Minor Neurological Complications Research Articles

Clinical Outcomes and Midterm Mortality After Carotid Endarterectomy: A Single Center Study

Background/Aims: This single-center study aimed to investigate the clinical outcomes and midterm mortality in patients who underwent carotid endarterectomy (CEA) for various indications. Methods: The study included 109 patients who underwent CEA at our institution. Demographic characteristics, indications for surgery, operative techniques, and early postoperative complications were recorded. Follow-up data were obtained for a mean period of 23.3 ± 17.2 months, and mortality causes, and neurological outcomes were analysed. Results: The mean age of the patients was 66.53 ± 8.00 years, with 73 men and 36 women. Indications for CEA included transient ischemic attack (TIA) in 21.1% and a history of ischemic stroke in 26.6% of patients. Overall, 86.2% had ipsilateral carotid stenosis of 70% or more. Most patients (89.9%) were operated under general anesthesia, and the conventional carotid endarterectomy technique was most employed (78.0%). The most frequent reconstruction method for the longitudinal carotid arteriotomy was Dacron patch plasty (56.0%). Early follow-up revealed low hospital mortality (0.9%) and limited postoperative complications (3.7% TIA, 1.8% major neurological complications, and 1.8% minor neurological complications). During the follow-up period, absolute survival was 87.0%. Conclusions: Our study demonstrates favourable early outcomes and acceptable long-term mortality rates following CEA. However, larger, and multicentre studies are warranted to further validate these results and enhance our understanding of CEA's long-term benefits

Reader Response: One-Stage, Limited-Resection Epilepsy Surgery for Bottom-of-Sulcus Dysplasia

Dr. Macdonald-Laurs et al. reported 38 patients with bottom-of-sulcus dysplasia (BOSD), who underwent a limited corticectomy and whose seizure outcomes indicated minor neurologic complications,1 echoing previous literature.2,3 Although subtle changes can be found from structural MRIs, combined fluorodeoxyglucose (FDG)–positron emission tomography (FDG-PET) and MRI imaging can produce high sensitivity in detecting these small lesions. Because these lesions are well confined, sulcus-centered resections could be considered for better function protection, while also guaranteeing the seizure outcome.4

Neurological Complications of Intrathecal Chemotherapy in Children: Experience in A Tertiary Care Hospital in Bangladesh

Background: Intrathecal (IT) chemotherapeutic agents have a narrow therapeutic index and high potential for toxicity. Though severe side effects are rare, but sometime consequences of IT chemotherapy can be catastrophic.
 Objectives: The objective of the study was to observe the neurological complications of intrathecal chemotherapy administrations in patients getting treatment for childhood malignancy.
 Methods: This prospective study included 33 patients who received IT chemotherapy on 76 occasions from July 2020 to December 2020 at Dr. M R Khan Shishu Hospital and ICH. We documented all the neurological complications within two weeks of IT chemotherapy. We defined minor neurological complications as headache, backache, fever, nausea, or vomiting. Major neurological complications were defined as nuchal rigidity, paresthesia, paralysis, or chemical arachnoiditis. All the cases were managed according to the internationally standard protocol.
 Results: Among the patients who received IT chemotherapy 64% were male and 36% were female. The mean age of child was 7 years. The most common diagnosis was BCP (B cell precursor) ALL (75.8%), followed by T-cell ALL (15.1%), APML (Acute promyelocytic leukemia) (6.1%), and B lymphoblastic Lymphoma (3%). Therapy consisted of methotrexate alone in 73 (96.1%) occasions, and cytarabine alone in 3(3.9%) occasions. Minor events occurred in 17(22.4%) occasions but no patient developed major events after administration of IT chemotherapy. Among the side effects a total of 5 (6.6%) occasions children developed nausea, 4 (5.3%) had back pain, 3 (3.9%) had headache, 2 had (2.6%) vomiting, 2 (2.6%) had dizziness and 1(1.3%) developed fever after IT chemotherapy administration. No patient developed major neurological events like neck rigidity, paralysis and chemical arachnoiditis. About 77.6% occasions, children did not develop any side effects after IT chemotherapy administration.
 Conclusion: No major toxic neurological events occurred but only minor neurological complications developed after IT chemotherapy administration. It is important for clinicians to be aware of the adverse events and consider them when treating patients with IT chemotherapy.
 DS (Child) H J 2021; 37(1): 15-20

Reader Response: One-Stage, Limited-Resection Epilepsy Surgery for Bottom-of-Sulcus Dysplasia.

Dr. Macdonald-Laurs et al. reported 38 patients with bottom-of-sulcus dysplasia (BOSD), who underwent a limited corticectomy and whose seizure outcomes indicated minor neurologic complications,1 echoing previous literature.2,3 Although subtle changes can be found from structural MRIs, combined fluorodeoxyglucose (FDG)-positron emission tomography (FDG-PET) and MRI imaging can produce high sensitivity in detecting these small lesions. Because these lesions are well confined, sulcus-centered resections could be considered for better function protection, while also guaranteeing the seizure outcome.4

Operative variations in temporal lobe epilepsy surgery and seizure and memory outcome in 226 patients suffering from hippocampal sclerosis

ABSTRACT Objective: The aim of this retrospective cohort study was to assess seizure and memory outcomes following temporal lobe surgery in patients suffering from medically refractory temporal lobe epilepsy (TLE) and hippocampal sclerosis (HS). Methods: A retrospective monocentric data analysis was performed in consecutive patients who were operated on during 2002–2018. In the first decennium, standard temporal lobe resections (TLR) were predominately performed, and later, antero-temporal lobe resections (ATLR) were mainly performed. Seizure and memory outcomes over time were assessed according to ILAE/Engel classification and the Berlin Amnesia Test (BTA), respectively. Results: Altogether, 231 surgeries were performed on 226 patients (mean age, 40 years [range, 10–68 years]; male: female, 1:1.4; mean seizure duration, 25 years; and mean follow-up duration, 4.75 years [range, 1–16]). Recently, outcomes of 78.3% of the patients in the total cohort were classified as Engel class I, with 54.9% of patients being completely seizure free. The recent cohort of ATLR since 2012 showed significant more completely seizure-free patients than before 2012 (Engel IA 46.6% versus 67.7%, p < 0.0025, χ 2), although the Kaplan Meier analysis of all patients favors TLR for better seizure outcome (61% ATLR vs 73% TLR seizure free after 5 yrs, log rank p < 0.001). Verbal memory improved significantly in non-dominant patients. Minor neurological complications were noted (permanent severe complications, 0.4%; temporary severe complications, 4.8%). Conclusion: Significant improvements in seizure and memory outcomes were observed over time, with surgical technique and seizure duration as important prognostic factors. Early admittance for surgery may favor an excellent seizure outcome in patients undergoing temporal lobe resection for HS.

Arteriotomy for Carotid Endarterectomy, from Common to Interna or Externa?

Objectives: In this study, we described and compared a modified carotid endarterectomy surgical technique. Our comparison was between arteriotomy incision from common to interna and from common to externa.&#x0D; Methods: This study included 73 isolated carotid anrterctomy operations from two different centers. We performed external incision in 61 cases (Group A) and internal incision in 12 cases (Group B). We also elaborated perioperative data and surgical results between Groups. All cases were performed under general anaesthesia.&#x0D; Results: 2 patients in Group A and 2 patients in Group B died at the early postoperative period due to severe neurological deteriorations in 3 and myocardial infarction in 1 case. All cases were solely operated for carotid artery stenosis. None of these patients were presenting contrlaterally serious carotid artery lesions. 4 patients from Group A and 3 patients from Group B were receiving haemodialysis, perioperatively. Trancient minor neurological complications such as lingual deviation and/or facial asymmetry which were associated with N.Hypoglossus injuries, was observed in 8 cases and 2 cases in Group A and Group B, respectively. Patchplasty was necessary in 5 from Group A. No patchplasty was applied in Group B. We tried to avoid carotid shunt from common to interna in all standart procedures. However, carotid shunt was mandatory in 4 patients and in 1 patient from Group A and B.&#x0D; Conclusion: Our modified carotid incision from common to externa is almost always suitable for internal plaque removal. Thus, an incision to interna can be avoided which prevents internal artery narrowing, endothelial disruption and/or occlusion prone deterioration and internal artery intraoperative dissection risks. Therefore, we believe that an incision from common to external carotid artery is the first choice surgical approach for carotid endarterectomy.&#x0D;

Arthroscopic capsular release and continuous upper arm brachial block in frozen shoulder – A midterm outcome analysis

ObjectiveThis prospective study aims to evaluate the efficacy of Continuous upper arm brachial block (modified interscalene block) with an arthroscopic capsular release in the outcome of resistant frozen shoulder cases. MethodsWe studied 123 patients who underwent arthroscopic capsular release and subacromial decompression for resistant frozen shoulder cases between June 2016 and July 2019. Postoperative analgesia was provided with Continuous upper arm brachial block and ambulatory patient-controlled analgesia pump for 2–3 weeks. The patients were started on regular physiotherapy on the first postoperative day. All the patients were followed up at 3rd week, 6th week, 3rdmonth, 6th month, 1st year, and 2nd year with VAS and Constant-Murley scores. ResultsAt a mean follow-up period of 18 months, there was a statistically significant improvement in the range of motion, VAS scores, and Constant-Murley scores postoperatively (p < .01). None of the cases required postoperative opioid administration for pain control. Minor neurological complications like recurrent laryngeal nerve palsy and Horner's syndrome were seen in few cases that resolved with titration of the drug dose. ConclusionOur study verifies the use of continuous upper arm brachial block (CUABB) with a portable infusion pump for 2–3 weeks in arthroscopic capsular release for resistant frozen shoulder cases. It significantly reduced postoperative pain in the initial two weeks that aided with early recovery of the shoulder movements and functions without an increased incidence of acute or chronic neurologic complications.

Abstract WP6: Safety of Acute Carotid Stenting Treatment in Acute Symptomatic Patients

Carotid stenting (CAS) has been shown to be equivalent to carotid endarterectomy in symptomatic patients; however its optimal timing remains unclear. In this study, we aim to evaluate the safety of CAS when performed within the first 48 hours of symptom onset. We performed a retrospective analysis of a prospectively collected database of consecutive CAS patients admitted to our comprehensive stroke center with TIA/stroke and ipsilateral symptomatic carotid stenosis &gt;50% from 2014 to 2019. Medical records were retrospectively reviewed for demographic, clinical and procedural data and outcomes. Acute and delayed treatment were defined as ≤48 and &gt;48 hours from last known well (LKW) respectively. The primary endpoint was procedure-related major complications (stroke with NIHSS increase of ≥4, myocardial infarction, parenchymal hemorrhage type 2 or death) ≤30 days after CAS. Secondary endpoints were procedure-related minor neurological (stroke with NIHSS increase of &lt;4 and reperfusion injury) and non-neurological (groin puncture hematoma, acute anemia and arrhythmia) complications. Functional outcome was assessed by discharge and 90 days mRS, dichotomized as good (0-2) and bad (3-6). A total of 72 patients were included in the analysis, 36 in each group. There was no difference in age, NIHSS at presentation, gender, incidence of TIA as presentation or percentage of TPA received. The acute group differed significantly from the delayed group in number of thrombectomies (36.1% vs. 5.6%, p=0.001) and median time from LKW to CAS (15.9 hours vs. 88.0 hours, p&lt;0.001). There were significantly more carotid occlusions in the acute group when compared to the delayed group (37.8% vs. 2.2, p&lt;0.0001). Overall, the acute group did not show significant difference from the delayed group in major (2.8% vs. 5.6%, p=1.0), minor neurological (13.9% vs. 2.8%, p=0.09) and minor non-neurological complication rates (13.9% vs. 8.3%, p=0.7). Rates of good outcomes were not significantly different between the two groups at discharge (52.8% vs. 50%) or 90 days (75% vs. 63%). CAS can be performed safely in acute symptomatic carotid stenosis patients within the first 48 hours from symptom onset.

Incidence of Neurological Complications Secondary to Intrathecal Chemotherapy Used As Either Prophylaxis or Treatment of Leptomeningeal Carcinomatosis

Purpose:To examine the incidence and frequency of neurological complications secondary to intrathecal chemotherapy.Introduction:Intrathecal (IT) chemotherapeutic agents have a narrow therapeutic index and high potential for toxicity. Though severe side effects are considered rare, consequences of IT chemotherapy administration can be catastrophic. The most common neurotoxic side effect is chemical arachnoiditis, manifesting typically as headache and/or fever, but more severe symptoms have also been reported including paraplegia, cranial nerve palsies, and seizures. The true incidence of neurological complications is not well quantified, and many cases of toxicity may go unrecognized or unreported. Here we detail neurologic complications of IT chemotherapy in adult patients over a two-year time period at our institution.Patients and Methods:Sixty-three patients received IT chemotherapy between January 2014 and December 2015 at Jackson Memorial Hospital and were included in this analysis. We cataloged all neurological complications within four days of IT chemotherapy. We defined minor neurological complications as headache, backache, nuchal rigidity, fever, nausea, or vomiting. Major neurological complications were defined as paresthesia, cranial nerve palsy, paralysis, or asthenia. For each administration of IT chemotherapy we recorded the type and dose of chemotherapy, and results of associated CSF cytology and flow cytometry.Results:Of the 63 patients who received IT chemotherapy treatment, 44 (70%) were male. 20 (32%) patients identified as non-Hispanic, 41 (65%) identified as Hispanic, and 2 (3%) identified as Haitian. The average age at time of treatment was 47.87 years (median: 49, range 22-72). 14 (22%) of patients were HIV positive. At time of IT chemotherapy treatment, 18 (29%) patients had known malignancy present in the CNS.Of the 208 recorded administrations of IT chemotherapy, 197 (95%) included methotrexate and 122 (59%) included cytarabine. The incidence of major neurologic adverse events for all patients receiving IT chemotherapy was 6.8%. The rate of major events was 9.2% for methotrexate with or without hydrocortisone, 9.1% for cytarabine with or without hydrocortisone, and 5.4% for methotrexate and cytarabine combined with or without hydrocortisone. There was no statistically significant difference in rate of major events when the three drug combinations were compared (p=0.562). The rate of minor neurologic events was 38.3% for all cases of patients receiving IT chemotherapy, 42.4% for methotrexate with or without hydrocortisone, 36.4% for cytarabine with or without hydrocortisone, and 35.5% for methotrexate and cytarabine combined with or without hydrocortisone. There was no statistically significant difference in rate of minor events when comparing the three different drug combinations (p=0.604). The adverse events encountered most frequently were headache (15.9%), nausea (13.6%), vomiting (9.6%), back pain (5.8%), and fever (5.8%). The most frequent major adverse events were asthenia (4.3%) and paresthesia (3.8%).Discussion and Conclusion:More than one third of all IT chemotherapy administration events resulted in at least one minor side effect, with roughly 7% resulting in at least one major effect. Headache, nausea, vomiting, back pain, and fever were the most common events encountered-all of which are common sequelae of chemical arachnoiditis.In the cases of major neurologic events we considered potential contamination of the IT methotrexate. Though never confirmed at our institution, Zeng et. al. (J Clin Oncol, 2011) investigated the development of paraplegia amongst patients who received IT methotrexate, discovering trace amounts of vincristine that contaminated intrathecal drugs produced by a manufacturing plant in China causing a large outbreak of severe neurological damage. Murata et al. (J Med Case Rep, 2015) reported a case of demyelination secondary to myelopathy attributed to an IT methotrexate dose. Outbreaks of severe adverse reactions to IT chemotherapy, especially when temporally related, should prompt suspicion of potential chemotherapy contamination.It is important for clinicians to be aware of the adverse events described in this study and consider them seriously when treating patients with IT chemotherapy.* Byrnes D, Dermarkarian C, and Kahn R contributed equally to this work DisclosuresNo relevant conflicts of interest to declare.

Complications of Epilepsy Surgery: A Single Surgeon's Experience from South India

Epilepsy surgery is largely underused in developing counties as a result of many misconceptions. The current study evaluates complications of epilepsy surgery performed by a single surgeon from South India. A retrospective analysis was performed of 697 consecutive patients who underwent epilepsy surgery. Complications were classified as minor and major medical, neurologic, and psychiatric complications. The study population was divided into groups of surgery for temporal lobe epilepsy (TLE), extratemporal lobe epilepsy (ETLE), and other procedures. Incidence of complications was compared in children aged ≤12 years and those aged >12 years. Engel class I and IIA was classified as favorable outcomes. The average age of the cohort was 21.9 ± 11.15 years, with 300 (42.8%) females. The mortality was 0.14%. Medical complications were observed in 2%: minor in 10 patients (1.43%) and major in 4 patients (0.57%). In patients with TLE (n= 467), minor and major neurologic complications were observed in 18 patients (3.9%) and 4 patients (0.9%), respectively, and 14 patients (2.9%) had psychiatric complications. In 175 patients with ETLE, the lesion was in noneloquent area in 108; no patients had major and 20 patients (18.5%) had minor neurologic complications. In the remaining 67 patients with ETLE with eloquent area surgery, 29 patients (43.2%) had neurologic deficits as expected, and 12 (17.9%) had major neurologic deficit. Age did not influence complications. Engel favorable outcome was reported in 400 patients with TLE (85.7%) and 116 patients with ETLE (65.2%). In the current study, risk of mortality was 0.1% and rate of overall major complications was 1.4%. Epilepsy surgery should be increasingly used in developing countries.

Transradial access for visceral endovascular interventions in morbidly obese patients: safety and feasibility.

Transradial access (TRA) has been shown to lower morbidity and bleeding complications compared to transfemoral access in percutaneous coronary interventions. Morbid obesity, commonly defined as a body mass index (BMI) ≥40 kg/m2, has been shown to be a risk factor for access site complications irrespective of access site. This study evaluates the safety and feasibility of performing visceral endovascular interventions in morbidly obese patients via TRA. Procedural details, technical success, and 30-day major and minor access site, bleeding, and neurological adverse events were prospectively recorded in a database of 1057 procedures performed via the radial artery. From this database we identified 22 visceral interventions performed with TRA in 17 morbidly obese patients (age: 53 ± 11 years, female: 71%) with a median BMI of 42.7 kg/m2. Interventions included radio-embolization (n = 7, 31.8%), chemo-embolization (n = 6, 27.3%), uterine fibroid embolization (n = 4, 18.2%), renal embolization (n = 2, 9.1%), hepatic embolization (n = 1, 4.5%), lumbar artery embolization (n = 1, 4.5%), and renal angioplasty (n = 1, 4.5%). The technical success was 100%. There were no major or minor adverse access site, bleeding, or neurological complications at 30 days. This study suggests visceral endovascular interventions performed in morbidly obese patients are safe and feasible.

Endovascular repair for acute traumatic transection of the descending thoracic aorta: experience of a single centre with a 12-years follow up.

BackgroundMost blunt aortic injuries occur in the proximal proximal descending aorta causing acute transection of this vessel. Generally, surgical repair of the ruptured segment of aorta is associated with high rates of morbidity and mortality and in this view endovascular treatment seems to be a valid and safer alternative. Aim of this article is to review our experience with endovascular approach for the treatment of acute traumatic rupture of descending thoracic aorta.MethodsFrom April 2002 to November 2014, 11 patients (9 males and 2 females) were referred to our Department with a diagnosis of acute transection of thoracic aorta. Following preoperative Computed Tomography (CT) evaluation, thoracic endovascular aortic repair (TEVAR) with left subclavian artery coverage was performed. Follow-up consisted clinical and instrumental (CT, Duplex ultrasound) controls at discharge, 1, 3 and 6 months and yearly thereafter.ResultsAt 12-year follow up, the overall survival for the entire patients cohort was 100 %, no major or minor neurological complications and no episode of left arm claudication occurred. Cardiovascular, respiratory and bleeding complications, in the early period, was represented by minor, non fatal events. No stent graft failure, collapse, leak or distal migration were detected at CT scan during the entire follow up period.ConclusionsAccording to our experience, despite the small number of patient population, TEVAR procedure with with left subclavian artery coverage, performed in emergency settings, seems to provide excellent long term results.Trials registrationThe protocol was registered at a public trials registry, www.clinicaltrials.gov (trial identifier NCT02376998).

Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery.

OBJECT Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.

Complication analysis in nitinol stent-assisted embolization of 486 intracranial aneurysms.

Stent-assisted embolization (SAE) has broadened the scope of endovascular cerebral aneurysm treatment. The risks associated with stent selection and configuration are poorly defined. In this study, the authors aimed to characterize the risk factors that contribute to complications in SAE of intracranial aneurysms. Over a 10-year period, a single surgeon treated 486 aneurysms with SAE in which open-cell Neuroform or closed-cell Enterprise stents were used. Single stents were used in 386 cases, overlapping stents were deployed in 80 cases, and Y-configuration stents were used in the remaining 20 cases. All neurological complications, which included transient deficits, were analyzed; disabling strokes and death were considered major complications. The chi-square test and multivariate logistic regression were used to evaluate the influence of aneurysm size and morphology, aneurysm location, stent selection, and stent configuration on complication rates. There were 7 deaths (1.4%), 9 major strokes (1.9%), and 18 minor neurological complications (3.7%). For all complications, multivariate analysis revealed that large aneurysm size (10-25 mm; p = 0.01), giant aneurysm size (> 25 mm; p = 0.04), fusiform aneurysm morphology (p = 0.03), and using a Y-configuration stent (p = 0.048) were independent risk factors. For the major complications, independent risk factors included an aneurysm in the posterior circulation (p = 0.02), using an overlapping stent configuration (p = 0.03), and using a Y-configuration stent (p < 0.01). In this series, SAE for cerebral aneurysm treatment carried an acceptable complication rate. With continued innovations in techniques and devices and with increased experience, the complication rates associated with SAE may be even lower in the future.

Impact of obesity on complications and patient-reported outcomes in adult spinal deformity surgery

Background Adult spinal deformity (ASD) surgery is known for its high complication rate. Obesity is known to be a risk factor for increased complications in orthopedic procedures, but its specific effect in adult spinal deformity (ASD) surgery is not well understood. This study looks at the impact of obesity on complications and HRQOL in adult spinal deformity surgery. Methods Retrospective review of a multicenter prospective database of operative ASD patients. Obesity was defined by a BMI &#8805 + 30. Outcomes included complications (total, minor, major, implant related, radiographic, infection, revision, and neurologic injury), blood loss (EBL), operative time, length of stay (LOS), and patient reported questionnaires (ODI, SF-36, SRS). The impact of obesity was studied using multivariate Poisson, linear, or logistic regression modeling. Models accounted for confounders, as determined by univariate analysis and expert opinion. Results In total, 395 patients were identified (284 non-obese, 112 obese), with 2-year follow up on 225 patients. Regression models showed that obesity increased the risk of overall complications (IRR 1.28, P = 0.01), major complications (IRR 1.57, P = 0.005), and wound infection (OR 4.74, P = 0.006). Absolute weight, but not BMI, increased the incidence of implant-related complications (weight – IRR 1.12 per 10 kg increase in weight P = 0.05, BMI P = 0.69) Obesity did not increase the number of minor complications ( P = 0.33), radiographic complications ( P = 0.75), neurologic complications ( P = 0.48) or need for revision surgery ( P = 0.74). Obesity was not significantly associated with OR time ( P = 0.15), LOS ( P = 0.9) or EBL ( P = 0.38). Both groups experienced significant improvement over time, as measured on the ODI ( P = 0.0001), SF-36 ( P = 0.0001), and SRS ( P = 0.0001). However, the overall improvement was less for obese patients (SRS P = 0.02, ODI P = 0.003, SF-36 P = 0.001). They also had a lower rate of improvement over time (SRS P = 0.008, ODI P = 0.0001 SF-36 P = 0.0001). Conclusions This study reveals that obese patients have an increased risk of complications following ASD correction. Despite increased complications, obese patients do benefit from ASD surgery, however their improvement in HRQOL is less than that of non-obese patients.

Percutaneous Suture-Based Closure Device for Management of Inadvertent Subclavian Artery Catheterization

Central venous catheterization is performed to secure pathways for large amounts of saline, drug infusion, parenteral nutrition support, and hemodialysis. Accidental subclavian artery cannulation is a possible complication of central venous catheterization. Here, we report two cases of 8 Fr. chemoports inadvertently inserted in subclavian arteries during internal jugular venous catheterizations. The chemoports were removed successfully, and puncture sites were repaired using suture-based closure devices (Perclose). One patient experienced minor neurological complications after the procedure. With effective management, the patient was treated with no sequelae. To our knowledge, this is the first report of stroke after procedures using suture-based devices. (Korean J Med 2014;87:200-204)

Stereotactic Radiosurgery with Neoadjuvant Embolization of Larger Arteriovenous Malformations: An Institutional Experience

Objective. This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs. Methods. Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011. Results. The median volume of AVM in this series was 28 cm3 and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9–136 months). Overall procedural complications occurred in 14 patients. There were 13 minor neurologic complications and 1 major complication (due to embolization) while four patients had posttreatment hemorrhage. Thirty-eight patients (40%) were cured radiographically. The postradiosurgery actuarial rate of obliteration was 45% at 5 years, 56% at 7 years, and 63% at 10 years. In multivariate analysis, larger AVM size, deep venous drainage, and the increasing number of embolization/SRS sessions were negative predictors of obliteration. The number of embolizations correlated positively with the number of stereotactic radiosurgeries (P < 0.005). Conclusions. Multimodality endovascular and radiosurgical approach is an efficacious treatment strategy for large AVM.

Studies on postoperative neurological complications, particularly cognitive dysfunction

Postoperative respiratory and circulatory complications are increasingly successfully managed by advanced medical technologies. However, prevention of central nervous system (CNS) complications is not as successful. This trend seems to be more apparent in developed countries, where most patients undergoing surgeries are elderly people with coexisting diseases. For example, neuropsychological dysfunction after cardiopulmonary bypass (CPB) has been reported in more than half of patients during the early postoperative period [1]. Many original reports and review articles regarding this topic have been published in this journal. In particular, cognitive dysfunctions following cardiac and orthopedic surgery are often discussed. Cerebral infarction can be fatal or can cause severe disabilities. Hence, this complication is the most serious central neurological complication after surgery. Fortunately, however, the incidence of severe cases is not very high, the overall stroke rate in an analysis of large cohorts reportedly being approximately 1–2 % [1, 2]. However, the incidence of minor neurological complications following major surgeries is quite high, with cognitive dysfunction being far more common than stroke [2]. Although these are categorized as ‘‘clinically minor complications,’’ they are capable of interfering with the life of patients postoperatively. There is wide variation among the reported rate of cognitive dysfunction after major surgery [1, 2]. In the immediate postoperative period, the incidence ranges as high as 80–90 %, which means that almost all patients experience cognitive abnormalities after major surgery. However, at several months after the surgery, the incidence decreases to less than half of the patients, further decreasing to around one-fourth of patients at 1 year after the surgery. Although it may be true that most of the early cognitive loss is transient, multiple longitudinal studies demonstrated that, in some cases, it persists for several years after surgery, especially after cardiac surgery [3]. The incidence of long-lasting neurological symptoms seems not to be negligible. Minor neurological injuries, such as cognitive dysfunctions, do not necessarily increase the number of bedridden patients as seen after stroke. However, the extremely high incidence compared to stroke makes these injuries extremely problematic, in terms of the social impact, such as quality of life of an aged population and economic burden on healthcare resources. Among the various postoperative cognitive dysfunctions, postoperative cognitive decline (POCD) represents trivial cognitive dysfunction [2]. After a surgical procedure, patients frequently complain of memory loss and lack of concentration. Symptoms of such subtle cognitive abnormalities experienced after an operation are described as POCD. Although minor symptoms are not noticeable to other people, the patients themselves can sense the apparent abnormalities. Minor cognitive dysfunction itself is not life threatening, and the subtle differences in cognitive performance are extremely difficult to measure. For this reason, the true prevalence of POCD is uncertain. S. Saito (&) Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan e-mail: shigerus@showa.gunma-u.ac.jp

Complications of epilepsy surgery—A systematic review of focal surgical resections and invasive EEG monitoring

Underutilization of epilepsy surgery remains a major problem and is in part due to physicians' misconceptions about the risks associated with epilepsy surgery. The purpose of this study was to systematically review the literature on complications of focal epilepsy surgery. A literature search was conducted using PubMed and Embase to identify studies examining epilepsy surgery complications. Abstract and full text review, along with data extraction, was done in duplicate. Minor medical and neurologic complications were defined as those that resolved completely within 3 months of surgery, whereas major complications persisted beyond that time frame. Descriptive statistics were used to report complication proportions. Invasive monitoring: Minor complications were reported in 7.7% of patients, whereas major complications were reported in only 0.6% of patients undergoing invasive monitoring. Resective surgery: Minor and major medical complications were reported in 5.1% and 1.5% of patients respectively, most common being cerebrospinal fluid (CSF) leak. Minor neurologic complications occurred in 10.9% of patients and were twice as frequent in children (11.2% vs. 5.5%). Minor visual field defects were most common (12.9%). Major neurologic complications were noted in 4.7% of patients, with the most common being major visual field defects (2.1% overall). Perioperative mortality was uncommon after epilepsy surgery, occurring in only 0.4% of temporal lobe patients (1.2%extratemporal). The majority of complications after epilepsy surgery are minor or temporary as they tend to resolve completely. Major permanent neurologic complications remain uncommon. Mortality as a result of epilepsy surgery in the modern era is rare.

Intracranial Aneurysms: Midterm Outcome of Pipeline Embolization Device—A Prospective Study in 143 Patients with 178 Aneurysms

To evaluate the midterm clinical and angiographic outcomes after pipeline embolization device (PED) placement for treatment of intracranial aneurysms. This prospective nonrandomized multicenter study was approved by the review boards of all involved centers; informed consent was obtained. Patients (143 patients, 178 aneurysms) with unruptured saccular or fusiform aneurysms or recurrent aneurysms after previous treatment were included and observed angiographically for up to 18 months and clinically for up to 3 years. Study endpoints included complete aneurysm occlusion; neurologic complications within 30 days and up to 3 years; clinical outcome of cranial nerve palsy after PED placement; angiographic evidence of occlusion or stenosis of parent artery and that of occlusion of covered side branches at 6, 12, and 18 months; and clinical and computed tomographic evidence of perforator infarction. There were five (3.5%) cases of periprocedural death or major stroke (modified Rankin Scale [mRS] > 3) (95% confidence interval [CI]: 1.3%, 8.4%), including two posttreatment delayed ruptures, two intracerebral hemorrhages, and one thromboembolism. Five (3.5%) patients had minor neurologic complications within 30 days (mRS = 1) (95% CI: 1.3%, 8.4%), including transient ischemic attack (n = 2), small cerebral infarction (n = 2), and cranial nerve palsy (n = 1). Beyond 30 days, there was one fatal intracerebral hemorrhage and one transient ischemic attack. Ten of 13 patients (95% CI: 46%, 93.8%) completely recovered from symptoms of cranial nerve palsy within a median of 3.5 months. Angiographic results at 18 months revealed a complete aneurysm occlusion rate of 84% (49 of 58; 95% CI: 72.1%, 92.2%), with no cases of parent artery occlusion, parent artery stenosis (<50%) in three patients, and occlusion of a covered side branch in two cases (posterior communicating arteries). Perforator infarction did not occur. PED placement is a reasonably safe and effective treatment for intracranial aneurysms. The treatment is promising for aneurysms of unfavorable morphologic features, such as wide neck, large size, fusiform morphology, incorporation of side branches, and posttreatment recanalization, and should be considered a first choice for treating unruptured aneurysms and recurrent aneurysms after previous treatments. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120422/-/DC1.