Permanent Morbidity Rate Research Articles

Preemptive strategies and lessons learned from complications encountered with microvascular decompression for hemifacial spasm.

Microvascular decompression (MVD) is the only curative treatment modality for hemifacial spasm (HFS). Although generally considered to be safe, this surgical procedure is surrounded by many risks and possible complications. The authors present the spectrum of complications that they met in their case series, the possible causes, and the strategies recommended to minimize them. The authors reviewed a prospectively maintained database for MVDs performed from 2005 until 2021 and extracted relevant data including patient demographics, offending vessel(s), operative technique, outcome, and different complications. Descriptive statistics with uni- and multivariable analyses for the factors that may influence the seventh, eighth, and lower cranial nerves were performed. Data from 420 patients were obtained. Three hundred seventeen of 344 patients (92.2%) with a minimum follow-up of 12 months had a favorable outcome. The mean follow-up (standard deviation) was 51.3 ± 38.7 months. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Statistical analyses showed that the immediate postoperative disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits. MVD is safe and effective for treating HFS with a low rate of permanent morbidity. Proper patient positioning, sharp arachnoid dissection, and endoscopic visualization under facial and auditory neurophysiological monitoring are the key points to minimize the rate of complications in MVD for HFS.

Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis.

Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.

Complications of planned home births in the Czech Republic.

This study evaluated complications that can occur during planned home births that require transfer to the hospital. These factors were assessed to improve the current status of deliveries performed outside health care facilities in the Czech Republic. This prospective cohort study included data on 105 cases of complicated home births during 2017 to 2021 using an online form accessible to all hospital maternity wards in the Czech Republic. Planned home births were complicated by fetal/neonatal causes, maternal causes, and combined fetomaternal complications in 28 (26.7%), 20 (19%), and 2 (1.9%) cases, respectively. The need for transfer was most often realized after the birth of the fetus (86; 81.9%); however, it was realized during birth in 19 (18.1%) cases. The following complications were noted most often: postpartum hemorrhage (23; 21.9%); neonatal asphyxia (17; 16.2); placental retention (14; 13.3%); birth injury (12; 11.4%); neonatal hypothermia (5; 4.8%); and placental birth (5; 4.8%). Indications for transfer during labor were as follows: labor obstruction (10; 9.5%); fetal hypoxia (5; 4.8%); bleeding during labor (2; 1.9%); preeclampsia (1; 0.9%); and fetal malformation (1; 0.9%). Perinatal death occurred in 8 (7.6%) cases. Permanent neonatal morbidity occurred in 4 (3.8%) cases. Patients with home birth complications were transferred to the hospital most often after the birth of the fetus. The low proportion of transfers during childbirth is caused by the unprofessional management of planned home births, resulting in a high number of perinatal deaths and high rate of permanent neonatal morbidity.

Diversion-p64: results from an international, prospective, multicenter, single-arm post-market study to assess the safety and effectiveness of the p64 flow modulation device

BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years.ObjectiveTo assess the safety and angiographic efficacy of the p64 flow modulation device.MethodsDiversion-p64 is an international, prospective,...

Endovascular treatment of unruptured intracranial aneurysms with flow diverters: A retrospective long-term single center analysis.

The introduction of flow diverters (FDs) in 2007 greatly enhanced the treatment of intracranial aneurysms. Here, we present our long-term clinical experience in treating unruptured intracranial aneurysms with FDs. 107 patients with unruptured aneurysms and treated with an FD between 2010 and 2019 were retrospectively reviewed. Aneurysm occlusion, procedural complications, and clinical outcome were evaluated. Angiographic follow-up was available for 93 patients with a mean long-term follow-up time of 28.4 ± 21.6months. Additional coiling was performed in 15.1% of patients (n = 14). Adequate aneurysm occlusion (Kamran grades 3 and 4) at long-term follow-up was achieved in 94.6% of patients (n = 88). 3.2% (n = 3) required endovascular retreatment since the last follow-up showed a lack of aneurysm occlusion (Kamran grade 0) due to a foreshortening of the FD. Incomplete opening of the FD and parent vessel occlusion was seen in 1.1% (n = 1) and 3.2% (n = 3) of patients, respectively. In-stent stenosis was observed in 57% (n = 53) of cases at short-term follow-up and 22.6% (n = 21) at long-term, which were moderate and asymptomatic overall. In-stent stenosis decreased significantly between short- and long-term follow-ups (31.4 ± 17.0% vs 9.7 ± 13.6%, respectively; p ≤ 0.001). Thromboembolic and hemorrhagic events occurred in 7.5% (n = 7) and 1.1% (n = 1) of patients, respectively. Good clinical outcome (modified Rankin scale: 0-2) was obtained in 97.8% (n = 91) leading to an overall treatment-related morbidity of 2.2% (n = 2). There was no procedural mortality. Our study shows that FD treatment of unruptured intracranial aneurysms is effective and safe with high occlusion rates and low rates of permanent morbidity at long-term follow-up.

Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches.

Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs. Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors. Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80-490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99-2232.24, p = 0.01). One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.

Comaneci plus Balloon-assisted Embolization of Ruptured Wide-necked Cerebral Aneurysms.

Recently, avant-garde combinations of ancillary devices as an adjunct to coil embolization for acutely ruptured and wide-necked cerebral aneurysms have emerged. This study sought to investigate the feasibility, safety and durability of the simultaneous combination of temporary neck-bridging devices plus balloon-assisted coiling(BAC) to treat acutely ruptured and wide-necked cerebral aneurysms. Aretrospective review was performed of patients with ruptured and wide-necked intracranial bifurcation aneurysms treated with temporary stent plus balloon-assisted coiling. Anatomical features, technical details, intraprocedural complications, clinical and angiographic results were reviewed. Preprocedural and follow-up clinical statuses were evaluated using the modified Rankin scale(mRS). A total of 21 patients (mean age 54.5 years, range 37-72 years) were identified. The immediate postprocedural angiography revealed complete aneurysm occlusion in 85.7% (18/21) of the cases. Aperiprocedural complication developed in 9.5% of the cases. There was no mortality in this study. The permanent morbidity rate was 4.7%. Long-term follow-up angiography was performed in 18of 21patients (85.7%) (the mean follow-up period was 21months). The rate of complete aneurysm occlusion at final follow-up was 89.4%. The results of this study confirmed that temporary stent plus balloon-assisted coiling is adurable and relatively safe endovascular technique for the treatment of ruptured wide-necked bifurcation aneurysms located in both the posterior and anterior cerebral circulation.

A Single Flow Re-direction Endoluminal Device for the Treatment of Large and Giant Anterior Circulation Intracranial Aneurysms.

PurposeThe purpose of this study was to report the author’s experiences in treating large (10–25 mm) and giant (>25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications.Materials and MethodsA total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients.ResultsSix (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335–17.816; p=0.034) was the only independent risk factor for procedure-related complications on multivariate logistic regression analysis.ConclusionThe procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.

Endovascular treatment of posterior inferior cerebellar artery trunk aneurysm.

The posterior inferior cerebellar artery (PICA) generally originates from the vertebral artery (VA) and is the most complex cerebellar artery. Aneurysms can occur at any site along the PICA trunk. Although most PICA aneurysms are located at the VA-PICA junction, a small proportion is located at the PICA trunk. Endovascular treatment (EVT) of aneurysms in the PICA trunk may be difficult and complex. We performed a review to expound upon EVT of PICA trunk aneurysms. The PICA can be divided into five segments (p1-5); the p1-3 segments are proximal segments, and the p4-5 segments are distal segments. Most PICA trunk aneurysms are dissecting aneurysms. Sometimes, the PICA can give rise to flow-related aneurysms in association with cerebellar arteriovenous malformations. Most aneurysms of the PICA trunk require aggressive treatment, especially those that have ruptured. Currently, the EVT mainly includes selective coiling with/without stent assistance and parent artery occlusion. Recently, some new devices, such as flow diversion and Barricade and Kaneka ED coils, can be used to treat PICA trunk aneurysms. The risk of complications with EVT seems to be higher; however, most complications are only transient or mild, and some are even clinically silent. In addition, open surgery is still an important option. For PICA trunk aneurysms, the treatment choice should be assessed on a case-by-case basis. The rate of permanent morbidity of the EVT is low. EVT is an effective method for treating PICA trunk aneurysms.

Basal ganglia cavernous malformations: case series and systematic review of surgical management and long-term outcomes.

Reports on basal ganglia cavernous malformations (BGCMs) are rare. Here, the authors report on their experience in resecting these malformations to offer insight into this infrequent disease subtype. The authors retrospectively reviewed a prospectively managed departmental database of all deep-seated cerebral cavernous malformations (CCMs) treated at Stanford between 1987 and 2019 and included for further analysis those with a radiographic diagnosis of BGCM. Moreover, a systematic literature review was undertaken using the PubMed and Web of Science databases. The departmental database search yielded 331 patients with deep-seated CCMs, 44 of whom had a BGCM (13.3%). Headache was the most common presenting sign (53.5%), followed by seizure (32.6%) and hemiparesis (27.9%). Lesion location involved the caudate nucleus in 21.4% of cases compared to 78.6% of cases within the lentiform nucleus. Caudate BGCMs were larger on presentation and were more likely to present to the ependymal surface (p < 0.001) with intraventricular hemorrhage and hydrocephalus (p = 0.005 and 0.007, respectively). Dizziness and diplopia were also more common with lesions involving the caudate. Because of their anatomical location, caudate BGCMs were preferentially treated via an interhemispheric approach and were less likely to be associated with worsening perioperative deficits than lentiform BGCMs (p = 0.006 and 0.045, respectively). Ten patients (25.6%) were clinically worse in the immediate postoperative period, 4 (10.2%) of whom continued to suffer permanent morbidity at the last follow-up. A long-term good outcome (modified Rankin Scale [mRS] score 0-1) was attained in 74.4% of cases compared to the 69.2% of patients who had presented with an mRS score 0-1. Relative to their presenting mRS score, 89.8% of patients had an improved or unchanged status at the last follow-up. The median postoperative follow-up was 11 months (range 1-252 months). Patient outcomes after resection did not differ among surgical approaches; however, patients presenting with hemiparesis and lesions involving the globus pallidus or posterior limb of the internal capsule were more likely to suffer neurological deficits during the immediate perioperative period. Patients who had undergone awake surgeries were more likely to suffer neurological decline at the early as well as the late follow-up. When adjusting for awake craniotomy as a potential confounder of lesion location, a BGCM involving the posterior limb was predictive of developing early postoperative deficits, but this finding did not persist at the long-term follow-up. Surgery is a safe and effective treatment modality for managing BGCMs, with an estimated long-term permanent morbidity rate of around 10%.

Treatment results and long-term outcomes of endovascular treatment of 96 unruptured anterior communicating artery aneurysms: A large single-center study

ObjectiveData on endovascular treatment of unruptured anterior communicating artery (AcomA) aneurysms remain limited. Therefore, to clarify the outcomes of treatment for unruptured AcomA aneurysms, we retrospectively analyzed a single-center series of 96 unruptured AcomA aneurysms treated endovascularly. MethodsEndovascular treatment of 100 unruptured AcomA aneurysms was performed at our institution between May 2009 and May 2019; of these, 96 consecutive aneurysms (95 patients) were included in this retrospective study. Recanalization and retreatment rates were investigated for 76 aneurysms through follow-up using time-of-flight magnetic resonance angiography or digital subtraction angiography for ≥ 2 years after treatment. ResultsThe rate of total procedure-related complications was 19.8%. The rates of thromboembolic complications, hemorrhagic complications, and intraprocedural aneurysm bleeding were 12.5%, 6.3%, and 3.1%, respectively, with no poor outcomes (modified Rankin Scale score 2–6) resulting from thromboembolic and hemorrhagic complications at 180 days after treatment. The permanent morbidity rate was 1.0%. Multivariate analysis revealed that maximum diameter (>10 mm), neck size (>4 mm), and stent use were independently associated with symptomatic cerebral infarction. Endovascular retreatment was conducted for two aneurysms (2.6%), and the cumulative recanalization rate was 5.3% (4/76) over a mean follow-up period of 48.2 ± 23.7 months. ConclusionThis study indicates that although there is a relatively high possibility of overall procedure-related complications with endovascular treatment for unruptured AcomA aneurysms, most complications are temporary and mild, with a permanent morbidity rate of approximately 1.0%.

Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms.

Wide-necked bifurcation aneurysms remain a challenge for endovascular surgeons. Dual-stent-assisted coiling techniques have been defined to treat bifurcation aneurysms with a complex neck morphology. However, there are still concerns about the safety of dual-stenting procedures. Stent plus balloon-assisted coiling is a recently described endovascular technique that enables the coiling of wide-necked complex bifurcation aneurysms by implanting only a single stent. To investigate the feasibility, efficacy, safety, and durability of this technique for the treatment of wide-necked bifurcation aneurysms. A retrospective review was performed of patients with wide-necked intracranial bifurcation aneurysms treated with stent plus balloon-assisted coiling. The initial and follow-up clinical and angiographic outcomes were assessed. Preprocedural and follow-up clinical statuses were assessed using modified Rankin scale. A total of 61 patients (mean age: 54.6± 10.4 yr) were included in the study. The immediate postprocedural digital subtraction angiography revealed complete aneurysm occlusion in 86.9% of the cases. A periprocedural complication developed in 11.5% of the cases. We observed a delayed ischemic complication in 4.9%. There was no mortality in this study. The permanent morbidity rate was 3.3%. The follow-up angiography was performed in 55 of 61 patients (90.1%) (the mean follow-up period was 25.5± 27.3 mo). The rate of complete aneurysm occlusion at the final angiographic follow-up was 89.1%. The retreatment rate was 1.8%. The results of this study showed that stent plus balloon-assisted coiling is a feasible, effective, and relatively safe endovascular technique for the treatment of wide-necked bifurcation aneurysms located in the posterior and anterior circulation.

Clinical and Angiographic Outcomes After Stent-Assisted Coiling of Cerebral Aneurysms With Laser-Cut and Braided Stents: A Comparative Analysis of the Literatures.

Introduction: Stent-assisted coiling (SAC) plays an important role in endovascular treatment of intracranial aneurysms (IAs). This comparative analysis examines the safety and efficacy of SAC in general and compares clinical and angiographic outcomes between laser-cut stents and braided stents.Methods: Relevant English-language studies were identified via a PubMed search for published articles regarding outcomes of SAC using laser-cut stents and braided stents published from 2015 to 2020. Data from 56 studies that met our inclusion criteria were pooled and statistically compared.Results: A total of 4,373 patients harboring with 4,540 IAs were included. Patients were divided into two groups on the basis of stent type: laser-cut stents (2,076 aneurysms in 1991 patients; mean follow-up, 12.99 months) and braided stents (2,464 aneurysms in 2382 patients; mean follow-up, 18.41 months). Overall, the rates of successful stent deployment, thromboembolic events, stent stenosis, periprocedural intracranial hemorrhage, permanent morbidity, mortality, and recanalization were 97.72, 4.72, 2.87, 1.51, 2.14, 1.16, and 6.06%, respectively. Laser-cut stents were associated with a significantly higher rate of successful deployment (p = 0.003) and significantly lower rate of periprocedural intracranial hemorrhage (p = 0.048). Braided stents were associated with a significantly lower rate of permanent morbidity (p = 0.015).Conclusion: SAC of IAs using laser-cut stents or braided stents was effective and safe. Rates of thromboembolic events, stent stenosis, mortality, and recanalization were comparable between the stent types. Braided stents were associated with lower permanent morbidity while laser-cut stents were associated with more favorable rates of successful deployment and periprocedural intracranial hemorrhage.

Limitations of Flow Diverters in Posterior Communicating Artery Aneurysms.

Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.

The p48 flow diverter: First clinical results in 25 aneurysms in three centers.

The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75-3mm. We report our first clinical experiences. Between March 2018-January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29-73 years). In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9-34.2%) and mortality was 4.5% (1 of 22, 95%CI <0.01-23.5%). Most complications were procedure-related and not device-specific. Of 22 patients with 25 aneurysms treated with p48, 18 patients with 20 aneurysms had angiographic follow-up after 5-18 months. Of 19 aneurysms, 10 were occluded and 7 showed a remnant. Two aneurysms were open after 6 months. Three aneurysms were still not occluded after 12, 14, and 18 months and these 3 were retreated. Retreatment rate was 16% (3 of 19) and the adequate occlusion rate was 90% (17 of 19). Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately.

Derivo embolization device in the treatment of unruptured intracranial aneurysms: a prospective multicenter study

BackgroundFlow diverters (FD) are used regularly for the endovascular treatment of unruptured intracranial aneurysms. We aimed to assess the safety and effectiveness of the Derivo embolization device (DED) with respect...

How I do it: trans-cortical approach for insular diffuse glioma.

The function-based resection using trans-cortical approach for removing insular diffuse glioma shares a positive benefit-to-risk ratio with a low rate of permanent morbidity. The technique requires intraoperative functional brain mapping to be performed under awake condition using direct electrical stimulations at both cortical and subcortical levels to identify brain connectivity supporting neurocognition. The trans-cortical approach is a safe and efficient technique to remove insular diffuse glioma. Intraoperative functional brain mapping under awake condition allows preserving brain connectivity and tailoring the resection. Great care must be taken in preventing vascular damages, and particularly the lenticulostriate arteries.

Seizure and neuropsychological outcomes in a large series of selective amygdalohippocampectomies with a minimally invasive subtemporal approach.

Debate continues over proper surgical treatment for mesial temporal lobe epilepsy (MTLE). Few large comprehensive studies exist that have examined outcomes for the subtemporal selective amygdalohippocampectomy (sSAH) approach. This study describes a minimally invasive technique for sSAH and examines seizure and neuropsychological outcomes in a large series of patients who underwent sSAH for MTLE. Data for 152 patients (94 women, 61.8%; 58 men, 38.2%) who underwent sSAH performed by a single surgeon were retrospectively reviewed. The sSAH technique involves a small, minimally invasive opening and preserves the anterolateral temporal lobe and the temporal stem. All patients in the study had at least 1 year of follow-up (mean [SD] 4.52 [2.57] years), of whom 57.9% (88/152) had Engel class I seizure outcomes. Of the patients with at least 2 years of follow-up (mean [SD] 5.2 [2.36] years), 56.5% (70/124) had Engel class I seizure outcomes. Preoperative and postoperative neuropsychological test results indicated no significant change in intelligence, verbal comprehension, perceptual reasoning, attention and processing, cognitive flexibility, visuospatial memory, or mood. There was a significant change in word retrieval regardless of the side of surgery and a significant change in verbal memory in patients who underwent dominant-side resection (p < 0.05). Complication rates were low, with a 1.3% (2/152) permanent morbidity rate and 0.0% mortality rate. This study reports a large series of patients who have undergone sSAH, with a comprehensive presentation of a minimally invasive technique. The sSAH approach described in this study appears to be a safe, effective, minimally invasive technique for the treatment of MTLE.

Relevance of Distal Arterial Collapse in Stenting of Atherosclerotic Near-Occlusion of the Carotid Artery.

Carotid near-occlusion has been subclassified into near-occlusion with and without collapse. We aimed to compare the technical success and perioperative complication rates of carotid artery stent placement with special attention to these subtypes to see whether there is a clinical relevance of this subclassification. From January 2014 to January 2018, we retrospectively evaluated all patients with atherosclerotic extracranial carotid stenosis treated by carotid artery stent placement. Patients with near-occlusion were identified based on DSA findings. Patient characteristics, the presence of criteria for near-occlusion and collapse, arterial diameters, technical success rate, and perioperative (≤30 days) complications were analyzed. We identified 59 near-occlusions in 58 (46 men, 11 with collapse) patients. Forty-one patients (70.7%) were symptomatic. Technical success rate was 98.3% (58 of 59 procedures). In 1 case of near-occlusion with collapse, we were not able to pass through the stenosis. Compared with patients without collapse (4.2% of 48 cases), those with collapse (30% of 10 stented patients) had significantly higher rates of postintervention hyperperfusion syndrome (P = .032). In the whole cohort, the permanent morbidity and mortality rate was 3.4% (1.7% permanent morbidity and 1.7% mortality). For asymptomatic and symptomatic near-occlusion groups, the rates were 0% and 4.9%, respectively. The composite risk of stroke, death, and myocardial infarction was similar between the groups with and without collapse (P = .682). Rate of hyperperfusion syndrome (with or without permanent deficit) was similar (P = 1) in preoperatively symptomatic patients versus asymptomatic patients (9.8% vs 5.9%). Internal carotid artery diameter consistently increased after carotid artery stent placement in patients with collapse and was not related to the development of hyperperfusion syndrome. Care should be taken to minimize hyperperfusion risk in patients with near-occlusion undergoing CAS, especially in the subgroup of patients with collapse and in patients with both symptomatic and asymptomatic carotid stenosis.

Clinicodemographic profile of diabetic ketoacidosis and its management in hospitalized children – A prospective study

Background: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with Type 1 diabetes (T1DM). In developing countries, mortality is between 6 and 24%. Recent studies have documented that DKA in association with cerebral edema (CE) accounted for a mortality of 1–24% with a high rate of permanent neurologic morbidity. Objective: The objective of the study was to study the demographic profile, clinical presentation at the time of admission, management, and complications of patients diagnosed as T1DM with DKA. Materials and Methods: A prospective observational study was conducted among children admitted in PICU MGM hospital, Warangal, Telangana between December 2016 and November 2018. Children up to the age of 18 years diagnosed as T1DM who presented with DKA were included in the study. Sociodemographic profile, dietary intake, and treatment history of children were collected using a pre-designed pro forma. Clinical features and management were noted. Results: A total of 51 children were included in the study. Among them, 32 (62.74%) cases were newly diagnosed and 19 (37.2%) were previously diagnosed. A majority of the children belonged to lower socioeconomic status with 40% of the children suffering from severe grade of malnutrition. Classical symptoms of polyuria, polydipsia, and polyphagia were observed in 32 patients (62.74%). Vomiting was observed in 59% of cases, tachypnea in 82.35%, and abdominal pain in 29.41% of cases. About 54.90% of cases presented with severe and 33.3% with moderate DKA. Administration of regular insulin was the main modality of management in all cases. The major complication observed was hypoglycemia followed by cerebral edema. Conclusion: Cerebral edema with septic shock is a life-threatening complication of patients suffering with DKA. Active management with regular insulin can avert major complications and can lead to better outcomes.