Kim Jm

Pure Spinal Epidural Cavernous Hemangioma with Intralesional Hemorrhage: A Rare Cause of Thoracic Myelopathy

Although cavernous hemangiomas occur frequently in the intracranial structures, they are rare in the spine. Most of spinal hemangiomas are vertebral origin and pure epidural hemangiomas not originating from the vertebral bone are very rare. Our spinal hemangioma case is extremely rare because of its pure epidural involvement and intralesional hemorrhage. A 64-year-old man presented with progressive paraparesis from two months ago. His motor weakness was rated as grade 4/5 in bilateral lower extremities. He also complained of decreased sensation below the T4 sensory dermatome, which continuously progressed to the higher dermatome level. Magnetic resonance imaging demonstrated thoracic spinal tumor at T3-T4 level. The tumor was located epidural space compressing thoracic spinal cord ventrally. The tumor was not involved with the thoracic vertebral bone. We performed T3-5 laminectomy and removed the tumor completely. The tumor was not infiltrating into intradural space or vertebral bone. The histopathologic study confirmed the epidural tumor as cavernous hemangioma. Postoperatively, his weakness improved gradually. Four months later, his paraparesis recovered completely. Here, we present a case of pure spinal epidural cavernous hemangioma, which has intralesional hemorrhage. We believe cavernous hemangioma should be included in the differential diagnosis of the spinal epidural tumors.

The Autoclaving of Autologous Bone is a Risk Factor for Surgical Site Infection After Cranioplasty

BACKGROUNDnThis retrospective study was designed to evaluate the effectiveness of autoclaving for the prevention of surgical site infection (SSI) after cranioplasty.nnnMETHODSnPatients who underwent cranioplasty with autologous bone were enrolled. SSI was defined as an infection requiring bone flap removal. Risk factors of SSI, as reported by other researchers, and microbiologic features of SSI were analyzed. All bone flaps were preserved in a deep freezer (-70°C). Autoclaving of the preserved autologous bone flap before cranioplasty was performed for 5 minutes at 135°C in the 26 patients.nnnRESULTSnEighty patients were enrolled. The mean age was 53.3 years and the male/female ratio was 3:2. Causes of craniectomy included trauma (nxa0= 37) and nontrauma (nxa0= 43). The mean time interval between craniectomy and cranioplasty was 49.7 days. The SSI rate after cranioplasty with autologous bone was 17.5% (nxa0= 14). In univariate analysis, the cranioplasty operation time (Pxa0= 0.09) and the use of autoclaved bone (Pxa0= 0.00) were supposed to be risk factors for SSI. The use of autoclaved autologous bone was found to be the only risk factor of SSI (Pxa0= 0.01; hazard ratioxa0= 8.88) in binary logistic regression analysis. Non-methicillin-resistant Staphylococcus aureus (MRSA) causes were more frequent in the autoclaved group (MRSA, 30%; non-MRSA, 70%) compared with the nonautoclaved group (MRSA, 100%) (Pxa0= 0.07). A microscopic examination showed that autoclaving after long-term cryopreservation may result in a loss of bone viability.nnnCONCLUSIONSnAutoclaving of autologous bone causes SSI after cranioplasty and it seems to increase the risk of non-MRSA infection by normal skin flora.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

Delayed Brain Infarction due to Bilateral Vertebral Artery Occlusion Which Occurred 5 Days after Cervical Trauma

Vertebral artery (VA) injuries usually accompany cervical trauma. Although these injuries are commonly asymptomatic, some result in vertebrobasilar infarction. The symptoms of VA occlusion have been reported to usually manifest within 24 hours after trauma. The symptoms of bilateral VA occlusions seem to be more severe and seem to occur with shorter latencies than those of unilateral occlusions. A 48-year-old man had a C3-4 fracture-dislocation with spinal cord compression that resulted from a traffic accident. After surgery, his initial quadriparesis gradually improved. However, he complained of sudden headache and dizziness on the 5th postoperative day. His motor weakness was abruptly aggravated. Radiologic evaluation revealed an infarction in the occipital lobe and cerebellum. Cerebral angiography revealed complete bilateral VA occlusion. We administered anticoagulation therapy. After 6 months, his weakness had only partially improved. This case demonstrates that delayed infarction due to bilateral VA occlusion can occur at latencies as long as 5 days. Thus, we recommend that patients with cervical traumas that may be accompanied by bilateral VA occlusion should be closely observed for longer than 5 days.