World Neurosurg
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Anticoagulant therapy is common and complicates the operative management of acute and mixed-density subdural hematomas (SDHs). The risk of reoperation inferred by anticoagulant (AC) medication and the ability of reversal agents to reduce hemorrhagic complications in patients presenting with AC-associated SDHs are not fully understood. ⋯ Anticoagulant use was not associated with an increased reoperation rate, suggesting that reversal of AC may have eliminated the hemorrhagic risk conferred by these medications. Patients on ACs were significantly older, harbored more medical comorbidities, and had a worse functional outcome at discharge.
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Primary closure of the surgical wound during neurosurgical procedures is sometimes difficult because of limited ability to expand the scalp, or because the skin defect is large. Hence, our institution recently adopted the technique of intraoperative tissue expansion using a Foley catheter for these cases. We describe this easily accomplished, readily available, effective, economical technique and describe our experience performing the technique. ⋯ Intraoperative skin expansion using a Foley catheter-which is easily performed, readily available, and economical-can be used to achieve surgical wound closure during various neurosurgical procedures.
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Case Reports
Brain radionecrosis after adjuvant radiation therapy for a primary intracerebral undifferentiated sarcoma.
Primary intracranial sarcomas of the central nervous system are rare tumors. They mainly arise from intracranial mesenchymal tissue present in the meninges and can occur at any age. Sometimes osteosarcoma can involve the skull rather than long body bones. In this latter case it is the more common subtype. Surgery, when possible, is a mandatory option often associated with radiation therapy (RT) and chemotherapy. Brain radionecrosis (BRN) is commonly observed due to the growing use of radiosurgery and higher cumulative doses of radiation therapy. The combination of perfusion magnetic resonance imaging and 18fluoro-deoxy-glucose positron emission tomography can help to differentiate tumor progression from radiation injury. Steroids, anticoagulants, and bevacizumab usually control BRN. However, BRN can also have an unfavorable course. ⋯ Primary intracranial sarcomas of the central nervous system are less prevalent among older adults with respect to the younger population. The use of RT alone or combined with chemotherapy is aimed at prolonging survival. However, it is not clearly defined if adjuvant treatments affect this parameter in older patients. RT should be carefully discussed owing to its potential severe neurologic toxicity. Indeed, a BRN can have a significant impact on quality of life and lead to death in certain cases.
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Case Reports
De novo cavernoma formation in a patient with Cowden syndrome and Lhermitte-Duclos disease.
Cowden syndrome (CS) is an autosomal dominant genodermatosis with a predisposition for the development of multiple cancers, benign hamartomas, and extracranial vascular malformations. Rarely, intracranial lesions like meningiomas and vascular malformations can also be present with CS. These vascular malformations include developmental venous anomalies, arteriovenous fistulae and cavernomas. Most cases of cavernomas are thought to be congenital, although in recent literature they have been shown to occur de novo with other conditions (e.g., other vascular malformations, trauma, postcranial surgery, viral infection, and genetic disorders). ⋯ We present a case of a patient with CS and LDD who had de novo cavernoma development several years after the initial diagnosis, as well as a review of the literature. We highlight the need of surveillance neuroimaging for patients with CS, as there is the risk of new development of vascular abnormalities (particularly cavernomas).
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Intracranial iatrogenic aneurysms (IIAs) developing after external ventricular drain (EVD) placement or removal have been only rarely reported. Most of these reports assumed a traumatic etiology; however, some have demonstrated an inflammatory origin. We have presented the case of an IIA that developed after an EVD had been inserted to treat acute hydrocephalus secondary to a ruptured arteriovenous malformation. We also performed a literature review and discussed how these IIAs might have an inflammatory rather than a traumatic etiology and how they might lie behind some of the cases of idiopathic hemorrhage observed after EVD manipulation. ⋯ IIAs associated with EVD placement or removal have been described as a rare complication of the procedure. Despite the scarce number of cases reported and the lack of histological examinations, common features such as a distal location, an incidental diagnosis, and a benign clinical course might suggest a mycotic or inflammatory origin rather than a traumatic etiology. Considering the high volume of EVDs placed annually, this complication might be more frequent than reported. Further studies investigating the association of risk factors for inflammatory aneurysms and hemorrhage incidence after EVD could provide information on this intriguing topic.