Allen H. Maniker

Hemorrhagic complications of external ventricular drainage.

OBJECTIVE: Despite the widespread use of external ventricular drainage (EVD), the frequency of associated hemorrhagic complications remains unclear. This retrospective study examined the frequency of hemorrhagic complications of EVD and attempted to discern associated risk factors. METHODS: Treatment records from 160 patients admitted during a 2.5-year period who required EVD placement were reviewed. Indications for placement of EVD included acute complications of cerebrovascular disease (n = 94), traumatic brain injury (n = 36), primary hydrocephalus (n = 16), and tumor (n = 14). Patients received either a 3.0 or 2.5-mm outer diameter ventricular catheter (n = 82 and 78, respectively). Postinsertion computed tomographic scans were obtained within 24 hours on all patients and were analyzed for any new hemorrhage related to the ventricular catheter. Patient age, sex, catheter type, and dimensions of hemorrhage were also analyzed. RESULTS: The incidence of EVD-related hemorrhage was 33 ± 0.04%. However, the incidence of detectable change in the clinical neurological examination was 2.5%. A significant proportion of EVD-related hemorrhages were small (<4 cm3), punctate, intraparenchymal hematomas. Patients with cerebrovascular disease exhibited an increased incidence (39%) of hemorrhage. The mean volume of intraparenchymal hemorrhage was larger in patients who received the 2.5-mm ventricular catheter, as well as those admitted for cerebrovascular disease. CONCLUSION: Hemorrhagic complications of EVD placement are more common than previously suspected. Admitting diagnosis seems to have an effect on the development of an associated hemorrhage and its size. Catheter gauge has an effect on hematoma volume. Most of the hemorrhages seen on postinsertion computed tomographic scans do not cause detectable changes in the clinical examination.

Candidal Pituitary Abscess: Case Report

We report a case of a culture-proven intrasellar Candida albicans abscess. A 36-year-old woman presented with a history of headaches, menstrual irregularities, and mild symptoms of diabetes insipidus. She was neurologically intact at the time of a transsphenoidal surgery for a presumed pituitary adenoma. An extensive work-up revealed that although the patient was seronegative for human immunodeficiency virus, she was immunocompromised with a T-cell dysfunction. Fungal abscesses of the pituitary gland have rarely been reported. This is the first documented case of a patient who is seronegative for human immunodeficiency virus who becomes infected by an ordinarily innocuous fungus, Candida albicans.

Candidal Pituitary Abscess

We report a case of a culture-proven intrasellar Candida albicans abscess. A 36-year-old woman presented with a history of headaches, menstrual irregularities, and mild symptoms of diabetes insipidus. She was neurologically intact at the time of a transsphenoidal surgery for a presumed pituitary adenoma. An extensive work-up revealed that although the patient was seronegative for human immunodeficiency virus, she was immunocompromised with a T-cell dysfunction. Fungal abscesses of the pituitary gland have rarely been reported. This is the first documented case of a patient who is seronegative for human immunodeficiency virus who becomes infected by an ordinarily innocuous fungus, Candida albicans.

Failure of hydroxyapatite cement to set in repair of a cranial defect: case report.

OBJECTIVE AND IMPORTANCE Hydroxyapatite cement, a new biomaterial that is being marketed as a method for reconstructing cranial defects, offers many advantages. We document, herein, the complete dissolution and failure of this material to set in a surgically dry field, under optimal conditions, an occurrence that has not been previously reported. CLINICAL PRESENTATION Hydroxyapatite cement was used for reconstruction of a frontal bone defect secondary to a traumatic depressed cranial fracture in a 9-year-old male patient. At the time of suture removal on postoperative Day 6, we observed serous discharge from the wound, a reappearance of the cranial defect, and brain pulsations visible subcutaneously. INTERVENTION The patient was returned to the operating room, at which time we learned that the hydroxyapatite cement had migrated out of the defect; small concretions of the cement were scattered throughout the subgaleal space. The concretions of cement in the subgaleal space and the small amount of cement remaining in the defect were removed, and titanium mesh was used. An excellent cosmetic result was achieved. CONCLUSION Although offering many advantages, hydroxyapatite cement does carry a risk of failure to set, despite optimal technique. Causes for failure to set, as well as possible modifications in the use of material and technique, are discussed.

Cerebral aneurysm in the HIV patient: A report of six cases

BACKGROUND In view of the almost certain mortality of the acquired immune deficiency syndrome (AIDS) patient, controversy may arise as to how to treat those individuals with concomitant aneurysmal disease. METHODS We conducted a retrospective case review of six patients seen in a 1-year period, who had a history of either being positive for human immunodeficiency virus (HIV) or prior opportunistic pneumonias and who, therefore, by Centers for Disease Control definition, have frank AIDS. The patients, who were in otherwise stable health, presented with subarachnoid hemorrhage from angiographically demonstrated ruptured berry aneurysms. RESULTS There was no increased incidence of postoperative infections and the quality of life of the surviving five patients was quite good. CONCLUSIONS In a patient in stable health, the diagnosis of HIV infection should not necessarily preclude the established regimen for the treatment of aneurysmal disease.

MRI-documented regression of a herniated cervical nucleus pulposus: A case report

Abstract An MRI-documented case of regression of a herniated cervical nucleus pulposus in a neurologically intact patient is presented.

Failure of Hydroxyapatite Cement Set in Repair of a Cranial Defect: Case Report

OBJECTIVE AND IMPORTANCE: Hydroxyapatite cement, a new biomaterial that is being marketed as a method for reconstructing cranial defects, offers many advantages. We document, herein, the complete dissolution and failure of this material to set in a surgically dry field, under optimal conditions, an occurrence that has not been previously reported. CLINICAL PRESENTATION: Hydroxyapatite cement was used for reconstruction of a frontal bone defect secondary to a traumatic depressed cranial fracture in a 9-year-old male patient. At the time of suture removal on postoperative Day 6, we observed serous discharge from the wound, a reappearance of the cranial defect, and brain pulsations visible subcutaneously. INTERVENTION: The patient was returned to the operating room, at which time we learned that the hydroxyapatite cement had migrated out of the defect; small concretions of the cement were scattered throughout the subgaleal space. The concretions of cement in the subgaleal space and the small amount of cement remaining in the defect were removed, and titanium mesh was used. An excellent cosmetic result was achieved. CONCLUSION: Although offering many advantages, hydroxyapatite cement does carry a risk of failure to set, despite optimal technique. Causes for failure to set, as well as possible modifications in the use of material and technique, are discussed.

Rapid recurrence of craniopharyngioma during pregnancy with recovery of vision: A case report

Although enlargement of pituitary adenomas during pregnancy is a well documented phenomenon, this is rarely seen with craniopharyngiomas. Discussed here is the case of a patient whose initial presentation, operation, rapid regrowth, and reoperation of a pathologically proven solid craniopharyngioma, occurred during the course of a single pregnancy. Further, the rapid regrowth of the tumor resulted in total blindness for 48 hours prior to reoperation. Repeat transsphenoidal operation resulted in a gross total removal, restoration of vision, and allowed for the cesarean section delivery of a healthy infant.

The use of Hypertonic Saline in the Treatment of Post-Traumatic Cerebral Edema: A Review

Effective methods for treating cerebral edema have recently become a matter of both extensive research and significant debate within the neurosurgery and trauma surgery communities. The pathophysiologic progression and outcome of different forms of cerebral edema associated with traumatic brain injury have yet to be fully elucidated. There are heterogeneous factors influencing the onset and progress of post-traumatic cerebral edema, including the magnitude and type of head injury, age, co-morbid conditions of the patient, the critical window for therapeutic intervention and the presence of secondary insults including hypoxia, hypotension, hypo/hyperthermia, degree of raised intracranial pressure (ICP), and disruption of blood brain barrier (BBB) integrity. Although numerous studies have been designed to improve our understanding of the etiology of post-traumatic cerebral edema, therapeutic interventions have traditionally been focused on minimizing secondary insults especially raised ICP and improving cerebral perfusion pressure. More recently, fluid resuscitation strategies using hyperosmolar agents such as pentastarch and hypertonic saline (HS) have achieved some success. HS treatment is of particular interest due to its apparent advantageous action over other types of hyper-osmotic solutions in both clinical and laboratory studies. In this review, we provide a summary of recent literature concerning the pathogenesis and mechanisms involved in the various types of cerebral edema, and the possible mechanisms of action of HS for the treatment cerebral edema.

Acute posttraumatic pituitary gland hemorrhage.

We report the first case of CT and MRI of acute posttraumatic hemorrhage into a normal pituitary gland. The patient, a 24-year-old man, was admitted to our institution following an assault. There was a brief loss of consciousness, and he complained of headaches and dizziness. The patient denied any pertinent medical history. Physical examination revealed a right frontal abrasion and periorbital ecchymosis. Neurological and neuroophthalmological evaluations were normal. The Glasgow Coma Scale score was 15. A CT scan at the time of admission revealed a hyperdensity in the pituitary gland consistent with an acute bleed (Fig. 1). There were no other abnormalities. An MR scan obtained within 24 h confirmed the presence of an acute hemorrhage in the pituitary gland. On the T1weighted images, the signal of the area of the bleed was isointense (Fig. 2) and on the T2-weighted MR images markedly hypointense as compared with the normal adenohypophysis (Fig. 3). The postcontrast (0.01 mmol/kg Gd-DTPA) MR image did not demonstrate the presence of a pituitary tumor. Follow-up endocrine profile, including prolactin, somatotropic (growth) hormone, thyroidstimulating hormone, T4, and adrenocorticotropic hormone, was within normal limits.