Intracranial Complications Research Articles

Pott’s Puffy Tumor in Young Age: A Systematic Review and Our Experience

Background: Pott’s Puffy Tumor (PPT) in young-age patients is a rare clinical entity characterized by osteomyelitis of the frontal bone with a subperiosteal abscess collection. Previous reviews primarily consist of small, retrospective case series and anecdotal reports. This study aims to present the largest, most up-to-date systematic review of essential clinical findings, diagnostic modalities, microbiologic considerations, and treatment approaches for managing PPT in pediatric and adolescent populations. Methods: PubMed, Scopus, and Web of Science databases were systematically screened until 3 January 2024. The protocol of this investigation was registered on PROSPERO in January 2024, and the systematic review was performed according to the PRISMA statement. The study included 184 patients from 109 articles and an additional case from the authors’ institution. Results: PPT commonly stems from untreated rhinosinusitis, respectively, acute pansinusitis, frontal acute rhinosinusitis and chronic rhinosinusitis, and direct head trauma. Infections typically involve a polymicrobial anaerobe-predominant microbiome. Computed tomography and magnetic resonance imaging are routinely used for presurgical assessment and posttreatment surveillance. Intracranial complications were significantly associated with the type of surgical treatment (p value < 0.0001). Conclusions: PPT is a significant and relatively morbid disease often under-recognized and misdiagnosed due to its variable clinical presentation. Management includes both antimicrobial therapy and surgical intervention, emphasizing the importance of an interdisciplinary approach.

Drainage of middle cranial fossa epidural abscess through mastoidectomy: Our experience and review of the literature

Background: Otitis media (OM) can uncommonly lead to intracranial complications. Epidural abscesses represent a large proportion of cases; however, literature regarding the optimal surgical management of otogenic epidural abscesses is sparse. Favorably located epidural abscesses may be amenable to drainage through a transmastoid approach because the tegmen mastoideum lies immediately inferior to the middle cranial fossa (MCF). Case Description: We report 3 pediatric patients with OM complicated by epidural abscesses of the MCF. The ages ranged from 3 to 6 years old, with 2 females and 1 male. All 3 patients had acute mastoiditis with an abscess of the MCF ranging from 1.6 cm to 6.3 cm at the largest dimension. All patients underwent canal wall-up mastoidectomy with the evacuation of the MCF abscess through a small window, 0.7 × 0.7 cm or less, created in the tegmen mastoideum. All patients were successfully treated through this approach and had complete resolution of their infection on follow-up imaging. There were no postoperative temporal lobe encephaloceles. Conclusion: This is one of the few descriptions of the treatment of an otogenic epidural abscess of the MCF through a transmastoid approach. Collaboration with neurosurgery is vital because their familiarity with the intracranial space helped to guide the accurate direction of dissection. This highlights the importance of a multidisciplinary approach in the treatment of epidural intracranial abscess of the MCF through this approach. The risk of postoperative temporal lobe encephalocele was minimized due to the small tegmen defect size.

Importance of brain MRI to evaluate immediate intracranial complications after carotid stenting in patients with significant carotid stenosis

Importance of brain MRI to evaluate immediate intracranial complications after carotid stenting in patients with significant carotid stenosis

Cost-effectiveness analysis of transthoracic echocardiographic assessment in patients with ischemic stroke or TIA of undetermined cause

BackgroundThe multicenter ATTEST study recently assessed 1084 patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause and found that routine transthoracic echocardiography (TTE) detects abnormalities with treatment implications (i.e., major cardiac sources of embolism) in only 1 % of patients, of whom most (91 %) also had major electrocardiographic (ECG)-abnormalities. In this study, we performed a cost-effectiveness analysis of different TTE strategies. MethodsWe compared the cost-effectiveness of three strategies of TTE assessment: (1) TTE in all patients; (2) TTE only in patients with major ECG-abnormalities; and (3) TTE not performed. Input data were derived from ATTEST and systematic literature reviews. A Markov model was developed that simulated recurrent ischemic stroke or TIA and intracranial and gastro-intestinal bleeding complications in patients with ischemic stroke or TIA of undetermined cause. Primary outcome was the additional costs per additional quality-adjusted life-year (QALY) from a Dutch societal perspective. ResultsPerforming TTE only in patients with major ECG-abnormalities led to 0.0083 additional QALYs and €108 additional costs per patient as compared with not performing TTE (€12,987/QALY). Performing TTE in all patients resulted in 0.0005 additional QALYs and €422 additional costs per patient as compared with performing TTE only in case of major ECG-abnormalities (€805,336/QALY). ConclusionsIn patients with ischemic stroke or TIA of undetermined cause, a strategy of performing TTE only in patients who also had major ECG-abnormalities resulted in the most favorable ratio of additional costs per additional QALY. This supports performing TTE only in patients, who also have major ECG-abnormalities.

Successful Microsurgical Clipping under Extracorporeal Membrane Oxygenation Treatment for a Poor-Grade Subarachnoid Hemorrhage Patient with Severe Pulmonary Neurogenic Lung

AbstractHemorrhagic strokes are considered as contraindications of extracorporeal membrane oxygenation (ECMO) therapy because of anticoagulant administration and ECMO-associated coagulopathy. We present a rare case of successful microsurgical clipping under ECMO for a poor-grade subarachnoid hemorrhage (SAH) patient with severe neurogenic pulmonary edema (NPE). A 50-year-old man presenting with the sudden loss of consciousness was diagnosed with poor-grade SAH with severe NPE, and was intubated. Because of severe hypoxemia refractory to conventional treatment, venovenous ECMO was used 6 hours after admission. To avoid thrombosis inside the ECMO circuit despite no anticoagulants, a heparin-bonded ECMO was maintained at a comparatively high blood flow rate. Subsequently, the patient underwent a microsurgical clipping under ECMO. Intraoperatively we had difficulty in bleeding control, and therefore the multiple transfusions were necessary to correct anemia and ECMO-associated coagulopathy. The aneurysmal clipping was accomplished without hemorrhagic intracranial complications. After 2 years from onset, his activities of daily life were independent. To our knowledge, this is the first report of successful microsurgical clipping for poor-grade SAH under ECMO without any anticoagulants. The use of a heparin-bonded ECMO tubing, maintenance of a slightly higher ECMO pump speed, and multiple transfusions to correct ECMO-associated coagulopathy could make the micro-neurosurgical procedures under ECMO possible. This report demonstrated the possibility to extend the range of application of microsurgical clipping for poor-grade SAH patients requiring ECMO treatment.

Management of Otogenic Meningitis: A Proposal for Practical Guidelines from a Multicenter Experience with a Systematic Review.

Background: Otogenic meningitis represents the most common and life-threatening complication of infective middle ear diseases. However, no guidelines are available to describe the optimal management strategy and the role of surgical intervention. Methods: A six-year multicenter retrospective study on consecutive patients treated for otogenic meningitis caused by acute otitis and re-exacerbation of chronic otitis at the University Hospital of Verona and Modena was performed, and a systematic review regarding acute otitis media-related meningitis in accordance with the PRISMA 2020 statement was then conducted. Results: From the clinical chart analysis, 16 patients with surgical indications according to our decision-making flow chart were reviewed, with most of them undergoing surgery within 7 days of admission (n = 13, 81%). The systematic review ultimately utilized 24 studies (16 case reports and 8 case series) published between 1990 and 2023, with the overall analysis involving a total of 181 patients. Conclusion: The primary treatment for acute bacterial meningitis relies on antibiotic therapy, with surgical intervention being employed in the event of complications and when the initial treatment is not effective within 48 h. The objective of surgery is to sterilize the tympanic and mastoid cavity, thereby eradicating the suspected infective foci and managing any eventual intracranial complications.

A multicentre observational study of paediatric head and neck abscesses

IntroductionIn winter of 2022/3 paediatric ENT surgeons across the UK observed that the incidence of severe abscesses in the head and neck and associated complications was higher than seen in previous years. We aimed to collate and evaluate data from across the UK to establish if this was a true rise in cases, and to describe the factors associated. MethodsA multicentre retrospective data collection was undertaken from 13 units across the UK. Patients admitted between September 2022–February 2023 with a head and neck abscess including sinogenic, otogenic, deep and superficial neck abscesses were included. Demographic, disease specific, management and outcome data were collected. Hospital episode statistic data were also requested and analysed to allow for comparison with previous 10 years of head and neck abscesses. Results262 patients with abscesses of the head and neck were admitted during the study period, 100 between September and November and 163 between December and February. Mastoid abscesses were the most common abscess across both groups. The rate of group A streptococcus + culture results rose significantly from 12 % in autumn group to 30 % in winter (p = 0.02). The rate of intracranial complications rose from 10 % to 18 % (p = 0.11) and the rate of venous thrombosis rose over the same timeframe from 3 % to 14 % (p = 0.01). DiscussionThis study demonstrated a statistically significant rise in the rate of group A streptococcus associated abscesses when comparing Autumn and Winter 2022/2023. Over the same timeframe a statistically significant rise in the proportion of patients with venous thromboses associated with H&N abscesses was noted. Interestingly, despite perceived national consensus regarding a spike in abscess incidence, the number of abscesses seen in winter 2022/2023 was in keeping with expected rates of paediatric H&N abscesses, based on pre covid year-on-year rise in incidence.

Sigmoid Sinus Thrombosis In A Child With Unsafe Type Of Chronic Otitis Media

Introduction: Sigmoid sinus thrombosis, an uncommon condition, is described as a possible intra-cranial complication of both acute & chronic otitis media in standard texts. However, current medical literature mostly describes this condition in relation to acute otitis media. We are reporting a case of sigmoid sinus thrombosis as a complication of chronic otitis media. Case Report: A 10-year-old male child presented with history of long-standing right sided ear discharge and deafness. His immediate presenting complaints were swelling in the postaural region along with severe ipsilateral headache & fever for the past seven days. On clinical examination, ear findings were suggestive of chronic otitis media with cholesteatoma with mastoiditis. CT scan showed loss of architecture of the mastoid antrum and air cells with destruction of bone of mastoid cortex and complete erosion of sinus plate. MRI with contrast confirmed the presence of sigmoid sinus thrombosis. Patient was initially administered iv antibiotics and then operated. Modified radical mastoidectomy was done along with evacuation of the thrombus from the sigmoid sinus. Patient had a quick and uneventful postoperative recovery. Conclusion: Sigmoid sinus thrombosis, a rare intra-cranial complication of otitis media, can lead to several other complications including death if left untreated. Early detection and management are crucial for favourable outcome.

Application and development of super minimally invasive surgery concept in acoustic neuroma resection

With the development of medicine, surgery has also experienced the development and evolution from traditional surgery to minimally invasive surgery, and then to super minimally invasive surgery (SMIS). Meanwhile, reducing surgical trauma and preserving and reconstructing nerve function have gradually become new goals of modern vestibular schwannoma (VS) resection surgery. The surgery of VS can be divided into hearing-preserving surgery (retrosigmoid approach and middle fossa approach) and non-hearing-preserving surgery (traditional translabyrinthine approach), according to whether the patient has practical hearing before operation. Improving the hearing preservation rate of hearing-preserving surgery and reconstructing the hearing of patients with non-hearing-preserving surgery are major challenges and hotspots. The traditional translabyrinthine approach has the highest proportion in the Department of Otolaryngology-Head and Neck Surgery, with the advantages of high facial nerve preservation rate and few intracranial complications. However, due to the resection of the cochlear nerve and labyrinth, the cochlea develops fibrosis, and patients lose the opportunity to reconstruct hearing through cochlear implantation. The new modified translabyrinthine approach can preserve the cochlear nerve and effectively reduce cochlear fibrosis, providing an opportunity for cochlear implantation to reconstruct the hearing. This is another important breakthrough in vestibular schwannoma surgery.

MR Imaging in Covid-19-Associated Invasive Fungal Sinusitis.

We witnessed a sharp peak in the incidence of invasive fungal sinusitis, particularly mucormycosis, in patients with history of coronavirus disease 2019 (COVID-19) infection in India. Rhino-orbito-cerebral mucormycosis (ROCM) is a fulminant rapidly progressive disease. Early diagnosis significantly improves patient survival and outcomes. Hence, neuroimaging plays a very important role. We studied the magnetic resonance (MR) imaging manifestations of invasive fungal sinusitis and established an imaging protocol, which helps in early diagnosis of the disease per se as well as its complications. We evaluated the differences between COVID-19-associated and non-COVID-19-associated ROCM. We retrospectively analyzed the MR imaging manifestations of 91 histopathologically proven cases of post-COVID-19-invasive fungal sinusitis. We observed stage I disease limited to sinuses in 25.2%, stage II disease with intraorbital spread in 23%, and stage III disease with intracranial spread in 51.6% of our patients. Dural involvement was the commonest and earliest sign of stage III disease. Direct parenchymal invasion from the adjacent paranasal sinuses was the commonest pattern of cerebral involvement, involving basifrontal lobe (14.2%) followed by anteromedial temporal lobe (5.4%). We observed orbital and intracranial complications including subperiosteal orbital abscess (1%), cavernous sinus involvement (29.6%), angioinvasion (15.3%), perineural spread (9.8%), and osteomyelitis of skull base and craniofacial bones (45%). Contrary to non-COVID-19-associated ROCM, we did not observe any case with superior ophthalmic vein/dural venous sinus thrombosis or basilar artery angioinvasion in our study. In our study, stage III disease was most commonly due to direct parenchymal invasion into frontal and temporal lobes from the adjacent frontal and sphenoid sinuses, respectively. The commonest vascular complications in our study were cavernous sinus involvement followed by angioinvasion into the cavernous ICA leading to watershed infarcts.

Ischemic stroke in cancer patients: possibilities of reperfusion therapy in elderly patients

Globally, stroke and malignancies represent a major public health burden. Cancer and stroke are two clinical manifestations that are related: cancer patients have twice the risk of stroke than the general population [1]. Types of cancer most commonly associated with ischemic stroke are lung cancer, pancreatic cancer, breast cancer and prostate cancer [2]. An analysis of patients with ischemic stroke and concomitant cancer who underwent inpatient treatment at the regional vascular center in Botkin Hospital. A total of 199 patients with ischemic stroke and malignancy were analyzed. 68 patients received reperfusion therapy and 131 patients did not receive reperfusion therapy. As a result of the analysis, it was concluded that reperfusion therapy is possible and necessary for patients with malignant tumors. The risk of developing extracranial hemorrhages associated with the oncological process is extremely low, and the development of intracranial hemorrhagic complications does not significantly worsen the outcome of the disease. The severity of stroke in the presence of cancer was for the most part due to the stroke itself, its size and location, and depended less on the stage of cancer.

Haemorrhagic intracranial complications associated with vaccine-induced thrombocytopenia or central venous thrombosis after COVID-19 vaccination: postulated underlying mechanisms with literature and case review.

Despite the unequivocal medical and social advantages of introducing vaccines against the novel coronavirus SARS-CoV-2, there were also some concerns regarding possible post-vaccination adverse events. Most of these are mild. But in rare cases, severe neurological symptoms including ischaemic stroke, intracranial haemorrhage (ICH), cerebral venous and sinus thrombosis (CVT), and thrombosis with thrombocytopenia (TTS) have been observed. Literature data suggests that thrombosis with thrombocytopenia was the major underlying cause of the ICH; dural venous sinuses/cerebral veins were indicated as the primarily affected sites of thrombosis. Our review confirms the previously documented suspicion that CVT and TTS are most likely to occur following vector-type, rather than mRNA, vaccine administration. The postulated mechanism of TTS is similar to heparin-induced thrombocytopenia (HIT) both clinically and serologically. Although ICH and VITT are very rare side effects of the COVID-19 vaccine, for patients with risk factors for thrombosis (e.g. pregnancy), physicians should carefully consider the benefit/risk ratio of vaccination.

Subdural empyema—a rare complication of chronic otitis media: a case report

BackgroundSubdural empyema is an extremely rare and fatal intracranial complication of chronic otitis media. Due to its rarity and vague symptoms, it is often diagnosed late if not completely missed; specially in developing countries where the diagnostic modalities are hardly available or accessible. To the best knowledge of the authors, this is a preliminary reported case of subdural empyema as a complication of chronic otitis media in Eritrea. It aims to provide vital information on the clinical presentation, preferred diagnostic modalities, and the proper management of such cases.Case reportAn 8 years old female patient from the Rashaida ethnic group presented with fever, right ear purulent discharge, right post-auricular swelling, and altered mental status. Prior to her admission, she had history of recurrent purulent discharge from her right ear for almost 2 years, and had been diagnosed with chronic otitis media. Upon admission her GCS was 13/15 which later on deteriorated to be 3/15 on day 3. MRI was done and showed a right fronto-tempo-parietal subdural empyema with mass effect, shifting the midline to the left. She was immediately started on empirical broad-spectrum antibiotics. After the diagnosis was made, craniotomy was done, and 30 ml of pus was removed from the subdural space. Culture and sensitivity of the pus obtained intraoperatively was done but produced no yield. Hence, she was continued on the empirically started antibiotics. The patient’s condition was well improved by post-operative day 4.ConclusionIt is important to have a high index of suspicion of intracranial complications in patients with history of chronic otitis media or other otologic complaints, who present with neurologic manifestations. Subdural empyema still being uncommon even among the intracranial complications of COM, it is often missed. Hence, timely diagnosis with MRI, immediate surgical evacuation of the empyema along with the prolonged administration of broad-spectrum antibiotics is highly recommended.

Intracranial complications secondary to acute bacterial sinusitis requiring neurosurgical intervention before and after the onset of the COVID-19 pandemic.

Intracranial complications of acute bacterial sinusitis are rare pathologies that occur in children, and are associated with significant neurological morbidity and mortality. There is a subjective concern among neurosurgeons that the incidence of this rare disease has increased since the onset of the novel COVID-19 pandemic. The primary objective of this study was to review the presentation and management of patients admitted at the authors' institution with intracranial extension of sinusitis, to better understand the local disease burden relative to the COVID-19 pandemic. This is a single-center retrospective observational cohort study. The patients underwent neurosurgical intervention for intracranial extension of sinusitis between January 1, 2007, and March 1, 2023. The historical cohort was defined as those patients who presented prior to March 2020. Clinical covariates such as surgical and microbiological data were collected and analyzed. A total of 78 patients (55 historical, 23 new) were included; they had a median age of 11.7 years and a male predominance of 69.2%. There was a significant increase in the annual rate of neurosurgical intervention for suppurative intracranial extension of acute bacterial sinusitis after the onset of the COVID-19 pandemic, with an average of 4.2 cases per year prior to March 2020 compared to 7.7 cases per year after that date (p = 0.013). This increase was largely driven by the unprecedented case volume of 13 cases in 2022. Patients in the new cohort were older (p = 0.009) and more likely to have Pott's puffy tumor/frontal bone osteomyelitis (p = 0.003) at the time of presentation than patients in the historical cohort. Patients in the new cohort had lower rates of readmission within 30 days of discharge than those in the historical cohort (p = 0.047). In both cohorts, patients with seizure on presentation were more likely to have neurological sequelae at last follow-up (p = 0.004), which occurred at a median of 2.9 months after discharge. Clinicians encountering pediatric patients presenting with persistent symptoms of acute bacterial sinusitis must have a high index of suspicion for suppurative intracranial extension. Prompt neuroimaging and subsequent neurosurgical intervention are critical to ensure timely diagnosis and treatment. The results in this study show a significant increase in the number of neurosurgical interventions for suppurative intracranial extension of sinusitis per year after the onset of the COVID-19 pandemic. Further research is needed to understand the underlying pathophysiology of this clinical phenomenon.

Neurological Outcomes Following Craniotomy for Extracorporeal Membrane Oxygenation-Associated Intracranial Hemorrhage: Case Series and Literature Review

BackgroundIntracranial hemorrhage (ICH) is a potential complication associated with extracorporeal membrane oxygenation (ECMO), which has been increasingly utilized in recent years. A paucity of data exists describing patient outcomes following invasive neurosurgical interventions in patients receiving ECMO therapy. The purpose of this study was to assess the clinical and functional outcomes in patients who underwent cranial neurosurgery for the management of an ECMO-associated intracranial complication. MethodsThis was a single-institution retrospective review of adult patients who underwent craniotomy or craniectomy after sustaining an intracranial hemorrhagic complication of ECMO therapy from 2008-2023. Anticoagulation status, operative indication, surgical details, post-operative course, and functional outcome were recorded. A systematic review of the prior literature was performed to contextualize our institutional results within previous reports. ResultsFour adult patients were identified at our institution who underwent craniotomy or craniectomy for the neurosurgical management of an ECMO-associated ICH. One patient (25%) ultimately made a satisfactory recovery (mRS 3 at one year). The surviving patient had a notably higher GCS (7T vs 3T), had not received anticoagulation at the time of surgery, and did not experience post-operative re-accumulation or expansion of their hemorrhage, distinguishing factors from the other three included. Review of the existing literature identified 15 adult patients who underwent craniotomy while receiving ECMO therapy, of which four (26.7%) had a long-term favorable neurologic outcome. ConclusionsThe overall prognosis following neurosurgical intervention for the management of ECMO-associated intracranial complications was poor in our case series, which was corroborated by our literature review.

'X' marks the spot! Utilising factor Xa inhibitors to optimise thromboprophylaxis in multiple myeloma.

Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality among multiple myeloma patients. Chang and colleagues' findings indicate that factor Xa inhibitors are as effective as warfarin in preventing VTE without raising the risk of gastrointestinal or intracranial bleeding complications. Commentary on: Chang etal. The comparative efficacy and safety of factor Xa inhibitors and warfarin for primary thromboprophylaxis in multiple myeloma patients undergoing immunomodulatory therapy. Br J Haematol 2024;205:473-477.

Clinical analysis of cases of otogenic sigmoid sinus thrombosis in children

Objective:To analyze the clinical characteristics of middle ear mastoiditis combined with sigmoid sinus thrombophlebitis in children. Methods:Author retrospectively analyzed the clinical data of 6 children with middle ear mastoiditis combined with sigmoid sinus thrombophlebitis who were hospitalized in the Department of Infectious Diseases and Department of Neurology with first diagnosis of fever/headache, and subsequently underwent middle ear mastoidectomy in our department. All patients underwent comprehensive otoscopic, audiologic, imaging, and pathogenetic examinations. Clinical manifestations, pathogenetic features, treatment methods and prognosis were summarized, and the follow-up period was 3-6 months. Results:All 6 cases were first diagnosed with intracranial complications such as fever and headache in the internal medicine department. Within one month, all patients developed ear symptoms including pain, discharge, and hearing loss. Audiologic examination revealed conductive hearing loss in five cases and total deafness in one case. MRI, MRV and MRA examinations suggested that there were 6 cases of middle ear infection combined with thrombophlebitis of the ethmoid sinus, of which 3 cases had thrombus in the ethmoid sinus. 6 cases received surgical treatments: 2 cases of radical mastoidectomy+grommet Insertion, and 4 cases of radical mastoidectomy. Pathogenetic examination identified Streptococcus pneumoniae in three cases, Pseudomonas aeruginosa in one case, Enterobacter cloacae complex in one case, and no pathogens were detected in one case. Postoperative pathology was inflammatory granulation in all 6 cases. Follow-up was 3-6 months with no recurrence of intracranial and middle ear lesions on regular review. Conclusion:Children with recurrent fever, headache, and a recent history of acute and chronic otitis media should be evaluated for the possibility of sigmoid sinus thrombophlebitis, and imaging tests should be performed in a timely manner to clarify the diagnosis. Once diagnosed, surgery to remove the lesions around the ethmoid sinus, smooth drainage combined with antibiotic therapy is the most direct and effective treatment, and anticoagulation therapy is given when necessary. Timely diagnosis, multidisciplinary collaboration, and accurate timing of the management of primary foci and comorbidities are crucial to the treatment of the disease.

An algorithm for the surgical approach to spontaneous temporal bone CSF leak

ObjectiveTo suggest a comprehensive algorithm for the surgical approach for correcting of sources of temporal bone CSF leaks. MethodsA case series for patients operated in a single academic tertiary referral center between 2011 and 4.2022. Included in the study were 46 patients, 5 of whom had a bilateral problem, resulting in 51 pathologic temporal bones. The presentation was an active CSF leak (38 patients) or bacterial otogenic meningitis (8 patients). Follow up ranged from 8 months to 5 years. ResultsOf the 42 ears operated via the default middle fossa approach, 37 were successful (88 %) in controlling CSF leak. None had intracranial complications or sensorineural hearing loss. Location, number and size of the defects, hearing status, associated superior semicircular canal dehiscence, additional intra-temporal or intra-cranial pathologies may indicate a transmastoid approach. Of the six ears that had a canal wall up mastoidectomy as a primary procedure, one required revision due to ongoing CSF leak. Five revision cases and three primary cases were effectively sealed with a subtotal petrosectomy and obliteration. One was lost to follow-up. Hearing was reconstructed with bone-anchored hearing implants in 6 out of these 8 ears. ConclusionsThe middle fossa approach could be used as a default approach for sealing TD. There are a number of indications for transmastoid approaches in both primary and revision cases. Obliteration of the ear was used in all revision cases. The suggested algorithm can help in planning surgery for temporal bone CSF leaks or a history of otogenic meningitis.

Diagnostic role of sonography in early detection and surgical intervention of an epidural abscess: A case report

AbstractIntroductionIntracranial epidural abscesses require swift diagnosis and treatment. While magnetic resonance imaging (MRI) is preferred for its detailed visualisation, it is costly and time‐consuming. Transcranial sonography offers a rapid, portable and cost‐effective alternative for assessing brain lesions.MethodsWe present a case study involving the diagnosis and management of an intracranial epidural abscess in a 25‐year‐old man with a traumatic brain injury who underwent a craniectomy and later developed fever and drowsiness in the intensive care unit.ResultsUsing transcranial point‐of‐care ultrasound, a hypoechoic collection was identified at the surgical site, prompting further imaging with computed tomography (CT) and MRI, which confirmed the diagnosis of an epidural abscess. Prompt surgical intervention led to the resolution of symptoms and a favourable clinical outcome.ConclusionThis case highlights the potential utility of brain sonography as an efficient and cost‐effective initial diagnostic tool for detecting intracranial complications, particularly in postoperative patients with altered sensorium and fever, where timely intervention is crucial.

Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial.

Clinical outcomes in acute ischemic stroke due to medium vessel occlusion (MeVO) are often poor when treated with best medical management. Data from non-randomized studies suggest that endovascular treatment (EVT) may improve outcomes in MeVO stroke, but randomized data on potential benefits and risks are hitherto lacking. Thus, there is insufficient evidence to guide EVT decision-making in MeVO stroke. The primary aim of the ESCAPE-MeVO trial is to demonstrate that acute, rapid EVT in patients with acute ischemic stroke due to MeVO results in better clinical outcomes compared to best medical management. Secondary outcomes are to demonstrate the safety of EVT, its impact on self-reported health-related quality of life, and cost-effectiveness. Based on previously published data, we estimate a sample size of 500 subjects to achieve a power of 85% with a two-sided alpha of 0.05. To account for potential loss to follow-up, 530 subjects will be recruited. ESCAPE-MeVO is a multicenter, prospective, randomized, open-label study with blinded endpoint evaluation (PROBE design), clinicaltrials.gov: NCT05151172. Subjects with acute ischemic stroke due to MeVO meeting the trial eligibility criteria will be allocated in a 1:1 ratio to best medical care plus EVT versus best medical care only. Patients will be screened only at comprehensive stroke centers to determine if they are eligible for the trial, regardless of whether they were previously treated at a primary care center. Key eligibility criteria are (1) acute ischemic stroke due to MeVO that is clinically and technically eligible for EVT, (2) last-known well within the last 12 h, (3) National Institutes of Health Stroke Scale > 5 or 3-5 with disabling deficit, (4) high likelihood of salvageable tissue on non-invasive neuroimaging. The primary outcome is the modified Rankin scale 90 days after randomization (shift analysis), whereby modified Rankin Score 5 and 6 will be collapsed into one category. Secondary outcomes include dichotomizations of the modified Rankin Score at 90 days, 24 h National Institutes of Health Stroke Score, difference between 24 h and baseline National Institutes of Health Stroke Score, mortality at 90 days, health-related quality of life (EQ-5D-5 L), Lawton scale of instrumental activities of daily living score, reperfusion quality (MeVO expanded Thrombolysis in Cerebral Infarction Score) and infarct volume at 24 h, and cost-effectiveness of endovascular recanalization. Safety outcomes include symptomatic and asymptomatic intracranial hemorrhage and procedural complications. The ESCAPE-MeVO trial will demonstrate the effect of endovascular thrombectomy in addition to best medical management vis-à-vis best medical management in patients with acute ischemic stroke due to MeVO and provide data for evidence-based treatment decision-making in acute MeVO stroke. The raw data discussed in this mansucript will be made available by the corresponding author upon reasonable request.