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Chau D, Barnard ZR, Muelleman TJ, Olszewski AM, D'Agostino AK, Maya MM, Nisson PL, Peng KA, Schievink WI, Lekovic GP. Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23300. [PMID: 37728168 PMCID: PMC10595135 DOI: 10.3171/case23300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. OBSERVATIONS A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. LESSONS Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.
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Affiliation(s)
- Dominic Chau
- 1Division of Neurosurgery, House Institute, Los Angeles, California
| | | | | | - Adam M Olszewski
- 1Division of Neurosurgery, House Institute, Los Angeles, California
| | | | - Marcel M Maya
- 4Imaging, Cedars-Sinai Hospital and Medical Center, Los Angeles, California
| | | | - Kevin A Peng
- 2Division of Neuro-otology, House Institute, Los Angeles, California
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Shah S, Yang GL, Le DT, Gerges C, Wright JM, Parr AM, Cheng JS, Ngwenya LB. Examining the Emergency Medical Treatment and Active Labor Act: impact on telemedicine for neurotrauma. Neurosurg Focus 2020; 49:E8. [PMID: 33130613 DOI: 10.3171/2020.8.focus20587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/18/2020] [Indexed: 11/06/2022]
Abstract
The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.
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Affiliation(s)
- Sanjit Shah
- 1Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - George L Yang
- 1Department of Neurological Surgery, University of Cincinnati College of Medicine
| | - Diana T Le
- 2University of Cincinnati College of Medicine, Cincinnati
| | | | - James M Wright
- 3Case Western Reserve University School of Medicine, Cleveland.,4Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio; and
| | - Ann M Parr
- 5Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Joseph S Cheng
- 1Department of Neurological Surgery, University of Cincinnati College of Medicine.,2University of Cincinnati College of Medicine, Cincinnati
| | - Laura B Ngwenya
- 1Department of Neurological Surgery, University of Cincinnati College of Medicine.,2University of Cincinnati College of Medicine, Cincinnati
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Nagesh M, Patel KR, Mishra A, Yeole U, Prabhuraj AR, Shukla D. Role of repeat CT in mild to moderate head injury: an institutional study. Neurosurg Focus 2020; 47:E2. [PMID: 31675712 DOI: 10.3171/2019.8.focus19527] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan. METHODS This is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables. RESULTS A total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention. CONCLUSIONS The role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.
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Chen CC, Chen SW, Tu PH, Huang YC, Liu ZH, Yi-Chou Wang A, Lee ST, Chen TH, Cheng CT, Wang SY, Chou AH. Outcomes of chronic subdural hematoma in patients with liver cirrhosis. J Neurosurg 2019; 130:302-311. [PMID: 29393757 DOI: 10.3171/2017.8.jns171103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE: Burr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown. METHODS: A nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed. RESULTS: The in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC. CONCLUSIONS: Even for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.
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Affiliation(s)
| | - Shao-Wei Chen
- Divisions of2Thoracic and Cardiovascular Surgery and
| | | | | | | | | | | | - Tien-Hsing Chen
- 3Department of Cardiology, Chang Gung Memorial Hospital, Keelung Branch and Linkou Medical Center, Taoyuan City, Taiwan
| | - Chi-Tung Cheng
- 4Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University; and
| | - Shang-Yu Wang
- 4Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University; and
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Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B, Morrison JF, Williams JR, Collins S, Monteiro K, Asaad WF. Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 2019; 129:1305-1316. [PMID: 29303442 DOI: 10.3171/2017.7.jns17988] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David J Segar
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,2Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Meghal Shah
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Benjamin Drapcho
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John F Morrison
- 3Department of Neurosurgery, University at Buffalo, New York
| | - John R Williams
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,5Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - Kristina Monteiro
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,7Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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Motiei-Langroudi R, Stippler M, Shi S, Adeeb N, Gupta R, Griessenauer CJ, Papavassiliou E, Kasper EM, Arle J, Alterman RL, Ogilvy CS, Thomas AJ. Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation. J Neurosurg 2019; 129:1143-1150. [PMID: 29243977 DOI: 10.3171/2017.6.jns17130] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEChronic subdural hematoma (CSDH) is commonly encountered in neurosurgical practice. However, surgical evacuation remains complicated by a high rate of reoperation. The optimal surgical approach to reduce the reoperation rate has not been determined. In the current study, the authors evaluated the prognostic value of clinical and radiographic factors to predict reoperation in the context of CSDH.METHODSA retrospective review of 325 CSDH patients admitted to an academic medical center in the United States, between 2006 and 2016, was performed. Clinical and radiographic factors predictive of the need for CSDH reoperation were identified on univariable and multivariable analyses.RESULTSUnivariable analysis showed that warfarin use, clopidogrel use, mixed hypo- and isointensity on T1-weighted MRI, greater preoperative midline shift, larger hematoma/fluid residual on first postoperative day CT, lesser decrease in hematoma size after surgery, use of monitored anesthesia care (MAC), and lack of intraoperative irrigation correlated with a significantly higher rate of reoperation. Multivariable analysis, however, showed that only the presence of loculation, clopidogrel or warfarin use, and percent of hematoma change after surgery significantly predicted the need for reoperation. Our results showed that 0% (no reduction), 50%, and 100% hematoma maximum thickness change (complete resolution of hematoma after surgery) were associated with a 41%, 6%, and < 1% rate of reoperation, respectively. The use of drains, either large diameter or small caliber, did not have any effect on the likelihood of reoperation.CONCLUSIONSAmong many factors, clopidogrel or warfarin use, hematoma loculation on preoperative CT, and the amount of hematoma evacuation on the first postoperative CT were the strongest predictors of reoperation.
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Koduri S, Wilkinson DA, Griauzde JM, Gemmete JJ, Maher CO. Development of bilateral dural arteriovenous fistulae following pial synangiosis for moyamoya syndrome: case report. J Neurosurg Pediatr 2019; 24:9-13. [PMID: 30978680 DOI: 10.3171/2019.2.peds18603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/08/2019] [Indexed: 11/06/2022]
Abstract
Moyamoya syndrome predisposes patients to ischemic or hemorrhagic stroke due to progressive narrowing of intracranial vessels with subsequent small-vessel collateralization. Dural arteriovenous fistulae (DAVFs) are most commonly noted after venous sinus or cortical vein thrombosis and are believed to be primarily due to venous hypertension and elevated sinus pressures, although there is no known association with moyamoya syndrome, or with surgical treatment for moyamoya disease (MMD). The authors present the case of a 14-year-old girl with Down syndrome treated using pial synangiosis for MMD who subsequently was noted to have bilateral DAVFs. This case provides a new perspective on the origins and underlying pathophysiology of both moyamoya syndrome and DAVFs, and also serves to highlight the importance of monitoring the moyamoya population closely for de novo cerebrovascular changes after revascularization procedures.
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Palmer AW, Albert GW. Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants. J Neurosurg Pediatr 2019; 23:480-485. [PMID: 30717055 DOI: 10.3171/2018.11.peds18322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate. METHODS In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention. RESULTS Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement. CONCLUSIONS The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.
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Affiliation(s)
- Angela W Palmer
- 1Department of Neurosurgery, University of Arkansas for Medical Sciences; and
- 2Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Gregory W Albert
- 1Department of Neurosurgery, University of Arkansas for Medical Sciences; and
- 2Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
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Rumalla K, Smith KA, Letchuman V, Gandham M, Kombathula R, Arnold PM. Nationwide incidence and risk factors for posttraumatic seizures in children with traumatic brain injury. J Neurosurg Pediatr 2018; 22:684-693. [PMID: 30239282 DOI: 10.3171/2018.6.peds1813] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/25/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPosttraumatic seizures (PTSs) are the most common complication following a traumatic brain injury (TBI) and may lead to posttraumatic epilepsy. PTS is well described in the adult literature but has not been studied extensively in children. Here, the authors utilized the largest nationwide registry of pediatric hospitalizations to report the national incidence, risk factors, and outcomes associated with PTS in pediatric TBI.METHODSThe authors queried the Kids' Inpatient Database (KID) using ICD-9-CM codes to identify all patients (age < 21 years) who had a primary diagnosis of TBI (850.xx-854.xx) and a secondary diagnosis of PTS (780.33, 780.39). Parameters of interest included patient demographics, preexisting comorbidities, hospital characteristics, nature of injury (open/closed), injury type (concussion, laceration/contusion, subarachnoid hemorrhage, subdural hematoma, or epidural hematoma), loss of consciousness (LOC), surgical management (Clinical Classification Software code 1 or 2), discharge disposition, in-hospital complications, and in-hospital mortality. The authors utilized the IBM SPSS statistical package (version 24) for univariate comparisons, as well as the identification of independent risk factors for PTS in multivariable analysis (alpha set at < 0.05).RESULTSThe rate of PTS was 6.9% among 124,444 unique patients hospitalized for TBI. The utilization rate of continuous electroencephalography (cEEG) was 0.3% and increased between 2003 (0.1%) and 2012 (0.7%). The most common etiologies of TBI were motor vehicle accident (n = 50,615), accidental fall (n = 30,847), and blunt trauma (n = 13,831). However, the groups with the highest rate of PTS were shaken infant syndrome (41.4%), accidental falls (8.1%), and cycling accidents (7.4%). In multivariable analysis, risk factors for PTS included age 0-5 years (compared with 6-10, 11-15, and 16-20 years), African American race (OR 1.4), ≥ 3 preexisting comorbidities (OR 4.0), shaken infant syndrome (OR 4.4), subdural hematoma (OR 1.6), closed-type injury (OR 2.3), brief LOC (OR 1.4), moderate LOC (OR 1.5), and prolonged LOC with baseline return (OR 1.8). Surgically managed patients were more likely to experience PTS (OR 1.5) unless they were treated within 24 hours of admission (OR 0.8). PTS was associated with an increased likelihood of in-hospital complications (OR 1.7) and adverse (nonroutine) discharge disposition (OR 1.2), but not in-hospital mortality (OR 0.5). The overall utilization rate of cEEG was 1.3% in PTS patients compared with 0.2% in patients without PTS. Continuous EEG monitoring was associated with higher rates of diagnosed PTS (35.4% vs 6.8%; OR 4.9, p < 0.001).CONCLUSIONSPTS is common in children with TBI and is associated with adverse outcomes. Independent risk factors for PTS include younger age (< 5 years), African American race, increased preexisting comorbidity, prolonged LOC, and injury pattern involving cortical exposure to blood products. However, patients who undergo urgent surgical evacuation are less likely to develop PTS.
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Affiliation(s)
- Kavelin Rumalla
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Kyle A Smith
- 2Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Vijay Letchuman
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | - Mrudula Gandham
- 1School of Medicine, University of Missouri-Kansas City, Missouri; and
| | | | - Paul M Arnold
- 2Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
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Bergin SM, Dunn AL, Smith LGF, Drapeau AI. Management of hydrocephalus in infants with severe hemophilia A: report of 2 cases. J Neurosurg Pediatr 2018; 23:159-163. [PMID: 30485223 DOI: 10.3171/2018.8.peds18409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/29/2018] [Indexed: 11/06/2022]
Abstract
The authors report on the clinical course of two infants with severe hemophilia A (HA) and concomitant progressive hydrocephalus that required management with a ventriculoperitoneal shunt. The first child, with known HA, presented with a spontaneous intracranial hemorrhage and acquired hydrocephalus. He underwent cerebrospinal fluid diversion with a temporary external ventricular drain, followed by placement of a ventriculoperitoneal shunt. The second child had hydrocephalus secondary to a Dandy-Walker malformation and was diagnosed with severe HA during preoperative evaluation. He underwent placement of a ventriculoperitoneal shunt after progression of the hydrocephalus. The authors also review the treatment of hydrocephalus in patients with HA and describe the perioperative protocols used in their two cases. Treatment of hydrocephalus in infants with HA requires unique perioperative management to avoid complications.
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Affiliation(s)
- Stephen M Bergin
- 1Department of Neurosurgery.,2Medical Scientist Training Program
| | - Amy L Dunn
- 3Nationwide Children's Hospital Division of Hematology, Oncology & BMT; and
| | | | - Annie I Drapeau
- 1Department of Neurosurgery.,4Nationwide Children's Hospital Division of Pediatric Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
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Abel TJ, Varela Osorio R, Amorim-Leite R, Mathieu F, Kahane P, Minotti L, Hoffmann D, Chabardes S. Frameless robot-assisted stereoelectroencephalography in children: technical aspects and comparison with Talairach frame technique. J Neurosurg Pediatr 2018; 22:37-46. [PMID: 29676681 DOI: 10.3171/2018.1.peds17435] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Robot-assisted stereoelectroencephalography (SEEG) is gaining popularity as a technique for localization of the epileptogenic zone (EZ) in children with pharmacoresistant epilepsy. Here, the authors describe their frameless robot-assisted SEEG technique and report preliminary outcomes and relative complications in children as compared to results with the Talairach frame-based SEEG technique. METHODS The authors retrospectively analyzed the results of 19 robot-assisted SEEG electrode implantations in 17 consecutive children (age < 17 years) with pharmacoresistant epilepsy, and compared these results to 19 preceding SEEG electrode implantations in 18 children who underwent the traditional Talairach frame-based SEEG electrode implantation. The primary end points were seizure-freedom rates, operating time, and complication rates. RESULTS Seventeen children (age < 17 years) underwent a total of 19 robot-assisted SEEG electrode implantations. In total, 265 electrodes were implanted. Twelve children went on to have EZ resection: 4 demonstrated Engel class I outcomes, whereas 2 had Engel class II outcomes, and 6 had Engel class III-IV outcomes. Of the 5 patients who did not have resection, 2 underwent thermocoagulation. One child reported transient paresthesia associated with 2 small subdural hematomas, and 3 other children had minor asymptomatic intracranial hemorrhages. There were no differences in complication rates, rates of resective epilepsy surgery, or seizure freedom rates between this cohort and the preceding 18 children who underwent Talairach frame-based SEEG. The frameless robot-assisted technique was associated with shorter operating time (p < 0.05). CONCLUSIONS Frameless robot-assisted SEEG is a safe and effective means of identifying the EZ in children with pharmacoresistant partial epilepsy. Robot-assisted SEEG is faster than the Talairach frame-based method, and has equivalent safety and efficacy. The former, furthermore, facilitates more electrode trajectory possibilities, which may improve the localization of epileptic networks.
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Affiliation(s)
- Taylor J Abel
- 1Clinique de Neurochirurgie, and.,2Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Ricardo Amorim-Leite
- 3Clinique Neurologique, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France; and
| | - Francois Mathieu
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Philippe Kahane
- 3Clinique Neurologique, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France; and
| | - Lorella Minotti
- 3Clinique Neurologique, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France; and
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Freund B, Probasco JC, Ritzl EK. Seizure incidence in the acute postneurosurgical period diagnosed using continuous electroencephalography. J Neurosurg 2018:1-7. [PMID: 30067470 DOI: 10.3171/2018.1.jns171466] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDelay in diagnosis and subsequent treatment of nonconvulsive seizures can lead to worsened outcomes. The gold standard in detecting nonconvulsive seizures is continuous video-electroencephalography (cEEG). Compared to routine, 30-minute EEG, the use of cEEG increases the likelihood of capturing intermittent nonconvulsive seizures. Studies of critically ill patients in intensive care units demonstrate a particularly high rate of nonconvulsive seizures. Some of these studies included postneurosurgical patients, but often subanalyses of specific populations were not done. In particular, few studies have specifically evaluated postneurosurgical patients by using cEEG in the acute postoperative setting. Therefore, the incidence and predictors of acute postneurosurgical seizures are unclear.METHODSIn this study, the authors focused on patients who were admitted to the neurological critical care unit following neurosurgery and who underwent cEEG monitoring within 72 hours of surgery.RESULTSA total of 105 cEEG studies were performed in 102 patients. Twenty-nine patients demonstrated electrographic (subclinical) seizures, of whom 10 had clinical seizures clearly documented either before or during cEEG monitoring. Twenty-two patients had subclinical seizures only detected on cEEG, 19 of whom did not have clinical seizure activity at any point during hospitalization. Those with seizures were more likely to have had a history of epilepsy (p = 0.006). The EEG studies of patients with seizures were more likely to show lateralized periodic discharges (p = 0.012) and lateralized rhythmic delta activity (p = 0.012). The underlying neuropathological disorders most associated with seizure risk were lobar tumor on presentation (p = 0.048), subdural hematoma (SDH) requiring craniotomy for evacuation (p = 0.002), subarachnoid hemorrhage (SAH) (p = 0.026), and perioperative SAH (p = 0.019). In those undergoing craniotomy, the presence of SDH (p = 0.032), particularly if requiring evacuation (p = 0.003), increased the risk of seizures. In those without preoperative intracranial bleeding, perioperative SAH after craniotomy was associated with a higher incidence of seizures (p = 0.014). There was an additive effect on seizure incidence when perioperative SAH as well as concomitant intraparenchymal hemorrhage and/or stroke were present. The clinical examination of the patient, including the presence or absence of altered mental status and the presence or absence of repetitive movements, was not predictive of subclinical seizures.CONCLUSIONSIn postneurosurgical patients referred for cEEG monitoring, there is a high rate of both clinical and subclinical seizures in the early postoperative period. Seizures are particularly common in patients with SDH or lobar tumor and perioperative SAH. There was an additive effect on seizure incidence when more extensive brain injury was present. As expected, those with a history of epilepsy also demonstrated higher seizure rates. Further studies are needed to evaluate the time period of maximum seizure incidence after surgery, and the effects acute postneurosurgical seizures have on long-term outcomes.
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Perry A, Graffeo CS, Brinjikji W, Copeland WR, Rabinstein AA, Link MJ. Spontaneous occult intracranial hypotension precipitating life-threatening cerebral venous thrombosis: case report. J Neurosurg Spine 2018; 28:669-678. [PMID: 29600909 DOI: 10.3171/2017.10.spine17806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is an uncommon headache etiology, typically attributable to an unprovoked occult spinal CSF leak. Although frequently benign, serious complications may occur, including cerebral venous thrombosis (CVT). The objective of this study was to examine a highly complicated case of CVT attributable to SIH as a lens for understanding the heterogeneous literature on this rare complication, and to provide useful, evidence-based, preliminary clinical recommendations. A 43-year-old man presented with 1 week of headache, dizziness, and nausea, which precipitously evolved to hemiplegia. CT venography confirmed CVT, and therapeutic heparin was initiated. He suffered a generalized seizure due to left parietal hemorrhage, which subsequently expanded. He developed signs of mass effect and herniation, heparin was discontinued, and he was taken to the operating room for clot evacuation and external ventricular drain placement. Intraoperatively, the dura was deflated, suggesting underlying SIH. Ventral T-1 CSF leak was identified, which failed multiple epidural blood patches and required primary repair. The patient ultimately made a complete recovery. Systematic review identified 29 publications describing 36 cases of SIH-associated CVT. Among 31 patients for whom long-term neurological outcome was reported, 25 (81%) recovered completely. Underlying coagulopathy/risk factors were identified in 11 patients (31%). CVT is a rare and potentially lethal sequela occurring in 2% of SIH cases. Awareness of the condition is poor, risking morbid complications. Evaluation and treatment should be directed toward identification and treatment of occult CSF leaks. Encouragingly, good neurological outcomes can be achieved through vigilant multidisciplinary neurosurgical and neurocritical care.
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Affiliation(s)
| | | | | | - William R Copeland
- 3Division of Neurosurgery, Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | | | - Michael J Link
- Departments of1Neurologic Surgery.,5Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota; and
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14
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Abstract
OBJECTIVE The aim of this study was to assess the outcome of neurosurgical treatment in children with bleeding diathesis and also to evaluate the current management plan applied in the authors' service. METHODS The authors retrospectively analyzed all cases in which neurosurgical procedures were performed in pediatric patients presenting with intracranial hematoma due to an underlying bleeding tendency over a 5-year period at their institution. They evaluated the patients' neurological symptoms from the initial referral, hematological abnormalities, surgical treatment, neurological outcome, and scores on the Pediatric Glasgow Outcome Scale-Extended (GOS-E Peds) obtained 1 year after the last operation. RESULTS Five patients with a bleeding diathesis who underwent surgery for intracranial hematoma were identified; the diagnosis was hemophilia A in 3 cases, idiopathic thrombocytopenic purpura in 1 case, and severe aplastic anemia in 1 case. Intracerebral hematoma (ICH) (n = 4) and acute subdural hematoma (n = 1) were confirmed on radiological investigations. In 2 of the 4 patients with ICH, the diagnosis of bleeding diathesis was made for the first time on presentation. Four patients (all male) were younger than 2 years; the patient with severe aplastic anemia and spontaneous ICH was 15 years old and female. The duration of symptoms varied from 24 hours to 5 days. Neurological examination at 1 year's follow-up showed complete recovery (GOS-E Peds score of 1) in 3 cases and mild weakness (GOS-E Peds score of 2) in 2 cases. CONCLUSIONS Neurosurgical management of patients with bleeding diathesis should be carried out in a tertiary-care setting with multidisciplinary team management, including members with expertise in neuroimaging and hematology, in addition to neurosurgery. Early diagnosis and prompt treatment of a bleeding diathesis is crucial for full neurological recovery.
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15
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Hansen JB, Frazier T, Moffatt M, Zinkus T, Anderst JD. Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces. J Neurosurg Pediatr 2018; 21:31-37. [PMID: 29099352 DOI: 10.3171/2017.7.peds17317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs. METHODS The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs. RESULTS Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08-0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03-0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5-7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05-0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms. CONCLUSIONS The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.
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Affiliation(s)
| | | | | | - Timothy Zinkus
- 2Radiology, Children's Mercy Hospital, Kansas City, Missouri
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16
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Franko LR, Sheehan KM, Roark CD, Joseph JR, Burke JF, Rajajee V, Williamson CA. A propensity score analysis of the impact of surgical intervention on unexpected 30-day readmission following admission for subdural hematoma. J Neurosurg 2017; 129:1008-1016. [PMID: 29271714 DOI: 10.3171/2017.6.jns17188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored. METHODS This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission. RESULTS Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08-0.49). CONCLUSIONS Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.
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Affiliation(s)
| | - Kyle M Sheehan
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | | | | | - James F Burke
- 3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | - Venkatakrishna Rajajee
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | - Craig A Williamson
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
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17
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Sundström N, Lagebrant M, Eklund A, Koskinen LOD, Malm J. Subdural hematomas in 1846 patients with shunted idiopathic normal pressure hydrocephalus: treatment and long-term survival. J Neurosurg 2017; 129:797-804. [PMID: 29076787 DOI: 10.3171/2017.5.jns17481] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematoma (SDH) is the most common serious adverse event in patients with shunts. Adjustable shunts are used with increasing frequency and make it possible to noninvasively treat postoperative SDH. The objective of this study was to describe the prevalence and treatment preferences of SDHs, based on fixed or adjustable shunt valves, in a national cohort of patients with shunted idiopathic normal pressure hydrocephalus (iNPH), as well as to evaluate the effect of SDH and treatment on long-term survival. METHODS Patients with iNPH who received a CSF shunt in Sweden from 2004 to 2015 were included in a prospective quality registry (n = 1846) and followed regarding SDH, its treatment, and mortality. The treatment of SDH was categorized into surgery, opening pressure adjustments, or no treatment. RESULTS During the study period, the proportion of adjustable shunts increased from 75% to 95%. Ten percent (n = 184) of the patients developed an SDH. In 103 patients, treatment was solely opening pressure adjustment. Surgical treatment was used in 66 cases (36%), and 15 (8%) received no treatment. In patients with fixed shunt valves, 90% (n = 17) of SDHs were treated surgically compared with 30% (n = 49) in patients with adjustable shunts (p < 0.001). There was no difference in long-term patient survival between the SDH and non-SDH groups or between different treatments. CONCLUSIONS SDH remains a common complication after shunt surgery, but adjustable shunts reduced the need for surgical interventions. SDH and treatment did not significantly affect survival in this patient group, thus the noninvasive treatment offered by adjustable shunts considerably reduces the level of severity for this common adverse event.
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Affiliation(s)
- Nina Sundström
- Departments of1Radiation Sciences, Biomedical Engineering, and
| | - Marcus Lagebrant
- 2Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Departments of1Radiation Sciences, Biomedical Engineering, and
| | | | - Jan Malm
- 2Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
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18
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Oh A, Sawvel M, Heaner D, Bhatia A, Reisner A, Tubbs RS, Chern JJ. Changes in use of cervical spine magnetic resonance imaging for pediatric patients with nonaccidental trauma. J Neurosurg Pediatr 2017; 20:271-277. [PMID: 28665242 DOI: 10.3171/2017.2.peds16644] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Past studies have suggested correlations between abusive head trauma and concurrent cervical spine (c-spine) injury. Accordingly, c-spine MRI (cMRI) has been increasingly used in radiographic assessments. This study aimed to determine trends in cMRI use and treatment, and outcomes related to c-spine injury in children with nonaccidental trauma (NAT). METHODS A total of 503 patients with NAT who were treated between 2009 and 2014 at a single pediatric health care system were identified from a prospectively maintained database. Additional data on selected clinical events were retrospectively collected from electronic medical records. In 2012, a clinical pathway on cMRI usage for patients with NAT was implemented. The present study compared cMRI use and clinical outcomes between the prepathway (2009-2011) and postpathway (2012-2014) periods. RESULTS There were 249 patients in the prepathway and 254 in the postpathway groups. Incidences of cranial injury and Injury Severity Scores were not significantly different between the 2 groups. More patients underwent cMRI in the years after clinical pathway implementation than before (2.8% vs 33.1%, p < 0.0001). There was also a significant increase in cervical collar usage from 16.5% to 27.6% (p = 0.004), and more patients were discharged home with cervical collar immobilization. Surgical stabilization occurred in a single case in the postpathway group. CONCLUSIONS Heightened awareness of potential c-spine injury in this population increased the use of cMRI and cervical collar immobilization over a 6-year period. However, severe c-spine injury remains rare, and increased use of cMRI might not affect outcomes markedly.
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Affiliation(s)
| | - Michael Sawvel
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta
| | - David Heaner
- Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta
| | - Amina Bhatia
- Pediatric Surgery, Emory University, Atlanta; and.,Children's Physician Group, Pediatric Surgery, Children's Healthcare of Atlanta, Georgia; and
| | - Andrew Reisner
- Neurosurgery, Emory University School of Medicine.,Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta
| | - R Shane Tubbs
- Department of Neurosurgery, University of Alabama Birmingham School of Medicine, Birmingham, Alabama
| | - Joshua J Chern
- Neurosurgery, Emory University School of Medicine.,Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta
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19
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Lee JJ, Segar DJ, Morrison JF, Mangham WM, Lee S, Asaad WF. Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury. J Neurosurg 2017; 128:236-249. [PMID: 28186445 DOI: 10.3171/2016.5.jns16255] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.
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Affiliation(s)
| | | | - John F Morrison
- 1Warren Alpert Medical School of Brown University.,2Department of Neurosurgery, Rhode Island Hospital
| | | | - Shane Lee
- 3Brown Institute for Brain Science.,4Department of Neuroscience, Brown University; and
| | - Wael F Asaad
- 1Warren Alpert Medical School of Brown University.,2Department of Neurosurgery, Rhode Island Hospital.,3Brown Institute for Brain Science.,4Department of Neuroscience, Brown University; and.,5Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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20
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Scoco A, Emily Bennett E, Recinos V. Cortical herniation through compressive subdural membrane in an infant with a history of a large bihemispheric subdural hematoma and subdural-peritoneal shunt: case report. J Neurosurg Pediatr 2017; 19:168-173. [PMID: 27885943 DOI: 10.3171/2016.8.peds16108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cortical herniation through subdural membrane formation is a rare complication of chronic subdural fluid collections and may occur following subdural shunting. The authors present a unique case of progressive cortical herniation through a compressive subdural membrane that occurred concomitant with a functioning subdural-peritoneal shunt.
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Affiliation(s)
- Aleka Scoco
- Case Western Reserve University School of Medicine; and
| | - E Emily Bennett
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Violette Recinos
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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21
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Joseph JR, Smith BW, Garton HJL. Blunt prenatal trauma resulting in fetal epidural or subdural hematoma: case report and systematic review of the literature. J Neurosurg Pediatr 2017; 19:32-37. [PMID: 27739945 DOI: 10.3171/2016.7.peds16282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Blunt prenatal trauma is known to have consequences to the developing brain, and can result in subdural hematoma (SDH) or epidural hematoma (EDH). The authors present a case of blunt prenatal trauma resulting in a fetal SDH, intraparenchymal hematoma, and intraventricular hemorrhage, and perform a systematic review of the literature. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant studies (up to April 2016) that reported on cases of fetal SDH or EDH after blunt prenatal trauma were identified from the PubMed database. The primary outcome was fetal mortality, and the secondary outcome was neurological outcome. Fourteen studies were included in the analysis, comprising a total of 14 patients including the present case. The average gestational age at discovery of hemorrhage was 30.1 weeks. Nine mothers were in a motor vehicle collision and 3 were assaulted; the mechanism of injury for 2 mothers was not defined. Twelve patients had SDH, 1 had EDH, and 1 had conflicting reports. Three patients had intrauterine fetal demise, and 3 died in the neonatal period after birth. Three patients had persistent neurological deficit, and 5 were neurologically intact. Fetal SDH or EDH after blunt trauma to the mother trauma is rare and is associated with mortality. However, a significant number of patients can have good neurological outcomes.
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Affiliation(s)
- Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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22
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Zuckerman SL, Prather CT, Yengo-Kahn AM, Solomon GS, Sills AK, Bonfield CM. Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis. Neurosurg Focus 2016; 40:E9. [PMID: 27032926 DOI: 10.3171/2016.1.focus15608] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.
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Affiliation(s)
- Scott L Zuckerman
- Vanderbilt Sports Concussion Center, and
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Gary S Solomon
- Vanderbilt Sports Concussion Center, and
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Allen K Sills
- Vanderbilt Sports Concussion Center, and
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christopher M Bonfield
- Vanderbilt Sports Concussion Center, and
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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Abstract
OBJECTIVE The Brain Trauma Foundation recommendation regarding the timing of surgical evacuation of epidural hematomas and subdural hematomas is to perform the procedure as soon as possible. Indeed, faster evacuation is associated with better outcome. However, to the authors' knowledge, no study has looked at where delays in intrahospital care occurred for patients suffering from traumatic intracranial mass lesions. The goals of this study were as follows: 1) to characterize the performance of a Level 1 trauma center in terms of delays for emergency trauma craniotomies, 2) to review step by step where delays occurred in patient care, and 3) to propose ways to improve performance. METHODS A retrospective review was conducted covering a 5-year period of all emergency trauma craniotomies. Demographic data, injury severity, neurological status, and functional outcome data were collected. The time elapsed between emergency department (ED) arrival and CT imaging, between CT imaging and arrival at the operating room (OR), between ED arrival and OR arrival, between OR arrival and skin incision, and between ED arrival and skin incision were calculated. Patients were also subcategorized as either having immediate life-threatening emergencies (E0) or life-threatening emergencies (E1). The operative technique was also reviewed (standard craniotomy opening vs immediate bur hole decompression followed by craniotomy). RESULTS The study included 166 patients. Of these, 58 (35%) were classified into the E0 group and 108 (64.2%) into the E1 group. The median ED-to-CT delay was 54 minutes with no significant difference between the E0 and the E1 groups. The median CT-to-OR time delay was 57 minutes. The median delay for the E0 group was 39 minutes and that for the E1 group was 70 minutes (p = 0.002). The median delay from ED to OR arrival for patients with a CT scanning done at an outside hospital was 75 minutes. The median delay from ED to OR arrival was 85 minutes for the E0 group and 127 minutes for the E1 group (p < 0.0001). The median delay from OR arrival to skin incision was 35 minutes (E0: median 27 minutes; E1: median 39 minutes; p < 0.0001). The median total time elapsed between ED arrival and skin incision was 150 minutes (E0: median 131 minutes; E1: median 180 minutes). Overall, only 17% of patients underwent immediate bur hole decompression, but the proportion climbed to 41% in the E0 group. A lower Glasgow Coma Scale score was associated with a shorter delay (p = 0.0004). CONCLUSIONS A long delay until surgery still exists for patients requiring urgent mass lesion evacuation. Many factors contribute to this delay, including performing imaging and transfer to and preparation in the OR. Strategies can be implemented to reduce delays and improve the delivery of care.
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Affiliation(s)
- Judith Marcoux
- Department of Neurology and Neurosurgery, McGill University; and,Departments of 2 Neurosurgery and
| | - David Bracco
- Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Rajeet S Saluja
- Department of Neurology and Neurosurgery, McGill University; and,Departments of 2 Neurosurgery and
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24
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Farahmand D, Sæhle T, Eide PK, Tisell M, Hellström P, Wikkelsö C. A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus. J Neurosurg 2015; 124:359-67. [PMID: 26315004 DOI: 10.3171/2015.1.jns141301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The study aim was to examine the effect of gradually reducing the opening pressure on symptoms and signs in the shunt treatment of idiopathic normal pressure hydrocephalus (iNPH). METHODS In this prospective double-blinded, randomized, controlled, double-center study on patients with iNPH, a ventriculoperitoneal shunt with an adjustable Codman Medos Valve was implanted in 68 patients randomized into 2 groups. In 1 group (the 20-4 group) the valve setting was initially set to 20 cm H2O and gradually reduced to 4 cm H2O over the course of the 6-month study period. In the other group (the 12 group), the valve was kept at a medium level of 12 cm H2O during the whole study period. All patients were clinically evaluated using 4 tests preoperatively as well as postoperatively at 1, 2, 3, 4, and 6 months. The test scores between the 2 groups (20-4 and 12) were compared for each clinical evaluation. RESULTS Fifty-five patients (81%) were able to complete the study. There were no significant differences between the 2 groups (20-4 and 12) preoperatively or at any time postoperatively. Both groups exhibited significant clinical improvement after shunt insertion at all valve settings compared with the preoperative score, with the greatest improvement observed at the first postoperative evaluation. The clinical improvement was significant within the first 3 months, and thereafter no significant improvement was seen in either group. CONCLUSIONS Gradual reduction of the valve setting from 20 to 4 cm H2O did not improve outcome compared with a fixed valve setting of 12 cm H2O. Improvement after shunt surgery in iNPH patients was evident within 3 months, irrespective of valve setting.
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Affiliation(s)
- Dan Farahmand
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; and
| | | | - Per Kristian Eide
- Department of Neurosurgery and.,Faculty of Medicine, Oslo University Hospital, Oslo, Norway
| | - Magnus Tisell
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; and
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; and
| | - Carsten Wikkelsö
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; and
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Kerr EE, Prevedello DM, Jamshidi A, Ditzel Filho LF, Otto BA, Carrau RL. Immediate complications associated with high-flow cerebrospinal fluid egress during endoscopic endonasal skull base surgery. Neurosurg Focus 2015; 37:E3. [PMID: 25270143 DOI: 10.3171/2014.7.focus14294] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic expanded endonasal approaches (EEAs) to the skull base are increasingly being used to address a variety of skull base pathologies. Postoperative CSF leakage from the large skull base defects has been well described as one of the most common complications of EEAs. There are reports of associated formation of delayed subdural hematoma and tension pneumocephalus from approximately 1 week to 3 months postoperatively. However, there have been no reports of immediate complications of high-volume CSF leakage from EEA skull base surgery. The authors describe two cases of EEAs in which complications related to rapid, large-volume CSF egress through the skull base surgical defect were detected in the immediate postoperative period. Preventive measures to reduce the likelihood of these immediate complications are presented.
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Affiliation(s)
- Edward E Kerr
- Departments of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
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Yokosuka K, Uno M, Matsumura K, Takai H, Hagino H, Matsushita N, Toi H, Matsubara S. Endoscopic hematoma evacuation for acute and subacute subdural hematoma in elderly patients. J Neurosurg 2015; 123:1065-9. [PMID: 25909568 DOI: 10.3171/2014.10.jns14915] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopic surgery was performed for acute or subacute subdural hematoma (SDH), and its effectiveness and safety in elderly patients were evaluated. METHODS Between September 2007 and November 2013, endoscopic surgery was performed in 11 elderly patients with acute SDH (8 patients) and subacute SDH (3 patients). The criteria for surgery were as follows: 1) the presence of clinical symptoms; 2) age older than 70 years; 3) no brain injury (intracerebral hematoma, brain contusion); 4) absence of an enlarging SDH; and 5) no high risk of bleeding. Hematoma evacuation was performed with a 4-mm rigid endoscope with a 0° lens and a malleable irrigation suction cannula. RESULTS Endoscopic surgery was performed under local anesthesia. The mean age of the patients was 82.6 years (range 73-91 years). There were 5 female and 6 male patients. The mean preoperative Glasgow Coma Scale score was 12, and 5 patients had been receiving antithrombotic drug therapy. The mean operation time was 85 minutes. Only 1 patient had rebleeding, and reoperation with the same technique was performed uneventfully in this individual. A total of 7 patients had a good recovery (modified Rankin Scale Score 0-2) at discharge. CONCLUSIONS Endoscopic hematoma evacuation of acute and subacute SDH is a safe and effective method of clot removal that minimizes operative complications. This technique may be a less invasive method for treating elderly patients with acute and subacute SDHs.
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Affiliation(s)
- Kimihiko Yokosuka
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kohei Matsumura
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hirotaka Hagino
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Nobuhisa Matsushita
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroyuki Toi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg 2015; 123:1209-15. [PMID: 25794342 DOI: 10.3171/2014.9.jns141550] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Chronic subdural hematomas (SDHs) are more common among veterans and elderly persons than among members of the general population; however, precise incidence rates are unknown. The purposes of this study were 1) to determine the current incidence of chronic SDH in a US Veterans Administration (VA) population and 2) to create a mathematical model for determining the current and future incidence of chronic SDH as a function of population age, sex, and comorbidity in the United States VA and civilian populations. METHODS To determine the actual number of veterans who received a radiographic diagnosis and surgical treatment for SDH during 2000-2012, the authors used the VISN03 VA database. On the basis of this result and data from outside the United States, they then created a mathematical model accounting for age, sex, and alcohol consumption to predict the incidence of SDH in the VA and civilian populations during 2012-2040. RESULTS Of 875,842 unique (different patient) visits to a VA hospital during the study period, 695 new SDHs were identified on CT images. Of these 695 SDHs, 203 (29%) required surgical drainage. The incidence rate was 79.4 SDHs per 100,000 persons, and the age-standardized rate was 39.1±4.74 SDHs per 100,000 persons. The authors' model predicts that incidence rates of chronic SDH in aging United States VA and civilian populations will reach 121.4 and 17.4 cases per 100,000 persons, respectively, by 2030, at which time, approximately 60,000 cases of chronic SDH will occur each year in the United States. CONCLUSIONS The incidence of chronic SDH is rising; SDH is projected to become the most common cranial neurosurgical condition among adults by the year 2030.
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Affiliation(s)
- David Balser
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and
| | - Sameer Farooq
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and
| | - Talha Mehmood
- Department of Neurosurgery, New York University School of Medicine; and
| | - Marleen Reyes
- Department of Neurosurgery, New York University School of Medicine; and
| | - Uzma Samadani
- New York Harbor Healthcare System, Manhattan Veterans Administration, New York;,Department of Neurosurgery, New York University School of Medicine; and.,Steven and Alexandra Cohen Veterans Center for the Study of Post-Traumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, New York
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Blauwblomme T, Di Rocco F, Bourgeois M, Beccaria K, Paternoster G, Verchere-Montmayeur J, Sainte-Rose C, Zerah M, Puget S. Subdural to subgaleal shunts: alternative treatment in infants with nonaccidental traumatic brain injury? J Neurosurg Pediatr 2015; 15:306-9. [PMID: 25555119 DOI: 10.3171/2014.9.peds1485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The ideal treatment for subdural hematomas (SDHs) in infants remains debated. The aim of this study was to analyze the safety and efficiency of subduro-subgaleal drainage in SDH. METHODS The authors conducted a single-center open-label study between August 2011 and May 2012. Data were prospectively collected in a database and retrospectively analyzed. RESULTS Eighteen patients (male/female ratio 1.25) with a median age of 5 months were surgically treated. All had preoperative symptoms of intracranial hypertension or seizures. The SDH was bilateral in 16 cases, with a median width of 12 mm. Success of the procedure was noted in 14 of the 18 patients. There was no intraoperative complication or postoperative infection. Drainage failure was attributable to suboptimal positioning of the subdural drain in 2 cases and to migration in 1 case. CONCLUSIONS Subduro-subgaleal drainage is an efficient treatment that could be proposed as an alternative to external subdural drainage or subduroperitoneal drainage.
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Samadani U, Farooq S, Ritlop R, Warren F, Reyes M, Lamm E, Alex A, Nehrbass E, Kolecki R, Jureller M, Schneider J, Chen A, Shi C, Mendhiratta N, Huang JH, Qian M, Kwak R, Mikheev A, Rusinek H, George A, Fergus R, Kondziolka D, Huang PP, Smith RT. Detection of third and sixth cranial nerve palsies with a novel method for eye tracking while watching a short film clip. J Neurosurg 2014; 122:707-20. [PMID: 25495739 DOI: 10.3171/2014.10.jns14762] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT Automated eye movement tracking may provide clues to nervous system function at many levels. Spatial calibration of the eye tracking device requires the subject to have relatively intact ocular motility that implies function of cranial nerves (CNs) III (oculomotor), IV (trochlear), and VI (abducent) and their associated nuclei, along with the multiple regions of the brain imparting cognition and volition. The authors have developed a technique for eye tracking that uses temporal rather than spatial calibration, enabling detection of impaired ability to move the pupil relative to normal (neurologically healthy) control volunteers. This work was performed to demonstrate that this technique may detect CN palsies related to brain compression and to provide insight into how the technique may be of value for evaluating neuropathological conditions associated with CN palsy, such as hydrocephalus or acute mass effect. METHODS The authors recorded subjects' eye movements by using an Eyelink 1000 eye tracker sampling at 500 Hz over 200 seconds while the subject viewed a music video playing inside an aperture on a computer monitor. The aperture moved in a rectangular pattern over a fixed time period. This technique was used to assess ocular motility in 157 neurologically healthy control subjects and 12 patients with either clinical CN III or VI palsy confirmed by neuro-ophthalmological examination, or surgically treatable pathological conditions potentially impacting these nerves. The authors compared the ratio of vertical to horizontal eye movement (height/width defined as aspect ratio) in normal and test subjects. RESULTS In 157 normal controls, the aspect ratio (height/width) for the left eye had a mean value ± SD of 1.0117 ± 0.0706. For the right eye, the aspect ratio had a mean of 1.0077 ± 0.0679 in these 157 subjects. There was no difference between sexes or ages. A patient with known CN VI palsy had a significantly increased aspect ratio (1.39), whereas 2 patients with known CN III palsy had significantly decreased ratios of 0.19 and 0.06, respectively. Three patients with surgically treatable pathological conditions impacting CN VI, such as infratentorial mass effect or hydrocephalus, had significantly increased ratios (1.84, 1.44, and 1.34, respectively) relative to normal controls, and 6 patients with supratentorial mass effect had significantly decreased ratios (0.27, 0.53, 0.62, 0.45, 0.49, and 0.41, respectively). These alterations in eye tracking all reverted to normal ranges after surgical treatment of underlying pathological conditions in these 9 neurosurgical cases. CONCLUSIONS This proof of concept series of cases suggests that the use of eye tracking to detect CN palsy while the patient watches television or its equivalent represents a new capacity for this technology. It may provide a new tool for the assessment of multiple CNS functions that can potentially be useful in the assessment of awake patients with elevated intracranial pressure from hydrocephalus or trauma.
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Affiliation(s)
- Uzma Samadani
- New York Harbor Health Care System, Manhattan Veteran's Administration;
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Abstract
Traumatic brain injuries afflict a large number of pediatric patients. The most severe injuries lead to increased intracranial pressure and herniation, with resultant changes in the brainstem. Traumatic brainstem hemorrhages have previously been associated with poor neurological outcome and fatality. However, this report discusses 2 pediatric patients who sustained severe head trauma with subsequent brainstem hemorrhages, and yet experienced good neurological outcome; the possible mechanism is described.
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Affiliation(s)
- Alexandra D Beier
- Division of Pediatric Neurological Surgery, University of Florida Health Jacksonville, Florida; and
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