Acute cerebellar edema after traumatic brain injury in a child. a case report

Traumatic brain injuries (TBI) are a major cause of morbidity and mortality in children. Malignant cerebral edema is described to occur more often in children than in adults. Its infratentorial analogous, a malignant cerebellar edema, has not been reported yet. A 10-year-old boy fell from a height of 3 m where he sustained a TBI. Approximately 36 h after trauma, a significant drop in Glasgow Coma Scale (GCS) occurred accompanied by bilateral fixed and dilated pupils. A computed tomography (CT) scan revealed an underlying acute cerebellar edema without evidence of a sinus vein thrombosis or cerebellar contusions. Immediate suboccipital decompressive surgery and insertion of an external ventricular drain (EVD) were performed. Early postoperative CT imaging showed increasing, space-occupying frontal contusions and perilesional edema, which is why an additional bifrontal craniectomy was performed. A posttraumatic hydrocephalus occurring on the 27th day after trauma was treated with a ventricular-peritoneal shunt. On follow-up, 6 months after trauma, he showed a GCS of 15 with no evident neurological findings. This case report is the first to describe and discuss an acute cerebellar edema occurring after TBI. Its acute complications of brainstem compression and obstructive hydrocephalus are effectively treated by immediate suboccipital decompression and EVD insertion

Posttraumatic cerebrovascular injuries in children. A systematic review

INTRODUCTION: Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. METHODS: We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. RESULTS: After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF`s and TA`s, and data from randomized controlled trials is lacking. CONCLUSION: While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children

Conscious Experience and Psychological Consequences of Awake Craniotomy

Background: Experiencing cranial surgery under awake conditions may expose patients to considerable psychological strain METHODS: This study aimed to investigate the occurrence and course of psychological sequelae following awake craniotomy (AC) for brain tumors in a series of 20 patients using a broad, validated psychological assessment preoperatively, intraoperatively, postoperatively and a standardized follow-up of 3 months. In addition, the association of the preoperative psychological condition (including, but not limited to, anxiety and fear) with perioperative pain perception and interference was assessed. RESULTS: AC did not induce any shift in the median levels of anxiety, depression, and stress symptoms already present prior to the procedure. Furthermore, anxiety and depression were all moderately to strongly associated over time (all P < 0.05). Stress symptoms also correlated positively over all times of measurement. Stress 3 days after surgery was strongly associated with stress 3 months after surgery (P < 0.001), whereas the correlation between preoperative and immediate postoperative stress showed a statistical trend (P = 0.07). Preoperative fear was not related to intraoperative pain, but to pain and its interference with daily activity on the third postoperative day (P < 0.001 and P < 0.01, respectively)

Intradural cystic schwannomas of the spine: A case-based systematic review of an unusual tumor

Introduction: Cystic schwannomas have only been reported in a few case reports/series. As a result, they may be misdiagnosed and a standardized management approach remains challenging to establish. Research question: The aim of this study was to compile all reported cases of cystic schwannomas and analyze the perioperative course based on a systematic review of the literature with an additional two cases from the authors’ experience. Material and methods: We conducted a search of MEDLINE and CENTRAL databases for spinal intradural extramedullary cystic schwannomas, in accordance to the PRISMA statement. All title/abstracts were screened, and a full-text review of the remaining articles was conducted. The results were compiled in tables and summarized using means and standard deviation (SD), median and interquartile range, and percentage and 95% confidence intervals. Results: We identified 263 articles, of which 35, which reported 54 cases, were included. Including our case-reports (n = 56), patients had a mean age of 47.7 years (SD ± 13.0 years) at presentation, 57% were males, and most lesions were lumbar (43%). The most common symptoms were pain (82%) and muscle weakness (68%) with 84% of patients showing neurological findings. 70% of patients showed a complete relief of symptoms after surgery and 96% reported improvement. Only four complications were reported. Discussion and conclusion: Schwannomas should be considered in the differential diagnosis of intradural extramedullary cystic lesions. Patients typically present with subacute to chronic pain and/or neurologic changes. Surgical resection is the primary therapeutic modality and usually has a good to excellent outcome

28. International perspectives on the current practice of acute spinal cord injury management: results of a global survey

Translational research on the importance of secondary injury mechanisms has promoted development of management strategies for patients with acute spinal cord injuries (SCIs). These findings have been adopted in guidelines such as the 2013 AANS/CNS and the 2017 AOSpine guidelines on SCI management. However, despite these guidelines, uncertainty remains regarding optimal hemodynamic management, timing of surgical decompression and the use of steroids. The goal of this study was to examine knowledge, adoption and barriers to guideline implementation around these three key areas of SCI management. We sought to examine the current international practices of spine care professionals regarding the acute administration of steroids, hemodynamic management, and timing of surgical decompression in acute SCI. A survey was distributed to all members of AOSpine International on October 1st, 2021. The questionnaire was structured into (1) demographic data and preferred practices surrounding (2) steroid use, (3) hemodynamic management and (4) timing of surgical decompression. Data were analyzed in Stata version 16.1. A total of 593 members completed the survey including orthopaedic surgeons (54,3%, n=319), neurosurgeons (35.6%; n=209), and traumatologists (8.4%; n=49). Most [61.2% (n=352)] respondents were from low and middle-income countries (LICs and MICs) with 38.8% (n=223) from high income countries (HICs). There was a bimodal distribution with regard to the administration of steroids with 53.6% using this neuroprotective option (n=256) and 46.4% (n=222) not. Respondents from LICs and MICs were more likely to administer steroids than HICs (178 vs 78, p <.001). Interestingly, when steroids were given, AIS A patients were less likely to receive steroids (72.6%; n=185), than AIS B (82.8%; n=211) and AIS C patients (76.5%; n=195). A total of 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment in the intensive care unit or an analogous setting. Whereas 24.2% (n=51) of orthopedic surgeons would not use MAP targeted treatment at their institutions; this was the case in only 12.8% (n=20) for neurosurgeons, (p <.05). In LICs and MICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%, n=193) as compared to HICs, (89%, n=138; p < .05). The majority of respondents (87.8%) reported that patients with SCIs would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 231 (62.4%) stated they encounter logistical barriers in their institutions. This was particularly evident in LICs and MICs, where 129 respondents (57.9%) indicated that early intervention would be rather unlikely to accomplish (p < .001). This survey highlights challenges in the implementation of standardized practice regarding the use of steroids, hemodynamic management and practical use of early surgical intervention, despite clear evidence for surgeon preference to implement a “Time is Spine” approach. This work highlights the importance of continuing to refine SCI guidelines. Moreover, future research efforts will need to address barriers of guideline implementation, such as logistic hurdles in the implementation of early decompressive surgery. This abstract does not discuss or include any applicable devices or drugs

Current Practice of Acute Spinal Cord Injury Management: A Global Survey of Members from the AO Spine

Study Design: Cross-sectional, international survey. Objectives: To examine current international practices as well as knowledge, adoption, and barriers to guideline implementation for acute spinal cord injury (SCI) management. Methods: A survey was distributed to members of AO Spine. The questionnaire was structured to obtain demographic data and preferred acute SCI practices surrounding steroid use, hemodynamic management, and timing of surgical decompression. Results: 593 members completed the survey including orthopaedic surgeons (54.3%), neurosurgeons (35.6%), and traumatologists (8.4%). Most (61.2%) respondents were from low and middle-income countries (LMICs). 53.6% of physicians used steroids for the treatment of acute SCIs. Respondents from LMICs were more likely to administer steroids than HICs (178 vs. 78; P <.001). 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment. In LMICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%) as compared to HICs (89%; P <.05). The majority of respondents (87.8%) reported that patients would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 62.4% of respondents stated they encounter logistical barriers in their institutions. This was particularly evident in LMICs, where 57.9% of respondents indicated that early intervention was unlikely to be accomplished, while only 21.1% of respondents from HICs stated the same (P <.001). Conclusion: This survey highlights challenges in the implementation of standardized global practices in the management of acute SCI. Future research efforts will need to refine SCI guidelines and address barriers to guideline implementation

Trends in the Use of Corticosteroids in the Management of Acute Spinal Cord Injury in North American Clinical Trials Networks (NACTN) Sites

Immunomodulatory therapeutics represent a potential neuroprotective strategy for the management of acute spinal cord injury (SCI). One of the most intensely debated neuroprotective drugs has been methylprednisolone sodium succinate (MPSS). MPSS was initially investigated for its role in mitigating lipid peroxidation. More recently, the anti-inflammatory/immunomodulatory properties of MPSS have been increasingly appreciated. Over the past two decades, several systematic reviews and clinical practice guidelines related to MPSS use in SCI have been published. The goal of this study was to investigate the temporal changes in the use of steroids at North American Clinical Trials Network (NACTN) centers and to correlate these with the evolution in published literature and guidelines. Data on patients enrolled from 2008 - 2018 in the prospective, multicenter NACTN registry, and in whom information related to the use of steroids was available, were analyzed. Patients were stratified as to whether they received steroids or not. The primary outcome was the change in the rate of steroid use per year between 2008 and 2018. Secondary outcomes included cardiac, gastrointestinal & genitourinary (GIGU), pulmonary and dermatologic complications. We identified 608 patients, of whom 171 (28.1%) were given steroids. In 2008 and 2009, the prevailing paradigm across NACTN centers was in favor of steroid administration and as such 70% (n=56) of patients received steroids in 2008 and 71.9% (n=46) in 2009. An abrupt practice reversal was observed in 2010, whereby only 19.7% of patients (n=14) received steroids, a trend that continued over subsequent years. Increasing literature in the 2000s arguing against the use of steroids culminated in the 2013 CNS/AANS practice guidelines for the management of acute SCI. These guidelines recommended against the use of MPSS for the treatment of acute SCI. Over the following years (2013-2018), steroids continued to be an uncommonly used therapeutic option in NACTN centers (range 3.9-16.9%). Patients receiving steroids had significantly higher rates of pulmonary complications (87%, n=147) compared to those not receiving steroids (73%, n=265; p=0.0003). However, compared to patients receiving steroids, those who did not receive steroids had significantly higher rates of cardiac (40%, [n=146] versus 23%, [n=39]; p=0.0001) and gastrointestinal/genitourinary complications (55%, [n=189], versus 31%, [n=52]; p<0.0001). The 2013 AANS/CNS guidelines and preceding literature appeared to have an impact on dramatically lowering the rates of corticosteroid use for acute SCI in NACTN sites after 2009. Of note, this analysis may not reflect the impact of the 2017 AO Spine Clinical Practice guidelines, which suggested the use of methylprednisolone as a valid practice option for acute SCI, especially for cervical injuries. Enhanced patient involvement in the clinical decision-making process and opportunities to personalize SCI management exist in reference to the use of MPSS in acute SCI

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

STUDY DESIGN: Scoping Review. OBJECTIVE: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular &amp; Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae