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jcrmhscasereports · 2 years ago

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Delayed onset of intracerebral tension pneumocephalus 2 years after an anterior skull base fracture: Case report by Sokchan Sim in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Pneumocephalus, the presence of air within the cranial cavity, is most commonly caused by trauma, tumor, infection and fistulation into the intracranial cavity or secondary to neurosurgery. We describe an unusually delayed neurological deficit from intracerebral tension pneumocephalus, 2 years following a head trauma with anterior skull base fracture. A 22-year-old man presented to our neurosurgical consultation with recurrent seizures and progressive right hemiparesis. The brain CT scan without iv contrast revealed an intracerebral tension pneumocephalus in the left frontal lobe, and a persistent hole in the left anterior frontal skull base connecting to pneumocephalus. We performed a left frontal craniotomy, and dura-plasty using galea flap to cover the skull-base bone defect. The patient has recovered gradually from his motor deficit after this surgery, finally to the level that he could play his favorite guitar. This is a rare case of a delayed development neurological deficit due to pneumocephalus from a “ball-valve” effect secondary to an old anterior skull base fracture.

Key words: Pneumocephalus, hemiparesis, craniotomy, dura-plasty

INTRODUCTION

Pneumocephalus is an air entrapment in the cranial cavity. It is commonly seen after head and facial trauma, ear infections, and tumors of the skull base or neurosurgical interventions. In some extremely rare cases, it happens spontaneously. Pneumocephalus is a complication of head injury in 3.9–9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h). In tension pneumocephalus, the continuous accumulation of intracranial air is thought to be caused by a “ball-valve” mechanism. In turn, this may lead to a mass effect on the brain, with subsequent neurological deterioration and signs of herniation. Delayed tension pneumocephalus is extremely rare and requires proper neurosurgical attention. Surgical treatment involves aspiration of air into a syringe and closure of the dura defect through a cranial surgery.

CASE REPORT

A 22-year-old male presented to our neurosurgical consultation with chronic headaches, progressive right-sided weakness and occasional seizures. Two years prior to this visit, he suffered a severe traumatic brain injury by motorcycle accident. He had lost his consciousness for three days, and hospitalized in a provincial hospital for two weeks without any surgical intervention. He was then discharged home with persistent rhinorrhea for 10 months before it ceased spontaneously. 18 months after his injury, this patient began having progressive weakness on his right side of the body, and some episodes of seizures. He also reported occasional headaches. He was otherwise healthy before this accident. On examination, the young man had full consciousness, was alert and oriented. He had grade 3 out of 5 hemiparesis on his right side. A brain CT scan without iv contrast was obtained revealing a large pneumocephalus in the left frontal lobe. We noted a continuity of the air and the anterior skull base defect. (Figure.1)

CSF examination and culture were negative for infection, as well as the nasal swab.

Figure 1: A. Axial view of the CT scan showing hypodensity area in the left frontal lobe, pneumocephalus. B. Sagittal view presenting the large air space with its connection to the frontal skull base. C. Coronal view showing the bony defect of the anterior skull base.

We decided to perform the surgery by doing bi-coronal approach for a left frontal craniotomy and repair of the dura defect on the frontal skull base using the pedunculated galea flap. (Figure.2)

Figure 2 :A. Bi-coronal incision with preservation of large frontal galea. B. Galea still attached to the frontal base is lifted up.

The surgery went well without any complication. The post-operative course was without any significant event. No sign of infection was noticed. The patient recovered gradually from his motor deficit on his right side. The post-operative CT scan showed complete resorption of the intracerebral pneumocephalus. (Figure.3). Intravenous prophylactic antibiotics were used to prevent meningitis.

Figure 3: Post-operative CT scan showing no hypodensity area in the left frontal lobe, complete disappearance of the pneumocephalus A. Axial view B. Sagittal view C. Coronal view. Noted the small bone defect from craniotomy site.

At one-month follow-up, his motor function on the right body became normal that he could play his favorite guitar again. At three-month follow up, he had an episode of new seizures, we controlled his seizures with anti-epileptic drugs for two years afterward.

DISCUSSION

The term “pneumocephalus” was first coined more than one century ago by Luckett and Wolff independently. The term “tension pneumocephalus” was proposed by Ectors, Kessler, and Stern in 1962. Pneumocephalus or also known as pneumatocele or intracranial aerocele is defined as the presence of air in the epidural, subdural, or subarachnoid space, within the brain parenchyma or ventricular cavities. It is a complication of head injury in 3.9 – 9.7% cases. It also appears after supratentorial craniotomy surgery. The accumulation of intracranial air can be acute, less than 72 hours, or delayed, more than 72 hours.

Two mechanisms have been proposed to explain pneumocephalus. In the first mechanism, the pathophysiologic process starts with Cerebro-Spinal Fluid (CSF) leak in the presence of associated discontinuity of the cranium and leptomeningeal disruption. Subsequent development of relative negative Intra-cranial Pressure (ICP) results in a sufficient “vacuum effect” to cause additional accumulation of air within the cranial cavity. This air is generally distributed in the subarachnoid space. The second mechanism is based on the presence of a “one-way valve” at the site of the leptomeningeal tear. In this case, we found on the CT scan images a bone and dura defect in the left anterior skull base, in connection with intracerebral air collection. The air went in, and was trapped inside the frontal cerebral parenchyma. Slowly it became larger and more significant, putting mass effect into the brain tissue of the patient’s frontal lobe. The patient had experienced rhinorrhea (CSF leak through the nose) after the head trauma but disappeared spontaneously after 10 months. He then developed right hemiparesis and experienced episodes of seizures. Recurrent headaches were also a main complaint. These signs and symptoms were described in previous reports about tension pneumocephalus.

The diagnostic imaging for pneumocephalus is CT scan. “Mount Fuji sign” is described when there are bilateral hypoattenuation collections, causing compression and separation of the frontal lobes on CT scan. In our case, an intraparenchymal air-filled long cavity was seen in the left frontal lobe, with its tip connecting to the frontal skull base.

Most cases of pneumocephalus tend to resolve spontaneously with conservative management. Nonoperative management involves oxygen therapy, maintaining the patient supine or in Trendelenburg position, prophylactic antimicrobial therapy (especially in posttraumatic cases), adequate analgesia, frequent neurologic checks, and repeated CT scans. The use of continuous high concentration inspired oxygen as a treatment modality for traumatic pneumocephalus may have certain theoretical benefits. Prompt decompression of intracranial air is the initial treatment of symptomatic pneumocephalus. The principles of subsequent treatment parallel those for a CSF leak. It is important to identify the site where the communication between the air cavity and the external environment occurs. If the site can be identified, the passage should be sealed off, thereby decreasing the possibility of worsening or recurrent pneumocephalus. Effective therapy of tension pneumocephalus through a controlled decompression using a closed water-seal drainage system has also been described. In our case, we performed a full scale left frontal craniotomy to evacuate air from the intraparenchymal cavity, closure of the skull base defect by using pedunculated galea flap, re-enforced by bio-glue as a sealing material.

CONCLUSION

Tension pneumocephalus is a life-threatening neurosurgical case. Although the development of this massive intracerebral air trap was delayed in this case, it caused significant neurological deficit. The patients who suffer from head trauma, with CSF leak should be subject for long term follow up.

Disclosure: Nothing to disclose, and there was no conflict of interest among the authors.

Research ethics: Informed consent has been obtained from the patient.

For more information: https://jmedcasereportsimages.org/about-us/

For more submission : https://jmedcasereportsimages.org/

#Pneumocephalus #hemiparesis #craniotomy #dura-plasty #CT #neurosurgical #headaches #Cerebro-Spinal Fluid #ICP #Intra-cranial Pressure #CSF #Sokchan Sim #jcrmhs

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didanawisgi · 4 years ago

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2020 Yale-G’s Monthly Clinical Updates According to www.uptodate.com

(As of 2020-11-12, updated in Yale-G’s 6th-Ed Kindle Version; will be emailed to buyers of Ed6 paper books)

Chapter 1: Infectious Diseases

Special Viruses: Coronaviruses

Coronaviruses are important human and animal pathogens, accounting for 5-10% community-acquired URIs in adults and probably also playing a role in severe LRIs, particularly in immunocompromised patients and primarily in the winter. Virology: Medium-sized enveloped positive-stranded RNA viruses as a family within the Nidovirales order, further classified into four genera (alpha, beta, gamma, delta), encoding 4-5 structural proteins, S, M, N, HE, and E; severe types: severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and novel coronavirus (2019-nCoV, which causes COVID-19). Routes of transmission: Similar to that of rhinoviruses, via direct contact with infected secretions or large aerosol droplets. Immunity develops soon after infection but wanes gradually over time. Reinfection is common. Clinical manifestations: 1. Coronaviruses mostly cause respiratory symptoms (nasal congestion, rhinorrhea, and cough) and influenza-like symptoms (fever, headache). 2. Severe types (2019-nCoV, MERS-CoV, and SARS-CoV): Typically with pneumonia–fever, cough, dyspnea, and bilateral infiltrates on chest imaging, and sometimes enterocolitis (diarrhea), particularly in immunocompromised hosts (HIV+, elders, children). 3. Most community-acquired coronavirus infections are diagnosed clinically, although RT-PCR applied to respiratory secretions is the diagnostic test of choice.

Treatment: 1. Mainly consists of ensuring appropriate infection control and supportive care for sepsis and acute respiratory distress syndrome. 2. In study: Chloroquine showed activity against the SARS-CoV, HCoV-229E, and HCoV-OC43 and remdesivir against 2019-nCoV. Dexamethasone may have clinical benefit.

Prevention: 1. For most coronaviruses: The same as for rhinovirus infections, which consist of handwashing and the careful disposal of materials infected with nasal sec retions. 2. For novel coronavirus (2019-nCoV), MERS-CoV, and SARS-CoV: (1) Preventing exposure by diligent hand washing, respiratory hygiene, and avoiding close contact with live or dead animals and ill individuals. (2) Infection control for suspected or confirmed cases: Wear a medical mask to contain their respiratory secretions and seek medical attention; standard contact and airborne precautions, with eye protection.

Hepatitis A: HAV vaccine is newly recommended to adults at increased risk for HAV infection (substance use treatment centers, group homes, and day care facilities for disabled persons), and to all children and adolescents aged 2 to 18 years who have not previously received HAV vaccine.

Hepatitis C: 8-week glecaprevir-pibrentasvir is recommended for chronic HCV infection in treatment-naive patients. In addition to the new broad one-time HCV screening (17-79 y/a), a repeated screening in individuals with ongoing risk factors is suggested.

New: Lefamulin is active against many common community-acquired pneumonia pathogens, including S. pneumoniae, Hib, M. catarrhalis, S. aureus, and atypical pathogens.

New: Cefiderocol is a novel parenteral cephalosporin that has activity against multidrug-resistant gram-negative bacteria, including carbapenemase-producing organisms and Pseudomonas aeruginosa resistant to other beta-lactams. It’s reserved for infections for which there are no alternative options.

New: Novel macrolide fidaxomicin is reserved for treating the second or greater recurrence of C. difficile infection in children. Vitamin C is not beneficial in adults with sepsis and ARDS.

Chapter 2: CVD

AF: Catheter ablation is recommended to some drug-refractory, paroxysmal AF to decrease symptom burden. In study: Renal nerve denervation has been proposed as an adjunctive therapy to catheter ablation in hypertensive patients with AF. Alcohol abstinence lowers the risk of recurrent atrial fibrillation among regular drinkers.

VF: For nonshockable rhythms, epinephrine is given as soon as feasible during CPR, while for shockable rhythms epinephrine is given after initial defibrillation attempts are unsuccessful. Avoid vasopressin use.

All patients with an acute coronary syndrome (ACS) should receive a P2Y12 inhibitor. For patients undergoing an invasive approach, either prasugrel or ticagrelor has been preferred to clopidogrel. Long-term antithrombotic therapy in patients with stable CAD and AF has newly been modified as either anticoagulant (AC) monotherapy or AC plus a single antiplatelet agent.

Long-term antithrombotic therapy (rivaroxaban +/- aspirin) is recommended for patients with AF and stable CAD. Ticagrelor plus aspirin is recommended for some patients with CAD and diabetes.

VTE (venous thromboembolism): LMW heparin or oral anticoagulant edoxaban is the first-line anticoagulants in patients with cancer-associated VTE.

Dosing of warfarin for VTE prophylaxis in patients undergoing total hip or total knee arthroplasty should continue to target an INR of 2.5.

Chapter 3: Resp. Disorders

Asthma: Benralizumab is an IL-5 receptor antibody that is used as add-on therapy for patients with severe asthma and high blood eosinophil counts.

Recombinant GM-CSF is still reserved for patients who cannot undergo, or who have failed, whole lung lavage.

Pulmonary embolism (PE): PE response teams (PERT, with specialists from vascular surgery, critical care, interventional radiology, emergency medicine, cardiac surgery, and cardiology) are being increasingly used in management of patients with intermediate and high-risk PE.

Although high-sensitivity D-dimer testing is preferred, protocols that use D-dimer levels adjusted for pretest probability may be an alternative to unadjusted D-dimer in patients with a low pretest probability for PE.

Non-small cell lung cancer (NSCLC): Newly approved capmatinib is for advanced NSCLC associated with a MET mutation, and selpercatinib for those with advanced RET fusion-positive. Atezolizumab was newly approved for PD-L1 high NSCLC.

Circulating tumor DNA tests for cancers such as NSCLC are increasingly used as “liquid biopsy”. Due to its limited sensitivity, NSCLC patients who test (-) for the biomarkers should undergo tissue biopsy.

Cystic Fibrosis (CF): Tx: CFTR modulator therapy (elexacaftor-tezacaftor-ivacaftor) is recommended for patients ≥12 years with the F508del variant.

Vitamin E acetate has been implicated in the development of electronic-cigarette, or vaping, product use associated lung injury.

Chapter 4: Digestive and Nutritional Disorders

Comparison of Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC):

Common: They are two major types of chronic cholestatic liver disease, with fatigue, pruritus, obstructive jaundice, similar biochemical tests of copper metabolism, overlapped histology (which is not diagnostic), destructive cholangitis, and both ultimately result in cirrhosis and hepatic failure. (1) PBC: Mainly in middle-aged women, with keratoconjunctivitis sicca, hyperpigmentation, and high titer of antimitochondrial Ab (which is negative for PSC). (2) PSC: Primarily in middle-aged men, with chronic ulcerative colitis (80%), irregular intra- and extra-hepatic bile ducts, and anti-centromere Ab (+).

CRC: Patients with colorectal adenomas at high risk for subsequent colorectal cancer (CRC) (≥3 adenomas, villous type with high-grade dysplasia, or ≥10 mm in diameter) are advised short follow-up intervals for CRC surveillance. Pembrolizumab was approved for the first-line treatment of patients with unresectable or metastatic DNA mismatch repair (dMMR) CRC.

UC and CRC: Patients with extensive colitis (not proctitis or left-sided colitis) have increased CRC risk.

Eradication of H. pylori: adding bismuth to clarithromycin-based triple therapy for patients with risk factors for macrolide resistance.

Thromboelastography and rotational thromboelastometry are bedside tests recommended for patients with cirrhosis and bleeding.

Pancreatic cancer: Screening for patients at risk for hereditary pancreatic cancer (PC): Individuals with mutations in the ataxia-telangiectasia mutated gene and one first-degree relative with PC can be screened with endoscopic ultrasound and/or MRI/magnetic retrograde cholangiopancreatography.

Olaparib is recommended for BRCA-mutated advanced pancreatic cancer after 16 weeks of initial platinum-containing therapy.

HCC (unresectable): New first-line therapy is a TKI (sorafenib or sunitinib) or immune checkpoint inhibitor atezolizumab plus bevacizumab, +/- doxorubicin. Monitor kidney toxicity for these drugs.

UC: Ustekinumab (-umab) anti-interleukin 12/23 antibody, is newly approved for the treatment of UC.

Crohn disease: The combination of partial enteral nutrition with the specific Crohn disease exclusion diet is a valuable alternative to exclusive enteral nutrition for induction of remission.

Obesity: Lorcaserin, a 5HT2C agonist that can reduce food intake, has been discontinued in the treatment of obesity due to increased malignancies (including colorectal, pancreatic, and lung cancers).

Diet and cancer deaths: A low-fat diet rich in vegetables, fruits, and grains experienced fewer deaths resulted from many types of cancer.

Note that H2-blockers (-tidines) are no longer recommended due to the associated carcinogenic N-nitrosodimethylamine.

Gastrointestinal Stromal Tumors (GIST):

GIST is a rare type of tumor that occurs in the GI tract, mostly in the stomach (50%) or small intestine. As a sarcoma, it’s the #1 common in the GI tract. It is considered to grow from specialized cells in the GI tract called interstitial cells of Cajal, associated with high rates of malignant transformation.

Clinical features and diagnosis: Most GISTs are asymptomatic. Nausea, early satiety, bloating, weight loss, and signs of anemia may develop, depending on the location, size, and pattern of growth of the tumor. They are best diagnosed by CT scan and mostly positive staining for CD117 (C-Kit), CD34, and/or DOG-1.

Treatment: Approaches include resection of primary low-risk tumors, resection of high-risk primary or metastatic tumors with a tyrosine kinase inhibitor (TKI) imatinib for 12 months, or if the tumor is unresectable, neoadjuvant imatinib followed by resection. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. Avapritinib or ripretinib (new TKI) is recommended for advanced unresectable or metastatic GIST with PDGFRA mutations.

Anal Cancer:

Anal cancer is uncommon and more similar to a genital cancer than it is to a GI malignancy by etiology. By histology, it is divided into SCC (#1 common) and adenocarcinoma. Anal cancer (particularly SCC among women) has increased fast over the last 30 years and may surpass cervical cancer to become the leading HPV-linked cancer in older women. A higher incidence has been associated with HPV/HIV infection, multiple sexual partners, genital warts, receptive anal intercourse, and cigarette smoking. SCCs that arise in the rectum are treated as anal canal SCCs.

Clinical features and diagnosis: 1. Bleeding (#1) and itching (often mistaken as hemorrhoids). Later on, patients may develop focal pain or pressure, unusual discharges, and lump near the anus, and changes in bowel habits. 2. Diagnosis is made by a routine digital rectal exam, anoscopy/proctoscopy plus biopsy, +/- endorectal ultrasound.

Treatment: Anal cancer is primarily treated with a combination of radiation, chemotherapy, and surgery—especially for patients failing the above therapy or for true perianal skin cancers.

Chapter 5: Endocrinology

Diabetes (DM): Liraglutide can be added as a second agent for type-2 DM patients who fail monotherapy with metformin or as a third agent for those who fail combination therapy with metformin and insulin. Metformin is suggested to prevent type 2 DM in high-risk patients in whom lifestyle interventions fail to improve glycemic indices. Metabolic (bariatric) surgery improves glucose control in obese patients with type 2 DM and also reduce diabetes-related complications, such as CVD. Teprotumumab, an insulin-like growth factor 1 receptor inhibitor, can be used for Graves’ orbitopathy if corticosteroids are not effective. Subclinical hypothyroidism should not be routinely treated (with T4) in older adults with TSH <10 mU/L.

Chapter 6: Hematology & Immunology

Anticoagulants: Apixaban is preferred to warfarin for atrial fibrillation with osteoporosis because it lowers the risk of fracture. Rivaroxaban is inferior to warfarin for antiphospholipid syndrome.

Cancer-associated VTE: LMW heparin or oral edoxaban is the first-line anticoagulant prophylaxis.

NH-Lymphoma Tx: New suggestion is four cycles of R(rituximab)-CHOP for limited stage (stage I or II) diffuse large B cell non-Hodgkin lymphoma (DLBCL) without adverse features. New suggestions: selinexor is for patients with ≥2 relapses of DLBCL, and tafasitamab plus lenalidomide is for patients with r/r DLBCL who are not eligible for autologous HCT.

Chimeric antigen receptor (CAR)-T (NK) immunotherapy is newly suggested for refractory lymphoid malignancies, with less toxicity than CAR-T therapy. Polatuzumab + bendamustine + rituximab (PBR) is an alternative to CAR-T, allogeneic HCT, etc. for multiply relapsed diffuse large B-C NHL.

Refractory classic Hodgkin lymphoma (r/r cHL) is responsive to immune checkpoint inhibition with pembrolizumab or nivolumab, including those previously treated with brentuximab vedotin or autologous transplantation.

Mantle cell lymphoma: Induction therapy is bendamustine + rituximab or other conventional chemoimmunotherapy rather than more intensive approaches. CAR-T cell therapy is for refractory mantle cell lymphoma.

AML: Gilteritinib is a new alternative to intensive chemotherapy for patients with FLT3-mutated r/r AML.

Oral decitabine plus cedazuridine is suggested for MDS and chronic myelomonocytic leukemia.

Multiple myeloma (MM): Levofloxacin prophylaxis is suggested for patients with newly diagnosed MM during the first three months of treatment. For relapsed MM: Three-drug regimens (daratumumab, carfilzomib, and dexamethasone) are newly recommended.

Transplantation: As the transplant waitlist continues to grow, there may be an increasing need of HIV-positive to HIV-positive transplants.

Porphyria: Porphyria is a group of disorders (mostly inherited) caused by an overaccumulation of porphyrin, which results in hemoglobin and neurovisceral dysfunctions, and skin lesions. Clinical types, features, and diagnosis: I. Acute porphyrias: 1. Acute intermittent porphyria: Increased porphobilinogen (PBG) causes attacks of abdominal pain (90%), neurologic dysfunction (tetraparesis, limb pain and weakness), psychosis, and constipation, but no rash. Discolored urine is common. 2. ALA (aminolevulinic acid) dehydratase deficiency porphyria (Doss porphyria): Sensorimotor neuropathy and cutaneous photosensitivity. 3. Hereditary coproporphyria: Abdominal pain, constipation, neuropathies, and skin rash. 4. Variegate porphyria: Cutaneous photosensitivity and neuropathies. II. Chronic porphyrias: 1. Erythropoietic porphyria: Deficient uroporphyrinogen III synthase leads to cutaneous photosensitivity characterized by blisters, erosions, and scarring of light-exposed skin. Hemolytic anemia, splenomegaly, and osseous fragility may occur. 2. Cutaneous porphyrias–porphyria cutanea tarda: Skin fragility, photosensitivity, and blistering; the liver and nervous system may or may not be involved. III. Lab diagnosis: Significantly increased ALA and PBG levels in urine have 100% specificity for most acute porphyrias. Normal PBG levels in urine can exclude acute porphyria. Treatment: 1. Acute episodes: Parenteral narcotics are indicated for pain relief. Hemin (plasma-derived intravenous heme) is the definitive treatment and mainstay of management. 2. Avoidance of sunlight is the key in treating cutaneous porphyrias. Afamelanotide may permit increased duration of sun exposure in patients with erythropoietic protoporphyria.

Chapter 7: Renal & UG

Membranous nephropathy (MN): Rituximab is a first-line therapy in patients with high or moderate risk of progressive disease and requiring immunosuppressive therapy.

Diabetes Insipidus (DI): Arginine-stimulated plasma copeptin assays are newly used to diagnose central DI and primary polydipsia, often alleviating the need for water restriction, hypertonic saline, and exogenous desmopressin.

Prostate cancer: Enzalutamide (new androgen blocker) is available for metastatic castration-sensitive prostate cancer. Cabazitaxel, despite its great toxicity, is suggested as third-line agent for metastatic prostate cancer. Either early salvage RT or adjuvant RT is acceptable after radical prostatectomy for high-risk disease.

UG cancers: Nivolumab plus ipilimumab is suggested in metastatic renal cell carcinoma for long-term survival.

Enfortumab vedotin is suggested in locally advanced or metastatic urothelial carcinoma. Maintenance avelumab is recommended with other chemotherapy in advanced urothelial bladder cancer. Pyelocalyceal mitomycin is suggested for low-grade upper tract urothelial carcinomas.

Chapter 8: Rheumatology

Janus kinase (JAK) inhibitors (upadacitinib, filgotinib) are new options for active, resistant RA and ankylosing spondylitis.

Graves’ orbitopathy: new therapy–teprotumumab, an insulin-like growth factor 1 receptor inhibitor.

Chapter 9: Neurology & Special Senses

Epilepsy: Cenobamate, a novel tetrazole alkyl carbamate derivative that inhibits Na-channels, provides a new treatment option for patients with drug-resistant focal epilepsy. A benzodiazepine plus either fosphenytoin, valproate, or levetiracetam is recommended as the initial treatment of generalized convulsive status epilepticus.

Migraine: Lasmiditan is a selective 5H1F receptor agonist that lacks vasoconstrictor activity, new therapy for patients with relative contraindications to triptans due to cardiovascular risk factors.

Stroke: New recommendation for cerebellar hemorrhages >3 cm in diameter is surgical evacuation. TBI: Antifibrolytic agent tranexamic acid is newly recommended for moderate and severe acute traumatic brain injury (TBI).

Ofatumumab is a new agent that may delay progression of MS.

Chapter 10: Dermatology

Minocycline foam is a new topical drug option for moderate to severe acne vulgaris.

Melanloma: Nivolumab plus ipilimumab in metastatic melanoma has confirmed long-term survival. With sun-protective behavior, melanoma incidence is decreasing.

New: Tazemetostat is suggested in patients with locally advanced or metastatic epithelioid sarcoma (rare and aggressive) ineligible for complete surgical resection.

Psoriasis: New therapies for severe psoriasis and psoriatic arthritis: a TNF-alpha inhibitor (infliximab or adalimumab, golimumab) or IL-inhibitor (etanercept or ustekinumab) is effective. Ixekizumab is a newly approved monoclonal antibody against IL-17A. Clinical data support vigilance for signs of symptoms of malignancy in patients with psoriasis.

Chapter 11: GYH

Breast cancer: Although combined CDK 4/6 and aromatase inhibition is an effective strategy in older adults with advanced receptor-positive, HER2-negative breast cancer, toxicities (myelosuppression, diarrhea, and increased creatinine) should be carefully monitored. SC trastuzumab and pertuzumab is newly recommended for HER2-positive breast cancer.

Whole breast irradiation is suggested for most early-stage breast cancers treated with lumpectomy. Accelerated partial breast irradiation can be an alternative for women ≥50 years old with small (≤2 cm), hormone receptor-positive, node-negative tumors.

Endocrine therapy is recommended for breast cancer prevention in high-risk postmenopausal women.

Uterine fibroids: Elagolix (oral gonadotropin-releasing hormone antagonist) in combination with estradiol and norethindrone is for treatment of heavy menstrual bleeding (HMB) due to uterine fibroids.

Chapter 12: OB

Table 12-6: Active labor can start after OS > 4cm, and 6cm is relatively more acceptable but not a strict number.

Table 12-7: Preeclampsia is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria, or of hypertension and significant end-organ dysfunction with or without proteinuria, in the last half of pregnancy or postpartum. Once a diagnosis of preeclampsia is established, testing for proteinuria is no longerdiagnostic or prognostic. “proteinuria>5g/24hours” may only indicate the severity.

Mole: For partial moles, obtain a confirmatory hCG level one month after normalization; for complete moles, reduce monitoring from 6 to 3 months post-normalization.

Chapter 14: EM

SHOCK RESUSCITATION

Emergency treatment—critical care!

“A-B-C”: Breathing: …In mechanically ventilated adults with critical illness in ICU, intermittent sedative-analgesic medications (morphine, propofol, midazolam) are recommended.

Chapter 15: Surgery

Surgery and Geriatrics: Hemiarthroplasty is a suitable option for patients who sustain a displaced femoral neck fracture.

Chapter 16: Psychiatry

Depression: Both short-term and maintenance therapies with esketamine are beneficial for treatment-resistant depression.

Schizophrenia: Long-term antipsychotics may decrease long-term suicide mortality.

Narcolepsy: Pitolisant is a novel oral histamine H3 receptor inverse agonist used in narcolepsy patients with poor response or tolerate to other medications. Oxybate salts, a lower sodium mixed-salt formulation of gamma hydroxybutyrate is for treatment of narcolepsy with cataplexy.

Chapter 17: Last Chapter

PEARLS—Table 17-9: Important Immunization Schedules for All (2020, USA)

Vaccine Birth 2M 4M 6M 12-15M 2Y 4-6Y 11-12Y Sum

HAV 1st 2nd (2-18Y) 2 doses

HBV 1st 2nd 3rd (6-12M) 3 doses

DTaP 1st 2nd 3rd 4th (15-18M) 5th + Td per 10Y

IPV 1st 2nd 3rd (6-18M) 4th 4 doses

Rotavirus 1st 2nd 2 doses

Hib 1st 2nd (3rd) (3-4th) 3-4 doses

MMR 1st 2nd 2 doses

Varicella 1st 2nd + Shingles at 60Y

Influenza 1st (IIV: 6-12Y; LAIV: >2Y (2nd dose) 1-2 doses annually

PCV 1st 2nd 3rd 4th PCV13+PPSV at 65Y

MCV (Men A, B) 1st Booster at 16Y

HPV 9-12Y starting: <15Y: 2 doses (0, 6-12M); >15Y or immunosuppression: 3 doses (0, 2, 6M).

Chapter 17 HYQ answer 22: No routine prostate cancer screening (including PSA) is recommended and answer “G” is still correct–PSA

screening among healthy men is not routinely done but should be indicated in a patient with two risk factors.

#medical school #Resources

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mcatmemoranda · 5 years ago

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It was a kid who got hit in the head with a metal baseball bat. As soon as it said he had clear rhinorrhea and bruises around his eyes, I knew it was a basilar skull fracture.

In basilar skull fracture, there is a fracture through the base of the skull involving the sphenoid bone, ethmoid bone, temporal bone, and/or the occipital bone. These types of fractures require a high mechanism of injury and can cause tearing of the meninges which can cause leaking of cerebrospinal fluid. The cerebrospinal fluid can build up behind the tympanic membrane and leak out the eustachian tube resulting in CSF rhinorrhea. If there is a rupture of the tympanic membrane, the patient will display CSF otorrhea. The patient can also have CSF rhinorrhea if there is a fracture of the anterior skull. One can tell if the ear or the nose are leaking CSF fluid by placing a drop of the fluid on a paper towel. The blood should coalesce in the center and form a ring of clear fluid on the periphery indicating CSF fluid. Other signs of basilar skull fracture include: Seventh cranial nerve palsy, hemotympanum (visual blood behind the tympanic membrane), periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), vertigo. Management includes performing a CT scan of the head, cervical spine, and facial bones to look for other pathology, consultation with a neurosurgeon, and airway management if necessary. Consider a discussion of prophylactic antibiotics with the neurosurgeon.

Bottom Line: Basilar skull fractures should be suspected in patients with periorbital ecchymosis, otorrhea, rhinorrhea, battle's signs. Although the above injuries can occur when a patient has a basilar skull fracture, none of the other injuries will cause findings of battle's signs, periorbital ecchymosis, etc.

#basilar skull fracture #raccoon eyes #battle sign #rhinorrhea #otorrhea #clear rhinorrhea #clear otorrhea

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thebrainandspine · 3 years ago

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The Brain and Spine, Max Super Speciality Hospital in Delhi has specialized facility of operation theatres and well equipped departments. The Cerebrospinal Fluid Leak Treatment in India is given by the hospital by best doctors appointed here. Visit The Brain and Spine in Delhi for the best treatment.

#best neuro doctor in delhi #Herniated Disc Surgery in delhi #Cerebrospinal Fluid Leak Treatment in India

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mayomhospital05 · 3 years ago

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ourhaileydavies · 3 years ago

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Juniper Publishers-Open Access Journal of Head Neck & Spine Surgery

A Rare Case of Traumatic Leptomeningeal Cyst in Adult: Case Report

Authored by Aneesh KM

Abstract

Traumatic leptomeningeal cysts are a rare complication of a childhood skull fracture. Clinical manifestations of a childhood trauma are very rare in adults and usually presents as a nontender subcutaneous mass with progressive neurological deficit and seizures.

Keywords: Leptomeningeal cyst; Adult; Trauma; Seizures; Skull fracture

Abbrevations: CT: Computed Tomography; MRI: Magnetic Resonance Imaging; CSF: Cerebrospinal Fluid; T1WI: T1-Weighted Images; T2WI: T2-Weighted Images

Case Report

A 28-year-old male presenting with a gradually increasing scalp swelling in the left parietal region over a long period and seizures. The patient was conscious. On physical examination, there was a cystic swelling over the left parietal prominence. The swelling was compressible but non-tender and non-pulsatile. There was a history of head injury during infancy (Figure 1-5).

A non-contrast enhanced head computed tomography (CT) examination was performed on a multidetector CT (Lightspeed ultra, GE Medical Systems) and demonstrated a large calvarial defect in the left parietal region with irregular and beveled margins. An adjacent CSF density cystic lesion of size 42x41mm noted in the left high parietal lobe. The cyst was seen communicating with the subarachnoid space and also seen extending though the calvarial defect. Mild widening of sulcal spaces and hypodense areas also noted in the surrounding brain parenchyma due to encephalomalacia. The cystic lesion was seen closely abutting the left lateral ventricle with focal dilatation of the ventricle. But there was no communication of the cyst with the ventricle. Corrective surgery was done. The intraoperative and postoperative period was uneventful.

Discussion

Growing skull fractures usually occur due to severe head trauma during the first three years of life, particularly in infancy. Incidence reported is only.05 to.1% of skull fracture in childhood [1,2]. Cause for growing skull fractures is multifactorial but the main factor is tear in the dura mater. The pulsatile force of CSF and pressure of growing brain will cause cerebral or subarachnoid herniation through the dural tear which causes the fracture in the thin skull to enlarge. This interposition of tissue prevents osteoblasts from migrating, inhibiting fracture healing. The resorption of the adjacent bone by the continuous pressure from tissue herniation through the bone gap adds to the progression of the fracture line (Tables 1-2).

Table abbreviations: CT = Computed Tomography, MRI = Magnetic Resonance Imaging, CSF = Cerebrospinal fluid, T1WI= T1-weighted images, T2WI= T2-weighted images.

The brain extrusion may be present shortly after diastatic linear fracture in neonates and young infants [3] resulting in focal dilatation of the lateral ventricle near the growing fracture. This focal dilatation may be seen in adults which is also seen in this case. This focal dilatation is reversible and may normalize after surgical repair [4]. Cranial defects never increase if the underlying dura is intact. Leptomeningeal cyst never occurs if the dura is intact.

Another risk factor is severity of underlying trauma. A linear fracture associated with hemorrhagic contusion of subjacent brain suggests a trauma significant enough to cause dural laceration. Cystic changes at the growing fracture site may be because of cystic encephalomalacia. Post traumatic aneurysms and subdural hematomas have also been reported to accompany growing skull fractures [6,7]. Though most patients show damage to underlying brain, this finding is not a prerequisite for the development of growing skull fractures [8].

These skull fractures after reaching maximum extent will cease to grow and remain stable throughout adulthood [2,5].

A depressed fracture usually does not become a growing fracture [9] but a linear fracture extending from a depressed one can become one [10].

A fracture with a diastasis of >4mm may be considered at risk of developing a growing skull fracture [3,11,12]. But a post traumatic diastasis of a cranial suture is an unusual site for a growing fracture. Growing fractures can even be seen in usually in linear fractures in thin areas of skull base associated with dural laceration, for e.g.: Orbital roof, ethmoid plate, frontal sinus.

These fractures commonly present as a progressive, scalp mass that appears sometime after head trauma sustained during infancy. There may seizures and hemiparesis, but an asymptomatic palpable mass may be the sole sign. The usual site is the parietal region. A growing fracture at the skull base may present with ocular proptosis or CSF rhinorrhea or otorrhea.

A plain radiograph may show a fracture line that crosses a coronal or lambdoid suture, but it is usually limited to a parietal bone [13]. CT or MRI demonstrates a cystic lesion near the fracture site communicating with the subarachnoid spaces and extending though the bony defect. Margins of bony defect may be beveled or irregular. Adjacent brain parenchyma usually shows mild encephalomalacia changes and focal atrophy. Gliosis may also see in the adjacent brain parenchyma. On CT scan gliosis is seen as hypodense areas. On MRI gliosis is seen as hypointense T1 and hyperintense T2 signals.

Because of neurological deterioration and of seizure disorder surgical correction of growing fractures is recommended.

Even though traumatic leptomeningeal cyst is rare in adults, it should be considered in the differential diagnosis of intracranial cystic lesions with adjacent calvarial defects.

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#Head and neck surgery #Leptomeningeal cyst #Trauma #Skull fracture #seizures #swelling

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