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BMC Infectious Diseases Mar 2023Disseminated Clostridium septicum infection is an uncommon complication associated with malignancies, particular colonic adenocarcinoma. The organism appears to...
BACKGROUND
Disseminated Clostridium septicum infection is an uncommon complication associated with malignancies, particular colonic adenocarcinoma. The organism appears to preferentially colonize large masses in rare individuals and subsequently seed the blood via mucosal ulceration. This has rarely been reported to lead to central nervous system infection and, in several cases, rapidly progressive pneumocephalus. In the few cases reported, this was a universally fatal condition. The current case adds to the reports of this extremely rare complication and provides a unique and complete clinicopathologic characterization with autopsy examination, microscopy, and molecular testing.
CASE PRESENTATION
A 60-year-old man with no known past medical history was discovered having seizure-like activity and stroke-like symptoms. Blood cultures turned positive after six hours. Imaging revealed a large, irregular cecal mass as well as 1.4 cm collection of air in the left parietal lobe that progressed to over 7 cm within 8 h. By the following morning, the patient had lost all neurologic reflexes and died. Post-mortem examination revealed brain tissue with multiple grossly evident cystic spaces and intraparenchymal hemorrhage, while microscopic exam showed diffuse hypoxic-ischemic injury and gram-positive rods. Clostridium septicum was identified on blood cultures and was confirmed in paraffin embedded tissue from the brain by 16 S ribosomal sequencing and from the colon by C. septicum specific PCR.
CONCLUSIONS
C. septicum is an anaerobic, gram-positive rod that can become invasive and is strongly associated with gastrointestinal pathology including colonic adenocarcinomas. Central nervous system infection with rapidly progressive pneumocephalus is a rarely reported and universally fatal complication of disseminated C. septicum infection.
Topics: Male; Humans; Middle Aged; Clostridium septicum; Clostridium Infections; Pneumocephalus; Colonic Neoplasms; Adenocarcinoma
PubMed: 36997864
DOI: 10.1186/s12879-023-08160-9 -
Cureus Feb 2023The use of invasive intracranial electroencephalogram (EEG) monitoring in the patient with a cerebrospinal fluid (CSF) diversionary shunt presents a conundrum -- the...
The use of invasive intracranial electroencephalogram (EEG) monitoring in the patient with a cerebrospinal fluid (CSF) diversionary shunt presents a conundrum -- the presence of a percutaneous electrode passing into the intracranial compartment presents a pathway for entry of pathogens to which a chronically implanted device like a shunt is especially susceptible to infection.In this case report, we describe the clinical and radiological features, medical and surgical management, and treatment outcomes of pediatric patients with shunted hydrocephalus who underwent invasive intracranial monitoring over an eight-year period. Three cases of children undergoing invasive intracranial monitoring were included in this study. Invasive monitoring for each patient occurred over three to six days. In each case, invasive intracranial monitoring was completed successfully, without resulting infection or shunt malfunction. While the second procedure was complicated by the formation of a pneumocephalus, there was no associated midline shift, and invasive intracranial monitoring was completed without incidence. Each patient received further surgery that successfully reduced seizure frequency. This study suggests that, while children with CSF diversionary shunts are at an inherently increased risk for infection and other complications, invasive intracranial monitoring is a relatively safe and feasible option in these patients. Future studies should explore the optimal duration for intracranial monitoring in pediatric patients with chronically implanted devices.
PubMed: 36968898
DOI: 10.7759/cureus.35279 -
Journal of Neurosurgery. Case Lessons Mar 2023This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure....
BACKGROUND
This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure. Furthermore, the authors highlight the concomitant diagnosis of tension pneumocephalus requiring evacuation prior to hyperbaric therapy.
OBSERVATIONS
A 68-year-old male developed acute ST-segment elevation and hypotension during elective disconnection of a posterior fossa dural arteriovenous fistula. The semi-sitting position had been used to minimize cerebellar retraction, raising the concern for acute air embolism. Intraoperative transesophageal echocardiography was utilized to establish the diagnosis of air embolism. The patient was stabilized on vasopressor therapy, and immediate postoperative computed tomography revealed air bubbles in the left atrium along with tension pneumocephalus. He underwent urgent evacuation for the tension pneumocephalus followed by hyperbaric oxygen therapy to manage the hemodynamically significant air embolism. The patient was eventually extubated and went on to fully recover; a delayed angiogram revealed complete cure of the dural arteriovenous fistula.
LESSONS
Hyperbaric oxygen therapy should be considered for an intracardiac air embolism resulting in hemodynamic instability. In the postoperative neurosurgical setting, care should be taken to exclude pneumocephalus requiring operative intervention prior to hyperbaric therapy. A multidisciplinary management approach facilitated expeditious diagnosis and management for the patient.
PubMed: 36941197
DOI: 10.3171/CASE2342 -
Surgical Neurology International 2023The aim of this study was to report the demographics and clinical features of patients with penetrating traumatic brain injury (PTBI) during the past 5 years in Rajaee...
BACKGROUND
The aim of this study was to report the demographics and clinical features of patients with penetrating traumatic brain injury (PTBI) during the past 5 years in Rajaee Hospital, a tertiary referral trauma center in Shiraz, southern Iran.
METHODS
We conducted a 5-year retrospective evaluation of all patients diagnosed with PTBI who were referred to Rajaee Hospital. We retrieved the following items from the hospital's database and PACS system: patients' demographics, on-admission Glasgow Coma Scale (GCS), presence of trauma to other organs, duration of the hospital and ICU stay, the neurosurgical interventions, any necessity of tracheostomy, duration of ventilator dependency, the entrance point of the trauma in the skull, type of assault, length of trajectory in the brain parenchyma, the number of remaining objects in the brain, the occurrence of any hemorrhagic phenomenon, the cross of the bullet from the midline or coronal suture, and the presence of the pneumocephalus.
RESULTS
A total of 59 patients with a mean age of 28.75 ± 9.40 had PTBI over the 5 years. The mortality rate was 8.5%. Stab wounds, shotguns, gunshots, and airguns were the cause of injury in 33 (56%), 14 (23.7%), 10 (17%), and 2 (3.4%) patients, respectively. The median initial GCS of patients was 15 (3-15). Intracranial hemorrhage was observed in 33 cases, subdural hematoma in 18 cases, intraventricular hemorrhage in eight cases, and subarachnoid hemorrhage in four cases. The mean duration of hospitalization was 10.05 ± 10.75 (ranging from 1 to 62 days). Furthermore, 43 patients experienced ICU admission with mean days of 6.5 ± 5.62 (1-23). The temporal and frontal regions were the most common entrance points, in 23 and 19 patients, respectively.
CONCLUSION
The incidence of PTBI is relatively low in our center, possibly due to the prohibition of possession or using warm weapons in Iran. Further, multicenter studies with larger sample sizes are needed to determine prognostic factors associated with worse clinical outcomes after PTBI.
PubMed: 36895251
DOI: 10.25259/SNI_1160_2022 -
Neurology and Therapy Jun 2023This purpose of this work is to give a detailed description of a surgical technique for frameless robot-assisted asleep deep brain stimulation (DBS) of the centromedian...
Frameless Robot-Assisted Asleep Centromedian Thalamic Nucleus Deep Brain Stimulation Surgery in Patients with Drug-Resistant Epilepsy: Technical Description and Short-Term Clinical Results.
INTRODUCTION
This purpose of this work is to give a detailed description of a surgical technique for frameless robot-assisted asleep deep brain stimulation (DBS) of the centromedian thalamic nucleus (CMT) in drug-resistant epilepsy (DRE).
METHODS
Ten consecutively enrolled patients who underwent CMT-DBS were included in the study. The FreeSurfer "Thalamic Kernel Segmentation" module and experience target coordinates were used for locating the CMT, and quantitative susceptibility mapping (QSM) images were used to check the target. The patient's head was secured with a head clip, and electrode implantation was performed with the assistance of the neurosurgical robot Sinovation. After opening the dura, the burr hole was continuously flushed with physiological saline to stop air from entering the skull. All procedures were performed under general anesthesia without intraoperative microelectrode recording (MER).
RESULTS
The mean age of the patients at surgery and onset of seizures was 22 years (range 11-41 years) and 11 years (range 1-21 years), respectively. The median duration of seizures before CMT-DBS surgery was 10 years (2-26 years). CMT was successfully segmented, and its position was verified by experience target coordinates and QSM images in all ten patients. The mean surgical time for bilateral CMT-DBS in this cohort was 165 ± 18 min. The mean pneumocephalus volume was 2 cm. The median absolute errors in the x-, y-, and z-axes were 0.7 mm, 0.5 mm, and 0.9 mm, respectively. The median Euclidean distance (ED) and radial error (RE) was 1.3 ± 0.5 mm and 1.0 ± 0.3 mm, respectively. No significant difference was found between right- and left-sided electrodes regarding the RE nor the ED. After a mean 12-month follow-up, the average reduction in seizures was 61%, and six patients experienced a ≥ 50% reduction in seizures, including one patient who had no seizures after the operation. All patients tolerated the anesthesia operation, and no permanent or serious complications were reported.
CONCLUSIONS
Frameless robot-assisted asleep surgery is a precise and safe approach for placing CMT electrodes in patients with DRE, shortening the surgery time. The segmentation of the thalamic nuclei enables the precise location of the CMT, and the flow of physiological saline to seal the burr holes is a good way to reduce the influx of air. CMT-DBS is an effective method to reduce seizures.
PubMed: 36892782
DOI: 10.1007/s40120-023-00451-2 -
Annals of Maxillofacial Surgery 2022Maxillofacial trauma accounts for a high percentage of patients reporting to the emergency medicine department and being admitted in the hospital. The purpose of this...
INTRODUCTION
Maxillofacial trauma accounts for a high percentage of patients reporting to the emergency medicine department and being admitted in the hospital. The purpose of this study was to form a direct association between maxillofacial fractures and traumatic brain injury (TBI).
METHODS
Ninety patients with maxillofacial fractures that reported to/were referred to the Department of Oral and Maxillofacial Surgery were observed for features indicative of TBI based on clinical presentation and radiological interpretations. Parameters such as loss of consciousness, vomiting, dizziness, headache, seizures and the requirement for intubation, cerebrospinal fluid rhinorrhoea and otorrhoea were also assessed. Appropriate radiographs for the diagnosis of the fracture were taken followed by a computed tomography (CT) scan when indicated in accordance to the Canadian CT Head Rule. These scans were then assessed for contusion, extradural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage, pneumocephalus and cranial bone fracture.
RESULTS
A total of 90 patients were evaluated, of which 91.1% were males and 8.9% were females. Association between the occurrence of head injury and different maxillofacial bone fractures using the Chi-square test showed a statistical significance of <0.001 in patients with naso-orbito-ethmoid as well as frontal bone fractures. There was a clear association between fractures present in the upper as well as the middle third of the face and traumatic head injury ( ≤ 0.001).
DISCUSSION
Patients with the frontal bone and zygomatic bone fractures have a high prevalence of TBI. Patients with the upper and middle third of the face injury are more prone to traumatic head injury and importance should be given to patients with the same and prevent poor prognosis.
PubMed: 36874785
DOI: 10.4103/ams.ams_169_21 -
Radiology Case Reports Apr 2023Pneumocephalus is defined as air in the intracranial space. It is commonly caused by traumatic skull fractures and is diagnosed by head plain computer tomography....
Pneumocephalus is defined as air in the intracranial space. It is commonly caused by traumatic skull fractures and is diagnosed by head plain computer tomography. Treatment involves initial stabilization of vital signs and surgical intervention if symptoms do not resolve. We report a unique case of pneumocephalus following sneeze suppression.
PubMed: 36815145
DOI: 10.1016/j.radcr.2023.01.057 -
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 -
Operative Neurosurgery (Hagerstown, Md.) May 2023Using electrocorticography for research (R-ECoG) during deep brain stimulation (DBS) surgery has advanced our understanding of human cortical-basal ganglia...
BACKGROUND
Using electrocorticography for research (R-ECoG) during deep brain stimulation (DBS) surgery has advanced our understanding of human cortical-basal ganglia neurophysiology and mechanisms of therapeutic circuit modulation. The safety of R-ECoG has been established, but potential effects of temporary ECoG strip placement on targeting accuracy have not been reported.
OBJECTIVE
To determine whether temporary subdural electrode strip placement during DBS implantation surgery affects lead implantation accuracy.
METHODS
Twenty-four consecutive patients enrolled in a prospective database who underwent awake DBS surgery were identified. Ten of 24 subjects participated in R-ECoG. Lead locations were determined after fusing postoperative computed tomography scans into the surgical planning software. The effect of brain shift was quantified using Lead-DBS and analyzed in a mixed-effects model controlling for time interval to postoperative computed tomography. Targeting accuracy was reported as radial and Euclidean distance errors and compared with Mann-Whitney tests.
RESULTS
Neither radial error nor Euclidean distance error differed significantly between R-ECoG participants and nonparticipants. Pneumocephalus volume did not differ between the 2 groups, but brain shift was slightly greater with R-ECoG. Pneumocephalus volume correlated with brain shift, but neither of these measures significantly correlated with Euclidean distance error. There were no complications in either group.
CONCLUSION
In addition to an excellent general safety profile as has been reported previously, these results suggest that performing R-ECoG during DBS implantation surgery does not affect the accuracy of lead placement.
Topics: Humans; Electrocorticography; Deep Brain Stimulation; Pneumocephalus; Brain; Tomography, X-Ray Computed
PubMed: 36701668
DOI: 10.1227/ons.0000000000000582 -
Archives of Clinical and Medical Case... 2022There has been a recognizable surge in cosmetic surgery in recent years, partly influenced by social media, and the easy accessibility to such medical procedures. As...
There has been a recognizable surge in cosmetic surgery in recent years, partly influenced by social media, and the easy accessibility to such medical procedures. As with all types of surgery, the risks of complications are real, and in this specific setting, they tend to occur in a younger age group. Here, we discuss a rare complication and subsequent presentation of tension pneumocephalus, following an episode of cardiac arrest in a 58 year old female, during elective cosmetic-facial surgery. Typically, pneumocephalus develops when there are skull or facial bone fractures, and presents characteristically with leakage of cerebrospinal fluid from the ears and/or nose. The absence of the typical clinical signs and the lack of a clinical history or radiologically evidence of skull or facial bone fractions, may result in a delayed diagnosis, permanent brain injury and death. Awareness of such an unusual complication is therefore crucial when considering any surgery to the head and face (including cosmetic surgery), or following prolonged resuscitative efforts, which may well develop days after the inciting event.
PubMed: 36686216
DOI: 10.26502/acmcr.96550553