Objective: To evaluate how multimodal intraoperative neuromonitoring (IONM) changes during spinal ependymoma (SE) resection correlate with long-term neuro-functional outcomes.Methods: A retrospective analysis of patients aged 18 years or older who underwent surgical resection for SE over a 10-year period was conducted. IONM changes were defined as sustained transcranial motor evoked potential (TcMEP) and/or somatosensory evoked potential (SSEP) signal decrease of 50% or greater from baseline. Primary endpoints were postoperative modified McCormick Neurologic Scale (MNS) scores at postoperative day (POD) < 2, 6 weeks, 1 year, and 2 years. Univariate and multivariate analyses were performed.Results: Twenty-nine patients were identified. Average age was 44.2 ± 15.4 years. Sixteen (55.2%) were male and 13 (44.8%) were female. Tumor location was 10 cervical-predominant (34.5%), 13 thoracic-predominant (44.8%), and 6 lumbar/conus-predominant (20.7%). A majority (69.0%) were World Health Organization grade 2 tumors. Twentyfour patients (82.8%) achieved gross total resection. Thirteen patients (44.8%) had a sustained documented IONM signal change and 10 (34.5%) had a TcMEP change with or without derangement in SSEP. At POD < 2, 6 weeks, 1 year, and 2 years, MNS was significantly higher for those when analyzing subgroups with either any sustained IONM or TcMEP ± SSEP signal attenuation > 50% below baseline (all p < 0.05).Conclusion: Sustained IONM derangements > 50% below baseline, particularly for TcMEP, are significantly associated with higher MNS postoperatively out to 2 years. Intraoperative and postoperative management of these patients warrant special consideration to limit neurologic morbidity.
Objective: Spinal arachnoid cysts (SACs) are rare lesions that often present with back pain and myelopathy. There is a paucity of literature evaluating the impact of surgical timing on neurological outcomes for primary SAC management. To compare long-term neurological outcomes in patients who were managed differently and to understand natural progression of SAC.Methods: We conducted a retrospective analysis of adult patients treated for SAC at our institution from 2010 to 2021, stratified into 3 groups (conservative management only, surgical management, or conservative followed by surgical management). Study outcome measures were neurological outcomes as measured by modified McCormick Neurologic Scale (MNS), postoperative complications, and cyst recurrence. Nonparametric analysis was performed to evaluate differences between groups for selected endpoints.Results: Thirty-six patients with SAC were identified. Eighteen patients were managed surgically. The remaining 18 patients were managed conservatively with outpatient serial imaging, 7 of whom (38.9%) ultimately underwent surgical treatment due to neurological decline. Most common presenting symptoms included back pain (50.0%), extremity weakness (36.1%), and numbness/paresthesia (36.1%). Initial/preoperative (p = 0.017) and 1-year postoperative (p = 0.006) MNS were significantly different between the 3 groups, but not at 6 weeks or 6 months postoperatively (p > 0.05). Additionally, at 1 year, there was no difference in MNS between patients managed surgically and those managed conservatively but ultimately underwent surgery (p > 0.99).Conclusion: Delayed surgical intervention in minimally symptomatic patients does not seem to result in worse long-term neurofunctional outcomes. At 1 year, postoperative MNS were significantly higher in both surgical groups, when compared to the conservative group highlighting worsening clinical picture regardless of preoperative observational status.
A 9-year-old male presented to the Children’s Colorado Emergency Department (ED) after losing consciousness and falling face-first onto a sidewalk while being escorted from a 4th of July parade. He had a mild headache and nausea that worsened as the parade progressed. En route to the hospital, his temperature was 105℉ and he had a tonic-clonic seizure. He had had a head injury one week prior. He had been jumping on a trampoline with siblings when his sister landed on his head. There was no loss of consciousness and he denied headache or nausea afterward. Computed tomography (CT) of his head (not shown) had been reportedly negative. By the time he arrived at the ED this time, he was awake but still had a headache and nausea. On examination, he had nuchal rigidity with gait ataxia and positive Romberg testing. Head CT (Fig. 1A) showed a focal linear hyperdensity in the region of the left Sylvian fissure. There was concern for subarachnoid hemorrhage (SAH) given his two recent head injuries. Later, the same hyperdensity was retrospectively noted on his previous CT. Subsequent magnetic resonance imaging with angiography (MRI/MRA) (Fig. 1B) revealed the hyperdensity to be a large left temporal lobe developmental venous anomaly (DVA). There was no aneurysm. By the next morning, the patient’s symptoms and findings had all resolved. It was thought that he had suffered acute hyperthermia. Developmental venous anomalies of the brain are congenital abnormalities that arise from incomplete development of the venous system. They can be found in up to 2.6 % of autopsy studies and are thought to be harmless. They can be associated with sporadic cerebral cavernous malformations. Rare cases of hemorrhage have been reported, but usually in association with cavernous malformations. As DVAs provide venous drainage to the brain, it is important not to damage them during resection of cavernous malformations. The Sylvian fissure is a common place for both posttraumatic and aneurysmal SAH. Sometimes, after trauma, it is unclear whether SAH resulted from the trauma or from aneurysmal rupture. As shown in this report, however, hyperdensity in the region of the Sylvian fissure on CT may not represent SAH. In certain circumstances, if further imaging is being contemplated to search for the source of SAH, providers may consider MRI/MRA with contrast versus CT or catheter angiography, as other lesions will be better seen on MR imaging.
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