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A subdural abscess and infected blood patch complicating regional analgesia for labour.

We report two very unusual cases of infection complicating labour analgesia. The first case was a sub-dural abscess presenting with deep-seated backache seven days after combined spinal-epidural analgesia for labour. The second was a painful lumbar swelling and septicaemia that presented three days after a blood patch for a post dural puncture headache. Because of their complicated and unusual presentation, the diagnosis and management of both were initially delayed.

Abscess↗

Horner syndrome after unintended subdural block. A report of 2 cases.

Horner syndrome is considered a common finding after epidural analgesia or anesthesia in obstetric patients. Conversely, Horner syndrome is very uncommon in nonobstetric patients. We report 2 cases of Horner syndrome after attempted epidural lumbar anesthesia in 2 patients undergoing peripheral vascular surgery. Spinal fluoroscopy with contrast medium showed subdural catheterization in both cases. Horner syndrome after lumbar epidural anesthesia can be an indicator of inadvertent subdural catheter placement.

Aged↗

Phase relationships between different subdural electrode recordings in man.

Almost all brain-computer interfaces (BCIs) ignore information related to the phase coupling between electroencephalogram (EEG) or electrocorticogram (ECoG) recordings from different electrodes. This paper investigates whether additional information can be found when calculating the amount of synchronization between two electrode channels by using a phase locking measurement called the phase locking value (PLV). Special emphasis is put on the beta band (around 20 Hz) as well as the gamma band (high frequencies up to 95 Hz), which can only be used when subdural electrode recordings are available.

Action Potentials↗

Diagnosis of bacterial cerebellitis: diffusion imaging and proton magnetic resonance spectroscopy.

Diffusion-weighted imaging and in vivo proton magnetic resonance spectroscopy ((1)H magnetic resonance spectroscopy) have demonstrated great potential in differentiating intracranial lesions of various pathologies. This report describes a case of a 12-year-old child with cerebellitis and subdural empyema that manifested presence of succinate, acetate, lactate, and amino acids on in vivo (1)H magnetic resonance spectroscopy from a large area of restricted diffusion in the vermis on diffusion-weighted imaging, a finding specific for bacteria-induced infection. The child made a complete clinical and imaging recovery on conservative management.

Central Nervous System Bacterial Infections↗

Subdural intracranial pressure monitoring in severe head injury: clinical experience with the Codman MicroSensor.

BACKGROUND: Our main objective was to study the clinical outcome and complications of the subdural ICP monitoring with the CMS (Johnson and Johnson Medical Ltd, Raynhan, MA) in severe head injury. METHODS: A retrospective analysis of patients with head injury with a GCS score of 8 or less was performed. Patients with severe systemic injury with hypotension (systolic blood pressure of <90 mm Hg on admission), a GCS score of 3 with fixed and dilated pupils after resuscitation, a GCS score of 3 to 4 whose family refused aggressive treatment, and those who were dead on arrival were excluded from this study. During the period from January 1997 to April 2004, 120 patients with severe head injuries were included and met criteria for insertion of a subdural ICP monitoring device (CMS). RESULTS: A total of 120 patients (84 males and 36 females), aged 16 to 80 years old (mean, 43.8 +/- 14.4), were enrolled in the study. The average duration of ICP monitoring device use was 7.6 +/- 0.4 days (range, 2-14 days). The overall clinical outcomes of these patients were as follows: mortality rate, 13.5%; percentage of unfavorable outcomes, 17.3%; percentage of favorable outcomes, 69.2%. There were no complications such as CNS infection or hemorrhage in this study. CONCLUSION: A subdural transducer-tipped catheter (CMS) can be used as the first-line equipment for monitoring ICP in patients with severe head injury. The clinical results are similar with other recent studies, but no complication such as infection or hemorrhage occurred in this study.

Adolescent↗

Subdural engraftment of serotonergic neurons following spinal hemisection restores spinal serotonin, downregulates serotonin transporter, and increases BDNF tissue content in rat.

Spinal hemisection injury at T13 results in development of permanent mechanical allodynia and thermal hyperalgesia due to interruption and subsequent loss of descending inhibitory modulators such as serotonin (5-HT) and its transporter (5-HT(T)). We hypothesize that lumbar transplantation of non-mitotic cells that tonically secrete 5-HT and brain-derived neurotrophic factor (BDNF) will restore alterations in 5-HT and 5-HT(T) systems within the spinal dorsal horn. We used an immortalized rat neuronal cell line derived from E13 raphe (RN46A-B14) which is shown to secrete 5-HT and BDNF in vitro and in vivo. Three groups (n=35) of 30 day old male Sprague-Dawley rats were spinally hemisected at T13 and 28 days later received either lumbar RN46A-V1 control empty-vector (n=15) or RN46A-B14 (n=15) intrathecal grafts, or no transplant. Twenty-eight days following transplantation, animals were perfused and tissue examined for changes in 5-HT, 5-HT(T), and BDNF at the site of transplantation or at lumbar enlargements (L5). Immunohistochemistry revealed that RN46A-B14, but not RN46A-V1 cells, increased 5-HT tissue staining at L5 in the dorsal white matter as well as in superficial dorsal horn laminae I and II on both ipsilateral and contralateral sides, results confirmed by ELISA. Transplantation of RN46A-B14 cells significantly reduced ipsilateral 5-HT(T), upregulated after injury. Significantly increased levels of BDNF were also observed after RN46A-B14 transplantation but were not localized to particular spinal laminae. These results are consistent with recovery of locomotor function and reductions in chronic pain behaviors observed behaviorally after RN46A-B14 transplantation and supports the pragmatic application of cell-based therapies in correcting damaged circuitry after spinal cord injury.

Animals↗

Subdural spinal lipoma with posterior fossa extension.

A case is described of subdural spinal lipoma with posterior fossa extension and the world literature is reviewed. A high proportion of high cervical lipomas extend into the posterior cranial fossa. Many cases were probably missed in the pre-computed tomography era. Those cases with posterior fossa growth are more likely to be found in infants or those cases with symptoms dating from birth; most present with quadriparesis. All cases of high cervical lipoma demonstrated by myelography should be submitted to brain computed tomography in order to exclude posterior fossa extension and demonstrate the presence of hydrocephalus.

Adolescent↗

Bicoherence of intracranial EEG in sleep, wakefulness and seizures.

The hypothesis that the intracranial EEG has local structure and short-term non-stationarity is tested with a little-studied measure of non-linear phase coupling, the bicoherence in human subdural and deep temporal lobe probe data from 11 subjects during sleeping, waking and seizure states. This measure of cooperativity estimates the proportion of energy in every possible pair of frequency components, F1, F2 (from 1 to 50 Hz in this study), that satisfies the definition of quadratic phase coupling (phase of component at F3, which is F1 + F2, equals phase of F1 + phase of F2). Derived from the bispectrum, which segregates the non-Gaussian energy, auto-bicoherence uses the frequency components in one channel; cross-bicoherence uses one channel for F1 and F2 and another for F3. These higher order spectra are used in physical systems for detection of episodes of non-linearity and transients, for pattern recognition and robust classification, relatively immune to Gaussian components and low signal to noise ratios. Bicoherence is found not to be a fixed character of the EEG but quite local and unstable, in agreement with the hypothesis. Bicoherence can be quite different in adjacent segments as brief as 1.6 s as well as adjacent intracranial electrodes as close as 6.5 mm, even when the EEG looks similar. It can rise or fall steeply within millimeters. It is virtually absent in many analysis epochs of 17s duration. Other epochs show significant bicoherence with diverse form and distribution over the bifrequency plane. Isolated peaks, periodic peaks or rounded mountain ranges are either widely scattered or confined to one or a few parts of the plane. Bicoherence is generally an invisible feature: one cannot usually recognize the responsible form of non-linearity or any obvious correlate in the raw EEG. During stage II/III sleep overall mean bicoherence is generally higher than in the waking state. During seizures the diverse EEG patterns average a significant elevation in bicoherence but have a wide variance. Maximum bispectrum, maximum power spectrum, maximum and mean bicoherence, skewness and asymmetry all vary independently of each other. Cross-bicoherence is often intermediate between the two auto-bicoherence spectra but commonly resembles one of the two. Of the known factors that contribute to bicoherence, transient as distinct from ongoing wave forms can be more important in our data sets. This measure of non-linear higher moments is very sensitive to weak quadratic phase coupling; this can come from several kinds of waveforms. New methods are needed to evaluate their respective contributions. Utility of this descriptor cannot be claimed before more carefully defined and repeatable brain states are studied.

Electroencephalography↗

Trauma of the central nervous system in children.

In summary, the care of the patient with head trauma is not dissimilar to any other acutely ill individuals. Careful, systematic observation and recording of changing factors and physical signs is necessary. Proper application and appropriate treatment in response to dynamic changes will provide a satisfactory result as in any other form of illness or trauma. The patient with multiple injuries may call for compromise in treatment, however with the exception of gross hemorrhage, the head injury should take precedence in the early period following injury for there are other factors that may prove fatal. Do not accept unnecessary delay in the treatment of other injuries on the grounds that the patient has had a head injury. The orthopedic surgeon can treat the fractured femur, the plastic surgeon-the face, and the general surgeon-the abdomen, without jeopardizing brain recovery. The treatment of the patient with head trauma, as treatment of any other individual in present day medical practice, has become more of a team effort, not only involving the neurosurgeon, but the pediatrician, the specialist in pulmonary physiology, and other expert groups.

Brain Edema↗

Delayed magnetic resonance imaging with GdD-DTPA differentiates subdural hygroma and subdural effusion.

BACKGROUND: Posttraumatic subdural fluid collection is not a single clinical entity but can be divided into subdural hygroma and subdural effusion. Appropriate treatment requires preoperative differentiation. Delayed magnetic resonance (MR) imaging with intravenous administration of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA) was used to differentiate subdural hygroma and subdural effusion. METHODS: Timed arterial blood specimens were taken after intravenous Gd administration in patients with posttraumatic subdural fluid collections (five subdural hygromas and 13 subdural effusions). Delayed MR imaging was performed 1 hour after administration of Gd-DTPA. Gd-DTPA concentrations in the subdural fluid and blood specimens were measured by ion coupled plasma emission spectrometry. Dynamic biologic modeling was used to calculate the transfer rate constant for Gd-DTPA influx into these subdural fluid collections. RESULTS: The Gd concentrations in subdural hygromas and subdural effusions were 16 +/- 6 and 79 +/- 12 nmol/mL, respectively. The transfer rate constants for subdural hygromas and subdural effusions were 4.8 +/- 2.1 and 20.6 +/- 2.1 (x10(-4))min(-1), respectively. These values were significantly higher in subdural effusions than in subdural hygromas (p < 0.01). Delayed MR imaging with Gd showed significantly higher mean enhancement of 77.1 +/- 14.2% for subdural effusions compared to 4.6 +/- 3.1% for subdural hygromas (p < 0.01). CONCLUSIONS: Delayed MR imaging with Gd can differentiate subdural hygroma and subdural effusion.

Aged↗

Intradural spinal hibernoma: case report.

BACKGROUND: Hibernoma is a rare, benign tumor arising from vestigial remnants of brown adipose tissue. It usually affects muscle and subcutaneous tissue and is asymptomatic and slow growing. METHODS: A review of the worldwide literature contains about 110 cases of hibernomas. However, only two cases (including our case) of hibernoma located in the intradural spine have been reported. We present an extremely rare case of intradural extramedullary spinal hibernoma and summarize the magnetic resonance imaging (MRI) findings of the lesion. CASE DESCRIPTION: A 35-year-old woman suffered from motor weakness and numbness of the left upper extremity. Cervical spinal MRI revealed an intradural extramedullary mass at C7. She underwent surgery via the posterior approach and the lesion was completely removed. Histopathologic examination showed multivacuolated cells with centrally placed nuclei, and the diagnosis of hibernoma was made. CONCLUSIONS: Because the CT and MRI findings of hibernoma are almost same as those of other lipomatous tumors, a surgical specimen of this tumor is necessary to establish the correct diagnosis. Early diagnosis and total resection are necessary as some cases showed malignant features or rapid growth. Etiologically, the tumor may have developed by the ectopic growth or migration of adipose tissue.

Adult↗