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Spinal solitary fibrous tumour (SFT) is an uncommon tumour with few cases reported in the literature. It rarely originates at the craniocervical junction. To our knowledge, only eight cases of spinal SFT located at the craniocervical junction have been reported in the literature. We presented a patient with a craniocervical junction SFT and discussed its clinical presentation, radiological features, pathology, management and outcome. This was the first patient reported in the literature with a recurrent craniocervical junction SFT treated with Gamma Knife radiosurgery. The treatment reduced the tumour volume by more than 85% within 12 months.

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Sacral spinal cord ependymoma is an uncommon pathology. Most of the reported cases are consistent with a myxopapillary ependymoma histopathologic subtype. Non-myxopapillary ependymomas rarely occur in the sacral region. Most lesions are intradural; however, rare extradural cases can occur. We present the case of a 46-year-old female patient diagnosed with a grade II sacral extradural ependymoma, emphasising the importance of an interdepartmental case approach for diagnosis and management. Even though grade II ependymomas are considered low grade, the potential for recurrence and metastatic disease has been reported. There are no treatment guidelines for these rare tumours besides gross total resection.

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Lemierre syndrome is an often misdiagnosed disease caused by an anaerobic bacterial infection that produces thrombophlebitis of the internal jugular vein and septic metastasis to distal organs, especially the lungs. Carotid stenosis or thrombosis is a rare complication. We present a patient with Lemierre syndrome who developed malignant cerebral oedema secondary to an ischaemic stroke which required a decompressive craniectomy.

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BACKGROUND: Surgical site infection (SSI) is a well-documented complication in patients who undergo posterior spine instrumentation with most studies reporting an incidence of 1%-12%. Some studies have documented that a diluted sterile povidone-iodine (PVI) solution can be safely used in posterior spinal fusion surgeries as an antiseptic; in this study, we analyzed its effectiveness in reducing SSI. METHODS: This retrospective study consisted of consecutive patients who underwent elective posterior lumbar instrumentation performed by a single surgeon from 2016 to 2019. In the first 134 patients, wounds were irrigated before arthrodesis and closure with 1 L of 0.9% normal saline solution; in the subsequent 144 patients, wound irrigation was with a solution of 35 mL of sterile 10% PVI. Both groups were analyzed to determine if wound irrigation with sterile PVI solution decreased SSIs. RESULTS: There were 9 (6.7%) SSIs in the 0.9% normal saline solution group versus 1 (0.7%) SSI in the PVI group (P = 0.008). PVI solution had a relative risk for SSI of 0.093 (P = 0.008) and an adjusted odds ratio of 0.113 (P = 0.05). Increased body mass index and posterolateral spine fusion with laminectomy were significant risk factors for SSI (P = 0.04 and P = 0.030, respectively). CONCLUSIONS: Wound irrigation with PVI solution significantly reduced SSI in elective posterior lumbar instrumentation cases. Subgroup analysis provided significant results to recommend use of PVI solution for SSI prevention, particularly in overweight and obese patients. We also recommend its use in patients with risk factors for SSI, such as longer operative time and unintended durotomy.

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Intradural extramedullary spinal cavernous malformations (CMs) remain the least common variant of these lesions and can originate from the inner surface of the dura mater, the pial surface of the spinal cord, and the blood vessels in the spinal nerves. Root-based-only extramedullary CMs are very rare in the thoracic region with only four cases reported. We present a case of 56-year-old male with 1-year progression of lower extremities weakness. Magnetic resonance imaging demonstrated a hyperintense lesion in the upper thoracic region. Surgical exploration revealed a CM with origin in the second thoracic nerve root with gross total resection. Histopathological examination confirmed a CM. The patient had complete recovery of neurological function at 3 months interval. Intradural extramedullary CM is extremely rare entity that must be considered in the differential diagnosis of intradural extramedullary lesions. Surgical resection is the treatment of choice to prevent further neurological damage.

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OBJECTIVE: The purpose of this study was to determine the effect of the timing of surgery on the neurological function of patients with a cervical spinal cord injury. METHODS: Retrospectively, an analysis was done of patients who underwent decompression and/or spinal cord stabilization surgeries from 2010 through 2014 for cervical trauma. All patients were older than 18 years of age, had had surgery at our facility, and had made at least 1 follow-up visit. American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores were compared for patients who underwent early surgeries (less than 72 hours after trauma) and for those who underwent late surgeries (more than 72 hours after trauma). RESULTS: There were a total of 107 patients. Sixty-two patients had spinal cord injuries. The average age was 38.6 years, and 84% of the participants were male. The most common mechanism of trauma was motor vehicle accident. Twenty-nine percent of the patients developed neurogenic shock and 27% experienced respiratory failure during the first week after admission. Seventeen patients died during the study period. A multivariate analysis of AIS score improvement revealed that the only significant factor was incomplete neurological injury. There was no significant difference in the percentage of patients that improved with early surgery compared to that of those that improved after late surgery. CONCLUSION: Traumatic cervical spinal cord injury is associated with high mortality and morbidity. Early surgery was not associated with an improved neurological outcome at long-term follow-up. The benefit of early surgery was seen only in terms of decreasing each patient's length of hospital stay.

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OBJECTIVE: Shunt infection is the most common complication following a Cerebrospinal fluid (CSF) diversion procedure with devastating consequences. This study analyzes the efficacy of different shunt systems in reducing early shunt infections in the pediatric population. METHODS: Retrospective case study analysis of 177 pediatric patients with hydrocephalus de novo shunted using hydromer-coated (HC) shunt systems, antibiotic-impregnated (AI) shunt systems and standard non impregnated shunt systems was performed and compared for the incidence of shunt infection in the early postoperative period. RESULTS: Group A consisted of standard shunt systems with 63 patients, Group B were HC shunt systems with 67 patients and group C consisted of 47 patients with antibiotic-impregnated shunt systems. Mean age in Group A was 1.36 +/- 3.36 years Mean age in Group B was 2.32 +/- 4.69 years. Mean age in Group C: 0.64 +/- 1.70 years. In terms of shunt infections, HC group had 4 shunt infections (6.25%), as compared to the control group, where 7 patients (10.45%) had infections. The AI group had 1 infection (2.13%). When comparing HC systems versus Standard Non-Impregnated There were 3 shunt malfunction in Group A (4.8%), 2 shunt malfunction in group B (3.3%) and 0 shunt malfunction in Group C (0%). CONCLUSION: Hydromer-coated shunt systems and antibiotic-impregnated shunt system represent a superior alternative to standard shunt systems for the reduction of shunt infection in the early post operative period.

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OBJECTIVE: The management of thoracolumbar burst fractures often includes combined anterior/posterior approaches with prolonged operative time and complications. The transpedicular approach offers a posterior only approach with circumferential reconstruction and decompression. We aim to present the experience of a single center in the management of thoracolumbar burst fractures using a posterior-only approach for circumferential stabilization and report on this technique's effectiveness in restoring the alignment of the thoracolumbar junction. METHODS: A case review of the medical records of patients admitted to the adult neurosurgery service (from January 2011 through June 2014) with traumatic non-pathological thoracolumbar burst fractures and subsequently treated with a transpedicular corpectomy (including the placement of an expandable cage) was performed, retrospectively. RESULTS: A total of 20 patients underwent a posterior transpedicular corpectomy consisting of anterior column reconstruction using an expandable cage with supplementary posterior fixation within 72 hours of injury. The average pre-operative canal compromise was 69%. The average pre-operative kyphotic angle was 21.6°. The average post-operative kyphotic angle was 5.15°, with an average correction of 16.45°. There were 11 patients with pre-operative neurological compromises, of which patients, 8 experienced variable degrees of recovery. The average operating time was 410.5 minutes (range, 240-550 min). The average blood loss was 880 mL (range, 650-1500). Three patients experienced complications during surgery; 1 patient died. CONCLUSION: The transpedicular approach for circumferential reconstruction and stabilization provides an alternative technique for the management of thoracolumbar fractures, having an acceptable risk and the associated lower morbidity of a posterioronly approach.

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OBJECTIVE: A rare, low-grade tumor found in the hypothalamus and anterior third ventricle, a chordoid glioma presents a challenge to neurosurgeons: Its successful resection is complicated by its inconvenient location. CASE DESCRIPTION: A 42-year-old male patient presented with a 1-year history of major depressive disorder, with psychotic features associated with generalized tonic-clonic seizures. Brain magnetic resonance imaging (MRI) with contrast revealed a suprasellar mass extending into the third ventricle To resect the lesion, an interhemispheric transcallosal transventricular subfornical approach was used. Pathology revealed a chordoid glioma. The patient had a complicated post-operative period that included the development of neurogenic diabetes insipidus, followed by intractable hyponatremia and death (caused by malignant brain edema). CONCLUSION: A chordoid glioma is a rare neoplasm that, in 2000, was incorporated into the World Health Organization (WHO) classification of central nervous system tumors. Due to its rarity, it is seldom considered in the differential diagnosis of suprasellar masses. Moreover, its unusual presentation and difficult location present a challenge for surgical and medical management.

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INTRODUCTION: There are limited data with regards to the associated risk of post-operative seizures in patients with surgically treated chronic subdural hematomas (CSDHs). The use of anti-epileptic drugs (AEDs) is associated with significant side effects. METHODS: A retrospective chart review was performed on patients operated via burr hole for CSDH in our institution from 2004 to 2013. Post-operative seizures at 1-year follow-up were identified. Demographic data, medical history, and imaging characteristics were recorded. RESULTS: A total of 220 patients were included in the study. Post-operative seizures occurred in 2.3%. The mean time of onset of seizures was 8.4 days. No difference in age and gender between seizing and non-seizing groups was identified p > 0.05. Mean midline shift was 4.6 mm in seizing group vs. 4.2 mm in non-seizing group, p > 0.05. Mean thickness was 14.6 mm in patients without post-operative seizures and 18.4 mm in patients with post-operative seizures, p > 0.05. There was no significant difference in post-operative seizure incidence related to the side or location of the CSDHs. CONCLUSIONS: The incidence of post-operative seizures in patients with CSDH evacuated via burr holes was low. Prophylactic AEDs should not be routinely administered if no other risk factor for seizure exists. Demographic and clinical factors did not appear to influence post-operative seizures.

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BACKGROUND: Adequate adrenal response is fundamental for the maintenance of physiological homeostasis in the setting of trauma and severe illness. Patients with neurogenic shock are at risk of severe consequences if adrenal insufficiency (AI) is not rapidly identified and treated. OBJECTIVE: To analyze the incidence of AI in patients with acute cervical spinal cord injury and its effect on in-hospital complications. METHODS: The medical records of patients older than 18 years who were admitted to the adult neurosurgery service at the University District Hospital as the result of neurogenic shock after acute cervical spinal cord injury from January 2004 to December 2009 were reviewed retrospectively. RESULTS: One hundred ninety-nine patients were admitted with acute cervical spinal cord injury. A total of 37 patients met the pre-established criteria for neurogenic shock. The incidence of AI in patients with neurogenic shock was 22%. The average random cortisol was 9.3 µg/dL in patients with AI versus 29.2 µg/dL in non-AI. The presence of AI was positively correlated with complications and an increase in the risk of intubation (P = 0.01 and P = 0.002). The 30-day mortality rate in patients with AI was 13% compared with the 3% in the non-AI group (P = 0.39). CONCLUSIONS: Adrenal insufficiency is a poorly recognized complication in patients with acute cervical spinal cord injury and its aggressive treatment is of utmost importance to avoid further neurological injury.

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OBJECTIVE: Vagus nerve stimulation (VNS) is considered an alternative treatment for patients with medically refractory epilepsy who are not candidates for resective surgery. It consists of intermittent electrical stimulation of the left vagus nerve in the neck. Such stimulation has been demonstrated to be efficacious, safe, and well tolerated, offering these patients another option for seizure control. The aim of this study was to evaluate the experience of VNS at the University of Puerto Rico, and to examine demographic data, types of seizures, and seizure-control outcomes among treated subjects. This study is the first account of VNS in a pediatric population living in the Caribbean area. METHODS: A retrospective analysis of 13 patients treated at the University Pediatric Hospital in San Juan, Puerto Rico, was undertaken. Different types of seizures were identified and managed. RESULTS: The mean age at implantation was 12 years; 77% of patients were female. The most common type of seizure treated was generalized tonic-clonic (24%), followed by complex partial (23%). Sixty-nine percent of patients demonstrated a reduction in monthly seizure frequency. Ninety-three percent of caregivers reported improvements in alertness and communication. CONCLUSION: Vagus nerve stimulation is a safe and effective way to treat medically refractory epilepsy and should be considered as a non-pharmacological treatment for select patients with medically refractory epilepsy.

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OBJECTIVE: To determine the frequency of pediatric brain tumors treated at the University Pediatric Hospital of Puerto Rico over a 6-year period and examine the demographic data and tumor histology of patients in different age groups. METHODS: A retrospective study was undertaken at the University Pediatric Hospital. We included patients with brain tumors that had been newly diagnosed during the period covering from January 2002 to December 2007. All cases were analyzed by age, gender, histologic diagnosis, and affected area. RESULTS: One hundred thirty-six patients were included in the study. Overall, males were more frequently affected than were females. Children in the 1 to 4 years old age group had the highest number of newly diagnosed brain tumors. Regarding anatomic location, supratentorial tumors were more frequent than were infratentorial tumors. The most common single tumor was the pilocytic astrocytoma (WHO grade I), representing 31% of the total pediatric brain tumors. CONCLUSION: Our results provide an objective platform for further epidemiological studies and for the development of local health strategies for the timely diagnosis and treatment of the most common pediatric tumors in Puerto Rico.

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INTRODUCTION: Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for certain types ofhydrocephalus. Depending on patient's age and etiology of hydrocephalus, it carries a success rate of around 90%. However, as in any surgical procedure, inherent risks are present and a risk-benefit analysis must be done prior to selecting patients for this intervention. OBJECTIVE: To evaluate retrospectively the experience of ETV at the University of Puerto Rico and examine the etiological factors, demographic data and symptoms among the Puerto Rico population. This study represents the data of one neurosurgeon and is the first account of endoscopic third ventriculostomy as a mode of treatment in the Caribbean area. METHODS: Retrospective analysis was undertaken of 29 patients treated at the University Pediatric Hospital (UPH) and University District Hospital (UDH) in San Juan was undertaken Different etiologies of hydrocephalus were identified and managed. RESULTS: The most common indication for ETV was aqueductal stenosis (59%) with male predominance (55%). Also, the most common population treated were adults (72%) and the most common symptom presented were headaches (52%) and gait disturbances (43%). CONCLUSIONS: Endoscopic third ventriculostomy is a safe and effective way to treat hydrocephalus and should be considered as first choice of treatment for certain patients with hydrocephalus unless otherwise contraindicated.

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Encapsulation of proteins in polyester microspheres by coacervation methods frequently causes protein inactivation and aggregation. Furthermore, an often-substantial amount of the encapsulated proteins is released within the first 24 h from the microspheres. To overcome these problems poly(ethylene glycol) (PEG) was employed as excipient and protein-modifying agent. The model protein horseradish peroxidase (HRP) was chemically modified or co-lyophilized with PEG of differing molecular weights, namely PEG(5000), PEG(20000), and PEG(40000). The lyophilized preparations were encapsulated in poly(D,L-lactide-co-glycolic) acid (PLGA) microspheres by a coacervation method. Covalent modification of HRP with PEG increased the encapsulation efficiency (EE) from 83% to about 100% while PEG when used as an excipient reduced the EE. Encapsulation caused aggregation of ca. 5% of non-modified HRP and the residual specific activity was only 57%. Covalent modification with PEG reduced HRP aggregation to less than 1% and improved its residual activity to more than 95%. When PEG was used as excipient similar results were found with respect to a reduction in encapsulation-induced aggregation, but no more than 80% of residual activity was obtained even for the best formulation after encapsulation. It was also found that covalent modification of HRP with PEG substantially reduced the unwanted initial "burst" release observed during the initial 24 h of in vitro release from about 70% to 23%. Furthermore, HRP activity and stability were also improved during in vitro release for HRP-PEG conjugates. The data show that covalent modification of proteins with PEG might be useful to improve protein stability during coacervation encapsulation and subsequent release as well as to increase EE and reduce the burst release.

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