Mónica Rivero-Garvía

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.

Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters.

IntroductionMany strategies have been developed with the aim of reducing external ventricular drain-related infections. Antibiotic-impregnated catheters are one of them.Material and methodsWe report 648 cases of external ventricular drain from a total of 534 patients treated at the Virgen del Rocío Hospital between 1995 and 2006. Three subgroups were considered: group 1 included patients treated between 1995 and 2000, as well as a total of 190 external ventricular drains and 59 cases of infection (31.05%); group 2, with patients treated between 2000 and 2004 and managed with a minimal handling protocol, included 210 external ventricular drains and nine cases of infection (4.29%); and group 3, treated between 2004 and 2006, with 248 external ventricular drains and six cases of infection (2.41%). This latter subgroup included patients managed with a minimal handling protocol and antibiotic-impregnated catheters.ResultsInfection rate was 17% when non-antibiotic-impregnated catheters were employed and 2.41% when antibiotic-impregnated catheters were inserted (p < 0.001). This difference was statistically significant before and after the introduction of a minimal handling protocol, with percentages of 5.31% and 3.27%, respectively (p < 0.001; odds ratio 0.08; absolute risk reduction 27.26%). However, no statistically significant difference was observed in infection rate when the impact of a minimal handling protocol was considered: 4.29% when only the protocol was introduced and 2.41% when both the protocol and antibiotic-impregnated catheters were used (p > 0.05).ConclusionMinimal handling protocols constitute an essential strategy in the reduction of external ventricular drain-related infections. Besides that, the use of antibiotic-impregnated catheters may reduce infection-related hospital costs.

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.

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.

Primary Cerebral Radiotherapy-Induced Rhabdomyosarcoma: Treatment with Intraoperative Carmustine Implants

Introduction: Primary cerebral rhabdomyosarcomas (cRMS) are extremely rare, with only 41 cases reported in the literature. Survival of patients with localized cRMS is 70% after 5 years but not in the case of intracranial neoplasms, where survival rarely exceeds 10 months. Case report: A 10-year-old female patient with a history of acute lymphoblastic leukemia (ALL) and holocranial radiotherapy (RT) 6 years ago, referred after partial surgical resection of a left parietal lesion, diagnosed as an embryonal tumor with mixed neuronal-glial differentiation (WHO grade IV). A second operation was performed for complete resection and placement of intracavitary chemotherapy (carmustine). The pathology revealed a high-grade undifferentiated neoplasm positive for myogenin and desmin that was compatible with cRMS. In the immunohistochemistry study, the neoplasm was positive for vimentin, myogenin, and desmin, as is characteristic of cRMS, and negative for synaptophysin and enolase, ruling out primitive neuroectodermal embriogenic tumor (PNET). Given a diagnosis of cRMS, a combined thoracoabdominal PET-CT scan was performed without finding other primary lesions and a bone marrow study was also performed without observing abnormalities. Consequently, the diagnosis was established as primary cRMS. Discussion: Among the long-term sequelae of radiotherapy, neurocognitive disorders, brain disorders such as leukomalacia, vascular diseases, or secondary tumors, ranging from benign lesions such as meningiomas to more aggressive lesions such as ependymomas, which are high-grade gliomas, are described. In the brain MRI, our patient showed a radiotherapy-induced periventricular leukomalacia and a malignant lesion: a cRMS. The use of carmustine in this disease may facilitate local control.

Conceptos básicos sobre la fisiopatología cerebral y la monitorización de la presión intracraneal

INTRODUCTION Many brain processes that cause death are mediated by intracranial hypertension (ICH). The natural course of this condition inevitably leads to brain death. The objective of this study is to carry out a systematic review of cerebral pathophysiology and intracranial pressure (ICP) monitoring. DEVELOPMENT Studying, monitoring, and recording ICP waves provide data about the presence of different processes that develop with ICH. CONCLUSIONS Correct monitoring of ICP is fundamental for diagnosing ICH, and even more importantly, providing appropriate treatment in a timely manner.

Ventriculobiliary Shunts, Another Option

The basic management of hydrocephalus includes shunts to the peritoneum and atrium. However, there are particularly complex patients in whom it is necessary to look for atypical places for implanting the distal catheter. Since 2000, 1,325 shunts have been implanted in pediatric patients. Only 3 patients required a ventriculobiliary shunt. We report 3 cases: a 7-year-old boy with a surgically treated complex heart disease, a 16-month-old girl with hydrocephalus secondary to a brain tumor and multiple bacteremias secondary to an infection of the central venous reservoir, and a 4-year-old girl with nonreabsorptive hydrocephalus caused by intraventricular bleeding due to premature birth, necrotizing enterocolitis and shunt infections with abdominal pseudocysts, which caused multiple abdominal septations and, finally, a nonreabsorptive peritoneum. At present, cases 1 [45 months after ventriculobiliary shunt (VBS)] and 3 (27 months after VBS) are symptom free, while case 2 (14 months after VBS) died of infectious respiratory complications. The gold standard for the treatment of nonreabsorptive hydrocephalus is a ventriculoperitoneal shunt, the second option is a ventriculoatrial shunt, and the third option is uncertain. In our short experience, a ventriculo-gallbladder shunt is a good option when there is no abdominal hypertension.

Plasmocytoma of C1 in a child. Case report

Background and aimVertebral involvement is a common occurrence in myelomas, but isolated involvement of the high cervical spine is exceptionally rare. This factor, together with the pediatric age of our patient, makes this case the first report of a plasmocytoma involving C1.Case reportA 14-year-old boy, without neurological involvement, presented with cervical pain and a palpable posterior neck mass. Cervical spine radiographs showed an osteolytic lesion at C1 compressing the cervical spinal canal and instability of the craniocervical junction. After a complete study, the patient was diagnosed with solitary plasmocytoma. A sequential treatment was instituted that consisted of radiotherapy after craniocervical junction stabilization with an halo-jacket, followed by occipitocervical stabilization with instrumented arthrodesis that was accompanied by resection of the residual C1 tumor and, finally, with consolidation of the oncological treatment with further radiotherapy.ConclusionThe treatment of choice for a cervical solitary plasmocytoma consists of a combination of chemotherapy, corticosteroids, radiotherapy, and immunotherapy, but the main neurosurgical problem is the craniocervical instability as occurred in other tumor of the cervical column.

Treatment of glioblastoma multiforme with high doses of carmustine intracavitary, in an infant.

Local therapy with nitrosourea compounds (e.g., carmustine [1,3-bis [2-chloroethyl]-1-nitrosourea] wafers) is currently included in the integral treatment offer for patients with glioblastoma multiforme (GBM) [2, 7, 10, 11]. The laboratory recommends that the maximum number of 3.8% carmustine wafers that can be implanted per patient is eight. However, in clinical practice, exceptional cases, such as the one presented here, may arise. In this case, the tumour occupied practically the entire hemisphere, and a higher number of wafers was required to fill the bed completely. The literature includes cases such as that described by Olivi et al. [6], in which doses of up to 20% carmustine per wafer, i.e., five times the recommended dose, can be used with relative safety. However, the ideal dose for children has not yet been defined.

Intracranial hypertension in 2 cases of craniometaphyseal dysplasia: differing surgical options

Craniometaphyseal dysplasia (CMD) is a very rare bone disorder characterized by abnormally developed metaphyses in long bones and sclerosis of the craniofacial bones. In this paper, the authors report 2 cases of children diagnosed with CMD and chronic intracranial hypertension with deletion in exon 9 of the human ANK gene (ANKH). After intracranial monitoring, a different treatment was chosen for each patient. One of the patients was treated using CSF shunting because ventriculomegaly in the absence of a Chiari malformation was also observed on cerebral MR imaging. The other patient underwent cranial expansion and decompressive craniotomy of the posterior fossa, because ventriculomegaly was excluded after cerebral MR imaging and cervical MR imaging showed a Chiari malformation Type I. The origin of intracranial hypertension in CMD is multifactorial. Previous intracranial pressure monitoring and a thorough understanding of neuroimaging studies are essential to achieve an accurate diagnosis and effective treatment.