[287926]
In 2002: pt admitted for surgery of posterior fossa brain tumor. Well until one year prior when they developed headaches. Headaches progressed over time. Head ct and mri in nov. Revealed tumor. Pmh: no previous surgeries, no chemotherapy. Meds: decadron given prior to procedure followed by taper after procedure. Preoperative diagnosis: posterior fossa brain tumor and hydrocephalus. Operation: right frontal ventriculostomy; suboccipital craniotomy & resection of posterior fossa fourth ventricular and skull base tumor with c1 laminectomy; microdissection. Tumor cavity lined with surgicel; timesh cranial planning; dural patch graft of bovine pericardium -no- react dura shield, product number 555-ds; shelhigh, inc. -. Pt transferred to picu in satisfactory condition. In 12/02: pt transferred to medical floor with ventriculostomy. One week later, ventriculostomy removed. The next day, pt transferred to rehab unit. Post-op ataxia, dysphagia, cn vi & vii palsies, diplopia & dysconjugate gaze. In 2003: pt was noted to have leakage of csf from the former ventriculostomy site -enough leakage to make their hair and bed wet-. Sutures placed with subsequent resolution of the csf leak. In 03: pt developed fever and neck pain and stiffness. Csf: rbc =212, 160, wbc=9,123 -81% pmns-, protein=710, glucose=38, no organisms were seen. Ceftriaxone and vancomycin were initiated. Subsequently pt complained of severe lower back pain and neurological status declined. Csf cultures and bacterial pcr were negative. Two days later: transfered back to neurosurgery service. Mri of spine and brain revealed abnormal nerve root clumping and enhancement within the lumbar sacral spine as well as linear dural enhancement throughout the spine. Differential included arachnoiditis/post operative change, infection, and csf spread of tumor though tumor was considered much less likely. Three days later: increased somnolence, ct: acute hydrocephalus. To or for ventriculostomy. Preop diagnosis: acute hydrocephalus; posterior fossa tumor, status post resection. Operation: placement of right frontal ventriculostomy with rickham reservoir for external ventricular drainage; lumbar puncture attempted at 3 different levels did not produce fluid. Ventric fluid: rbc=43, wbc= 7 -57% pmns-, protein=12, glucose=75. Bacterial & fungal cx negative. Increasing leg pain, decreasing neurological function. Eventually total paralysis of lower extremities and loss of bowel and bladder control. Two days later to or for exploration/biopsy of abnormality around nerve roots. Preop diagnosis: intraspinal process tumor versus infection. Procedure: l4/5 laminectomy, intradural and extramedullary exploration. Intraoperative description: thick, white mucoid material, poor to partially organized, coating nerve roots in subdural space. Cultures obtained. Postop diagnosis: intradural spinal infection consistent with a subdural empyema. Two days later culture of dural tissue during or in january 2003 grew aspergillus fumigatus. Ctx and vanco stopped. Antifungal therapy initiated -ambisome and voriconazole-. The next day, neck surgical wound breakdown. Culture subsequently grew aspergillus spp from broth only. Four days later mri: markedly increased nodular dural enhancement thoroughout spine, most severe mid-thoracic to sacrum; new enhancing fluid collection within suprasellar cistern, possible abscess. Ct scan of neck/thorax/abd/pelvis showed no other areas of involvement with aspergillus. Echo: no vegetations. Ophtho exam normal. Subsequent cultures have showed no growth of fungus. Three days later it ampho started. Eventually on a regimen of ambisome -10/kg/day-, voriconazole, it amphotericin -1mg/day-. In 3/03: continues on antifungal therapy. Radiologically disease has stabilized. Clinically, the pt appears to be regaining some strength in lower extremities.
Patient Sequence No: 1, Text Type: D, B5