Essam A. Elgamal

Efficacy and Safety of Prophylactic Large Dose of Tranexamic Acid in Spine Surgery: A Prospective, Randomized, Double-blind, Placebo-controlled Study

Study Design. This is a double blind randomized placebo controlled study, after obtaining approval of ethics committee in the hospital and informed written consent, 64 patients were randomized equally into 2 groups (tranexamic acid (TA) and placebo). Objective. To evaluate efficacy and safety of large doses of TA on blood loss during spinal operations. Summary of Background Data. Blood loss associated with spinal operations is a common potential cause of morbidity and often requires blood transfusion which subject patients to the known risks of blood transfusion including transmission of diseases. TA is used routinely to reduce bleeding in cardiac, orthopaedic, and hepatic surgery, however, its use in neurosurgery is uncommon and only few studies reported the use of antifibrinolytic drugs in spine surgery. Methods. Sixty-four consecutive patients undergoing spinal surgery with expected significant blood loss at King Khalid University Hospital between June 2005 and December 2006 were randomly assigned to 2 groups, TA and placebo. Shortly after the induction of anesthesia, patients received either TA or placebo as a loading dose of 2 g (for adults) or 30 mg/kg (for children), followed immediately by continuous infusion of 100 mg/h (for adults) or 1 mg/kg/h (for children) during surgery and for 5 hours after the operation. Outcome measures included total (i.e., intraoperative and postoperative) blood loss, amount of blood transfusion, as well as postoperative hemoglobin, and hematocrite levels. The data were analyzed by means of Statistical Package for the Social Science Version 12.0. The results were presented as mean ± SD. Independent Student t test was used to compare the 2 groups and differences were considered significant if the P-value was <0.05. Results. There were 39 males and 25 females, ranging in age from 4 to 86 years with a mean of 51 and median of 56 years. Eighteen patients had multilevel anterior cervical discectomies with or without internal fixation, 22 patients had decompressive surgery (12 laminectomies and 10 intersegmental decompressions) for multiseg- ment spinal stenosis, 15 patients had laminectomy with posterior spinal fixation, and remaining 9 patients had laminectomy and excision of spinal tumor. Statistical analysis showed no significant differences between the 2 study groups with regard to age, sex, weight, preoperative hemoglobin, and hematocrite levels, type of surgery, as well as operative time. In contrast, patients who received TA had 49% reduction of blood loss (P < 0.007) and required 80% less blood transfusion (P < 0.008) than patients who received placebo. The hospital stay was shorter in the TA group, but it did not achieve statistical significance. There were no complications related to the use of large doses of TA in this study. Conclusions. Prophylactic use of large doses of TA provides an effective, safe, and cheap method for reducing blood loss during and after spinal operations. Hence, TAmay help in reducing not only transfusion related complications but also operative expenses. Considering the limited number of patients in this study, our results need, however, to be validated on a larger number of patients, probably in a multicenter study.

Hemifacial spasm caused by pontine glioma : case report and review of the literature

Hemifacial spasm (HFS) is an involuntary paroxysmal contractions of the facial musculature, caused generally by vascular compression of the seventh cranial nerve at its root exit zone from the brain stem. The case of an adult man harbouring brain stem glioma (BSG) whose only neurological signs were left HFS and mild facial weakness is reported. Radiological and neurophysiological findings are described. No responsible vessel could be identified during surgery, but the causative lesion was found to be an astrocytic tumour encasing the facial nerve at its root exit zone from the brain stem. The rarity of such a condition prompted us to review the literature. Nine cases, including our patient presenting with HFS caused by BSG, are reviewed.

Aneurysmal subarachnoid hemorrhage in the first year of life: case report and review of the literature

IntroductionPrimary subarachnoid hemorrhage is rare in infancy. A bleeding arterial aneurysm as its cause is even less frequent. A review of the literature turned up 85 cases of cerebral aneurysm that occurred in the 1st year of life, 63 of them presenting with subarachnoid hemorrhage (SAH).Case reportThe authors report a case of an 8-month-old boy who presented with seizures due to ruptured anterior communicating (ACom) artery aneurysm with subsequent subarachnoid and intraventricular hemorrhage. The infant was operated successfully, without complications.DiscussionIn this report the authors highlight certain clinical and diagnostic features, surgical considerations, and outcomes of aneurysmal subarachnoid hemorrhage in the 1st year of life.

Fatal Haemorrhage in Medulloblastoma following Ventricular Drainage

Haemorrhage in medulloblastoma is reported to be very rare. The authors report a case of a 13-year-old boy who presented with headache, unsteadiness, diplopia and papilloedema due to posterior fossa medulloblastoma causing obstructive hydrocephalus. Six hours following placement of an external ventricular drain, he suddenly became comatose with respiratory arrest. The cause was marked upward herniation of the anterior vermis and downward herniation of the cerebellar tonsils due to massive spontaneous intratumoural haemorrhage extended into the ventricular system. This atypical clinical course of fatal haemorrhage in medulloblastoma after insertion of external ventricular drainage is reported and the literature discussed.

Nocardia brain abscess: severe CNS infection that needs aggressive management; case report

SummaryNocardia brain abscess is a rare central nervous system (CNS) infection that carries a high mortality rate reaching 34% which is considered the highest amongst brain abscesses caused by microorganisms. All available literature is in the form of retrospective studies and small case series. In this case report the authors present a patient whose course of disease was stormy and required multiple neurosurgical procedures. The clinical outcome, long-term follow up and a review of the literature is discussed.

Sudden death in children due to intracranial mass lesion

Study objectiveIntracranial causes of sudden and unexpected death in children are uncommon and are usually due to trauma, epilepsy or to catastrophic haemorrhage associated with neoplasms or vascular malformations. We sought to review the presenting symptoms and signs of intracranial mass lesions that led to sudden death to guide clinicians in early identification of these potentially treatable conditions.MethodsAll cases of sudden unexpected death attributed to intracranial mass lesion that occurred from 1996 to 2002 at the Oxford Radcliffe Hospitals, NHS Trust, were reviewed.ResultsDuring the study period, six children, aged between 10 weeks and 12 years, died suddenly with intracranial mass lesions other than haematomas. All of them were unsuspected of having a neurological disease prior to death. All patients were found to have an intracranial mass lesion. There were colloid cyst (n=2), glioblastoma multiform (n=1), primitive neuro-ectodermal tumour (n=1), pyogenic abscess (n=1) and histologically unverified tumour (n=1). Presenting features included headache and vomiting in four cases, vomiting longer than 1 week in three and lethargy in four cases. Three patients were misdiagnosed with viral illness.ConclusionThe case series highlights a life-threatening but misleading presentation of intracranial mass lesions. The diagnosis of viral illness should be made cautiously when headache and vomiting occur in the absence of focal complaints. A history of vomiting exceeding a few days duration warrants further investigation. Persistent lethargy should be considered a neurological rather than a non-specific clinical sign.

Complete recovery of severe quadriparesis caused by stab wound at the craniocervical junction

Non-missile penetrating spinal cord injuries are uncommon, and involvement of the craniocervical junction is even less frequent. The author reports a case of 42-year-old male who presented with quadriparesis immediately following stab injury inflicted with a kitchen knife to the back of his neck. The knife was retained in the patient’s neck. Neurological examination revealed spastic paraplegia and severe weakness of the left upper limb and the right-hand grip, and sensory disturbance from C2 and downwards. In addition to these symptoms, cerebrospinal fluid (CSF) was leaking from the wound. Computerised tomography (CT) scan showed the blade passed through the spinal canal and its tip reached the odontoid peg. After retrieval of the knife, his quadriparesis recovered. The management and outcome of the patient are described.

Large primary leiomyoma causing progressive cervical deformity

Leiomyomas are benign smooth tumors that rarely affect the neck area. Complete surgical resection is the treatment of choice. Here, we describe a 13-year-old girl with a large leiomyoma of the neck, which increased in size after incomplete resection. The tumor caused progressive cervical kyphotic deformity, difficulty breathing and severe malnourishment. The tumor was resected successfully in a second surgery, and the patient is stable after 3 years of follow-up. Histopathologically, the tumor was consistent with leiomyoma and showed strong reactivity to specific smooth muscle markers, such as desmin and caldesmon. This is the second reported case demonstrating massive growth of a leiomyoma, with emphasis on complete resection from the beginning.

Aneurysmal subarachnoid haemorrhage in the first year of life

Dear Editor: In response to Dr. Tekkök’s letter commenting on our published article [1], I would first like to thank him for drawing the attention of the readers to his landmark article published in 1997 [2]. Honestly, for some reason or another, his article was missed from my reference list. I came across his article and read it with great interest, but unfortunately during the writing up of the manuscript, it was missed. I deeply apologize for that and I thank him again for sparing some of his valuable time to comment on our article and for bringing it to the readers’ attention. References

Cerebrospinal fluid hydrothorax, an unusual complication of ventriculoperitoneal shunt

Cerebrospinal fluid (CSF) hydrothorax is a very rare complication following ventriculoperitoneal (VP) shunt. We report a 14-month-old boy, who was diagnosed to have open neural tube defect associated with ventriculomegaly. He underwent VP shunt at the age of 1 months. He presented with high-grade fever, shortness of breath, tachypnea, wheezy chest, and productive cough. Plain chest X-ray and computerized tomography revealed pleural effusion with distal catheter of the shunt located in the right pleural cavity. He underwent externalization of the distal catheter followed by VP shunt revision. In the present case, CSF hydrothorax resulted from migration of the distal catheter into the pleural cavity. We reviewed 17 hitherto reported cases in the literature and the causes that lead to CSF hydrothorax are discussed. We emphasize the importance of careful and proper placement of the distal catheter during the tunneling procedure to prevent life-threatening complications.