Man-in-the-barrel syndrome: Case report of ventral epidural abscess and review of the literature

Background: Man-in-the-barrel syndrome (MBS) is an uncommon clinical condition for which patients present with bilateral brachial diplegia but intact lower extremity strength. This syndrome is typically attributed to a cranial/cortical injury rather than a spinal pathology. Case Description: A 62-year-old diabetic male presented with bilateral upper extremity paresis attributed to a ventral cervical epidural abscess diagnosed on magnetic resonance imaging. Emergent cervical decompression resulted in slight improvement of upper extremity strength. However, he later expired due to sepsis and respiratory compromise. Conclusion: Establishing the correct diagnosis via clinical examination and proceeding with appropriate management of MBS attributed to a cervical epidural abscess is critical to achieve a good outcome

Reducing Superfluous Opioid Prescribing Practices After Brain Surgery: It Is Time to Talk About Drugs

BACKGROUND: Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE: To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS: A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS: A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P \u3c .001). Refill requests also decreased by 56% (17% vs 8%, P = .027) despite both groups having similar baseline characteristics. There was no increase in pain scores at outpatient follow-up (1.23 vs 0.85, P = .105). CONCLUSION: A dramatic reduction in opioids prescribed was achieved without affecting refill requests, patient satisfaction, or perceived analgesia. The use of targeted didactic education to safely improve opioid prescribing following intracranial surgery uniquely highlights the ability of simple, evidence-based interventions to impact clinical decision making, lessen potential patient harm, and address national public health concerns

Effects Of Dopamine Oxidation Products In Relation To Oxidative Stress And Parkinson\u27s Disease

The formation of low-potential, highly reactive dopamine oxidation products in the substantia nigra promotes cell death via mechanisms that have yet to be established. To identify the main pathway that is responsible for the cytotoxicity, extensive analysis of aminochrome and 5-cysteinyldopamine was done. It was found that aminochrome forms reactive oxygen species more readily than 5-cysteinyldopamine by redox-cycling with molecular oxygen. To be able to carry out experiments in vivo to efficiently test the low-potential products\u27 effects on cells and how they promote cell death, 3-methyl-5-anilino-1,2-benzoquinone (3-MAQ) was synthesized to act as an analogue of aminochrome and possibly also 5-cysteinyldopamine\u27s oxidation products. Experiments demonstrating the cytotoxicity of 3-MAQ were carried out in vivo using mouse embryonic fibroblasts. In conclusion, we have found that thiols such as cysteine protect against aminochrome\u27s formation, and we were able to synthesize a compound that can help in the study of aminochrome\u27s effects in vivo

Giant Choroid Plexus Papilloma Resection Utilizing a Transcollation System

BACKGROUND: Large vascular brain tumors pose an exceptional challenge in young children. Choroid plexus papilloma (CPP) is an example of a rare, often large and especially vascular neuroepithelial tumor that most commonly arises in children under 5 yr old. Although patients may be cured by total resection, this tumor poses significant surgical risks and challenges related to intraoperative hemostasis. OBJECTIVE: To describe our experience using a transcollation system during brain tumor surgery in a child to achieve hemostasis and minimize blood loss while preserving normal brain tissue. METHODS: A 3-yr-old girl presented following a fall and was found to have a giant CPP growing from the right lateral ventricle. Given the vascularity of the tumor and the low intravascular reserve in a small child, a transcollation device was used to reduce blood loss intraoperatively. RESULTS: Gross total resection was achieved with approximately 300 mL of blood loss without complications. The patient did well postoperatively. Imaging performed at 3 mo after resection revealed return of normal brain architecture. CONCLUSION: Transcollation devices appear to be an effective and safe addition to the armamentarium of neurosurgical hemostatic options in intracranial tumor resection in which there is a high risk of intraoperative hemorrhage

Decreasing morbidity with nasal cerebrospinal fluid leak repair: No fat or fascia and no nasal packing

Introduction: A myriad of methods have been described to repair low- and high-flow nasal cerebrospinal fluid (CSF) leaks, but significant practice variations remain. While the majority of published repair techniques have led to excellent outcomes regardless of CSF leak type, less consideration has been given to the morbidity of commonly performed CSF leak repair methods, such as fat and fascia harvest and nasal packing. The purpose of the study was to determine whether high success rates could still be achieved for CSF leak repair while avoiding the morbidity of fat or fascia lata harvest and nasal packing. Methods: This was a prospective case series of 56 patients undergoing CSF leak repair of 58 skull base defects. There were 30 low-flow leaks (\u3c1 cm dural defects or normal intracranial pressure, ICP) and 28 high-flow leaks (\u3e1 cm dural defects or elevated ICP). CSF leaks were due to various etiologies, including iatrogenic during skull base tumor resection (n = 32), meningoencephaloceles (n = 18), iatrogenic from sinus surgery (n = 4), and accidental head trauma (n = 4). Defects were located in the following locations: cribriform plate (n = 21), sella (n = 18), planum sphenoidale and tuberculum sellae (n = 12), other sphenoid sinus walls (n = 5), clivus (n = 1), and posterior table of frontal sinus (n = 1). Two-layered reconstruction was performed in 36 cases, with an epidural inlay layer of either porcine collagen (Biodesign duraplasty graft™) (n = 33) or nasal septal bone (n = 3), and nasal mucosa for the onlay layer. Mucosa was harvested as a free mucosal graft for 90% of low-flow CSF leaks (27/30), and vascularized nasoseptal mucosal flap for 68% of high-flow CSF leaks (19/28). For the other low-flow leaks, nasoseptal flaps were used (3/30), and for the other high-flow CSF leaks, no vascularized flaps were available, so free mucosal grafts were used (9/28). Monolayer onlay reconstructions were performed with nasal mucosa in 22 cases: 11 free mucosal grafts and 1 nasoseptal flap for low-flow leaks; 3 free mucosal grafts and 7 nasoseptal flaps for high-flow leaks. No remote site fat or fascia lata harvest was performed. A dural sealant was always applied to graft or flap edges. No nasal or sinus packing was ever placed. Patients remained bedrest for 24 to 48 hours postoperatively before ambulation. For high-flow CSF leaks, a lumbar drain was used in 21 cases (75%) for 48 hours before clamping and ambulation. Results: Of the 58 patients, only 1 failed initial CSF leak repair (98.3% success). The patient leaked on postoperative day 2 after a low-flow CSF leak repair during a transsphenoidal resection of a pituitary adenoma, but resolved with lumbar drain diversion alone. Therefore, no patients required revision surgery. Conclusion: Low- and high-flow CSF leaks were successfully repaired in nearly all cases with porcine collagen or nasal septal bone epidural inlay grafts, and free mucosal graft or nasoseptal flap onlays. Fat or fascia lata grafts and nasal packing were not necessary for achieving excellent CSF leak closure rates, and morbidity was reduced by avoiding their use

Vertical vector surgical knot in endoscopic endonasal surgery and repair: An exonasal knot for endonasal application

Developing innovative surgical approaches through narrow anatomic corridors requires continual adaptation surgical techniques and maneuvers. Regarding skull base surgery, endoscopic endonasal approaches have become extremely popular, resulting in lower patient morbidity, without sacrificing clinical outcomes. Although surgical approaches have changed dramatically over the last few decades, suturing and knot tying in these narrow corridors have not been developed at the same pace. Endoscopic repair of skull base defects after endoscopic endonasal surgery is often achieved with 90-95% success through multilayered reconstruction with a variety of grafts or flaps, sealants, and possibly sinonasal packing to avoid postoperative cerebrospinal fluid leaks. These high success rates are achieved without any direct suturing of the grafts/flaps to adjacent tissues. In some situations, perhaps suturing could limit the risk of graft/flap migration, and increase the chance of graft/flap water-tight closure and integration. The utility of endonasal suturing of grafts/flaps is largely unknown because intranasal geometry restricts the hand and instrument movements needed to achieve traditional surgeons\u27 or square knots. The current study demonstrates a suturing technique resulting in a facile surgical knot through vertical vector motions, making it an ideal candidate when operating through narrow corridors. The advantages of this technique are its cost-effectiveness, the ability to use any type of needle or suture for tissue approximation, and the elimination of horizontal vectors and maneuvers which are limited in endonasal. This facile knot can be employed during endoscopic endonasal surgery potentially to facilitate watertight closure in scenarios where it is felt necessary or when repairing vascular structures

Expanded Endonasal Approach for Resection of Extradural Infratemporal Fossa Trigeminal Schwannoma: 2-Dimensional Operative Video

The infratemporal fossa (ITF) is bounded superiorly by the skull base, specifically the greater wing of the sphenoid, which contains foramen ovale. It is bordered posteriorly by the temporal bone, including the petrous portion of the carotid canal, anteriorly by the posterior wall of the maxillary sinus, laterally by the mandible, and medially by the pterygoid body and lateral pterygoid plate. In this video, we report a case of a rare, exclusively extradural, schwannoma originating from the third division of the trigeminal nerve with a widened foramen ovale at the skull base. The tumor filled the ITF and extended laterally just through the sigmoid notch of the mandible. The patient complained of left cheek and lower jaw numbness and intermittent left jaw spasms. The tumor was deemed appropriate for endoscopic resection. To access the ITF, left-sided endoscopic sinus surgery, a modified endoscopic Denker\u27s approach, and posterior nasal septectomy were first performed. A nasoseptal flap was also harvested in case an intraoperative cerebrospinal fluid (CSF) leak required repair. Dissection was carried out through the posterior wall of the maxillary sinus and pterygopalatine fossa to reach the ITF. Tumor resection was achieved through a 2-surgeon, 4-handed approach in which appropriate traction and countertraction were carefully applied to tease the tumor away from the skull base and dehiscent carotid canal. No CSF leak or carotid injury occurred, and the posterior maxillary sinus wall defect was repaired with the nasoseptal flap. The patient did well postoperatively. The patient consented to the procedure in a standard fashion

Malignant cerebral edema associated with radiation and laser ablation for brain tumors

Objective: Our aim was to investigate whether laser interstitial thermal therapy (LITT) and radiotherapy (RT) in close succession to each other induced worsening symptomatic cerebral edema. Background: LITT is an image-guided technique that uses high temperatures to ablate pathological tissue and is commonly used for recurrent or deeply seated tumors. Some patients are also treated with adjuvant RT. Design/Methods: We retrospectively reviewed records of patients who underwent Visualase LITT at our institution (March 2014-February 2016) and RT less than 60 days apart. Magnetic resonance imaging (MRI) brain and clinical information were reviewed at three time points (pre-treatment, post-LITT, and post-RT). Data is presented as a median (range). Results: We studied 10 patients with brain tumor; 8 glioblastoma, 1 anaplastic astrocytoma, and 1 metastasis, 6 (60%) were men, age at treatment was 61.5 (52-76) years. There were 6 cortical versus 4 subcortical tumors. The majority of patients underwent LITT followed by RT except for 2. Time interval between LITT and RT was 24 (9-43) days. Increased ablation volume post-LITT compared to pre-operatively tumor volume was seen in 9 patients with a mean enlargement of 15% overall. RT treatments included external beam fractionated radiation treatment (EBRT) (n=8), EBRT with stereotactic radiosurgery (SRS) (n=1), and fractionated SRS (n=1). Pre-treatment MRI showed cerebral edema in 9 patients. Post-LITT MRI showed worsening cerebral edema in 4 patients, 3 were symptomatic (1 had disease progression). One patient who received RT prior to LITT had asymptomatic cerebral edema post-RT that improved post-LITT. Post-RT MRI showed worsening symptomatic cerebral edema in a patient who had EBRT+SRS. Avastin was used in 1 patient and 2 patients had prolonged use of steroids (\u3e65 days). Conclusions: LITT and RT treatment can induce symptomatic cerebral edema which can be effectively managed with steroids and/or Avastin. Treating physicians need to be cognizant of this risk