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Medicine May 2024Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and...
RATIONALE
Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported.
PATIENT CONCERNS
A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself.
DIAGNOSES
Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury.
INTERVENTIONS
Conservative treatment without surgery.
OUTCOMES
Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69.
LESSONS
Very-low-velocity PHI might be successfully treated with conservative treatment.
Topics: Humans; Male; Middle Aged; Head Injuries, Penetrating; Wounds, Stab; Tomography, X-Ray Computed; Self-Injurious Behavior; Magnetic Resonance Imaging; Conservative Treatment
PubMed: 38701288
DOI: 10.1097/MD.0000000000037896 -
World Journal of Clinical Cases Jul 2023Subarachnoid-pleural fistula (SPF) is a complex and rare condition characterized by a pathological shunt between the subarachnoid and pleural spaces. It can lead to the...
BACKGROUND
Subarachnoid-pleural fistula (SPF) is a complex and rare condition characterized by a pathological shunt between the subarachnoid and pleural spaces. It can lead to the accumulation of cerebrospinal fluid (CSF) in the pleural space, pneumocephalus, and the development of central nervous system infection. Trauma or thoracic spinal surgery are common causes of SPF, with symptoms including postural headache, consciousness status changes, and dyspnea. The combination of SPF and subdural hygroma is a severe and rare condition, with little existing literature on its clinical correlation.
CASE SUMMARY
We report a case of an 83-year-old male patient with traumatic SPF and bilateral frontal subdural hygroma following a fall from height. The patient initially presented with severe lower back and buttock pain. During admission, the patient developed worsening lower limb weakness and pleural effusion. Further investigation revealed the presence of subdural hygromas with mass effect, requiring emergency bilateral subdural drainage. A multidisciplinary approach was undertaken to manage this complex condition, including intervention for hypovolemic CSF status and subdural hygroma management. The pleural effusion eventually resolved and the patient attained a higher level of consciousness after bilateral hygroma drainage surgery. We also reviewed the present literature relating to this rare combination of medical conditions.
CONCLUSION
Traumatic SPF with subsequent subdural hygroma is a rare but serious combination. Although the optimal treatment strategy for this complex condition remains uncertain, our literature review suggested that a multidisciplinary approach, including intervention for hypovolemic CSF and management of the subdural hygroma, is the most beneficial.
PubMed: 37583858
DOI: 10.12998/wjcc.v11.i21.5173 -
Otology & Neurotology : Official... Sep 2023The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus....
OBJECTIVE
The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement.
STUDY DESIGN
Prospective cohort study.
SETTING
Tertiary academic medical center.
PATIENTS
Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022.
INTERVENTIONS
CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT).
MAIN OUTCOME MEASURES
Postoperative skull base defects on CT, pneumocephalus, or intracranial complications.
RESULTS
The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m 2 . Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively.
CONCLUSION
Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.
Topics: Humans; Female; Middle Aged; Male; Bone Cements; Durapatite; Continuous Positive Airway Pressure; Pneumocephalus; Prospective Studies; Retrospective Studies; Skull Base; Cerebrospinal Fluid Leak; Treatment Outcome
PubMed: 37464456
DOI: 10.1097/MAO.0000000000003964 -
Turkish Neurosurgery 2024The paramedian forehead flap (PMFF) has been well described for nasal reconstruction. However, it has never been reported for use in the repair of high flow anterior...
The paramedian forehead flap (PMFF) has been well described for nasal reconstruction. However, it has never been reported for use in the repair of high flow anterior skull base cerebrospinal fluid (CSF) leaks. The patient was a 55 year-old African American male cocaine abuser who initially presented with a high flow anterior skull base CSF leak, extensive pneumocephalus, and intra-cerebral and intra-ventricular abscesses with an oro-nasal-cerebral fistula. The patent initially underwent bi-frontal craniotomy, exenteration of the frontal sinus, abdominal fat graft, resection of intra-cerebral abscesses, and repair of high flow anterior skull base CSF leak with a pedicled pericranial flap (PF). Eighteen months after the patient's surgery, he had resumed his use of cocaine and suffered necrosis of his PF. This caused his high flow CSF leak to recur. After extensive psychiatric treatment, he stopped cocaine use and was subsequently repaired with a pedicled de-epithelialized PMFF originating off the bilateral supratrochlear arteries. The patient has had no CSF leak for 3 years, and primary closure of the forehead was achieved with good cosmetic outcome. This case highlights the use of PMFF for the treatment of recurrent high flow anterior skull base CSF leak. It also highlights the importance of treatment of the patient's underlying medical disorder, in this case, the patient's addiction to cocaine. We provide a detailed discussion for the use of the de-epithelialized PMFF and how it can be utilized as a vascularized reconstructive technique to repair complex refractory CSF leaks.
Topics: Humans; Male; Middle Aged; Forehead; Brain Abscess; Cerebrospinal Fluid Leak; Cocaine; Frontal Sinus; Skull Base
PubMed: 28944942
DOI: 10.5137/1019-5149.JTN.20662-17.1 -
World Neurosurgery Apr 2024To describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely...
OBJECTIVE
To describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely decompression in the event of tension pneumocephalus and spares the need for additional surgery.
METHODS
We conducted a retrospective analysis of 20 patients with CSDH who underwent burr hole craniostomy and 20 patients who underwent the same procedure alongside the placement of a 5 Fr neonatal feeding tube as a backup drainage for the anterior craniostomy. Depending on the situation, the secondary drain stayed for a maximum of 72 hours to be opened and used in emergency settings for drainage, aspiration, or as a 1-way valve with a water seal.
RESULTS
The outcomes of 20 patients who underwent this procedure and 20 controls are described. One patient from each group presented tension pneumocephalus. One was promptly resolved by opening the backup drain under a water seal to evacuate pneumocephalus and the other patient had to undergo a reopening of the craniostomy.
CONCLUSIONS
The described variation of burr hole craniostomy represents a low-cost and easy-to-implement technique that can be used for emergency decompression of tension pneumocephalus. It also has the potential to reduce reoperation rates and CSDH recurrence. Prospective controlled research is needed to validate this approach further.
PubMed: 38692567
DOI: 10.1016/j.wneu.2024.04.138 -
World Neurosurgery Aug 2023Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like... (Review)
Review
Tension Pneumocranium Following Transsphenoidal Surgeries-A Case Report and Systematic Review of Literature with Analysis of Predisposing Factors and Treatment Regimens: Is Early Skull Base Repair Better than Conservative Treatment?
BACKGROUND
Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like multiple transnasal transsphenoidal (TNTS) procedures, intraoperative cerebrospinal fluid leak, obstructive sleep apnea, continuous positive airway pressure, violent coughing, nose blowing, positive pressure ventilation on TP outcomes is also unknown.
METHODS
PubMed, Embase, Cochrane, and Google Scholar were searched for articles using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Multivariate logistic regression analysis was done using STATA/ BE ver 17.0.
RESULTS
Thirty-five studies with 49 cases of endoscopic TNTS surgeries were included. Tension pneumocephalus was seen in 77.5% (n = 38), tension pneumosella in 7 (14.28%), and tension pneumoventricle in 4 (8.16%). Nonfunctional pituitary adenomas (40.81%) were most common lesions associated with TP. The need of mechanical ventilation was significantly higher in patients who received conservative management (odds ratio, 1.34; confidence interval, 0.65-2.74) (P < 0.01). However, incidence of meningitis or mortality were not influenced by factors like age, gender, pathological diagnosis, initial conservative management or early skull base repair, use of adjuvant radiation, intraoperative cerebrospinal fluid leak, multiple TNTS explorations, or presence of precipitating factors.
CONCLUSIONS
Nonfunctional pituitary adenomas were the most common lesions associated with TP. Multiple TNTS procedures did not increase incidence of meningitis or mortality. Conservative management increased the need for mechanical ventilation but did not worsen the mortality outcomes.
Topics: Humans; Pituitary Neoplasms; Conservative Treatment; Postoperative Complications; Skull Base; Cerebrospinal Fluid Leak; Meningitis; Causality
PubMed: 37141943
DOI: 10.1016/j.wneu.2023.04.109 -
Neurology India 2023
Topics: Humans; Pneumocephalus; Brain Injuries, Traumatic; Tomography, X-Ray Computed
PubMed: 37929482
DOI: 10.4103/0028-3886.388070 -
The International Journal of... May 2024Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of...
PURPOSE
Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH).
CASE PRESENTATION
An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day.
CONCLUSION
TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.
PubMed: 38716712
DOI: 10.1080/00207454.2024.2352767 -
Turkish Journal of Ophthalmology Jun 2024A 4-year-old boy was referred to our tertiary hospital after a penetrating adnexal injury by a large-breed dog to the left orbital area. There was an increase in...
A 4-year-old boy was referred to our tertiary hospital after a penetrating adnexal injury by a large-breed dog to the left orbital area. There was an increase in lacrimation, which was thought to be due to an inflammatory reaction. However, it was discovered that the lacrimation increased in the reverse-Trendelenburg position and with the Valsalva maneuver. Halo sign and beta transferrin test were positive, which led to the diagnosis of cerebrospinal fluid (CSF) fistula, and the patient was operated using a supraorbital craniotomy. A dural tear was visualized and sutured appropriately, then fibrin glue and an autologous galeal graft were applied to the tear. The CSF oculorrhea stopped postoperatively, and the patient was discharged after 10 days of follow-up. The patient had no recurrent CSF leakage at 4-year follow-up. Although CSF oculorrhea is rare and may be difficult to discern from lacrimation, the presence of pneumocephalus and halo sign should suggest fistula repair.
Topics: Humans; Male; Animals; Child, Preschool; Dogs; Cerebrospinal Fluid Leak; Bites and Stings; Tomography, X-Ray Computed; Eye Injuries, Penetrating; Craniotomy; Orbit; Orbital Diseases
PubMed: 38818968
DOI: 10.4274/tjo.galenos.2024.45087 -
Heliyon Feb 2024A 54-year-old female with diabetes was admitted with fever and altered consciousness. Laboratory tests revealed venous blood glucose level of 43.79 mmol/L. Computed...
A 54-year-old female with diabetes was admitted with fever and altered consciousness. Laboratory tests revealed venous blood glucose level of 43.79 mmol/L. Computed tomography (CT) scans of the head, chest, and abdomen showed a right-sided pneumothorax, consolidation, and atelectasis in the right lung; a large heterogeneous density lesion with fluid and gas-fluid levels in the liver; and scattered gas shadows in both kidneys, respectively. Blood and puncture fluid cultures indicated infection with . Based on the susceptibility profiles of the isolates, imipenem was administered intravenously to treat the infection. On the third day of hospitalization, the patient's condition worsened, with head CT showing an extensive cerebral infarction and multiple gas accumulations in the right cerebral hemisphere, as well as a large-area cerebral infarction in the left parietal and occipital lobes. Ultimately, the patient died of multiple organ dysfunction on the fourth day after initial presentation. Although the isolates from the patient showed sensitivity to imipenem, this antibiotic shows poor entry into the central nervous system. The death of the patient indicates that the selection of antibiotics that can cross the blood-brain barrier may be crucial in the outcome of this type of case. Therefore, antibiotics that can penetrate the blood-brain barrier should be selected as soon as possible, and empirical treatment must be initiated immediately after clinical suspicion of invasive , even if the diagnosis has not been determined.
PubMed: 38380024
DOI: 10.1016/j.heliyon.2024.e25745