Liquor Fistula Research Articles

Percutaneous full-endoscopic bullet removal from the C2 vertebra in a pediatric patient.

Gunshot injuries (GSIs) to the spine constitute approximately 17% to 21% of all traumatic spinal injuries, with the cervical spine being the second most frequently affected region. There is a lack of approved algorithms for patients with GSIs to the spine. Surgical intervention is controversial; however, it is generally considered in cases involving neurological deterioration with incomplete deficit, externalized liquor fistula, instability, installed toxicity, and risk of migration. Detailed information on pediatric patients is limited, primarily due to the predominance of adult patients. This study presents the full-endoscopic removal of a bullet in the C2 vertebra of a pediatric patient. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23230.

Aplasia cútis congênita no couro cabeludo: relato de caso e revisão de literatura

Introduction: Congenital Cutaneous Aplasia is a rare skin lesion, usually restricted to the scalp, characterized by a focal absence of cutaneous tissue, sometimes involving muscles, periosteum and dura mater. There are several etiologies described, such as poor neural tube closure, vascular anomalies, pressure necrosis in the localized embryo, among others. Method: We report the case of a newborn at the first physical examination with an annular vesicular lesion, in the occipital region, of 0.8 cm in greater diameter, with hyaline / bloody content and peripheral hyperemia. After a clinical diagnosis was made, we opted for conservative treatment with topical application of hydrogel until complete healing. The patient was then discharged from the hospital, with subsequent Residência Pediátrica; 2023: Ahead of Print. DOI: 10.25060/residpediatr-2023-566 return and resolution of the lesion at 30 days of life. Conclusion: Congenital cutaneous aplasia is a rare disease, which can affect only the scalp, but can also present with the absence of part of the skullcap, which increases mortality due to the increased risk of complications such as liquor fistula, meningoencephalitis and bleeding.

Aplasia cútis congênita no couro cabeludo: relato de caso e revisão de literatura

INTRODUCTION: Congenital Cutaneous Aplasia is a rare skin lesion, usually restricted to the scalp, characterized by a focal absence of cutaneous tissue, sometimes involving muscles, periosteum and dura mater. There are several etiologies described, such as poor neural tube closure, vascular anomalies, pressure necrosis in the localized embryo, among others. METHOD: We report the case of a newborn at the first physical examination with an annular vesicular lesion, in the occipital region, of 0.8 cm in greater diameter, with hyaline / bloody content and peripheral hyperemia. After a clinical diagnosis was made, we opted for conservative treatment with topical application of hydrogel until complete healing. The patient was then discharged from the hospital, with subsequent return and resolution of the lesion at 30 days of life. CONCLUSION: Congenital cutaneous aplasia is a rare disease, which can affect only the scalp, but can also present with the absence of part of the skullcap, which increases mortality due to the increased risk of complications such as liquor fistula, meningoencephalitis and bleeding.

Spontaneous cerebrospinal fluid rhinorrhoea during pregnancy-case report and review of literature

Abstract Objectives Rhinoliquorrhea is a condition where cerebrospinal fluid (CSF) leaks due to a liquor fistula formation of traumatic or non-traumatic origin. It can be associated with increased intracranial pressure often due to idiopathic intracranial hypertension (IIH), typically found in young and obese female patients. Case presentation A 27-year-old woman, 2 gravida, 1 para, presented with clear rhinorrhoea. After a beta-trace-protein test the diagnosis of CSF leakage was determined. The woman had had a traumatic car accident in 2018 but had never developed clear rhinorrhoea, especially not in her first pregnancy after the accident. Due to stable condition of the mother further diagnostics were postponed until after the birth. An elective caesarean section was performed in 40 + 0 weeks of gestations. The structural bone defect in the posterior wall of the sphenoid sinus was surgically repaired by defect coverage postpartum. Conclusions Nasal CSF leakage in pregnancy has previously been described in four other case reports with mostly traumatic etiology. Additionally, IIH is an important diagnosis to keep in mind. So far there are no guidelines or evidence-based recommendations regarding to optimal fistula treatment of pregnant women available. For therapy a prophylactic antibiotic therapy, surgical reconstruction with sealing and a wait-and-see strategy should be considered and discussed.

COMPLICATIONS AFTER PARTIAL, TOTAL OR EXTENDED SACRECTOMY: A CASE SERIES

ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.

Long-Term Outcomes of a New Minimally Invasive Approach in Chiari Type 1 and 1.5 Malformations: Technical Note and Preliminary Results

The treatment options for patients with Chiari malformation type 1 (CM1) and Chiari malformation type 1.5 (CM1.5) have not yet been standardized. In these malformations, the main factors include obstruction at the level of the foramen magnum and dural and ligamentous thickening. Here we present our outcomes of surgery and decompression using a minimally invasive surgery (MIS) technique. Sixty-one patients admitted to our clinics between 2009 and 2016 due to CM1 or CM1.5 and who had undergone MIS were investigated retrospectively. All patients were followed up for a mean period of 55 months, both clinically and radiologically, and the outcomes were recorded. All 61 patients underwent foramen magnum decompression through a 1.5-cm mini-open incision, C1 laminectomy and C2 medial inner side tour, posterior atlanto-occipital membrane removal, external dural delamination, and widening of the internal dura with longitudinal incisions. Fifty-six patients (91.8%) were satisfied with the outcome, 4 patients (6.5%) remained the same, and 1 patient (1.6%) reported a poor outcome. Forty-five percent of the patients with syringomyelia demonstrated resolution within 2 years, and 92% demonstrated resolution in 5 years. Scoliosis was seen in 5 patients (8.1%). The rate of benefit from the surgical procedure was statistically significant (P= 0.0045), and no patient required additional surgery because of poor decompression. MIS is effective for uncomplicated cases of CM1 and CM1.5 due to its minimal connective and muscular tissue damage, short surgical duration, short recovery time, early mobilization, effective posterior foramen magnum widening, lack of liquor fistula development, and better clinical and radiologic improvement during long-term follow-up.

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction.

To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries. Avaliar a correlação entre o tratamento, as características das lesões e o resultado clínico em pacientes com lesões traumáticas na junção craniocervical. Estudo retrospectivo de pacientes maiores de 18 anos tratados de forma conservadora ou cirúrgica, entre 2010 e 2013. Foram analisados 37 pacientes, 73% eram do sexo masculino e a média de idade foi de 41,7 anos. Inicialmente 32% dos pacientes foram submetidos a tratamento cirúrgico, e 68% foram submetidos a tratamento conservador. Sete pacientes (29%) do grupo conservador foram submetidos posteriormente à cirurgia. No grupo cirúrgico, houve sete casos de fratura de odontóide tipo II, dois casos de fratura de elementos posteriores do áxis, um caso de luxação C1-C2, um caso de deslocamento occipito-cervical e um caso de fraturas de C1 e C2 e luxação facetária. Um paciente apresentava déficit neurológico, melhorando após o tratamento. Houve duas complicações pós-cirúrgicas, uma fístula liquórica e uma infecção de ferida operatória (reabordada). No grupo conservador, predominaram as fraturas do odontóide (oito) e dos elementos posteriores de C2 (cinco). Em dois casos, havia também fraturas em outros segmentos da coluna. Nenhum dos pacientes deste grupo apresentou deterioração neurológica. As lesões da junção craniocervical são raras, sendo mais frequentes as fraturas do odontóide e dos elementos posteriores do áxis. Nossos resultados recomendam o tratamento cirúrgico precoce para os pacientes com fraturas do odontóide tipo II e lesões ligamentares, e tratamento conservador para os demais pacientes.

Post-traumatic Tension Pneumoventricle: Case Report

AbstractPneumoventricle and liquoric fistula are possible complications of traumatic brain injury (TBI), the main cause of morbimortality related to trauma in Brazil. Liquoric fistulae are more common after direct trauma with skull base fractures. However, pneumoventricle is rare and occurs due to excessive cerebrospinal fluid (CSF) drainage in the presence of a poorly compliant ventricle system, resulting in the influx of air to its interior. The pathophysiology of tension pneumoventricle remains uncertain. However, the traumatic cause is certain and multiple bone fractures of the face and liquoric fistula may contribute to the process. If symptomatic, the tension pneumoventricle can cause rapid clinical deterioration. The authors aim to report a rare case of post-TBI tension pneumoventricle with complete resolution and without signs of recurrence of the liquoric fistula after surgical treatment.

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction

ABSTRACTObjective To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction.Methods This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets.Results We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration.Conclusion Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries.

Specific aspects of plastic reconstruction of skull base defects with sphenoid sinus localization

The article describes the specific aspects of the combined method of plastic reconstruction of skull base defects in patients with nasal liquorrhea with sphenoid sinus localization. 15 patients with CSF fistula localization in sphenoid sinus underwent this surgery. In 8 cases meningocele was diagnosed. The main advantages of this technique are as follows: good visualization of all sphenoid sinus section, secure plasty of liquor fistula, functionality, preservation of anatomic continuity of nasal cavity and sphenoid sinus.

Eyelid liquoric fistula secondary to orbital meningocele

Liquoric fistula (LF) is defined as the communication of the subarachnoid space with the external environment, which main complication is the development of infection in the central nervous system. We reported the case of a patient with non-traumatic eyelid liquoric fistula secondary to orbital meningocele (congenital lesion), which main clinical manifestation was unilateral eyelid edema. Her symptoms and clinical signs appeared in adulthood, which is uncommon. The patient received surgical treatment, with complete resolution of the eyelid swelling. In conclusion, eyelid cerebrospinal fluid (CSF) fistula is a rare condition but with great potential deleterious to the patient. It should be considered in the differential diagnosis of unilateral eyelid edema, and surgical treatment is almost always mandatory.

Transplantation of autologous bone marrow stem cells in patients with chronic spinal cord injury

Stem cells are being investigated by their potential use in regenerative medicine. There is currently a lack of effective clinical therapy for a number conditions, such as severe spinal cord injury (SCI). SCI can lead to chronic paraplegia, considered an irreversible condition. The administration of stem cells has been tested as a potential therapy for SCI. In the present study we evaluated the feasibility, safety and potential efficacy of autologous mesenchymal stem cells (MSC) transplantation in patients with chronic complete SCI. We conducted a phase I/II, non-controlled study in 14 patients of both genders aging between 18-65 years, with ASIA A classified chronic traumatic SCI. Baseline somatosensory evoked potentials (SSEP), spinal magnetic resonance imaging (MRI) and urodynamics were assessed before and after treatment. Pain rating was performed using the McGill Pain Questionnaire and a visual analogue score scale. Bone marrow-derived MSC were cultured and characterized by flow cytometry, cell differentiation assays and G-band karyotyping, showing morphological and phenotypic characteristics of MSC, as well as genetic stability. MSC were injected directly into the lesion following laminectomy and durotomy. Transplantation of bone marrow derived MSC was an overall safe procedure. All of the patients were discharged within 48 hours after surgery. Only one patient developed a post-operatory complication, evolving a liquoric fistula that was treated by an additional surgical procedure. Nine patients had improvements in urologic function. All patients displayed variable improvements in sensitivity and 8 patients developed lower limbs motor functional gains, principally in the hip flexors. All patients had variable improvements in ASIA global scores. Additionally, 6 patients had changes in the AIS score to grade B and one to grade C. A direct correlation between motor gain and lesion level and an inverse correlation between light touch gain and lesion volume were found 6 months after transplantation. One patient presented changes in SSEP 3 and 6 months after MSC transplantation. Although there is an abundance of studies describing the natural history of neurologic functional gains during the first year post-SCI, there is a lack of data regarding the degree of neurological recovery that may naturally occur during prolonged follow up investigation. In the present study, we enrolled only patients with chronic and complete spinal cord injury (ASIA A) whom had previously been subjected to decompressive surgery and lengthy rehabilitation protocols without acquiring significant motor or sensory gains. Although this was not a controlled study, based on the patient profiles and the expected spontaneous gains, our study showed potential benefits of MSC transplantation treatment, in variable degrees of motor and sensory improvements, clinical pain measures and urodynamics parameters. The use of MSC presents several advantages, such as isolation from bone marrow aspirates and large-scale expansion in cell culture procedures, which are feasible to be performed in autologous transplantations. We conclude that intralesional transplantation of autologous MSC in spinal cord injury patients is safe and feasible, and may provide some progressive benefits. We are currently beginning new clinical trials based on MSC therapy for SCI.

Gunshot injuries in the spine.

Review article. To review the literature regarding treatment approaches in cases of gunshot wounds (GSWs) affecting the spine. Brazil. Narrative review of medical literature. GSWs are an increasing cause of morbidity and mortality. Most patients with spinal GSW have complete neurological deficit. The injury is more common in young men and is frequently immobilizing. The initial approach should follow advanced trauma life support, and broad-spectrum antibiotic therapy should be initiated immediately, especially in patients with perforation of the gastrointestinal tract. The indications for surgery in spinal GSW are deterioration of the neurologic condition in a patient with incomplete neurological deficit, the presence of liquor fistula, spinal instability, intoxication by the metal from the bullet or risk of bullet migration. Surgical treatment is associated with a higher complication rate than conservative treatment. Therefore, the surgeon must know the treatment limitations and recognize patients who would truly benefit from surgery.

Clinical and laboratorial characterization and post-surgical follow-up of 87 patients with non-functioning pituitary macroadenomas

It was to assess the main characteristics of patients undergoing pituitary tumor surgery. Eighty-seven patients (44 men; 44.8±13 years old) were included. The main symptoms were visual alterations (87.3%), headache (70.1%), diminished libido (34.4%), galactorrhea (22.9%) and hair loss (19.5%). The axes affected were gonadotropic (72.6%), thyrotropic (48.4%) and corticotropic (38.7%), without significant changes after surgery. The average largest tumor diameter was 3.1 cm before surgery and 1.56 cm after surgery. The most frequent postoperative complications were hydro-electrolyte and acid-base disorders (12%), diabetes insipidus (9%), visual field alterations (9%), liquoric fistula (8%) and nasal obstruction (7%). The patients were affected by more than one complication. Although a decrease in tumor volume was achieved through surgery, hormonal deficiencies persisted in most of the patients and new surgical approaches were necessary for dealing with tumor recurrence or persistence.

Observation of successful treatment of penetrating traumatic brain injury followed by nasal liquorrhea for 61 years

An observation of penetrating traumatic brain injury, made by awl in childhood, followed by remittent nasal liquorrhea and purulent meningoencephalitis for 61 years, is given.For diagnosis clarifying biochemical study of nasal secretion, rhinologic study, MRI and CT-cisternography of the brain were performed. Liquor fistula was closed in two stages, ethmoid bone meningocele, causing obturation of left half of the nose, was removed.On the first stage, using transnasal approach, ethmoid bone meningocele was removed, on the next stage liquor fistula was discharged, using transcranial intradural approach. Anterior cranial fossa base defect was closed with temporal muscle fragment and fixed with fibrin-thrombin glue.

Spontaneous spinal liquor fistula: case report

A clinical case of spinal liquor fistula on dural bend of nerve root at thoracic spine is described.Open microsurgical operation was performed, place of fistula location was sewn and glued up. After operation a considerable improvement was marked: disappearance of headache, complete regress of neurological symptoms.Spontaneous spinal liquor fistulas may cause intracranial hypotension. The optimal method of such patients treatment is open microsurgical liquor leak reparation.

Fístula liquórica traumática com luxação de globo ocular: relato de caso

This report describes the only case in the literature of globe luxation due to traumatic cerebrospinal fluid fistula to the orbit caused by fire gun with ocular globe maintenance. E.N., female, white, 7 months, admitted with left orbitocranial injury by fire gun. Ocular globe luxation was detected with complete ocular motility restriction and absence of pupillary reflex in the left orbit. Computed tomography showed fracture of the medial orbital wall; bone fragments near the apex of the orbit and a stretched optic nerve. Surgical exploration was performed, showing liquor fistula through the ethmoid-sphenoid wall that was blocked with sponge (Gelfoam®) plus organic glue in the left orbit posterior wall, with immediate resolution of the proptosis and ocular integrity maintenance. Although controversial, maintenance of the ocular globe instead of enucleation was performed due to the integrity of the globe in this case. Despite the blindness, we considered the result to the proposed treatment excellent, once the maintenance of the ocular globe provides a good appearance and will contribute to an adequate facial bone development.

Diagnosis and treatment of isolated sphenoid sinus disease: a review of 109 cases

Conclusion. Endoscopic transethmoidal sphenoidotomy performed mainly in the early stages of the pathology and by expert hands is [WX1]very effective in treating isolated sphenoid sinus disease. Objective. This study aimed to investigate the causes of isolated sphenoid sinus disease identified in 109 patients and report on the most appropriate diagnostic and therapeutic patterns for an earlier diagnosis and a successful treatment of the disease. Subjects and methods. A total of 109 subjects with various isolated sphenoid pathologies were first examined by general objective examination, nasal sinus endoscopy, CT scan of paranasal sinuses, and in some cases with MRI. Then, they underwent medical and/or surgical treatment. Results. Nineteen patients (17.43%) had isolated sphenoiditis, 6 (5.5%) fungal sinusitis, 30 (27.52%) mucocele, 6 (5.5%) fibrous dysplasia, 6 (5.5%) meningoencephalocele, 5 (4.58%) inverted papilloma, 4 (3.66%) epidermoid carcinoma, 10 (9.17%) liquor fistula, 1 (0.9%) rhabdomyosarcoma, 1 (0.9%)chordoma, and 1 (0.9%) had carotid pseudoaneurysm. Evidence of definitive diagnosis by endoscopy was obtained in less than half of the cases. CT scan, however, sometimes in combination with MRI, determined the pathology in all the cases. A follow-up of at least 4 years post-surgery showed good results in all the patients who underwent endoscopic transethmoidal sphenoidotomy.

Surgical treatment of scoliosis in spinal muscular atrophy

To describe the early and late postoperative data from SMA patients with surgical procedure. Clinical data and radiographic imaging from 14 SMA patients with surgical treatment of scoliosis were reviewed, and all were reassessed clinically with new spinal radiographs and a questionnaire. The mean follow-up were 22 months. The mean preoperative Cobb angle was 78.4 . All patients presented pelvic obliquity (mean 25.5 ) and 11 had cifosis. The mean age at time of surgery was 12 years and 3 months. All patients were treated with posterior spinal fusion with Luque-Galveston instrumentation in 12 and Cotrel-Dubousset instrumentation in 2. The average curve correction at the immediate postoperative was 64.3% for scoliosis and 36.4% for cifosis, with the pelvic obliquity correction of the 70.9%. The complications were liquoric fistula and infection earlier in one case, and lately wire looseness of T1 in 2 patients. It was detected mean lost of the correction at the final assessment of the 0.26 of the scoliosis and the 1.28 of the pelvic obliquity. Relatives and the patients related good improvement regarding to esthetic aspects, posture balance, body care, as well as respiratory problems. The spinal fusion for scoliosis in SMA patients has a satisfactory impact for esthetic, quality of life and respiratory function, with minimal lost of corrected deformities and few complications.

Fatal Intraoperative Anaphylaxis Related to Aprotinin after Local Application of Fibrin Glue

To the Editor:—We report a case of intraoperative fatal anaphylaxis. The chronology of the event and the subsequent evaluation strongly point to a role of the aprotinin contained in the fibrin glue locally applied to the operating field.This letter is accompanied by an Editorial View. Please see: Moss J: Allergic to anesthetics. Anesthesiology 2003; 99:521-3.A 52-yr-old man underwent surgery for a painful lumbar disc herniation. His past medical history included a rhinoplasty, and his only other medical problem was a glaucoma treated with carteolol. After premedication with hydroxyzine 100 mg, anesthesia was induced with midazolam, propofol, and rocuronium and maintained with sufentanil and desflurane. No event occurred for 2 h until application of 0.2 ml of fibrin glue (Tissucol® Kit 500 U/ml; Baxter, Maurepas, France) on a dural tear. Blood pressure decreased immediately (60 mmHg), accompanied by a bronchospasm and a skin rash. The anesthetic agents were discontinued. The patient received hydroxyethyl-starch and intravenous epinephrine, but cardiac arrest developed. Cardiac massage was started and was soon followed by defibrillation. Stabilization of hemodynamic parameters was achieved with epinephrine infusion (epinephrine 3 mg/h). Right heart and pulmonary artery catheterism performed in the intensive care unit showed a low cardiac output with low left and right filling pressure. Despite intensive inotropic support, the patient died 48 h later from multiorgan failure.The plasma levels of histamine and tryptase were increased 2 h after initial symptoms, confirming anaphylaxis. Antiaprotinin immunoglobulin (Ig) E and antiquaternary ammoniums immunoglobulins were identified in the preoperative serum of the patient (table 1).No drugs other than those cited above had been given during the 2 h preceding the shock, except for Tissucol®. The chronology does not point to a role of neuromuscular blocking agents, because a 2-h interval had elapsed between the injection of rocuronium and the shock. Our patient had specific IgE against quaternary ammoniums (detected on his preoperative stored plasma), but this has little predictive value because antiquaternary ammoniums IgE are present in 10% of the population without allergic reaction to neuromuscular blocking agents. 1An allergic reaction to latex may occur at any time during surgery, but the negativity of antilatex IgE in the preoperative serum does not support this hypothesis in our case. The chronology of events and the presence of antiaprotinin IgE in the preoperative serum strongly argue in favor of an allergic mechanism induced by fibrin glue.Fibrin glue is effective for hemostasis and sealing of tissue wounds but has been associated with severe anaphylactic reactions. 2Since 1990, Tissucol® has been composed of human coagulation factors and bovine aprotinin. The aprotinin role is to delay the destruction of the glue by fibrinolysis. None of the allergic cases following exposure to fibrin glue related to human coagulation factors. Bovine aprotinin was therefore held responsible. 3More than 100 cases of allergy to intravenous aprotinin have been published, essentially after reexposure to the drug. 4,5In our patient, the antiaprotinin IgE level was moderately positive, indicating previous sensitization. Cases of allergy after local application of the product are rare, and our case is the first related death reported. A case similar to ours was described after neurosurgery with local injection of fibrin glue for closure of a liquor fistula, which resulted only in a generalized skin rash. 6After further enquiry, we discovered that fibrin glue had been applied during the previous rhinoplasty 5 yr before. It has been demonstrated in cardiovascular surgery that locally given aprotinin results in a 10% 12-month prevalence of IgG antibodies. 7On the other hand, it has been observed in cardiovascular surgery that even a careful research of exposure history is not very sensitive to identify patients with aprotinin-specific antibodies. 8In case of known previous exposure to aprotinin, a preoperative allergologic workup is usually performed. However, the predictive value of the tests (prick-test, specific antiaprotinin IgG or IgE) has not been studied for aprotinin local application. Because the prevalence of reactions to aprotinin is higher in patients with a reexposure interval less than 6 months, such a short interval should be considered a relative contraindication to fibrin glue application. 5This is the first report of a fatal case of intraoperative anaphylactic shock related to local aprotinin. Because the preoperative questioning to investigate previous exposure to fibrin glue is difficult, and because an allergologic workup cannot be performed in every patient, the liberal use of fibrin glue must be weighed in relation to the risk of allergy.