Epidural adhesiolysis complicated by cefazolin-induced status epilepticus: two cases

Cefazolin is a strong epileptogenic agent. We describe two patients presenting with status epilepticus, apparently caused by intrathecal leakage of cefazolin via incidental dural puncture during spinal epidural adhesiolysis. Our cases suggest that the local use of antibiotics, particularly cefazolin, in the form of a mixture with contrast medium during a spinal procedure is not advisable, because of the possible incidental intrathecal leakage and the high convulsive potential of the antibiotics.     

Eosinophilic Granuloma Presenting as an Epidural Hematoma and Cyst

Langerhans'' cell histiocytosis (LCH) is a rare immunologic disorder characterized by histiocyte proliferation in multiple organ systems. Eosinophilic granuloma, a benign bone lesion, represents a focal form of LCH. We experienced a case of Langerhans'' cell histiocytosis in a patient who presented with intracranial epidural hematoma and cyst on the midline of the frontal skull. A 10-year-old boy presented with a rapidly growing large scalp mass on the midline frontal area after mild head trauma. The scalp mass was painless and immobile. Plain skull x-ray showed a punched-out bone lesion. Computed tomography and magnetic resonance imaging showed a non-enhancing osteolytic lesion presenting with an epidural hematoma and cyst on the midline of the frontal skull. The lesion of the skull was completely resected and the patient''s recovery was uneventful. The acute presentation of a solitary eosinophilic granuloma of skull with an epidural hematoma has been described in only five cases in the literature and we report the first case of LCH presenting as an intracranial epidural hematoma on frontal area.     

锥颅治疗12例儿童后颅窝硬膜外血肿的临床体会

目的 分析12例儿童后颅窝硬膜外血肿的诊断与治疗.方法 回顾性分析天津环湖医院2008 -2012年收治的12例儿童后颅窝硬膜外血肿患者.通过连续复查头颅CT,发现该组患者硬膜外血肿早期CT即表现为等密度或混杂密度,全部病例均在局麻下颅骨锥孔血肿抽吸.结果 12例患者均恢复良好,无术后再出血,无严重并发症及死亡.结论 后颅窝硬膜外血肿早期临床症状较轻且不特异,血肿量一旦增加,将严重威胁生命,故应密切观察CT变化,动态复查头颅CT;后颅窝硬膜外血肿早期常常即可呈液态,锥孔血肿抽吸是治疗这部分患者的有效治疗手段,但应严格把握手术时机、手术适应证及禁忌证.     

125例小儿外伤性单纯硬膜外血肿的诊断与治疗

目的 探讨小儿外伤性单纯硬膜外血肿的诊断及治疗。方法 回顾性分析了125例小儿外伤性单纯硬膜外血肿的临床特征、影像学资料、治疗方法及预后。结果 手术治疗110例，开颅血肿清除98例，锥颅血肿穿刺引流术12例，保守治疗15例。118例临床痊愈，治愈率94．4％。植物生存1例，死亡6例，死亡率为4．8％。结论 小儿外伤性单纯硬膜外血肿确诊主要依靠影像学资料，其治疗可采取不同的方法即开颅向肿清除术、锥颅血肿引流术及保守治疗。     

Clinical Characteristics of Spinal Epidural Abscess Accompanied by Bacteremia

ObjectiveThe treatment of choice for spinal epidural abscess (SEA) generally is urgent surgery in combination with intravenous antibiotic treatment. However, the optimal duration of antibiotic treatment has not been established to date, although 4–8 weeks is generally advised. Moreover, some researchers have reported that bacteremia is a risk factor for failure of antibiotic treatment in SEA. In this study, we investigated the clinical characteristics of SEA accompanied by bacteremia and also determined whether the conventional 4–8 weeks of antibiotic treatment is sufficient. MethodsWe retrospectively reviewed the medical records and radiological data of 23 patients with bacterial SEA who underwent open surgery from March 2010 to April 2020. All patients had bacteremia preoperatively and underwent weeks of perioperative antibiotic treatments based on their identified organisms until all symptoms of infection disappeared. All patients underwent microbiological studies of peripheral blood, specimens from SEA and concomitant infections. The mean follow-up duration was 35.2 months, excluding three patients who died. ResultsThe male : female ratio was 15 : 8, and the mean age was 68.9 years. The SEA most commonly involved the lumbar spinal segment (73.9%), and the mean size was 2.9 vertebral body lengths. Mean time periods of 8.4 days and 16.6 days were required from admission to diagnosis and from admission to surgery, respectively. Concomitant infections more frequently resulted in delayed diagnosis (p=0.032), masking the symptoms of SEA. Methicillin-sensitive Staphylococcus aureus was the most commonly identified pathogen in both blood and surgical specimens. Seventeen patients (73.9%) showed no deficits at the final follow-up. The overall antibiotic treatment duration was a mean of 66.6 days, excluding three patients who died. This duration was longer than the conventionally advised 4–8 weeks (p=0.010), and psoas or paraspinal abscess required prolonged duration of antibiotic treatment (p=0.038). ConclusionSEA accompanied by bacteremia required a longer duration (>8 weeks) of antibiotic treatment. In addition, the diagnosis was more frequently delayed in patients with concomitant infections. The duration of antibiotic treatment should be extended for SEA with bacteremia, and a high index of suspicion is mandatory for early diagnosis, especially in patients with concomitant infections.     

神经内镜治疗分隔型慢性硬膜下血肿（附16例分析）

目的探讨神经内镜在治疗分隔型慢性硬膜下血肿中的应用价值。方法回顾性分析16例分隔型慢性硬膜下血肿病人的手术治疗方法。采用神经内镜在直视下先冲洗硬膜下血肿腔并对腔壁上的小出血点给予电凝止血,术野清晰后找到血肿腔分隔并将其造瘘,确保充分开放每个分隔,最后待冲洗液完全清亮后将血肿腔与正常硬膜下腔之间的隔膜充分打通,术后不放置引流。结果本组术后头痛症状均明显改善。术后2个月复查CT显示硬膜下腔完全恢复正常,随访3个月～8年,无复发。结论神经内镜治疗分隔型慢性硬膜下血肿是一种直观、便捷、安全、有效的微侵袭技术。     

利器致颅脑穿透伤三例报告并文献复习

目的 探讨利器致颅脑穿透伤的发生特点、主要并发症及手术治疗策略.方法 分析3例利器致颅脑穿透伤病例的病例特点,并文献复习.结果 3例病例均发生在非常见部位,1例引起了大脑前动脉的损伤,并引起下视丘损伤、脑脊液鼻漏及颅内感染,另2例引起了静脉窦的损伤,手术后3例患者均有较好的预后.结论 利器致颅脑穿透伤可发生在头颅各部位,临床表现主要与直接损伤的组织结构有关,需注意脑脊液漏、颅内感染等并发症；动脉、静脉窦的损伤需在充分术前准备的情况下,术中及时恰当处理可取得较好预后.     

Time course of Hashimoto's encephalopathy revealed by MRI: report of two cases

The MRI manifestations of Hashimoto's Encephalopathy (HE) can vary from normal appearance, ischemic lesions, demyelination, vasogenic edema to atrophy. The diverse MRI features of HE reported in the literature made it difficult to understand the pathological process and monitoring the prognosis. To investigate the dynamic changes of MRI manifestations in HE, two cases of HE were retrospectively analyzed with a series of longitudinal MRI data, including T2 weighted image (T2WI), T1 weighted image (T1WI), fluid attenuated inversion recovery image (FLAIR), diffusion weighted image and diffusion tensor image(DTI). Although similar acute ischemic manifestations were observed at the onset of HE in both cases, at follow-up, we observed different evolutions of HE on MRI between the two cases. It might partially account for the diversity of MRI findings (for example, a certain stage of HE). Clinical and MRI findings at follow-up also indicated that early treatment contributed to the recovery of lesions.     

交通伤致外伤性基底节区血肿106例分析

目的 探讨交通伤致外伤性基底节区血肿的发生机制、诊断和治疗.方法 回顾所收治的106例交通伤致外伤性基底节区血肿病人的临床资料,按照伤情进行分组,统计分析各组的合并伤情况、治疗手段及预后效果.结果 单纯颅脑外伤者67例,伴有其他脏器及肢体损伤者39例.采用手术治疗者94例,其中73例行开颅血肿清除去骨瓣减压术加业低温治疗,21例行锥颅血肿穿刺置管外引流术;保守治疗12例.伤后6个月根据格拉斯哥预后评分,良好35例,中残47例,重残11例,死亡13例.结论 头部突然旋转运动可能是交通伤致外伤性基底节区血肿的病因,人院头颅CT检杏足有效的诊断方法,治疗方法要尽量兼顾脑保护的措施.     

Use of subdural drain for chronic subdural haematoma? A 4-year multi-centre observational study of 302 cases

Chronic subdural haematoma (CSDH) is a common neurosurgical condition and is more prevalent in the ageing population. Studies have suggested that placement of subdural drains after burr-hole drainage was associated with lower recurrence rates. However, a considerable proportion of surgeons remained unconvinced of the effectiveness of drain placement and concerns exist with the potential complications this additional manoeuvre entails such as infection or bleeding. The aim of the present study is to evaluate the impact of subdural drain on CSDH recurrence and its safety. This is a multicentre observational study. Data of consecutive patients with burr-hole drainage performed for CSDH in three hospitals in Hong Kong during a four-year period from January 2008 to December 2011 were prospectively collected and retrospectively analysed. The primary outcome was symptomatic recurrence requiring re-operation. Secondary outcomes included the modified Rankin scales (mRS), morbidity and mortality at six months. A total of 302 patients were identified. The recurrence rate was 8.72% (13/149) with drain placement versus 16.3% (25/153) with no drain (Odds Ratio = 0.489, 95%CI 0.240–0.998; p = 0.0463). Local wound infection, subdural empyema, acute subdural haematoma and other complications had no significant difference. Six-month mRS, 30-day mortality and six-month mortality were comparable in both groups. In conclusion, the use of subdural drain significantly reduced recurrence with no significant increase in complications.     

Pain due to epidural tumor in cancer patients. Report of two cases and differential diagnosis

The cases of two patients with inguinal pain as the only symptom of a T12 metastatic lesion is reported. The patterns of pain referrals from tumor lesions to the spine, epidural space, and spinal cord are reviewed. Focal back pain and pain reported in a distal distribution can both be associated with epidural or cord disease. The differential diagnosis of back pain in patients with cancer can be difficult but may be crucial in differentiating important neurological complications of systemic neoplasms.Suported in part by Italian Research Council grant N. ACRO 96.00692.PF39 and Italian Association for Cancer Research grant N. AIRC 198512.     

骨瓣成形术清除迟发性骑跨横窦巨大硬膜外血肿

目的探讨骨瓣成形术清除迟发性骑跨横窦巨大硬膜外血肿的临床效果。方法对11例迟发性骑跨横窦巨大硬膜外血肿,采用枕部倒"U"切口骨瓣成形清除血肿的手术方法。结果术前幕上血肿约40~120 ml,幕下血肿约10~15 ml左右。骑跨横窦巨大硬膜外血肿均被清除彻底,且止血可靠,骨瓣复位稳定。结论与传统手术方式相比,骨瓣成形术清除骑跨横窦的硬膜外血肿具有进颅迅速、直视止血、不留颅骨缺损等优点。     

Radicular Compression by Intraspinal Epidural Gas Bubble Occurred in Distant Two Levels after Lumbar Microdiscectomy

The authors report a case of symptomatic epidural gas accumulation 2 weeks after the multi-level lumbar surgery, causing postoperative recurrent radiculopathy. The accumulation of epidural gas compressing the dural sac and nerve root was demonstrated by CT and MRI at the distant two levels, L3-4 and L5-S1, where vacuum in disc space was observed preoperatively and both laminectomy and discectomy had been done. However, postoperative air was not identified at L4-5 level where only laminectomy had been done in same surgical field, which suggested the relationship between postoperative epidural gas and the manipulation of disc structure. Conservative treatment and needle aspiration was performed, but not effective to relieve patient''s symptoms. The patient underwent revision surgery to remove the gaseous cyst. Her leg pain was improved after the second operation.     

脑立体定向手术治疗Meige综合征二例报告并文献复习

目的 探讨立体定向深部脑刺激术( DBS)和脑内核团毁损术在Meige综合征(MS)中的临床应用.方法 2例患者术前均采用Burke - Fahn - Marsden肌张力障碍运动评分(BFMDRS),1例MS患者行双侧苍白球内侧核(GPi) DBS手术治疗,1例患者行单侧GPi射频毁损术治疗.结果 行双侧GPi - DBS患者术后随访1年改善达83.7％(BFMDRS评分由术前的22.5分减少为4分),随访2年改善率达69.1％左右(BFMDRS评分由22.5分减少为6分),疗效较为稳定.1例行立体定向右侧GPi毁损术,术后1周疗效明显,BFMDRS从28分减少到6分,改善达78.6％;术后3个月BFMDRS评分为15分,改善率为46.2％,术后6个月随访,所有症状恢复到术前水平.结论 双侧GPi - DBS对于传统治疗无效的Meige综合征患者是一种安全有效的治疗方法;对于不能接受DBS手术的患者,行苍白球或丘脑毁损手术也是值得推荐的一种方法.     

Recovery from acute paraplegia due to spontaneous spinal,epidural hematoma under minimal-dose acetyl-salicylic acid

OBJECTIVE: Spontaneous spinal epidural hematoma (SEH) has not been reported under anti-thrombotic therapy with acetyl-salicylic acid (ASA) in a dosage of 50 mg/d. METHODS: Spinal MRI, emergency laminectomy. RESULTS: A 77-yo, HIV-negative female under longterm treatment over three years with ASA 50 mg/d for varicositas, prescribed by her general practitioner, experienced sudden onset back pain with radiation towards both knees after getting up in the morning. One-and-a-half hours later she also developed ascending hypesthesia and weakness originating from both distal lower limbs. Three hours after onset, hypesthesia had reached the T10-level bilaterally and she had become paraplegic. There was reduced intestinal motility, stool incontinence, and urinary hesitancy. MRI of the thoraco-lumbar spine demonstrated a SEH T9-L1 indenting the dural sack and compressing the myelon. Immediately after emergency laminectomy T10-12 with micro-surgical evacuation of the clot, 12 h after onset, she could move both legs again and was able to walk with support 7 days after surgery. CONCLUSIONS: This case shows that SEH occurs under a minimal dose of ASA and that such patients rapidly recover upon immediate surgical decompression and evacuation of the hematoma.     

Recovered neuronal viability revealed by Iodine-123-iomazenil SPECT following traumatic brain injury

We evaluated cortical damages following traumatic brain injury (TBI) in the acute phase with [¹²³I] iomazenil (IMZ) single photon emission computed tomography (SPECT). In all, 12 patients with cerebral contusion following TBI were recruited. All patients underwent IMZ SPECT within 1 week after TBI. To investigate the changes in distribution of IMZ in the cortex in the chronic phase, after conventional treatment, patients underwent IMZ SPECT again. A decrease in the accumulation of radioligand for the central benzodiazepine receptor in the cortex corresponding to the contusion revealed with computed tomography (CT) scans and magnetic resonance imaging (MRI) were shown on IMZ SPECT in the acute phase in all patients. In 9 of 12 patients (75%), images of IMZ SPECT obtained in the chronic phase of TBI showed that areas with a decreased distribution of IMZ were remarkably reduced in comparison with those obtained in the acute phase. Both CT scans and MRI showed a normal appearance of the cortex morphologically, where the binding potential of IMZ recovered in the chronic phase. Reduced binding potential of radioligand for the central benzodiazepine receptor is considered to be an irreversible reaction; however, in this study, IMZ accumulation in the cortex following TBI was recovered in the chronic phase in several patients. [¹²³I] iomazenil SPECT may have a potential to disclose a reversible vulnerability of neurons following TBI.