Neurosurgery Blog


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

Safety of Superior Petrosal Vein Sacrifice During Microvascular Decompression of the Trigeminal Nerve

WORLD NEUROSURGERY 103: 84-87, 2017

Microvascular decompression (MVD) is a safe and effective treatment for trigeminal neuralgia. Cerebellar venous infarction is a complication associated with surgical sacrifice of the superior petrosal vein (SPV). The SPV intervenes between the trigeminal nerve and the surgeon. Optimal exposure of the cisternal trigeminal nerve, particularly at the brainstem, can be achieved by sacrificing the SPV. We analyzed a cohort of 224 patients to determine the frequency of cerebellar venous infarction.

METHODS: Retrospective analysis of records and neuroradiology for patients undergoing trigeminal MVD at the Manchester Skull Base Unit between August 1st 2008 and July 31st 2015.

RESULTS: A total of 184 of 224 (82%) patients had coagulation and division of the main stem of the SPV. There were no cases of venous infarction. There was one case of mild, transient, cerebellar symptoms and signs, with no radiologic evidence of venous infarction. This patient had SPV sacrifice at surgery but also had postoperative thrombosis of the transverse sinus. Venous sinus thrombosis affected 5 of 184 (2.7%) patients. A total of 208 of 224 (93%) patients had a good outcome with improvement or resolution of their trigeminal neuralgia at 3 months.

CONCLUSIONS: The overall rate of venous complications in this study was 2.7%; however, we had no cases of venous infarction in 184 patients who had sacrifice of the SPV. The incidence of venous infarction associated with SPV obliteration during MVD surgery is therefore <0.5%. SPV sacrifice may be used where necessary to optimize visualization of the root entry zone and maximize the chance of effective decompression of the trigeminal nerve.

A Simple and Reliable Method for the Diagnosis of Ventriculoperitoneal Shunt Malfunction

OBJECTIVE: To provide a simple and reliable method for the diagnosis of ventriculoperitoneal shunt malfunction.

METHODS: A total of 14 participants were enrolled in this study, consisting of 7 patients with suspected shunt malfunction and 7 control cases with apparent normal drainage. In all cases, 0.1 mL of 5% glucose solution was injected into the reservoir and 0.1 mL of cerebrospinal fluid was withdrawn from the reservoir 20 minutes later to measure glucose concentration.

RESULTS: The glucose concentration in cerebrospinal fluid of the shunt malfunction group was greater than that of the control group (P < 0.05).

CONCLUSIONS: The proposed method is reliable, safe, and relatively simple for the diagnosis of ventriculoperitoneal shunt malfunction and provides a reference for treatment.

Cerebral Revascularization for Aneurysms in the Flow-Diverter Era

Neurosurgery 80:759–768, 2017

Cerebral bypass has been an important tool in the treatment of complex intracranial aneurysms. The recent advent of flow-diverting stents (FDS) has expanded the capacity for endovascular arterial reconstruction.

OBJECTIVE: We investigated how the advent of FDS has impacted the application and outcomes of cerebral bypass in the treatment of intracranial aneurysms.

METHODS: We reviewed a consecutive series of cerebral bypasses during aneurysm surgery over the course of 10 years. FDS were in active use during the last 5 years of this series. We compared the clinical characteristics, surgical technique, and outcomes of patients who required cerebral bypass for aneurysm treatment during the preflow diversion era (PreFD) with those of the postflow diversion era (PostFD).

RESULTS: We treated 1061 aneurysms in the PreFD era (from July 2005 through June 2010) and 1348 in the PostFD era (from July 2010 through June 2015). Eighty-five PreFD patients (8%) and 45 PostFD patients (3%) were treated with cerebral bypass. PreFD patients had better baseline functional status compared to PostFD patients with average preoperative modified Rankin Scale score of 0.55 in PreFDand 1.18 in PostFD.

CONCLUSION: After the introduction of FDS, cerebral bypass was performed in a lower proportion of patients with aneurysms. Patients selected for bypass in the flow-diverter era had worse preoperative modified Rankin Scale scores indicating a greater complexity of the patients. Cerebral bypass in well-selected patients and revascularization remains an important technique in vascular neurosurgery. It is also useful as a rescue technique after failed FDS treatment of aneurysms.

Is lumbar facet fusion biomechanically equivalent to lumbar posterolateral onlay fusion?

J Neurosurg Spine 26:586–593, 2017

This study was designed with the following research objectives: 1) to determine the efficacy of facet fusion with recombinant human bone morphogenetic protein–2 (rhBMP-2) on an absorbable collagen sponge (ACS) in an ovine lumbar facet fusion model; 2) to radiographically and histologically compare the efficacy of lumbar facet fusion with rhBMP-2/ACS to facet fusion with an iliac crest bone graft (ICBG); and 3) to biomechanically compare lumbar facet fusion with rhBMP-2/ACS to lumbar posterolateral fusion (PLF) with ICBG.

METHODS The efficacies of the 3 treatments to induce fusion were evaluated in an instrumented ovine lumbar fusion model. Eight sheep had 10 cm3/side ICBG placed as an onlay graft for PLF at L2–3. At the adjacent L3–4 level, 0.5 cm3/ side ICBG was placed for facet fusion. Finally, 0.5 cm3/side rhBMP-2/ACS (0.43 mg/ml) was placed for facet fusion at L4–5. CT scans were obtained at 2, 4, and 6 months postoperatively with 2 reviewers conducting an evaluation of the 6-month results for all treated spinal levels. All 8 sheep were killed at 6 months, and all posterolateral instrumentation was removed at this time. The spines were then sectioned through L3–4 to allow for nondestructive unconstrained bio- mechanical testing of the L2–3 and L4–5 segments. All treated spinal levels were analyzed using undecalcified histology with corresponding microradiography. Statistical comparisons were made between the treatment groups.

RESULTS The PLF with ICBG (ICBG PLF group) and the rhBMP-2 facet fusion (rhBMP-2 Facet group) treatment groups demonstrated similar levels of stiffness, with the rhBMP-2 Facet group having on average slightly higher stiffness in all 6 loading directions. All 8 levels in the autograft facet fusion treatment group demonstrated CT radiographic and histological fusion. All 8 levels in the rhBMP-2 Facet group showed bilateral CT radiographic and histological fusion. Six of 16 rhBMP-2/ACS-treated facet defects demonstrated small intraosseous hematomas or seromas. Four of the 8 levels (50%) in the ICBG PLF treatment group demonstrated bilateral histological fusion. Three of 8 levels in the ICBG PLF treatment group showed unilateral fusion. One of the 8 levels in the ICBG PLF treatment group demonstrated bilateral histological nonfusion.

CONCLUSIONS Both rhBMP-2/ACS and autograft demonstrated 100% efficacy when used for facet fusion in the instrumented ovine model. However, the ICBG PLF treatment group only demonstrated a 50% bilateral fusion rate. Biomechanically, the ICBG PLF and rhBMP-2 Facet groups demonstrated similar stiffness in all 6 loading directions, with the rhBMP-2 Facet group having on average slightly higher stiffness in all directions.

Reappearance of arteriovenous malformations after complete resection of ruptured arteriovenous malformations

J Neurosurg 126:1088–1093, 2017

Ruptured arteriovenous malformations (AVMs) are often obliterated after emergency microsurgical treatment. However, some studies have reported AVM recurrence after the obliteration of ruptured AVMs. The authors report their experience with AVM recurrence after successful microsurgical treatment of ruptured AVMs.

METHODS The authors reviewed the medical data of 139 consecutive patients who underwent microsurgery at the authors’ institution for ruptured AVM between 2002 and 2012. Each patient underwent a conventional cerebral angiography examination immediately after the surgery. Subsequent follow-ups were performed with MR angiography after 6 months, and, if there was no indication of AVM recurrence, patients were followed up with conventional cerebral angiography between 1 and 2 years after the treatment; pediatric patients were followed up until age 18 years. Recurrence was defined as new radiological evidence of an AVM at the site of a ruptured AVM or a new hemorrhage in patients with angiographically documented AVM obliteration on postoperative angiograms.

RESULTS The mean age of the patients at the time of ruptured AVM diagnosis was 30.8 years (SD ± 5, range 4–69 years), and 44 of the patients were younger than 18 years (the mean age at diagnosis in this pediatric subgroup was 11.4 years [range 4–17.9 years]). Complete AVM obliteration after the initial microsurgery was observed in 123 patients (89.5%). Reappearance of an AVM was noted in 7 patients between 12 and 42 months after the treatment, and all of these patients were younger than 18 years. The recurrent AVM was located in an eloquent zone in 4 patients, and deep venous drainage was noted in 3 patients. Radiosurgery was performed in 6 of these patients, and 1 patient underwent another microsurgical procedure. The authors noted only one rebleeding due to an AVM recurrence during the latency period after radiosurgery.

CONCLUSIONS The recurrence of an AVM is fairly rare and affects mostly pediatric patients. Therefore, especially in children, long-term angiographic follow-up is required to detect AVM recurrence or an AVM remnant. The authors stress the need for discussion involving a multidisciplinary neurosurgical team to decide on treatment in cases of any AVM recurrence or remnant.

Surgery for meningioma in the elderly and long-term survival

J Neurosurg 126:1201–1211, 2017

The purpose of this study was to compare long-term prognosis after meningioma surgery in elderly and younger patients as well as to compare survival of elderly patients with surgically treated meningioma to survival rates for the general population.

METHODS Five hundred meningioma patients (median follow-up 90 months) who underwent surgery between 1994 and 2009 were subdivided into “elderly” (age ≥ 65 years, n = 162) and “younger” (age < 65 years, n = 338) groups for uni- and multivariate analyses. Mortality was compared with rates for the age- and sex-matched general population.

RESULTS The median age at diagnosis was 71 in the elderly group and 51 years in the younger group. Sex, intracranial tumor location, grade of resection, radiotherapy, and histopathological subtypes were similar in the 2 groups. Highgrade (WHO Grades II and III) and spinal tumors were more common in older patients than in younger patients (15% vs 8%, p = 0.017, and 12% vs 4%, p = 0.001, respectively). The progression-free interval (PFI) was similar in the 2 groups, whereas mortality at 3 months after surgery was higher and median overall survival (OS) was shorter in older patients (7%, 191 months) than in younger patients (1%, median not reached; HR 4.9, 95% CI 2.75–8.74; p < 0.001). Otherwise, the median OS in elderly patients did not differ from the anticipated general life expectancy (HR 1.03, 95% CI 0.70–1.50; p = 0.886). Within the older patient group, PFI was lower in patients with high-grade meningiomas (HR 24.74, 95% CI 4.23–144.66; p < 0.001) and after subtotal resection (HR 10.57, 95% CI 2.23–50.05; p = 0.003). Although extent of resection was independent of perioperative mortality, the median OS was longer after gross-total resection than after subtotal resection (HR 2.7, 95% CI 1.09–6.69; p = 0.032).

CONCLUSIONS Elderly patients with surgically treated meningioma do not suffer from impaired survival compared with the age-matched general population, and their PFI is similar to that of younger meningioma patients. These data help mitigate fears concerning surgical treatment of elderly patients in an aging society.

Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury

Acta Neurochir (2017) 159:615–622

Intracranial pressure (ICP) monitoring represents an important tool in the management of traumatic brain injury (TBI). Although current information exists regarding ICP monitoring in secondary decompressive craniectomy (DC), little is known after primary DC following emergency hematoma evacuation.

Methods: Retrospective analysis of prospectively collected data. Inclusion criteria were age ≥18 years and admission to the intensive care unit (ICU) for TBI and ICP monitoring after primary DC. Exclusion criteria were ICU length of stay (LOS) <1 day and pregnancy. Major objectives were: (1) to analyze changes in ICP/cerebral perfusion pressure (CPP) after primary DC, (2) to evaluate the relationship between ICP/CPP and neurological outcome and (3) to characterize and evaluate ICP-driven therapies after DC.

Results: A total of 34 patients were enrolled. Over 308 days of ICP/CPP monitoring, 130 days with at least one episode of intracranial hypertension (26 patients, 76.5%) and 57 days with at least one episode of CPP <60 mmHg (22 patients, 64.7%) were recorded. A statistically significant relationship was discovered between the Glasgow Outcome Scale (GOS) scores and mean post-decompression ICP (p < 0.04) andbetween GOS and CPP minimum (CPPmin) (p < 0.04). After DC, persisting intracranial hypertension was treated with: barbiturate coma (n = 7, 20.6%), external ventricular drain (EVD) (n = 4, 11.8%), DC diameter widening (n = 1, 2.9%) and removal of newly formed hematomas (n = 3, 8.8%).

Conclusion: Intracranial hypertension and/or low CPP occurs frequently after primary DC; their occurence is associated with an unfavorable neurological outcome. ICP monitoring appears useful in guiding therapy after primary DC.


The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus

J Neurosurg 126:945–971, 2017

The relationship of the white matter tracts to the lateral ventricles is important when planning surgical approaches to the ventricles and in understanding the symptoms of hydrocephalus. The authors’ aim was to explore the relationship of the white matter tracts of the cerebrum to the lateral ventricles using fiber dissection technique and MR tractography and to discuss these findings in relation to approaches to ventricular lesions.

METHODS Forty adult human formalin-fixed cadaveric hemispheres (20 brains) and 3 whole heads were examined using fiber dissection technique. The dissections were performed from lateral to medial, medial to lateral, superior to inferior, and inferior to superior. MR tractography showing the lateral ventricles aided in the understanding of the 3D relationships of the white matter tracts with the lateral ventricles.

RESULTS The relationship between the lateral ventricles and the superior longitudinal I, II, and III, arcuate, vertical occipital, middle longitudinal, inferior longitudinal, inferior frontooccipital, uncinate, sledge runner, and lingular amygda-loidal fasciculi; and the anterior commissure fibers, optic radiations, internal capsule, corona radiata, thalamic radiations, cingulum, corpus callosum, fornix, caudate nucleus, thalamus, stria terminalis, and stria medullaris thalami were defined anatomically and radiologically. These fibers and structures have a consistent relationship to the lateral ventricles.

CONCLUSIONS Knowledge of the relationship of the white matter tracts of the cerebrum to the lateral ventricles should aid in planning more accurate surgery for lesions within the lateral ventricles.

Causes of poor outcome in patients admitted with good-grade subarachnoid haemorrhage

Acta Neurochir (2017) 159:559–565

Surgical risk in patients with unruptured aneurysms is well known. The relative impact of surgery and natural history of subarachnoid haemorrhage (SAH) on patients in good clinical condition (World Federation of Neurological Surgeons [WFNS] grades 1 and 2) is less well quantified. The aim of this study was to determine causes of poor outcome in patients admitted in good grade SAH.

Methods A retrospective study of prospectively collected data among WFNS-1 and -2 patients: demographics, SAH and aneurysm-related data, surgical complications and outcome as assesed by the Glasgow Outcome Scale (GOS). Causes of poor outcome (GOS 1–3) were determined.

Results During a 7-year period (2009–15), 56 patients with SAH WFNS-1 (39 patients) or WFNS-2 (17 patients) were treated surgically (21 men, 35 women; mean age, 52.4 years). According to the Fisher scale, 19 patients were grade 1 or 2; 37 patients were grade 3 or 4. Most aneurysms were located at anterior communicating (26) or middle cerebral (15) artery.

Altogether, 11 patients (19.6%) achieved GOS 1–3. This was attributed to SAH-related complications in six patients (rebleeding, vasospasm), surgery in four patients (postopera-tive ischaemia in two, haematoma and ventriculitis in one patient each), grand-mal seizure with aspiration in one patient. Age over 60 years (p = 0.017) and presence of hydrocephalus (p < 0.001) were statistically significant predictors of poor GOS; other variables (e.g. sex, Fisher grade, aneurysm size or location, use of temporary clips, intraoperative rupture, vasospasm) were not significant.

Conclusions Patients admitted in good-grade SAH achieve favourable outcome following surgical aneurysm repair in the majority of cases. Negative factors include age over 60 years and presence of hydrocephalus. Aneurysm surgery following good-grade SAH still carries a small but significant risk similar to that shown in large multi-institutional trials.

Middle cerebral artery aneurysms with intracerebral hematoma—the impact of side and volume on final outcome

Acta Neurochir (2017) 159:543–547

Middle cerebral artery aneurysms (MCA aneu-rysms) belong to the most frequent type of intracranial aneurysms forming an intracerebral hematoma. The consequences of the hematoma—the laterality, the impact of ICH volume and size of the aneurysm with the final outcome of these patients had not been studied in detail in this location, and we focused on the analysis of these factors.

Methods Patients with MCA aneurysms and associated intracerebral hematomas with a volume ≥10 ml were studied; these were treated from January 2006 to December 2015. During this period, more than 700 patients with spontaneous sub-arachnoid hemorrhage were admitted to the Department of Neurosurgery, University Hospital Brno. The data were collected from the subarachnoid hemorrhage database of the unit and from the local hospital registry. All consecutive patients at the treating center were involved in this retrospective study. We collected clinical data such as age, gender, aneurysm lo-cation, preoperative hematoma size, Hunt-Hess grade and type of surgical procedures. We focused on the analysis of the final outcome [Glasgow Outcome Scale (GOS) score] in relation to ICH volume, side of bleeding and finally the relationship between aneurysm size and the volume of ICH.

Results Fifty-eight patients with an MCA aneurysm and ICH were included; the mean age of this series was 59.4 years. Thirty-six patients (62%) had clinical status Hunt-Hess 4–5 on admission. The mean size of the intracerebral hematoma was 47.1 ml (10–133 ml). Most frequently, in 30 patients (52%), the hematoma had bled into the temporal lobe. Fifty three patients were operated on, and 5 were treated conservatively because of their poor condition. Twenty-three patients (40%) had a favorable Glasgow Outcome Scale score, and 35 (60%) had an unfavorable outcome including 20 patients (35%) who died. Of the 53 patients operated on, 20 (38%) underwent decompressive hemicraniectomy (DHC). Patients with an unfavorable outcome had significantly larger hematomas with a median size of 54 ml, whereas those with a favorable outcome had a median size of 26 ml (p = 0.0022). Larger hematomas were found on the right side. The cutoff volume for an unfavorable outcome in ICH was 25 ml. The outcomes were not related to the side of the ICH (p = 0.42), and the aneurysm size did not predetermine the ICH volume (p = 0.3159).

Conclusion Our study confirms the benefit of the active treatment of patients with MCA aneurysms and associated ICH. A significant proportion of these patients achieves a favorable outcome. No association between the side of bleeding and outcome was demonstrated. Hematomas larger than 25 ml have a greater tendency to lead to an unfavorable outcome. The treatment decision-making process should not differ for either side.


Management of posterior inferior cerebellar artery aneurysms

Acta Neurochir (2017) 159:549–558

Posterior inferior cerebellar artery (PICA) aneurysms are an uncommon, heterogeneous group of aneurysms with poorer clinical outcomes compared to other intracranial aneurysms. We performed a multicenter retrospective study to analyze the outcome in a large series of patients treated with modern microsurgical and endovascular techniques.

Methods Records of 94 patients treated for PICA aneurysms between 2000 and 2015 at three large tertiary referral centers were retrospectively reviewed.

Results Eighty-three patients met inclusion criteria and of these, two died before treatment, leaving 81 treated patients (43 underwent endovascular and 38 surgical treatment). Among patients treated endovascularly, procedure-related complications occurred in four cases (11.8%). Six patients (19.4%) suffered from complications directly associated with surgery. Recurrences occurred in 0% of surgical and in 16.3% of endovascularly treated patients, requiring treatment. Patients with unruptured asymptomatic aneurysms had good outcomes. In the group of 67 ruptured aneurysms, 16 endovascularly (47.1%) and 15 surgically (48.4%) treated patients had modified Rankin scale (mRS) scores of 3–6. Of patients in poor neurological condition (Hunt & Hess (H&H) IV–V at admission), 84.6% suffered a poor clinical outcome. Fifty percent of patients with distal and 31.9% pa- tients with proximal ruptured PICA aneurysms suffered a poor neurological outcome.

Conclusions This study of PICA aneurysms demonstrates that results of both treatment modalities are comparable. However, endovascular treatment is associated with higher risks of recurrence, requiring additional treatment. Outcomes were mostly impacted by clinical state at admission.

The new WHO 2016 classification of brain tumors

Acta Neurochir (2017) 159:403–418

The understanding of molecular alterations of tumors has severely changed the concept of classification in all fields of pathology. The availability of high-throughput technologies such as next-generation sequencing allows for a much more precise definition of tumor entities. Also in the field of brain tumors a dramatic increase of knowledge has occurred over the last years partially calling into question the purely morphologically based concepts that were used as exclusive defining criteria in the WHO 2007 classification.

Methods Review of the WHO 2016 classification of brain tumors as well as a search and review of publications in the liter- ature relevant for brain tumor classification from 2007 up to now.

Results The idea of incorporating the molecular features in classifying tumors of the central nervous system led the authors of the new WHO 2016 classification to encounter inevitable conceptual problems, particularly with respect to linking morphology to molecular alterations. As a solution they introduced the concept of a “layered diagnosis” to the classification of brain tumors that still allows at a lower level a purely morphologically based diagnosis while partially forcing the incorporation of molecular characteristics for an “integrated diagnosis” at the highest diagnostic level. In this context the broad availability of molecular assays was debated. On the one hand molecular antibodies specifically targeting mutated proteins should be available in nearly all neuropathological laboratories. On the other hand, different high-throughput assays are
accessible only in few first-world neuropathological institutions. As examples oligodendrogliomas are now primarily defined by molecular characteristics since the required assays are generally established, whereas molecular grouping of ependymomas, found to clearly outperform morphologically based tumor interpretation, was rejected from inclusion in the WHO 2016 classification because the required assays are currently only established in a small number of institutions.

Conclusion In summary, while neuropathologists have now encountered various challenges in the transitional phase from the previous WHO 2007 version to the new WHO 2016 clas- sification of brain tumors, clinical neurooncologists now face many new diagnoses allowing a clearly improved understand- ing that could offer them more effective therapeutic opportu- nities in neurooncological treatment. The new WHO 2016 classification presumably presents the highest number of modifications since the initial WHO classification of 1979 and there- by forces all professionals in the field of neurooncology to intensively understand the new concepts. This review article aims to present the basic concepts of the new WHO 2016 brain tumor classification for neurosurgeons with a focus on neurooncology.

Can segmental mobility be increased by cervical arthroplasty?

Neurosurg Focus 42 (2):E3, 2017

Many reports have successfully demonstrated that cervical disc arthroplasty (CDA) can preserve range of motion after 1- or 2-level discectomy. However, few studies have addressed the extent of changes in segmental mobility after CDA or their clinical correlations.

METHODS Data from consecutive patients who underwent 1-level CDA were retrospectively reviewed. Indications for surgery were medically intractable degenerative disc disease and spondylosis. Clinical outcomes, including visual analog scale (VAS)–measured neck and arm pain, Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) scores, were analyzed. Radiographic outcomes, including C2–7 Cobb angle, the difference between pre- and postoperative C2–7 Cobb angle (DC2–7 Cobb angle), sagittal vertical axis (SVA), the difference between pre- and post- operative SVA (DSVA), segmental range of motion (ROM), and the difference between pre- and postoperative ROM (DROM), were assessed for their association with clinical outcomes. All patients underwent CT scanning, by which the presence and severity of heterotopic ossification (HO) were determined during the follow-up.

RESULTS A total of 50 patients (mean age 45.6 ± 9.33 years) underwent a 1-level CDA (Prestige LP disc) and were followed up for a mean duration of 27.7 ± 8.76 months. All clinical outcomes, including VAS, NDI, and JOA scores, improved significantly after surgery. Preoperative and postoperative ROM values were similar (mean 9.5° vs 9.0°, p > 0.05) at each indexed level. The mean changes in segmental mobility (DROM) were -0.5° ± 6.13°. Patients with increased segmental mobility after surgery (DROM > 0°) had a lower incidence of HO and HO that was less severe (p = 0.048) than those whose DROM was < 0°. Segmental mobility (ROM) was significantly lower in patients with higher HO grade (p = 0.012), but it did not affect the clinical outcomes. The preoperative and postoperative C2–7 Cobb angles and SVA remained similar. The postoperative C2–7 Cobb angles, SVA, DC2–7 Cobb angles, and DSVA were not correlated to clinical outcomes after CDA.

CONCLUSIONS Segmental mobility (as reflected by the mean ROM) and overall cervical alignment (i.e., mean SVA and C2–7 Cobb angle) had no significant impact on clinical outcomes after 1-level CDA. Patients with increased segmental mobility (DROM > 0°) had significantly less HO and similarly improved clinical outcomes than those with decreased segmental mobility (DROM < 0°).

Incidence and predictors of dural venous sinus pressure gradient in idiopathic intracranial hypertension and non-idiopathic intracranial hypertension headache patients: results from 164 cerebral venograms

Journal of Neurosurgery – 126(2):Pages 347-353

Cerebral venous pressure gradient (CVPG) from dural venous sinus stenosis is implicated in headache syndromes such as idiopathic intracranial hypertension (IIH). The incidence of CVPG in headache patients has not been reported.

METHODS: The authors reviewed all cerebral venograms with manometry performed for headache between January 2008 and May 2015. Patient demographics, headache etiology, intracranial pressure (ICP) measurements, and radiographic and manometric results were recorded. CVPG was defined as a difference ≥ 8 mm Hg by venographic manometry.

RESULTS: One hundred sixty-four venograms were performed in 155 patients. There were no procedural complications. Ninety-six procedures (58.5%) were for patients with IIH. The overall incidence of CVPG was 25.6% (42 of 164 procedures): 35.4% (34 of 96 procedures) in IIH patients and 11.8% (8 of 68 procedures) in non-IIH patients. Sixty procedures (36.6%) were performed in patients with preexisting shunts. Seventy-seven patients (49.7%) had procedures preceded by an ICP measurement within 4 weeks of venography, and in 66 (85.7%) of these patients, the ICP had been found to be elevated. CVPG was seen in 8.3% (n = 5) of the procedures in the 60 patients with a preexisting shunt and in 0% (n = 0) of the 11 procedures in the 77 patients with normal ICP (p < 0.001 for both). Noninvasive imaging (MR venography, CT venography) was assessed prior to venography in 112 (68.3%) of 164 cases, and dural venous sinus abnormalities were demonstrated in 73 (65.2%) of these cases; there was a trend toward CVPG (p = 0.07). Multivariate analysis demonstrated an increased likelihood of CVPG in patients with IIH (OR 4.97, 95% CI 1.71–14.47) and a decreased likelihood in patients with a preexisting shunt (OR 0.09, 95% CI 0.02–0.44).

CONCLUSIONS: CVPG is uncommon in IIH patients, rare in those with preexisting shunts, and absent in those with normal ICP.

Ventriculostomy-related infections in subarachnoid hemorrhage patients

Acta Neurochir (2017) 159:317–323

This study was performed to investigate the incidence and etiology of ventriculostomy-related infections (VRIs) in patients with subarachnoid hemorrhage (SAH) and to assess adherence to local clinical guidelines regarding empirical antimicrobial therapy and diagnostic routines.

Methods: A total of 191 consecutive SAH patients treated in the neuro-intensive care unit of Uppsala University Hospital between 2010 and 2013 were included retrospectively. Information regarding cerebrospinal fluid samples, bacterial cultures, ventriculostomy treatment, patient characteristics, and antibiotic treatment were collected from electronic patient records.

Results: Eleven patients developed VRI, resulting in an incidence of 5.8% per patient, 5.4% per ventriculostomy catheter, and 4.1 per 1000 catheter days. Coagulase-negative staphylococci caused nine cases of VRI and Klebsiella pneumoniae and Staphylococcus aureus caused one each. Empirical VRI therapy was initiated on 97 occasions in 81 subjects (42.4%). Out of the 11 patients with VRI, four did not receive empirical antibiotic therapy before the positive culture result. The clinical actions performed after analysis of CSF samples were in line with the action suggested by the local guidelines in 307 out of 592 cases (51.9%).

Conclusions: The incidence of VRI in our cohort was comparable to what has previously been reported. Coagulase-negative staphylococci was the most common agent. Our study demonstrates the difficulty in diagnosing VRI in SAH patients. Improved adherence to clinical guidelines could to some extent reduce the use of empirical antibiotic treatment, but better diagnostic methods and routines are needed.

Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Percutaneous Endoscopic Lumbar Discectomy: Revision Surgery for Recurrent Herniation After Microendoscopic Discectomy

WORLD NEUROSURGERY 99: 89-95, 2017

Most patients with recurrence of microendoscopic discectomy (MED) need to receive revision surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and percutaneous endoscopic lumbar discectomy (PELD) are common operative methods for MED recurrence, but no study has been made to compare the clinical outcomes of these 2 surgical methods as revision surgery for MED recurrence.

METHODS: A total of 105 patients who underwent either MIS-TLIF (58 patients) or PELD (47 patients) for revision of MED recurrence were included in this study. Perioperative outcomes (operation time, blood loss, and hospital stay), total cost, pain and functional scores (visual analog scale, Oswestry Disability Index, 12-item short form health survey) with a 12-month follow-up visit and review of complications and recurrence within 12 months postoperatively were recorded and assessed.

RESULTS: No significant difference of clinical outcome over time was observed between these 2 approaches. Compared with MIS-TLIF, PELD was associated with greater satisfaction in the early stage after surgery; this effect was equalized after 3 months postoperatively. PELD brought advantages in terms of shorter operation time, shorter hospital stay, less blood loss, and lower total cost compared with MIS-TLIF; however, PELD was also associated with a higher recurrence rate than MIS-TLIF.

CONCLUSIONS: Neither of these 2 surgical methods gave a clear advantage in long-term pain or function scores. Compared with MIS-TLIF, PELD could lead to a better perioperative result and less cost; however, the higher recurrence rate could not be ignored. Taking these characteristics into consideration was instrumental in pursuing personalized treatment for MED recurrence.

Deadly falls: operative versus nonoperative management of Type II odontoid process fracture in octogenarians

Journal of Neurosurgery: Spine – 26(1): 4-9

Type II odontoid fracture is a common injury among elderly patients, particularly given their predisposition toward low-energy falls. Previous studies have demonstrated a survival advantage following early surgery among patients older than 65 years, yet octogenarians represent a medically distinct and rapidly growing population. The authors compared operative and nonoperative management in patients older than 79 years.

METHODS  A single-center prospectively maintained trauma database was reviewed using ICD-9 codes to identify octogenarians with C-2 cervical fractures between 1998 and 2014. Cervical CT images were independently reviewed by blinded neurosurgeons to confirm a Type II fracture pattern. Prospectively recorded outcomes included Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), additional cervical fracture, and cord injury. Primary end points were mortality at 30 days and at 1 year. Statistical tests included the Student t-test, chi-square test, Fisher’s exact test, Kaplan-Meier test, and Cox proportional hazard.

RESULTS  A total of 111 patients met inclusion criteria (94 nonoperative and 17 operative [15 posterior and 2 anterior]). Mortality data were available for 100% of patients. The mean age was 87 years (range 80–104 years). Additional cervical fracture, spinal cord injury, GCS score, AIS score, and ISS were not associated with either management strategy at the time of presentation. The mean time to death or last follow-up was 22 months (range 0–129 months) and was nonsignificant between operative and nonoperative groups (p = 0.3). Overall mortality was 13% in-hospital, 26% at 30 days, and 41% at 1 year. Nonoperative and operative mortality rates were not significant at any time point (12% vs 18%, p = 0.5 [in-hospital]; 27% vs 24%, p = 0.8 [30-day]; and 41% vs 41%, p = 1.0 [1-year]). Kaplan-Meier analysis did not demonstrate a survival advantage for either management strategy. Spinal cord injury, GCS score, AIS score, and ISS were significantly associated with 30-day and 1-year mortality; however, Cox modeling was not significant for any variable. Additional cervical fracture was not associated with increased mortality. The rate of nonhome disposition was not significant between the groups.

CONCLUSIONS  Type II odontoid fracture is associated with high morbidity among octogenarians, with 41% 1-year mortality independent of intervention—a dramatic decrease from actuarial survival rates for all 80-, 90-, and 100-year-old Americans. Poor outcome is associated with spinal cord injury, GCS score, AIS score, and ISS.

Comparing clinical outcomes of repeat discectomy versus fusion for recurrent disc herniation utilizing the N2QOD

J Neurosurg Spine 26:39–44, 2017

Recurrent lumbar disc herniation (RLDH) is a significant cause of morbidity in patients undergoing lumbar discectomy and has been reported to occur in up to 18% of cases. While repeat discectomy is often successful in treating these patients, concern over repeat RLDH may lead surgeons to advocate instrumented fusion even in the absence of instability. The authors’ goal was to compare clinical outcomes for patients undergoing repeat discectomy versus instrumented fusion for RLDH.

Methods The authors used the National Neurosurgery Quality and Outcomes Database (N2QOD) to assess outcomes of patients who underwent repeat discectomy versus instrumented fusion at a single institution from 2012 to 2015. Primary outcomes included Oswestry Disability Index (ODI) score, visual analog scale (VAS) score, and quality-adjusted life year (QALY) measures. Secondary outcomes included hospital length of stay, discharge status, and hospital charges.

Results The authors identified 25 repeat discectomy and 12 instrumented fusion patients with 3- and 12-month follow-up records. The groups had similar ODI and VAS scores and QALY measurements at 3 and 12 months. Patients in the instrumented fusion group had significantly longer hospitalizations (3.7 days vs 1.0 days, p < 0.001) and operative times (229.6 minutes vs 82.7 minutes, p < 0.001). They were also more likely to be female (p = 0.020) and to be discharged to inpatient rehabilitation instead of home (p = 0.036). Hospital charges for the instrumented fusion group were also significantly higher ($54,458.29 vs $11,567.05, p < 0.001). Rates of reoperation were higher in the repeat discectomy group (12% vs 0%), but the difference was not statistically significant (p = 0.211).

Conclusions Repeat discectomy and instrumented fusion result in similar clinical outcomes at short-term follow-up. Patients undergoing repeat discectomy had significantly shorter operative times and length of stay, and they incurred dramatically lower hospital charges. They were also less likely to require acute rehabilitation postoperatively. Further research is needed to compare these two management strategies.

Image-guided resection of aggressive sacral tumors

Neurosurg Focus 42 (1):E15, 2017

The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors.

Methods: The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type.

Results: Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type.

Conclusions: Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma


J Neurosurg 125:1344–1351, 2016

Intracerebral hematoma (ICH) with subarachnoid hemorrhage (SAH) indicates a unique feature of intracranial aneurysm rupture since the aneurysm is in the subarachnoid space and separated from the brain by pia mater. Broad consensus is lacking regarding the concept that ultra-early treatment improves outcome. The aim of this study is to determine the associative factors for ICH, ascertain the prognostic value of ICH, and investigate how the timing of treatment relates to the outcome of SAH with concurrent ICH.

Methods The study data were pooled from the SAH International Trialists repository. Logistic regression was applied to study the associations of clinical and aneurysm characteristics with ICH. Proportional odds models and dominance analysis were applied to study the effect of ICH on 3-month outcome (Glasgow Outcome Scale) and investigate the effect of time from ictus to treatment on outcome.

Results Of the 5362 SAH patients analyzed, 1120 (21%) had concurrent ICH. In order of importance, neurological status, aneurysm location, aneurysm size, and patient ethnicity were significantly associated with ICH. Patients with ICH experienced poorer outcome than those without ICH (OR 1.58; 95% CI 1.37–1.82). Treatment within 6 hours of SAH was associated with poorer outcome than treatment thereafter (adjusted OR 1.67; 95% CI 1.04–2.69). Subgroup analysis with adjustment for ICH volume, location, and midline shift resulted in no association between time from ictus to treatment and outcome (OR 0.99; 95% CI 0.94–1.07).

Conclusions The most important associative factor for ICH is neurological status on admission. The finding regarding the value of ultra-early treatment suggests the need to more robustly reevaluate the concept that hematoma evacuation of an ICH and repair of a ruptured aneurysm within 6 hours of ictus is the most optimal treatment path.

KEY WORDS intracerebral hematoma; subarachnoid hemorrhage; outcome assessment; intracranial aneurysm; vascular disorders

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


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