There is a well-documented association between Cushing's syndrome (CS) and hypercoagulability. However, there is limited data on the risk of venous thromboembolic events (VTEs) after surgery for Cushing's disease (CD). There is no consensus on optimal postoperative anticoagulation strategies in this group. This review gathers information on the rates of VTE after surgery for CD, as well as reported prophylaxis strategies in this population.
A literature search was performed using Cochrane Library, EMBASE, and Ovid MEDLINE databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A narrative review of papers discussing mechanisms of hypercoagulability in CS was conducted.
Twenty-five relevant papers were identified out of 944 papers yielded. Pooled postoperative VTE incidence in patients undergoing transsphenoidal surgery for CD was 2% (58 out of 2997). The pooled rate of VTE-associated mortality based on the 23 studies that reported this information was 0.2% (6 out of 2077). There were no cases of postoperative VTE in the 191 patients undergoing adrenalectomy for benign adrenocorticotropic hormone-independent CS. Ten studies reported information on perioperative thromboprophylaxis strategies in transsphenoidal surgery for CD and adrenalectomy for adrenocorticotropic hormone-independent CS.
Postoperative VTE in CD is a source of morbidity, with a rate of 2% and mortality rate of 0.2%, highlighting that surgical resection of the corticotroph adenoma does not necessarily result in immediate resolution of hypercoagulability. Increased production of coagulation factors, impaired fibrinolysis, inflammation, and CS-associated metabolic risk factors all factor into the pathogenesis of CS-associated hypercoagulability. Further study is needed on an optimal pharmacologic prophylaxis strategy.
Objective: To evaluate the effects of a multimodal management technique combining surgical muscle wrapping, clipping, and flow-diverter stent (FDS) placement in patients with ruptured blood blister-like aneurysms (BBAs) in the internal carotid artery (ICA).
Methods: In a retrospective case series review from 2020 to 2023, 3 patients with ruptured ICA BBAs underwent multimodal management, an approach combining muscle wrapping, surgical clipping, and FDS embolization. The aneurysm sac was initially packed and wrapped with multiple tailored temporalis muscle grafts and then secured using fenestration clips, with good preservation of the ICA branches. The FDS was placed 2-3 weeks after the clipping.
Results: All 3 patients had right ICA BBAs (mean age, 52 years). The modified Hunt and Hess grades ranged from 2 to 3, and the Fisher grades ranged from 3 to 4. The mean angiography follow-up time was 27.7 months (15, 31, and 37 months). There were no instances of symptomatic vasospasm or visible ischemic stroke during follow-up computed tomography. No patient required cerebrospinal fluid shunt implantation, and all achieved favorable neurological outcomes (modified Rankin scale 0-1). Follow-up digital subtraction angiography revealed no evidence of aneurysm recurrence or significant ICA stenosis.
Conclusions: We discuss a promising multimodal management approach for ruptured ICA BBAs combining muscle wrapping, surgical clipping, and FDS embolization. This technique was safe and effective in preventing re-rupture, achieving positive short-term clinical outcomes. Further research and more extensive studies are required to validate the long-term efficacy of this approach.
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is often complicated by cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI), which significantly impact patient outcomes. The study aimed to investigate the predictive value of systemic serum biomarker levels for CVS and DCI following aSAH.
Methods: We retrospectively analyzed data for 450 aSAH patients admitted to University Hospital Düsseldorf between January 2011 and October 2021. Serum biomarkers were measured on admission. The occurrence of CVS and DCI was assessed based on clinical and radiological criteria. Multivariate logistic regression analysis was performed to determine the independent association of serum biomarkers with CVS and DCI. We compared the predictive values of various models using the area under the receiver operating characteristic curve.
Results: Of the 450 patients, 126 (28.0%) developed CVS, 123 (27.3%) developed DCI, and 62 (13.8%) developed co-occurring CVS and DCI. Patients with CVS, DCI, or both had significantly higher admission C-reactive protein (CRP) levels than those without these complications (P < 0.001). Elevated CRP levels were independently associated with an increased risk of CVS, DCI, and co-occurring CVS and DCI (P < 0.05). CRP demonstrated a higher predictive value for CVS (area under the curve [AUC]: 0.811) and co-occurring CVS and DCI (AUC: 0.802) compared to DCI alone (AUC: 0.690).
Conclusions: Our findings suggest that admission systemic CRP levels can serve as a more valuable predictor for developing CVS than DCI following aSAH. Incorporating CRP into clinical assessments may aid in risk stratification and early intervention strategies for patients at high risk of these complications.
Objective: The aim of this study is to determine the maximum loss of median and ulnar nerve substances that can be treated by direct suture in elbow flexion and to quantify this elbow flexion. The other objective is to determine the participation of the wrist position in this direct suture in elbow flexion.
Methods: We performed an experimental study on 6 ulnar nerve lesions and 6 median nerve lesions. For each defect, a direct tensionless suture was performed with elbow flexion and in three different positions of the wrist (wrist extension, neutral position, and wrist flexion).
Results: A 90° elbow flexion allowed direct suturing of defects up to 40 mm in the 3 positions of the wrist. A bowstringing effect (i.e., increase of the perpendicular distance of the nerve from the axis of rotation of the elbow) was noted starting from 25 mm of nerve defect. Wrist extension placed tension on the nerve suture for both nerves.
Conclusions: The results of this first anatomical study clarified the conditions for direct suturing of ulnar and median nerve defects in the flexed elbow position and flexed wrist position. This is an approach to consider for limited nerve defects to the elbow or when allograft harvesting is to be avoided.
Background: The relationship of spinopelvic parameters with spondylolisthesis is widely explored. However, there is scarce evidence on correlation of tuberculosis of lumbar spine with respect to spinopelvic harmony. The current study aims to find the association between functional outcomes and spinopelvic parameters in lumbar spine tuberculosis treatment.
Methods: A total of 47 patients with active tuberculosis confined to lumbar spine were prospectively analyzed and divided into 2 groups according to mode of intervention. Group A included 26 operatively managed patients and group B had 21 conservatively managed cases. Functional parameters comprising Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) along with spinopelvic radiologic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], lumbar lordosis [LL], PI-LL, sagittal vertical axis) in both groups were analyzed at 0 and 6 months of follow-up.
Results: Both the groups showed significant improvement from initial presentation to final follow-up in ODI (Group A: 85.4 ± 12.1-12.3 ± 3.2, P = 0.02; Group B: 82.5 ± 10.06-36.8 ± 11.9, P = 0.04) and VAS (Group A: 8.1 ± 1.2-1.4 ± 0.9, P = 0.02; Group B: 8.5 ± 0.09-3.5 ± 1.1, P = 0.02). Statistically significant (P < 0.05) difference was observed in both functional outcome parameters between the 2 groups at 2-month and 6-month follow-up, compared with nonsignificant difference (P > 0.05) at presentation. Better improvements of spinopelvic parameters of PT, SS, LL, PI-LL were observed in Group A and in both groups the difference of these parameters correlated with differences of functional outcome parameters, though PI showed no correlation.
Conclusions: The spinopelvic parameters played significant role in functional outcome. There is better functional outcome when LL is adequately restored. Surgical correction offered betterment of spinopelvic parameters like PT, SS, an sagittal vertical axis, which in turn leads to improvement in functional outcome.
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