Neurosurgical Team Research Articles

EP.TU.281Mind the Gap: Improving the Quality of Neurosurgical Discharge Summaries

Abstract Aims A discharge summary is a permanent record of a patient’s hospital visit and the primary means of handover between care providers. Studies show they often lack precision and omit important information. This may compromise quality and continuity of care yet they are frequently written by the most junior clinicians on a ward with little guidance or formal education on how to write one. The aim of this study was to develop some specific guidelines to improve the quality of discharge summaries in a busy neurosurgical unit. Methods A survey was designed to identify the challenges faced by junior medical staff in writing discharge summaries. The essential components of a good neurosurgical discharge summary were identified by group of senior neurosurgeons. Summaries were retrospectively audited against these components. We then designed a simple visual aid and placed it above computer stations in the junior doctors’ offices. Formal departmental teaching session followed. After three months we re-audited the discharge summaries retrospectively to measure any effect of our intervention. Results Half of the neurosurgical team rated summaries as below expectations. Challenges included poor ward round documentation and a lack of clear expectations regarding structure and essential components. After the intervention, ward round documentation and discharge summary quality improved dramatically. Conclusions Although various recommendations about writing good discharge summaries exist, they are generally vague and not specific to neurosurgical practice. The development of a simple specialty specific discharge summary guide can improve discharge summary quality and should be encouraged in all specialties.

Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience.

Background: The gravity of “second wave” of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the “second wave of COVID-19” at a tertiary health care centre in North India.Methods: This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement.Results: All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted.Conclusion: Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.

Decompressive Hemicraniectomy for Middle Cerebral Artery Stroke: Indications and Perioperative Care.

Decompressive hemicraniectomy (DHC) is a procedure performed in the setting of malignant cerebral edema after a large middle cerebral artery stroke. The decision to proceed with surgical decompression is one that must be made judiciously and rapidly. Although this can be a life-saving surgery, it does not necessarily improve the patient's quality of life. The neurosurgical team must thoroughly discuss the patient's comorbidities, age, dominant versus nondominant hemispheric injury, and neurological expectations, and the procedure itself (ie, risks, benefits, expected postoperative course, goals of care) with the patient and his or her family before DHC. This article briefly reviews the anatomy of the brain and stroke presentation and provides an overview of DHC and the perioperative course. The article concludes with a case study of a patient with a medical history of hypertension and prediabetes who presents to the emergency department after a fall and undergoes an emergent DHC.

Instituting an intrathecal baclofen pump program at an academic institution.

Intrathecal baclofen (ITB) therapy via an implantable infusion system is an effective treatment for severe medical refractory spasticity and can significantly improve quality of life for patients, but it is not without risk. A structured clinical program with regular maintenance and pump failure protocols is essential to ensure patient safety. We outline two distinct institutional experiences of developing a multidisciplinary ITB program, one pediatric and one adult. At our adult institution, management is divided between the physical medicine and rehabilitation (PMR) and neurosurgical teams. PMR responsibilities include patient selection, baclofen injection and tone assessment, pump titration/maintenance, and outpatient follow-up. Neurosurgery responsibilities include inpatient management, intrathecal access, pump insertion and evaluation in cases of suspected pump failure. At our pediatric institution, PMR is responsible for patient selection, tone assessment during baclofen trial (lumbar puncture and baclofen injection is provided by interventional radiology), inpatient management/titration, pump titration/maintenance, evaluation in cases of suspected pump failure, and outpatient follow-up. Neurosurgery responsibilities include patient selection, inpatient management, pump insertion, evaluation and emergent surgical treatment in cases of suspected pump failure. ITB therapy is an effective treatment for severe medical treatment-resistant spasticity that significantly improves quality of life for many patients but is not without risk. The implementation of a structured multidisciplinary program is essential to ensure patient safety and best practice. This article is protected by copyright. All rights reserved.

Comparison of Surgical versus Conservative Management of Borderline Traumatic Extradural Hematomas Without Neurological Deficit

Objective: To compare the outcome of surgical versus conservative treatment of traumatic extradural hematoma in the supratentorial regin.
 Material and Methods: It was a prospective randomized controlled trial conducted in Departments of Neurosurgery, Allied Hospitals, Faisalabad between December 2019 to November, 2020. A total of 100 patients Supratentorial EDH; fulfilling the selection criteria were enrolled. All patients underwent clinical and radiological assessment of EDH volume by the same neurosurgical team. The patients were then divided randomly into two groups by using the lottery methods. Group A patients were conservatively managed. Group B underwent surgery. All surgeries were done by the same surgical team. Glasgow outcome scale was noted in 5 days after admission or surgery in both groups.
 Results: The patients average age was 29.96 years, male to female ratio was 1.7:1. The mean volume of hematoma was 24.68 and 27.56 in group A (conservative group) and Group B (operated group) respectively. The favorable outcome was noted in all the patients and no mortality occurred in any patients.
 Conclusion: Both surgical and conservative treatments are equally effective in terms of a favorable outcome and mortality occurrence in management of traumatic EDH <30ml without neurological deficit. The conservative treatment is safe and cost-effective in borderline patients.

Virtual Reality During Brain Mapping for Awake-Patient Brain Tumor Surgery: Proposed Tasks and Domains to Test

Virtual reality (VR) use in health care has increased over the past few decades, with its utility expanding from a teaching tool to a highly reliable neuro-technology adjunct in multiple fields including neurosurgery. Generally, brain tumor surgery with the patient awake has only been performed for mapping of language and motor areas. With the rise of VR and advancing surgical techniques, neurosurgical teams are developing an increased understanding of patients' anatomo-functional connectivity. Consequently, more specific cognitive tasks are being required for the mapping and preservation of deeper layers of cognition. An extensive literature review was conducted with the inclusion criteria of manuscripts that described the use of VR during awake neurosurgery mapping. We identified 3 recent articles that met our inclusion criteria, yet none of them addressed the specific use of VR for cognition mapping. Consequently, a cognitive task phase was performed to search and craft the tasks and domains that better filled the spotted niche of this need inside the operating room. A proposed protocol was developed with 5 potential uses of VR for brain mapping during awake neurosurgery, each of them with a specific proposed example of use. The authors advocate for the use of a VR protocol as a feasible functional tool in awake-patient brain tumor surgery by using it as a complement during cognitive screening in addition to language testing.

Balancing task sensitivity with reliability for multimodal language assessments.

Intraoperative tasks for awake language mapping are typically selected based on the language tracts that will likely be encountered during tumor resection. However, diminished attention and arousal secondary to perioperative sedatives may reduce a task's usefulness for identifying eloquent cortex. For instance, accuracy in performing select language tasks may be high preoperatively but decline in the operating room. In the present study, the authors sought to identify language tasks that can be performed with high accuracy in both situational contexts so the neurosurgical team can be confident that speech errors committed during awake language mapping result from direct cortical stimulation to eloquent cortex, rather than from poor performance in general. We administered five language tasks to 44 patients: picture naming (PN), text reading (TR), auditory object naming (AN), repetition of 4-syllable words (4SYL), and production of syntactically intact sentences (SYNTAX). Performance was assessed using the 4-point scale of the quick aphasia battery 24 hours preoperatively and intraoperatively. We next determined whether or not accuracy on each task was higher preoperatively than intraoperatively. We also determined whether 1) intraoperative accuracy on a given task predicted intraoperative performance on the other tasks and 2) low preoperative accuracy on a task predicted a decrease in accuracy intraoperatively. Relative to preoperative accuracy, intraoperative accuracy declined on PN (3.90 vs 3.82, p = 0.0001), 4SYL (3.96 vs 3.91, p = 0.0006), and SYNTAX (3.85 vs 3.67, p = 0.0001) but not on TR (3.96 vs 3.94, p = 0.13) or AN (3.70 vs 3.58, p = 0.058). Intraoperative accuracy on PN and AN independently predicted intraoperative accuracy on the remaining language tasks (p < 0.001 and p < 0.01, respectively). Finally, low preoperative accuracy on SYNTAX predicted a decrease in accuracy on this task intraoperatively (R2 = 0.36, p = 0.00002). While TR lacks sensitivity in identifying language deficits at baseline, accuracy on TR is stable across testing settings. Baseline accuracy on the other four of our five language tasks was not predictive of intraoperative performance, signifying the need to repeat language tests prior to stimulation mapping to confirm reliability.

A Study on Maternal and Perinatal Outcome in Pregnant Women Presenting with First Trimester Vaginal Bleeding and Ultrasonographic Evaluation

This study is an analysis of five cases of orbital trauma causing proptosis, paralysis of extraocular muscles with or without associated visual failure. All the cases were treated by a ENT and Neurosurgical team. Either a frontal craniotomy or a lateral orbitotomy was performed. Plain X-rays of the skull and Computerised Tomography (C.T. Scanning) were the main investigations. Results were encouraging both functionally and cosmetically. Early diagnosis and an aggressive approach to orbital decompression can achieve good results

Anatomical Basis of the Zygomatic-Transmandibular Approach: Operative Video.

Tumor growth in infratemporal fossa (ITF) and parapharyngeal space (PPS) is generally slow and generates very few clinical manifestations, so it is not uncommon for tumors to reach large dimensions at the time of diagnosis, making necessary to perform ample approaches. In zygomatic-transmandibular approach (ZTMA), the access of the ITF and PPS is obtained by a combination of a pterional craniotomy plus a zygomatic-mandibular osteotomy. Tumor excision is achieved by its initial dissection from all of the neurovascular structures of the middle fossa by the neurosurgical team and the final resection by the head and neck team from below. In the first part of this video, we present a brief anatomical–surgical description of the ITF and PPS and in the second part, we show case of a trigeminal schwannoma that could be successfully removed through a ZTMA. Using this approach, an ample and safe exposure of the ITF and PPS is achieved, without affecting the chewing or facial nerve function and with excellent cosmetic results, so it can be considered as a reliable surgical option, particularly in cases of giant tumors that affect these regions ( Figs. 1 and 2 ). The link to the video can be found at: https://youtu.be/oxVFhzT8HsQ .

Rathke’s Cyst and Adrenal Insufficiency: A Rare Case of Hyponatremia

Abstract Background: Hyponatremia is the most common electrolyte abnormality encountered in clinical practice, the diagnosis of which can be challenging. A holistic approach with appropriate investigations is imperative to its diagnosis and management. We report this peculiar case of a patient with hypopituitarism secondary to Rathke’s cyst resulting in secondary Adrenal Insufficiency, thus causing Hyponatremia. Case Details: A 32 year male was admitted to hospital with an intractable headache and deterioration in his general wellbeing. His admission parameters revealed a GCS of 15 with normal observations. He had no evidence of meningism and examination of all other systems was unremarkable. He was not on any regular medications and there was no history of trauma. Bloods revealed a Sodium of 122mmol/l, the rest being normal. Investigations including a CT brain, CXR, paired serum &amp; urine osmolality, urinary sodium, Thyroid functions and a 9am cortisol were conducted. Radiological imaging was unremarkable. Subsequently, he was fluid restricted due to a euvolemic fluid status. Serum osmolality was 246 mmol/kg (275-295 mmol/kg), Urine osmolality 847 mmol/kg, urine sodium 85 mmol/l and a 9 am serum cortisol of 29 nmol/L, in keeping with Adrenal Insufficiency. A further decline in his Sodium to 116 mmol/L resulted in Hyponatremic Encephalopathy. In view of impending Adrenal crisis, IV hydrocortisone was commenced in conjunction with hypertonic Saline. This was followed by strict monitoring with cautious correction. An anterior Pituitary profile, serum testosterone and Prolactin were requested. Serum Testosterone levels were 0.4nmol/L (10.0-36nmol/L), FSH- 2.5 IU/L (1.0-11.0 IU/L) and LH- 1.9 IU/L (1.5-9.3 IU/L). Serum prolactin was 85mU/L (45-375 mU/L), TSH- 0.59 mU/L (0.30-6.00 mU/L), Free T4- 13.0 pmol/L (10.4-24.5 pmol/L), IGF1-135 ug/L (60-197 ug/L). This was suggestive of partial hypopituitarism. An MRI Pituitary revealed appearances in keeping with a Rathke’s cyst occupying the pituitary fossa without compromise of the Optic Chiasma. Once stable, he was safely discharged with follow-up appointments planned with the Endocrine and Neurosurgical teams. Discussion: Rathke cleft cysts are non-neoplastic cysts arising from the embryological remnants of Rathke’s pouch in the pituitary gland. Hormonal and visual manifestations can occur if these cysts enlarge and interfere with the Pituitary production and optic chiasma. A proposed mechanism causing Hyponatremia in the context of Cortisol deficiency is increased hypothalamic secretion of Corticotropin releasing hormone (CRH), a Vasopressin secretagogue. Cortisol feeds back negatively on CRH, which is removed with adrenal insufficiency. Hyponatremia is thus often seen in patients with adrenal insufficiency, caused by an inappropriate increase in vasopressin due to cortisol deficiency and inability to excrete free water.

Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons

Study designObservational retrospective survey-based study. IntroductionIntracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery. MethodologyA 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here. ResultsTwenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones. ConclusionDemography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.

3D Printing of Rapid, Low-Cost and Patient-Specific Models of Brain Vasculature for Use in Preoperative Planning in Clipping of Intracranial Aneurysms.

We developed a practical and cost-effective method of production of a 3D-printed model of the arterial Circle of Willis of patients treated because of an intracranial aneurysm. We present and explain the steps necessary to produce a 3D model from medical image data, and express the significant value such models have in patient-specific pre-operative planning as well as education. A Digital Imaging and Communications in Medicine (DICOM) viewer is used to create 3D visualization from a patient’s Computed Tomography Angiography (CTA) images. After generating the reconstruction, we manually remove the anatomical components that we wish to exclude from the print by utilizing tools provided with the imaging software. We then export this 3D reconstructions file into a Standard Triangulation Language (STL) file which is then run through a “Slicer” software to generate a G-code file for the printer. After the print is complete, the supports created during the printing process are removed manually. The 3D-printed models we created were of good accuracy and scale. The median production time used for the models described in this manuscript was 4.4 h (range: 3.9–4.5 h). Models were evaluated by neurosurgical teams at local hospital for quality and practicality for use in urgent and non-urgent care. We hope we have provided readers adequate insight into the equipment and software they would require to quickly produce their own accurate and cost-effective 3D models from CT angiography images. It has become quite clear to us that the cost-benefit ratio in the production of such a simplified model is worthwhile.

Management of an open nasofrontal encephalocele during the first day of life.

Nasofrontal encephaloceles are extremely rare craniofacial defects that present with herniation of cerebral tissue through the junction of the frontal and nasal bones. They often have a cutaneous covering which allows management to be delayed until early infancy, decreasing the risks of anesthesia and acute blood loss. Further bone development also facilitates cranial remodeling. Encephaloceles with a compromised cutaneous envelope pose an imminent threat to life due to the risk of meningitis, necessitating surgical repair in the first days of life. This report presents a patient born with an open nasofrontal encephalocele that underwent encephalocele excision, dural repair, and cranial remodeling on the first day of life. Anterior encephaloceles represent a spectrum of uncommon craniofacial dysraphias. Given the rarity of these diseases, it is important to understand their many presentations and the treatment options that exist for each. When the cutaneous covering of the encephalocele is compromised, surgical correction must be undertaken urgently to mitigate the mortality associated with neonatal meningitis. This represents the first report of an open nasofrontal encephalocele managed in the first day of life. A multidisciplinary surgical approach involving the neurosurgical and craniofacial surgical teams is paramount to the treatment and survival of such complicated patients.

Post Traumatic Orbital Decompression: Our Experience

This study is an analysis of five cases of orbital trauma causing proptosis, paralysis of extraocular muscleswith or without associated visual failure. All the cases were treated by a ENT and Neurosurgical team. Eithera frontal craniotomy or a lateral orbitotomy was performed. Plain X-rays of the skull and ComputerisedTomography (C.T. Scanning) were the main investigations. Results were encouraging both functionally andcosmetically. Early diagnosis and an aggressive approach to orbital decompression can achieve good results.

Endoscopic Endonasal Approach in Clival Chordoma Surgery: Case Series.

Chordomas are rare and slow-growing locally destructive bone tumors that can develop in the craniospinal axis. It is commonly found in the sacrococcygeal region whereas only 25-35% are found in the clival region. Headache with neurological deficits are the most common clinical presentations. Complete surgical resection either via open or endoscopic endonasal approaches are the main mode of treatment. Here, we report a series of 5 cases of clival chordomas which was managed via endoscopic endonasal approaches in our center. A retrospective analysis of patients who had undergone endoscopic endonasal resection of clival chordoma in Sarawak General Hospital from 2014 to 2018. A total of 5 cases were operated on endoscopically via a combine effort of both the otorhinolaryngology team and the neurosurgical team during the study period from year 2013 to 2018. From our patient, 2 were female and 3 were male patients. The main clinical presentation was headache, squinting of eye and nasopharyngeal fullness. All our patient had endoscopic endonasal debulking of clival tumor done, with average of hospital stay from 9 - 23days. Pos-operatively, patients were discharged back well. Endoscopic endonasal resection of clival chordomas gives good surgical resection results with low morbidity rates and therefore can be considered as a surgical option in centers where the surgical specialties are available.

Safety and Effectiveness of the Direct Endoscopic Endonasal Approach for Primary Sellar Pathology: A Contemporary Case Series of More Than 400 Patients

The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA. We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December2019. Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy. In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team.

Does communication between neurosurgeons and anesthesiologists improve preoperative efficiency?

BackgroundSuboptimal communication can lead to preventable preoperative delays. In our study, we aimed to identify factors delaying surgery in the immediate preoperative period. Our outcomes of interest were the anesthesia release to incision time (RIT) and preoperative expectations of neurosurgery and anesthesia providers. Additionally, we introduced new communication goals prior to induction, to examine the impact on preoperative efficiency. MethodsThe study is a prospective cohort analysis evaluating communication in the immediate preoperative period. In 42 consecutive cranial neurosurgical cases, a questionnaire was given to neurosurgical and anesthesia providers, and their responses were recorded. Halfway through this study, a formal pre-induction checklist was implemented that included expected duration of surgery, expected blood loss, surgical positioning, and intraoperative medication requirements. ResultsComparing the cohorts before and after implementing the checklist, no difference in release to incision time was observed. However, the difference in estimated procedure time was significantly decreased after implementation of the formal pre-induction checklist. Further, there was a trend towards better agreement in estimated blood loss, although results did not achieve statistical significance. These delays all demonstrated a statistically significant decrease after the new communication goals were executed. ConclusionWhile no statistically significant change in release to incision time was uncovered during our study, there was evidence that communication between teams improved after implementation of the checklist. Additionally, we observed less discrepancy in estimated case length and blood loss, suggesting focused communication goals aligned expectations of the neurosurgical and anesthesia teams.

Intradural Cauda Equina Tumors: Early Surgical Experience of a Small Neurosurgical Team

Background Data: Cauda equina syndrome (CES) is a rare situation and is one of the few surgical emergencies in neurosurgery. While L4-L5 disc is the most common cause of CES, ependymoma and schwannoma are the most common tumors affecting cauda equina. Purpose: To present our experience and outcome of management of cauda equina tumors. Study Design: A retrospective clinical case study. Patients and Methods: We operated upon 22 cases with known cauda equina tumors at our institution in the period between October 2016 and April 2020. All patients were subjected to detailed general, neurological, and radiological evaluation both preoperatively and postoperatively according to our follow-up protocol. Moreover, the modified McCormick scale (MMS) has been used for pre- and postoperative functional evaluation. Patients underwent operation using the posterior midline approach, with neuromonitoring applied in 50% of patients. Results: The mean age was 44 ± 12.5 years. Nine (41%) patients were female and 13 (59%) were male. Ninety-one percent of patients presented with radiculopathy. Fifty percent of cases presented with schwannoma. Growth total tumor resection was achieved in 20 cases (91%). The last follow-up showed marked improvement in radiculopathy, motor power deficit, and MMS compared to preoperative values. Immediate postoperative motor power deterioration was reported in two cases. Recurrence was reported in one case of ependymoma at a two-year follow-up visit that underwent operation with no further recurrence after 1-year follow-up. Conclusion: The data of this study may suggest that most cauda equina tumors are benign and favorable outcome could be achieved in small-sized lesions with a short history and good preoperative clinical status. (2020ESJ220)

Strategies to continue epilepsy surgery during the coronavirus disease (COVID-19) crisis

Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2. COVID-19 was initially detected in Wuhan, China in late 2019, and has rapidly spread worldwide. As the battle against COVID-19 becomes more and more long-term, it has become important to consider how to perform epilepsy surgery in the environment with the COVID-19 crisis. In this review article, we propose strategies for institutions that perform epilepsy surgery. First, we discuss the importance of coordinating neurosurgical team and inter-hospital collaboration as a hospital-based initiative. Next, we describe three surgical activities: preoperative evaluation, perioperative management, and during operation. We also discuss management of outpatients as a postoperative strategy. Finally, we mention the importance of psycho-logical support for medical staff, patients, and caregivers. By utilizing these strategies, we should make the best efforts to provide the necessary surgical treatment to patients with epilepsy, even in the COVID-19 era.

Management of Moderate Blunt Thoracic Aortic Injuries in Patients with Intracranial Hemorrhage

Blunt thoracic aortic injuries (BTAIs) are the second most common cause of death due to blunt-force trauma in the United States. Patients with minimal injuries do not typically require surgical repair, whereas patients with severe injuries are treated emergently. Moderate aortic injuries are repaired in a semielective fashion, but the optimal management of patients with moderate BTAI with associated intracranial hemorrhage (ICH) is unknown. We sought to analyze the management and outcomes of patients presenting with concomitant moderate BTAI and ICH. Consecutive patients who received a thoracic endovascular aortic repair (TEVAR) at our institution for treatment of moderate BTAI between January 2014 and December 2017 were retrospectively reviewed as part of an institutional review board-approved protocol. Patients were classified by our BTAI classification into "minimal", "moderate", or "severe". ICH was identified on computed tomography scan and its severity determined by the neurosurgical team. Outcome measures included surgical timing and surgical outcomes. Fifty-two patients had a moderate BTAI and underwent TEVAR, 20 (38 %) of whom presented with ICH. Median time from admission to surgery was 58.5hr for patients with ICH and 26.5hr for non-ICH patients. Intraoperative heparin was administered in all patients without ICH and in 19 of 20 (95%) patients with ICH after the ICH met criteria for stability. Protamine reversal was utilized in 80% of patients with ICH and 75% of non-ICH patients. No patient developed ischemic stroke or spinal cord ischemia. Worsening ICH was seen in only one patient, who also received heparin infusion for pulmonary embolus 24hr before TEVAR. There were no aortic-related mortalities in either group. Thirty-day all-cause mortality was 5% for patients with ICH and 3% for non-ICH patients. Patients with moderate BTAI and stable ICH are not at increased risk of TEVAR-related complications. Administration of intraoperative heparin during TEVAR appears to be safe and does not worsen ICH.