Rate Of Neurological Deficits Research Articles

Efficacy and Safety of Dual Antiplatelet Therapy with the Routine Use of Prasugrel for Flow Diversion of Cerebral Unruptured Aneurysms

PurposePrasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen.MethodsThis retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded.ResultsDuring the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%.ConclusionsDual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.

Assessment of Post-Operative Outcomes of Surgical Excision of Gliomas of the Eloquent Areas of the Brain under Awake versus General Anaesthesia

Background Surgical excision of eloquent gliomas can be done under general anaesthesia or awake anaesthesia. Surgical excision of eloquent gliomas using awake anaesthesia helps to avoid intra-operative manipulation of the eloquent areas of the brain and thus avoid post-operative neurological deficits. Aim to compare the operative outcomes of eloquent glioma resection performed under general anaesthesia compared to awake anaesthesia to assess the safety and effectiveness of each intervention. Materials and Methods This systematic review and meta-analysis were conducted in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Metaanalysis Of Observational Studies in Epidemiology (MOOSE) statement. PRISMA and MOOSE are reporting checklists for Authors, Editors, and Reviewers of Meta-analyses of interventional and observational studies. According to International committee of medical journal association (ICJME), reviewers reported their findings according to each of the items listed in those checklists (1). Results Seven studies reported the early motor deficit, while the rest of the studies have no data concerning early motor deficit. The overall effect estimates did not favor awake craniotomy over general anesthesia in terms of motor deficit (RR 0.92, 95% CI 0.48– 1.4). The pooled studies showed significant heterogeneity (p = 0.001; I2 =85%. Conclusion The use of awake craniotomy for surgical resection of gliomas of the eloquent areas is largely limited to small retrospective studies. Within these studies, awake craniotomy achieves both an acceptable rate of GTR and a low rate of persistent neurological deficits. The results of this study illustrate the potential feasibility of awake craniotomy for surgical resection of gliomas of the eloquent areas and emphasize the need for future prospective studies to better determine its efficacy and outcome.

Comparison of the outcomes between total arch replacement and nontotal arch replacement in patients with acute type A aortic dissection

ObjectiveTo compare the outcomes between total arch replacement (TAR) and nontotal arch replacement (non-TAR) in patients with acute type A aortic dissection (ATAAD).MethodsBetween 2006 and 2018, 275 ATAAD patients were divided into 2 groups, the TAR group (n = 63) and the non-TAR group (n = 212), and multiple variables were analyzed.ResultsThe TAR patients were older than the non-TAR patients (61.5 ± 11.8 vs. 57.4 ± 14.5 years, p = 0.024). The TAR group had longer operative, cardiopulmonary bypass, aortic clamping, and circulatory arrest times than the non-TAR group (all p < 0.001). The overall hospital mortality rate was 8.7% with no statistically significant difference between the TAR and non-TAR groups (9.5% vs. 8.5%, p = 0.799). There was no significant difference in the incidence of acute kidney injury (AKI), intubation time, incidence of postoperative atrial fibrillation (AF), or reoperation for bleeding or reintervention rates between the TAR and non-TAR groups (68.3% vs. 65.7% (p = 0.912), 44.8% vs. 33.8% (p = 0.127), 30.2% vs. 22.6% (p = 0.222), 9.5% vs. 9.5% (p = 0.189), and 7.9% vs. 7.1% (p = 0.077), respectively). The TAR group had a higher rate of new permanent neurological deficit (PND) than the non-TAR group and longer median length of hospital stay (17.5% vs. 6.1% (p < 0.001) and 9 vs. 12 days (p = 0.049), respectively). TAR (relative risk (RR) 3.66, p = 0.005) and preoperative cardiopulmonary resuscitation (CPR) (RR 6.60, p = 0.019) were risk factors of PND. Survival rate was similar between the two groups.ConclusionThe mortality rates in ATAAD patients with TAR and non-TAR were similar. However, the incidence of new permanent postoperative neurological deficit was significantly higher, and the length of hospital stay was longer in patients with TAR. TAR in ATAAD should be avoided especially in patients who have experienced preoperative CPR to abate risk of PND.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear. To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up. The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death. Early vs delayed or selective coronary angiography and revascularization if indicated. Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year. A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups. This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation. ClinicalTrials.gov Identifier: NCT02750462.

Predictors of postoperative complications and functional outcomes in pediatric patients with surgically treated fourth ventricle tumors.

Tumors of the fourth ventricle are frequently treated pathologies in pediatric neurosurgery. Data regarding predictors for permanent neurological deficits, long-term functional outcomes, cerebellar mutism (CM), the extent of resection (EOR), and oncological outcomes are scarce. We attempt to contribute to this topic with an analysis of our institutional cohort. A retrospective single-center study of patients aged ≤ 19years who underwent primary surgical resection of a fourth ventricular tumor over a 15-year period (2006-2021). Predictors analyzed included age, gender, surgical approach, anatomical pattern, tumor grade, EOR, tumor volume, and others as appropriate. One hundred six patients were included (64 males, mean age 7.3years). The rate of permanent neurological deficit was 24.2%; lateral tumor extension (p = 0.036) and tumor volume greater than 38 cm3 (p = 0.020) were significant predictors. The presence of a deficit was the only significant predictor of reduced (less than 90) Lansky score (p = 0.005). CM occurred in 20.8% of patients and was influenced by medulloblastoma histology (p = 0.011), lateral tumor extension (p = 0.017), and male gender (p = 0.021). No significant difference between the transvermian and telovelar approach in the development of CM was detected (p = 0.478). No significant predictor was found for the EOR. EOR was not found to be a significant predictor of overall survival for both low-grade and high-grade tumors; however, gross total resection (GTR) was protective against tumor recurrence compared to near-total or subtotal resection (p < 0.001). In addition, survival was found to be better in older patients (≥ 7.0years, p = 0.019). The overall rate of postoperative complications remains high due to the eloquent localization. Older patients (> 7years) have been found to have better outcomes and prognosis. Achieving GTR whenever feasible and safe has been shown to be critical for tumor recurrence. CM was more common in patients with medulloblastoma and in patients with tumors extending through the foramen of Luschka. The telovelar approach uses a safe and anatomically sparing corridor; however, it has not been associated with a lower incidence of CM and neurological sequelae in our series, showing that each case should be assessed on an individual basis.

Characterization of the influence of spinopelvic parameters on thoracolumbar trauma.

The current Roussouly classification identifies four groups of "normal" sagittal spine morphology, which has greatly expanded the understanding of normal heterogeneity of the spine. While there has been extensive characterization of the influence of spinopelvic parameters on outcomes after degenerative spine surgery, the influence of spinopelvic parameters on thoracolumbar trauma has yet to be described. The goal of this study was to determine if spinopelvic parameters and global spine morphology influence fracture location, fracture morphology, and rate of neurological deficit in the setting of thoracolumbar trauma. Of 2896 patients reviewed in the authors' institutional spine database between January 2014 and April 2020 with an ICD-9/10 diagnosis of thoracolumbar trauma, 514 met the inclusion criteria of acute thoracolumbar fracture on CT and visible femoral heads on sagittal CT. Pelvic incidence (PI) was calculated on sagittal CT. Demographic and clinical data including age, sex, BMI, smoking status, concomitant cervical fracture, mechanism of injury, major fracture location, neurological deficit, AO Spine thoracolumbar injury classification, and management type (operative vs nonoperative) were collected. Patients were stratified into high-PI (≥ 50°) and low-PI (< 50°) groups. Patients with high PI had a lower incidence of fractures in the lower lumbar spine (below L2) compared with patients with low PI (16% vs 8%, p < 0.01). The last lordotic vertebrae were observed between T10 and L4, and of fractures that occurred at these levels, 75% were at the last lordotic vertebrae. Fall from height was the most common cause of neurological deficit, accounting for 47%. Of the patients presenting with a fall from height, AO Spine type B distraction injuries were more common in the high-PI group (41% vs 18%, p = 0.01). Similarly, within the same subgroup, AO Spine type A compression injuries were more common in the low-PI group (73% vs 53%, p = 0.01). Spinopelvic parameters and sagittal balance influence the location and morphology of thoracolumbar fractures. Fractures of the thoracolumbar junction are strongly associated with the inflection point, which is defined by sagittal alignment. While the importance of considering sagittal balance is known for decision-making in degenerative spinal pathology, further studies are required to determine if spinopelvic parameters and sagittal balance should play a role in the decision-making for management of thoracolumbar fractures.

Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis.

Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.

The Association of Lumbar Plexus Lengthening With Neurological Deficit After Adult Spinal Deformity Surgery.

Retrospective cohort study. This study aimed to evaluate the association between nerve lengthening after adult deformity correction and motor deficits dervied from the upper lumbar plexus or femoral nerve. Adult spinal deformity (ASD) surgery is associated with high rates of neurological deficits. Certain postoperative deficits may be related to lengthening of the upper lumbar plexus (ULP) and/or femoral nerve (FN) after correction of lumbar deformity. Patients with ASD who underwent posterior-only corrective surgery from the sacrum to L3 or above were included. The length of each lumbar nerve root was calculated geometrically using the distance from the foramen to the midpoint between the anterosuperior iliac crest and pubic symphysis on AP and lateral radiographs. The mean lengths of the L1 to 3 and L2 to 4 nerve roots were used to define the lengths of the ULP and FN, respectively. Preoperative to postoperative changes in nerve length were calculated. Neurological examination was performed at discharge. Proximal weakness (PW) was defined as the presence of weakness compared with baseline in either hip flexors or knee extensors. Multiple linear regression analysis was used for estimating the postoperative lengthening according to the magnitude of preoperative curvature and postoperative correction angles. A total of 202 sides were analyzed in 101 patients, and PW was present on 15 (7.4%) sides in 10 patients. Excluding the 10 cases with three-column osteotomies, those with PW had a significantly higher rate of pure sagittal deformity ( P <.001) and greater nerve lengthening than those without PW (ULP 24 vs. 15mm, P =0.02; FN 18 vs. 11mm, P =0.05). No patient had advanced imaging showing neural compression, and complete recovery of PW occurred in eight patients at one-year follow-up. After ASD surgery, lengthening of the ULP was associated with PW. In preoperative planning, surgeons must consider how the type of correction may influence the risk for nerve lengthening, which may contribute to postoperative neurological deficit.

Does Low-Grade Versus High-Grade Bilsky Score Influence Local Recurrence and Overall Survival in Metastatic Spine Tumor Surgery?

Spinal cord compression caused by spinal tumors is measured using the epidural spinal cord compression scale, also known as the Bilsky score. Whether Bilsky score predicts short-/long-term outcomes remains unknown. The objectives were to determine the correlation of Bilsky score 0-1 vs 2-3 with regards to (1) preoperative presentation, (2) perioperative variables, and (3) long-term outcomes. A single-center, retrospective evaluation of a cohort of patients undergoing metastatic spine surgery was performed between 01/2010 and 01/2021. Multivariable logistic/linear/Cox regression were performed controlling for age, body mass index, race, total decompressed levels, tumor size, other organ metastases, and postoperative radiotherapy/chemotherapy. Of 343 patients with extradural spinal metastasis, 92 (26.8%) were Bilsky 0-1 and 251 (73.2%) were Bilsky 2-3. Preoperatively, patients with Bilsky 2-3 lesions were older ( P = .008), presented more with sensory deficits ( P = .029), and had worse preoperative Karnofsky Performance Scale (KPS) ( P = .002). Perioperatively, Bilsky 2-3 patients had more decompressed levels ( P = .005) and transpedicular decompression ( P < .001), with similar operative time ( P = .071) and blood loss ( P = .502). Although not statistically significant, patients with Bilsky 2-3 had more intraoperative neuromonitoring changes ( P = .412). Although rates of complications ( P = .442) and neurological deficit ( P = .852) were similar between groups, patients with Bilsky 2-3 lesions had a longer length of stay ( P = .007) and were discharged home less frequently ( P < .001). No difference was found in 90-day readmissions ( P = .607) and reoperation ( P = .510) Long-term: LR ( P =.100) and time to LR (log-rank; P =0.532) were not significantly different between Bilsky 0-1 and Bilsky 2-3 lesions. However, patients with Bilsky 2-3 lesions had worse postoperative KPS ( P < .001), worse modified McCormick scale score ( P = .003), shorter overall survival (OS) (log-rank; P < .001), and worse survival at 1 year ( P = .012). Bilsky 2-3 lesions were associated with shorter OS on multivariable Cox regression (hazard ratio = 1.78, 95% CI = 1.27-2.49, P < .001), with no significant impact on time to LR (hazard ratio = 0.73, 95% CI = 0.37-1.44, P = .359). Bilsky 2-3 lesions were associated with longer length of stay, more nonhome discharge, worse postoperative KPS/modified McCormick scale score, shorter OS, and reduced survival at 1 year. Higher-grade Bilsky score lesions appear to be at a higher risk for worse outcomes. Efforts should be made to identify metastatic spine patients before they reach the point of severe spinal cord compression..

Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. MethodsA systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. ResultsSix stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. ConclusionsA universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

Postoperative Complications and Neurological Deficits After Petroclival Region Meningioma Resection: A Case Series.

Surgical management of meningiomas involving the petroclival junction remains a challenge because of nearby critical neurovascular structures. To describe surgical approach selection, outcomes, and factors associated with postoperative complications and neurological deficits in a series of patients undergoing resection of petroclival region meningiomas. Retrospective review of patients undergoing symptomatic petroclival region meningioma resection was performed. Logistic regression was performed to identify variables associated with postoperative complications and new neurological deficits. Sixty-five patients underwent 54 one-stage and 11 two-stage resections with median follow-up of 51 months. Most tumors were World Health Organization grade 1 (90.8%), and the median volume was 23.9 cm 3 . Posterior petrosectomy and anterior petrosectomy were performed in 67.1% and 6.6% of operations, respectively. The gross or near total resection rate was 15.4%, and 8 patients (12.3%) progressed on follow-up. The surgical complication rate was 26.2% with no perioperative mortalities. Postoperatively, 45.8% of patients had new, persistent neurological deficits, with cranial nerves VII palsy being most common. On multivariate analysis, higher body mass index (odds ratio [OR]: 1.1, P = .04) was associated with risk of surgical complications. Longer operative time (OR: 1.4, P = .004) and staged procedures (OR: 4.9, P = .04) were associated with risk of new neurological deficit on follow-up, likely reflecting more challenging tumors. Comparing early vs later career surgeries performed by the senior author, rates of severe complications and neurological deficits decreased 23.1% and 22.3%, respectively. Petroclival region meningiomas remain surgically challenging, but improved outcomes are seen with surgeon experience. These data help inform patients on perioperative morbidity risk and provide a guide for surgical approach selection.

Spinal fractures in fused spines: nonoperative treatment is a reliable alternative.

Spinal fractures in fused spines such as in ankylosing spondylitis or DISH are typically of type B or C fractures where operative treatment is recommended. The mortality rate in non-operatively treated patients is reported to be 51%. The purpose of this study was to investigate the mortality rate, complication rate and demographics of patients following non-operatively treatment in fused spine injuries. Between 2019 and 2021, a retrospective study was conducted including all patients who presented to our trauma center with a spinal fracture of a fused spine. Radiology and patient charts were analyzed for fracture pattern, complications, neurological deficit, comorbidities, and mortality rate. A total of 49 patients were found at a mean age was 79.8 ± 10.9years and primarily males were affected in 65.3%. All fractures were of type B and the thoracic spine was involved in 85.7%. The mean follow-up was 6.3 ± 8.2months and fusion was obtained in all patients. No neurological deficit was observed in any. A total of 13 patients died at a mean age of 86.5 ± 10.0years after 157.1 ± 158.1days. 6 patients (10.2%) deceased within the first 6weeks at a mean age of 91.8 ± 3.8years. One patient each suffered from heart failure, an acute delirium, end stage colon cancer and subdural hemorrhage. This study shows that the mortality rate in the first 6weeks following a fracture in a fused spine is 10.2% for patients above the age of 90years. Therefore, non-operative treatment should be taken into consideration as the mortality rate in other studies may be overestimated. III, retrospective study.

Complications of Cerebral Spinal Fluid Drainage in Thoracoabdominal Aortic Procedures

Spinal cord ischemia is a devastating complication of thoracoabdominal aortic procedures. Prophylactic cerebral spinal fluid (CSF) drainage has been shown to reduce the rates of postoperative neurologic deficit. Recent articles have cited a high rate of complications secondary to CSF drain placement, ranging from 7.6% to 9%, with the most worrisome being intracranial hemorrhage (ICH) and have concluded that the risks of drain use may outweigh the benefits. A single-center retrospective cohort study was conducted to investigate our rates of CSF drain-related complications. Patients were included if they underwent a thoracic or thoracoabdominal aortic procedure and had a CSF drain placed in the perioperative period. Patients with pre-existing neurologic deficits or who presented with aortic rupture were excluded. Major complications were defined as permanent paraplegia, ICH, epidural hematoma or abscess, meningitis, or catheter retention requiring a reoperation. Minor complications that were tracked included transient parasthesia, CSF leak, post-dural puncture headache, asymptomatic blood in the CSF, drain failure, and catheter retention not requiring a reoperation. There were 129 patients in the 15-year period who received a CSF drain for spinal cord protection (Table I). Of these, 122 patients (94.6%) had prophylactic CSF drains, 4 had drains placed postoperatively, and 3 patients had both preoperative and postoperative drains. The most common indication for surgery was thoracoabdominal aortic aneurysm (n = 57; 44.2%) (Table I), and the majority of cases were performed endovascularly (n = 72; 55.8%). There were five occurrences of permanent paraplegia for a rate of 3.9% (Table II). There were no cases of ICH nor other major complications due to spinal drain placement. The rate of minor complications was 26.4%, with the most common being transient parasthesia (n = 13; 10.1%) (Table II). No association was found between complication rates and either indication for procedure or type of operation. The rate of minor complications in this cohort is comparable to prior literature, but our major complication rates due to spinal drain insertion were found to be lower, with no incidence of ICH. The rate of permanent paraplegia in the cohort was 3.9%, which is similar to previous studies. The lack of spinal drain placement complications may be due to a well-defined spinal drain protocol at our center and the small group of dedicated anesthesiologists working with vascular surgery. Further research is required to determine which patients benefit most from prophylactic CSF drainage.Table IPatient characteristicsFull cohort (N = 129)Basic demographicsAge, mean (SD), years65.7 (12.3)Gender, No. (%) Male73 (56.6) Female56 (43.4)BMI, mean (SD)29.1 (6.4)Comorbidities, No. (%) Hypertension101 (78.3) Dyslipidemia60 (46.5) Coronary artery disease30 (23.3) COPD29 (22.4) Chronic kidney disease27 (20.9) Diabetes mellitus20 (15.5)Smoking history, No. (%) Current smoker44 (34.1) Prior smoker52 (40.3)Previous aortic operation, No. (%)64 (49.6)Aortic characteristics, No. (%) TAAA57 (44.2)Extent I25 (43.8)Extent II5 (8.8)Extent III16 (28.1)Extent IV11 (19.3)Mean size (SD), cm6.3 (1.2) Acute aortic syndrome, No. (%)40 (31.0)Acute dissection18 (45.0)PAU13 (32.5)IMH9 (22.5)Chronic dissection, No. (%)31 (24.0)Other indication, No. (%)1BMI, Body mass index; COPD, chronic obstructive pulmonary disease; IMH, intramural hematoma; PAU, penetrating aortic ulcer; SD, standard deviation; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab Table IIStudy outcomesFull cohort (n = 129)TAAA (n = 57)AAS (n = 40)Chronic dissection (n = 31)Major complications, No. (%)5 (3.9)0 (0)3 (7.5)2 (6.5) Permanent paraplegia5 (3.9)0 (0)3 (7.5)2 (6.5) Epidural hematoma0 (0)0 (0)0 (0)0 (0) Epidural abscess0 (0)0 (0)0 (0)0 (0) ICH0 (0)0 (0)0 (0)0 (0) Meningitis0 (0)0 (0)0 (0)0 (0) Catheter reoperation0 (0)0 (0)0 (0)0 (0)Minor complications, No. (%)34 (26.4)14 (24.6)12 (30.0)8 (25.8) Temporary parasthesia13 (10.1)7 (12.3)4 (10.0)2 (6.5) Asymptomatic bleed8 (6.2)1 (1.8)3 (7.5)4 (12.9) PDPH6 (4.7)3 (5.3)2 (5.0)1 (3.2) Drain failure5 (3.9)2 (3.5)2 (5.0)1 (3.2) CSF leak2 (1.6)1 (1.8)1 (2.5)0 (0) Catheter nonoperative0 (0)0 (0)0 (0)0 (0)AAS, Acute aortic syndrome; CSF, cerebrospinal fluid; ICH, intracranial hemorrhage; PDPH, post-dural puncture headache; TAAA, thoracoabdominal aortic aneurysm. Open table in a new tab

Neurophysiological monitoring during endovascular treatment of brain arteriovenous malformations: A meta-analysis.

Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM. This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling. Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07). Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.

Primary Spinal Infections in Patients With Hematologic Immunocompromising Conditions: A Systematic Literature Review

Primary spinal infections (PSIs) are a group of infectious diseases characterized by inflammation of the end plate-disk unit or its surroundings. PSI is considered more prevalent and aggressive among patients with chronic immunocompromised states. Association of PSIs, immunocompromising cancers, and hemoglobinopathies has not been systematically analyzed. We conducted a systematic review to study characteristics, clinical presentation, and mortality of patients with PSI in the setting of hematologic disease. A systematic literature search in PubMed, Web of Science, and Scopus was conducted in April 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included retrospective case series and individual case reports. On careful review, 28 articles published between 1970 and 2022 were selected. These studies featured 29 patients who met inclusion criteria (mean age 29 years, age range 1.5 to 67 years; 63.3% male). Lumbar infection was the most common location (65.5%), with Salmonella (24.1%) as the main causative microorganism. Neurologic compromise was present in 41% of patients, and surgical intervention occurred in 48.3%. Average antibiotic duration was 13 weeks. The postoperative complication rate was 21.4%, with a mortality of 6.9%. PSI in patients with hematologic disease, while having shorter periods to diagnosis, presents increased rates of neurologic deficit, surgical intervention, and complications.

Clinical and Radiological Correlation of Spinal Tuberculosis

Objective: The aim of this study is to establish a comprehensive understanding of the clinical and radiological features of spinal tuberculosis, and to evaluate their correlation in order to enhance diagnostic accuracy, management strategies, and patient outcomes. Study Design: This was a retrospective, observational, cross-sectional study. Place of Study: The research was conducted at the Department of Neuro-Sugery, Darul -Sehat Hospital and Neurology and Radiology Department of Creek General Hospital, both tertiary care hospital of Karachi. Duration of Study: Data were collected over a period of two years from January 2021 to December 2022. Methodology: A total of 120 patients diagnosed with spinal tuberculosis were included in this retrospective, observational, cross-sectional study.. Demographic data, clinical presentations, laboratory findings, and radiological findings were collected and analyzed. The radiological features were assessed using X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans. Statistical analysis was performed to identify correlations between clinical and radiological findings and their associations with patient outcomes. Results: The mean age of patients was 46.3 years, with a slight male predominance. The most common clinical manifestations were back pain (89.3%), neurological deficits (57.3%), and constitutional symptoms (45.3%). The thoracic spine was predominantly affected (61.3%), followed by the lumbar (28%) and cervical regions (10.7%). Radiological findings demonstrated vertebral destruction (90.7%), disc space narrowing (83.3%), paravertebral abscesses (76%), and epidural involvement (58%). A strong correlation was observed between the severity of clinical manifestations and the extent of radiological abnormalities. Patients with extensive vertebral destruction and spinal cord compression showed significantly higher rates of neurological deficits. Conclusion: This study highlights the crucial role of clinical and radiological correlation in the diagnosis and management of spinal tuberculosis. Early recognition of the disease, prompt initiation of appropriate treatment, and regular monitoring of clinical and radiological progress can significantly improve patient outcomes and reduce long-term complications. Keywords: spinal tuberculosis, clinical features, radiological features, correlation, diagnosis, management, prognosis.

Microsurgery Versus Stereotactic Radiosurgery for Treatment of Patients With Brain Arteriovenous Malformation: A Systematic Review and Meta-Analysis.

Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial. To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs. Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence. Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups. Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients.

Model of small-focal ischemic cerebral infarction as a basis for the development of new methods of stroke therapy

Background. Among the existing experimental models of cerebral stroke in large animals, there is no possibility to create a focal brain infarction of limited volume, which would provide an opportunity to evaluate both the endogenous potential of neuroregeneration and to establish the effectiveness of new drugs on postischemic brain remodeling.&#x0D; Aim. Development of a method for modeling small-focal ischemic infarction of the cerebral cortex in a mini-pig.&#x0D; Material and methods. The study used mature female mini-pigs of the Vietnamese fold-bellied breed. Two-level occlusion of the great vessels was performed by ligation of the right common carotid artery and subsequent cauterization of the distal branches of the middle cerebral artery. In the postoperative period, the survival rate of animals and neurological deficit were assessed. On the 7th day, the animals were taken out of the experiment, the brain was isolated from the cranial box. Macroscopic and microscopic examinations included analysis of the localization and area of cerebral infarction, as well as morphological changes in the infarcted and peri-infarcted areas of the cerebral cortex.&#x0D; Results. With a 100% survival rate of experimental animals on the 3rd day after the operation, a neurological examination revealed violations of skin sensitivity and muscle tone in the hind and fore limbs, which partially recovered a week after the onset of ischemic stroke. Macroscopic examination of the brain on the 7th day after the operation visually revealed a small-focal ischemic cerebral infarction in the parietal lobe of the left hemisphere. Histological analysis of the cerebral cortex revealed a wedge-shaped necrotic focus of ischemic injury. In the peri-infarction region of the brain, reactive tissue changes with preserved nerve cells, mostly without visible damage, were found.&#x0D; Conclusion. The developed two-level method of stroke modeling in a mini pig induces ischemic cerebral infarction of limited volume in the parietal lobe; non-critical histological changes in the peri-infarct area and a slight neurological deficit suggest the possibility of using this model to develop new methods of stroke therapy.

Multiple craniotomies in a single surgery — the resection of scattered brain metastases

Patients with brain metastases (BM), who can benefit from resection of multiple scattered lesions, often will not be offered a procedure involving multiple craniotomies in one session due to the overall poor prognosis. However, carefully selected candidates may well benefit from the resection of multiple lesions using multiple craniotomies through a significantly shortened hospital stay, aggressive decompression, and rapid eligibility for adjuvant therapies. In this retrospective analysis, the records of patients, who were treated for multiple BM using one surgical session involving multiple craniotomies, were reviewed. A group of patients with multiple BM, whose surgery only involved one craniotomy, were assigned to a control group. Clinical and surgical characteristics, preoperative and postoperative Karnofsky Performance Scale (KPS), complication rate, preoperative tumor size, number of lesions, number of craniotomies, skin incisions, and intraoperative repositioning of patients were recorded. Thirty-three patients were included in the multiple-craniotomy group. Thirty patients underwent two craniotomies, while three cases involved three craniotomies. Seven patients (21%) were intraoperatively repositioned from a prone to a supine position, which required an average of 23.3 ± 9.3 min from wound closure to the following skin incision. Thirty-six patients with multiple BM and matching characteristics, who received only one craniotomy for the dominant lesion, served as the control group. No difference was detected in postoperative KPS (p = 0.269), complication rate (p = 0.612), rate of new postoperative neurological deficits (p = 0.278), length of intensive care unit (ICU) (p = 0.991), and hospital stay (p = 0.913). There was a significant difference in average preoperative tumor size (p = 0.002), duration of surgery (p < 0.001), and extent of resection (p = 0.002). In the age of personalized medicine, selected patient may benefit from a single surgery for BM using multiple craniotomies. This study shows no significant increase of the perioperative complication rate for surgeries with multiple craniotomies.

The Impact of Extent of Ablation on Survival of Patients With Newly Diagnosed Glioblastoma Treated With Laser Interstitial Thermal Therapy: A Large Single-Institutional Cohort.

Upfront laser interstitial thermal therapy (LITT) can be used as part of the treatment paradigm in difficult-to-access newly diagnosed glioblastoma multiforme (ndGBM) cases. The extent of ablation, though, is not routinely quantified; thus, its specific effect on patients' oncological outcomes is unclear. To methodically measure the extent of ablation in the cohort of patients with ndGBM and its effect, and other treatment-related parameters, on patients' progression-free survival (PFS) and overall survival (OS). A retrospective study was conducted on 56 isocitrate dehydrogenase 1/2 wild-type patients with ndGBM treated with upfront LITT between 2011 and 2021. Patient data including demographics, oncological course, and LITT-associated parameters were analyzed. Patient median age was 62.3 years (31-84), and the median follow-up duration was 11.4 months. As expected, the subgroup of patients receiving full chemoradiation was found to have the most beneficial PFS and OS (n = 34). Further analysis showed that 10 of them underwent near-total ablation and had a significantly improved PFS (10.3 months) and OS (22.7 months). Notably, 84% excess ablation was detected which was not related to a higher rate of neurological deficits. Tumor volume was also found to influence PFS and OS, but it was not possible to further corroborate this finding because of low numbers. This study presents data analysis of the largest series of ndGBM treated with upfront LITT. Near-total ablation was shown to significantly benefit patients' PFS and OS. Importantly, it was shown to be safe, even in cases of excess ablation and therefore could be considered when using this modality to treat ndGBM.