Traumatic subarachnoid-mediastinal fistula mimicking a ruptured aorta

A 35-year-old man, injured in an automobile accident was found to have a subarachnoid-mediastinal fistula that mimicked a ruptured aorta. Of 16 reported cases of traumatic subarachnoid-mediastinal fistula, this is only the third in which the fistulous communication was with the extrapleural space only. The possibility of subarachnoid-mediastinal fistula, although rare, should be entertained in injuries to the thoracocervical spine when neurologic symptoms are present.     

Cerebrospinal fluid cutaneous fistula after epidural analgesia in a child

BACKGROUND AND OBJECTIVES: Cerebrospinal fluid cutaneous fistulae are rare complications of neuraxial needle procedures. CASE REPORT: We present the first reported case of a persistent cerebrospinal fluid cutaneous fistula in a child who underwent epidural analgesia. Careful assessment and circumspect treatment of this cerebrospinal fluid cutaneous fistula led to an excellent outcome in this child. CONCLUSIONS: Assessment can be challenging in young children, and guidelines for management are absent. Technical issues in treatment are discussed in addition to pitfalls in diagnosis in young children.     

An unusual post-traumatic occipitocervical pseudomeningocele: case report

BACKGROUND: A rare case of massive post-traumatic subcutaneous pseudomeningocele probably communicating with the cisterna magna, is reported. CASE DESCRIPTION: An 8-year-old boy sustained a severe injury to the nape of the neck, after which he developed a huge local subcutaneous swelling containing cerebrospinal fluid (CSF). Communication of the subcutaneous CSF collection with the cisterna magna or any other site of dural fistula could not be identified. After a lumbo-peritoneal CSF shunt, the swelling resolved completely. CONCLUSION: The clinical features of a rare case of symptomatic post-traumatic cerebrospinal fluid pseudomeningocele are elaborated.     

A successfully treated case of cerebrospinal fluid fistula caused by fracture of the sella turcica

Fracture of the sella turcica is rare and is associated with many complications. We successfully treated a cerebrospinal fluid fistula caused by a fracture of the sella turcica. A 66-year-old male in a motor vehicle accident was admitted to an outside hospital with disturbance of consciousness. A computed tomography (CT) scan of the head revealed a subarachnoid hemorrhage and pneumocephalus. Cerebrospinal fluid rhinorrhea developed after admission. Repair of the fistula was attempted without success, and the patient was transferred to our hospital for further examination and treatment. A fracture of the sella turcica was clearly visualized on coronal and sagittal head CT and on a three-dimensional reconstructed CT (3D-CT) image. The source of the CSF fistula was thought to be the anterior wall of the sella turcica. Through a bifrontal interhemispheric approach, the cerebrospinal fluid fistula was repaired microscopically with the assistance of endoscopy. Postoperatively, the fistula stopped completely. Coronal and sagittal head CT and 3D-CT images are useful for making a diagnosis of CSF leakage. Endoscopic images can assist in observation of the dead angle of the microscope.     

Extradural giant multiloculated arachnoid cyst causing spinal cord compression in a child

BACKGROUND: Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Enlargement may cause progressive signs and symptoms caused by spinal cord compression. They are associated with trauma, surgery, arachnoiditis, and neural tube defects. Most nontraumatic spinal extradural arachnoid cysts are thought to be congenital. DESIGN: Case report and literature review. FINDINGS: A 9-year-old boy with mild paraparesis was found to have an extradural multiloculated arachnoid cyst with fibrous septa at T4-L3 levels and anterior compression and displacement of the spinal cord. CONCLUSIONS: Definitive treatment of arachnoid cyst entails radical cyst removal and dura cleft repair. Formation of a postoperative cerebrospinal fluid fistula may require external lumbar drainage.     

Stab wounds of the spinal cord by a kitchen knife: report of a case

A case of spinal cord injury due to stab wounds by a kitchen knife is presented. A 41-year-old male was hospitalized because of spinal cord injury resulting from stab wounds inflicted with a kitchen knife in the posterior cervical area. Neurological examination on admission showed paraplegia, disappearance of deep tendon reflex in both lower extremities, sensory disturbance below T1 level, left Horner's syndrome and urinary disturbance. In addition to these symptoms cerebrospinal fluid was leaking from the wounds. An emergency operation was performed. After laminectomy of C7 and T1, we found that the spinal cord was almost completely split at C7/T1 level. Dural plasty was performed. Neurologically, sensory disturbance was slightly improved at 4 months after the injury. Initial MRI (TR: 200 msec, TE: 20 msec) revealed high intensity at C7/T1 level which was damaged by the kitchen knife. MRI 5 months after the injury revealed low intensity on T1 weighted imaged, high intensity on T2 and proton weighted image. The occurrence of the spinal cord injury due to stab wounds by a kitchen knife is very rare in Japan. MRI is useful in the diagnosis of stab wounds of the spinal cord.     

Spinal cord injury in experimental thoracic aortic occlusion: investigation of combined methods of protection.

The efficacy of combined methods of spinal cord protection during thoracoabdominal aortic reconstruction was evaluated because a recent clinical study failed to substantiate the value of cerebrospinal fluid drainage when used alone in the prevention of paraplegia. The effect of cerebrospinal fluid drainage and aortofemoral shunting were analyzed with regard to neurologic outcome and spinal cord blood flow in a model of thoracic aortic occlusion. In addition, we studied the use of motor-evoked potentials as compared with somatosensory-evoked potentials in monitoring cord perfusion. Thirty-two dogs underwent proximal and distal thoracic aortic occlusion for 60 minutes. The control group (n = 8) underwent thoracic aortic cross-clamping only. Spinal cord protection was used in three groups: cerebrospinal fluid drainage alone (n = 8), aortofemoral shunting alone (n = 8), and cerebrospinal fluid drainage and aortofemoral shunting (n = 8). Neurologic outcome improved in all treatment groups as compared with controls (p less than 0.001). The addition of cerebrospinal fluid drainage to aortofemoral shunting did not further improve neurologic outcome. Spinal cord blood flow measured with microspheres in the lumbar gray matter was significantly higher in the dogs with aortofemoral shunting (+/- cerebrospinal fluid drainage) as compared with those with cerebrospinal fluid drainage alone (p less than 0.05) or the controls (p less than 0.001). Aortofemoral shunting also prevented the development of acidosis and hyperglycemia. Loss or changes in amplitude and latency of motor-evoked potentials did not distinguish between the groups. Loss of somatosensory-evoked potentials had a high sensitivity (92%) but lower specificity (68%) in predicting neurologic injury, whereas loss of motor-evoked potentials had a high specificity (100%) but a very low sensitivity (16%). We conclude that cerebrospinal fluid drainage or aortofemoral shunting significantly improve spinal cord blood flow and neurologic outcome. The greatest increase in spinal cord blood flow was seen with aortofemoral shunting, which also prevented metabolic disturbances of reperfusion. Although the addition of cerebrospinal fluid drainage to aortofemoral shunting was the only group in which no neurologic injury occurred, this group did not have a significant improvement in outcome when compared with aortofemoral shunting alone. Spinal cord ischemia was more accurately detected with somatosensory-evoked potentials when aortofemoral shunting was used, whereas motor-evoked potentials recorded from the spinal cord were not sensitive enough to predict neurologic injury.     

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.     

Paraplegia following elective endovascular repair of abdominal aortic aneurysm: reversal with cerebrospinal fluid drainage.

Paraplegia secondary to spinal cord ischaemia is a rare but devastating complication of abdominal aortic aneurysm repair. We report a case of paraplegia following elective endovascular repair of an infrarenal aortic aneurysm. A cerebrospinal fluid (CSF) drain was immediately inserted and resulted in full neurological recovery. This case highlights the fact that endovascular techniques are prone to similar complications as open surgery, and the importance of prompt cerebrospinal fluid drainage in cases of spinal cord ischaemia.     

Changes in fatty acids composition in cerebrospinal fluid of patients with myelopathy

The composition of fatty acids in the cerebrospinal fluid of patients with cervical myelopathy, thoracic myelopathy, cauda equina syndrome, and spinal cord injury were measured by gas chromatography. The relationship between the change in fatty acids composition and the improvement of symptoms and pathology were studied. The percent distribution of eicosadienoic acid (C20: 2) in fatty acids composition was found to be significantly increased in the cerebrospinal fluid of patients with cervical and thoracic myelopathies (p less than 0.05), and with incomplete spinal cord injury (p less than 0.01) against control group. Although the high percent distribution, especially over 10%, of C20: 2 in the cerebrospinal fluid of the patients with cervical or thoracic myelopathy before operation decreased after operation, no correlation was found between the decrease of percent distribution of C20: 2 and improvement of symptoms. A positive relationship was found between the decrease of percent distribution of C20: 2 and the improvement in symptom of patients with central spinal cord injury.     

Percutaneous computer tomography-guided technique to close postsurgical cerebrospinal fluid fistulas of the frontal sinus

BACKGROUND: The occurrence of cerebrospinal fluid fistulas of the frontal sinus after anterior skull base surgery is not rare. The extracerebral techniques to repair cerebrospinal fluid fistulas are often used, especially because they avoid open-air surgical operations. METHODS: A percutaneous CT-guided technique to close postsurgical cerebrospinal fluid fistulas of the frontal sinus in three patients after anterior skull base surgery is presented in this report. Ten millimeters of human fibrin glue was injected into the frontal sinus through one of the burr holes of the bone flap by an 18-gauge spinal needle. RESULTS: After an average follow-up period of 2.8 years, all three patients are in excellent general and neurological conditions and have not shown any further signs of rhinoliquorrhea. CONCLUSIONS: The presented percutaneous CT-guided technique can be considered a valid and harmless solution to closer small or moderate cerebrospinal fluid fistula that occurred after anterior skull base surgery.     

Non-traumatic cerebrospinal fluid rhinorrhea of sphenoid origin

The posterior wall of the sphenoid sinus is rarely implicated as a site of spontaneous cerebrospinal fluid fistula. Presented here is a case of CSF rhinorrhea of this nature, including the diagnosis workup and endoscopic approach permitting closure of the fistula.     

Successful use of a vascularized intercostal muscle flap to seal a persistent intrapleural cerebrospinal fluid leak in a child

The diagnosis and management of a persistent intrapleural-dural cerebrospinal fluid fistula following excision of a large mediastinal ganglioneuroma with intraspinal extension is reported. Use of a vascularized intercostal muscle flap to close the dural fistula was curative in this 4-year-old patient.     

Tau protein in the cerebrospinal fluid is a marker of brain injury after aortic surgery

BACKGROUND: Tau is a protein localized primarily in neurons, especially in the axonal compartment. Cerebrospinal fluid tau levels are elevated in acute stroke and head traumas. The purpose of this study is to elucidate the alterations of cerebrospinal fluid tau levels in patients with or without neurologic complication after aortic surgery. METHODS: Twenty-eight patients undergoing descending thoracic (n = 8) or thoracoabdominal (n = 20) aortic surgery were enrolled. Cerebrospinal fluid tau levels were measured before operation and at seven time points up to the 72nd postoperative hour, and were compared with cerebrospinal fluid S100B levels. RESULTS: Two patients developed brain infarction, including the one with paraplegia. In these patients, 20-fold to 100-fold tau elevation was observed, but S100B elevation was less evident in the patient without paraplegia. Three other patients developed spinal cord injury. Additional three patients suffered from temporary neurologic dysfunction of the brain. Tau levels in the latter three patients showed tenfold elevation and were higher than those in the three patients with spinal cord injury or those in the patients without neurologic complication up to 24 postoperative hours. The S100B levels were also higher in the three patients with temporary neurologic dysfunction of the brain than in the patients without neurologic complication at the conclusion of surgery. From 6 to 24 postoperative hours, they were higher in the three patients with spinal cord injury than in the patients without neurologic complication. CONCLUSIONS: These preliminary results suggest that cerebrospinal fluid tau levels reflect brain injury. Because tau levels may separate the patients with temporary neurologic dysfunction, they may serve as a useful marker of brain injury.     

How to prevent spinal cord injury during endovascular repair of thoracic aortic disease

The incidence of spinal cord injury in thoracic endovascular aortic repair (TEVAR) has been 3–5 % from recent major papers where sacrifice of the critical intercostal arteries is inevitable by a stent graft. Hemodynamic stability, which depends on a network of blood vessels around the cord is most important not only during but also after stent-graft deployment. High risk factors of spinal cord injury during endovascular aortic repair are (1) coverage of the left subclavian artery, (2) extensive coverage of long segments of the thoracic aorta, (3) prior downstream aortic repair, (4) compromising important intercostal (T8–L1), vertebral, pelvic and hypogastric collaterals, and (5) shaggy aorta. Preoperative, intraoperative, and postoperative managements have been required to prevent spinal cord injury with TEVAR. For imaging assessment of blood supply to spinal cord including Adamkiewicz artery, prophylactic cerebrospinal fluid drainage is mandatory, and monitoring motor-evoked potential is recommended for high risk factors of spinal cord injury. Mean arterial pressure should be maintained over 90 mmHg after stent-graft placement for a while to prevent delayed spinal cord ischemia in high-risk patients of spinal cord ischemia. Finally, because spinal cord injury during TEVAR is not rare and negligible, perioperative care during TEVAR should be strictly performed according to the protocol proposed by each cardiovascular team.     

主动脉手术的脊髓保护

脊髓损伤是胸主动脉手术后的严重并发症,影响手术后脊髓并发症发生的因素包括手术过程中脊髓缺血的时间及程度、主动脉修复后脊髓血运的重建状况、多种生化因素、缺血-再灌注损伤等。目前主动脉手术中脊髓的保护手段有:提高手术技术和改进手术方法;增加脊髓的血液供应,包括提供机械性动力的血液灌注和动脉分流,脑脊液分流;利用低温降低脊髓的代谢率;应用药物防止脊髓缺血-再灌注损伤。现就脊髓的血液循环特点、脊髓损伤的发生机制和脊髓保护的最新进展进行综述。     

The importance of fluid-structure interaction in spinal trauma models

While recent studies have demonstrated the importance of the initial mechanical insult in the severity of spinal cord injury, there is a lack of information on the detailed cord-column interaction during such events. In vitro models have demonstrated the protective properties of the cerebrospinal fluid, but visualization of the impact is difficult. In this study a computational model was developed in order to clarify the role of the cerebrospinal fluid and provide a more detailed picture of the cord-column interaction. The study was validated against a parallel in vitro study on bovine tissue. Previous assumptions about complete subdural collapse before any cord deformation were found to be incorrect. Both the presence of the dura mater and the cerebrospinal fluid led to a reduction in the longitudinal strains within the cord. The division of the spinal cord into white and grey matter perturbed the bone fragment trajectory only marginally. In conclusion, the cerebrospinal fluid had a significant effect on the deformation pattern of the cord during impact and should be included in future models. The type of material models used for the spinal cord and the dura mater were found to be important to the stress and strain values within the components, but less important to the fragment trajectory.     

Lymphatic fluid fistula: an extremely rare complication of posterior lumbar transpedicular screw fixation. Case report

The authors describe the unique case of a patient who had undergone posterior stabilization of the lumbar spine complicating the course of a lymphatic fistula. A lymphatic fistula is a rare complication of posterior lumbar surgery. Predisposing factors include individual anatomy, scarring adherences due to previous abdominal operations or surgical maneuvers deep in the plane of the transverse processes. Because the onset of lymphatic fistulas is subtle, and because they are associated with a high mortality rate and require multidisciplinary treatment, care is needed to avoid misdiagnosing these lesions as the more common cerebrospinal fluid fistula.     

An unusual stab wound of the cervical spinal cord: a case report

STUDY DESIGN: A rare case of a laterally directed stab wound injury of the cervical spinal cord is reported. OBJECTIVE: To describe the unusual mechanism of injury of this case and its clinical features. The surgical indications for penetrating injuries of the spinal cord are discussed. SUMMARY OF BACKGROUND DATA: Spinal stab wound injuries are rare, and the literature on the subject is scant. There has been only one large clinical review from South Africa, published in 1977. The clinical features and the injury mechanism of a laterally directed stab wound to the cervical spine have not been previously described. METHODS: An 18-year-old man was stabbed in the right side of the neck at C1-C2. The blade penetrated the spine laterally and went through the ligaments without affecting the bony structures. On admission the patient had tetraplegia and was in respiratory failure. Radiologic investigation showed the retained blade passing through the cord but showed no bony or vascular injuries. RESULTS: Before extraction, the knife was followed to its tip with careful dissection. Because no cerebrospinal fluid leak was noted in the area, the dura was not exposed. After surgery, magnetic resonance images showed a complete transection of the spinal cord at C1-C2. The patient was neurologically unchanged in follow-up examinations. CONCLUSION: Laterally directed horizontal stab wounds of the spine are particularly dangerous because the blade can pass between two vertebrae to transect the cord. The neurologic injury that results is irreversible. The more common stab wounds, inflicted from behind, usually produce incomplete cord damage.     

Pitfalls in the diagnosis of acute abdominal conditions

Sixteen cases of intraspinal tumors in patients ranging from 10 weeks to 11 years and three months are presented. The two youngest patients in this series are younger than any previously recorded. It is suggested that it is possible to make an early diagnosis of spinal cord pressure in infants and young children. Complete neurologic examination and study of the cerebrospinal fluid are essential. Sensory examination is of great value in even the youngest patient if the examiner is sufficiently persistent. Injection of iodized oil should be necessary in rare instances only, but where needed it is invaluable.