Transient Neurological Deficits Research Articles

Long-term seizure outcome in frontal lobe epilepsy surgery

PurposeThe purpose of this study was to report long-term seizure outcome in patients who underwent frontal lobe epilepsy (FLE) surgery. MethodThis retrospective study included 44 consecutive subjects who underwent resective surgery for intractable FLE at IRCCS NEUROMED (period 2001–2014), followed up for at least 2 years (mean: 8.7 years). All patients underwent noninvasive presurgical evaluation and/or invasive electroencephalography (EEG) monitoring when nonconcordant data were obtained or epileptogenic zone was hypothesized to be close to the eloquent cortex. Electroclinical, neuroimaging, surgical data, and histology were compared to seizure outcome. ResultsMean epilepsy duration was 19 years; mean age at surgery was 31.6 years. Preoperative magnetic resonance imaging (MRI) showed a frontal lesion in 86.4 % of cases. Scalp video-electroencephalography (VEEG) monitoring detected a focal ictal onset in 90% of cases. Twenty-seven patients (61.4%) underwent invasive recordings. Resections involved dorsolateral (47.7%), medial (9%), orbital (13.6%), and rolandic (13.6%) region. Lobectomy within functional boundaries was performed in the remaining 7 cases (16%). Transient and permanent neurological deficits were observed in 2 and 3 cases, respectively. Histology revealed focal cortical dysplasia (45.5%), World Health Organization (WHO) I–II grade tumors (15.9%), gliosis (22.7%), vascular malformations (4.5%), Rasmussen encephalitis (6.8%), and normal tissue (4.5%). At last observation 68.1% of patients were in Engel's class I, 11.4% in class II, 9% in class III, and 11.4% in class IV. A favorable outcome was associated with focal ictal scalp EEG onset (p = 0.0357). ConclusionSurgery is a safe treatment option in drug-resistant FLE with a satisfying long-term outcome. These data highlight the importance of an appropriate selection of potential surgical candidates.

Impact of white matter changes on neurologic outcomes of total arch replacement using antegrade cerebral perfusion

ObjectiveTo evaluate the impact of white matter changes on neurologic outcomes after total arch replacement using antegrade cerebral perfusion. MethodsWhite matter changes were assessed using a visual Fazekas scale on preoperative magnetic resonance images. From October 1999 to December 2016, 359 patients who had demonstrated changes on preoperative magnetic resonance imaging underwent elective total arch replacement using antegrade cerebral perfusion. Patients were classified into 3 severity groups: mild (100 patients), moderate (158 patients), and severe (101 patients). Mean follow-up time was 4.8 ± 3.6 years. Multivariate logistic regression methods were used to evaluate for an independent association between white matter changes and postoperative neurological outcomes. ResultsHospital mortality was 2.8% (10/359), and no significant differences were found across the 3 groups (P = .604). Multivariate analysis demonstrated that the severity of white matter change was significantly associated with both postoperative permanent neurologic deficit (odds ratio, 5.77; 95% confidence interval, 1.58-38.4, P = .005) and transient neurologic deficit (odds ratio, 2.46; 95% confidence interval, 1.45-4.37, P < .001). ConclusionsWhite matter changes, defined using the visual Fazekas scale on preoperative magnetic resonance imaging, were significantly associated with significant postoperative adverse neurologic outcomes after total arch replacement using antegrade cerebral perfusion.

Middle-column preserved pedicle subtractionclosing-opening wedge osteotomy to treat thoracolumbar kyphosis deformity in ankylosing spondylitis

Objective To investigate the effectiveness and safety of middle-column preserved pedicle subtraction closing-opening wedge osteotomy for the treatment of ankylosing spondylitis (AS)-related thoracolumbar kyphosis. Methods From January 2010 to December 2016, eleven patients (9 males and 2 females) who underwent one-level middle-column preserved pedicle subtraction osteotomy with an average age of 40.8 years (21-68 years) were reviewed. The average thoracolumbar kyphosis angle (TLK) was 50.5°±9.6° and the average lumbar lordosis angle was -2.5°±24.1°. The thoracolumbar kyphosis, sagittal vertical axis (SVA), lumbar lordosis, pelvic tilt, sacral slope, thoracic kyphosis, Scoliosis Research Society (SRS) 22, Oswestry disability index (ODI) score, the length of anterior column and posterior column at the pre- and post-operation, operation time, perioperative blood loss and complications were recorded. Results The osteotomy sites of 11 cases included 7 in L2, 2 in L3 and 2 in T12. Theaver-age operation time was 156.8 min (120-220 min). The average blood loss was 604.5 ml (350-900 ml). The average time of follow-up was 24 months (12-42 months). Complications were encountered in 2 patients. There were 1 casewith transient neurological deficits, another case with incision infection. No serious neurological or vascular complications occurred in all cases. The thoracolumbar kyphosis (TLK), lumbar lordosis, pelvic tilt, sacral slope, thoracic kyphosis, SRS 22 and ODI score were improved significantly. The preoperative TLK cobb was 50.5° (36°-66°), which improved to 5.1° (1°-11°) at the final follow-up with a mean correction rate of 89.9%. Sagittal migrationwas improved from 184.6 mm preoperatively to 79.2 mm atthe final follow-up with an average correctionrate of 49.3%. The differences of the length of posterior column of osteotomy site after operation showed no statistical significance. A1l patients had solid fusion at osteotomy site and no instrumentational failure and loosening were found over the follow up. Conclusion Middle-column preserved pedicle subtraction closing-openingwedge osteotomy is safe and effective for correction of the thoracolumbar kyphosis deformity occurring in ankylosing spondylitis, resulting in satisfactory out comes with acceptable complications. Key words: Spondylitis, ankylosing; Kyphosis; Osteotomy; Treatment outcome

Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique.

The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author's series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures. Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up. We identified eight patients, six males, and two females with a mean age of 37.9years (range 20-71years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3mm. Five patients were treated < 72h of injury, two patients had failed halo vest for 8-10weeks, and one patient was operated after 6months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6months (range 1-49months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient. Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity.

OC03 AXILLARY VERSUS FEMORAL ARTERY CANNULATION IN AORTIC ARCH SURGERY: A SINGLE CCENTRE EXPERIENCE

Background and Aim: The best strategy of arterial cannulation during aortic arch replacement is still debated. We reported our experience with the Axillary and Femoral artery cannulation, comparing the incidence of major neurological events and in-hospital mortality. Methods: Between 1996 and 2016, 938 consecutive patients (pts) underwent arch replacement in our center. We included only two groups of patients, according to the type of arterial cannulation: Axillary group with 282 pts and Femoral group with 409 pts. Baseline characteristics of the patients are reported in Table 1. Results: The hemiarch replacement was performed more often in Femoral group (57.2% vs 38.3%, p = .001). The Femoral cannulation was the most commonly used in urgent/emergent cases (56% vs 36.9%, p = .001). Cardiopulmonary bypass time (Axillary: 216.08 ± 61.47 vs Femoral: 203.78 ± 63.69; p = .001), Cross-Clamp Time (141.12 ± 47.5 vs 132.71 ± 49.10; p = .016), Circulatory Arrest Time (2.51 ± 1.74 vs 4.26 ± 2.49; p = .001) and antegrade selective cerebral perfusion time (69.19 ± 34.46 vs 58.84 ± 34.94; p = .001) were longer in Axillary group. Hospital mortality was similar between the two groups (12.1% vs 13.9%, p = .546) as well as for permanent neurological deficit (6.7% vs 7.3%, p = .881). Transient neurological deficit is significantly higher in the Axillary group (17.4% vs 11.0%, p = .022). Conclusions: Our study confirms that Axillary and Femoral artery cannulations were associated with similar outcomes after aortic arch surgery. The Axillary cannulation was used more frequently in complex repair of the aortic arch, while the Femoral can be still considered a viable option, especially in urgent/emergent cases.

OC85 TREATMENT OF AORTIC INSUFFICIENCY THROUGH AORTIC LEAFLETS REMODELLING: AN EXCELLENT ALTERNATIVE TO REPLACEMENT

Background and Aim: Aortic valve repair can be considered a valid alternative to replacement in patients with aortic regurgitation. Recent data report excellent results mainly for patients with aortic root dilatation associated with anatomically normal aortic valve. No data are up-to-date available about the results of the repair in patients with degenerative aortic valve (prolapse, thickness, perforation and/or retraction of the leaflets, congenital malformations). We analyzed retrospectively our data. Methods: From January 2011 to November 2017, we have treated 90 patients with degenerative aortic valve insufficiency (IA) through sugical remodelling of the aortic leaflets. The failure mechanism conditioned the choice of technique (shaving, correction of prolapse, raphe excision, use of pericardium, commissural re-orientation). Pre and postoperative transesophageal echocardiography as well as transthoracic echocardiography for follow-up were performed for each patient. Results: No in-hospital mortality was reported, two late deaths (2.22%)both for non cardiac cause. Three patiens (3.33%) needed, after repair, intraoperative aortic valve replacement while two (2.22%)at follow-up. Postoperative complications were low: 2 (2.22%)transient low output syndrome, 3 (3.33%)postoperative bleeding, 1 (1.11%)transient neurological deficit, 1 (1.11%)temporary renal failure, 3 (3.33%)acute myocardial ischemia. No thromboembolic and haemorragic events was referred, as well as endocarditis. Early or late recurrence of IA &gt; 2 was detected in 4 pts (4,44%). Conclusions: Remodelling of the aortic valve leaflets represents an attractive and valid alternative to aortic valve replacement in patients with aortic valve insufficiency, mainly in young patients. In our experience the results are excellent in terms of short and middle term survival, postoperative complications and freedom from reoperation. It remains to be established if the remodeling of the cusps is comparable to the replacement of the valve in terms of late results.

Can perfusion CT unmask postictal stroke mimics? A case-control study of 133 patients.

To study the diagnostic value of volume perfusion CT (VPCT) in patients with transient focal neurologic deficits following and during epileptic seizures, that mimic symptoms of stroke. A retrospective case-control study was performed on 159 patients who presented with a seizure and received an emergency VPCT within the first 3.5 hours of admission, after being misjudged to have an acute stroke. The reference test was a clinical-based, EEG-supported diagnostic algorithm for seizure. We included 133 patients: 94 stroke-mimicking cases with postictal focal neurologic deficits ("Todd phenomenon," n = 67) or ongoing seizure on hospital admission ("ictal patients," n = 27), and 39 postictal controls without focal neurologic deficits. Patients with Todd phenomenon showed normal perfusion (64%), hypoperfusion (21%), and hyperperfusion (14%) on early VPCT. Ictal patients displayed more hyperperfusion compared to postictal patients (p = 0.015). Test sensitivity of hyperperfusion for ictal patients is 38% (95% confidence interval [CI] 20.7%-57.7%), specificity 86% (95% CI 77.3%-91.7%), positive predictive value is 42% (95% CI 27.5%-58.7%), and the negative predictive value 83% (95% CI 78.6%-86.9%). A cortical distribution was seen in all hyperperfusion scans, compared to a cortico-subcortical pattern in hypoperfusion (p < 0.001). A history of complex focal seizure and age were associated with hyperperfusion (p = 0.046 and 0.038, respectively). VPCT can differentiate ictal stroke mimics with hyperperfusion from acute ischemic stroke, but not postictal patients who display perfusion patterns overlapping with ischemic stroke. This study provides Class IV evidence that VPCT accurately differentiates ictal stroke mimics from acute ischemic stroke.

The Role of Intraoperative MRI in Awake Neurosurgical Procedures: A Systematic Review.

Background: Awake craniotomy for brain tumors remains an important tool in the arsenal of the treating neurosurgeon working in eloquent areas of the brain. Furthermore, with the implementation of intraoperative magnetic resonance imaging (I-MRI), one can afford the luxury of imaging to assess surgical resection of the underlying gross imaging defined neuropathology and the surrounding eloquent areas. Ideally, the combination of I-MRI and awake craniotomy could provide the maximal lesion resection with the least morbidity and mortality. However, more resection with the aid of real time imaging and awake craniotomy techniques might give opposite outcome results. The goal of this systematic review.is to identify the available literature on combined I-MRI and awake craniotomy techniques, to better understand the potential morbidity and mortality associated.Methods: MEDLINE, EMBASE, and CENTRAL were searched from inception up to December 2016. A total of 10 articles met inclusion in to the review, with a total of 324 adult patients.Results: All studies showed transient neurological deficits between 2.9 to 76.4%. In regards to persistent morbidity, the mean was ~10% (ranges from zero to 35.3%) with a follow up period between 5 days and 6 months.Conclusion: The preliminary results of this review also suggest this combined technique may impose acceptable post-operative complication profiles and morbidity. However, this is based on low quality evidence, and is therefore questionable. Further, well-designed future trials with the long-term follow-up are needed to provide various aspects of feasibility and outcome data for this approach.

Early Clinical Outcomes of Hybrid Arch Frozen Elephant Trunk Repair With the Thoraflex Hybrid Graft

Hybrid aortic arch surgery has evolved to include several technical variations, with most including an off-label use of a conventional thoracic endograft. We describe the early clinical outcomes of the Thoraflex Hybrid graft (Vascutek, Glasgow, Scotland) specifically designed for the treatment of complex arch and proximal descending aortic disease. Between January 2014 and April 2017, 40 consecutive patients (66 ± 14 years of age, 45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the multibranched Thoraflex Hybrid graft at 9 Canadian centers. Surgical indications included transverse arch or proximal descending aortic aneurysm in 100%, acute dissection in 10%, chronic dissection in 43%, and acute aortic rupture in 1 patient. Antegrade cerebral perfusion and moderate hypothermia (24.3 ± 1.8°C) were employed in all cases. All 40 device implants were successful. The 30-day or in-hospital mortality was 5%. Stroke and transient neurological deficits occurred in 5% and 3% of patients, respectively. Two (5%) patients experienced transient spinal cord ischemia-there were no instances of permanent paraplegia. Mean follow-up was 550 ± 328 days and late complications included type A aortic dissection in 1 patient, type B dissection in 2 patients, and further distal endografting in 2 patients. Survival at 30 days, 1 year, and 2 years was 95%, 95%, and 90%, respectively. Hybrid aortic arch and frozen elephant trunk repair with the Thoraflex Hybrid graft appearstobe associated with good clinical outcomes, despitebeing early in the learning curve with this graft. Further investigation with this device is warranted toestablish its role within the variations of hybrid archrepair.

Case Series about the Changed Antiplatelet Protocol for Carotid Endarterectomy in a Teaching Hospital: More Patients with Complications?

Introduction In the Netherlands, clopidogrel monotherapy increasingly replaces acetylsalicylic acid and extended release dipyridamole as the first-choice antiplatelet therapy after ischemic stroke. It is unknown whether the risk of peri- and postoperative hemorrhage in carotid artery surgery is higher in patients using clopidogrel monotherapy compared with acetylsalicylic acid and extended release dipyridamole. We therefore retrospectively compared occurrence of perioperative major and (clinical relevant) minor bleedings during and after carotid endarterectomy of two groups using different types of platelet aggregation inhibition after changing our daily practice protocol in our center. Material and Methods A consecutive series of the most recent 80 carotid endarterectomy patients (November 2015–August 2017) treated with the new regime (clopidogrel monotherapy) were compared with the last 80 (January 2012–November 2015) consecutive patients treated according to the old protocol (acetylsalicylic acid and dipyridamole). The primary endpoint was any major bleeding during surgery or in the first 24 to 72 hours postoperatively. Secondary outcomes within 30 days after surgery included minor (re)bleeding postoperative stroke with persistent or transient neurological deficit, persisting or transient neuropraxia, asymptomatic restenosis or occlusion, (transient) headache. Reporting of this study is in line with the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ statement. Results Although statistical differences were observed, from a clinical perspective both patients groups were comparable. Postoperative hemorrhage requiring reexploration for hemostasis occurred in none of the 80 patients in the group of the clopidogrel monotherapy (new protocol) and it occurred in one of the 80 patients (1%) who was using acetylsalicylic acid and dipyridamole (old protocol). In three patients (4%) in the clopidogrel monotherapy and one patient (1%) in the acetylsalicylic acid and extended release dipyridamole protocol an ipsilateral stroke was diagnosed. Conclusion In this retrospective consecutive series the incidence of postoperative ischemic complications and perioperative hemorrhage after carotid endarterectomy (CEA) seemed to be comparable in patients using clopidogrel monotherapy versus acetylsalicylic acid and extended release dipyridamole for secondary prevention after a cerebrovascular event. This study fuels the hypothesis that short- and midterm complications of clopidogrel and the combination acetylsalicylic acid and extended release dipyridamole are comparable.

Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children's hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Endovascular Treatment of Transverse–Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up

Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs. From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed. Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n= 29) or near-complete (n= 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in1. Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

Efficacy of Carotid Endarterectomy for Mild (

Carotid endarterectomy (CEA) is known to reduce stroke risk in patients with symptomatic, moderate to severe carotid stenosis but has no apparent impact in patients with symptomatic, mild (less than 50%) carotid stenosis. However, recent development of noninvasive imaging modalities has shown that a certain subgroup of patients are at high risk for further ischemic events despite antiplatelet therapy. This study, therefore, aimed to clarify the patients' clinical features and explore the impact of CEA for them. This prospective cohort study included 74 patients who underwent CEA for symptomatic carotid stenosis between April 2012 and December 2016. Of these, 16 (22%) had mild (less than 50%) carotid stenosis. Their demographic, radiologic, intraoperative, and pathologic findings were precisely analyzed, and their outcome after CEA was examined for 38.5 ± 13.3 months. Of these 16 patients, 12 had already been treated with antiplatelets against previous ischemic cerebrovascular or coronary artery diseases. Plaque magnetic resonance imaging revealed that all patients had vulnerable plaque, including lipid-rich plaque (n= 6) and intraplaque hemorrhage (n= 10). Intraoperative observations confirmed this. Histologic analysis revealed that inflammatory cells and fragile angiogenesis were widely found in the specimens. Only 1 patient experienced transient (less than 30 days) neurologic deficit after CEA, and none of them repeated cerebrovascular events during the follow-up period. It is not rare the patients who are at high risk for subsequent ischemic events because of vulnerable plaque despite mild (less than 50%) carotid stenosis. Magnetic resonance imaging is quite useful to noninvasively detect such vulnerable plaque. CEA is a promising procedure to treat these patients.

Graft Replacement of Kommerell Diverticulum and In Situ Aberrant Subclavian Artery Reconstruction

This study aimed to evaluate the early and long-term outcomes of graft replacement of Kommerell diverticulum and in situ reconstruction of aberrant subclavian arteries in adults. Seventeen patients, 6 symptomatic and 11 with right aortic arch, underwent open repair of Kommerell diverticulum from October 1999 to September 2017. Two of these patients underwent open surgical treatment of a ruptured aneurysm. Surgical indications were dilatation of Kommerell aneurysm (n= 9), the presence of a nondissecting aneurysm with Kommerell diverticulum (n= 6), acute type A aortic dissection (n= 1), and complicated acute type B aortic dissection (n= 1). Ten patients underwent total arch replacement and descending aorta replacement through a thoracotomy. Five patients underwent arch replacement and in situ reconstruction through a median sternotomy. All patients except 1 also underwent in situ reconstruction of their aberrant subclavian artery. In-hospital death occurred in 1 patient (5.9%), who underwent total arch replacement for a ruptured aneurysm. Permanent neurologic deficit did not occur in any patient, whereas transient neurologic deficit occurred in 2 patients (11.8%). Five- and 10-year survival rates were 85.2 ± 9.8% and 75.8 ± 12.5%, respectively. There was no symptom recurrence or stenosis of the reconstructed subclavian arteries. Early outcomes of graft replacement of Kommerell diverticulum and in situ aberrant subclavian artery reconstruction were acceptable. As for long-term outcomes, symptomatic improvement and an excellent patency rate among reconstructed aberrant subclavian arteries suggest that in situ surgical repair is an effective treatment option.

Borle's triangle: A reliable anatomical landmark for ease of identification of facial nerve trunk during parotidectomy

PurposeAn accurate understanding of the anatomy, identification and preservation of facial nerve is critical in performing successful functional parotidectomies. The current literature is replete with inconsistencies of various landmarks when used alone for identification of facial nerve trunk (FNT). The purpose of the paper is to introduce a new anatomical triangle, Borle's triangle (BT) for safer and reliable operative identification of FNT during parotodectomies. Patients and methodsBetween Aug 2014 and Dec 2017, twelve patients who reported with unilateral disease of the parotid gland with intact facial nerve function who underwent superficial or complete parotidecomies were included in the study. BT was conceptualized by intersection of three imaginary lines drawn along anatomical structures and forming a triangle comprising of angles a, b and c. ResultsIntroperatively, BT helped reliably identify the FNT and its branches successfully in all the cases. The mean distance of FNT from angle b was found to be 12.18 ± 1.7 mm. Transient neurological deficits with one or more branches were seen in four cases whilst, one case had transient deficit with all the five peripheral branches. All of them spontaneously resolved completely by the end of three months post operatively. ConclusionsWhen used in isolation, substantial variations exist in distances measured from anatomic landmarks to the main FNT in the literature. The BT utilizes three commonly used anatomical landmarks. It predictably helps in proper anatomic orientation, identification and preservation of FNT and branches with ease in parotidectomies.

Leptomeningeal Enhancement Is Associated with Transient Neurologic Deficits after Flow Diversion of Intracranial Aneurysms

To evaluate the relationship between blood-brain barrier disruption and transient neurologic deficits (TNDs) after neuroendovascular interventions (NEIs) using postcontrast T2/FLAIR (pcFLAIR) imaging. This is a prospective study of 41 consecutive patients undergoing flow diversion therapy for unruptured aneurysm treatment. Patients underwent postprocedural magnetic resonance imaging within 24 hours of the procedure, including diffusion-weighted imaging (DWI) and pcFLAIR sequences. Regression analyses were performed to identify risk factors for developing TNDs. In total, 13 patients (31.7%) developed neurologic complications ranging from visual field defects to dense hemiplegia. All deficits were transient, resolving spontaneously within 72 hours. Five of 13 patients (38.5%) with TNDs had presence of lesions on DWI whereas the remaining 8 patients (61.5%) did not. In contrast, all patients who developed TNDs had leptomeningeal enhancement on pcFLAIR imaging, and no patient with normal pcFLAIR imaging developed TNDs. Regression analysis revealed the extent of pcFLAIR enhancement is associated with development of postprocedure neurologic deficits (P < 0.0001). Video electroencephalography monitoring was performed in 4 symptomatic patients manifesting severe deficits. In all instances electroencephalography demonstrated ipsilateral hemispheric slowing and eventual resolution corresponding to ensuing clinical improvement. Only 1 of these 4 patients presented with a lesion on DWI. This study challenges conventional dogma that TNDs are ischemic in etiology and suggests blood-brain barrier impairment may be a potential alternative mechanism. These findings are applicable to stroke and other reversible neurologic diseases.

Towards unambiguous reporting of complications related to deep brain stimulation surgery: A retrospective single-center analysis and systematic review of the literature.

Background and objectiveTo determine rates of adverse events (AEs) related to deep brain stimulation (DBS) surgery or implanted devices from a large series from a single institution. Sound comparisons with the literature require the definition of unambiguous categories, since there is no consensus on the reporting of such AEs.Patients and methods123 consecutive patients (median age 63 yrs; female 45.5%) treated with DBS in the subthalamic nucleus (78 patients), ventrolateral thalamus (24), internal pallidum (20), and centre médian-parafascicular nucleus (1) were analyzed retrospectively. Both mean and median follow-up time was 4.7 years (578 patient-years). AEs were assessed according to three unambiguous categories: (i) hemorrhages including other intracranial complications because these might lead to neurological deficits or death, (ii) infections and similar AEs necessitating the explantation of hardware components as this results in the interruption of DBS therapy, and (iii) lead revisions for various reasons since this involves an additional intracranial procedure. For a systematic review of the literature AE rates were calculated based on primary data presented in 103 publications. Heterogeneity between studies was assessed with the I2 statistic and analyzed further by a random effects meta-regression. Publication bias was analyzed with funnel plots.ResultsSurgery- or hardware-related AEs (23) affected 18 of 123 patients (14.6%) and resolved without permanent sequelae in all instances. In 2 patients (1.6%), small hemorrhages in the striatum were associated with transient neurological deficits. In 4 patients (3.3%; 0.7% per patient-year) impulse generators were removed due to infection. In 2 patients electrodes were revised (1.6%; 0.3% per patient-year). There was no lead migration or surgical revision because of lead misplacement. Age was not statistically significant different (p>0.05) between patients affected by AEs or not. AE rates did not decline over time and similar incidences were found among all patients (423) implanted with DBS systems at our institution until December 2016. A systematic literature review revealed that exact AE rates could not be determined from many studies, which could not be attributed to study designs. Average rates for intracranial complications were 3.8% among studies (per-study analysis) and 3.4% for pooled analysis of patients from different studies (per-patient analysis). Annual hardware removal rates were 3.6 and 2.4% for per-study and per-patient analysis, respectively, and lead revision rates were 4.1 and 2.6%, respectively. There was significant heterogeneity between studies (I2 ranged between 77% and 91% for the three categories; p< 0.0001). For hardware removal heterogeneity (I2 = 87.4%) was reduced by taking study size (p< 0.0001) and publication year (p< 0.01) into account, although a significant degree of heterogeneity remained (I2 = 80.0%; p< 0.0001). Based on comparisons with health care-related databases there appears to be publication bias with lower rates for hardware-related AEs in published patient cohorts.ConclusionsThe proposed categories are suited for an unequivocal assessment of AEs even in a retrospective manner and useful for benchmarking. AE rates in the present cohorts from our institution compare favorable with the literature.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P76. Growing rods instrumentation for early-onset spinal deformities at five-year follow-up

BACKGROUND CONTEXT The growing rod (GR) technique is a viable alternative for current nonfusion operations of early-onset scoliosis. Conventional GR rods are lengthened to allow for spinal growth to occur, but rod lengthening requires multiple invasive operations performed under general anaesthesia. Such operations are highly costly and associated with negative psychosocial outcomes. Growing rods with a sliding pedicle screw system (GRSPSS), a newly invented instrumentation, has been developed to treat spinal deformities without the need for repeated operative lengthening. A retrospective review of patients treated by the GRSPSS for early-onset spinal deformity was performed at a >5-year follow-up to describe clinical outcomes caused by this instrumentation. PURPOSE To study the safety and effectiveness of the GRSPSS. STUDY DESIGN/SETTING A retrospective study. PATIENT SAMPLE Eighteen. OUTCOME MEASURES Cobb angle. Complications. METHODS We implanted the GRSPSS in 33 early-onset scoliosis patients, 18 of whom had reached a 5-year follow-up at the time of the study. We used standard, clinical radiographic methods to measure the magnitude of spinal curvature and spinal length. RESULTS Our sample comprised 18 patients (10 girls and 8 boys) with a mean age of 8years old. The mean preoperative curve, 66.8°, was corrected to 28° at 4 weeks' follow-up. This magnitude of correction was maintained at the 5-year follow-up. T1–S1 spinal height [RH1] gained an average of 35 mm from postoperative measurements to those taken at 5-years' follow-up. Complications in the sample population included transient neurological deficit (n=1) and mild, recoverable skin infection at one end of the rods (n=3) during the early postoperative period. Two patients required minimally invasive revision surgery because of shoulder imbalance. There were no other neurological deficits or evidence of implant failure. CONCLUSIONS The GRSPSS procedure can effectively correct spinal deformity at a 5-year follow-up, with an acceptable incidence of complication. This new instrumentation may be a promising approach for facilitating spinal growth without repeated lengthening operations.

Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL)

The authors make a narrative review on "headache syndrome and transient neurological deficits with cerebrospinal fluid lymphocytosis (CRL)," a rare, underdiagnosed disorder of little knowledge by physicians specializing in care in the emergency room. Aspects of the clinical picture, diagnosis, prognosis, and treatment are discussed&#x0D;

Repeat Radiosurgery Treatment After Cavernous Malformation Radiosurgery

Of cavernous malformations (CMs) treated with radiosurgery (RS), 5% bleed after 2-year initial latency period. This rate is similar to failure rate of RS for other pathologies, which often require repeat RS for favorable outcome. The aim of this pilot study was to define failure of CM RS and to assess safety of second RS. Retrospective analysis was performed of 7 of 345 CMs retreated with RS; 6 CMs were deep-seated, and 1was superficial. Median time between the 2 treatments was 8 years (range, 3-16 years), and median follow-up time after second RS was 3 years (range, 1-9 years). Following the 2-year latency period after RS, 6% of deep-seated and 5% of hemispheric CMs, and 6% of deep-seated and 2% of hemispheric lesions caused transient neurologic deficits without hemorrhage. A second treatment was indicated for rebleed in 5 cases and for recurrent transient neurologic deficits in 2 cases. Prescribed dose was 15 Gy (range, 12-20 Gy) at first treatment and 12 Gy (range, 12-18 Gy) at second treatment. Target volumes were 692 mm3 (range, 54-2400 mm3) and 935 mm3 (range, 150-1550 mm3) at first and second treatments, respectively, and treatment volumes were 811 mm3 (range, 79-2500 mm3) and 962 mm3 (range, 194-1750 mm3), respectively. Differences in treatment parameters were not significant. Reason for failure was inaccurate target definition in only 2 cases. There were no bleeds, morbidity, or mortality after second RS. Second RS applied to previously treated CMs is safe and may be effective. Further investigations are needed to verify these findings and assess long-term benefit of second RS.