Organized under the supervision of Dr. Klodian Allajbeu, CEO of the American Hospital, this conference in Pristina will feature prominent figures in global neurosurgery, Mentor Petrela, MD, PhD, Chev LH, PU-PH Fr, WANS, IFAANS, and Prof. Emmanuel Houdart PU PH, as keynote speakers.

With over 15,000 surgical interventions in the brain, spine, and spinal cord, Mentor Petrela and his specialized team have been invited to join the World Academy of Neurological Surgery in 2014, consisting of 100 selected neurosurgeons worldwide.

Prof. Emmanuel Houdart PU PH, with admirable global experience, heads the Interventional Neuroradiology Unit in the Department of Neuroradiology since 1997. The unit annually performs 800 cerebral angiographies and 500 endovascular interventions in the brain, spinal cord, and ENT region, making it one of the most experienced centers in France for interventional neuroradiology.

In addition to clinical work, Prof. Emmanuel Houdart PU-PH conducts research on evaluating new techniques for treating intracranial aneurysms, cerebral arteriovenous malformations, and pulsatile tinnitus related to atherosclerosis of cerebral arteries.

Specialists and trainees in ENT, Neurosurgery, Neurology, and Radiology are welcomed to attend.

During this 2-days masterclass, EUSOBI experts and Cambridge team discussed clinical indications and applications of US, DBT, CEM, breast MRI and different image guided procedures, including advanced techniques, with a special focus on personalized screening and AI in breast imaging.

The participants found very interesting the interactive, case based and hands on workshops where they performed different US guided procedures guided by the expert breast radiologists.

Core tip: It is general belief that subdural infratentorial empyema needs to be approached through an ample decompressive craniectomy. We present a case of infratentorial empyema managed successfully with burr hole evacuation of infratentorial empyema. We analyzed the characteristics of the case and reviewed the surgical techniques. Go to:

INTRODUCTION

Infratentorial empyema has been reported most frequently as a complication of middle ear or mastoid purulent infection. The neurological diagnosis may present with difficulties due to insidious development. However, it represents a serious condition necessitating prompt surgical evacuation. Suboccipital craniectomy is claimed to be the gold standard for the treatment of subdural empyema in the posterior fossa, aiming at brainstem and cerebellar decompression together with pus evacuation[1]. Go to:

CASE REPORT

A 17-year-old female was admitted to the department of infectious diseases with high fever, moderate headache, right ear pain, general fatigue and malaise. Right hypoacusia and neck rigidity was revealed at physical examination. One week’s dosage of oral amoxiclav before hospitalization was ineffective. A fundoscopy did not reveal any evident papillary edema.

In the absence of an intracranial hypertension, a lumbar puncture (LP) was done (November 3, 2006) and turbulent cerebrospinal fluid (CSF) was extracted. Laboratory examination revealed 8900 cells/dL, proteinorrachia 1.65 g/L. Blood test showed leukocytosis 25200, erythrocyte sedimentation rate 45 s within the first hour, hemoglobin 12.8 mg/dL. A computed tomography (CT) of the head excluded any mass occupying lesion. Despite the negative cultures of the CSF, the diagnosis of purulent meningitis was made and combined therapy was started with ampicillin 3.0 g four times a day (qid), amykacin 0.5 g twice daily (bid) and kemicetine 1.0 g thrice daily (tid).

Another LP (March 21, 2006) revealed 212 cells/dL, proteinorrachia 0.33 g/L, lymph cells 90%, meningeal cells 5%, neutrophils 5% (Table (Table11).

Table 1

Summary of cerebrospinal fluid and blood tests

Neutro: Neutrophils; HGB: Hemoglobin; Lymph: Lymphocytes; Mening: Meningeal cells; CSF: Cerebrospinal fluid.

With combined antibiotic therapy, the headache, ear pain and neck rigidity improved until the night of March 22, 2006 when the patient presented with confusion, somnolence, neck rigidity, positive Brudzinski and Kernig signs and horizontal nystagmus. The next morning, the patient had a Glasgow Coma Score (GCS) of 8 (E = 2; V = 3; M = 3). CT of the head with intravenous contrast injection documented right posterior cranial fossa empyema 6 cm × 5 cm compressing the right cerebellar lobe that appeared slightly edematous. There was compression of the fourth ventricle and herniation of cerebellar tonsils beyond the occipital foramen associated with three ventricular hydrocephalus. Right mastoid cells were opaque as in case of mastoiditis (Figure (Figure1A).1A). The patient was immediately transferred to neurosurgery for emergency evacuation of empyema. On admission, the patient was in coma GCS 5 (E = 1; V = 2; M = 2), with spontaneous extension of the head in the lateral recumbent position. Under local anesthesia with the patient in left lateral position with the head posed on the head support of the surgical bed, a 6 cm hockey stick incision over the right suboccipital area was made. A burr hole was drilled 2 cm on the right side and 2 cm under the right transverse sinus that corresponded to just in the center of the empyema. Dura mater was discovered attached to the inner layer of the bone without any extradural collection. The tip of a 20 F needle in a syringe was introduced through the dura and 22 mL of pus was withdrawn. At the end of aspiration, a small incision of the dura exposed at the burr hole was done. Cerebellar flocculi were visible without any space left for a catheter to be introduced in the subdural space for eventual drainage. The soft tissue around the

burr hole was rinsed with gentamycin and iodopovidone solution and closure of the wound was done. Intravenous vancomycin 1.0 g tid, ciprinol 200 mg tid was administered. Within one hour, the patient became conscious GCS 12 (E = 3; V = 4; M = 5) and the day after surgery was GCS 15. The culture exam showed no growth of microorganisms. Four days after surgery, the neurological status was normal except for the right hypoacusia. A control CT of the head in the third postoperative day showed complete evacuation of empyema, return of right cerebellar lobe to the normal position and reappearance in the midline of the fourth ventricle with resolution of the supratentorial hydrocephalus (Figure (Figure1B).1B). Right mastoid cells were still hyperdense. The patient was transferred to the department of otorhinolaryngology for the surgical treatment of mastoiditis. On March 27, 2006, the patient underwent radical right mastoidectomy under general anesthesia. Treatment with vancomycin 1 g tid, ciprinol 200 mg tid, flagyl 500 mg tid was administered until April 4, 2006. After that, ceporin 1 g daily was continued until April 10, 2006. The patient was discharged on April 22, 2006.

More than six years after surgery, the patient remains disease free and leads a normal life. She does not complain of hypoacusia on the right ear and refuses a control magnetic resonance imaging (MRI) of the head.

DISCUSSION

Infratentorial empyema is a rare complication of bacterial infection of the middle ear or mastoid and constitutes only a small percentage of intracranial empyema. It is a life threatening condition due to its mass effect of direct compression to the brain stem and associated supratentorial hydrocephalus. Clinical diagnosis of infratentorial empyema is easily delayed due to its insidious onset and progression[2].

Clinical signs of infratentorial empyema were mostly absent, with lack of cerebellar findings and cranial nerve deficits in approximately 75% of the patients[2]. In our case, herniation of cerebellar tonsils manifested with head extension after the patient had already entered a stuporous state.

Most of the reviews on the subject advise an ample decompressive occipital craniectomy, especially in cases of extension of empyema to the cerebellopontine angle[1]. Ample decompression may serve for managing of cerebellar edema, even after pus evacuation, but it carries other risks, such as brain swelling, infarction or hemorrhage that may result from an injudicious aggressive opening of the dura[3].

In the presented case, there was no evident extension of the pus to the cerebellopontine angle. Furthermore, pus collection was limited to one side of the occipital squama without excessive cerebellar edema. Most of the mass effect seemed to be caused by empyema. We believe that the consequential three ventricular hydrocephalus was the cause of the comatose state. Spontaneous positioning of the head in extension came with the herniation of cerebellar tonsils in the foramen magnum. Our surgical choice was also influenced by the emergency for immediate evacuation of empyema. In such a situation, we adapted burr hole evacuation of empyema that reopened the fourth ventricle, resolving the hydrocephalus. Through a burr hole, we were able to drain the complete volume of empyema calculated in the CT, verified after the small dura opening that showed cerebellar flocculi, having reached the dura, leaving no space for a subdural drain. Intravenous perfusion with mannitol solution 20% and 15 degree upright position of the head were adapted to alleviate possible cerebellar edema and restore CSF dynamics. In their review, Bok et al[3] conclude that burr holes should not be disregarded as a method of treating subdural empyema.

The successful management of our patient demonstrates that a complete evacuation of subdural empyema can be obtained with equal efficiency through a single burr hole, as with other more invasive approaches such as craniotomy or craniectomy. The mass effect reduction after evacuation of pus was sufficient in our case to remove obstruction from the fourth ventricle and treat the hydrocephalus.

The combination of antibiotics was directed by clinical judgment since the culture study of pus and blood did not reveal any pathogens for a subsequent antibiogram[4]. Blood culture is reported to be sensitive in only 15% of cases[4]. Streptococcus pneumoniae has been known to

be the most common cause of acute otitis media, sinusitis and pneumonia and one of the most important causes of bacterial meningitis[5-7]. In critically ill patients, cefotaxime or ceftriaxone is most often the primary alternative[8]. Other alternative drugs include the carbapenems, newer quinolones, clindamycin, telithromycin, linezolid and vancomycin. Treatment guidelines often recommend the use of β-lactam/macrolide combinations as empirical therapy for patients with severe illness[8-10].

Mastoidectomy was done four days after empyema evacuation, with the patient neurologically recovered from coma. Combined surgical and medical treatment led to complete cure of our patient.

In conclusion, burr hole evacuation may be equally as efficient as other more invasive surgical approaches in the case of infratentorial empyema. This is true especially in the case of cerebellar convexity empyema without extension to the cerebellopontine angle. Once the mass effect of the pus is removed, resolution of hydrocephalus may be expected because of decompression of the fourth ventricle. Whenever complete pus evacuation is possible and there is a lack of extensive cerebellar edema in preoperative CT or MRI, such a technique may be the efficient approach for emergent treatment.

Footnotes

P- Reviewers Bahl A, Habibi Z S- Editor Gou SX L- Editor Roemmele A E- Editor Lu YJ

References

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Abstract

Patient: Female, 45

Final Diagnosis: Arterio-venous fistula of the splean

Symptoms: Lef-side abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Objective:

Rare disease

Background

A splenic arterial-venous fistula (SAVf) is caused by an abnormal discharge of the distal splenic artery into the corresponding vein. This pathology should be especially suspected in cases when patients complain of a vague left flank pain associated with a loud murmur, or acute portal hypertension not related to chronic liver disease. They may be asymptomatic or lead rapidly to the development of portal hypertension [1,2].

Myxoma is the most common benign tumor of the heart. It is found accidentally, as in this case, or could present with various clinical signs [3,4]. To the best of our knowledge, SAVf with concomitant atrial myxoma represent a unique pathology, previously unreported in the literature. Go to:

Case Report

A 45-year-old woman presented with a vague left flank pain. The pain started 3 years ago but became more persistent and was associated with a loud pulsatile murmur. The patient was a well

nourished Caucasian female. The liver was not palpable and no signs of jaundice were observed. The rest of the physical examination was unremarkable. Heart rate was regular and rhythmic. Blood pressure was 110/80 mm Hg. The liver and kidney test results were normal, and the rest of laboratory test results were unremarkable. An ECG revealed normal sinus rhythm. The patient had no prior history of abdominal trauma, accidental injury, or abdominal surgery.

Abdominal echography showed multiple round hypo-echoic lesions in the splenic hilum, most likely representing dilated splenic vessels. CTA revealed a tortuous dilated splenic artery and aneurismal dilatation of the splenic vein associated with an early opacification of the portal system. The dimensions of the aneurysm were: cranial-caudal 57 mm, latero-lateral 43 mm, and antero-posterior 24 mm. CTA also showed an intrasplenic venous aneurysm, which was presumed to be the location of the fistula (Figure 1A–1C).

Figure 1.

(A) Axial computed tomography in the arterial phase showed dilatation of splenic artery, aneurismal dilation of the splenic vein, and small intra-parenchymal splenic aneurysm. (B, C) Reformatted maximum intensity projection (MIP) and volume rendering techniques (VRT) images in the coronal plane showed tortuous dilated splenic artery and multiple aneurismal dilatation of the splenic vein.

Celiac and splenic arteriographies were carried out and showed a tortuous splenic artery with a large venous aneurysm combined with premature portal and splenic vein filling and marked opacification of the spleno-portal axis (Figure 2A, 2B).

Figure 2.

(A, B) Angiography showed a splenic arteriovenous fistula.

The patient was seen by the cardiologist to evaluate potential complications from SAVf. The cardiologist noticed that the patient had non-frequent palpitations, effort dyspnea, but no chest pain and normal cardiac function. Transthoracic echocardiography showed a large mass in the left atrium. Subsequently, the patient had a cardiac CT, which showed a large mass arising from the inter-atrial septum and protruding towards the mitral valve, consistent with atrial myxoma (Figure 3A, 3B). Based on the presence of both pathologies, surgical treatments were required.

Figure 3.

(A, B) Computed tomography showed a large atrial mass protruding towards the mitral valve.

Initially, the patient underwent a successful cardiac surgery. During the operation, a large mass was identified attached to the septum of the left atrium with a thin peduncle that measured approximately 1 cm. The mass was removed and the defect in the atrial septum was covered with an autologous pericardial patch. Several weeks after the cardiac operation, the patient underwent laparotomy with dissection of SAVf and splenectomy. The postoperative period was uneventful in both cases. After several months of follow-up, the patient was doing well and did not present any complaints.

Discussion

SAVf was first described by Wiegert in the 19th century. Atrial myxoma is the most common type of benign cardiac tumor in adults. The literature does not reveal any connection between these 2 entities and we speculate that they are separate diseases, which were diagnosed at the same time. Further studies would be helpful to explore a possible connection between these 2 pathologies. The mechanism of SAVf formation is an abnormal route of communication of a splenic artery aneurysm (SAA) with the corresponding vein. The predisposing factors for arterial aneurism are increased blood flow and arterial wall damage associated with weakness of the smooth muscle layer. The cause can be congenital, infectious, due to pancreatitis, acquired after trauma or accidental penetrating injury, and prior surgery in the abdominal cavity. It is more common in multiparous women than in men, with a sex ratio 4 to 1 [1,2]. SAVFs may stay clinically silent for a long period of time. When the aneurism is formed, the patient complains of discreet pain and bruit in the left flank, as observed in our patient.

Myxoma is mostly located in the left atrium, but in rare cases it is encountered in the right atrium. There is a recognized female predilection. The clinical presentation is variable; approximately 20% of myxomas are asymptomatic, or have general symptoms like weakness and weight loss. Depending on the degree of prolapse of the mass into the mitral valve, it could be associated with valvular obstruction, arrhythmia, or embolic diseases, particularly in the brain. The myxomas of the right side of the heart present with symptoms of heart failure. As the number of imaging diagnostic procedures is increasing, more myxomas are accidentally detected. They may be associated with multiple endocrine neoplasia (MEN) syndromes, known as the Carney triad [3,4].

The hemodynamic changes in SAVf may lead to a sudden increase of portal venous pressure, which is manifested with gastrointestinal bleeding, varices, and ascites. Portal hypertension due to chronic liver disease usually requires a longer period of time. Increased portal pressure is associated with splenomegaly and other gastrointestinal signs [5,6]. This patient had a normally sized spleen and liver. The liver had no parenchymal changes and the portal vein was normal.

Cardiac symptoms have been reported by Gunther and include tachycardia, left ventricular dilatation, and ischemic disease of the myocardium [7]. Our patient had some cardiac symptoms that were more related to atrial myxoma.

Vague pain in the left flank was the most persistent symptom in our patient. She started complaining 3 years ago, but because of the vague nature and undetermined echographic findings, she had not been diagnosed. The estimated risk of rupture depends on the size of the aneurysm. There is an increased risk during pregnancy, but this was not the case for our patient [8].

Her past medical history was uneventful. Besides past pregnancies, we did not find any cause to speculate about the origins of this SAVf.

The CTA imaging findings were straightforward in both SAVf and atrial myxoma. The differential diagnoses of primary atrial mass include fibroelastoma, rhabdomyoma, fibroma, lymphoma, and sarcoma. Rhabdomyoma and fibroma mostly affect children, and the other tumors have different clinical and morphological features [9]. Nowadays, the treatment of SAVf is based on endovascular embolization [10]. Because of the complexity of this case, different stage operations were performed. Go to:

Conclusions

CTA is very accurate and helpful in delineating anomalies like SAVf and atrial myxoma and in prompt management. Further study need to be done to explore any connections between them.

References:

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