divides patients into 3 groups: those with systemic inflammatory reactions or "cytokine storms" (group 1), those with status epilepticus but no cytokine storm (group 2), and others (group 3). Glasgow Outcome Scale (GOS) scores of 1-3 were defined as unfavorable, while a GOS score of 4 or 5 was defined as a favorable outcome in this study. DC was performed for select patients with life-threatening signs of brainstem compression. RESULTS Nineteen patients (mean age: 23.3 months) were included in the study, 8 (42.1%) of whom had an unfavorable outcome. There was no significant correlation between the types of pathogens and outcome. Unfavorable outcomes were observed in significantly more patients in group 1 (87.5%) than group 2 (14.3%) and group 3 (0%). There was a significant association between diffuse brain edema and unfavorable outcomes (72.7%). Neurosurgical DC was performed in 2 patients to alleviate life-threatening brainstem compression: one with a cytokine storm and diffuse bilateral brain edema, and the other with prolonged status epilepticus causing diffuse right-sided brain edema. The GOS score was 3 and 4, respectively. CONCLUSION The risk factors for clinical deterioration in pediatric acute encephalopathy were evaluated based on a variety of classifications, including the new syndromic classification. Laboratory features of cytokine storms and radiological evidence of diffuse brain edema were associated with unfavorable outcomes. The role of surgical decompression is still controversial and should be assessed on a case-by-case basis.
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Affiliation(s)
- Goichiro Tamura
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
| | - Takayuki Inagaki
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
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17
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Bourke D, Woon K. Craniectomy for acute disseminated encephalomyelitis. Pract Neurol 2020:practneurol-2020-002705. [PMID: 32978272 DOI: 10.1136/practneurol-2020-002705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 11/03/2022]
Abstract
A 17-year-old girl underwent emergency bifrontal craniectomy for severely raised intracranial pressure with brainstem compression, having developed acute disseminated encephalomyelitis (ADEM) following Epstein-Barr virus infection. We discuss the current evidence for craniectomy in both ADEM and infective encephalitis and propose an approach to management.
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Affiliation(s)
- David Bourke
- Neurology, Wellington Hospital, Newtown, New Zealand
| | - Kelvin Woon
- Neurosurgery, Wellington Hospital, Newtown, New Zealand
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18
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Kim HW, Kim CH, Kim JK, Kim MY. Fatal infectious encephalitis as a complication of medication-related osteonecrosis of the jaw. ORAL AND MAXILLOFACIAL SURGERY CASES 2020. [DOI: 10.1016/j.omsc.2020.100178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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19
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Ozoner B, Gungor A, Hasanov T, Toktas ZO, Kilic T. Neurosurgical Practice During Coronavirus Disease 2019 (COVID-19) Pandemic. World Neurosurg 2020; 140:198-207. [PMID: 32474101 PMCID: PMC7255756 DOI: 10.1016/j.wneu.2020.05.195] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Since the first detection in China, it has spread rapidly worldwide. The increased burden has substantially affected neurosurgical practice and intensive modifications have been required in surgical scheduling, inpatient and outpatient clinics, management of emergency cases, and even in academic activities. In some systems, nonoverlapping teams have been created to minimize transmission among health care workers. In cases of a massive burden, neurosurgeons may need to be reassigned to COVID-19 wards, or teams from other regions may need to be sent to severely affected areas. Recommendations are as following. In outpatient practice, if possible, appointments should be undertaken via telemedicine. All staff assigned to the non-COVID treatment unit should be clothed in level 1 personal protective equipment. If possible, postponement is recommended for operations that do not require urgent or emergent intervention. All patients indicated for surgery must receive COVID-19 screening, including a nasopharyngeal swab and thorax computed tomography. Level 2 protection measures are appropriate during COVID-19-negative patients' operations. Operations of COVID-19-positive patients and emergency operations, in which screening cannot be obtained, should be performed after level 3 protective measures. During surgery, the use of high-speed drills and electrocautery should be reduced to minimize aerosol production. Screening is crucial in all patients because the surgical outcome is highly mortal in patients with COVID-19. All educational and academic conferences can be undertaken as virtual webinars.
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Affiliation(s)
- Baris Ozoner
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey.
| | - Abuzer Gungor
- Department of Neurosurgery, Umraniye Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Teyyup Hasanov
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Zafer Orkun Toktas
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Turker Kilic
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey
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20
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Pesce A, Palmieri M, Armocida D, Frati A, Santoro A. Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part. Neurosurgery 2020; 87:E48-E49. [PMID: 32293677 PMCID: PMC7184435 DOI: 10.1093/neuros/nyaa115] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Alessandro Pesce
- IRCCS - "Neuromed" Pozzilli (IS), Italy.,A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | - Mauro Palmieri
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | - Daniele Armocida
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
| | | | - Antonio Santoro
- A.U.O. "Policlinico Umberto I" Neurosurgery Division Sapienza University, Rome Human Neurosciences Department Roma, Italy
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21
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Liu Y, Zhou W. Clinical features and surgical treatment of epilepsy after viral encephalitis. BRAIN SCIENCE ADVANCES 2019. [DOI: 10.1177/2096595819896177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Encephalitis is an acute inflammatory process of the brain parenchyma, which is often caused by viral infection. It is an vital cause of acute symptomatic seizures and subsequent epilepsy. The incidence of unprovoked and recurrent seizures after previous infections of the central nervous system is high and accounts for 1%~5% of the cases of epilepsy. Viral encephalitis (VE) is directly caused by viral infection. The occurrence of seizures after VE is associated with poor prognosis. In survivors of VE, among other neurological sequelae, the risk of developing epilepsy is increased 10-fold. The risk of severe neurological sequelae after VE is particularly high in very young children. Studies on seizure occurrence, possible underlying mechanisms, clinical characteristics, and clinical treatment (especially surgical treatment) of VE have yielded only limited detailed data. We reviewed the most recent literature on the clinical features and surgical treatment of post-VE epilepsy.
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Affiliation(s)
- Yiou Liu
- Department of Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing 100040, China
| | - Wenjing Zhou
- Department of Epilepsy Center, Tsinghua University Yuquan Hospital, Beijing 100040, China
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22
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Zhang J, Tian W, Chen J, Yu J, Zhang J, Chen J. The application of polyetheretherketone (PEEK) implants in cranioplasty. Brain Res Bull 2019; 153:143-149. [PMID: 31425730 DOI: 10.1016/j.brainresbull.2019.08.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/19/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023]
Abstract
Cranioplasty is a challenge to neurosurgeons, especially considering protection of intracranial contents. In recent years, material choice for cranioplasty is still controversial, which brings complexity to this seemingly straightforward procedure. PEEK, a tough, rigid, biocompatible material, has been used more recently in cranioplasty to provide better protection. The aim of this review is to summarize the outcome of research conducted on the material for cranioplasty applications. We also reviewed the comparison of PEEK with several common materials in previous articles. This is also the most complete data review article at present. In addition, the combination of nano-materials and PEEK is also a hotspot of research, so we have made a careful review of this aspect. We also summarized our own experience, telling about the future prospects of PEEK in the field of clinical cranioplasty should be highlighted. Improving the bioactivity, porosity, thinning, biocompatibility, antibacterial ability, integration and cost reduction of PEEK implants without affecting their mechanical properties is a major challenge.
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Affiliation(s)
- Jibo Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Weiqun Tian
- Department of Biomedical Engineering, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China
| | - Jiayi Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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23
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Liu Y, Zhou W. Clinical features and surgical treatment of epilepsy after viral encephalitis. BRAIN SCIENCE ADVANCES 2019. [DOI: 10.26599/bsa.2019.9050002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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24
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Byun YH, Ha EJ, Ko SB, Kim KH. Decompressive craniectomy for herpes simplex encephalitis complicated by frank intracerebral hemorrhage: a case report and review of the literature. BMC Neurol 2018; 18:176. [PMID: 30352560 PMCID: PMC6198426 DOI: 10.1186/s12883-018-1181-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022] Open
Abstract
Background Herpes simplex encephalitis is the most common type of sporadic encephalitis worldwide. Frank intracerebral hemorrhage complicating the disease course in herpes simplex encephalitis patients is rare, especially cases where surgical decompression is necessary. Here, we report a previously healthy female with herpes simplex encephalitis who underwent surgical decompression due to temporal lobe hemorrhage. Case presentation A previously healthy 34-year-old Korean female presented with fever, myalgia and severe headache. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe. Polymerase chain reaction testing of the cerebrospinal fluid confirmed the presence of herpes simplex virus 1. The patient was admitted for close observation and intravenous acyclovir. On hospital day 3, she had a sudden onset of vomiting and severe headache. Brain CT showed frank temporal lobe hemorrhage. Despite aggressive medical treatment, she became increasingly drowsy. Ultimately, she underwent emergency right decompressive craniectomy, expansile duraplasty and intracranial pressure monitor insertion. The patient recovered fully without any neurological deficits or neuropsychological problems. She was discharged after completion of 2 weeks of acyclovir and returned 2 months later for cranioplasty. Conclusions Patients with severe herpes simplex encephalitis complicated by intracerebral hemorrhage or malignant cerebral edema should undergo aggressive medical treatment. Surgical decompression should also be actively considered in these severe cases to prevent further neurological deterioration.
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Affiliation(s)
- Yoon Hwan Byun
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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25
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Kusulja M, Santini M. Decompressive craniectomy as salvage treatment in herpes simplex encephalitis: Two case reports. Int J Infect Dis 2018; 73:49-51. [PMID: 29870796 DOI: 10.1016/j.ijid.2018.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022] Open
Abstract
Herpes simplex encephalitis is a rare disease with significant morbidity and mortality, although targeted therapy is widely available. This report presents two cases of herpes simplex encephalitis in previously healthy, young adults treated with acyclovir, who developed severe brain edema. Decompressive craniectomy prevented imminent brain herniation and a fatal outcome in both of these patients.
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Affiliation(s)
- Marija Kusulja
- Department of Neuroinfections and Intensive Care Medicine, University Hospital for Infectious Diseases "Dr Fran Mihaljević", Zagreb, Croatia.
| | - Marija Santini
- Department of Neuroinfections and Intensive Care Medicine, University Hospital for Infectious Diseases "Dr Fran Mihaljević", Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
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26
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Todeschi J, Gubian A, Wirth T, Coca HA, Proust F, Cebula H. Multimodal management of severe herpes simplex virus encephalitis: A case report and literature review. Neurochirurgie 2018; 64:183-189. [PMID: 29730051 DOI: 10.1016/j.neuchi.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/28/2017] [Accepted: 10/29/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is the most frequent sporadic encephalitis in the world. In severe cases of HSE, the pathology usually progresses with an increase in intracranial pressure secondary to cerebral edema and/or hemorrhagic necrosis. Currently no high-power studies exist regarding the management of severe HSE and most of the papers reported in the literature are case reports. Decompressive craniectomy, effective in some cases of pharmaco-resistant intracranial hypertension (ICH) resulting from other causes, may be suggested in severe HSE, with several good results reported in the literature. CASE DESCRIPTION The case of a 26-year-old man with severe HSE and a subsequent ICH is reported. In dealing with an ICH rebellious to conservative treatment, it was decided to perform a right decompressive hemicraniectomy, associated with a right temporal polectomy. The postoperative evolution was satisfactory, with normal neuropsychological tests and a Glasgow Outcome Scale of 1. CONCLUSION Although herpes simplex encephalitis is sometimes devastatingly complicated by intracranial hypertension, its management lacks consensus and reliable data in the literature remains scarce. Surgical as well as conservative treatment, used together in a multimodal approach, may hold the key to a greater control of intracranial pressure, thus resulting in a better outcome. In this multimodal management, the window of opportunity where surgery may be considered is small, and must be discussed further and more precisely in future articles.
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Affiliation(s)
- J Todeschi
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - A Gubian
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - T Wirth
- Department of neurology, hôpital de Hautepierre, 67200 Strasbourg, France
| | - H-A Coca
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - F Proust
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - H Cebula
- Department of neurosurgery, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
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27
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Afshari FT, Wysota B, Oswal M, Mazibrada G, White EA. Emergency Foramen Magnum Decompression for Tonsillar Herniation Secondary to Meningoencephalitis. Case Rep Neurol 2018; 10:95-100. [PMID: 29681828 PMCID: PMC5903160 DOI: 10.1159/000488235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/07/2018] [Indexed: 11/19/2022] Open
Abstract
Tonsillar herniation and coning is a rare and often late presentation of meningoencephalitis, and is associated with poor neurological outcome. We report the case of a 16-year-old female who presented unresponsive with radiological evidence of tonsillar herniation secondary to meningoencephalitis. She underwent an emergency foramen magnum decompression and C1 laminectomy with full recovery and no residual neurological deficit.
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Affiliation(s)
- Fardad T Afshari
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Barbara Wysota
- Department of Neurology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Michelle Oswal
- Department of Neurology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Gordan Mazibrada
- Department of Neurology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Edward A White
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham, United Kingdom
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28
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29
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Anterior Temporal Lobectomy for Refractory Status Epilepticus in Herpes Simplex Encephalitis. Neurocrit Care 2017; 25:458-463. [PMID: 27473208 DOI: 10.1007/s12028-016-0302-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Herpes simplex virus (HSV) is a common cause of viral encephalitis that can lead to refractory seizures. The primary treatment of HSV encephalitis is with acyclovir; however, surgery sometimes plays a role in obtaining tissue diagnosis or decompression in cases with severe mass effect. We report a unique case in which anterior temporal lobectomy was successfully used to treat refractory status epilepticus in HSV encephalitis. METHODS Case report and review of the literature. RESULTS We report a case of a 60-year-old man with HSV encephalitis, who presented with seizures originating from the right temporal lobe refractory to maximal medical management. Right anterior temporal lobectomy was performed for the purpose of treatment of refractory status epilepticus and obtaining tissue diagnosis, with ultimate resolution of seizures and excellent functional outcome. CONCLUSIONS We suggest that anterior temporal lobectomy should be considered in cases of HSV encephalitis with refractory status epilepticus with clear unilateral origin.
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30
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Taba P, Schmutzhard E, Forsberg P, Lutsar I, Ljøstad U, Mygland Å, Levchenko I, Strle F, Steiner I. EAN consensus review on prevention, diagnosis and management of tick‐borne encephalitis. Eur J Neurol 2017; 24:1214-e61. [DOI: 10.1111/ene.13356] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 06/01/2017] [Indexed: 12/30/2022]
Affiliation(s)
- P. Taba
- Department of Neurology and Neurosurgery University of Tartu Tartu Estonia
| | - E. Schmutzhard
- Department of Neurology Medical University Innsbruck Innsbruck Austria
| | - P. Forsberg
- Department of Clinical and Experimental Medicine and Department of Infectious Diseases Linköping University Linköping Sweden
| | - I. Lutsar
- Department of Microbiology University of Tartu Tartu Estonia
| | - U. Ljøstad
- Department of Neurology Sørlandet Hospital Kristiansand Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Å. Mygland
- Department of Neurology Sørlandet Hospital Kristiansand Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - I. Levchenko
- Institute of Neurology Psychiatry and Narcology of the National Academy of Medical Sciences of Ukraine Kharkiv Ukraine
| | - F. Strle
- Department of Infectious Diseases University Medical Centre Ljubljana Ljubljana Slovenia
| | - I. Steiner
- Department of Neurology Rabin Medical Center Petach Tikva Israel
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31
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Management of adult infectious encephalitis in metropolitan France. Med Mal Infect 2017; 47:206-220. [PMID: 28336304 DOI: 10.1016/j.medmal.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 02/06/2023]
Abstract
Infectious encephalitis is a severe disease leading to a high mortality and morbidity. The most frequent causes include Herpes simplex virus, Varicella Zoster virus, Listeria monocytogenes, and Mycobacterium tuberculosis. Urgent treatment is required (anti-infective therapy and nonspecific supportive care). The aim of this study was to define treatment strategy, empirical and after microbiological documentation at 48hours, through a systematic literature review.
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32
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Lan SY, Lin JJ, Hsia SH, Wang HS, Chiu CH, Lin KL. Analysis of Fulminant Cerebral Edema in Acute Pediatric Encephalitis. Pediatr Neonatol 2016; 57:402-407. [PMID: 26852357 DOI: 10.1016/j.pedneo.2015.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/30/2015] [Accepted: 11/14/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Acute pediatric encephalitis with fulminant cerebral edema can rapidly become fatal or result in devastating neurological sequelae. METHODS All cases coded with the discharge diagnosis of acute encephalitis between January 2000 and December 2010 were reviewed. Of the 1038 children with acute pediatric encephalitis, 25 were enrolled in our study with ages ranging from 5 months to 16 years. RESULTS The major neurological symptoms included an altered level of consciousness (72%), vomiting (60%), and headache (48%). The onset of neurological symptoms to signs of brain herniation ranged from 0 days to 9 days. Nineteen (76%) patients had a seizure 24-48 hours prior to showing signs of fulminant cerebral edema, and 12 (48%) patients developed status epilepticus. Sixteen patients died, and no survivors returned to baseline. Risk factors for seizures and status epilepticus were compared between the fulminant cerebral edema group (n = 25, 19 seizures, including 12 status epilepticus) and control group (nonfulminant cerebral edema) (n = 1013, 444 seizures, including 141 status epilepticus; p = 0.001 for seizures and p < 0.001 for status epilepticus). CONCLUSION Our findings indicate that preceding seizures and status epilepticus are significant risk factors for fulminant cerebral edema in children with acute encephalitis.
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Affiliation(s)
- Shih-Yun Lan
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Critical Care and Emergency Medicine, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Center, Division of Pediatric Infection, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan.
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- Chang Gung Children's Hospital Study Group for Children with Encephalitis/Encephalopathy Related Status Epilepticus and Epilepsy (CHEESE), Taoyuan, Taiwan
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Outcome in patient-specific PEEK cranioplasty: A two-center cohort study of 40 implants. J Craniomaxillofac Surg 2016; 44:1266-72. [DOI: 10.1016/j.jcms.2016.07.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/24/2016] [Accepted: 07/01/2016] [Indexed: 11/18/2022] Open
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Singhi P, Saini AG, Sahu JK, Kumar N, Vyas S, Vasishta RK, Aggarwal A. Unusual Clinical Presentation and Role of Decompressive Craniectomy in Herpes Simplex Encephalitis. J Child Neurol 2015; 30:1204-7. [PMID: 25156666 DOI: 10.1177/0883073814546688] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 07/01/2014] [Indexed: 11/17/2022]
Abstract
Decompressive craniectomy in pediatric central nervous infections with refractory intracranial hypertension is less commonly practiced. We describe improved outcome of decompressive craniectomy in a 7-year-old boy with severe herpes simplex encephalitis and medically refractory intracranial hypertension, along with a brief review of the literature. Timely recognition of refractory intracranial hypertension and surgical decompression in children with herpes simplex encephalitis can be life-saving. Additionally, strokelike atypical presentations are being increasingly recognized in children with herpes simplex encephalitis and should not take one away from the underlying herpes simplex encephalitis.
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Affiliation(s)
- Pratibha Singhi
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arushi Gahlot Saini
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nuthan Kumar
- Department of Pediatrics, Unit of Pediatric Neurology and Neurodevelopment, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar Vasishta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
OPINION STATEMENT Decompressive craniectomy (DC) involves the removal of a portion of the skull in the setting of life threatening brain edema or potentially uncontrollable intracranial pressures. Often performed on an emergent basis, evaluation and arrangement for DC should be swift and decisive. However, the evidence base for DC in the wide range of conditions for which it is currently performed is still developing. The procedure is associated with a number of complications and ethical considerations; thus, its place in contemporary practice remains controversial. While randomized trials conducted in the last decade have provided valuable data on the indications, eligibility criteria, and outcomes for DC in the treatment of traumatic brain injury and malignant middle cerebral artery infarction, important outstanding issues continue to complicate the decision to pursue DC on an individual case basis and in the number of other clinical settings presenting with brain edema and intracranial hypertension. In this review, we present the existing evidence and remaining questions regarding DC in various neurologic conditions including traumatic brain injury, ischemic stroke, subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, encephalitis, and others. We also discuss perioperative considerations and ethical issues likely to be encountered by clinicians caring for patients and families who are considering or have undergone DC.
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Safain MG, Roguski M, Kryzanski JT, Weller SJ. A review of the combined medical and surgical management in patients with herpes simplex encephalitis. Clin Neurol Neurosurg 2015; 128:10-6. [DOI: 10.1016/j.clineuro.2014.10.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 09/29/2014] [Accepted: 10/26/2014] [Indexed: 12/30/2022]
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Kolias AG, Kirkpatrick PJ, Hutchinson PJ. Decompressive craniectomy: past, present and future. Nat Rev Neurol 2013; 9:405-15. [PMID: 23752906 DOI: 10.1038/nrneurol.2013.106] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.
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Affiliation(s)
- Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK.
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