Bradley Dengler

Pseudomyogenic hemangioendothelioma (epithelioid sarcoma-like hemangioendothelioma, fibroma-like variant of epithelioid sarcoma) of the thoracic spine.

PurposePseudomyogenic hemangioendothelioma is a soft tissue tumor found in young adults, predominantly males. The tumor has been reported in various locations in the body, including the head, neck, chest wall, abdominal wall, genital region, and extremities. Until now, there has been no indication of occurrence in the spine.MethodsA 25-year-old male presented with spinal cord compression, due to an extradural tumor involving the third and fourth thoracic vertebrae with extension into the right pleural cavity.ResultsHistopathologic examination revealed a pseudomyogenic hemangioendothelioma, also described as epithelioid sarcoma-like hemangioendothelioma, or fibroma-like variant of epithelioid sarcoma.ConclusionWe describe the first occurrence of pseudomyogenic hemangioendothelioma in the thoracic spine. According to previous reports based on other locations, the tumor has an indolent clinical course with a small risk of metastasis, therefore complete macroscopic excision is the treatment of choice. Local recurrence may occur even with complete surgical resection, requiring close follow-up; adjuvant therapy is warranted.

Incidence and morbidity of craniocervical arterial dissections in atraumatic subarachnoid hemorrhage patients who underwent aneurysmal repair

Background No studies have assessed the incidence of craniocervical arterial dissections (CCADs) and its association to mortality in hospitalized patients with a primary diagnosis of atraumatic subarachnoid hemorrhage (SAH) requiring aneurysmal repair. We hypothesize that the incidence of CCADs in these patients has increased over time as well as its association to mortality. Methods We conducted a 9 year retrospective assessment of the incidence of CCADs in patients hospitalized with a primary diagnosis of an SAH requiring repair and the effect of CCAD on mortality. Using the Nationwide Inpatient Sample (NIS), we queried records from 2003 to 2011 for an ICD-9 (International Classification of Diseases-9) code corresponding to admissions for atraumatic SAH. Demographical data, incidence of CCADs, type of aneurysmal repair, length of hospital stay, and hospital mortality were recorded. Multivariate logistical regression models were fitted to assess for the impact of CCAD on inhospital mortality and morbidity. Results During the period 2003–2011, of the NIS reported 18 260 patients who required aneurysmal SAH repair, 9737 (53.32%) underwent endovascular coiling and 8523 (46.48%) had surgical clipping. There were 131 patients in the cohort with reported CCADs: 94 (71.75%) of these patients had received endovascular coiling repair and 37 (28.25%) had undergone surgical clipping repair. Patients who underwent endovascular coiling had a higher rate of CCADs in this cohort (OR 2.94; 95% CI 2.00 to 4.31, p<0.0001). The incidence of CCADs in this population increased by an average rate of 9.4% per year (OR 1.14; 95% CI 1.06 to 1.23, p<0.0006), from 0.49% in 2003 to 1.10% in 2011. The diagnosis of CCAD added 3 and 6 more days to median length of hospitalization stay for surgical clipping and endovascular coiling, respectively. The unadjusted rate of mortality was 8.4% in the CCADs subgroup, and the presence of CCAD was not a predictor of mortality in our multivariate regression model (OR 0.68; 95% CI 0.36 to 1.27, p=0.2244). Conclusions Our study indicates an annual increase in the incidence of CCADs in patients admitted with SAH who require aneurysmal repair. More than two-thirds of these patients that developed CCADs had undergone endovascular coiling repair. A diagnosis of CCAD increased the length of hospital stay but had no statistically significant association with mortality in this patient population.

Pulmonary embolism in severe traumatic brain injury

INTRODUCTION Pulmonary emboli (PE) is a significant source of morbidity and mortality in the trauma patients. The use of chemical prophylaxis to prevent deep venous thrombosis and subsequent PE is still controversial given its risk of increased intracranial hemorrhage expansion. OBJECTIVE In the present study, we evaluated the incidence of PE in severe traumatic brain injury. METHODS Retrospective review of patients who were admitted to a Neurosurgery unit from 2011 to 2013 with severe TBI who developed PE. RESULTS 155 patients met the study criteria. The incidence of PE was 2.58%. The cohort was mainly composed of white (71.6%), male (76.77%) with the mean age of 23.03 ± 15.79. There was no statistical difference between the patients who developed PE with prophylaxis and without (p = 0.58). Hospital length of stay was significantly increased by the development of a PE (27.82 ± 21.78 vs. 61.24 ± 25.74 days, p = 0.01). CONCLUSION Our data is limited by a low incidence of PE in this cohort, but does show an increased hospital length of stay. The true incidence of PE is unknown, so large-scale population studies are urgently needed and a high index of suspicion is required for diagnosis.

Tramadol may increases the efficacy of therapeutic plasma exchange in anti-NMDAR encephalitis

• The first-line treatments of anti-NMDAR encephalitis often take several weeks to months to control debilitating symptoms.

Reabsorption of a Calcified Herniated Nucleus Pulposus in a 14-Year-Old Boy

A 14-year-old boy was referred to our clinic for evaluation of worsening neck pain, shooting left arm pain, and arm numbness. His physical exam revealed decreased strength in the left C7 segment including the triceps M3/5, internal shoulder rotation M4/5, and pronation M4/5. He had decreased sensation to pinprick in the C7 dermatome, and his left triceps reflex was absent. He had no signs of myelopathy. Magnetic resonance imaging showed a large left-sided C6-7 disc herniation with impingement of the left C7 nerve root (Figure 1). Cervical computed tomography revealed that the herniated nucleus pulposus was entirely calcified (Figure 2; available at www.jpeds. com). The patient was treated conservatively with a cervical collar and nonsteroidal anti-inflammatory drugs. His symptoms resolved after 6 weeks, and repeat imaging showed complete reabsorption of the calcified nucleus pulposus (Figure 3; available at www.jpeds.com). Calcification of the nucleus pulposus in children and adolescents is a rare disorder of unknown etiology. The peak incidence is between 6 and 10 years of age, and males are predominately affected. Patients may present with neck pain, torticollis, and limited range of motion. In rare cases,