Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Frontal Sinus Breach During Routine Frontal Craniotomy

Neurosurgery 81:504–511, 2017

Frontotemporal craniotomies are commonly performed for a variety of neurosurgical pathologies. Infections related to craniotomies cause significant morbidity. We hypothesized that the risk of cranial surgical site infections (SSIs) may be increased in patients whose frontal sinuses are breached during craniotomy.

OBJECTIVE: To compare the rate of cranial SSIs in patients undergoing frontotemporal craniotomies with and without frontal sinus breach (FSB).

METHODS: We performed a retrospective analysis of all patients undergoing frontotemporal craniotomies for the management of cerebral aneurysms from 2005 to 2014. This study included 862 patients undergoing 910 craniotomies. Primary outcomeof interest was occurrence of a cranial SSI. Standard statistical methods were utilized to explore associations between a variety of variables including FSB, cranial SSI, and infections requiring reoperation.

RESULTS: Of the 910 craniotomies, 141 (15.5%) involved FSB. Of those involving FSB, 22 (15.6%) developed a cranial SSI, compared to only 56 of the 769 without FSB (7.3%; P = .001). Cranial SSI requiring reoperation wasmuch more likely in patients with FSB compared to those without a breach (7.8% vs 1.6%; P < .001). In those presenting with cranial SSIs, epidural abscess formation was more common with FSB compared to no FSB (27.3% vs 5.4%; P = .006). In multivariate analysis, breach of the frontal sinus was significantly associated with cranial SSI (OR 2.16; 95% CI 1.24-3.78; P = .01) and reoperation (OR 4.20; 95% CI 1.66-10.65; P = .003).

CONCLUSION: Patients undergoing frontotemporal craniotomies are at significantly greater risk of serious cranial SSIs if the frontal sinus has been breached.

Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?

Neurosurgery (2017) 80 (5): 746-753

Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern.

OBJECTIVE: To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin.

METHODS: Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not.

RESULTS: Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 μg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort.

CONCLUSIONS: The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.

The Use of Vancomycin Powder for Surgical Prophylaxis Following Craniotomy

Neurosurgery 80:754–758, 2017

Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery.

OBJECTIVE: To evaluate the efficacy of intrawound topical vancomycin for prevention of SSIs following open craniotomies.

METHODS: We retrospectively analyzed a large series of 350 patients from 2011 to 2015 in a pre/postintervention study of use of topical vancomycin to reduce postoperative craniotomy infection rates. We had a preintervention control group of 225 patients and a postintervention group of 125 patients that received intrawound topical vancomycin.

RESULTS: Our preintervention incidence of SSI was 2.2% and this was significantly reduced to 0% following introduction of topical vancomycin (P < .5). An ad hoc cost analysis suggested a cost savings of $59 965 with the use of topical vancomycin for craniotomies.

CONCLUSION: Our study found a significant reduction in SSI rates after introduction of topical vancomycin. Thus, this simple intervention should be considered in all open craniotomy patients as both infection prophylaxis and a potential cost saving intervention.

Hyperbaric oxygen therapy in spontaneous brain abscess patients

Hyperbaric oxygen therapy in spontaneous brain abscess patients

Acta Neurochir (2016) 158:1259–1267

There is a need to improve outcome in patients with brain abscesses and hyperbaric oxygen therapy (HBOT) is a promising treatment modality. The objective of this study was to evaluate HBOT in the treatment of intracranial abscesses.

Method This population-based, comparative cohort study included 40 consecutive adult patients with spontaneous brain abscess treated surgically between January 2003 and May 2014 at our institution. Twenty patients received standard ther- apy with surgery and antibiotics (non-HBOT group), while the remaining 20 patients also received adjuvant HBOT (HBOT group).

Results Resolution of brain abscesses and infection was seen in all patients. Two patients had reoperations after HBOT
initiation (10 %), while nine patients (45 %) in the non- HBOT group underwent reoperations (p = 0.03). Of the 26 patients who did not receive HBOT after the first surgery, 15 (58 %) had one or several recurrences that lead to a new treatment: surgery (n = 11), surgery + HBO (n = 5) or just HBO (n = 1). In contrast, recurrences occurred in only 2 of 14 (14 %) who did receive HBOT after the first surgery (p < 0.01). A good outcome (Glasgow Outcome Score [GOS] of 5) was achieved in 16 patients (80 %) in the HBOT cohort versus 9 patients (45 %) in the non-HBOT group (p = 0.04).

Conclusions HBOT was associated with less treatment failures and need for reoperation and seemingly with improved long-term outcome. Further, HBOT was well tolerated and safe. Prospective studies are warranted to establish the role of HBOT in the treatment of brain abscesses.

Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany


Acta Neurochir (2016) 158:847–853

There are various recommendations, but no generally accepted guidelines, to reduce the risk of external ventricular drainage (EVD)-associated infections. The primary objective of the present study was to evaluate the current practice of EVD in a European country and to set the results in perspective to published data.

Method A standardised questionnaire prepared by the Commission of Technical Standards and Norms of the German Society of Neurosurgery was sent to 127 neurosurgical units in Germany.

Results Data were analysed from 99 out of 127 neurosurgical units which had been contacted. Overall, more than 10,000 EVD procedures appear to be performed in Germany annually. There is disagreement about the location where the EVD is inserted, and most EVDs are still inserted in the operation theatre. Most units apply subcutaneous tunnelling. Impregnated EVD catheters are used regularly in only about 20 % of units. Single-shot antibiotic prophylaxis is given in more than half of the units, while continued antibiotic prophylaxis is installed in only 15/99 units at a regular basis. There are discrepancies in the management of prolonged EVD use with regard to replacement policies. Regular cerebrospinal fluid (CSF) sampling is still performed widely. There were no statistical differences in policies with regard to academic versus non-academic units.

Conclusions This survey clearly shows that some newer recommendations drawn from published studies penetrate much slower into clinical routine, such as the use of impregnated catheters, for example. It remains unclear how different policies actually impact quality and outcome in daily routine.

Outcome of conservative and surgical treatment of pyogenic spondylodiscitis

pyogenic spondylodiscitis

Eur Spine J (2016) 25:983–999

Spondylodiscitis is a spinal infection affecting primarily the intervertebral disk and the adjacent vertebral bodies. Currently many aspects of the treatment of pyogenic spondylodiscitis are still a matter of debate.

Purpose The aim of this study was to review the currently available literature systematically to determine the outcome of patients with pyogenic spondylodiscitis for conservative and surgical treatment strategies.

Methods A systematic electronic search of MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science regarding the treatment of pyogenic spondylodiscitis was performed. Included articles were assessed on risk of bias according the Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence and strength of recommendation was evaluated according the GRADE approach.

Results: 25 studies were included. Five studies had a high or moderate quality of evidence. One RCT suggest that 6 weeks of antibiotic treatment of pyogenic spondylodiscitis results in a similar outcome when compared to longer treatment duration. However, microorganism-specific studies suggest that at least 8 weeks of treatment is required for S. aureus and 8 weeks of Daptomycin for MRSA. The articles that described the outcome of surgical treatment strategies show that a large variety of surgical techniques can successfully treat spondylodiscitis. No additional long-term beneficial effect of surgical treatment could be shown in the studies comparing surgical versus antibiotic only treatment.

Conclusion There is a strong level of recommendation for 6 weeks of antibiotic treatment in pyogenic spondylodiscitis although this has only been shown by one recent RCT. If surgical treatment is indicated, it has been suggested by two prospective studies with strong level of recommendation that an isolated anterior approach could result in a better clinical outcome.

Stereoelectroencephalography-guided radiofrequency thermocoagulation in the epileptogenic zone

Reducing surgical site infections following craniotomy- examination of the use of topical vancomycin

J Neurosurg 123:1600–1604, 2015

Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates.

Methods A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum.

Results Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy.

Conclusions Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

Infections in patients undergoing craniotomy: risk factors associated with post-craniotomy meningitis

awake craniotomy

J Neurosurg 122:1113–1119, 2015

The authors performed a prospective study to define the prevalence and microbiological characteristics of infections in patients undergoing craniotomy and to clarify the risk factors for post-craniotomy meningitis.

Methods Patients older than 18 years who underwent nonstereotactic craniotomies between January 2006 and December 2008 were included. Demographic, clinical, laboratory, and microbiological data were systemically recorded. Patient characteristics, craniotomy type, and pre- and postoperative variables were evaluated as risk factors for meningitis

Results Three hundred thirty-four procedures were analyzed (65.6% involving male patients). Traumatic brain injury was the most common reason for craniotomy. Almost 40% of the patients developed at least 1 infection. Ventilatorassociated pneumonia (VAP) was the most common infection recorded (22.5%) and Acinetobacter spp. were isolated in 44% of the cases. Meningitis was encountered in 16 procedures (4.8%), and CSF cultures were positive for microbial growth in 100% of these cases. Gram-negative pathogens (Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Enterobacter cloaceae, Proteus mirabilis) represented 88% of the pathogens. Acinetobacter and Klebsiella spp. demonstrated a high percentage of resistance in several antibiotic classes. In multivariate analysis, the risk for meningitis was independently associated with perioperative steroid use (OR 11.55, p = 0.005), CSF leak (OR 48.03, p < 0.001), and ventricular drainage (OR 70.52, p < 0.001).

Conclusions: Device-related postoperative communication between the CSF and the environment, CSF leak, and perioperative steroid use were defined as risk factors for meningitis in this study. Ventilator-associated pneumonia was the most common infection overall. The offending pathogens presented a high level of resistance to several antibiotics.

Atlantoaxial Instability of Inflammatory Origin in Adults

Atlantoaxial Instability of Inflammatory Origin in Adults

Neurosurgery 76:E226–E232, 2015

Acquired atlantoaxial instability of inflammatory origin (Grisel syndrome) is a rare condition. It usually occurs in children with benign upper airway problems and responds well to immobilization, rarely requiring C1-2 arthrodesis. Our recent experience with 2 adult cases suggests this may not be true in an older subpopulation.

CLINICAL PRESENTATION: A 71-year-old man developed C1-2 instability in the setting of culture-negative endocarditis. Initial immobilization was attempted for 8 weeks but new imaging revealed progressive destruction of the odontoid and worsening instability. Symptoms resolved after C1-4 arthrodesis. A 35-year-old woman developed C1-2 instability after a molar extraction and otitis media. Despite 12 weeks of immobilization and antibiotics, symptoms persisted and the atlantodental interval increased. She was successfully treated with a C1-2 arthrodesis.

CONCLUSION: A literature review revealed 13 reports (14 cases) of inflammatory atlantoaxial instability in patients aged 18 and older since 1830. Including the 2 cases reported here, 11 cases underwent initial nonoperative treatment with durable satisfactory results in only 2 of them (18.2%). Aspiration of the C1-2 phlegmon was diagnostic in only 4 of these 16 cases. Destruction of the odontoid was seen in a minority of cases (5/16, 31.3%). In this first review of the topic since the introduction of screwbased C1-2 fixation, it is suggested that nonoperative treatment is futile for inflammatory atlantoaxial instability in adults and strong consideration should be given to C1-2 arthrodesis. This procedure can reliably produce good outcomes with minimal morbidity.

Lateral retroperitoneal approach for discitis and osteomyelitis

Direct lateral retroperitoneal approach for the surgical treatment of lumbar discitis and osteomyelitis

Neurosurg Focus 37 (2):E5, 2014

The medical management of discitis and osteomyelitis with long-term antibiotic therapy and bracing usually results in eradicated infection. Surgical management is appropriate when medical management fails and in some cases with pyogenic deformity or neurological deficit. The success of surgery depends on adequate debridement of the necrotic infected disc and vertebral body, along with anterior column reconstruction and vertebral stabilization. Debridement is typically performed via an anterior retroperitoneal approach, which can necessitate mobilization of the great vessels for proper exposure. Mobilization can be technically difficult and lead to vascular injury. The purpose of this study was to evaluate an alternative technique for the surgical treatment of lumbar discitis and osteomyelitis using a direct lateral retroperitoneal approach, which allows for thorough debridement and anterior column reconstruction while avoiding the need to mobilize the great vessels.

Methods. A retrospective chart analysis was performed for all patients who had presented with lumbar discitis and osteomyelitis and had undergone surgical management via the direct lateral retroperitoneal approach in the period from 2006 to 2013. Collected data included surgical blood loss, perioperative complications (wound infection, vascular injury, approach-related complications, and neurological injury), need for secondary procedures, microbiological and laboratory results, and efficacy of infection eradication. Imaging studies were reviewed as well.

Results. Ten patients, 7 male and 3 female, underwent this procedure at the authors’ institution in the defined period. Average blood loss was 272 ml (range 150–800 ml, with 800 ml in the only 2-level case). There were no vascular injuries. Average follow-up was 680 days, although 4 patients did not complete the follow-up beyond 6 months. Eight patients underwent immediate posterior pedicle screw instrumentation. Two patients did not undergo posterior instrumentation, and one of these developed a kyphotic deformity that required a secondary posterior procedure. Infection was eradicated in all patients according to a history, physical examination, imaging studies, and laboratory parameters (complete blood count, erythrocyte sedimentation rate, and C-reactive protein). One patient developed a painful neuroma at the iliac crest harvest site, and one patient had a retroperitoneal hematoma. Otherwise, there were no approach-related neurological injuries or complications. Neither was there any postoperative surgical site infection.

Conclusions. The direct lateral approach for the surgical treatment of lumbar discitis and osteomyelitis allows for thorough debridement and spinal reconstruction without the need to mobilize the great vessels. This technique effectively eradicated infection in all cases, with reasonable blood loss and no vascular injuries. This approach should be considered as an alternative to the open anterior approach. The authors recommend posterior instrumentation to prevent the development of kyphosis.

The complications and the position of the Codman MicroSensor™ ICP device: an analysis of 549 patients and 650 Sensors


Acta Neurochir (2013) 155:2141–2148

Complications of and insertion depth of the Codman MicroSensor ICP monitoring device (CMS) is not well studied. Objective To study complications and the insertion depth of the CMS in a clinical setting.

Methods We identified all patients who had their intracranial pressure (ICP) monitored using a CMS device between 2002 and 2010. The medical records and post implantation computed tomography (CT) scans were analyzed for occurrence of infection, hemorrhage and insertion depth.

Results In all, 549 patients were monitored using 650 CMS. Mean monitoring time was 7.0±4.9 days. The mean implantation depth was 21.3±11.1mm(0–88 mm). In 27 of the patients, a haematoma was identified; 26 of these were less than 1 ml, and one was 8 ml. No clinically significant bleeding was found. There was no statistically significant increase in the number of hemorrhages in presumed coagulopathic patients. The infection rate was 0.6 % and the calculated infection rate per 1,000 catheter days was 0.8.

Conclusion The risk for hemorrhagic and infectious complications when using the CMS for ICP monitoring is low. The depth of insertion varies considerably and should be taken into account if patients are treated with head elevation, since the pressure is measured at the tip of the sensor. To meet the need for ICP monitoring, an intraparenchymal ICP monitoring device should be preferred to the use of an external ventricular drainage (EVD).

A Simple Protocol to Prevent External Ventricular Drain Infections


Neurosurgery 72:993–999, 201

External ventricular drains (EVDs) are associated with high rates of infection, and EVD infections cause substantial morbidity and mortality.

OBJECTIVE: To determine whether the introduction of an evidence-based EVD infection control protocol could reduce the rate of EVD infections.

METHODS: This was a retrospective analysis of an EVD infection control protocol introduced in a tertiary care neurointensive care unit. We compared rates of cerebrospinal fluid culture positivity and ventriculitis for the 3 years before and 3 years after the introduction of an evidence-based EVD infection control protocol. A total of 262 EVD placements were analyzed, with a total of 2499 catheter-days.

RESULTS: The rate of cerebrospinal fluid culture positivity decreased from 9.8% (14 of 143; 11.43 per 1000 catheter-days) at baseline to 0.8% (1 of 119; 0.79 per 1000 catheterdays) in the EVD infection control protocol period (P = .001). The rate of ventriculitis decreased from 6.3% (9 of 143; 7.35 per 1000 catheter-days) to 0.8% (1 of 119; 0.79 per 1000 catheter-days; P = .02).

CONCLUSION: The introduction of a simple, evidence-based infection control protocol was associated with a dramatic reduction in the risk of EVD infection.

Infection rates of external ventricular drains are reduced by the use of silver-impregnated catheters


Acta Neurochir (2013) 155:875–881

External ventricular drainage (EVD) placement for temporary cerebrospinal fluid (CSF) diversion is a frequent therapeutic procedure. Several types of EVD catheters are currently available, some of which have an antibacterial effect. This study compares the rates of CSF infections in patients with different types of EVD catheters.

Methods This is a retrospective study of 403 patients with a total of 529 implanted EVDs. We analyze the occurrence of EVD-associated infections, microbiological diagnosis, type of EVD catheter (plain polyurethane vs. silver-impregnated), duration of CSF diversion, primary disease, and outcome.

Results There were a total of 29 patients with EVD infections in the whole study group (7.1 %). A pathogen was detected in all cases. Coagulase-negative staphylococci were detected most frequently (20 out of 29 cases, 70 %). The rate of infections by catheter type was 7.6 % (11 of 145) and 13.8 % (4 out of 29) for two different types of noncoated polyurethane catheters. Silver-impregnated polyurethane catheters became infected in 6.1 % (14 out of 228). The differences between non-coated and silver-coated catheters were statistically significant.

Conclusions This study provides comparative data on EVD infections with regard to the type of catheter. Silverimpregnated catheters showed significantly lower infection rates when compared to non-impregnated catheters. The results are critically discussed and compared with the published literature.

Comparison of Infection Rate With the Use of Antibiotic-Impregnated vs Standard Extraventricular Drainage Devices: A Prospective, Randomized Controlled Trial

Neurosurgery 71:6–13, 2012 DOI: 10.1227/NEU.0b013e3182544e31

External ventricular drainage (EVD) catheters provide reliable and accurate means of monitoring intracranial pressure and alleviating elevated pressures via drainage of cerebrospinal fluid (CSF). CSF infections occur in approximately 9% of patients. Antibiotic-impregnated (AI) EVD catheters were developed with the goal of reducing the occurrence of EVD catheter-related CSF infections and their associated complications.

OBJECTIVE: To present an international, prospective, randomized, open-label trial to evaluate infection incidence of AI vs standard EVD catheters.

METHODS: Infection was defined as (1) proven infection, positive CSF culture and positive Gram stain or (2) suspected infection: (A) positive CSF culture with no organisms identified on initial Gram stain; (B) negative CSF culture with a gram-positive or -negative stain; (C) CSF leukocytosis with a white blood cell/red blood cell count .0.02.

RESULTS: Four hundred thirty-four patients underwent implantation of an EVD catheter. One hundred seventy-six patients in the AI-EVD cohort and 181 in the standard EVD catheter cohort were eligible for evaluation of infection. The 2 groups were similar in all clinical characteristics. Proven infection was documented in 9 (2.5%) patients (AI: 4 [2.3%] vs standard: 5 [2.8%], P = 1.0). Suspected infection was documented in 31 (17.6%) patients receiving AI and 37 (20.4%) patients receiving standard EVD catheters, P = .504. Duration of time to suspected infection was prolonged in the AI cohort (8.8 6 6.1 days) compared with the standard EVD cohort (4.6 6 4.2 days), P = .002.

CONCLUSION: AI-EVD catheters were associated with an extremely low rate of catheter-related infections. AI catheters were not associated with risk reduction in EVD infection compared to standard catheters. Use of AI-EVD catheters is a safe option for a wide variety of patients requiring CSF drainage and monitoring, but the efficacy of AI-EVD catheters was not supported in this trial.

Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes—a 10-year single-center study

Acta Neurochir (2012) 154:903–911. DOI 10.1007/s00701-012-1299-z

To analyze the variables determining morbidity, mortality and outcome in subjects with brain abscesses treated at a single center over a 10-year period.

Methods A retrospective study was conducted on a series of 59 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision. Such variables as age, gender, clinical presentation, number of days to diagnosis, location, number of lesions, predisposing factors, mechanism of infection, etiological agent, and therapy were analyzed independently. Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery, and classified according to a four-point gradual severity scale. Postoperative outcome was appraised through the Glasgow Outcome Scale (GOS) 6 months after surgery, 0–4 points were considered poor outcome and 5 points good outcome.

Results Eighty abscesses were diagnosed and surgically managed in 59 patients. The mean age was 44.69 years (range: 0.16-77); 59.3% were female. The median number of days to diagnosis was 7. Most frequent clinical presentations included fever (52.5%), headache (42.4%), and focal neurologic deficits (39%). Mechanism of infection was mainly hematogenous spread (32.2%). Stereotactically guided aspiration was the treatment of choice for 74.6% of the patients, whereas 25.4% of the cases were managed through open craniotomy excision. Outcome was favorable in 81.35% (n048) of the subjects. General morbidity was 27.1%, and mortality stood at 10.16%. Out of a total 38.98% (n023) of complications, two-thirds were due to medical causes. The analysis of variables revealed that only age (p00.02), immunosuppression (OR 5.83; p00.012) and hematogenous spread (p<0.01) were associated with poor outcomes.

Conclusions Immunosuppression, hematogenous spread and advanced age were predictors of poor prognosis. Most of the complications following brain abscess management were not directly related to surgery or surgical technique.

Neurosurgery and shaving: what’s the evidence?. A review

Journal of Neurosurgery Oct 2011 / Vol. 115 / No. 4 / Pages 670-678. DOI: 10.3171/2011.5.JNS102003.

Many neurosurgeons remove their patients’ hair before surgery. They claim that this practice reduces the chance of postoperative surgical site infections, and facilitates planning, attachment of the drapes, and closure. However, most patients dread this procedure.

The authors performed the first systematic review on shaving before neurosurgical procedures to investigate whether this commonly performed procedure is based on evidence. They systematically reviewed the literature on wound infections following different shaving strategies. Data on the type of surgery, surgery-related infections, preoperative shaving policy, decontamination protocols, and perioperative antibiotics protocols were collected.

The search detected 165 articles, of which 21 studies—involving 11,071 patients—were suitable for inclusion. Two of these studies were randomized controlled trials. The authors reviewed 13 studies that reported on the role of preoperative hair removal in craniotomies, 14 on implantation surgery, 5 on bur hole procedures, and 3 on spine surgery. Nine studies described shaving policies in pediatric patients.

None of these papers provided evidence that preoperative shaving decreases the occurrence of postoperative wound infections. The authors conclude that there is no evidence to support the routine performance of preoperative hair removal in neurosurgery. Therefore, properly designed studies are needed to provide evidence for preoperative shaving recommendations.

Effect of Antibiotic-Impregnated Shunts on Infection Rate in Adult Hydrocephalus: A Single Institution’s Experience

Neurosurgery 69:625–629, 2011 DOI: 10.1227/NEU.0b013e31821bc435

Cerebrospinal fluid (CSF) shunt infection remains a major cause of morbidity and mortality in the treatment of hydrocephalus. Studies have demonstrated the efficacy of antibiotic-impregnated shunt (AIS) systems in reducing CSF shunt infections in pediatric patients. Fewer studies evaluate the efficacy of AIS systems in adult hydrocephalus.

OBJECTIVE: To determine whether categorical conversion to AIS shunt systems reduced the incidence of shunt infection in adults.

METHODS: All adult patients undergoing CSF shunt insertion over a 7-year period were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. We retrospectively reviewed the first 250 cases of AIS catheter implantation and compared them with the immediately preceding 250 non-AIS cases to assess 1-year incidence of CSF shunt infection.

RESULTS: Five hundred shunt surgeries were performed for normal-pressure hydrocephalus in 378 patients (76%), pseudotumor cerebri in 83 patients (17%), and various obstructive/communicating hydrocephalus etiologies in 40 patients (8%). All patients were followed for 12 months. The mean age was 60 6 18 years. Baseline characteristics were similar between AIS (n = 250) and non-AIS (n = 250) cohorts. Overall, 13 patients (2.6%) experienced CSF shunt infection, occurring a mean of 2 6 2 months postoperatively. Shunt infection incidence was decreased in AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492). Staphylococcus epidermidis was the most common pathogen in AIS and non-AIS cohorts. Oxacillin resistance was not increased in the AIS cohort.

CONCLUSION: Categorical conversion to AIS catheters was associated with a reduced incidence of shunt infection. AIS catheters may be a reliable instrument for decreasing perioperative shunt colonization and subsequent infection in adults with hydrocephalus.

A standardized protocol to reduce cerebrospinal fluid shunt infection: The Hydrocephalus Clinical Research Network Quality Improvement Initiative

J Neurosurg Pediatrics 8:22–29, 2011. DOI: 10.3171/2011.4.PEDS10551

Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).

Methods. The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.

Results. Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19–3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43–14.41; p = 0.01) were associated with an increased risk of infection.

Conclusions. The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.

Prevention of Ventriculostomy-Related Infections With Prophylactic Antibiotics and Antibiotic- Coated External Ventricular Drains: A Systematic Review

Neurosurgery 68:996–1005, 2011 DOI: 10.1227/NEU.0b013e3182096d84

Ventriculostomy-related infection (VRI) is a severe complication of external ventricular drain use, occurring in 5% to 23% of patients. Preventive measures for VRI include prolonged prophylactic systemic antibiotics (PSAs) and an antibioticcoated external ventricular drains (ac-EVDs).

OBJECTIVE: We performed a systematic review of all studies evaluating PSAs and ac-EVD for VRI prevention through July 2010.

METHODS: Two reviewers independently assessed eligibility and evaluated study quality based on pre-established criteria. Observational studies and randomized clinical trials (RCTs) that fulfilled inclusion criteria were included in the meta-analysis.

RESULTS: Three RCTs and 7 observational studies met our inclusion criteria and were included in the analysis. The type of antibiotics and VRI definitions varied among these studies. Pooled analysis showed a protective effect of PSAs and ac-EVDs for VRI (risk ratio: 0.32; 95% CI: 0.18-0.56). Results showed moderate heterogeneity (I2 = 53%) explained by the difference in quality among the studies and the inclusion of 1 large positive cohort study. The effect of PSAs and ac-EVDs was unrelated to the type of study (RCT or observational, P for interaction = .55), the route of antibiotic administration (PSAs or ac-EVDs, P = .13), or the quality of the studies (suboptimal vs good/excellent, P = .55).

CONCLUSION: RCTs and observational-derived evidence support the use of PSAs throughout the duration of external ventricular drainage; similarly, the use of ac-EVDs to prevent VRI seems to be beneficial. Available data are heterogeneous and of suboptimal quality. Further research is needed to confirm the findings of this meta-analysis. There are not sufficient data to compare the protective effect of ac-EVDs and PSAs.

Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters

Acta Neurochir (2011) 153:647–651. DOI 10.1007/s00701-010-0905-1

Many strategies have been developed with the aim of reducing external ventricular drain-related infections. Antibiotic-impregnated catheters are one of them.

Material and methods We report 648 cases of external ventricular drain from a total of 534 patients treated at the Virgen del Rocío Hospital between 1995 and 2006. Three subgroups were considered: group 1 included patients treated between 1995 and 2000, as well as a total of 190 external ventricular drains and 59 cases of infection (31.05%); group 2, with patients treated between 2000 and 2004 and managed with a minimal handling protocol, included 210 external ventricular drains and nine cases of infection (4.29%); and group 3, treated between 2004 and 2006, with 248 external ventricular drains and six cases of infection (2.41%). This latter subgroup included patients managed with a minimal handling protocol and antibiotic-impregnated catheters.

Results Infection rate was 17% when non-antibioticimpregnated catheters were employed and 2.41% when antibiotic-impregnated catheters were inserted (p<0.001). This difference was statistically significant before and after the introduction of a minimal handling protocol, with percentages of 5.31% and 3.27%, respectively (p<0.001; odds ratio 0.08; absolute risk reduction 27.26%). However, no statistically significant difference was observed in infection rate when the impact of a minimal handling protocol was considered: 4.29% when only the protocol was introduced and 2.41% when both the protocol and antibiotic-impregnated catheters were used (p>0.05).

Conclusion Minimal handling protocols constitute an essential strategy in the reduction of external ventricular drain-related infections. Besides that, the use of antibiotic-impregnated catheters may reduce infection-related hospital costs.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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