Tumor or Hematoma?: An Unusual Case of an Extradural Lesion of the Lumbar Spine

Purpose: Spinal epidural hematoma is a rare clinical entity. We present a case of atypical contrast enhancement pattern in a chronic epidural hematoma of the lumbar spine mimicking an extradural tumor. Case Report: A 76-year-old man on treatment with oral anticoagulants presented with a 1-month history of lower back pain radiating into his right upper thigh accompanied by spinal claudication. Preoperative MRI showed a posterior epidural lesion compressing the cauda equina with almost homogeneous contrast enhancement. Surgery was performed under the presumptive diagnosis of spinal extradural neoplasm. Intraoperative and histological findings were consistent with a chronic spinal epidural hematoma. Postoperatively, the patient had instant relief of his symptoms. Conclusion: Chronic spinal epidural hematoma may resemble an extradural tumor, requiring surgery for histological confirmation and decompressio

Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score.

BACKGROUND: The Barrow Neurological Institute (BNI) score, measuring maximal thickness of aneurysmal subarachnoid hemorrhage (aSAH), has previously shown to predict symptomatic cerebral vasospasms (CVSs), delayed cerebral ischemia (DCI), and functional outcome. OBJECTIVE: To validate the BNI score for prediction of above-mentioned variables and cerebral infarct and evaluate its improvement by integrating further variables which are available within the first 24 h after hemorrhage. METHODS: We included patients from a single center. The BNI score for prediction of CVS, DCI, infarct, and functional outcome was validated in our cohort using measurements of calibration and discrimination (area under the curve [AUC]). We improved it by adding additional variables, creating a novel risk score (measure by the dichotomized Glasgow Outcome Scale) and validated it in a small independent cohort. RESULTS: Of 646 patients, 41.5% developed symptomatic CVS, 22.9% DCI, 23.5% cerebral infarct, and 29% had an unfavorable outcome. The BNI score was associated with all outcome measurements. We improved functional outcome prediction accuracy by including age, BNI score, World Federation of Neurologic Surgeons, rebleeding, clipping, and hydrocephalus (AUC 0.84, 95% CI 0.8-0.87). Based on this model we created a risk score (HATCH-Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus), ranging 0 to 13 points. We validated it in a small independent cohort. The validated score demonstrated very good discriminative ability (AUC 0.84 [95% CI 0.72-0.96]). CONCLUSION: We developed the HATCH score, which is a moderate predictor of DCI, but excellent predictor of functional outcome at 1 yr after aSAH

Neoplastic Meningitis: How MRI and CSF Cytology Are Influenced by CSF Cell Count and Tumor Type

Background. Although CSF cytology and MRI are standard methods to diagnose neoplastic meningitis (NM), this complication of neoplastic disease remains difficult to detect. We therefore reevaluated the sensitivity of gadolinium (GD)-enhanced MRI and cerebrospinal-fluid (CSF)-cytology and the relevance of tumor type and CSF cell count. Methods. We retrospectively identified 111 cases of NM diagnosed in our CSF laboratory since 1990 with complete documentation of both MRI and CSF cytology. 37 had haematological and 74 solid neoplasms. CSF cell counts were increased in 74 and normal in 37 patients. Results. In hematological neoplasms, MRI was positive in 49% and CSF cytology in 97%. In solid tumors, the sensitivity of MRI was 80% and of cytology 78%. With normal CSF cell counts, MRI was positive in 59% (50% hematological, 72% solid malignancies) and CSF cytology in 76% (92% in hematological, 68% in solid neoplasms). In cases of elevated cell counts, the sensitivity of MRI was 72% (50% for hematological, 83% for solid malignancies) and of CSF cytology 91% (100% for haematological and 85% for solid neoplasms). 91% of cytologically positive cases were diagnosed at first and another 7% at second lumbar puncture. Routine protein analyses had a low sensitivity in detecting NM. Conclusions. The high overall sensitivity of MRI was only confirmed for NM from solid tumors and for elevated CSF cell counts. With normal cell counts and haematological neoplasms, CSF-cytology was superior to MRI. None of the analysed routine CSF proteins had an acceptable sensitivity and specificity in detecting leptomeningeal disease

Sexual and urinary function following anterior lumbar surgery in females

AIMS Anterior lumbar interbody fusion procedures (ALIF) and total disc replacement (TDR) with anterior exposure of the lumbar spine entail a risk of a vascular injury and dysfunction of the sympathetic and parasympathetic nerves due to disturbance of the inferior and superior hypogastric plexus. While retrograde ejaculation is a known complication of the anterior spinal approach in males, post-operative sexual as well as urinary function in females has not yet been thoroughly investigated and was hence the aim of this study. METHODS Fifteen female patients documented their sexual and urinary function preoperatively, 3 months and 6 months postoperatively, using the validated questionnaires FSFI (Female Sexual Function Index) and ICIQ (International Consultation of Incontinence Questionnaire). Randomization tests were used to statistically analyze expectation values over time (two-sided, P < 0.05). RESULTS While no statistically significant change in the total FSFI score occurred over time, a significant increase in FSFI desire score was noted between preoperative (2.95 ± 0.8) and 6 months follow-up (3.51 ± 0.6, P = 0.02). Urinary continence remained unchanged over time. CONCLUSION In summary, ALIF and lumbar TDR do not seem to negatively influence sexual and urinary function in females. In contrast, increased sexual desire was noted, likely secondary to post-surgical pain relief

Precipitation downscaling in Canadian Prairie Provinces using the LARS-WG and GLM approaches

Two stochastic precipitation simulation models, namely the Long Ashton Research Station weather generator (LARS-WG) and a Generalized Linear Model-based weather generator (GLM-WG), are evaluated for downscaling daily precipitation at four selected locations (Banff, Calgary, Saskatoon and Winnipeg) in the Canadian Prairies. These weather generators model precipitation occurrence and amount components separately. Large-scale climate variables (including mean temperature, sea level pressure and relative humidity, derived from National Centers for Environmental Prediction reanalysis data) and observed precipitation records are used to calibrate and validate GLM-WG, while only observed precipitation records are used to calibrate and validate LARS-WG. A comparison of common statistical properties (i.e. annual/monthly means, variability of daily and monthly precipitation and monthly proportion of dry days) and characteristics of drought and extreme precipitation events derived from simulated and observed daily precipitation for the calibration (1961-1990) and validation (1991-2003) periods shows that both weather generators are able to simulate most of the statistical properties of the historical precipitation records, but GLM-WG appears to perform better than LARS-WG for simulating precipitation extremes and temporal variability of drought severity indices. For developing projected changes to precipitation characteristics, a change factor approach based on Canadian Global Climate Model (CGCM) simulated current (1961-1990) and future (2071-2100) period precipitation is used for driving simulations of LARS-WG, while for driving GLM-WG simulations, large-scale predictor variables derived from CGCM current and future period outputs are used. Results of both weather generators suggest significant increases to the mean annual precipitation for the 2080s. Changes to selected return levels of annual daily precipitation extremes are found to be both location- and generator-dependent, with highly significant increases noted for Banff with LARS-WG and for both Banff and Calgary with GLM-WG. Overall, 5- and 10-yr return levels are associated with increases (with the exception of Winnipeg) while 30- and 50-yr return levels are associated with site-dependent increases or decreases. A simple precipitation-based drought severity index suggests decreases in drought severity for the 2080s. © 2013 Canadian Water Resources Association