H. Gordon Deen

Recombinant Factor VIIa for Rapid Reversal of Warfarin Anticoagulation in Acute Intracranial Hemorrhage

OBJECTIVE To assess the effects of recombinant factor VIIa (rFVIIa) on hemorrhage volume and functional outcomes in warfarin-related acute intracranial hemorrhage (ICH), which has a 30-day mortality of more than 50%. PATIENTS AND METHODS We reviewed the clinical, laboratory, and radiographic features of a consecutive series of 7 patients (median age, 87 years; 5 women) with symptomatic, nontraumatic warfarin-related acute ICH treated with intravenous rFVIIa at St. Lukes Hospital in Jacksonville, Fla, between December 2002 and September 2003. Prestroke baseline functional status was assessed with the modified Rankin Scale. Outcome was assessed with the Glasgow Outcome Scale. RESULTS The international normalized ratio decreased from a mean of 2.7 before administration of rFVIIa to 1.08 after administration of rFVIIa. The median prestroke score on the modified Rankin Scale was zero. The median presenting score on the Glasgow Coma Scale was 14 (range, 4-15). The mean time from onset to treatment was 6.2 hours. The mean initial dose of rFVIIa was 62.1 microg/kg. One patient underwent placement of an external ventricular drain, and another underwent craniotomy and hematoma evacuation. Five of the 7 patients survived and were dismissed from the hospital with severe disability (Glasgow Outcome Scale, 3); 2 patients died during hospitalization. CONCLUSIONS Intravenous bolus administration of rFVIIa can rapidly lower the international normalized ratio and appears to be safe for patients with warfarin-related ICH. Prospective controlled studies are needed to determine whether rFVIIa can prevent hematoma expansion and improve neurologic outcomes in patients with warfarin-related ICH.

Symptoms of 100 patients with electromyographically verified carpal tunnel syndrome

To determine the symptoms of carpal tunnel syndrome (CTS), screening evaluations were performed in 244 consecutive patients with sensory symptoms in the hand and unequivocal slowing of median nerve conduction at the wrist. This yielded 100 patients thought to have no explanation other than CTS for their upper limb complaints. These patients completed a hand symptom diagram (HSD) and questionnaire (HSQ) about their symptoms. CTS symptoms were most commonly reported in median and ulnar digits, followed by median digits only and a glove distribution. Unusual sensory patterns were reported by some patients. Based on the HSQ, paresthesias or pain proximal to the wrist occurred in 36.5% of hands. The usefulness of the HSD and HSQ for diagnosis was determined by asking three physicians, blinded to the diagnosis, to rate the likelihood of CTS in the patients with CTS and in 50 patients with other causes of upper extremity paresthesia. The sensitivities of the instruments ranged from 54.1% to 85.5%. Combining the HSD and HSQ ratings increased the range of sensitivities to 79.3% to 93.7%.

Leflunomide-Associated Progressive Multifocal Leukoencephalopathy

A 68-YEAR-OLD MAN had a subacute progressive decline in speech and rightsided weakness after his rheumatoidarthritis regimenwas changedfromazathioprinetoleflunomide. His primary care physician diagnosedastroke.Threemonths later, in our neurology clinic, the patient soughttreatmentfortranscorticalmotor aphasia and mild right hemiparesis, and magnetic resonance imaging (MRI) was performed (Figure 1). Results showed bilateral subcortical, asymmetrical hyperintensities, without notable mass effect, in the frontal lobes, greater on the left than the right, and in the left parietal lobe. Gadolinium images (not shown) revealed no abnormal enhancement. Cerebrospinal fluid analysis revealed 3 white blood cells, no red blood cells, a glucose level within the reference range, an elevated protein level (48 mg/dL), and no organisms. Results of a polymerase chain reaction analysis for John Cunningham (JC) virus were negative. Analysis of a brain biopsy specimen confirmed the presence of progressive multifocal leukoencephalopathy (PML) (Figure 2). The patient’s condition improved with discontinuation of leflunomide and treatment with cytosine arabinoside (2 mg/kg intravenously each day for 5 days). The patient subsequently developed focal motor seizures with secondarily generalized seizures from the left frontal hemisphere (seen on an electroencephalogram that corresponded to the site of his PML and the biopsy), which required treatment with both oral phenytoin sodium and levetiracetam for adequateprophylaxis.Fourmonthsafter a brain biopsy was performed, the patient was hospitalized for focal motor status epilepticus, worsened aphasia, and right hemiparesis requiring adjustments in his anticonvulsant medications. Results of an MRI were essentially unchanged, showing persistent left frontal white matter abnormalities and postbiopsy changes withnogadoliniumenhancement. Six months after the biopsy, he had no further seizures, and examination showed improved speech from global aphasia to transcortical motor aphasia, residual right lower facial weakness, improved right arm and leg weakness, andspastichemipareticgait requiring a cane. One year later, the patient’s strengthhad improvednearly to normal, but he still had a mild spastic hemiparesis and gait. Unfortunately, because of his severe aphasia and gait instability, he was unable to return to his previous independent level of functioning. A follow-up MRI at 1 year appeared to have identical results to those of the MRI from the 6-month follow-up visit.

Minimally Invasive Procedures for Disorders of the Lumbar Spine

In the past decade, there has been a substantial increase in interest in minimally invasive procedures in all areas of medicine, particularly for spinal disorders. Some of these techniques represent notable advances in spinal care and have major roles in the care of patients with back-related symptoms. Other techniques appear to offer no benefit and in some cases may be less effective than conventional treatments. Percutaneous lumbar diskectomy techniques hold considerable promise; however, lumbar microdiskectomy is the gold standard for surgical treatment of lumbar disk protrusion with radiculopathy. Intradiskal electrothermal therapy is emerging as a useful option for selected patients with intractable mechanical back pain whose only other option historically has been a spinal fusion. Percutaneous fusion techniques are in their infancy and may prove to be beneficial for these patients as well. Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, has become the treatment of choice for many patients with intractable back pain secondary to vertebral insufficiency fractures. Spinal injections are important for evaluating and managing spinal pain and can be extremely useful diagnostically and therapeutically. This multidisciplinary review outlines the status of these procedures and offers suggestions for their use in patient care.

Analysis of early failures after lumbar decompressive laminectomy for spinal stenosis

OBJECTIVE To determine why some patients have no improvement after surgical treatment of lumbar spinal stenosis. DESIGN We conducted a retrospective study of patients who were referred to our institution between 1990 and 1993 because their symptoms were unchanged or worsened after lumbar decompressive laminectomy. MATERIAL AND METHODS For the 45 study patients (25 women and 20 men; mean age, 70.8 years), preoperative and postoperative clinical status, preoperative and postoperative imaging studies, and operative reports were analyzed. RESULTS Preoperatively, only 23 patients (51%) had the clinical syndrome of neurogenic claudication, and 15 (33%) had midline low-back pain without a radicular component. Three other patients had peripheral neuropathy, and three had atypical leg pain. Only 10 patients had radiographic evidence of severe lumbar canal stenosis; the others had moderate, mild, or no stenosis. In 10 patients, surgical decompression was inadequate. Only three patients had the triad of neurogenic claudication, radiographically confirmed severe lumbar stenosis, and adequate decompression of the lumbar canal and lateral recesses. CONCLUSION The most common pattern in patients with early failure after lumbar laminectomy was the absence of actual neurogenic claudication coupled with the absence of severe stenosis on preoperative imaging studies. The most common technical error was inadequate neural decompression. These data suggest that the outcome may be improved by more careful selection of patients and by performance of an adequate surgical decompression.

Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure

OBJECT Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable-shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). METHODS The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. RESULTS Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs. 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs. 27.0, respectively; p = 0.005). CONCLUSIONS Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

Diagnosis and Management of Lumbar Disk Disease

Acute low-back pain is one of the most common problems encountered by primary-care physicians. A few patients have severe neurologic impairment or evidence of cancer or other serious underlying systemic illness. For such patients, a broad differential diagnosis must be considered, and a prompt work-up and specialty consultation may be necessary. For most patients with acute low-back pain, extensive laboratory and imaging tests are unnecessary, and rapid improvement can be expected with only simple treatment measures. Physical therapy is useful in patients with refractory symptoms. Magnetic resonance imaging and other sophisticated spinal imaging should usually be reserved for patients who are being considered for an operation. Surgical referral should be considered for the patient with a documented lumbar disk herniation that correlates precisely with clinical findings. Surgical treatment is usually elective in patients with persistent radicular pain and a mild to moderate neurologic deficit, urgent in patients with severe or progressive monoradiculopathy, and emergent in patients with the cauda equina syndrome. Lumbar diskectomy with magnified vision is the surgical procedure of choice, and success rates of 80 to 90% can be expected in properly selected patients.

Sudden Progression of Lumbar Disk Protrusion During Vertebral Axial Decompression Traction Therapy

Vertebral axial decompression (VAX-D) is a form of spinal traction that is widely promoted as an effective and safe treatment of degenerated and herniated lumbar intervertebral disks. Information targeted at the general public emphasizes that the treatment is completely risk-free. We describe a patient with a large lumbar disk protrusion who experienced sudden, severe exacerbation of radicular pain during a VAX-D therapy session. Follow-up magnetic resonance imaging of the lumbar region showed marked enlargement of the disk protrusion, and urgent microdiskectomy was required. To our knowledge, this is the first reported complication of VAX-D therapy. This case shows that VAX-D therapy has the potential to cause sudden deterioration requiring urgent surgical intervention.

Lumbar peritoneal shunting with video-laparoscopic assistance: a useful technique for the management of refractory postoperative lumbar csf leaks

BACKGROUND Cerebrospinal fistulas and pseudomeningoceles can occur after lumbar spinal surgery, and are sometimes refractory to direct repair, external drainage, and blood patches. The authors report a technique for cerebrospinal fluid (CSF) diversion from the lumbar spine to the peritoneum to assist with the management of these difficult situations. METHODS Using video-laparoscopic assistance, two shunts are placed from the lumbar region into the peritoneal cavity: first, a lumbar subarachnoid space to peritoneum shunt; and second, a meningocele cavity to peritoneum shunt. Patients are ambulated immediately after the procedure. External drains are not used. RESULTS Four patients with refractory CSF leaks were successfully managed with this technique. Complications associated with prolonged bedrest and external drains were avoided. Ancillary procedures were minimized, and hospital stay was shortened. Laparoscopic assistance offered verification of accurate placement of the peritoneal catheter and shortened operative times. CONCLUSIONS Dual lumbar peritoneal shunts (intrathecal-peritoneal and meningocele cavity-peritoneal), placed with laparoscopic assistance, proved effective in the management of four patients with postoperative lumbar CSF leaks, who had failed to respond to conventional treatment.

Removal of an orbital metallic foreign body to facilitate magnetic resonance imaging: technical case report.

OBJECTIVE AND IMPORTANCE:Magnetic resonance imaging (MRI) is the imaging modality of choice for brain tumors and other lesions of the central nervous system. However, this procedure is contraindicated in patients with orbital metallic foreign bodies. In such cases, the usual clinical strategy is to manage the patient without the benefit of MRI scans and, instead, to rely on less sensitive imaging modalities in particular computed tomographic scanning. CLINICAL PRESENTATION:Two patients, one with a posterior fossa mass and one with suspected central nervous system lymphoma, were seen at our institution. MRI scanning was recommended, but had been precluded in both patients by the presence of metal fragments in the orbit. INTERVENTION:In each case, the orbital foreign body was successfully localized and removed. Postprocedure computed tomographic scanning confirmed complete removal. MRI scanning was then performed without difficulty. The first patient underwent posterior fossa craniotomy and removal of the tumor, which proved to be a medulloblastoma. The second patient was found to have evidence of lymphoma in the cranial base and meninges and was treated with radiotherapy and systemic and intrathecal chemotherapy. MRI scanning provided superior diagnostic information and spared both patients the risks and discomfort of myelography and exposure to ionizing radiation from multiple computerized tomographic scans. CONCLUSION:Two patients with central nervous system tumors underwent removal of a metal fragment in the orbit for the specific purpose of facilitating MRI scans. This is a practical, straightforward concept, which should be considered when MRI scanning is needed for optimal patient management.