Resident UPMC Pittsburgh, Pennsylvania, United States
Case Diagnosis: Clival chordoma resection complicated by ventriculitis following endoscopic endonasal approach
Case Description: 62 year-old Israeli male returned to the hospital one day after discharge for endoscopic endonasal approach (EEA) for resection of clival chordoma with severe fevers and altered mental status. Patient was found to have a necrotic nasal septal flap complicated by ventriculitis. Cultures were positive for Methicillin sensitive Staphylococcus aureus, Serratia marcescens, and Strep constellatus. He underwent additional EEA for debridement and reconstruction with a vascularized left lateral nasal wall flap. He was discharged to inpatient rehab (IPR) for six-weeks with dual beta-lactam antibiotic therapy with Oxacillin, Ceftriaxone and Flagyl. Upon admission, he presented with deficits in vision, balance, strength and coordination.
Discussions: Clival chordomas are slow growing malignant lesions arising from the embryonic notochord with an incidence of ~1 case per 100,000, accounting for less than 0.2% of all intracranial neoplasms. Clinical presentation is based on tumor origin site and direction of growth. Common complaints can include vague neurologic symptomatology, such as headache and diplopia. EEA is an innovative, minimally invasive approach to remove brain tumors using the nose and sinuses to access the base of the skull. Complications can include postoperative cerebrospinal fluid leak, sodium dysregulation, and acquisition of meningitis. On admission, our patient was experiencing visual, balance, strength and mild cognitive symptoms that were addressed in an inpatient rehab setting with rehabilitation therapies that included dynamic balance training with obstacle negotiation, targeting work responsibilities by using Microsoft applications, and employing partial and complete occlusion to improve binocular diplopia.
Conclusions: This case report further emphasizes the importance of inpatient rehabilitation in managing the sequelae of clival chordomas complicated by intracranial surgery. For surgeons who perform intracranial resections, understanding the importance of multidisciplinary rehabilitation therapies to monitor and shorten surgical complications, can help patients return home quicker with greater functional capacity.
