Deterioration Of Neurological Deficits Research Articles

Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations.

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Stagewise treatment of tandem lesions of the internal carotid artery in patients with ischaemic stroke

The study was aimed at assessing the results of a stagewise approach to surgical treatment of patients with ischaemic stroke and tandem lesions of coronary arteries. We analysed the results of treating a total of 19 patients with ischaemic stroke having endured in 2017-2018 surgical interventions for tandem lesions of the internal carotid artery. All 19 patients with tandem lesions underwent as the first stage of surgical treatment recanalization of the intracranial portion of the internal carotid artery. Nine patients were subjected to thromboextraction followed by carotid stenting (Group One), ten underwent thromboextraction and carotid endarterectomy (Group Two). One patient was subjected to simultaneous endovascular intervention at the intra- and extracranial level, in 18 patients reconstruction of the internal carotid artery at the extracranial level (second stage) was performed within a postponed period (3-5 days). In the postoperative period we assessed neurological deficit and the results of 90-day survival. No deterioration of neurological deficit was observed after the first stage of surgical treatment. There were statistically significant differences in the degree of regression of a stagewise treatment at discharge, with predominance in the second group. The 90-day survival rate had no prevalence in either group, despite 1 lethal outcome in a patient with simultaneous thromboextraction and stenting of the extracranial portion of the internal carotid artery. Adequate prevention of haemorrhagic transformation of the damaged zone of cerebral tissue in patients with ischaemic stroke caused by tandem lesions of carotid arteries may be ensured by means of selecting stagewise treatment, i. e., postponed elimination of extracranial stenosis of the internal carotid artery. Given a small sample size, the study requires further examination and assessment of the obtained results.

Case series of posterior instrumentation for repair of burst lumbar vertebral body fractures with entrapped neural elements.

Burst fractures of the lumbar vertebrae and laminar fractures associated with dural tears and entrapment of neural elements have been reported in the past as a relatively rare occurrence. To the best of our knowledge, there is no consensus on the approach to repairing these types of fractures. The objective of this study is to describe a method of repair for traumatic burst fractures of the lumbar spine and vertical laminar fractures associated with entrapped neural elements. Seventeen patients with lumbar burst fractures were treated from June 2015 through April 2017. Dural tear was detected in all cases included in this study (confirmed intra-operatively). All other burst fractures were excluded. In all cases, unilateral posterior fixation was performed with no distraction initially. The spinal canal was then decompressed; and the entrapped neural elements released. Formal distraction was performed after canal decompression to allow for ligamentotaxis, followed by reduction of the retropulsed fractured segments back into the vertebral body. Using this method we achieved satisfactory results in that none of the patients had further deterioration of neurological deficit and the fixation allowed for early mobilization. Continued improvement was seen at the time of follow up for each of the studied patients with improved neurology, pain and no CSF leak. Our institution has demonstrated successful use of a posterior instrumentation, spinal canal decompression, release of entrapped nerve roots, and reduction of the retropulsed segment, in patients with traumatic burst fracture of the lumbar vertebrae complicated by entrapped neural elements.

The Outcome of Pedicle Screw Instrumentation Removal for Chronic Low Back Pain

Introduction There have been a limited number of small case series reporting improvement in patients' function and pain scores following removal of pedicle screw metalwork for nontraumatic lumbar fusion surgery. The investigators' aim was to determine the degree of satisfaction from a patient cohort; and improvement in pain status after removal of pedicle screw instrumentation and factors that may influence the outcome. Methods Patients who had removal of pedicle screw instrumentation for posterolateral lumbar fusion in the preceding 2 years were identified from the database of a single spinal surgeon's case series. All patients completed pre- and postoperative Oswestry Low Back Pain Disability Questionnaire (ODI). Patient inclusion criteria were persistent axial low back pain imaging confirmed solid fusion, nonradicular symptoms and no other cause found for pain, for example, infection. Exclusion criteria included exchange of metal work, revision fusion, or other additional therapeutic procedures. Following removal of metal work via previous incisions, all patients had debridement of fibromuscular tissue and adhesiolysis, thorough saline lavage, and local bone grafting to the site of metal removal. Results A total of 21 patients were identified from the database with a mean follow-up of 14 months (range, 3–24 months). There were two postoperative hematomas requiring aspiration but no additional complications such infections, reoperations, or deterioration of neurological deficits. The former two patients did not record improvement in VAS and both were neutral in satisfaction. Treatment success as assessed from the ODI analysis was rated as excellent in 6 of 21, good in 7 of 21, fair in 5 of 21, and poor in 2 of 21. Reduced class II opioids, benzodiazepines, or neuromodulator use was reduced in 7of 21, no different in 11of 21, and increased in 3 of 21. The proportion of patients with an improvement in VAS was 13 of 21 (62%) with an improvement of at least 2 or more being (43%) 9 of 21 of patients surveyed. The visual analog scores were the only component of the ODI able to be assessed for all of the patients with mean scores of 5.9 preoperatively to 4.2 postoperatively ( p = 0.04). The proportion of patients with an improvement in VAS was 13 of 21 (62%) with an improvement of 2 or more being 9 of 21 (43%) of patients surveyed. Patients who did not receive analgesic benefit and/or had lower satisfaction from the removal of instrumentation procedure tended to be male, compensable, had experienced more years of symptoms, shorter times to metal wear removal, and an increased prevalence of preoperative class II opioid requirements. There was, however, no trend to a difference with regards to number or location of levels fused, number of procedures, presence of pseudoarthrosis or broken/loose metal wear and method of preoperative fusion confirmation. Of the 21 patients, 14 (67%) patients indicated that they would undergo the same treatment again given their experience and outcome. Conclusion In our series, removal of pedicle screw implants in individuals with ongoing low back pain following solid fusion lead to good or excellent results in two-third of patients and did not lead to any adverse effects and/or complications.

Stenting Therapy for Extra-Cranial Carotid Stenosis

We report our initial results of stent placement for extra-cranial carotid stenosis. Fifteen patients aged 54 to 83 years (10 men) with > 60% extra-cranial carotid stenosis were treated with percutaneous stent implantation. Four patients were asymptomatic. The rate of stenosis ranged from 60% to 93% (mean: 74%). Balloon-expandable stents (Palmaz stent: 11, Cordis stent: 1, GFX stent: 2) were placed for fourteen patients and for one patient a self-expandable stent was used (Memotherm biliary stent). The proximal protective balloon technique was used in the most possible cases during predilatation or stent placement. Angiography or ultrasonography was performed as the evaluation of restenosis after stent placement. The definition of restenosis was > 50% stenosis. The mean period of follow-up was 8.5 months (from 1 to 20 months). In all patients, carotid stents were successfully placed. The mean rate of stenosis immediately after the procedure decreased to 0%. The protective balloon technique could be used in ten patients during pre-dilatation, in six during stent placement. One patient suffered a transient ischemic attack immediately after predilatation. The symptoms disappeared completely 15 minutes after onset. There was no patient with relapse or deterioration of neurological deficits after the procedure. There was no restenosis and stent deformation in the follow-up period. In our small series, stent placement for extra-cranial carotid stenosis was performed with a low rate of morbidity and mortality. However, it is necessary to develop more flexible, more controllable stents with increased mesh densities for exclusive neurointervention. In addition, the development of a more reliable protective balloon technique to decrease procedurerelated complications is needed.

Epidemiología de los distintos tipos de epilepsia vascular en adultos

From studies of the incidence of epilepsy, figures of between 40 and 70 per 100,000 inhabitants are obtained whilst in studies of prevalence, 5 to 7 cases per 1,000 are found. Cerebrovascular disease is the commonest cause of epileptic crises in the developed world, being more frequent in patients aged over 60, who make up 50% of all cases. Depending on the moment of presentation of crises in relation to the cerebrovascular disease, these may be classified as herald crises or precursors of vascular epilepsy, early crises if they occur during the first week and late crises if they occur after. Whilst early crises are usually due to metabolic or cytotoxic factors, the late crises occur in true vascular epilepsy. When these patients are assessed it is also important to consider increased hospital mortality in those with early crises and possible deterioration of neurological deficit as sequelae following late epileptic crises.