Benefits Of Early Surgery Research Articles

Metabolic profiling of atypical meningioma and recurrent meningioma: a comparative analysis with proton magnetic resonance spectroscopy.

Meningiomas are predominantly benign, but some cases exhibit recurrent growth after surgery and undergo malignant transformation to WHO grade 2 or grade 3. Despite progress in genetic analyses, advancements in metabolomic analysis remain less established. Herein, the authors investigated metabolic activity differences between WHO grade 1 meningiomas and WHO grade 2 or 3 meningiomas by noninvasively using proton magnetic resonance spectroscopy (1H-MRS), aiming to preoperatively estimate malignancy. They also reviewed the literature to elucidate this aspect of meningioma research. At Ryukyu University Hospital, the authors focused on 93 patients diagnosed with meningioma between 2011 and 2021. The inclusion criteria encompassed prior surgery, pathological diagnoses of meningioma, and preoperative 1H-MRS. Group I included 71 patients with WHO grade 1 meningioma and group II included 22 patients, comprising 19 and 3 with WHO grade 2 and 3 meningioma, respectively. The authors retrospectively conducted a comparative analysis of patient backgrounds and tumor metabolites. Group I and II did not differ significantly in terms of patient demographic characteristics (age and sex). Group II demonstrated a significantly lower extent of tumor resection (p < 0.01), higher MIB-1 labeling index (LI) (p < 0.05), higher incidence of prior irradiation (p < 0.001), and increased rate of tumor recurrence (p = 0.005) compared to group I. According to 1H-MRS, all metabolites, except lactate, displayed significantly higher median creatine (Cr) ratios in group II than group I: glutamine/Cr was 8.46, glutamate/Cr was 9.49, lipid/Cr was 11.36, and choline/Cr was 2.77. According to the receiver operating characteristic (ROC) analysis, glutamine had the largest area under the curve of 0.765 among 10 metabolites, and the cutoff value for distinguishing between group I and II was 5.76. In cases pathologically graded as WHO grade 2 or 3 meningiomas, metabolic products such as glutamine, glutamate, lipids, and choline increased significantly. These changes were correlated with elevation of the MIB-1 LI. In group II, the mean MIB-1 LI was 8.58, significantly higher than in group I, suggesting a strong association with pathological malignancy. Therefore, 1H-MRS may help to noninvasively predict tumor metabolic activity and tumor recurrence. Furthermore, the authors concluded from the ROC analysis that glutamine may be a potential indicator of future growth of meningioma and benefits of early surgery.

22. Early vs (

<h3>BACKGROUND CONTEXT</h3> The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of the global aging population. <h3>PURPOSE</h3> To provide a head-to-head comparison of the neurological and functional outcomes of early (<24 hrs) vs late (24 hrs) surgical decompression for CCS. <h3>STUDY DESIGN/SETTING</h3> Propensity, score-matched analysis cohort study. <h3>PATIENT SAMPLE</h3> Participants were included if they had a documented baseline American Spinal Injury Association (ASIA) / International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) neurological examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS, as defined by apoint difference of five or more between baseline ASIA lower extremity motor score (LEMS) and upper extremity motor score (UEMS), in favor of the lower limbs (LEMS - UEMS 5). <h3>OUTCOME MEASURES</h3> The primary endpoint was motor recovery (upper extremity motor score (UEMS); lower extremity motor score (LEMS); AMS) at one year. Secondary endpoints were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at one year. <h3>METHODS</h3> This study identified CCS patients from three international, multicentre studies examining the timing of surgical decompression in spinal cord injury. Patients who underwent surgery for CCS (LEMS-UEMS5) were identified from three spinal cord injury (SCI) datasets (NACTN; STASCIS; NASCIS III). Propensity scores were calculated as the probability of undergoing early (< 24 hrs) compared to late (24 hrs) surgery using the logit method and adjusting for data source, age, injury mechanism, and baseline ASIA motor score (AMS), AIS grade, and neurological level. Propensity score matching was performed in a one-to-one ratio by an "optimal matching" technique. Effect sizes for outcomes were summarized by mean differences (MDs) or odds ratios (ORs) and associated 95% confidence intervals. <h3>RESULTS</h3> The final study cohort consisted of 186 patients with CCS. Baseline characteristics were balanced between matched early (N=93) and late (N=93) surgery groups. Early surgical decompression resulted in significantly improved recovery in upper limb (MD 2.3, P=0.047), but not lower limb (MD 1.1, P=0.256), motor function, as compared with late surgery. More patients in the early surgery group appeared to achieve complete independence in various functional activities, particularly those involving upper limb function; however, these associations did not reach statistical significance, and there was no difference in one-year FIM motor score (MD 4.4, P=0.182). On subgroup analysis, outcomes were comparable with early or late decompressive surgery in AIS grade D patients. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD 9.5, P=0.038), owing to gains in both upper and lower limb motor function. <h3>CONCLUSIONS</h3> This study found early (<24 hrs) compared to late (24 hrs) surgical decompression to result in improved recovery in upper limb motor function at one year in patients with central cord syndrome. The benefit of early surgery was especially realized in patients with AIS grade C injury. Treatment paradigms for central cord syndrome should be redefined to encompass early surgical decompression as a neuroprotective therapy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

358 Surgical Management of Spinal Cord Injuries: An Overview of Controversies

Abstract Aim Spinal Cord Injuries (SCI) are incredibly debilitating injuries associated with significant morbidity and financial burden, with an incidence of 12-16 per million population in the UK. There is currently no cure for SCI, with majority of interventions focusing on primary prevention of SCI or of further damage once SCI is sustained. We present an overview of the role of closed reduction, timing of surgery and role of steroids, and provide an algorithm for management of SCI. Method A search was carried out on PubMed, looking at notable reviews, consensus statements and trends in management of spinal cord injuries. This was cross-referenced with the NICE and BOAST guidelines for SCI. Results The efficacy of closed reduction in cervical fractures and necessity of pre-reduction MRI is still equivocal and remains a source of major debate amongst spinal surgeons. The timing of surgery remains controversial as studies have not consistently shown improved outcomes with early, aggressive surgery but there have been trends noted in the newer studies with some benefit of early surgery. The use of steroids in acute SCI has fallen out of favour with most guidelines not recommending them due to their equivocal benefit and unequivocal side-effect profile. Conclusions Prevention and pre-hospital management are crucial in the management of SCI, along with early spinal alignment restoration, decompression and stabilisation augmented by good long-term rehabilitation measures. There is a need for new randomised controlled trials assessing the role of closed reduction, need for pre-reduction MRI and timing of surgery in SCI.

The benefit of early surgery on overall survival in incidental low-grade glioma patients: A multicenter study.

The role of surgery for incidentally discovered diffuse incidental low-grade gliomas (iLGGs) is debatable and poorly documented in current literature. The aim was to identify factors that influence survival for patients that underwent surgical resection of iLGGs in a large multicenter population. Clinical, radiological, and surgical data were retrospectively analyzed in 267 patients operated for iLGG from 4 neurosurgical Centers. Univariate and multivariate analyses were performed to identify predictors of overall survival (OS) and tumor recurrence (TR). The OS rate was 92.41%. The 5- and 10-year estimated OS rates were 98.09% and 93.2%, respectively. OS was significantly longer for patients with a lower preoperative tumor volume (P = .001) and higher extent of resection (EOR) (P = .037), regardless the WHO-defined molecular class (P = .2). In the final model, OS was influenced only by the preoperative tumor volume (P = .006), while TR by early surgery (P = .028). A negative association was found between preoperative tumor volumes and EOR (rs = -0.44, P < .001). The median preoperative tumor volume was 15 cm3. The median EOR was 95%. Total or supratotal resection of T2-FLAIR abnormality was achieved in 61.62% of cases. Second surgery was performed in 26.22%. The median time between surgeries was 5.5 years. Histological evolution to high-grade glioma was detected in 22.85% of cases (16/70). Permanent mild deficits were observed in 3.08% of cases. This multicenter study confirms the results of previous studies investigating surgical management of iLGGs and thereby strengthens the evidence in favor of early surgery for these lesions.

Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment.

A prospective patient's database operated on a cauda equina syndrome (CES). The aim of our study was to identify prognosis factors for favorable functional recovery after CES. CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery. One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted. The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery. CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Abstract 14886: Outcome of Early Surgery in Active Infective Endocarditis in Terms of Intraoperative Valve Culture

Introduction: In recent years, the benefit of early surgery in active infective endocarditis (IE) has been reported. The drawback of early surgery is the risk that residual bacteria in the operative field may cause IE recurrence. Little is known regarding the relationship between intraoperative valve culture and recurrence. In the present study, we investigated the value of early surgery for IE based on the results of valve cultures. Hypothesis: Positive intraoperative valve cultures in early surgery are associated with recurrence. Methods: Between 2009 and 2017, 585 patients underwent valve surgery for definitive left-sided active IE at 14 affiliated hospitals. Early surgery was defined as surgery within 14 days from diagnosis, and patients with unknown valve culture results were excluded. We analyzed the short and mid-term outcome in patients with early surgery (n=228). These 228 patients were compared in two groups: positive (Group P, n=106) and negative (Group N, n=122) valve cultures. The primary outcome was all-cause mortality. Secondary outcomes were recurrence of IE. Mean follow-up time was 2.5±2.8 years. Results: Patients in group P had a significantly higher inflammatory response on preoperative blood tests (White blood cell count: 10.4 (8.3-14.5) vs. 8.2 (6.0-12.7) х10 3 /μl, p=0.005, C-reactive protein: 7.3 (3.8-11.0) vs. 3.8 (2.1-6.8) mg/dl, p&lt;0.001). Patients in group P also had a significantly shorter duration from diagnosis to surgery (2 (1-4) vs. 4 (1-9) days, p&lt;0.001). There was no significant difference in in-hospital mortality between the two groups (13/106 (12%) vs. 11/122 (9%), p=0.43). The overall survival rate at 1 and 5 years was 83% and 69% in group P, 82% and 75% in group N, respectively (p=0.85). The rate of freedom from the recurrence of endocarditis at 1 and 5 years postoperatively was 97% and 82% in group P, and 98% and 92% in group N, respectively (p=0.02). In Cox's hazard analysis, positive valve culture was a risk factor for IE recurrence in multivariate analysis (hazard ratio, 3.39; 95% confidence interval, 1.07 to 10.67; p=0.037). Conclusions: Positive valve culture cases in early surgery for active IE have a significantly increased risk of recurrence compared with valve culture-negative cases and require careful management.

Invasive and non-invasive quantification of myocardial fibrosis in primary mitral regurgitation: prognostic implications for post-operative remodelling, symptom burden and exercise capacity

Abstract Chronic primary mitral regurgitation (MR) exposes the left ventricle (LV) to volume overload and is associated with evidence of fibrosis on non-invasive imaging. It is not known whether fibrosis predicts outcome from surgery. This study aimed to 1) quantify myocardial fibrosis on histology and non-invasive imaging, 2) investigate any association between fibrosis and LV size and function, 3) determine the impact of fibrosis on post-operative outcome. Methods In a prospective observational multicentre study, 105 patients with severe MR (N=65/32/8 NYHA Class I/II/III respectively; mean age 63.1±13.4 years; male 73%; VO2max 91.2±22.4%) had multiparametric cardiac magnetic resonance (CMR), symptom assessment (Minnesota Living with Heart Failure Questionnaire (MLHFQ)) and cardiopulmonary exercise testing before and at 9 months following repair. Patients consented for up to 3 intraoperative LV biopsies for histological collagen volume fraction (CVF) quantification. Results 234 LV biopsies were feasible from 86 patients with median CVF of 14.6% [IQR 7.4–20.3]. Fibrosis was present even in NYHA Class I patients (13.6% [6.3–18.8]), and was significantly higher than the 3.3% [2.6–6.1] obtained from 8 autopsy controls without cardiac disease (P&amp;lt;0.001). Pre-operatively, there was no relationship between CVF and LV size, systolic function, ECV, late gadolinium enhancement, although it did correlate with MLHFQ (R=0.23, P=0.034). Conversely, ECV (27.4±3.3%) correlated with systolic (LVEF Rho=−0.22, P=0.029; LVESVi Rho=0.22, P=0.025, GCS Rho=0.31, P=0.002) and diastolic function (E/e' R=0.25, P=0.022), exercise capacity (%VO2max R=−0.22, P=0.030), with borderline correlation to MLHFQ (R=0.19, P=0.058). Post-operatively, although LVEF remained normal (defined as &amp;gt;50%) in all but 6 patients (LVEF pre 69.1±8.0 vs post 63.3±8.3%, P&amp;lt;0.001), there was a reduction in ECV (27.4±3.3 vs 26.6±2.8%, P=0.027) that was proportionate to its pre-operative expansion (Figure1), suggesting that fibrosis was reversible within our patients. Neither histological CVF nor ECV predicted change in LVESVi, LVEF, symptom burden or exercise capacity following repair. GCS was an independent predictor of post-operative LVESVi and LVEF on multiple linear regression models. Whilst improvements in symptom burden and exercise capacity was observed in NYHA II-III patients, this sub-group of patients failed to achieve the same level of fitness and symptom-free status as NYHA I patients (VO2max 92.2±18.8% vs 102.9±21.1%, P=0.017; MLHFQ 12 [5–26] vs 3 [0–10], P&amp;lt;0.001). Conclusions Myocardial fibrosis is present in primary MR, before the onset of symptoms. Due to its patchy nature, ECV but not fibrosis on histology is a better marker of pre-operative myocardial function and symptom status. Despite ECV reduction following successful MR surgery, symptomatic patients fail to regain exercise fitness and symptom-free status – providing further support for the benefits of early surgery. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Abstract Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre. Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome. Results 343 patients who were submitted to surgical clipping in the first 72 hours post-ictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Good-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge and at 6 months. Poor-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge. Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

Efficacy of Early Decompression Surgery Versus Epidural Injection in Management of Sciatica Due to Lumbar Disc Herniation–A Randomised Control Trial

Introduction: Sciatica is one of the most excruciating type of pain resulting due to irritation of the sciatic nerve in the lower back. Pain radiates along the distribution of the sciatic nerve in the lower limb. Lumbar disc herniation is commonly implicated as a cause of sciatica. Treatment options include initial conservative approach with epidural injection and analgesics and in patients with no relief decompression surgery performed. The short-term efficacy of the epidural injections is well established but the long-term outcome remains controversial. Even, spinal decompression surgeries have shown significant relief of symptoms at short term but in long term remain doubtful. This study attempts to compare both these treatment options in people with disabling chronic sciatic pain. Materials and Method: This prospective randomized controlled trial conducted on 25 patients for duration of 1 year with sciatica symptoms lasting for more than 6 weeks. Complete history and examination with imaging studies was carried out with pain assessment done by using a Roland Disability Questionnaire (RDQ) and Visual Analogue Scale (VAS). Follow up Assessment of the patient’s were done at regular interval of 0, 2, 4, 12, 26, 52 weeks post intervention. Results: Of the 25 patients 12 were assigned randomly to early surgery group and 13 to epidural injection group. Immediate post-op and follow up assessment showed significant improvement in pain and disability scores for patients randomized to early surgery group with a significant difference between areas under the curve. The short-term benefit of early surgery was no longer significant by 6 months and by the end of 1 year outcomes were similar between the two groups. Conclusion: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year in patients of both groups.

Benefits of Early Surgery on Clinical Outcomes After Degenerative Mitral Valve Repair

This study aimed to evaluate the clinical trends of mitral valve repair for degenerative mitral regurgitation and the benefit of early surgical intervention on repair durability in a high-volume center. From January 2003 to December 2015, 1,903 consecutive patients with severe degenerative mitral regurgitation underwent mitral valve repair at our institution. The timing of surgical intervention was evaluated by guideline-related indications including symptoms, atrial fibrillation, left ventricular dysfunction, and pulmonary hypertension. Clinical outcomes and risk factors for recurrent mitral regurgitation were analyzed. Over 13 years from 2003 to 2015, trends of preoperative characteristics demonstrated that the proportion of asymptomatic patients substantially increased. The 8-year overall survival, freedom from reoperation for mitral valve, and freedom from recurrent mitral regurgitation were 96%, 96%, and 85%, respectively. Ejection fraction less than 60%, left ventricular end-diastolic dimension greater than 60 mm, isolated anterior leaflet lesion, and intraoperative mild residual mitral regurgitation were independent predictive factors for recurrent mitral regurgitation. The incidence of recurrent mitral regurgitation was significantly lower in the early intervention group (3% versus 18%, p < 0.01). In subgroup analysis of asymptomatic patients, the incidence of recurrent mitral regurgitation was significantly lower in patients without guideline-related indications (3% versus 31%, p < 0.0001). Early surgical intervention for severe degenerative mitral regurgitation before symptoms, atrial fibrillation, and ventricular dysfunction are associated with excellent clinical outcomes. Besides complexity of leaflet lesion and repair quality, surgical timing also significantly affects repair durability. Early surgical intervention should therefore be recommended to reduce recurrent mitral regurgitation.

Pediatric surgeons and anesthesiologists expand the dialogue on the neurotoxicity question, rationale for early and delayed surgeries, and practice changes while awaiting definitive evidence.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

Complex communicating bronchopulmonary foregut malformation with pancreatic heterotopy depicted with fetal magnetic resonance imaging: a case report

Bronchopulmonary foregut malformation (BPFM) is a group of rare congenital anomalies that affect the respiratory and upper gastrointestinal tracts. We report here the first case of prenatal depiction of communicating BPFM, including extrapulmonary sequestration and foregut cyst, both with pancreatic differentiation. Magnetic resonance imaging on the fetus confirmed a polymalformative syndrome with right-lung and gastric cysts and allowed the detection of respiratory and alimentary tracts communication and aberrant feeding vessels. Diagnosis was confirmed after birth by multidetector computed tomography and postnatal pathologic findings. The patient, a boy, underwent surgery for respiratory distress at 4 weeks of life. This singular case confirms the benefits of early surgery for communicating BPFM.

Predictive Value of Age, Angle, and Refraction on Rate of Reoperation and Rate of Spontaneous Resolution in Infantile Esotropia

In the Early vs. Late Infantile Strabismus Surgery Study (ELISSS), 13.5% of children operated at 20 months vs. 3.9% of those operated at age 4 had gross binocular vision (Titmus Housefly). Reoperation rates were 28.7% in the former vs. 24.6% in the latter group and, although all were eligible for surgery at baseline at 11 SD 3.7 months, 8% in the early group vs. 20% in the late group were never operated, mostly because their angle decreased spontaneously. We assessed the predictive value of age, angle, and refraction in these matters.Methods: The ELISSS reoperation rates were first compared with those found in nine series of consecutive cases in nine university clinics operated during one particular year, between 6 and 23 years previously. Logistic regression was used to estimate the effect of postoperative angle and clinic on the chance of reoperation. Secondly, a meta-regression analysis was done of these and other reported reoperation rates. The mean age at operation and the mean duration of follow-up were regressed on the logistically transformed reported reoperation rates. Finally, to estimate the chance of spontaneous decrease of the angle without surgery, a random-effects model was fitted on the 6-monthly orthoptic measurements of angle and refraction in the ELISSS that antedated surgery, loss to follow-up, or final examination. In the random-effects model (see online-only supplement link or visit, www.simonsz.net), for ELISSS patients the random effect was defined as the deviation of the average angle, the fixed effect. A vector was defined based on age and spherical equivalent of the patient. The variance around the prediction consisted of uncertainty in the estimations, random effects, and residuals.Results: In the retrospective study, 204 patients who had been first operated between 6 and 23 years previously were eligible. A reoperation had been performed in 32 (19.3%) of the remaining 166 children who were 4.33 SD 1.35 years old at first surgery. The reoperation rate was 7.3% for those with a postoperative angle of −4° to +4° (N = 82), 25% for postoperative divergence > 5°, and 29% for postoperative convergence 10° to 14°. Strabismologists overestimated the reoperation rates at double. In the meta-regression analysis, 12 studies were included. Reoperation rates were between 60% and 80% for children first operated around age 1 and approximately 25% for children operated around age 4 (best fit: −0.221 Ln [age in months] + 1.1069; R2 = 0.5725). Finally, in the predictions of random-effects model, a small angle at age 1 and hyperopia of approximately +4 increased the chance of spontaneous decrease of the angle into a microstrabismus.Discussion: The benefit of early surgery for gross binocular vision is balanced by a higher reoperation rate and an occasional child being operated that would have had a spontaneous decrease into a microstrabismus without surgery. The fact that, in the ELISSS, hyperopia was associated with a decrease of the angle underscores the benefit of early refractive correction.

Early recombinant factor VIIa therapy in acute intracerebral hemorrhage: Promising approach

Intracerebral hemorrhage (ICH) is the most devastating form of stroke with a high morbidity and mortality. ICH constitutes about 20-30% of all strokes, with the prevalence being higher in Asian population. Treatment of ICH is predominantly conservative, which includes control of blood pressure, use of anti-cerebral edema measures such as mannitol and mechanical ventilation. The benefit of early surgery in ICH is debatable. Initial hematoma volume and subsequent growth in its size are important predictors of a poor outcome in ICH. This means that therapies aimed at preventing hematoma enlargement in the earliest possible window period could lead to a better outcome in ICH. Recombinant factor VIIa (rFVIIa) is one such agent, which has been shown to prevent hematoma expansion and improve outcome in acute ICH. The purpose of the current review is to focus on the evidence regarding the usefulness of rFVIIa in acute ICH.

Early Carotid Endarterectomy in Selected Stroke Patients

Although there are several reports suggesting the safety of performing carotid endarterectomy (CE) within 4 weeks (early) of a nondisabling stroke, at many institutions it is not standard practice. Benefits of early surgery may include reduction in the number of strokes or carotid occlusions during the time between stroke and surgery, as well as a reduction in the cost of medical care due to the elimination of interval anticoagulation and close follow-up. This review examines the outcomes of early CE in selected patients after a nondisabling stroke. A total of 1065 CEs were performed between November 1991 and April 1998. Seventy-five patients were identified by computerized hospital record and office chart review as having CE after a nondisabling stroke. Criteria for early surgery included 1) nondisabling stroke ipsilateral to a carotid stenosis >50%, 2) neurological stability, and 3) no evidence of hemorrhagic stroke or significant cerebral edema by CT/MRI evaluation. This review suggests that early CE can be performed in selected patients with an acceptable perioperative morbidity and mortality.

Management of fixed subaortic stenosis: A retrospective study of 57 cases

Although recommended by several investigators, the benefit of early surgery in patients with fixed subaortic stenosis has not been proved. Findings were reviewed of 57 patients with isolated fixed subaortic stenosis, including 27 surgically treated patients, with special emphasis on the occurrence of aortic regurgitation during a mean follow-up period of 6.7 years.The number of patients with aortic regurgitation increased preoperatively in the total group (23% at diagnosis to 54% after 3.7 years of follow-up). The prevalence of aortic regurgitation in the 27 surgically treated patients was higher (81%) than that in the nonsurgically treated group but remained unchanged after a mean postoperative period of 4.7 years. In all patients but one, aortic regurgitation remained of minor hemodynamic significance. One patient died during follow-up.After surgery, 15 patients (55%) showed a relapse; 11 redeveloped a subvalvular pressure gradient >39 mm Hg and discrete subvalvular ridges (range 6 months to 24 years after surgery, mean 7 years). In those patients with fixed subaortic stenosis, follow-up did not reveal any benefit from early surgery. The unpredictable course and sometimes very severe progression of this disease make frequent and careful follow-up necessary.

Results of Blepharoptosis Surgery with Early Postoperative Adjustment

The authors reviewed 157 cases (207 eyes) of blepharoptosis corrected by external levator resection. Twenty-eight patients (29 eyelids) had unsatisfactory results. The authors adjusted 13 eyelids within 1 week of surgery. Eleven eyelids were reoperated 6 or more weeks after surgery. The mean delay between the initial and final surgery in the early group was 2.0 weeks; and, for the late group, 33.5 weeks. For those having reoperations, there was no difference in the number of procedures required to achieve satisfactory outcomes. Four patients (5 eyelids) with unsatisfactory results were offered, but declined, late repair. Early or late reoperation is effective in correcting unsatisfactory results after external levator resection. The benefits of early surgery are a reduction in time to final result, the ease with which it is performed, potential cost savings, and the opportunity one has to correct unsatisfactory results.

Ultrasonography, HIDA scintigraphy or both in the diagnosis of acute cholecystitis?

The benefit of early surgery for patients with acute cholecystitis is now accepted but rapid accurate pre-operative diagnosis is important and the single best investigation has not yet been clearly established. All 47 patients with suspected acute cholecystitis admitted to a district general hospital during a 6 month period underwent ultrasonic examination and scintigraphy with HIDA within 48 h of admission. In 23 patients acute cholecystitis was proven. Ultrasound correctly diagnosed this in 21 patients but in 2, changes attributed to chronic cholecystitis only were detected. Two false positive ultrasound results also occurred, one in a patient with adenomyomatosis and acute pancreatitis, the other in a case of duodenitis. HIDA scan was diagnostic in 19 patients but in the remaining 4 the presence of abnormal liver function tests accounted for non-visualization of the biliary tree (a non-diagnostic result). In the absence of jaundice a HIDA scan is the more specific test for confirming acute cholecystitis.