Szu-Kai Hsu

Thoracic Vertebral Osteomyelitis Caused by Burkholderia cepacia in an Immunocompetent Adult

To the Editor: Apreviously healthy 71-year-old female complained of back pain 2 mo before admission to the hospital. She was a farmer and worked with vegetables and plants on a daily basis. A physical examination at the time of her admission revealed no remarkable findings except for local tenderness in her mid-thoracic region. Her body temperature on admission was 37.5 C. Laboratory examination demonstrated a white blood cell (WBC) count of 20,640/ mcL, with 80% segmented neutrophils, and a C-reactive protein concentration of 5.6 mg/dL. Plain radiographs of the patient’s spine revealed an osteolytic lesion of the T5 vertebral body. Magnetic resonance (MR) images of the thoracolumbar spine revealed a destructive lesion in the T5 and T6 vertebral bodies (Figs. 1A,B), which appeared as a hypointensity on T1-weighted MR images and a hyperintensity on T2-weighted MR images. Initially, cefazolin and gentamicin were prescribed. A computed tomography (CT)-guided biopsy of the T6 vertebral body was performed through the right pedicle of T6 on the day after the patient’s admission. Pathology examinations confirmed a chronic inflammatory reaction. Serial cultures of blood, urine, sputum, and biopsy tissues revealed no growth. Because of persistent fever and back pain, the patient was treated empirically with oxacillin 1.5 g q6h beginning on day four after her admission. The patient experienced persistent fever and weakness in her left leg, and more severe destructive osteomyelitis with epidural extension and cord compression were found on the MR images of her thoraco-lumbar spine (Fig. 2A). Decompression surgery, consisting of posterior laminectomies of T5 and T6 and a transpedicular biopsy, were done on day 18 of hospitalization. Tissue culture revealed no growth. The patient’s antibiotic therapy was then changed to ceftriaxone 2 g q12 h. However, progressive bilateral weakness of the patient’s lower limbs, and urinary retention were noted. Progressive extension of the epidural abscess, together with collapse of the T5–T6 vertebral bodies (which compressed the spinal cord) were demonstrated in MR images (Fig. 2B). The patient then underwent transthoracic corpectomies at T5 and T6, with internal fixation of an autologous bone graft (from the iliac crest) on day 36 after her first operation. Tissue culture confirmed Burkholderia cepacia infection. After antibiotic susceptibility tests showed the infecting organism to be sensitive to ceftazidime, meropenem, trimethoprim-sulfamethoxazole, and levofloxacin, the patient’s antibiotic therapy was changed again, to levofloxacin 250 mg q8h. However, her pulmonary compliance and function were poor after open chest surgery, and she succumbed about 2 wk after her second operation from septic shock and respiratory failure. Burkholderia cepacia, a gram-negative bacillus, is an important pathogen that infects patients particularly with cystic fibrosis (CF) and chronic granulomatous diseases, and immunocompromised patients [1,2]. This bacterium is found commonly in moist environments in association with soil, water, and plant roots [3]. The types of infection caused most commonly by B. cepacia are bacteremia, urinary tract infection, surgical site infection, septic arthritis, peritonitis, softtissue infection, endocarditis, and respiratory tract infection [4,5]. Several predisposing factors, including CF, chronic granulomatous diseases, indwelling intravascular catheters, assisted ventilation, and intravenous drug abuse increase the risk of infection with B. cepacia [1,6]. Contaminated fluids, such as tap water and nebulizer, irrigation, and dialysis fluids, have also been reported as sources of B. cepacia infection [1,7,8]. Vertebral osteomyelitis caused by B. cepacia is described rarely, with only three cases, consisting of two cases of cervical and one case of lumbar osteomyelitis, reported in the literature [3,6,8]. The diagnosis of B. cepacia infection in these three cases was confirmed by CT-guided biopsy or open surgery. All of the patients recovered gradually after the prescription of suitable antibiotics, possibly aided by decompressive surgery. The sources of the patients’ infections were probably intravenous drug abuse, previous rhinoplasty with contaminated fluid, and an unnoticed external wound that occurred either during a fall on an icy road or from intramuscular stimulation therapy. Antimicrobial resistance of B. cepacia has been considered a great challenge in treating infection caused by the organism [1]. To the best of our knowledge, B. cepacia infection involving the thoracic spine in

Chronic subdural hematoma: Differences between unilateral and bilateral occurrence

Chronic subdural hematoma (CSDH) is one of the most common neurological diseases. However, bilateral CSDH is more infrequent than unilateral CSDH, and the clinical and radiological characteristics are not well-defined. We aimed to investigate the clinical and radiological differences between bilateral and unilateral CSDH. A retrospective study was performed on 75 surgically-treated CSDH patients from January 2011 to December 2015. These patients were divided into unilateral and bilateral CSDH groups. The clinical features, radiological findings, surgical outcome, occurrence of postoperative intracranial bleeding, and recurrence were analyzed. 30.7% of patients had bilateral CSDH. The mean age was 79years and 68.8years for the bilateral and unilateral CSDH patients, respectively (p=0.001). The presence of a history of alcohol abuse was 8.7% and 32.7% in the bilateral and unilateral CSDH patients, respectively (p=0.028). The patients with bilateral CSDH were more likely to present with nausea or vomiting (p=0.048). A lesser degree of midline shift on computed tomographic (CT) scan was also observed in the bilateral group (p=0.001). Most patients had a favorable postoperative outcome, even with bilateral CSDH. In this study, we found that the patients with bilateral CSDH were older, had a lower prevalence of a history of alcohol abuse, presented more commonly with nausea or vomiting, and had a lesser degree of midline shift on CT. Burr-hole craniostomy with a closed-drainage system is a feasible and effective surgical technique for the treatment of unilateral or bilateral CSDH.

Accurate Localization of Aneurysm Neck Margins in Clipping of a Carotid Cave Aneurysm Using Intraoperative Dual-Volume 3-Dimensional Volume-Rendering Rotational Angiography

BACKGROUND Full visualization of the aneurysm neck is usually impossible in a classical pterional craniotomy when a paraclinoid aneurysm is located on the opposite side of the internal carotid artery. Optic nerve (ON) retraction is required for better aneurysmal exposure, but ON injuries may occur. CLINICAL DESCRIPTION In a case of a 70-year-old female harboring a carotid cave aneurysm, we introduced a new method to delineate better the margins of the aneurysm neck by using intraoperative 3-dimensional (3D) rotational angiography (RA) with dual-volume reconstruction. After complete exposure of the aneurysm, we placed a straight clip adjacent to the aneurysm for localization purposes and performed 3D-RA to locate the distal end of the aneurysm neck relative to the localization clip. With a better anatomic understanding of the neck position, we were able to reduce ON retraction and position the clip across the aneurysm neck more precisely. CONCLUSIONS With the advantage of a hybrid operating room, we introduced a novel technique to define the margins of the obscured aneurysm neck more clearly by obtaining a 3D-RA dual-volume reconstruction image to locate the aneurysm neck relative to a localization clip. This technique facilitates the clipping procedure and also reduces the risk related to ON retraction during surgical exposure of a paraclinoid aneurysm.

Rendering a ruptured arteriovenous malformation more susceptible to spontaneous obliteration as a possible treatment strategy for cerebral AVM

Abstract Spontaneous regression of cerebral arteriovenous malformation (AVM) is a rare phenomenon, but its occurrence is an important consideration in treatment planning. A 58-year-old male was found to have a high-flow AVM of Spetzler–Martin Grade III. Before his scheduled treatment, the AVM ruptured with a large parenchymal hemorrhage. Following emergency decompressive surgery, a targeted embolization procedure was performed to obliterate the ruptured weak point and to reduce the shunting flow. The residual AVM became a malformation harboring angio-architectural factors favoring spontaneous obliteration. Together with other favorable clinical factors, including prior parenchymal hemorrhage and neurosurgical intervention, the residual AVM spontaneously regressed in 2 months. This case highlighted a possible treatment strategy in that, for a ruptured AVM in which definite treatment is not possible, an alternative is to treat the AVM into a situation in which as many favorable factors as possible for spontaneous AVM regression are present.

Regression of moyamoya-associated weak spots on the distal anterior choroidal artery following surgical revascularization

A 20-year-old female with moyamoya disease presented with acute intraventricular hemorrhage. Cerebral angiography demonstrated that the anterior choroidal artery (AChA) was responsible for the bleeding, but the precise point of rupture was unpredictable, because multiple angiographic weak spots were found on the artery. As direct targeting of the rupture point was unfeasible, we performed encephalo-duro-arterio-synangiosis to decrease the hemodynamic overload on the AChA. This revascularization procedure alone successfully induced the regression of all weak points. In this report, we demonstrated that, when direct targeting of weak points was not feasible, a revascularization procedure was an acceptable alternative.

The Decrease of Pressure Gradient in Spontaneous Intracranial Hypotension Treated by Epidural Blood Patch: An Illustrated Case

Epidural blood patch (EBP) is an effective method for patients suffering from spontaneous intracranial hypotension (SIH). Because the clinical symptoms dramatically improved after EBP, the immediate increase in the intracranial pressure from the direct sealing of the spinal cerebrospinal fluid (CSF) leak has been proposed. However, this hypothesis was not proved according to the real-time ICP monitoring. Therefore, the real effect of EBP is still unknown. We report a case of SIH resulting from the spinal CSF leak. EBPs were performed and ICP levels were analyzed based on the real-time ICP monitoring. His previous neurologic deficit improved dramatically after EBPs. The decreased pressure gradient may be the reason for patients with dramatic recovery from SIH after EBP.

Post-herpetic like Median Nerve Neuralgia by Brachial Artery Pseudoaneurysm Impingement: A Case Report

Brachial artery pseudoaneurysms are exceedingly uncommon but should be considered in the workup of a patient with median neuralgia and/or neuropathy following arterial punctures in the cubital fossa. We reported on a case in which the prodromal symptoms of median nerve compression caused by a brachial artery pseudoaneurysm led to the misdiagnosis of post-herpetic neuralgia before the occurrence of full blown neuropathy symptoms.This 63 year-old male patient, who suffered from spontaneous subarachnoid hemorrhage, received continuous arterial pressure monitoring at right brachial artery in intensive care unit. Following removal of the arterial catheter, the patient developed dysesthetic burning pain in the right forearm along median nerve dermatome, which was initially diagnosed as post-herpetic neuralgia by dermatologists. In the following weeks, a pulsatile swelling at cubital fossa was noticed, and signs of median neuropathy also occurred. Nerve conduction studies (NCS) showed no responses in the median motor and sensory nerves. Both ultrasonography and arterial angiography confirmed the presence of a large pseudoaneurysm. Surgical excision of pseudoaneurysm was then performed, followed by brachial artery reconstruction using interposition basilic vein graft. After surgery, median neuropathy remained, but dysesthetic pain resolved. One year after operation, NCS still failed to show responses in median nerve. Our case demonstrated that, in the presence of median neuralgia following medical procedures in the cubital fossa, the importance of early suspicion and treatment of pseudoaneurysm formation cannot be overemphasized in order to avoid permanent palsies of median nerve.