Lumbar drain for CSF leakage: a word of caution

A continuous lumbar drain is a frequently practiced procedure to prevent cerebrospinal fluid (CSF) infection in post-operative neurosurgical cases. However, the level of CSF drained must correspond to the intracranial pressures, where any accidental increase in lumboventricular gradient by slipping of the drainage bag below the level of the iliac crest can lead to over drainage and catastrophe. The learning point is to use automated or manual measures to monitor Intra-Cranial Pressure (ICP) and sound alarm in such an event to prevent sagging of the brain.

Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational prove of principle study

Background Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30° upright position. Methods Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30° upright position. Results Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80–5.00) mm during normal transportation to 6.00 (IQR 5.75–6.40) mm (p < 0.001) during braking. ONSD’s increased in all subjects in supine position. After raising the headrest of the gurney 30° mean ONSD increased from 4.80 (IQR 4.67–5.02) mm during normal transportation to 4.90 (IQR 4.80–5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all. Conclusions ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP.

Dilemma of seizure prophylaxis in sub-arachnoid haemorrhage

There is around 10% risk of developing seizures in post subarachnoid hemorrhage (SAH) period. This is considered to be linked to decreased oxygenation of brain due to increase in intra-cranial pressure obviating use of anti-epileptic drugs (AED) as a prophylactic measure. This review was done to study the effect and changes of blood brain barrier permeability in subarachnoid hemorrhage with regard to the present knowledge available and how it could be utilized to open arenas for future research for the rationalization of therapy for such patients. There is no consensus till date on the etiopathogenesis due to which no established guidelines are present for the management of such patients. It is safer to approach the patient on a case by case basis and assess whether to give prophylaxis or not based on the risk of development of seizures and adverse event profile of drugs. Also, there is a need to conduct prospective studies in this arena so as to get some meaningful interpretations which could be of some use to the future therapeutic guidelines.

Pineal region tumors: A diverse pathology in the seat of the soul

Introduction: Pineal region tumors include a variety of neoplasms of different histological origin arising from the pineal gland itself and from structures of the parapineal area. It is a rare tumor which accounts for 0.4-1% of all intracranial tumors. The objective of this study was to describe the epidemiology, clinical presentation and histopathology of pineal region tumors at National Neurosurgical Referral Center, Nepal. Methods: This was a descriptive study of all cases of pineal region tumors which were operated between January 2013 and December 2019 at National Neurosurgical Referral Center, National Academy of Medical Sciences, Bir Hospital. Results: A total of 14 cases were operated during the study period. The mean age was 12 years (4-50 years) with male preponderance (64%). Most of these patients had clinical features of raised intracranial pressure due to obstructive hydrocephalus followed by oculomotor sign in the form of Perinaud syndrome and endocrine dysfunction. Most common histopathology was Pineoblastoma in our study (4 out of 14). Conclusion: Pineal region tumors are most commonly seen in adolescent age group. Most common symptoms were features of raised intra cranial pressure due to hydrocephalus followed by Perinaud syndrome. Pineal region tumors consist of diverse histopathological variants.

Multiple Viral Co-infections in a Pediatric Patient of Acute Encephalitis Syndrome (AES) - An Unique Case Report

The occurrence of viral co-infection is always a challenging issue in pediatrics which indicates underestimation of causal viral pathogens. A 6-year-old girl child from Patna had diagnosed a rare case of multi-viral co-infection in February 2020. She was manifested with oblivion along with high-grade fever, weakness, nasal bleed, headache, and body ache. She had altered sensorium with mildly dilated pupils. Her three classical meningeal sign i.e. Kernig's sign, Brudzinski's sign, and nuchal rigidity were found positive. She clinically investigated with a strong suspicion of viral infectivity. Awfully, she was diagnosed with multi-viral co-infection including Japanese Encephalitis, Dengue, Chikungunya, Cytomegalovirus, and Rubella where as HSV and VZV detected borderline. The IgM detection for JE using the CSF sample was found equivocal. The infection was also confirmed by CECT brain scanning. She got proper medication including antiemetic, antipyretic, antiepileptic drugs, antibiotics, anti-viral drugs, and 20% Mannitol for reducing the intra cranial pressure. After medication under proper clinical supervision, she improved completely with any seizures and viral infections. She advised for follow-up after a month. Such occurrences of multi-viral co-infections deserve proper attention and awareness among the healthcare experts about the severity of drugs.

Defisit Neurologis Iskemik Tertunda pada Perdarahan Subaraknoid akibat Rupture Aneurisma yang dilakukan Tindakan Coiling

Stroke dapat terjadi akibat terhentinya aliran darah ke otak, yang terjadi secara mendadak. Penyebab terbanyak stroke adalah berkurangnya pasokan darah ke otak (stroke iskemik). Penyebab stroke lainnya adalah perdarahan (stroke hemoragik). Perdarahan subaraknoid (SAH) biasanya dapat terjadi baik karena ruptur aneurisma, atau karena trauma. Perempuan, 46 tahun dengan GCS 14 (E4M6V4) dengan hipertensi tidak terkontrol mengalami nyeri kepala hebat. Dari pemeriksaan CT scan memperlihatkan adanya perdarahan subaraknoid dan edema sereberi. Pasien ini dilakukan tindakan coiling aneurisma cito dengan anestesia umum. Pasca coiling pasien dirawat di ruang intensive care unit (ICU). Pasca perawatan 1 hari di ICU, pasien dipindahkan ke ruang high care unit (HCU), dengan kondisi stabil. Penurunan kesadaran mulai terjadi saat perawatan hari kedua, sempat dilakukan pemasangan lumbar drain pada hari ketiga, untuk membantu mengurangi hidrosefalus dan juga menurunkan tekanan intra kranial. Pada perawatan hari ketigabelas kesadaran menurun drastis menjadi E1M1V1, pasien dipindahkan ke ruang ICU, dan meninggal esok harinya. Penurunan kesadaran pasca coiling diakibatkan oleh peningkatan tekanan intra kranial, yang pada kasus ini disebabkan oleh edema sereberi luas. Early Brain Injury ¬ditambah dengan adanya vasopasme menyebabkan terjadinya delayed ischemic neurological deficit. Terapi yang sudah dikerjakan baik farmakologis maupun non farmakologis, tetap tidak bisa memperbaiki keadaan pasien. Delayed Ischemic Neurological Defisit (DIND) Pasca Coiling Subarachnoid Hemorrhage (SAH) e.c Ruptur AneurismaAbstractStroke can occur due to the cessation of blood flow to the brain, which occurs suddenly. The most common cause of stroke is reduced blood supply to the brain (ischemic stroke). Another cause of stroke is bleeding in the brain (hemorrhagic stroke). Subarachnoid hemorrhage (SAH) usually results from ruptured aneurysms or because of trauma. Women, 46 years old with GCS 14 (E4M6V4) with uncontrolled hypertension experienced severe headache since 2 days before admitted to the hospital. The CT scan examination showed subarachnoid hemorrhage and edema of the brain. This patient then performed emergency coiling of aneurysm with general anesthesia. During the procedure the patient is in stable condition. Post coiling the patient was sent to the ICU room. After 1 day in ICU, the patient was transferred to high care unit (HCU) room, with stable condition. Decreased of consciousness began to occur during the second day of treatment, had done lumbar drain installation on the third day, to help reduce the hydrocephalus and also improve intra-cranial pressure. On the thirteenth day care GCS was decrease suddenly to E1M1V1, the patient was transferred to the ICU room, the next day the patient was declared dead. The decrease of consciousness post coiling results from an increase in intra-cranial pressure, which in this case is due to severe brain edema. Earlu brain injury along with the occurence of vasospasm lead to delayed ischemic neurological deficit. Pharmacological and non-pharmacological therapy had been given to the patient still couldn’t improve the patient condition

Neurological Perspectives of Neurogenic Pulmonary Edema

Background: Neurogenic pulmonary edema (NPE) is characterized by acute respiratory distress triggered by acute, severe compromise of the central nervous system (CNS). This review aims at summarizing and discussing recent and previous findings about the type and frequency of CNS triggers of NPE, pathogenesis, diagnosis, treatment, and outcome of patients experiencing NPE. Key Messages: NPE is diagnosed in the presence of pink, frothy sputum, pulmonary edema, bilateral opacities on X-ray, PaO2:PiO2 <200 mm Hg, acute CNS compromise with increased intra-cranial pressure, rapid resolution within 48–72 h, and the absence of alternative causes of respiratory distress. The most common cerebral triggers of NPE include enterovirus-71-associated brainstem encephalitis, subarachnoid bleeding, intracerebral bleeding, traumatic brain injury, epilepsy, ischemic stroke, intracranial/spinal surgery, multiple sclerosis, electroconvulsive therapy, subdural/epidural hematoma, intoxication, hypoxia, and hydrocephalus. Simultaneous treatment of CNS and pulmonary compromise is required. Cerebral treatment involves infectiologists, neurologists, and neurosurgeons. Pulmonary treatment is mainly supportive, but if ineffective, extracorporeal membrane oxygenation or thermodilution are alternative options. Applying intensive care measures, the outcome of NPE has improved. Summary: CNS-disease triggering NPE is more variegated than anticipated. Delineation of NPE from other pulmonary or cardiac conditions mimicking NPE is crucial to take appropriate measures and improve the outcome of these patients.