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Spontaneous intracranial hemorrhage presenting in a patient with vitamin K deficiency and COVID-19: illustrative case

Nathaniel R. Ellens and Howard J. Silberstein

BACKGROUND

Coronavirus disease 2019 (COVID-19) is known to cause more severe symptoms in the adult population, but pediatric patients may experience severe neurological symptoms, including encephalopathy, seizures, and meningeal signs. COVID-19 has also been implicated in both ischemic and hemorrhagic cerebrovascular events. This virus inhibits angiotensin-converting enzyme 2, decreasing angiotensin (1–7), decreasing vagal tone, disrupting blood pressure autoregulation, and contributing to a systemic vascular inflammatory response, all of which may further increase the risk of intracranial hemorrhage. However, there has only been one reported case of intracranial hemorrhage developing in a pediatric patient with COVID-19.

OBSERVATIONS

The authors discuss the first case of a pediatric patient with COVID-19 presenting with intracranial hemorrhage. This patient presented with lethargy and a bulging fontanelle and was found to have extensive intracranial hemorrhage with hydrocephalus. Laboratory tests were consistent with hyponatremia and vitamin K deficiency. Despite emergency ventriculostomy placement, the patient died of his disease.

LESSONS

This case demonstrates an association between COVID-19 and intracranial hemorrhage, and the authors have described several different mechanisms by which the virus may potentiate this process. This role of COVID-19 may be particularly important in patients who are already at a higher risk of intracranial hemorrhage, such as those with vitamin K deficiency.

InJournal of Neurosurgery: Case Lessons Volume 1: Issue 11 (Mar 2021)

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Revision rate of pediatric ventriculoperitoneal shunts after 15 years

Clinical article

Jonathan J. Stone, Corey T. Walker, Maxwell Jacobson, Valerie Phillips, and Howard J. Silberstein

Object

Ventriculoperitoneal (VP) shunt placement remains the mainstay treatment for pediatric hydrocephalus. These devices have a relatively high complication and failure rate, often requiring multiple revisions. The authors present a single institution's experience of pediatric patients treated with VP shunts. With an average follow-up time of 20 years, this study is among the longest reports of VP shunt revision in the literature to date. Hydrocephalus origins, shunt revision rates, and causes of shunt failure are described. Patients who underwent their first shunt revision more than 10 years after initial shunt placement were also explored.

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A retrospective chart review was performed on all pediatric patients who underwent VP shunt placement from January 1990 through November 1996 at the University of Rochester Medical Center. Only patients who had at least 15 years of follow-up since their initial shunting procedure were included.

Results

A total of 234 procedures were performed on 64 patients, with a mean follow-up of 19.9 years. Patients ranged from a few days to 17.2 years old when they received their original shunt, with a median age of 4 months; 84.5% of the patients required 1 or more shunt revisions and 4.7% required 10 or more. Congenital defects, Chiari Type II malformations, tumors, and intraventricular hemorrhage were the most common causes of hydrocephalus. Overall, patients averaged 2.66 revisions, with proximal (27%) and distal (15%) catheter occlusion, disconnection (11%), and infection (9%) comprising the most common reasons for shunt malfunction. Notably, 12.5% of patients did not require their first shunt revision until more than 10 years after initial device placement, a previously undescribed finding due to the short follow-up duration in previous studies.

Conclusions

This long-term retrospective analysis of pediatric VP shunt placement revealed a relatively high rate of complications with need for shunt revision as late as 17 years after initial placement. Catheter occlusion represented a significant percentage of shunt failures. Cerebrospinal fluid shunting has a propensity for mechanical failure and patients with VP shunts should receive follow-up through the transition to adulthood.

In开云手机版app下载安装最新版神经外科杂志:儿科开云体育app官方网站下载入口Volume 11 (2013): Issue 1 (Jan 2013)

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Treatment of hydrocephalus in an ovine model with an intraparenchymal stent

Gabrielle Santangelo, Thomas A. Pieters, Muhammad I. Jalal, Redi Rahmani, Howard J. Silberstein, and Jonathan J. Stone

OBJECTIVE

While CSF diversion is highly effective at treating hydrocephalus, shunting is unfortunately associated with a very high revision rate. Studies have demonstrated that proximal catheter obstruction is a major cause of failure. A novel proximal access device was developed, and pilot testing was performed in a sheep model of hydrocephalus.

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脑积水是诱导8使用ciste羊rnal injection of 4 ml of 25% kaolin, and the sheep were randomized to either a standard ventricular catheter or a novel intraparenchymal stent (IPS). Both groups received identical valves and distal catheters. The novel device included a 3D-printed stainless steel port and a 6 × 40–mm covered peripheral vascular stent. Animals were euthanized for signs of hydrocephalus or at a time point of 2 months. MRI was performed to determine ventricular size. Time to failure and Evans indices were compared using the Wilcoxon rank-sum test.

RESULTS

All 4 experimental devices were placed without difficulty into the right lateral ventricle. There was a trend toward longer survival in the experimental group (40 vs 26 days, p = 0.24). Within the IPS group, 3 of the 4 sheep did not experience clinical symptoms of shunt failure and had an average of 37% decrease in Evans index. While 3 of 4 traditional proximal catheters demonstrated debris within the inlet holes, there was no obstructive material found in the IPSs.

CONCLUSIONS

An IPS was successfully used to treat hydrocephalus in a sheep model. While statistical significance was not achieved, there were clear benefits to using a stent, including a decreased clog rate and the ability to perform a percutaneous revision. Further testing is needed to ensure efficacy and safety prior to human application.

In开云手机版app下载安装最新版神经外科杂志:儿科开云体育app官方网站下载入口Publish Before Print

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Risk factors associated with venous thromboembolism in patients undergoing spine surgery

Keaton Piper, Hanna Algattas, Ian A. DeAndrea-Lazarus, Kristopher T. Kimmell, Yan Michael Li, Kevin A. Walter, Howard J. Silberstein, and G. Edward Vates

OBJECTIVE

Patients undergoing spinal surgery are at risk for developing venous thromboembolism (VTE). The authors sought to identify risk factors for VTE in these patients.

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The American College of Surgeons National Surgical Quality Improvement Project database for the years 2006–2010 was reviewed for patients who had undergone spinal surgery according to their primary Current Procedural Terminology code(s). Clinical factors were analyzed to identify associations with VTE.

RESULTS

Patients who underwent spinal surgery (n = 22,434) were identified. The rate of VTE in the cohort was 1.1% (pulmonary embolism 0.4%; deep vein thrombosis 0.8%). Multivariate binary logistic regression analysis revealed 13 factors associated with VTE. Preoperative factors included dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race. Operative factors included surgery duration > 4 hours, emergency presentation, and American Society of Anesthesiologists Class III–V, whereas postoperative sepsis was the only significant postoperative factor. A risk score was developed based on the number of factors present in each patient. Patients with a score of ≥ 7 had a 100-fold increased risk of developing VTE over patients with a score of 0. The receiver-operating-characteristic curve of the risk score generated an area under the curve of 0.756 (95% CI 0.726–0.787).

CONCLUSIONS

A risk score based on race, preoperative comorbidities, and operative characteristics of patients undergoing spinal surgery predicts the postoperative VTE rate. Many of these risks can be identified before surgery. Future protocols should focus on VTE prevention in patients who are predisposed to it.

InJournal of Neurosurgery: Spine Volume 26 (2017): Issue 1 (Jan 2017)

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