Gregorio R. Boto

Penetrating brain injury by drill bit

Non-missile low velocity penetrating brain injuries are unusual among civilian population. They show specific characteristics different from missile wounds. In this paper we describe a rare case of self-inflicted penetrating head trauma by electric drill. We document neuroimaging studies and review the management concerning this pathology. To our knowledge, this is the first case of intracranial retained drill bit with such radiological findings reported in the literature. An 80-year-old male with no previous psychiatric disorder presented at our hospital after suffering an accident while working with an electric drill. Physical examination revealed right lower extremity plegia and three penetrating scalp wounds to the left parasagittal region. Skull X-ray and computed tomography demonstrated an intracranial metallic foreign body located in the left parietal lobe and an intraparenchymal hematoma with no mass effect close to the foreign body. The patient was taken to the operating room to remove the drill bit fragment. Antibiotic and antiseizure prophylaxis were administered. Postoperative computed tomography confirmed no residual metallic fragments and functional recovery was excellent. After psychiatric assessment, suicide attempt was confirmed and antidepressive therapy was then started. On follow-up, no complication was documented. It is essential to exclude penetrating brain trauma whenever a scalp wound is noticed in order to provide proper treatment and prevention care. The permanent neurological deficit in low velocity injuries is related to the degree and location of the primary injury. It also depends on an early diagnosis and treatment and the absence of delayed complications.

Do antibiotic-impregnated catheters prevent infection in CSF diversion procedures? Review of the literature

SUMMARY Cerebrospinal fluid shunting devices are foreign bodies internally or externally placed in a patient with the aim of improving the prognosis. Device-related infection is the most serious complication. Its importance arises from the high frequency of occurrence and the consequences that it implies in terms of morbidity and mortality. As a result, the presence of these two factors increases significantly hospital costs. Among many primary prevention measures investigated, one of those that has gained in importance over the last years is the use of antibiotic-impregnated catheters. Although their experimental development dates back to the 1970s, experience in clinical practice has not been settled until the last decade. This is the reason why only 22 studies on the usefulness of AICs in CSF shunting procedures in clinical practice have been published in the literature since their commercialization. Although experience with antibiotic-impregnated shunts continues growing, practice with antibiotic-impregnated external ventricular drains is much shorter. The present study reviews and analyses the different investigations performed in order to determine the efficacy of antibiotic-impregnated shunts and external ventricular drains with the aim of reducing device-related infectious complications. The results suggest that AICs reduce device-related infection as well as hospital costs. However, evidence is not enough to state categorical conclusions, and further large, prospective, randomized and double-blind studies must be performed in order to confirm these results and the efficacy of other antibiotic-impregnated devices. Further economic evaluation is required to confirm the benefit in terms of cost-effectiveness as well.

Protective effect of rifampicin and clindamycin impregnated devices against Staphylococcus spp. infection after cerebrospinal fluid diversion procedures

BackgroundInfection is a major complication of cerebrospinal fluid shunting procedures. The present report assesses the efficacy of such catheters in both shunts and external ventricular drains (EVDs) against infection and particularly against Staphylococcus spp. infection.MethodsAll shunt and EVD procedures performed by means of antibiotic-impregnated catheters (AICs) and non-AICs during the period of study were registered. In cases of shunt procedures, a minimal follow-up of 90 days was considered, as well as de novo insertion and catheter revisions. Single valve revisions were not included. In cases of EVD procedures, those catheters removed before the fifth post-insertion day were not included. A total of 119 cerebrospinal fluid shunting procedures performed with AICs were studied in comparison with 112 procedures performed by means of non-AICs.ResultsAntibiotic-impregnated catheters were associated with a significant decrease in both overall and staphylococcal infection (p = 0.030 and p = 0.045, respectively). The number needed to treat for AICs was 8 to prevent one infection and 14 to prevent one staphylococcal infection. When comparing with shunts, the use of EVDs was associated with a 37-fold increased likelihood of infection.ConclusionsAntibiotic-impregnated catheters are a safe and helpful tool to reduce CSF shunting device-related infections.

Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo

Fundamento y objetivo: La infeccion es una de las principales complicaciones asociadas a la colocacion de sistemas de derivacion de liquido cefalorraquideo (LCR). La utilizacion de cateteres impregnados con antibiotico (IA) parece disminuir la tasa de infeccion posquirurgica en la practica clinica. El objetivo de este trabajo ha sido determinar si el uso de sistemas IA reduce el riesgo de infeccion posquirurgica por Staphylococcus spp., principal agente de infeccion. Pacientes y metodo: Se identifico retrospectivamente a todos los pacientes a quienes se habian implantado cateteres impregnados con rifampicina y clindamicina en nuestro centro, incluidos cateteres externos (desde enero de 2006 hasta enero de 2007) y sistemas de derivacion interna (desde enero de 2004 hasta enero de 2007), y a aquellos a quienes se habian implantado cateteres externos y sistemas de derivacion interna sin IA durante los mismos periodos de tiempo. Mediante la prueba de la x2 se analizo y comparo el porcentaje de infeccion global, por Staphylococcus spp. y por bacilos gramnegativos en ambas cohortes. Resultados: Se registraron 65 procedimientos con cateteres IA y 66 procedimientos con cateteres no impregnados. Tanto el porcentaje de infeccion global como el porcentaje de infeccion por Staphylococcus spp. fueron significativamente menores en el grupo con cateteres IA (p = 0,046 y p = 0,029, respectivamente), sin que se observara un aumento significativo de las infecciones por bacilos gramnegativos. Conclusiones: El uso de sistemas de derivacion de LCR impregnados con rifampicina y clindamicina parece una herramienta util para reducir la aparicion de complicaciones infecciosas posquirurgicas por Staphylococcus spp. Deben llevarse a cabo estudios prospectivos, aleatorizados y doble ciego para confirmar estos resultados.

Normal perfusion pressure breakthrough phenomenon: what still remains unknown

Abstract We report two cases of normal perfusion pressure breakthrough phenomenon after total brain arteriovenous malformation removal. Hereby, we demonstrate that not only autoregulation impairment in the ipsilateral hemisphere occurs but also contralateral remote vessels response does. Such findings may be observed at 2–4 weeks and may resolve after 1–3 months.

Retropharyngeal pseudomeningocele formation as a traumatic atlanto-occipital dislocation complication: case report and review

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation is a rare complication, with only five cases described in the literature. It develops when a traumatic dural tear occurs allowing cerebrospinal fluid outflow, and it often appears associated with hydrocephalus. We present a case of a 29-year-old female who suffered a motor vehicle accident causing severe brain trauma and spinal cord injury. At hospital arrival the patient scored three points in the Glasgow Coma Scale. Admission computed tomography of the head and neck demonstrated subarachnoid hemorrhage and atlanto-occipital dislocation. Three weeks later, when impossibility to disconnect her from mechanical ventilation was noticed, a magnetic resonance imaging of the neck showed a large retropharyngeal pseudomeningocele. No radiological evidence of hydrocephalus was documented. Given the poor neurological status of the patient, with spastic quadriplegia and disability to breathe spontaneously due to bulbar-medullar injury, no invasive measure was performed to treat the pseudomeningocele. Retropharyngeal pseudomeningocele after atlanto-occipital dislocation should be managed by means of radiological brain study in order to assess for the presence of hydrocephalus, since these two pathologies often appear associated. If allowed by neurological condition of the patient, shunting procedures such as ventriculo-peritoneal or lumbo-peritoneal shunt placement may be helpful for the treatment of the pseudomeningocele, regardless of craniocervical junction management.

Dural cavernous haem angioma of the anterior cranial fossa

Extra-axial cavernous haem angiomas are uncommon lesions histologically identical to cavernomas in other locations. However, their radiological features and clinical behaviour may differ. They are frequently misdiagnosed preoperatively, as they often mimic other tumours. We describe a patient suffering from loss of the sense of smell, due to a cavernous haemangioma implanted in the dura mater of the anterior cranial fossa close to the olfactory bulb. To our knowledge, this is the first patient reported with such a lesion.

OriginalFactores de riesgo de infección en procedimientos de derivación de líquido cefalorraquídeoRisk factors for cerebrospinal fluid shunt infection

BACKGROUND AND OBJECTIVE Shunt-related infection is a major complication. The effort to face up to this problem has focused on therapy, analysis of risk factors and primary prevention. The aim of this study is to identify risk factors for cerebrospinal fluid shunt infection. MATERIAL AND METHOD We retrospectively reviewed all patients who underwent shunt placement at our hospital during the period of study. Procedures followed for less than 90 days were excluded. One hundred and nineteen procedures were included in the final analysis. RESULTS Infection rate per procedure was 8.4%. Previous cerebrospinal fluid infection, previous shunt and complete substitution of the shunt were identified as risk factors for infection in the univariate analysis. However, a multivariate analysis confirmed that previous cerebrospinal fluid infection was the only independent risk factor for shunt-related infection (p=0.011). CONCLUSION Previous cerebrospinal fluid infection is an independent risk factor for shunt-related infection. Other factors such as age, gender, etiology of hydrocephalus, previous shunt or complete substitution of the shunt were not associated with increased risk of infection.

Factores de riesgo de infección en procedimientos de derivación de líquido cefalorraquídeo

BACKGROUND AND OBJECTIVE Shunt-related infection is a major complication. The effort to face up to this problem has focused on therapy, analysis of risk factors and primary prevention. The aim of this study is to identify risk factors for cerebrospinal fluid shunt infection. MATERIAL AND METHOD We retrospectively reviewed all patients who underwent shunt placement at our hospital during the period of study. Procedures followed for less than 90 days were excluded. One hundred and nineteen procedures were included in the final analysis. RESULTS Infection rate per procedure was 8.4%. Previous cerebrospinal fluid infection, previous shunt and complete substitution of the shunt were identified as risk factors for infection in the univariate analysis. However, a multivariate analysis confirmed that previous cerebrospinal fluid infection was the only independent risk factor for shunt-related infection (p=0.011). CONCLUSION Previous cerebrospinal fluid infection is an independent risk factor for shunt-related infection. Other factors such as age, gender, etiology of hydrocephalus, previous shunt or complete substitution of the shunt were not associated with increased risk of infection.

Spinal cord and brain glioblastoma multiforme without previous craniotomy

The frequency of symptomatic spinal cord metastases from brain glioblastoma multiforme (GBM) is between 1.3 and 8.8%. In almost all cases, there has been a history of surgical manipulation or radiation therapy that might have altered the blood‐brain barrier and introduced tumor cells through the cerebrospinal fluid pathways. The interval between the intracerebral GBM and its intramedullary metastasis is 12‐14 months and the mean survival time, under this condition, never exceeds 6 months.2‐4 However, in the absence of previous surgery or radiotherapy, it is difficult to distinguish between true metastasic from multicentric central nervous system GBM, as occurred in our case. 1‐4 A 52-year-old woman presented with a 2-month history of cervical pain and numbness in the left upper extremity; she was admitted with progressive paraparesis and acute urinary retention. Cervical magnetic resonance (MR) imaging demonstrated an intramedullary C4‐6 mass, which enhanced after Gd injection (Fig. 1). The tumor was resected after cervical laminectomy. Histopathological examination revealed that the lesion was a GBM. Considering this diagnosis, we performed brain MR imaging 1 week after the spinal cord surgery and discovered an enhancing mass, 2 cm in diameter, located in the right atrium (Fig. 2). Twenty days after the initial surgery, the intracerebral lesion was resected and its histopathological features were also consistent with a GBM.