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Loya JJ, Yang C, Pennington Z, Brown NJ, Rae AI, Winer JL. Applications of supraorbital keyhole craniotomy in pediatric cranial trauma: illustrative series of two cases and systematic literature review. Childs Nerv Syst 2023; 39:3531-3541. [PMID: 37432398 DOI: 10.1007/s00381-023-06043-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/17/2023] [Indexed: 07/12/2023]
Abstract
Minimally invasive (MIS) approaches to neurosurgical diseases continue to increase in popularity due to their association with decreased infection risk, shorter recovery time, and improved cosmesis. Cosmesis and lower morbidity are especially important for pediatric patients. The supraorbital keyhole craniotomy (SOKC) is one MIS approach shown to be effective for both neoplastic and vascular pathologies in pediatric patients. However, it is limited data on its use in pediatric trauma patients. Two cases employing SOKC in pediatric trauma patients are presented here along with a systematic review of the literature. We queried PubMed, Scopus, and Web of Science databases from inception to August 2022 using the Boolean search term: (supraorbital OR eyebrow OR transeyebrow OR suprabrow OR superciliary OR supraciliary) AND (craniotomy OR approach OR keyhole OR procedure) AND (pediatric OR children OR child OR young) AND "trauma". Studies that discussed the use of an SOKC in a pediatric patient having sustained trauma to the frontal calvarium and/or anterior fossa/sellar region of the skull base were included. Details were extracted on patient demographics, trauma etiology, endoscope use, and surgical and cosmetic outcomes. We identified 89 unique studies, of which four met inclusion criteria. Thirteen total cases were represented. Age and sex were reported for 12 patients, 25% of whom were male; the mean age was 7.5 years (range: 3-16). Pathologies included acute epidural hematoma (9), orbital roof fracture with dural tear (1), blowout fracture of the medial wall of the frontal sinus with supraorbital rim fracture (1), and compound skull fracture (1). Twelve patients were treated with a conventional operating microscope, while one underwent endoscope-assisted surgery. Only one significant complication (recurrent epidural hematoma) was reported. There were no reported cosmetic complications. The MIS SOKC approach is a reasonable option for select anterior skull base trauma in the pediatric population. This approach has been used previously for successful frontal epidural hematoma evacuation, which is often treated by a large craniotomy. Further study is merited.
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Affiliation(s)
- Joshua J Loya
- Department of Neurosurgery, Oregon and Health Sciences University, Portland, OR, USA
| | - Chenyi Yang
- Department of Neurosurgery, University of California Irvine, Orange, CA, USA
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nolan J Brown
- Department of Neurosurgery, University of California Irvine, Orange, CA, USA
| | - Ali I Rae
- Department of Neurosurgery, Oregon and Health Sciences University, Portland, OR, USA
| | - Jesse L Winer
- Department of Neurosurgery, Oregon and Health Sciences University, Portland, OR, USA.
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Ong V, Brown NJ, Pennington Z, Choi A, Shahrestani S, Sahyouni R, Abraham ME, Loya JJ. The Pterional Keyhole Craniotomy Approach: A Historical Perspective. World Neurosurg 2023; 179:77-81. [PMID: 37429377 DOI: 10.1016/j.wneu.2023.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
The pterional craniotomy is a workhorse of cranial surgery that provides access to the anterior and middle fossae. However, newer "keyhole" approaches, such as the micropterional or pterional keyhole craniotomy (PKC) can offer similar exposure for many pathologies while reducing surgical morbidity. The PKC is associated with shorter hospitalizations, reduced operative time, and superior cosmetic outcomes. Furthermore, it represents an ongoing trend toward smaller craniotomy size for elective cranial procedures. In this historical vignette, we trace the history of the PKC from its origins to its current role in the neurosurgeon's armamentarium.
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Affiliation(s)
- Vera Ong
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashley Choi
- California University of Science and Medicine, Colton, California, USA
| | - Shane Shahrestani
- Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA; Keck School of Medicine of USC, Los Angeles, California, USA
| | - Ronald Sahyouni
- Department of Neurosurgery, University of California, San Diego, La Jolla, California, USA
| | - Mickey E Abraham
- Department of Neurosurgery, University of California, San Diego, La Jolla, California, USA
| | - Joshua J Loya
- Department of Neurological Surgery, Oregon Health and Sciences University, Portland, Oregon, USA.
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Shahrestani S, Ton A, Brown NJ, Pennington Z, Loya JJ, Kuo C, Mehkri Y, Gendreau J, Diaz-Aguilar LD, Pham MH, Blaskiewicz D. Radiographic Outcomes following ACDF with Hyperlordotic Implants to Achieve Cervical Anterior Column Realignment (ACR). World Neurosurg 2022:S1878-8750(22)01593-5. [PMID: 36396055 DOI: 10.1016/j.wneu.2022.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Degenerative disc disease and progressive sagittal malalignment can both contribute to degenerative cervical myelopathy and radiculopathy. For patients with symptoms refractory to conservative management, anterior cervical discectomy and fusion (ACDF) is a thoroughly vetted intervention shown to improve pain and disability measures. Hyperlordotic implants can also help restore cervical sagittal balance through anterior column realignment (ACR). METHODS A consecutive bi-institutional series of patients who underwent ACDF with hyperlordotic polyetheretherketone (PEEK) implants between 2014 and 2016 was reviewed. All included patients underwent ACDF between C3 and C7 inclusive of a hyperlordotic PEEK cervical implant (>10° lordosis), and had ≥12 months of radiographic follow-up. Lateral radiographs were analyzed to compare pre- and postoperative cervical parameters. RESULTS Forty-six patients were included (mean age, 58.0 years; male, 35%). Mean body mass index was 28.3 kg/m2, and mean radiographic follow-up 14.4 months. Overall, cervical lordosis increased from -7.8° preoperatively to -14.8° postoperatively and to -15.7° at last follow-up (P < 0.001). Additionally, the mean segmental lordosis of ACR levels treated increased from -0.2° preoperatively to -4.8° postoperatively (P < 0.001), but no significant change was observed at last follow-up. Lastly, improvement in segmental lordosis was seen at both postoperative time points at the C3-C4 (P = 0.002 and P = 0.005, respectively), C4-C5 (P < 0.001 and P < 0.001, respectively), and C5-C6 levels (P < 0.001 and P < 0.001, respectively). CONCLUSIONS Our study demonstrates that hyperlordotic PEEK implants used for ACR effectively contribute to restoration of cervical lordosis in patients undergoing ACDF, potentially reducing the need for additional posterior surgery.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Andy Ton
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Zach Pennington
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua J Loya
- Department of Neurosurgery, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Cathleen Kuo
- Department of Neurosurgery, University at Buffalo College of Medicine, Buffalo, New York, USA
| | - Yusuf Mehkri
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | | | - Martin H Pham
- Department of Neurosurgery, University of California, San Diego, California, USA
| | - Donald Blaskiewicz
- Department of Neurosurgery, University of California, San Diego, California, USA.
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Liu MA, Gendreau JL, Loya JJ, Brown NJ, Keith A, Sahyouni R, Abraham ME, Gonda D, Levy ML. Management of pediatric clival chordoma with extension to the craniocervical junction and occipito-cervical fusion: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 2:CASE21434. [PMID: 36060426 PMCID: PMC9435547 DOI: 10.3171/case21434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chordomas are rare malignant neoplasms that develop from the primitive notochord with < 5% of the tumors occurring in pediatric patients younger than the age of 20. Of these pediatric chordomas, those affecting the craniocervical junction (C1–C2) are even more rare; therefore, parameters for surgical management of these pediatric tumors are not well characterized. OBSERVATIONS In this case, a 3-year-old male was found to have a clival chordoma on imaging with extension to the craniocervical junction resulting in spinal cord compression. Endoscopic-assisted transoral transclival approach for clival tumor resection was performed first. As a second stage, the patient underwent a left-sided far lateral craniotomy and cervical laminectomy for resection of the skull base chordoma and instrumented fusion of the occiput to C3. He made excellent improvements in strength and dexterity during rehab and was discharged after 3 weeks. LESSONS In pediatric patients with chordoma with extension to the craniocervical junction and spinal cord compression, decompression with additional occipito-cervical fusion appears to offer a good clinical outcome. Fusion performed as a separate surgery before or at the same time as the initial tumor resection surgery may lead to better outcomes.
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Affiliation(s)
- Matthew A. Liu
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Julian L. Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland
| | - Joshua J. Loya
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Nolan J. Brown
- Department of Neurosurgery, University of California Irvine, Orange, California; and
| | - Amber Keith
- Department of Neurosurgery, University of California Irvine, Orange, California; and
| | - Ronald Sahyouni
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Mickey E. Abraham
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - David Gonda
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
- Rady Children’s Hospital San Diego, California
| | - Michael L. Levy
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
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Loya JJ. Book Review: Cranial Anatomy & Surgical Approaches: A Study Guide. Oper Neurosurg (Hagerstown) 2020. [DOI: 10.1093/ons/opaa119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Itakura H, Achrol AS, Mitchell LA, Loya JJ, Liu T, Westbroek EM, Feroze AH, Rodriguez S, Echegaray S, Azad TD, Yeom KW, Napel S, Rubin DL, Chang SD, Harsh GR, Gevaert O. Magnetic resonance image features identify glioblastoma phenotypic subtypes with distinct molecular pathway activities. Sci Transl Med 2016; 7:303ra138. [PMID: 26333934 DOI: 10.1126/scitranslmed.aaa7582] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Glioblastoma (GBM) is the most common and highly lethal primary malignant brain tumor in adults. There is a dire need for easily accessible, noninvasive biomarkers that can delineate underlying molecular activities and predict response to therapy. To this end, we sought to identify subtypes of GBM, differentiated solely by quantitative magnetic resonance (MR) imaging features, that could be used for better management of GBM patients. Quantitative image features capturing the shape, texture, and edge sharpness of each lesion were extracted from MR images of 121 single-institution patients with de novo, solitary, unilateral GBM. Three distinct phenotypic "clusters" emerged in the development cohort using consensus clustering with 10,000 iterations on these image features. These three clusters--pre-multifocal, spherical, and rim-enhancing, names reflecting their image features--were validated in an independent cohort consisting of 144 multi-institution patients with similar tumor characteristics from The Cancer Genome Atlas (TCGA). Each cluster mapped to a unique set of molecular signaling pathways using pathway activity estimates derived from the analysis of TCGA tumor copy number and gene expression data with the PARADIGM (Pathway Recognition Algorithm Using Data Integration on Genomic Models) algorithm. Distinct pathways, such as c-Kit and FOXA, were enriched in each cluster, indicating differential molecular activities as determined by the image features. Each cluster also demonstrated differential probabilities of survival, indicating prognostic importance. Our imaging method offers a noninvasive approach to stratify GBM patients and also provides unique sets of molecular signatures to inform targeted therapy and personalized treatment of GBM.
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Affiliation(s)
- Haruka Itakura
- Division of Biomedical Informatics, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Achal S Achrol
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Lex A Mitchell
- Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | - Joshua J Loya
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Tiffany Liu
- Division of Biomedical Informatics, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Scott Rodriguez
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Sebastian Echegaray
- Department of Electrical Engineering, Stanford University, Stanford, CA 94305, USA
| | - Tej D Azad
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Kristen W Yeom
- Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | - Sandy Napel
- Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | - Daniel L Rubin
- Division of Biomedical Informatics, Department of Medicine, Stanford University, Stanford, CA 94305, USA. Department of Radiology, Stanford University, Stanford, CA 94305, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University, Stanford, CA 94305, USA
| | - Olivier Gevaert
- Division of Biomedical Informatics, Department of Medicine, Stanford University, Stanford, CA 94305, USA.
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Liu TT, Achrol AS, Mitchell LA, Du WA, Loya JJ, Rodriguez SA, Feroze A, Westbroek EM, Yeom KW, Stuart JM, Chang SD, Harsh GR, Rubin DL. Computational Identification of Tumor Anatomic Location Associated with Survival in 2 Large Cohorts of Human Primary Glioblastomas. AJNR Am J Neuroradiol 2016; 37:621-8. [PMID: 26744442 DOI: 10.3174/ajnr.a4631] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Tumor location has been shown to be a significant prognostic factor in patients with glioblastoma. The purpose of this study was to characterize glioblastoma lesions by identifying MR imaging voxel-based tumor location features that are associated with tumor molecular profiles, patient characteristics, and clinical outcomes. MATERIALS AND METHODS Preoperative T1 anatomic MR images of 384 patients with glioblastomas were obtained from 2 independent cohorts (n = 253 from the Stanford University Medical Center for training and n = 131 from The Cancer Genome Atlas for validation). An automated computational image-analysis pipeline was developed to determine the anatomic locations of tumor in each patient. Voxel-based differences in tumor location between good (overall survival of >17 months) and poor (overall survival of <11 months) survival groups identified in the training cohort were used to classify patients in The Cancer Genome Atlas cohort into 2 brain-location groups, for which clinical features, messenger RNA expression, and copy number changes were compared to elucidate the biologic basis of tumors located in different brain regions. RESULTS Tumors in the right occipitotemporal periventricular white matter were significantly associated with poor survival in both training and test cohorts (both, log-rank P < .05) and had larger tumor volume compared with tumors in other locations. Tumors in the right periatrial location were associated with hypoxia pathway enrichment and PDGFRA amplification, making them potential targets for subgroup-specific therapies. CONCLUSIONS Voxel-based location in glioblastoma is associated with patient outcome and may have a potential role for guiding personalized treatment.
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Affiliation(s)
- T T Liu
- From the Stanford Center for Biomedical Informatics Research and Biomedical Informatics Training Program (T.T.L., D.L.R.) Department of Radiology (T.T.L., L.A.M., W.A.D., K.W.Y., D.L.R.)
| | - A S Achrol
- Stanford Institute for Neuro-Innovation and Translational Neurosciences (A.S.A.) Institute for Stem Cell Biology and Regenerative Medicine (A.S.A.) Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - L A Mitchell
- Department of Radiology (T.T.L., L.A.M., W.A.D., K.W.Y., D.L.R.)
| | - W A Du
- Department of Radiology (T.T.L., L.A.M., W.A.D., K.W.Y., D.L.R.)
| | - J J Loya
- Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - S A Rodriguez
- Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - A Feroze
- Department of Neurological Surgery (A.F.), University of Washington School of Medicine, Seattle, Washington
| | - E M Westbroek
- Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - K W Yeom
- Department of Radiology (T.T.L., L.A.M., W.A.D., K.W.Y., D.L.R.)
| | - J M Stuart
- Biomolecular Engineering (J.M.S.), University of California Santa Cruz, Santa Cruz, California
| | - S D Chang
- Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - G R Harsh
- Department of Neurosurgery (A.S.A., J.J.L., S.A.R., E.M.W., S.D.C., G.R.H.), Stanford University School of Medicine, Stanford, California
| | - D L Rubin
- From the Stanford Center for Biomedical Informatics Research and Biomedical Informatics Training Program (T.T.L., D.L.R.) Department of Radiology (T.T.L., L.A.M., W.A.D., K.W.Y., D.L.R.)
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Achrol AS, Liu T, Mitchell LA, Loya JJ, Westbroek EM, Rodriguez S, Feroze A, Chang SD, Rubin D, Harsh GR. 123 Quantitative Volumetric Magnetic Resonance Perfusion Identifies a Distinct Vasculogenic Molecular Subtype of Human Glioblastoma Associated With Worse Clinical Outcomes. Neurosurgery 2015. [DOI: 10.1227/01.neu.0000467085.78226.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Loya JJ, Mindea SA, Yu H, Venkatasubramanian C, Chang SD, Burns TC. Intracranial hypotension producing reversible coma: a systematic review, including three new cases. J Neurosurg 2012; 117:615-28. [PMID: 22725982 DOI: 10.3171/2012.4.jns112030] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension-associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.
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Affiliation(s)
- Joshua J Loya
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5487, USA
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