Transient Neurological Deficits Research Articles

Endovascular Treatment of Small and Very Small Intracranial Aneurysms with the Woven EndoBridge Device.

The Woven EndoBridge has proved to be a safe and effective treatment, especially for wide-neck intracranial aneurysms. The recent fifth-generation Woven EndoBridge came with smaller devices. The purpose of this study was to assess the safety and efficiency of Woven EndoBridge treatment of small and very small aneurysms. Between September 2017 and March 2020, all consecutive patients treated with a 3- or 3.5 mm-width Woven EndoBridge device were included in this retrospective intention-to-treat study. Clinical and radiologic findings were evaluated at immediate and last-available follow-up. Angiographic outcome was assessed by an external expert reader. One hundred twenty-eight aneurysms were treated with a fifth-generation Woven EndoBridge device including 29 with a width of ≤3.5 mm. Ten aneurysms were ruptured (34%). In 3 cases (10%), Woven EndoBridge treatment could not be performed because the aneurysm was still too small for the smallest available Woven EndoBridge device and another endovascular strategy was chosen. The median follow-up time was 11.2 months. Complete and adequate occlusion was obtained in 71% and 90% of the treated aneurysms, respectively. Retreatment was needed in 2 cases (10%). Symptomatic ischemic complications leading to transient neurologic deficits occurred in 2 cases (7%) (1 procedure-related and 1 device-related) but with full spontaneous recovery at discharge. The fifth-generation Woven EndoBridge device seems to be a safe and technically feasible treatment for both ruptured and unruptured small and very small intracranial aneurysms, with satisfactory occlusion rates on midterm follow-up. However, further study is needed to evaluate longer-term efficiency.

Spectral analysis of EEG in etiological assessment of patients with transient neurological deficits

ObjectiveDifferentiating transient ischemic attack from stroke mimics may be difficult. Besides clinical evaluation and brain imaging, electroencephalography (EEG) may be a useful diagnostic tool. MethodsWe conducted spectral analysis on 67 EEG of patients who had presented a transient neurological deficit (TND) within the previous seven days. Expert clinicians provided the final diagnosis: transient ischemic attack, migraine with aura, focal seizure or “other”. We first calculated the relative power of the four EEG frequency bands (delta, theta, alpha and beta), in the whole hemisphere, then, according to the clinical symptoms, in the relevant electrodes of the symptomatic hemisphere. Finally, we calculated the relative power ratio between symptomatic and asymptomatic hemispheres. ResultsMedian age was 60.6 years (57% females). The etiological diagnosis was transient ischemic attack (27%), migraine with aura (11%), focal seizures (22%) and “other” (40%). We did not find significant differences in the theta and delta relative power analysis between groups. Over the symptomatic hemisphere only, we found a significant increase of the alpha relative power (p = 0.0026, p < 0.0001, p = 0.0014) in the migraine group compared to transient ischemic attack, migraine and focal seizures groups, and a significant decrease of the beta relative power (p = 0.0034, p = 0.0016, p = 0.0005) compared to the same groups. ConclusionsMigraine with aura presents a discriminative EEG relative power in comparison to transient neurological deficits of other origins. To further investigate the additive diagnosis value of EEG in other TND, future studies should be performed with an EEG obtained within the first 24 h after the onset of symptoms. SignificanceSpectral EEG analysis discriminates migraine with aura groups from other groups, but not at the individual level.

Retrograde inferior vena caval perfusion for total aortic arch replacement surgery: a randomized pilot study

ObjectivesAntegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.MethodsThis pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.ResultsA total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21–1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10–0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.ConclusionsRIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.Trial registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786.

Extracorporeal Membrane Oxygenation Utilization in Blunt and Penetrating Traumatic Injuries: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used treatment modality for severe respiratory insufficiency in trauma patients. Examining ECMO use specifically in blunt and penetrating traumas can aid in directing future protocols. We aim to evaluate the outcomes of ECMO use in both blunt and penetrating trauma patients through a systematic review of current literature. An online search of 2 databases (PubMed and Google Scholar) was performed to analyze studies, which evaluated the use of ECMO in blunt and penetrating traumas. Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Grading of Recommendations Assessment, Development and Evaluation guidelines were followed. Data extracted included mechanism of injury, injury severity scores (ISSs), complications, and mortality rates. The search demonstrated 9 studies that met our review inclusion criteria. A total of 207 patients were included, of which 64 (30.9%) were non-survivors and 143 (69.1%) were survivors. There was a total of 201 blunt traumas with 61 (30.3%) deaths, whereas penetrating traumas had 2 deaths (33.3%) out of 6 total patients. Complications reported included acute renal failure, hemorrhage at the cannula site, and transient neurological deficits. Most studies found better survival rates and less complications in younger patients and those with lower ISS. Expanding the use of ECMO to include blunt and penetrating trauma patients provides the trauma surgeons with another crucial potentially lifesaving tool with an overall survival rate of 70%. Anticipating increased future use of ECMO in blunt and penetrating trauma patients, distinct protocols ought to be instilled to better address the care needed for these critically ill trauma patients.

Awake Epilepsy Surgery in Patients with Focal Cortical Dysplasia

Awake craniotomy (AC) and direct electric stimulation emerged together with epilepsy surgery >80 years ago. The goal of our study was to evaluate the benefits of awake surgery in patients with drug-resistant epilepsy caused by focal cortical dysplasia (FCD) affecting eloquent areas. Our material included 95 patients with drug-resistant epilepsy and FCD, who were operated on between January 2009 and December 2018. These 95 patients were assigned into 3 groups: AC; general anesthesia (GA) with intraoperative neuromonitoring; and GA without intraoperative neuromonitoring. We investigated the following variables: age at surgery, lesion side, eloquent cortex involvement, brain mapping success rate, epilepsy surgery success rate, intraoperative complications, postoperative complications, and intraoperative changes of the preoperative resection plan according to results of the brain mapping by direct electric stimulation. We found statistically significant differences between the AC and GA groups in the mean age at operation, lesion side, eloquent localization, and postoperative transient neurologic deficit. Seizure outcome in the AC was satisfactory (71% complete seizure control) and comparable to the seizure outcome in the GA groups. Our preoperative plan was changed because of functional constraints in 6 patients (43%) operated on during AC. AC during epilepsy surgery for FCD in eloquent areas may change the preoperative plan. The good rate of postoperative seizure control and the absence of permanent postoperative neurologic deficit in our series is the main proof that AC is a useful tool in patients with FCD involving the eloquent cortex.

A Novel Clinical Nomogram to Predict Transient Symptomatic Associated with Infarction: The ABCD3-SLOPE Score.

Background It is hard to differentiate transient symptoms associated with infarction (TSI) from transient ischemic stroke (TIA) without MRI in the early onset. However, they have distinct clinical outcomes and respond differently to therapeutics. Therefore, we aimed to develop a risk prediction model based on the clinical features to identify TSI. Methods We enrolled 230 consecutive patients with transient neurologic deficit in the Department of Neurology, Tongji University Affiliated Tenth People's Hospital from March 2014 to October 2019. All the patients were assigned into TIA group (DWI-negative) or TSI group (DWI-positive) based on MRI conducted within five days of onset. We summarized the clinical characteristics of TSI by univariate and multivariate analyses. And then, we developed and validated a nomogram to identify TSI by the logistic regression equation. Results Of the 230 patients, 41.3% were diagnosed with TSI. According to the multivariate analysis, four independent risk factors, including smoking history, low-density lipoprotein cholesterol, brain natriuretic peptide precursor, and ABCD3 score, were incorporated into a nomogram. We developed a predictive model named ABCD3-SLOPE. The calibration curve showed good agreement between nomogram prediction and observation. The concordance index (C-index) of the nomogram for TSI prediction was 0.77 (95% confidence interval, 0.70-0.83), and it was well-calibrated. Conclusions Smoking history, low-density lipoprotein cholesterol, brain natriuretic peptide precursor, and ABCD3 score were reliable risk factors for TSI. ABCD3-SLOPE was a potential tool to quantify the likelihood of TSI.

Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience.

Background The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. Methods Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. Results The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality ( p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality ( p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. Conclusion Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

Outcome of the frozen elephant trunk procedure as a redo operation

The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19-35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23-3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.

Leukocyte Biomarkers for the Differential Diagnosis of Mild Acute Ischemic Stroke, Transient Ischemic Attack, and Stroke Mimic.

IntroductionThe differential diagnosis of transient ischemic attack (TIA) versus mild acute ischemic stroke (AIS) during the initial presentation to the emergency department is often difficult, as the diagnosis of both TIA and AIS relies on the presence of focal neurologic signs. As such, roughly 50% of patients with transient or mild neurologic deficits have an uncertain diagnosis prior to neuroimaging. Biomarkers, particularly leukocyte biomarkers, may be used by clinicians to diagnose mild AIS prior to neuroimaging, and this study is the first to describe the use of leukocyte biomarkers for the differentiation of mild AIS, TIA, and stroke mimic.MethodsWe performed a retrospective chart review of patients discharged from a local hospital with a discharge diagnosis of either TIA or AIS. Past medical history and complete blood cell count with differential upon admission were collected for all subjects. Statistical analyses were performed to compare immune cell parameters between the two groups. For all comparisons, logistic regression analysis was used to assess the effect of confounding variables, such as age, gender, and medical history for each study variable.ResultsOf all the immune parameters assessed in this study, the neutrophil percentage was the only significant biomarker that significantly differed between study groups. After adjustment for confounding variables using stepwise logistic regression, mild AIS patients were 5.3 times more likely than TIA cases to have a neutrophil percentage above the normal range.ConclusionOur results suggest that clinicians may utilize neutrophil percentage as an additional piece of information that may aid in their diagnosis of mild AIS versus TIA.

Cortical superficial siderosis in the general population: The Framingham Heart and Rotterdam studies.

We aimed to characterize cortical superficial siderosis, its determinants and sequel, in community-dwelling older adults. The sample consisted of Framingham (n = 1724; 2000-2009) and Rotterdam (n = 4325; 2005-2013) study participants who underwent brain MRI. In pooled individual-level analysis, we compared baseline characteristics in patients with cortical superficial siderosis to two reference groups: (i) persons without hemorrhagic MRI markers of cerebral amyloid angiopathy (no cortical superficial siderosis and no microbleeds) and (ii) those with presumed cerebral amyloid angiopathy based on the presence of strictly lobar microbleeds but without cortical superficial siderosis. Among a total of 6049 participants, 4846 did not have any microbleeds or cortical superficial siderosis (80%), 401 had deep/mixed microbleeds (6.6%), 776 had strictly lobar microbleeds without cortical superficial siderosis (12.8%) and 26 had cortical superficial siderosis with/without microbleeds (0.43%). In comparison to participants without microbleeds or cortical superficial siderosis and to those with strictly lobar microbleeds but without cortical superficial siderosis, participants with cortical superficial siderosis were older (OR 1.09 per year, 95% CI 1.05, 1.14; p < 0.001 and 1.04, 95% CI 1.00, 1.09; p = 0.058, respectively), had overrepresentation of the APOE ɛ4 allele (5.19, 2.04, 13.25; p = 0.001 and 3.47, 1.35, 8.92; p = 0.01), and greater prevalence of intracerebral hemorrhage (72.57, 9.12, 577.49; p < 0.001 and 81.49, 3.40, >999.99; p = 0.006). During a mean follow-up of 5.6 years, 42.4% participants with cortical superficial siderosis had a stroke (five intracerebral hemorrhage, two ischemic strokes and four undetermined strokes), 19.2% had transient neurological deficits and 3.8% developed incident dementia. Our study adds supporting evidence to the association between cortical superficial siderosis and cerebral amyloid angiopathy within the general population. Community-dwelling persons with cortical superficial siderosis may be at high risk for intracerebral hemorrhage and future neurological events.

Insular seizures and epilepsies: Ictal semiology and minimal invasive surgery.

The increased identification of seizures with insular ictal onset, promoted by the international development of stereo-electroencephalography (SEEG), has led to the recent description of larger cohorts of patients with insular or insulo-opercular epilepsies than those previously available. These new series have consolidated and extended our knowledge of the rich ictal semiology and diverse anatomo-clinical correlations that characterized insular seizures. In parallel, some experiences have been gained in the surgical treatment of insular epilepsies using minimal invasive procedures. The large majority of patients present with auras (mostly somatosensory and laryngeal) and motor signs (predominantly elementary and orofacial), an underlying focal cortical dysplasia, and an excellent postoperative seizure outcome. Many other subjective and objective ictal signs, known to occur in other forms of epilepsies, are also observed and clustered in five patterns, reflecting the functional anatomy of the insula and its overlying opercula, as well as preferential propagation pathways to frontal or temporal brain regions. A nocturnal predominance of seizure is frequently reported, whereas secondary generalization is infrequent. Some rare ictal signs are highly suggestive of an insular origin, including somatic pain, reflex seizures, choking spells, and vomiting. Minimal invasive surgical techniques have been applied to the treatment of insular epilepsies, including Magnetic Resonance Imaging-guided laser ablation (laser interstitial thermal therapy (LITT)), radiofrequency thermocoagulation (RFTC), gamma knife radiosurgery, and responsive neurostimulation. Rates of seizure freedom (about 50%) appear lower than that reported with open-surgery (about 80%) with yet a significant proportion of transient neurological deficit for LITT and RFTC. Significant progress has been made in the identification and surgical treatment of insular and insulo-opercular epilepsies, including more precise anatomo-clinical correlations to optimally plan SEEG investigations, and experience in using minimal invasive surgery to reduce peri-operative morbidity.

A case report on Syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL)

HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is a rare headache disorder previously known as Migraine with cerebrospinal fluid pleocytosis. The disease is characterized by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. It is a benign disorder and a stroke mimicker. We describe a case of 50 years old lady presented with acute onset headache, right hemi sensory tingling and bilateral papilloedema. Her blood test, MRI of brain and MRV was normal. CSF study revealed lymphocytic pleocytosis. The patient was discharged with full recovery. HaNDL syndrome is a diagnosis of exclusion. High degree of suspicion and characteristic clinical and laboratory findings are important to recognize.&#x0D; J Dhaka Medical College, Vol. 29, No.1, April, 2020, Page 89-91

Cervical ventral slot in rabbits (Oryctolagus cuniculus). Piezosurgery versus conventional technique.

ABSTRACTPurposeTo investigate the applicability of piezosurgery for cervical ventral slot (CVS), comparing it with the conventional technique of using high-speed burs for bone wear.MethodsThirty rabbits (Oryctolagus cuniculus) were divided into two treatment groups (T1 and T2) corresponding to CVS between C3-C4. In T1, the surgery was performed with piezoelectric apparatus, and in T2 with high-speed burs. The evaluated parameters were: duration of each stage of surgery, temperature variations during CVS, visibility of the surgical field, intra and postoperative complications, and anesthetic monitoring. At 14, 28, and 56 postoperative days, five animals from each treatment group were submitted for histopathological study of the surgical site.ResultsCompared with T2, T1 had more precise bone cut, and better visibility of the operative field, although it required longer total surgical time (p = 0.02) and triggered a greater number of intraoperative complications (p < 0.01), microscopic lesions in the spinal cord (p < 0.05), and transient neurological deficits in the postoperatively (p < 0.05).ConclusionsIt is necessary to perform surgical planning and have several tips of the piezoelectric instrument available for the safe use of the piezoelectric device in neurosurgery.

Efficacy of Different Doses of Intrathecal Chloroprocaine as Anaesthetic for Ureterorenoscopic Lithotripsy

Background amp Aims Ureterorenoscopic URSL surgeries for ureteric calculus are frequently done under spinal anaesthesia SA. Bupivacaine use related prolonged action and lignocaine caused transient neurological deficits prompted us to study preservative free 1 chloroprocaine a short acting local anaesthetic for URSL.Methods In this observational study after Institutional Ethics Committee approval 105 patients of either sex of ASA I and II in the age group of 18 to 60 years undergoing URSL under SA were enrolled. The subjects were to receive intrathecal chloroprocaine 40 45 and 50 mg respectively Group AB amp C. With monitoring and crystalloid preloading the study drug was given intrathecally. Haemodynamics sensory and motor blocks were assessed as per protocol along with procedure related complications and were documented. Data was analysed using ANOVA and post hoc analysis by Bonferroni test with stata version 14. p value lt0.05 was considered statistically significant.Results The three groups were comparable demographically and for surgical duration. The onset peak sensory block level onset of motor block perioperative haemodynamics were comparable between the groups p gt0.05. Group C had prolongation of sensory motor blockade 100.14plusmn6.58 min amp 86.14plusmn3.85 min and needed more time 140.14plusmn10.56 min for complete recovery of sensory blockade and discharge compared to group A and B which was statistically significant plt0.001.Conclusions 1 chloroprocaine can be safely administered intrathecally for URSL in dose range of 40-50 mg

Predictive value of intraoperative D-wave and m-MEP neurophysiological monitoring in patients with preoperative motor deficits in immediate and late postoperative period.

Background:Presence of preoperative motor deficits in patients poses a distinct challenge in monitoring the integrity of corticospinal tracts during spinal surgeries. The inconsistency of the motor-evoked potentials is such patients, limits its clinical utility. D-wave is a robust but less utilized technique for corticospinal tract monitoring. The comparative clinical value of these two techniques has not been evaluated in the patients with preoperative deficits.Objectives:The objective of the study was to compare the predictive utility of myogenic Motor Evoked Potentials (m-MEP) and D-wave in terms of recordability and their sensitivity and specificity in predicting transient and permanent new motor deficits.Materials and Methods:Thirty-one patients with preoperative motor deficit scheduled to undergo spinal surgery were included in the study. Intraoperative m-MEP and D-wave changes were identified and correlated with postoperative neurology in the immediate postoperative period and at the time of discharge.Results:The mean preoperative motor power of the patient pool in left and right lower limb was 2.97 ± 1.56 and 3.32 ± 1.49, respectively. The recordability of m-MEPs and D-wave was observed to be 79.4% and 100%, respectively. The m-MEP predicted the motor deterioration in immediate postoperative period with 100% sensitivity and 80% specificity, while D-wave had 14% sensitivity and 100% specificity. At the time of discharge, m-MEPs' specificity reduced to 61%, while D-wave demonstrated 100% specificity.Conclusions:D-wave has a better recordability than m-MEPs in neurologically compromised patients. D-wave predicts development of long-term deficits with 100% specificity, while m-MEPs have a high sensitivity for transient neurological deficit. A combination of D-wave and m-MEP is recommended for monitoring the integrity of the corticospinal tract in patients with preoperative motor deficits.

Endovascular Treatment of Small Wide-Neck Bifurcation Aneurysms with Single Solitaire AB Stent Technique.

We present our experience in using the single Solitaire AB stent for small wide-neck bifurcation aneurysms (WNBAs). During 18 months, 20 small (the largest width <10 mm) WNBAs were treated with the single Solitaire AB stent-assisted coiling. The patients were 12 women and 8 men, with a mean age of 52 years (range: 36-66 years). The mean aneurysm size was 4.2 mm (2-9 mm) and mean neck size was 3.9 mm (2-9 mm). Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. All 20 small WNBAs were adequately occluded after a single Solitaire AB stent placement. There were no procedural ruptures and no thromboembolic complications occurred. Two patients developed a transient neurological deficit. In 20 patients with angiographic follow-up at 6 months, 16 (80%) aneurysms remained adequately occluded. Clinical follow-up in the 20 patients revealed mRS 0-2 in all. Single Solitaire AB stent-assisted coil embolization for small WNBAs was safe and effective.

Multimodal Intraoperative Neurophysiological Monitoring in Spine Surgeries: The Experience at a Spine Centre through Years.

Study DesignRetrospective observational study.PurposeTo share our experience of multimodal intraoperative neurophysiological monitoring (IONM) used in Sakra World Hospital, Bengaluru in various spine surgeries.Overview of LiteratureThe development of new onset postoperative neurological deficits can be completely avoided. In order to avoid these, IONM has become a standard of care in recent times for early detection and manipulation of the surgical procedure to prevent postoperative neurological deficits.MethodsThis retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm.ResultsOf the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%.ConclusionsUse of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.

The Surgical Resection of Brainstem Glioma: Outcomes and Prognostic Factors

The management of brainstem glioma remains controversial, with increasing evidence supporting surgical resection as the primary treatment for a select subgroup of tumors. However, there remains no consensus on the specific benefits and risks, the selection of surgical candidates, and prognostic factors that may further refine surgical indications. A retrospective single-surgeon chart review was performed for all patients who underwent surgical treatment for radiographically suspected brainstem glioma between 2000 and 2017. Preoperative and postoperative radiographic evaluations on magnetic resonance imaging were conducted. Survival outcomes were collected, and machine-learning techniques were used for multivariate analysis. Seventy-seven patients with surgical treatment of brainstem glioma were identified, with a median age of 9 years (range, 0-58 years). The cohort included 64% low-grade (I and II) and 36% high-grade (III and IV) tumors. For all patients, the 1-year and 5-year overall survival were 76.4% and 62.3%, respectively. Transient neurologic deficit was present in 34% of cases, and permanent deficit in a further 29%. The radical surgical resection of brainstem gliomas can be performed with acceptable risk in well-selected cases and likely confers survival advantage for what is otherwise a rapidly and universally fatal disease. Various radiographic features are useful during patient selection and may guide treatment selection.

MIDCAB vs OPCAB for severe coronary artery disease: a comparative study

Abstract Background/Introduction MIDCAB (minimally invasive direct coronary artery bypass surgery) ± PCI/DES was compared to classical “off pump” coronary artery bypass surgery (OPCAB) for the treatment of severe coronary artery disease. Purpose We hypothesized that MIDCAB is associated with reduced perioperative morbidity and mortality. Methods Preoperative and postoperative clinical data were collected prospectively in 329 consecutive patients with severe coronary artery disease undergoing either a MIDCAB procedure ± PCI/DES (MIDCAB group), n=118 patients, or classical OPCAB (OPCAB group), n=211 patients, at our institution from January 2017 to July 2019. A matched analysis using the EuroSCORE II (81 patients per group) was done. Results The median of EuroSCORE II was 1.05 in both groups, p=1. All MIDCAB patients underwent a left-sided mini-thoracotomy and received a single LIMA-LAD graft, OPCAB patients received median 3 distal anastomoses, p&amp;lt;0.001. Operative time was shorter in MIDCAB patients, 160min vs. 240min, p&amp;lt;0.001. Maximum postoperative Troponin levels were lower in MIDCAB compared to OPCAB, 105 μg/l vs. 260 μg/l, p&amp;lt;0.001. Intubation time was shorter in MIDCAB, 7.0 h vs. 9.3 h, p=0.04, as was ICU time, p=0.02. Chest tube drainage after 24 hours was lower in MIDCAB patients, 405 mL vs. 555 mL, p&amp;lt;0.001. Transfusions of blood, platelets and fresh frozen plasma were rarely needed. Transfusion of erythrocytes were more common in OPCAB, 19%, vs. MIDCAB, 2.5%, p=0.001. A transient neurological deficit showed one (1.2%) patient in the OPCAB group, non in MIDCAB, p=0.3. A hybrid procedure was performed in 18 MIDCAB patients (22%) and 5 OPCAB patients (6.2%). In-hospital mortality was 0% in the MIDCAB group, and 1.2% in OPCAB patients, p=0.3. Conclusions MIDCAB is a good and safe option to treat severe coronary artery disease. MIDCAB is not only less invasive, but associated with reduced perioperative risk compared to standard OPCAB surgery even if a hybrid procedure is needed. Funding Acknowledgement Type of funding source: None

Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas.

Complete resection of symptomatic supratentorial cavernoma (SCA) and removal of the surrounding gliotic area is recommended to minimize the risk of persistent seizures or (re)bleeding. Surgery of SCA located in an eloquent area, can carry out severe postoperative neurological morbidity. We report a study aimed to assess feasibility, extent of resection and outcome after surgical removal of CA by cortico-subcortical intraoperative brain stimulation (ioBS) in the awake patient. Six patients diagnosed of symptomatic SCA located on an eloquent area and operated on while awake under local anaesthesia ioBS, were included. Preoperative planning included neuropsychologic assessment of language-related functions, sociocognitive functions and executive functions. Intraoperatively, we recorded the results achieved in the planned neuropsychological tasks when stimulation was applied (cortical and subcortical). Postoperative control 3D MRI was scheduled at 1 month after surgery to calculate extent of resection. Neuropsychological assessment at 6 months after surgery was performed in all cases. Six patients (5 females, 1 male) aged 24-48 years were included in our study. Locations of the lesions were right insular (n=1), left insular (n=1), left temporo-insular (n=1), left temporal (n=2) and left frontal (n=1). In all patients, positive findings were obtained during ioBS. In 5 patients, complete surgical resection was achieved. Two patients had postoperative transient neurological deficits, one case of hemiparesis, one case of dysnomia, both cleared over a 6-month period. Clinical follow-up revealed that all patients experienced complete recovery from preoperative symptoms within a year and five patients with seizures showed marked improvement and eventually quit antiepileptic drugs. Neuropsychological assessment at 6 months provided normal results compared to preoperative baseline in all domains. Our study suggests that ioBS in the awake surgery of symptomatic SCA located in eloquent areas, allows to increase the rate of complete resection, minimizing postoperative neurological and neuropsychological deficit, and improving postoperative seizures control.