Presenting symptoms and functional outcome of chronic subdural hematoma patients

BACKGROUND

Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes.

OBJECTIVE

To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH.

METHODS

We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders.

RESULTS

We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4).

CONCLUSION

Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.

Accuracy of Patient-Specific 3D-Printed Drill Guides for Pedicle and Lateral Mass Screw Insertion: An Analysis of 76 Cervical and Thoracic Screw Trajectories

STUDY DESIGN

Single-center retrospective case series.

OBJECTIVE

The purpose of this study was to assess the safety and accuracy of three-dimensional (3D)-printed individualized drill guides for pedicle and lateral mass screw insertion in the cervical and upper-thoracic region, by comparing the preoperative 3D surgical plan with the postoperative results.

SUMMARY OF BACKGROUND DATA

Posterior spinal fusion surgery can provide rigid intervertebral fixation but screw misplacement involves a high risk of neurovascular injury. However, modern spine surgeons now have tools such as virtual surgical planning and 3D-printed drill guides to facilitate spinal screw insertion.

METHODS

A total of 15 patients who underwent posterior spinal fusion surgery involving patient-specific 3D-printed drill guides were included in this study. After segmentation of bone and screws, the postoperative models were superimposed onto the preoperative surgical plan. The accuracy of the realized screw trajectories was quantified by measuring the entry point and angular deviation.

RESULTS

The 3D deviation analysis showed that the entry point and angular deviation over all 76 screw trajectories were 1.40 ± 0.81 mm and 6.70 ± 3.77°, respectively. Angular deviation was significantly higher in the sagittal plane than in the axial plane (P = 0.02). All screw positions were classified as "safe" (100%), showing no neurovascular injury, facet joint violation, or violation of the pedicle wall.

CONCLUSIONS

3D virtual planning and 3D-printed patient-specific drill guides appear to be safe and accurate for pedicle and lateral mass screw insertion in the cervical and upper-thoracic spine. The quantitative 3D deviation analyses confirmed that screw positions were accurate with respect to the 3D-surgical plan.Level of Evidence: 4.

International Subarachnoid Aneurysm Trial 2009

In the May 2009 issue of The Lancet Neurology, the 5-year follow-up results of the International Subarachnoid Aneurysm Trial (ISAT) were published. The authors concluded that, although the significant difference between coiling and neurosurgical clipping of ruptured intracranial aneurysms in terms of death and severe disability after 1 year has vanished (primary endpoint), coiling should still be favored over neurosurgical clipping because mortality rates significantly favored coiling. In this commentary, it is this particular conclusion that is challenged by combining data from previous ISAT publications with the current 5-year follow-up results. This modified intent-to-treat analysis clearly demonstrates that the significant advantage in terms of mortality in favor of the endovascularly treated patients is no longer present, with a hazard ratio of 0.80 in favor of endovascular treatment (95% confidence interval: 0.60–1.05; P = .10). Therefore, for everyday clinical practice and decision making, coiling and clipping are to be considered equivalent in the long term.

[Nocturnal back pain; a misdiagnosed symptom of spinal tumor]

Four patients had nocturnal back pain or pain that worsened when lying down. In one of these, a 49-year-old man, the medical history mentioned a malignancy, as a result of which a spinal metastasis was suspected. In the other three patients, a 52-year old woman and two men aged 48 and 60 years, the nocturnal back pain and the back pain worsening when lying down was not recognised as indication of a spinal tumour. As objective neurological symptoms were not established at initial investigation, a long period of discomfort and frustration followed before the spinal tumour was diagnosed eventually. The importance of recognising these early complaints is stressed. Nowadays, MRI is the technique of choice to answer the question whether there is a space occupying process in the spine.

Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands

OBJECTIVE

The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated effect on outcome will be of improved treatment.

METHODS

A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed.

RESULTS

Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the effects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively.

CONCLUSIONS

In two thirds of the patients with poor outcome the causes of poor outcome are the effects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor effects on the outcome of patients with subarachnoid haemorrhage.

[Clinical thinking and decision making in practice. A nurse with acute pain between shoulder blades]

A 50-year-old female nurse with an unremarkable medical history experienced acute midthoracic pain, irradiating to the chest and increasing during inspiration. Initial physical examination, laboratory tests, chest X-ray and electrocardiography all were normal. Pulmonary scintigraphy could not be performed in the early stage after admission. The clinical diagnosis of probable pulmonary embolism was made, and anticoagulant therapy was started. The following day, the patient gradually developed a spinal cord syndrome, eventually including paraplegia, bladder dysfunction and an incomplete sensory deficit with an upper level at the 5th thoracic dermatome, predominantly affecting temperature and pain sensation. Magnetic resonance imaging revealed a large anterior spinal epidural haematoma, extending from C7 down to T8. Urgent decompressive laminectomy and subsequent partial evacuation of the haematoma were performed, approximately 24 hours after the onset of neurological signs. No bleeding source was found during operation. The patient made a remarkable postoperative recovery.

Human radicular veins: regulation of venous reflux in the absence of valves

In the literature it is generally assumed that venous reflux within the radicular veins is prevented by the presence of bicuspid valves and narrowing of the transdural part of these vessels. Recently, we performed a human cadaver study of the internal vertebral venous plexus. Surprisingly, a large number of radicular and perimedullary veins appeared to be filled with Araldite CY 221 mixture, after injection of this material into the vertebral venous system, implicating reflux via the radicular veins and suggesting insufficiency of the presumed anti-reflux mechanism. Therefore, it was decided to study the radicular veins in order to determine and to investigate the presence or absence of anti-reflux mechanisms within this system. The vertebral venous systems of ten fresh human cadavers, between 64 and 93 years of age, were injected with Araldite CY 221 mixture. After polymerization, all cadavers were dissected and the spinal nerve sheaths, including nerve roots, radicular veins and epidural veins, were excised as a whole. After macroscopical examination, serial sections (40 microm) were cut on a freezing microtome and stained in Von Gieson medium. Every third section was stained immunohistochemically with smooth muscle antigen (SMA), to visualize smooth muscle cells. In all cadavers, a number of intradural radicular veins was filled with Araldite. Employing microscopical examination, no bicuspid valves were found. However, four structures were encountered that might serve as ananti-reflux-mechanism: 1) intravenous dural folds, 2) meandrous configuration, and 3) narrowing of the radicular veins at the point of penetration of the dura mater, and 4) varying numbers of smooth muscle fibers in the walls of the intradural and extradural parts of the radicular veins. Reflux via the radicular veins seems to be a physiological phenomenon. Structural valves have not been encountered during this study. Intravenous dural folds, meandrous configuration and narrowing of the transdural part of the radicular veins, and the presence of large numbers of smooth muscle cells in the radicular venous walls suggest the existence of a dynamic reflux-regulating system that has the ability to increase the intravascular resistance under conditions of venous hyperpression, in order to protect the spinal cord from venous pressure waves. Possibly, venous reflux via the radicular veins has a role in selective cooling of the spinal cord.

Morphology of the human internal vertebral venous plexus: a cadaver study after intravenous Araldite CY 221 injection

Reviewing the literature on the vascular anatomy of the spinal epidural space, it appeared that the knowledge of the internal vertebral venous plexus is limited. Injection studies of the entire internal vertebral venous plexus after application of modern techniques, to the best of our knowledge, have never been performed. Based on the clinical importance of these structures, it was decided to study the human vertebral venous system after Araldite CY 221 injection, in order to update the morphological characteristics of the internal vertebral venous system. The vertebral venous systems of ten fresh human cadavers, between 64 and 93 years of age, were injected with Araldite CY 221 mixture. All cadavers were dissected and the posterior and anterior internal vertebral venous plexuses were studied in detail. The anterior part of the internal vertebral venous plexus is fairly constant. On the contrary, the posterior internal vertebral venous plexus showed a striking segmental and interindividual variability. In the thoracic area, two types of traversing veins are observed. Both types show a somewhat symmetrical "inversed V" configuration. No anatomical valves were observed. Nevertheless, anterograde flushing (via the femoral veins) of the vertebral venous system appeared to proceed much faster than retrograde flushing (via the superior vena cava). The classical picture of the internal vertebral venous plexus appears a simplification of the actual situation. Especially in the posterior part, segmental and interindividual differences are prominent. The preferential direction of the flow during flushing suggests the presence of functional valves, which are probably located in the thoracic part of the posterior internal vertebral venous plexus, resulting from the typical shape of the veins in this area. This might explain the difficulties with imaging of the posterior part of the internal vertebral venous plexus in vitro as well as in vivo. Further study is needed to determine whether the configuration of the posterior internal vertebral venous plexus in younger individuals is different, compared with the presently studied aged subjects.

Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery

OBJECTIVE

To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome.

METHODS

A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded.

RESULTS

The proportion of patients that was operated on early--that is, within three days after SAH--was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome.

CONCLUSIONS

In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.

Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome

OBJECTIVE

We clarify the factors affecting postoperative outcomes in patients who have suffered spontaneous spinal epidural hematomas.

METHODS

We review 330 cases of spontaneous spinal epidural hematomas from the international literature and three unpublished cases of our own. Attention was focused on sex, age, medical history, mortality, size and position of the hematoma, vertebral level of the hematoma, preoperative neurological condition, operative interval, and postoperative result.

RESULTS

Sex, age, and size and position of the hematoma did not correlate with postoperative outcome. Mortality correlated highly with cervical or cervicothoracic hematomas, especially in patients with cardiovascular disease and those undergoing anticoagulant therapy. Incomplete preoperative sensorimotor deficit correlated highly with favorable outcomes (P < 0.0005), and recovery was significantly better when decompression was performed in < or = 36 hours in patients with complete sensorimotor loss (P < 0.05) and in < or = 48 hours in patients with incomplete sensorimotor deficit (P < 0.005).

CONCLUSION

The critical factors for recovery after spontaneous spinal epidural hematoma are the level of preoperative neurological deficit and the operative interval. The vertebral level of the hematoma did not correlate with postoperative results, which suggests that local compression, rather than vascular obstruction, is the main factor in producing neurological deficit.

Cerebellar dermoid tumor and occipital meningocele in a monozygotic twin: clues to the embryogenesis of craniospinal dysraphism

A case of monochorionic/monoamnionic twin with discordant occipital developmental malformations is presented. One female twin appeared to have an occipital meningocele with cerebellar aplasia and died immediately after birth. The other twin presented with signs and symptoms of raised intracranial pressure at the age of 7 months. Severe hydrocephalus was present due to an infected intracerebellar dermoid tumor with a contiguous occipital dermal sinus. The clinical and pathological characteristics are described and the different theories concerning twinning, embryogenesis, and dysmorphology in relation to neural tube defects are discussed. Analysis of the features of these monozygotic twins indicates that a meningocele is not a post-neurulation disorder but results from deficient neurulation, probably due to mesodermal insufficiency.

[Cerebellar abscess caused by an occipital dermal sinus in an infant]

A 7.5-month-old girl was admitted with the clinical signs and symptoms of raised intracranial pressure. This was caused by an obstructive hydrocephalus, due to cerebellar abscesses induced by an infected contiguous complete occipital dermal sinus. Staphylococcus aureus was cultured. The patient was treated by radical excision of the dermal sinus and the abscesses after initial external drainage of the lateral cerebral ventricle, followed by systemic antibiotic therapy. The different types of dermoid cysts of the posterior cranial fossa are described. Early detection of congenital dermal abnormalities along the craniospinal axis by routine examination of newborns is prognostically important. Computerised tomography or magnetic resonance imaging are the methods of choice for further investigation of suspect dermal lesions.

Dominant inherited distal spinal muscular atrophy with atrophic and hypertrophic calves

The clinical, electrophysiological, radiological and morphological data of 3 members of a family with autosomal dominant distal spinal muscular atrophy (DSMA) are reported. One patient has the clinical picture of peroneal muscular atrophy with atrophic calves. His father and sister suffer from cramps and fasciculations of the calves with true neurogenic muscular hypertrophy of the calves. The electromyogram and the biopsy specimen are conclusive for motor neuron disease in this family. These findings suggest that the DSMA variant as described by D'Alessandro et al. (Arch. Neurol. (1982) 39: 657-660), concerning benign spinal muscular atrophy with hypertrophy of the calves, has to be considered as a mild manifestation of DSMA.

Acute cerebellar ataxia in a child with transient pontine lesions demonstrated by MRI

A case of acute cerebellar ataxia with discrete signs of pyramidal and tegmental involvement is reported, several days after recovery from an upper respiratory infection of unknown etiology. Magnetic resonance imaging showed transient pontine lesions, disappearing in the convalescence phase. Laboratory tests established the etiologic diagnosis of post-infectious encephalitis. An allergic autoimmune response with subsequent demyelinisation is assumed. The important role of MR-imaging in similar acute syndromes is emphasized.

The spontaneous spinal epidural hematoma. A study of the etiology

From the literature 199 cases of spontaneous spinal epidural hematoma (SSEH) are analyzed. With these data and the vascular anatomical characteristics of the spinal epidural space, the theories on the etiology of the SSEH are discussed. There seems to be no relationship between the SSEH and arterial hypertension. The age highly affects the level-distribution of the SSEH. The authors have the opinion that the posterior internal vertebral venous plexus plays an important part in the etiology of the SSEH. In the literature the role of a vascular anomaly in the etiology of the SSEH is overestimated. The cluster-type dural artery can easily be mistaken for a vascular anomaly.

Myoclonic dystonia: effective treatment by cervical cord stimulation. A case report

A patient is described with myoclonic dystonia, a disorder characterized by a combination of dystonia and myoclonic contractions. A very good response to epidural cervical cord electrical stimulation was obtained. The findings in this case indicate that epidural cervical cord electrical stimulation could be a useful therapeutic approach in cases of myoclonic dystonia.