\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Development of Contained Cerebrospinal Fluid Leak Associated with
Changes in Atmospheric Pressure in one Patient with Decompressive
Craniectomy: Case Report.}



\author[1]{Luis Avellaneda}%
\author[1]{Lorena Garcia}%
\author[1]{Marco Rojas}%
\affil[1]{Hospital regional de la orinoquia}%


\vspace{-1em}



  
  \date{May 04, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Decompressive craniectomy is a measure in the management of intracranial
hypertension due to injuries that dont respond to initial measures.
cranial defects may present multiple complications associated with
management. Atmospheric pressure generates a force on adjacent brain
parenchyma, conditioning dynamic alterations in cerebral and
cerebrospinal flow.%
\end{abstract}%



\sloppy


\textbf{Article's Title:}

\textbf{Development of Contained Cerebrospinal Fluid Leak Associated
with Changes in Atmospheric Pressure in one Patient with Decompressive
Craniectomy: Case Report.}

\textbf{Authors' names and affiliations:}

Luis C. Avellaneda C\textsuperscript{1}, Lorena Garc\selectlanguage{ngerman}ía
A\textsuperscript{2}, Marco Antonio Rojas G\textsuperscript{3}

\textsuperscript{\textbf{1}} \textsubscript{Medical Surgeon in Orinoquia
Regional Hospital, Department of Neurosurgery, Yopal, Casanare-
Colombia-} \textbf{0000-0002-2833-2985}

\textsuperscript{2} \textsubscript{Epidemiologist Doctor in Orinoquia
Regional Hospital, Department of investigation, Yopal, Casanare-
Colombia-} \textbf{0000-0001-9557-0900}

\textsuperscript{3} \textsubscript{Neurosurgeon in Orinoquia Regional
Hospital, Department of Neurosurgery, Yopal, Casanare- Colombia-}

\textbf{0000-0002-5823-1560}

*Corresponding Author: Luis Avellaneda C.

Degree: Medical Surgeon, Assistant of Neurosurgery Department

Address: Street 15 N° 07-95 Manzana L. Yopal -Casanare, Colombia

Tel: Fax:+57 3105807119

E-mail: luiscarlosavellaneda92@gmail. Com

\textbf{A B S T R A C T}

\textbf{Background and Importance:} Decompressive craniectomy is a
measure in the management of intracranial hypertension due to injuries
that do not respond to initial measures, however, patients with cranial
defects may present multiple complications associated with management.
Atmospheric pressure generates a force on the adjacent brain parenchyma,
conditioning dynamic alterations in cerebral and cerebrospinal flow;
however, the effects caused of shallow dives in these patients should be
considered. \textbf{Case Presentation} : Male patients with history of
decompressive craniectomy, development contained cerebrospinal fluid
fistula after immersion in shallow waters, with subsequent presence of
neurological symptoms are documented. \textbf{Conclusion} : Little is
known about the effects of immersion and emersion repetitive in patients
with decompressive craniectomy, however, the presence of sudden changes
in pressure at shallow water can lead to neurological injuries

\textbf{Keywords} : Pressure, cerebrospinal fluid, Craniectomy

\textbf{Highlights:}

\selectlanguage{english}* Poor tolerance of immersion in patients with decompressive craniectomy

\selectlanguage{english}* Dives greater than 2 meters deep could cause neurological damage in
patients with post-surgical cranial defects.

\selectlanguage{english}* More studies are needed to determine intracranial dynamic changes in
patients undergoing immersion.

\textbf{Introduction}

Evangelista Torricelli, an Italian physicist and mathematician,
documented for the first time the effect that the mass of air has on the
liquid contained in a cylindrical structure, which was called
atmospheric pressure. Therefore, atmospheric pressure is the force per
unit area exerted by the earth's atmosphere, being 760mmHg above sea
level. The atmospheric pressure plays an important role in the various
systems of the human body, however, drastic changes in pressure can
cause an imbalance in these systems. (1)

\textbf{Case Presentation:}

A 24-year-old male, with a history of polytrauma in a traffic accident,
without any other antecedent, was admissioned with loss of
consciousness, associated with a right clavicle deformity. Income with
Glasgow scale 14/15, he required management in a COVID unit due to a
positive test, simple head CT scan on admission, evidence of left
frontoparietal and temporal laminate subdural hematoma associated with
left temporal contusion and cerebral edema, initiating neuroprotection
measures and antiedema measures. Him presented torpid neurological
evolution for which neurosurgical management was decided by
decompressive craniectomy(fig1) with slow evolution towards improvement.
During patient follow-up, he presented neurological improvement, without
residual neurologic deficits. However, the patient was readmitted 9
months after the trauma, reported immersion and emersion repetitively in
a river with approximately 2 meters deep, after that, him exhibited
right hemiparesis and secondary headache, for which he was admitted
performing neuroimaging studies and assessment by the department of
neurosurgery.

Computed tomography of the brain was initially performed, which showed
the presence of a hypo-iso dense extra-axial collection associated with
signs of adjacent cortical cerebral edema. It was decided to perform a
simple brain MRI, in order to rule out the presence of rebleeding, or
anomalies in the diffusion-weighted sequence, which were normal.
Cerebral cortex edema and presence of cerebrospinal fluid fistula
secondary to barotrauma are considered. (Fig 2). subsequently, it was
decided to continue outpatient follow-up.

\textbf{Discussion}

Within the complications in patients with decompressive craniectomy we
can divide them into early \textless{}4 weeks and late \textgreater{}4
weeks, it is associated with a complication rate of up to 53.9\%. (2)
Most authors agree that late-onset complications are related to abnormal
ICP, changes in CSF flow, and the direct effect of atmospheric pressure
acting on the brain and cerebral vascularization. However, a linear
decrease in icp is observed within the two first weeks between 7.8 +- 2.0
mm Hg to 1.8 +- 3.3 mm Hg with a greater decrease in the first month. (3)

On the other hand, air exerts pressure (1 atm) on the human body,
however, water is 800 times denser than air, causing an increase in body
pressure once immersed. Therefore, a 10-meter dive is the equivalent of
all the pressure exerted on sea level. (4) In this way, patients with
decompressive craniectomy are vulnerable to changes in the atmospheric
pressure, conditioning disorders of cerebral blood flow and
cerebrospinal fluid (5), as shown by McKnight JC et al. in divers with
deep descents. (6) The skull vault plays an important role as a barrier
against barometric pressure, even in those patients with deep and
prolonged immersions without generating major changes in cerebral blood
flow. On the other hand, a study by Benjamin A et al. In animal models
with decompressive craniectomy, it demonstrated the role played by
atmospheric pressure, generating a decrease in the rates of pulsation
and glial activation. (7)

\textbf{Conclusion:}

The skull vault is a vital structure, which allows it to withstand large
pressure changes constantly. however, in patients with decompressive
craniectomy, barometric pressure conditions dynamic changes in cerebral
and cerebrospinal blood flow, due to direct contact of atmospheric
pressure on the brain parenchyma. For this reason, patients with these
cranial defects consider not performing immersion maneuvers at depths
greater than 2 meters, because repetitive periods of immersion and
emersion condition an external suction effect, which could condition the
formation of a contained cerebrospinal fluid leak.

\textbf{Ethical Considerations} : This research has the informed consent
signed by the patient. We are in contact to continue monitoring and
evolution.

\textbf{Funding} : The authors declare that the study was carried out
and financed with the author's own resources. We dind't receive external
contributions.

\textbf{Conflict of interest} : The authors declare that they have no
conflict of interests.

\textbf{References} :

1. John B. West Torricelli and the Ocean of Air: The First Measurement
of Barometric Pressure PHYSIOLOGY 28: 66--73, 2013;
doi:10.1152/physiol.00053.2012

2. Gopalakrishnan MS, Shanbhag NC, Shukla DP, Konar SK, Bhat DI and Devi
BI (2018) Complications of Decompressive Craniectomy. Front. Neurol.
9:977. doi: 10.3389/fneur.2018.00977

3. Alexander Lilja-Cyron, Morten Andresen, Morten Andresen, Long-Term
Effect of Decompressive Craniectomy on Intracranial Pressure and
Possible Implications for Intracranial Fluid Movements. Neurosurgery
0:1--10, 2019
DOI:10.1093/neuros/nyz049\emph{www.neurosurgery-online.com}

4. Ian M. Wilcock, John B. Cronin and Wayne A. Hing Physiological
Response to Water Immersion. Sports Med 2006; 36 (9): 747-765

5. Sameer H. halani, Jason K. Chu, James G. Malcolm. Effects of
Cranioplasty on Cerebral Blood Flow Following Decompressive Craniectomy:
A Systematic Review of the Literature \emph{Neurosurgery 81:204--216,
2017} DOI:10.1093/neuros/nyx054 www.neurosurgery-online.com

6. McKnight JC et al. 2021 When the human brain goes diving: using
near-infrared spectroscopy to measure cerebral and systemic
cardiovascular responses to deep, breath-hold diving in elite
freedivers. Phil. Trans. R. Soc. B 376:
20200349.\emph{https://doi.org/10.1098/rstb.2020.0349}

7. Plog BA, Lou N, Pierre CA, Cove A, Kenney HM, Hitomi E, Kang H, Iliff
JJ, Zeppenfeld DM, Nedergaard M, Vates GE. When the air hits your brain:
decreased arterial pulsatility after craniectomy leading to impaired
glymphatic flow. J Neurosurg. 2019 May 17:1-14. doi:
10.3171/2019.2.JNS182675. Epub ahead of print. PMID: 31100725; PMCID:
PMC7331946

\textbf{Hosted file}

\verb`figures .docx`  available at \url{https://authorea.com/users/485118/articles/570642-development-of-contained-cerebrospinal-fluid-leak-associated-with-changes-in-atmospheric-pressure-in-one-patient-with-decompressive-craniectomy-case-report}

\selectlanguage{english}
\FloatBarrier
\end{document}

