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Acta Neurochirurgica Aug 2023Traditionally, functional neurosurgery relied in stereotactic atlases and intraoperative micro-registration in awake patients for electrode placement in Parkinson's...
BACKGROUND
Traditionally, functional neurosurgery relied in stereotactic atlases and intraoperative micro-registration in awake patients for electrode placement in Parkinson's disease. Cumulative experience on target description, refinement of MRI, and advances in intraoperative imaging has enabled accurate preoperative planning and its implementation with the patient under general anaesthesia.
METHODS
Stepwise description, emphasising preoperative planning, and intraoperative imaging verification, for transition to asleep-DBS surgery.
CONCLUSION
Direct targeting relies on MRI anatomic landmarks and accounts for interpersonal variability. Indeed, the asleep procedure precludes patient distress. A particular complication to avoid is pneumocephalus; it can lead to brain-shift and potential deviation of electrode trajectory.
Topics: Humans; Parkinson Disease; Deep Brain Stimulation; Neurosurgical Procedures; Brain; Magnetic Resonance Imaging
PubMed: 37318635
DOI: 10.1007/s00701-023-05659-7 -
Medicine Dec 2022To investigate the clinical, laboratory, and radiological features of meningitis after lumbar epidural steroid injection (M-ESI) without accompanying spinal infection,...
To investigate the clinical, laboratory, and radiological features of meningitis after lumbar epidural steroid injection (M-ESI) without accompanying spinal infection, data of patients with meningitis admitted between January 2014 and December 2021 in a single center were retrospectively reviewed. Among them, patients with a recent history of lumbar ESI were identified, and their medical records were collected. Patients with concomitant infections other than meningitis, including spinal epidural abscess, were excluded. Seven patients with M-ESI were identified. All patients presented with headache and fever without focal neurological deficits, and headache developed shortly after a procedure (median, 4 hours). Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis (median, 6729/μL), elevated protein level (median, 379.1 mg/dL), decreased ratio of CSF glucose to serum glucose (median, 0.29), and elevated lactate level (median, 8.64 mmol/L). Serum level of C-reactive protein was elevated in 6, but serum procalcitonin level was within normal range. No causative pathogen was identified in the microbiological studies. The most frequent radiologic feature was sulcal hyperintensity on fluid-attenuated inversion recovery images (57%), followed by pneumocephalus (43%). Symptoms subsided in a short period (median, 1 day) after initiating treatment with antibiotics and adjuvant intravenous corticosteroids. None of the patients experienced neurological sequelae. Though the cardinal symptoms and CSF findings of M-ESI were comparable to those of bacterial meningitis, M-ESI seems to have distinctive characteristics regarding the clinical course, laboratory parameters, and pneumocephalus.
Topics: Humans; Pneumocephalus; Retrospective Studies; Meningitis, Bacterial; Headache; Steroids
PubMed: 36595762
DOI: 10.1097/MD.0000000000032396 -
Frontiers in Surgery 2023Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for refractory dystonia. Neuroradiological target and stimulation...
BACKGROUND
Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for refractory dystonia. Neuroradiological target and stimulation electrode trajectory planning with intraoperative microelectrode recordings (MER) and stimulation are used. With improving neuroradiological techniques, the need for MER is in dispute mainly because of the suspected risk of hemorrhage and the impact on clinical post DBS outcome.
OBJECTIVE
The aim of the study is to compare the preplanned GPi electrode trajectories with final trajectories selected for electrode implantation after electrophysiological monitoring and to discuss the factors potentially responsible for differences between preplanned and final trajectories. Finally, the potential association between the final trajectory selected for electrode implantation and clinical outcome will be analyzed.
METHODS
Forty patients underwent bilateral GPi DBS (right-sided implants first) for refractory dystonia. The relationship between preplanned and final trajectories (MicroDrive system) was correlated with patient (gender, age, dystonia type and duration) and surgery characteristics (anesthesia type, postoperative pneumocephalus) and clinical outcome measured using CGI (Clinical Global Impression parameter). The correlation between the preplanned and final trajectories together with CGI was compared between patients 1-20 and 21-40 for the learning curve effect.
RESULTS
The trajectory selected for definitive electrode implantation matched the preplanned trajectory in 72.5% and 70% on the right and left side respectively; 55% had bilateral definitive electrodes implanted along the preplanned trajectories. Statistical analysis did not confirm any of the studied factors as predictor of the difference between the preplanned and final trajectories. Also no association between CGI and final trajectory selected for electrode implantation in the right/left hemisphere has been proven. The percentages of final electrodes implanted along the preplanned trajectory (the correlation between anatomical planning and intraoperative electrophysiology results) did not differ between patients 1-20 and 21-40. Similarly, there were no statistically significant differences in CGI (clinical outcome) between patients 1-20 and 21-40.
CONCLUSION
The final trajectory selected after electrophysiological study differed from the preplanned trajectory in a significant percentage of patients. No predictor of this difference was identified. The anatomo-electrophysiological difference was not predictive of the clinical outcome (as measured using CGI parameter).
PubMed: 37284558
DOI: 10.3389/fsurg.2023.1206721 -
Ear, Nose, & Throat Journal Apr 2024Pneumocephalus refers to air inside the cranium; however, otogenic pneumocephalus is rarely reported in the literature. The neurological presentations of pneumocephalus...
Pneumocephalus refers to air inside the cranium; however, otogenic pneumocephalus is rarely reported in the literature. The neurological presentations of pneumocephalus include headache, lethargy, confusion, disorientation, and seizure. Here, we have reported a case of a 42-year-old woman with extensive pneumocephalus and cerebrospinal fluid leak secondary to petrous bone cholesteatoma. She presented to the emergency department with sudden headache and left ear discharge. Physical examination revealed watery otorrhea through a hole in the tympanic membrane. Radiological studies demonstrated extensive soft tissue in the left middle ear and mastoid extending to the internal auditory canal. Free intracranial air was observed, and bony destruction was seen in the cochlea, vestibule, and semicircular canals. The patient was managed surgically via the transotic approach and fully recovered. Although otogenic pneumocephalus is rarely encountered in clinical practice, early diagnosis and urgent management are important to prevent fatal complications.
Topics: Female; Humans; Adult; Petrous Bone; Pneumocephalus; Cholesteatoma; Headache; Vestibule, Labyrinth
PubMed: 34587824
DOI: 10.1177/01455613211048966 -
Frontiers in Neurology 2022To compare the incidence of complications and constructive effects of cranioplasty with polyetheretherketone (PEEK) and titanium mesh after decompressive craniectomy,...
BACKGROUND
To compare the incidence of complications and constructive effects of cranioplasty with polyetheretherketone (PEEK) and titanium mesh after decompressive craniectomy, and to further explore potential risk factors of postoperative and post-discharge complications.
METHODS
A retrospective study was conducted on 211 patients who underwent PEEK or titanium mesh cranioplasty in the Department of Neurosurgery of Zhujiang Hospital, Southern Medical University, between July 2017 and September 2021. Demographic data, imaging data, and postoperative complications were recorded and statistically analyzed. Long-term effects and satisfaction degree were evaluated based on following-up telephone survey. Univariate and multivariate logistic regression models were used to analyze risk factors of postoperative and post-discharge complications of PEEK and titanium cranioplasty.
RESULTS
The total postoperative complication rates of the PEEK and titanium mesh groups were 38.7 and 51.4% ( = 0.063), and post-discharge complication rates were 34.7 and 36.0% ( = 0.703), respectively. The incidence of pneumocephalus during hospitalization (33.3% vs. 6.6%, < 0.001) and epidural effusion in the titanium mesh group were significantly higher than that in the PEEK group (18.0 vs. 6.6%, = 0.011). Patients in PEEK group were less likely to occur subcutaneous effusion after discharge than in TI group (2.0 vs. 10.5%, = 0.013). Multivariate logistic regression analysis revealed a history of ventriculoperitoneal shunt (VPS) before CP was an independent risk factor for postoperative overall complications ( = 0.023). Either superficial ( < 0.001) or intracranial infection ( = 0.001) was a risk factor for implant failure. Depressed skull defects ( = 0.024) and cranioplasty with titanium cranioplasty ( < 0.001) were associated with increased incidence of early pneumocephalus.
CONCLUSION
There were no differences in overall postoperative and post-discharge complication rates between the titanium mesh and PEEK. A history of VPS before cranioplasty was an independent risk factor for postoperative overall complications, and infection was a risk factor for implant failure. Finally, depression skull defects and titanium mesh implants increased the incidence of postoperative pneumocephalus. Our results aim to promote a better understanding of PEEK and titanium cranioplasty and to help both clinicians and patients make better choices on implant materials.
PubMed: 36212642
DOI: 10.3389/fneur.2022.926436 -
Journal of Medical Case Reports May 2023Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a...
INTRODUCTION
Epidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.
CASE PRESENTATION
We present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.
CONCLUSIONS
Although a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.
Topics: Pregnancy; Humans; Female; Young Adult; Adult; Analgesia, Epidural; Pneumocephalus; Headache; Labor, Obstetric; Pain Management
PubMed: 37231513
DOI: 10.1186/s13256-023-03955-5 -
Surgical Neurology International 2022Confirmation of whether a stereotactic biopsy was performed in the correct site is usually dependent on the frozen section or on novel tumor-specific markers that are...
BACKGROUND
Confirmation of whether a stereotactic biopsy was performed in the correct site is usually dependent on the frozen section or on novel tumor-specific markers that are not widely available. Immediate postoperative computed tomography (CT) or magnetic resonance (MR) is routinely performed in our service after biopsy. In this retrospective study, we have carefully analyzed these images in an attempt to determine the presence of markers that indicate appropriate targeting.
METHODS
Medical records and neuroimages of patients who underwent stereotactic biopsy of intracranial lesions were reviewed. The following variables were assessed: age, sex, anatomopathology, lesion site, complications, diagnostic accuracy, and the presence of image markers.
RESULTS
Twenty-nine patients were included in this case series. About 96.6% of the biopsies were accurate according to the permanent section. Of the 86.2% of patients with intralesional pneumocephalus on the postoperative images, 51.7% additionally presented petechial hemorrhage. In 13.8% of the cases, no image markers were identified.
CONCLUSION
This is the first report of intralesional pneumocephalus and petechial hemorrhage as indicators of appropriate targeting in stereotactic biopsy. In the majority of the cases, an immediate postoperative head CT, which is widely available, can estimate how adequate the targeting is. To use intralesional pneumocephalus/ petechial hemorrhages as not only postoperative but also as intraoperative markers of appropriate targeting, it is advised that the surgical wound should be temporarily closed and dressed after the biopsy so that the patient can undergo a CT/MR scan and be checked for the presence of theses markers before removing the stereotactic frame.
PubMed: 35855128
DOI: 10.25259/SNI_246_2022 -
Acute Medicine & Surgery 2024Traumatic pneumocephalus is commonly encountered after basal skull fractures and rarely associated with blunt chest trauma. Here, we report a case of pneumocephalus...
BACKGROUND
Traumatic pneumocephalus is commonly encountered after basal skull fractures and rarely associated with blunt chest trauma. Here, we report a case of pneumocephalus caused by traumatic pneumothorax and brachial plexus avulsion.
CASE PRESENTATION
A 20-year-old male was admitted to our hospital following a motorcycle accident with complete paralysis of the right upper limb. 2 days later, follow-up computed tomography revealed a slight right pneumothorax, pneumomediastinum around the neck, and intracranial air without skull fracture. Air migrates into the subarachnoid space through a dural tear caused by a brachial plexus avulsion. The pneumocephalus immediately improved after the insertion of a chest drain.
CONCLUSION
Pneumothorax combined with brachial plexus avulsion could lead to pneumocephalus. Immediate chest drainage might be the best way to stop the migration of air; however, care should be taken to not worsen cerebrospinal fluid leakage.
PubMed: 38765777
DOI: 10.1002/ams2.956 -
Diagnostics (Basel, Switzerland) Dec 2022Tension pneumocephalus is a neurosurgical emergency that occurs when air is trapped in the intracranial cavity, leading to brain compression and causing severe...
Tension pneumocephalus is a neurosurgical emergency that occurs when air is trapped in the intracranial cavity, leading to brain compression and causing severe neurological symptoms such as decreases in motor function, sensory function, and consciousness. Most cases of pneumocephalus require conservative treatment; however, because of the possible fatal complications, rapid diagnosis and appropriate treatment are important. Here, we present the case of an 81-year-old male patient who had undergone head trauma three hours prior to being admitted to our emergency room (ER) because of mental cloudiness. The radiologic findings showed tension pneumocephalus caused by an ethmoidal roof fracture. Emergency reconstruction of the ethmoidal roof with craniotomy was performed to remove the intracranial air using normal saline irrigation. By sharing our experience with this case, we hope to provide an option for the treatment of such cases.
PubMed: 36611383
DOI: 10.3390/diagnostics13010092 -
Clinical Neuroradiology Sep 2023Diffusion-weighted imaging (DWI) is important for differentiating residual tumor and subacute infarctions in early postoperative magnetic resonance imaging (MRI) of...
PURPOSE
Diffusion-weighted imaging (DWI) is important for differentiating residual tumor and subacute infarctions in early postoperative magnetic resonance imaging (MRI) of central nervous system (CNS) tumors. In cases of pneumocephalus and especially in the presence of intraventricular trapped air, conventional echo-planar imaging (EPI) DWI is distorted by susceptibility artifacts. The performance and robustness of a newly developed DWI sequence using the stimulated echo acquisition mode (STEAM) was evaluated in patients after neurosurgical operations with early postoperative MRI.
METHODS
We compared EPI and STEAM DWI of 43 patients who received 3‑Tesla MRI within 72 h after a neurosurgical operation between 1 October 2019 and 30 September 2021. We analyzed susceptibility artifacts originating from air and blood and whether these artifacts compromised the detection of ischemic changes after surgery. The DWI sequences were (i) visually rated and (ii) volumetrically analyzed.
RESULTS
In 28 of 43 patients, we found severe and diagnostically relevant artifacts in EPI DWI, but none in STEAM DWI. In these cases, in which artifacts were caused by intracranial air, they led to a worse detection of ischemic lesions and thus to a possible failed diagnosis or lack of judgment using EPI DWI. Additionally, volumetric analysis demonstrated a 14% smaller infarct volume detected with EPI DWI. No significant differences in visual rating and volumetric analysis were detected among the patients without severe artifacts.
CONCLUSION
The newly developed version of STEAM DWI with highly undersampled radial encodings is superior to EPI DWI in patients with postoperative pneumocephalus.
Topics: Humans; Echo-Planar Imaging; Pneumocephalus; Reproducibility of Results; Magnetic Resonance Imaging; Diffusion Magnetic Resonance Imaging; Central Nervous System; Neoplasms; Artifacts
PubMed: 36732415
DOI: 10.1007/s00062-023-01261-7