Joseph L. Voelker

Medical complications of head injury

There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.

Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence

BACKGROUND The role of prophylactic antibiotics (PABs) in preventing infections associated with intracranial pressure (ICP) monitors and external ventricular drains (EVD) is not well defined. METHODS This study includes an analysis of published reports and a survey of current practices regarding the use of PABs with ICP monitors and EVDs. A computerized data search and a review of the abstracts from two major national neurosurgical meetings over the past decade yielded 85 related articles. Three independent investigators, blinded to the title, author(s), institution(s), results, and conclusions of the articles used predetermined inclusion criteria to select studies for meta-analysis. Thirty-six responses were returned from 98 questionnaires (37%) mailed to university neurosurgical programs. RESULTS Among the articles reviewed, only two studies met the predetermined inclusion criteria for the meta-analysis, and they were of insufficient size to produce statistically significant results. Among the 36 programs that responded to the survey, 26 (72%) used PABs, mainly cephalosporins (46%) and semisynthetic penicillins (38%), with ICP monitors and EVDs. Twenty-two (85%) used one drug, and 4 (15%) used two drugs. Twenty-two (61%) of the total group reported intra-institutional variation in practices among individual staff neurosurgeons. Nineteen (53%) expressed interest in a retrospective study, and 27 (75%) expressed interest in a prospective study on the role of PABs in minor neurosurgical procedures. CONCLUSION No consensus regarding the use of PABs with ICP monitors and EVDs is noted. Randomized controlled trials of sufficiently large size with appropriate blinding are needed to address this issue.

Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation: case report

BACKGROUND Vertebral artery injury during posterior C1-2 transarticular screw fixation occurs in approximately 3% of patients and may remain asymptomatic or result in arteriovenous fistulae, occlusion, narrowing, or dissection of the vertebral artery, and lead to transient ischemic attacks, stroke, or death. CASE DESCRIPTION This is the first report of a pseudoaneurysm resulting from damage to the vertebral artery during the procedure. This 31-year-old male underwent posterior C1-2 transarticular screw fixation for unstable os odontoideum. Injury to the left vertebral artery occurred while the hole for the left screw was being drilled. Temporary control of bleeding with local pressure was followed by immediate postoperative angiography that revealed a left vertebral artery pseudoaneurysm. Although the patient remained asymptomatic, therapeutic anticoagulation was instituted 6 hours postoperatively. Increasing size of the pseudoaneurysm was noted on routine follow-up angiography 4 weeks later. Endovascular occlusion of the pseudoaneurysm and left vertebral artery, with preservation of vertebrobasilar flow through the right vertebral artery, was accomplished without neurological consequence. CONCLUSIONS Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation may be effectively treated with endovascular approaches.

Transient enlargement of an intracranial aneurysm during pregnancy: Case report

BACKGROUND The association of intracranial aneurysm and pregnancy is uncommon. Hemodynamic stress plays an important role in the growth of aneurysms. METHODS The authors report the case of an enlarging cavernous carotid aneurysm in a pregnant 15-year-old young woman. RESULTS The aneurysm was initially diagnosed prior to the patients pregnancy by both cross-sectional imaging and cerebral angiography. Further imaging evaluation was required during pregnancy, which demonstrated significant enlargement of the aneurysm. Following delivery, the lesion decreased in size. CONCLUSIONS We review potential factors associated with pregnancy that may increase hemodynamic stress and influence aneurysm growth. Additionally, the management of pregnancy-related intracranial aneurysms is discussed.

Clinical Aspects of Intracerebral Hemorrhage

This chapter reviews the clinical aspects of spontaneous intracerebral hemorrhage (SICH). Forty percent of aneurysms that bleed and two-thirds of arteriovenous malformations hemorrhages produce a SICH. Cerebral amyloid angiopathy may now be the third leading cause of SICH as it predominates in the elderly and its incidence is increasing as population ages. It is found that during SICH, bleeding may continue for some time but usually ceases within 6 hours. Small hematomas may dissect along white matter tracts, splitting them apart rather than destroying them. When this happens neurologic function can be restored after the clot resorbs. Large hematomas rupture into the parenchyma with destruction of tissue, elevation of intracranial pressure, and possibly herniation of brain substance under the falx, through the tentorial incisura, or through the foramen magnum. The elderly fare less well when afflicted by SICH. Associated cardiac, pulmonary, renal, or other medical disease also worsens prognosis. If the hemorrhage is related to anticoagulant therapy, outcome is usually poor with mortality in up to two-thirds.

Cranial epidural fibrous tumor associated with hyperostosis: a case report

This report describes an unusual frontal epidural fibrous tumor in an adult woman. There had been no prior surgical procedure, radiation therapy, or significant head trauma. Microscopically, the lesion consisted of hypocellular, sparsely vascular, dense fibrous tissue. The fibrous mass was accompanied by hyperostosis of the frontal bone. The clinical and pathological characteristics of this lesion are illustrated. The differential diagnosis is discussed with reference to the literature regarding intracranial fibrous lesions. We are unaware of previous report of similar lesions in this location.

More Learning in Less Time: Optimizing the Resident Educational Experience with Limited Clinical and Educational Work Hours

OBJECTIVE Resident education in the United States and elsewhere has undergone significant changes in recent years owing to work hour restrictions, requiring didactics to fit within a limited schedule, while being increasingly effective at accomplishing educational goals. METHODS A single small program experience in improving the didactic experience of residents is described. RESULTS Focused mentorship, curricula for intangibles, asynchronous education, and independent curricula all are useful tools in resident education. CONCLUSIONS Residents can be exposed to both clinical material and specialty-specific mores using focused and intentional educational techniques.

Giant calvarial intraosseous angiolipoma: a case report and review of the literature

Intraosseous angiolipomas are very rare tumors occurring most commonly in the ribs and mandible. Only two cases with intracranial involvement have been reported in the literature. We report a case of a giant calvarial angiolipoma and its surgical treatment in a 30-year-old female who presented with a slowly expanding skull mass and discuss relevant radiological, histological and surgical findings.