Urgent Neurosurgical Intervention Research Articles

Head injuries in prehospital and Emergency Department settings: a prospective multicenter cross-sectional study in France

BackgroundHead injuries are the leading cause of trauma in Emergency Departments (EDs). Recent studies have shown epidemiological changes in patients consulting ED for head injuries. The main objective of this study was to describe the profile of head injury patients consulting in the EDs in France and assess i) head injury severity across age groups; ii) the delay between the occurrence of head injury and ED arrival; iii) factors associated with traumatic intracranial hemorrhage (ICH).MethodsThis cross-sectional study collected patient data over a three-day period in March 2023. All adult patients (≥ 18 years old) admitted to the ED with a head injury (defined as a trauma to the head) were included. TBI severity was classified according to patients’ initial Glasgow Coma Scale score in the ED: severe (3–8); moderate (9 -12); mild (13–15); and simple head trauma in the absence of transient or persistent neurological symptoms.ResultsAmong the 71 participating EDs, 26,008 patients visited EDs and a total of 1070 patients (4.1%, IC 95 3.9—4.4) presented a head injury were included in the study, with a median age of 68.5 [37–85] years old. Most of the patients (66.7%) were referred to ED after a call to the Emergency Medical Dispatcher (EMD). The median time from head injury to ED visit was 2 h [1.0 – 5.5]. Ground-level falls were the leading cause of head injury (60.3%). Most of patient presented a simple head trauma (n = 715, 66.8%) followed by mild TBI (n = 337, 31.5%). CT head scans were performed for 636 patients (59.6%), of which 58 were positive. Traumatic ICH prevalence was 5.4% (95% CI: 4.1–6.9) and three patients (0.3%) required an urgent neurosurgical intervention. Neither preinjury anticoagulant (p = 0.97) nor antiplatelet (p = 0.93) use was associated with an increased risk of traumatic ICH.ConclusionsOne head injury patient out of two presenting in the ED is aged over 65 years. Patients referred by EMD were more likely to visit ED promptly. The majority of older patients underwent a head CT scan and preinjury anticoagulant use was not associated with increased risk of traumatic ICH.

Time to Recovery and Its Predictors in Patients with Traumatic Brain Injury Who Underwent Urgent Neurosurgical Intervention at ALERT Trauma Center, Ethiopia

Time to Recovery and Its Predictors in Patients with Traumatic Brain Injury Who Underwent Urgent Neurosurgical Intervention at ALERT Trauma Center, Ethiopia

Computed tomography and magnetic resonance imaging of diffuse axonal injury in brain trauma in young children: retrospective study

INTRODUCTION: Traumatic brain injury (TBI) is the leading cause of death and disability in children. Children’s TBI is associated with a number of characteristics that distinguish it from adults. Although the death rate associated with TBI has decreased over the past 2 decades, the disability of children who survived TBI continues to have a significant impact on the economy and public health of society as a whole.OBJECTIVE: To show the possibilities of computed tomography and magnetic resonance imaging in the diagnosis of traumatic diffuse axonal injuries in infants and young children.MATERIALS AND METHODS: In this work, we analyzed the CT and MRI data of 1334 children under 3 years of age with acute TBI who were treated at the Clinical and Research Institute of Emergency Pediatric Surgery and Trauma (730 boys, 604 girls). The age of the children was from 23 days to 3 years, the average age was 1 year 6 months. Computed tomography scans were performed on a 128-slice Ingenuity Elite scanner (Philips). Scanning of the area of interest (head + cervical spine) was carried out with the maximum possible reduction in indicators to minimize the radiation dose, including the iDose4 program. MRI was performed on a Phillips Achieva 3 T scanner with multiplanar T1- and T2WI, 2D and 3D isotropic images, FLAIR, SWI, DWI/DTI, and magnetic resonance angiography (MRA). No contrast enhancement was applied. Statistics: data processing was carried out using the GraphPad Prism 9 software package. The computing and graphic capabilities of the Excel spreadsheet editor were used. To compare the mean values of the data samples, ANOVA analysis of variance wasused; differences were considered significant at a significance level of p<0.05.RESULTS: 824 (61.8%) of 1334 children had a concussion, 510 (38.2%) had traumatic injuries of skull and brain from uncomplicated cephalohematomas and linear fractures to massive intracranial hematomas and total brain edema. Diffuse axonal injuries(DAI) type I and II on CT, further confirmed by MRI, were detected in 32 (6.27%) of all 510 children with TBI. 19 out of 32 hada combination with brain contusions, 13 with epi — and / or subdural hematomas of a small volume. MRI was performed in 89 out of 510 children under 3 years of age with intracranial injuries, in whom CT was initially performed. DAI of various types were detected by MRI in 92.13% (82/89) of the patients.DISCUSSION: DAI is one of the most common types of TBI, occurring in both mild and severe forms, and is a brain injury characterized by axonal disruption, resulting in lesions of white matter tracts over a wide area. Taking into account the fact that children with TBI were admitted to the institute with a significant spread (from 1 hour to 7 days), the initial CT scan was performed no later than one hour after admission and was supplemented by MRI. The criteria for CT and MRI prescribements after TBI were: clinical and neurological status at the time of admission. CT has low sensitivity for detecting DAI, as only large hemorrhagic (hyperdense) lesions of DAI are detected. The use of multiplanar reconstruction, as well as various options, such as 3D reconstruction, MIP and MinIP (maximum and minimum intensity projection) and others, allows for a detailed assessment of the brain parenchyma and increases the detection of DAI. In our study, DAI using MRI was detected in 92.13% of patients, and the most critical type of DAI III was detected in 100% of children with severe TBI with poor outcome and death of patients.CONCLUSION: Head CT is the preferred method for emergency radiology of TBI patients due to its affordability, speed of data acquisition, and ability to detect lesions requiring urgent neurosurgical intervention. In acute cases, MRI is chosen for patients with severe neurological impairment despite the absence of structural brain damage on CT. MRI is the method of choice for subacute and chronic TBI

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

The optimal perioperative management of antithrombotic therapy (ATT) in patients requiring urgent neurosurgical intervention for subdural hematoma (SDH) is poorly understood. The delicate equilibrium of effective hemostasis while preventing thrombosis is complex and relies on numerous factors such as indication for and type of ATT, medical comorbidities, and extent of neurological injury. This study aimed to analyze the impact of ATT and reversal strategies on surgical outcomes to highlight current challenges in the management of these high-risk patients. The authors performed a retrospective surgical cohort analysis of 100 patients undergoing urgent SDH evacuation at a level I trauma center between March 2020 and May 2021. The patients were first stratified into two cohorts based on preoperative ATT use and then further segregated by receipt of reversal agents. Statistical analysis included the chi-square test, Welch two-sample t-test, and multivariate logistic regression. The primary outcome was mortality. Secondary endpoints included radiographic SDH reexpansion, revision surgery, improvement in preoperative neurological deficits, and incidence of thromboembolism. A crossover cohort was secondarily analyzed in patients for whom ATT was interrupted for a minimum duration equal to effective drug metabolism. Finally, ATT reinitiation patterns were examined. Of 100 patients, 48% received ATT, 54.2% of whom were given reversal agents. ATT use was significantly associated with decreased rates of postoperative neurological improvement (p = 0.023) with trends toward increased mortality (p = 0.078), SDH reexpansion (p = 0.12), and need for revision surgery (p = 0.10). Patient crossover revealed a 4 times greater likelihood of death in patients without ATT interruption prior to surgery (p = 0.040) without an observable impact on secondary outcomes. ATT reversal contributed no improvement in outcomes other than a decreased intensive care unit length of stay when adjusted for in-hospital mortality (p = 0.014). The rate of postoperative thromboembolism following ATT reversal was 11.5%. ATT reinitiation was highly variable, occurring in 59.5% of patients, with median times of 17 and 15 days for antiplatelets and anticoagulants, respectively. Use of preoperative ATT portends poor clinical outcomes following nonelective SDH evacuation regardless of attempts to reverse these medications with replacement blood products. This study further reinforces the critical need for judicious use of ATT and optimization of reversal strategies in high-risk patient populations as best guided by multidisciplinary teams and evolving clinical practice guidelines.

Does Management at a Neuroscience Centre Improve Outcomes for Patients with a Severe Traumatic Brain Injury? A Systematic Review

Patients with severe Traumatic Brain Injuries (TBI) require management in hospital. However, should they be directly transported to a Neuroscience Centre (NC) or can they be safely treated at a local hospital before being subsequently transferred to an NC? This systematic review was undertaken to evaluate what effect transfers to an NC had on mortality rates amongst adult patients with a severe TBI. A systematic literature review was conducted using the databases Medline, CINAHL, Google Scholar and Cochrane. The inclusion criteria were: published between 2010 and 2023, adult patients (≥18) with severe TBI (Glasgow coma scale ≤8). The primary outcome studied was mortality. The secondary outcomes were, the impact that subsequent transfer to an NC had on mortality, the delay subsequent transfer had on surgery, and the accuracy of Emergency Medical Service (EMS) triage. The review analysed seven studies. Four reported no statistically significant difference in mortality in patients taken to an NC, despite NCs receiving more severely injured patients. Transferring patients from a local hospital to an NC was significantly associated with reduced mortality in one study (aOR, 0.79, 95% CI, 0.64-0.96), and reduced 24-hour (RR 0.31, 0.11-0.83) and 30-day (RR 0.66, 0.46-0.96) mortality in another. Subsequent transfers prolonged delays to surgery in several studies but were not statistically significant. This systematic review found that directly transporting severe TBI patients to an NC did not improve mortality. Mortality at 24-hour and 30-days was significantly reduced in patients who were subsequently transferred to an NC. A subset of patients benefit from urgent neurosurgical intervention as direct transfer to an NC improved their mortality rates. Severe TBI patients were accurately recognised by EMS staff. The skewing of more severely injured patients directly transported to an NC may be masking any survival benefit of direct NC admission.

Prehospital Predictors for Urgent Neurosurgical Intervention in the Head Trauma Patient: A 2-Year Multicenter Retrospective Study.

Traumatic brain injury (TBI) is the main cause of disability in the world. Prehospital diagnosis of patients requiring rapid neurosurgical intervention and the earliest possible introduction of procedures preventing secondary brain injuries (SBI) are crucial. Methodology and Study Population. The authors of this paper assumed that certain age groups with specific injuries are more likely to require urgent neurosurgical intervention compared with patients who did not require such an intervention. Out of 54,814 head CT scans, based on the inclusion criteria, 7,864 were selected for the study. Data such as sex, age, the mechanism of injury, comorbid trauma, and abnormal findings in the examination of patients qualified for urgent neurosurgical intervention were analyzed in order to find statistically significant factors through a comparison with all head trauma patients. Patients qualified for urgent neurosurgical intervention were significantly older compared with the others (63 years vs. 49 years). Patients transferred from the emergency department directly to the operating room were more often admitted to the hospital due to the fall (64.1% vs. 45.1%, p = 0.004). The following were observed much more commonly among the patients qualified for urgent neurosurgical intervention than in the entire study group of subjects with traumatic brain injury (TBI), e.g., calf deformity (2.2% vs. 0.1%, p = 0.019) and bleeding from the mouth (4.3% vs. 0.0%, p < 0.001). On the other hand, superciliary arch wounds were observed much less commonly than in the entire group (0.0% vs. 5%, p = 0.221). Patients admitted directly to the operating neurosurgical room from emergency departments constitute a small percentage of TBI patients, and their prognosis for normal performance status upon discharge is poor. Maximum efforts should be made to distinguish these patients and to start proper treatment even during prehospital care.

A Rare Case of Cladophialophora Isolated in a Renal Transplant Patient after Rejection Therapy

Cladophialophora bantiana is the most common cause of cerebral phaeohyphomycosis. A case of live-related renal allograft recipient complained of high-grade continuous fever on the 5th postoperative day (POD). No organism was isolated on cultures and no foci were found on chest X-ray. He was started on broad-spectrum antibiotics. The patient thereafter developed acute antibody-mediated plus acute cellular rejection on the 7th POD. He received a high dose methylprednisolone with plasmapheresis. On the 18th POD, the patient was diagnosed with right frontotemporal and basal ganglionic region abscess on magnetic resonance imaging of the brain. Urgent neurosurgical intervention was done and the sample was sent for investigation. Initially, there was suspicion of Aspergillus on culture. Injection of liposomal amphotericin B was given for 14 days, after which oral voriconazole was started. The patient improved initially but multiple abscesses recurred on the 46th POD. Abscess was drained. On the final culture report, C. bantiana was isolated. 5-flucytosine was added to voriconazole as dual antifungal therapy.

PMON39 A Perfect Storm – Multiple Causes of Hyponatremia in Patient With Pituitary Macroadenoma

Abstract Introduction Adrenal insufficiency is a life threatening condition, and prompt diagnosis and treatment are necessary. Here we present a case of hyponatremia which was thought to be multifactorial due to secondary adrenal insufficiency in the setting of a pituitary macro-adenoma, central hypothyroidism, SIADH in the setting of nausea as well as analgesic use. Case presentation A 23 y.o female patient presented to the hospital with headaches. MRI of the head revealed a 2.2 cm pituitary mass abutting the optic chiasm with no edema and no need for urgent neurosurgical intervention. Outpatient endocrine workup demonstrated following labs: Na 135 mmol/l (ref range 135 - 145), afternoon cortisol 9.3 mcg/dl (ref range 5.0 - 23.0), ACTH 19 pg/ml (ref range 7.2-63), GH 3.8 ng/ml (ref range &amp;lt;=7.1), Prolactin 16.0 ng/ml (ref range 4.8 - 23.3). Due to persistent headaches, she was taking high doses of Naproxen, which resulted in nausea and vomiting, and led to another ED visit. At this time, she was found to have Na 117 mmol/l, Serum osmolality 246 mOsm/kg (re range 285–295), Urine osmolality 554 mOsm/kg (ref range 40 - 1,400), Urine Na 146 mmol/L. TSH was 0.16 mIU/ml (ref range 0.27 - 4.20) and free T4 was 0.49 ng/dl (ref range 0.80 - 1.90). Endocrine was consulted and the pathogenesis for hyponatremia was thought to be multifactorial including central adrenal insufficiency masked by central hypothyroidism. Her cortisol levels as detailed above were done early afternoon and could not exclude at least some degree of central adrenal insufficiency. Additionally, hypothyroid state can significantly decrease metabolism of cortisol thus preventing acute drop in cortisol levels. She also seemed to have concomitant syndrome of inappropriate antidiuretic hormone secretion (SIADH), driven by both the pituitary tumor as well as nausea and vomiting. On top of that for her severe progressive headaches she was treated with non-steroidal anti-inflammatory agents and tramadol, both known to associate with hyponatremia. She was started on intravenous hydrocortisone, and subsequently oral levothyroxine. She had improvement in her sodium levels and did not require Tolvaptan. She was discharged on hydrocortisone and levothyroxine with outpatient endocrine and neurosurgery follow up. She is currently awaiting neurosurgical intervention. Discussion Secondary adrenal insufficiency is more common than primary adrenal insufficiency. Establishing the diagnosis of secondary adrenal insufficiency is challenging as it is not typically associated with classical signs and symptoms of adrenal insufficiency. Clinical manifestations tend to be more indolent as they result from glucocorticoid deficiency only and there is preservation of the aldosterone and adrenal androgen axis. What makes our patient interesting is the several factors as mentioned above which contributed to her severe hyponatremia. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Venture of a Tertiary Care Neurosurgical Center in Course of COVID-19 Lockdown without RT-PCR.

"I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient." Obliged by the aforementioned oath, no medical practitioner shall sit in a moral judgment on any patient but will treat their illness to the best of their ability whatever the circumstances. A clear concord was yet to be authorized after the World Health Organization (WHO) declared the global pandemic of severe acute respiratory syndrome coronavirus 2infection. As a diagnostic modality, WHO recommended real-time reverse transcription-polymerase chain reaction (RT-PCR) as a reliable test; however, its availability in a deprived nation like ours became a major restraining factor. Despite an asset of having high specificity, RT-PCR for coronavirus disease 2019has its own liability of having low sensitivity. Henceforth, as time passed by, the validity of the rapid diagnostic tests was put into question. In later months, a few centers around our periphery started conducting RT-PCR, but the time taken to obtain the result was long-drawn-out process and the patient who needed urgent neurosurgical intervention at Annapurna Neurological Institute and Allied Sciences had to wait. We would like to share our expedition through peaks and valleys of managing 215 patients during the vicious circle of lockdown and global pandemic.

Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center.

Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality

There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.

Urgent Neurosurgical Interventions in the COVID-19–Positive Pediatric Population

BackgroundUrgent neurosurgical interventions for pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are rare. These cases pose additional stress on a potentially vulnerable dysregulated inflammatory response that can place the child at risk of further clinical deterioration. Our aim was to describe the perioperative course of SARS-CoV-2–positive pediatric patients who had required an urgent neurosurgical intervention.MethodsWe retrospectively analyzed pediatric patients aged ≤18 years who had been admitted to a quaternary children's hospital with a positive polymerase chain reaction test result for SARS-CoV-2 virus from March 2020 to October 2021. The clinical characteristics, anesthetic and neurosurgical operative details, surgical outcomes, and non-neurological symptoms were collected and analyzed.ResultsWe identified 8 SARS-CoV-2–positive patients with a mean age of 8.83 years (median, 8.5 years; range, 0.58–18 years). Of the 8 patients, 6 were male. All children had had mild or asymptomatic coronavirus disease 2109. The anesthetic and surgical courses for these patients were, overall, uncomplicated. All the patients had been admitted to a specialized isolation unit in the pediatric intensive care unit for cardiopulmonary and neurological monitoring. The use of increased protective personal equipment during anesthesia and surgery did not impede a successful neurosurgical operation.ConclusionsSARS-CoV-2–positive pediatric patients with minimal coronavirus disease 2019–related symptoms who require urgent neurosurgical interventions face unique challenges regarding their anesthetic status, operative delays due to SARS-CoV-2 polymerase chain reaction testing, and requirements for additional protective personal equipment. Despite these clinical challenges, the patients in our study had not experienced adverse postoperative consequences, and no healthcare professional involved in their care had contracted the virus.

ACUTE PARALYSIS: PAN-SPINAL EPIDURAL ABSCESS IN SETTING OF POORLY CONTROLLED HIDRADENITIS SUPPURATIVA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease characterized by painful swollen lesions involving intertriginous regions. Complications of HS include lymphedema, squamous cell carcinoma, strictures, sacral osteomyelitis, and lumbosacral abscess. We present a case of a 38-year-old female with history of HS without any other comorbidities such as DM, ESRD, IV drug use, or recent surgical intervention (Reference 1), who developed life-threatening pan-spinal epidural abscess (pan-SEA) leading to acute paralysis. CASE PRESENTATION: A 38-year-old female with history of HS presented to the hospital with fevers, weakness, and lower abdominal pain radiating to her lower back for 2 days. Vital signs included blood pressure 125/73, heart rate 157, respiratory rate 20, temperature 39.4 C, and oxygen saturation 98% on room air. Initial exam revealed ill-appearing woman with an open sacral wound on top of the anal cleft. Pertinent labs included leukocytosis (30.1), lactic acid (5.3), CRP (>240), LDH (196), D-Dimer (6818), pro-calcitonin (87.14), and electrolyte imbalances (K 3.3, Mg 1.1, Phos < 1.0). Initial imaging included unremarkable CT Head without contrast, and CT abdomen/pelvis with contrast that indicated enhancing skin thickening along the right perineum. Despite aggressive fluid resuscitation and broad-spectrum antibiotics, patient developed worsening hypotension in setting of persistent tachycardia to 140s. Given concern for septic shock, she was transferred to intensive care unit. Subsequent exam was significant for sacral ulcer draining copious purulent discharge, decreasing strength in all 4 extremities, and neck pain upon flexion. She developed worsening oxygen requirements with rapidly progressing paralysis and suspected involvement of respiratory muscles, prompting intubation for airway protection. MRI CTL Spine demonstrated pan-SEA, with severe spinal cord compression from C2-C7, and to a lesser degree in thoracic spine. Patient underwent emergent neurosurgical decompression with C2-C7 posterior laminectomy, along with evacuation of epidural abscess. DISCUSSION: This case highlights HS in the life-threatening setting of pan-SEA leading to acute paralysis. While HS has been known to cause sacral abscesses that often require surgical incision and drainage, literature review did not yield any cases showing pan-SEA that required urgent neurosurgical intervention due to acute paralysis. The rapidly deteriorating neurological changes over a short time span (reference 2) with purulent discharge from the sacral ulcers from HS, in conjunction with the labs consistent with severe sepsis, led to an expedited MRI CTL Spine and improved outcome in our patient. CONCLUSIONS: We believe this case will help with rapid identification of pan-SEA in patients with HS, and emphasize the importance of urgent multidisciplinary approach to treatment. REFERENCE #1: Wang KY, Izbudak I. Panspinal Epidural Abscess. Ann Clin Case Rep. 2017; 2: 1239 REFERENCE #2: Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006 Nov 9;355(19):2012-20. doi: 10.1056/NEJMra055111. PMID: 17093252. REFERENCE #3: NA DISCLOSURES: No relevant relationships by Afolarin Ajose, source=Web Response No relevant relationships by Suvrat Chandra, source=Web Response No relevant relationships by Gabrielle De Allie, source=Web Response No relevant relationships by Allen Sanyi, source=Web Response No relevant relationships by timothy sobukonla, source=Web Response

Successful Nonoperative Management of Acute Spontaneous Idiopathic Spinal Epidural Hematoma Presenting as Cauda Equina Syndrome

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical condition with an estimated incidence of 0.1 in 1,00,000 population.[1] It has been most commonly described in the older age group in the 4th or 5th decade of life and most commonly found in the dorsal or dorsolumbar region.[2] It can present with a variety of clinical symptomatology, depending upon the site and extent of hematoma, usually in the form of acute cervical or back pain along with rapid onset of neurological deficits, often within first 12 hours of ictus and often requiring urgent neurosurgical intervention. However, its first manifestation as cauda equina syndrome is rare. Emergent surgical evacuation has remained the gold standard of treatment,[3] and only a handful of cases reported successful recovery with conservative management, and that too primarily in patients with a diffuse SSEH associated with blood dyscrasias or coagulopathy.[4] We describe a case of a 25-year-old healthy male, who presented with history of sudden onset severe back pain, followed by rapidly progressive paraplegia and cauda equina syndrome, four days after lifting heavy weight. He had to be catheterized for urinary retention. He presented to our clinic 1 month after the onset of symptoms, and by then, partial recovery of sensory, motor and autonomic deficits had already ensued. The coagulation profile was within normal parameters. His MRI performed immediately after the onset of symptoms demonstrated a T2-hyperintense lesion in posterior epidural space at L2-3 vertebral level, which was suggestive of a focal epidural hematoma with significant secondary canal compromise ( [Fig. 1 A,B] ). There was no evidence of associated flow-voids to suggest an associated vascular malformation. Due to delayed referral of patient and subacute stage of epidural hematoma with partial spontaneous recovery at the time of presentation, decision was taken to manage it conservatively with symptomatic pain management and limb physiotherapy. He recovered nearly completely over the next 1 month, and he was able to walk with minimal support and regained bladder function (American Spinal Injury Association [ASIA] D). His interval MRI demonstrated complete resolution of epidural hematoma ( [Fig. 2 A,B] ).

Indications for Inpatient Magnetoencephalography in Children - An Institution's Experience.

Magnetoencephalography (MEG) is recognized as a valuable non-invasive clinical method for localization of the epileptogenic zone and critical functional areas, as part of a pre-surgical evaluation for patients with pharmaco-resistant epilepsy. MEG is also useful in localizing functional areas as part of pre-surgical planning for tumor resection. MEG is usually performed in an outpatient setting, as one part of an evaluation that can include a variety of other testing modalities including 3-Tesla MRI and inpatient video-electroencephalography monitoring. In some clinical circumstances, however, completion of the MEG as an inpatient can provide crucial ictal or interictal localization data during an ongoing inpatient evaluation, in order to expedite medical or surgical planning. Despite well-established clinical indications for performing MEG in general, there are no current reports that discuss indications or considerations for completion of MEG on an inpatient basis. We conducted a retrospective institutional review of all pediatric MEGs performed between January 2012 and December 2020, and identified 34 cases where MEG was completed as an inpatient. We then reviewed all relevant medical records to determine clinical history, all associated diagnostic procedures, and subsequent treatment plans including epilepsy surgery and post-surgical outcomes. In doing so, we were able to identify five indications for completing the MEG on an inpatient basis: (1) super-refractory status epilepticus (SRSE), (2) intractable epilepsy with frequent electroclinical seizures, and/or frequent or repeated episodes of status epilepticus, (3) intractable epilepsy with infrequent epileptiform discharges on EEG or outpatient MEG, or other special circumstances necessitating inpatient monitoring for successful and safe MEG data acquisition, (4) MEG mapping of eloquent cortex or interictal spike localization in the setting of tumor resection or other urgent neurosurgical intervention, and (5) international or long-distance patients, where outpatient MEG is not possible or practical. MEG contributed to surgical decision-making in the majority of our cases (32 of 34). Our clinical experience suggests that MEG should be considered on an inpatient basis in certain clinical circumstances, where MEG data can provide essential information regarding the localization of epileptogenic activity or eloquent cortex, and be used to develop a treatment plan for surgical management of children with complicated or intractable epilepsy.

A Challenging Case of Pituitary Macroprolactinoma During Pregnancy

Introduction: Prolactinoma is the most common secreting pituitary adenoma diagnosed in women of reproductive age. The mainstay of treatment is pharmacotherapy with dopamine agonists. Management during pregnancy poses a considerable challenge to physicians. We describe a case of a patient who developed significant symptoms of pituitary enlargement following cessation of Cabergoline in pregnancy. Case Description: A 28-year-old female presented at age 16 with galactorrhea and oligomenorrhea. She was treated with Cabergoline for 12 years. Her peak prolactin was 191ng/ml (normal range, non-pregnant: 2.8-29.2ng/ml, pregnant: 9.7- 208.5ng/ml). On MRI, she had a 1cm tumor that was stable from 2016 to 2019. Prior to recent pregnancy, she remained compliant with Cabergoline 1.5mg twice weekly with prolactin levels that ranged between 30-44 ng/ml. After becoming pregnant in August 2019, Cabergoline was discontinued. During pregnancy, she did not initially schedule follow up with endocrinology. She developed blurred vision at 12 weeks gestation but did not seek medical care until 24 weeks gestation, at which time she was found by Ophthalmology to have bitemporal field cuts. MRI pituitary at 26 weeks showed marked enlargement and evidence of a left sided pituitary macroadenoma measuring 2cm with hemorrhagic component, suprasellar extension compressing the optic chiasm and subtle extension into the left cavernous sinus. She was recommenced on Cabergoline 1.5mg twice weekly but had no improvement in visual changes or MRI findings after two weeks. Her prolactin level at 30 weeks gestation was 170ng/ml. Neurosurgical evaluation resulted in urgent endoscopic transsphenoidal surgery at 30 weeks and pathology was consistent with prolactinoma. Post-operative outcomes were favorable with no evidence of pituitary hormonal deficiencies. Her visual abnormalities resolved, and she underwent delivery via C-section at 38 weeks gestation. She had intermittent breast milk production and her baby is in good health. She remains off Cabergoline with a prolactin level of 2.38ng/ml and no residual disease on MRI done 6 months postop. Conclusion: Tumor growth causing significant symptoms requiring intervention has been reported in 2.4% of microadenomas and 21% of macroadenomas. It is essential to periodically assess visual fields during pregnancy particularly in patients with macroadenomas. Dopamine agonists are discontinued during pregnancy unless symptomatic enlargement of prolactinoma occurs. In such cases, reinstitution of dopamine agonists usually results in positive outcomes and delivery can be considered if appropriate for gestational age. Further deterioration or lack of improvement necessitates urgent neurosurgical intervention in cases such as our patient.

Disorders of the Cauda Equina.

Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed. Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.

Use of a mobile CT scanner at professional boxing and MMA events: making combat sports safer

Professional boxing and mixed martial arts (MMA) are popular contact sports with high risk for both acute and chronic traumatic brain injury (TBI). Although rare, combatants have died in the ring/cage or soon after the completion of the bout. The cause of death in these cases is usually acute subdural hematoma, acute epidural hematoma, subarachnoid haemorrhage, intracranial haemorrhage, or second-impact syndrome (SIS). Neuroimaging or brain imaging (either CT scan or MRI brain) is currently included in the process of registering for a license to fight in a combat sport in most commissions in the United States and around the world. Neuroimaging in the immediate aftermath of a bout primarily serves to rule out acute traumatic brain injury. At present if concern for acute TBI in a combatant is raised either during or after the conclusion of a bout, based on the neurological evaluation by the ringside physician, the fighter is immediately transported via on-site ambulance to the nearest Level I trauma center for urgent CT scan head and neurosurgical intervention if deemed necessary. Some TBIs may not manifest immediately or manifest in a subtle fashion so as to escape detection by the ringside physicians in the immediate aftermath of a bout. In this commentary the use of a mobile CT scanner at professional boxing and MMA events is proposed with the intention of making these sports safer.

Audit of CT head request appropriateness for patients referred from emergency department

Introduction: Considering the usefulness and relative ease of Computerized Tomography (CT) based diagnosis, the propensity to request it in the Emergency Room setting when at times it is not really indicated can become an issue.&#x0D; Objective: To audit use of CT imaging in the emergency department of Rehman Medical Institute by evaluating the clinical practice for CT referral and compliance with clinical guidelines by NICE (National Institute for Health and Care Excellence).&#x0D; Materials &amp; Methods: This study was conducted at Radiology Department of Rehman Medical institute Peshawar in Oct-Dec 2019 on 100 patients referred for computed tomography (CT) head scans from the emergency department (ED), mostly performed outside normal working hours. Clinical record and CT reports of patients who had their CT head scans done between 1 January 2018 and September 2019 were reviewed. The imaging record of included patients was reproduced from the Picture Archiving and Communication system (PACS) and laboratory data were reviewed through the Hospital Management Information System (HMIS). Clinical details were reviewed to assess risk factors satisfying NICE criteria for a CT scan in those with head injuries. An urgent CT head scan request was deemed appropriate if it led to an immediate change in patient management. Appropriateness of the requests according to the various guidelines was also evaluated. The NICE guideline 176 was used as a standard of care. Data were entered and analyzed using Microsoft Excel.&#x0D; Results: For suspected brain injuries at least one of the NICE criteria was fulfilled by 84 patients, and 3 or more criteria by 16 patients with a history of head injury; 81% scans were both requested and performed in afternoon and night (between 1700 hrs and 0800 hrs). Most (70) patients were males; ages of patients were from 1- 90 years, most being 51-60 years. Most common presenting complaint was altered consciousness (85%); 51% of the advised CT scans were reported normal, 10% had skull fractures (base 2%, vault 8%), 13% extra-axial hemorrhages, 7% contusions, 7% only scalp hematoma, 6% intracerebral hemorrhages. 2% had infarcts and 2% were cerebral abscesses. Common change in patient management included intracranial bleed requiring urgent neurosurgical intervention and hemorrhagic stroke being ruled out. CT head scans also facilitated early discharge of the patients with head injuries and headache from the hospital.&#x0D; Conclusion: All (100%) patients had CT head in compliance with NICE guidelines and 81% of these were performed in off hours.&#x0D; Keywords: Head; Tomography; Craniocerebral Trauma.

Holospinal epidural abscess: An unexpected find

Introduction: Spinal epidural abscesses present infrequently in surgical practice resulting in neurological morbidity, and mortality. A rare find is the presence of an abscess involving the entire cervical, thoracic and lumbosacral regions of the spine, with limited reported cases in literature. When this is encountered urgent neurosurgical intervention is required to improve patient prognosis. Case Description: A 58-year-old, poorly controlled type II diabetic male, presented with a 3-week history of lower back pain and progressive limitation in ambulation. Further deterioration was observed in-hospital, with a sudden decline in power of the lower limbs from a Medical Research Council (MRC) grade 5 to 2. This prompted urgent magnetic resonance imaging of the whole spine, which depicted an epidural abscess extending from the cervical vertebrae - C3, to the sacrum - S1, with resulting compression of the spinal cord. An emergency multi-level laminectomy was performed with drainage of the epidural space. There was resolution of his sensory deficits and objective improvement in power of the lower limbs post-operation. Culture reports showed the culprit organism to be Escherichia coli. Conclusion: Severe back pain in the diabetic patient requires careful assessment and monitoring. Emergency surgical decompression within 72 hours of neurological symptoms improves prognostic outcomes in patients with spinal epidural abscesses. We contend that performing a multi-level laminectomy procedure is the best option for an extensive posterior spinal epidural abscesses without bony involvement. Other methods such as image-guided percutaneous drainage, catheter procedures and intermediate level fenestration procedures, while less invasive, may be more likely to fail.