Thirty-two patients with aneurysmal subarachnoid hemorrhage (SAH) were managed according to a protocol based on pain control and hemodynamic manipulation, monitored by an arterial line and Swan-Ganz catheter. Hemodynamic parameters were adjusted to four clinical situations. 1) For the unoperated patient with no neurological deficit, the regimen aims to maintain pulmonary wedge pressure (PWP) at 10 to 12 mm Hg, and the cardiac index (CI) and blood pressure (BP) at normal levels. 2) For the unoperated patient presenting with or developing neurological deficit, the PWP is increased until the deficit is reversed or the CI falls; the CI is high, and the BP normal. 3) For the postoperative patient with no neurological deficit, the PWP is maintained at 12 to 14 mm Hg, the CI is a high normal, and the BP is normal. 4) For the postoperative patient developing neurological deficit but showing no surgical complication on the computerized tomography scan, the PWP is increased until the deficit is reversed or the CI falls; the CI is high and the BP is increased with vasopressors if necessary. Fourteen patients developed neurological deficits either preoperatively, postoperatively, or both. Neurological deficits were repeatedly reversed by increasing the PWP, as measured hourly. In several patients an optimal wedge pressure was determined, below which deficits would reappear. In one patient whose neurological deficit was reversed on several occasions by increasing the PWP, the optimal PWP rose after each episode until it reached 22 mm Hg. Detailed event-related analysis of these patients' course illustrates these phenomena well. The optimal PWP varied from patient to patient, but ranged most frequently from 14 to 16 mm Hg. Meticulous monitoring of the patients' neurological status coupled with prompt correction of low PWP (assuming an adequate CI) has proven to be an effective way to prevent and reverse neurological deficits following aneurysmal SAH.
Ependymomas represent 4% of all primary central nervous system neoplasms in adults, with 30% occurring in the spinal cord. We describe a young man with neurological deficits following a motor vehicle accident who was found to have an intramedullary cervicothoracic ependymoma. CASE REPORTA previously healthy 18-year-old man presented to the emergency department following a motor vehicle accident. All four extremities were weak immediately following the accident, with right-sided weakness noted on initial physical examination. Head and cervical spine computed tomography (CT) revealed no abnormalities. Cervical spine magnetic resonance imaging (MRI) revealed an expansile intramedullary mass at the cervicothoracic junction (Figures 1a, 1b) and mild interspinous ligament sprain. Th e patient's neurologic defi cit resolved within 24 hours. Th e patient underwent laminectomy and laminoplasty with complete resection of the mass ( Figure 1c) and had an uncomplicated postoperative course. Neurological examination immediately following surgery revealed decreased right lower extremity proprioception, 2+/5 strength at the right L2 to L3 levels, and 4/5 strength at the right L4 to S1 levels. DISCUSSIONEpendymomas are the most common intramedullary neoplasm in adults and represent 60% of all intramedullary tumors. Th ey arise from ependymal cells lining the central canal of the spinal cord. Th ese tumors have a mean age of presentation of 38.8 years and a slight male predominance (57.4%) (1, 2). Th e clinical presentation of ependymoma is similar to that of other intramedullary lesions, with a prolonged history of slowly worsening myelopathic symptoms prior to diagnosis.MRI evaluation is the imaging modality of choice in the patient with suspected cord neoplasm. Ependymomas are typically iso-to hypointense relative to the spinal cord on unenhanced T1-weighted images, with the vast majority exhibiting at least some degree of enhancement following intravenous gadolinium administration (1, 3, 4). T2-weighted images usually reveal a hyperintense intramedullary lesion. Ependymomas may cause hematomyelia as well as subarachnoid hemorrhage, with 20% to 33% of lesions displaying a "cap sign" of signal hypointensity at the lesion margins secondary to hemosiderin deposition from intralesional chronic microhemorrhages. Cysts are often associated with ependymomas, with the majority representing nontumoral (polar) cysts at the margins of the lesion. True tumoral cysts (surrounded by enhancement) arise less frequently (1, 3, 4).The preferred treatment for spinal cord ependymomas is complete surgical resection. Current advances in microsurgical technique and intraoperative monitoring enable frequent complete resection without worsening postoperative neurologic function (5). In a series of 31 cases described by Chang et al (5), only 10% of cases were associated with worsening neurological function, while 26% showed improvement and the rest remained stable. The preoperative neurologic status of the patient is the greatest predictor of postoper...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.