Surgical neurology international最新文献

Background: Propofol is one of the most used intravenous anesthetic agents in traumatic brain injury (TBI) patients undergoing emergency neurosurgical procedures. Despite being efficacious, its administration is associated with dose-related adverse effects. The use of adjuvants along with propofol aids in limiting its consumption, thereby mitigating the side effects related to propofol usage. This study aims to compare the safety and efficacy of dexmedetomidine-propofol versus fentanyl-propofol-based total intravenous anesthesia (TIVA) in adult TBI patients.

Methods: A hundred patients posted for emergency evacuation of acute subdural hematoma were enrolled, and they were randomized into two groups of 50 each. Propofol-based TIVA with a Schneider target-controlled infusion model was used for induction and maintenance. Patients in Group F received fentanyl, and those in Group D received dexmedetomidine infusions as adjuvants. Advanced hemodynamic parameters were monitored. Intracranial pressure (ICP) and brain relaxation were measured after dural opening. The mean propofol consumption, number of additional fentanyl boluses, and blood samples for S100b (a biomarker of neuronal injury) were also collected.

Results: The mean propofol consumption in Group D (88.7 ± 31.8 μg/kg/min) was lower when compared to Group F (107.9 ± 34.6 μg/kg/min), (P = 0.005). The mean intraoperative fentanyl requirement and postoperative S100b were significantly reduced in Group D. Subdural ICPs and brain relaxation scores were comparable. Hemodynamic parameters were well maintained in both groups.

Conclusion: In TBI, dexmedetomidine as an adjunct to propofol-based TIVA results in a greater reduction in total propofol consumption and intraoperative opioid requirements while maintaining hemodynamic stability when compared to fentanyl.

Background: Causes of cerebrospinal fluid (CSF) rhinorrhea could be divided into primary (spontaneous) and secondary (head trauma and iatrogenic). Idiopathic intracranial hypertension (IIH) has emerged as a cause for spontaneous CSF rhinorrhea but is still underestimated, may be overlooked and needs special consideration in management. The objective of this study is to demonstrate spontaneous CSF rhinorrhea as the primary presentation of IIH and explore the algorithm of management.

Methods: All patients with spontaneous (primary) CSF rhinorrhea were included with complete clinical and radiological assessment. We performed lumbar puncture and CSF pressure measurements in the lateral decubitus position for all included patients to detect those with intracranial hypertension. A pressure of 20 cmH2O in cases of CSF rhinorrhea is considered a cutoff for diagnosing raised intracranial pressure. When intracranial hypertension was diagnosed, patients were subjected immediately to lumboperitoneal shunt. If CSF leakage stopped after shunt insertion, we would not perform skull base repair, and the patient was sent for follow-up. However, if CSF leakage did not stop after shunt insertion despite normalization of intracranial tension or recurrence of CSF rhinorrhea despite shunt patency or there was intracranial pneumocephalus, skull base repair would be performed.

Results: During the period of the study, 293 cases of CSF rhinorrhea were seen. Only 42 (14.3%) patients were diagnosed with spontaneous CSF rhinorrhea, and the remaining were posttraumatic. Thirty-seven patients (88.1%) of 42 patients revealed high CSF pressure readings. All 37 patients received lumboperitoneal shunt followed by CSF rhinorrhea stoppage. Later, during follow-up, 7 patients developed recurrence of leakage; 3 of them revealed shunt obstruction, and rhinorrhea improved after shunt revision. The other 4 patients revealed patent shunt and needed skull base repair.

Conclusion: Spontaneous CSF rhinorrhea is considered secondary to IIH until proven otherwise. Initial placement of lumboperitoneal shunt may provide an effective alternative to skull base repair for the treatment of patients with IIH presenting with CSF rhinorrhea.

Background: Intracranial arteriovenous malformations (AVMs) are extremely rare in the pediatric population, with an estimated prevalence of 0.014-0.028%. About 75-80% of pediatric AVMs present with intracranial hemorrhage, a source of significant morbidity and mortality. Awake craniotomy (AC) has become the standard approach for resecting eloquent area intracranial lesions in the adult population. Its use, however remains limited in the pediatric population and has very rarely been reported for an AVM of the motor cortex in this age group.

Case description: We report the case of a 17-year-old, right-handed boy who presented to our setup with a 2-month history of left-sided hemiparesis and left facial hypoesthesia following an episode of acute loss of consciousness (ALOC) while playing football. A computed tomography scan done after ALOC revealed an AVM in the right frontoparietal cortex with associated acute hemorrhage. Digital subtraction angiography (DSA) was done which revealed a right-sided grade II AVM with arterial supply from the right middle cerebral artery and venous drainage into the superior sagittal and cavernous sinuses. The patient underwent elective neuronavigation-guided right frontoparietal AC and resection of AVM. Postoperative DSA revealed no residual disease. The patient's neurologic deficits showed improvement in the first few days following surgery. He was discharged with advice to follow up in a neurosurgery clinic to monitor his postoperative recovery and ensure compliance with physiotherapy.

Conclusion: This case represents only the second pediatric patient in the available medical literature to have ever undergone AC for intracranial AVM resection. Pediatric AVMs are a rare entity and pose the risk of significant morbidity and mortality. Awake surgery has the potential to reduce iatrogenic neurological deficits in the pediatric population significantly. More work must be done to increase pediatric patient compliance with awake surgery.

Background: Stereoelectroencephalography (SEEG) is a common diagnostic surgical procedure for patients with medically refractory epilepsy. We aimed to describe our initial experience with the recently released NeuroOne Evo SEEG electrode product (Zimmer Biomet, Warsaw, IN) and review technical specifications for other currently approved depth SEEG electrodes.

Methods: We performed a record review on the first five patients implanted with NeuroOne Evo SEEG electrode product using the robotic stereotactic assistance robot platform and described our surgical technique in detail. We recorded technical specifications of all currently Food and Drug Administration-approved SEEG electrodes for comparison.

Results: Our initial 5 surgical patients were reviewed. The average total time of operation was 92 min, with an average of 16.8 electrodes. The estimated time per electrode insertion was <2 min. There were no intracranial hemorrhages or hardware complications noted during monitoring. Monitoring provided diagnostic information in all patients, and removal and incision healing proceeded without issues.

Conclusion: NeuroOne SEEG electrodes can be implanted with efficiency and provide a valuable additional tool for the epilepsy surgeon. A tapered drill bit prevents the bolt from being placed beyond the inner cortex and may reduce the risk of brain contusion or inadvertent advancement of anchor bolts, and the electrode internal stylet also affords the potential to reduce the number of trajectory passes.

Mesh terms: Epilepsy, EEG, Drug-resistant Epilepsy, Intracranial EEG.

Background: Epilepsy poses significant challenges globally, with varied clinical, social, and economic impacts. Despite advances in treatment, epilepsy-related mortality remains a concern. This study aimed to analyze the demographic and regional distributions of epilepsy-related mortality in the United States (U.S.) from 1999 to 2020, identifying high-risk populations for targeted interventions.

Methods: Data on death certificates were obtained from the 1999 to 2020 Centers for Disease Control and Prevention Wide-Ranging Online Study Epidemiologic Research (CDC-WONDER) database. We gathered data on demographics, place of death, and urban/rural classification. Mortality rates per 100,000 people were computed and classified according to state, year, sex, race/ethnicity, and urban/rural status. Trends were examined using Joinpoint regression.

Results: A total of 12,573 deaths (age <35), 22,947 (35-64), and 21,782 (65+) were attributed to epilepsy. Mortality rates varied by age group, sex, race/ethnicity, and region. Trends showed significant increases, notably in middle-aged and older adults, with higher rates in males and nonHispani, African American populations.

Conclusion: Epilepsy-related mortality exhibits demographic and regional disparities in the U.S. Understanding these patterns can guide targeted interventions to mitigate mortality risk.

Background: The presence of a human tail is a rare condition resulting from an embryonic remnant that fits the definition of a caudal appendage. It may be a vestigial (true) or a pseudotail. Both may be considered markers of underlying intraspinal abnormalities.

Case description: The present case documents a 5-year-old girl with a caudal appendage in the lumbar region, with a previously normal neurological examination. Spinal magnetic resonance imaging (MRI) showed the presence of occult spinal dysraphism associated with a cutaneous appendage with lipomatous content. We performed microsurgical treatment to excise the lesion and explore the occult spinal dysraphism. A histopathological examination revealed mature adipose tissue with blood vessels and nerve fibers and no bone or cartilage tissue.

Conclusion: The presence of a tail-like appendage in the lumbosacral region must alert to the possibility of underlying occult spinal dysraphism. Preoperative assessment must include a complete neurological examination and a detailed MRI evaluation.

Background: This study aimed to analyze the incidence of delayed cerebral ischemia (DCI) and outcome stratified by age in patients who suffered aneurysmal subarachnoid hemorrhage.

Methods: A cohort study with patients from Christ the Redeemer Hospital from 2014 to 2020, with 359 patients separated into 2 groups, 48 of them aged under 40 years and 311 aged 40 years or over.

Results: In patients under 40 years of age, DCI was found in 81.3%, while in patients aged 40 or over, it was 61.4%. A relative risk of 1.32 (confidence interval: 1.12-1.55), with P = 0.013. After multivariate assessment, patients aged under 40 years were found to have a 27-39% higher risk of presenting DCI.

Conclusion: We identified that age under 40 years is a risk factor for the occurrence of DCI.

Background: Traumatic brain injury (TBI) remains the predominant cause of mortality and disability among the pediatric population. At present, there are no radiation-free, simple, and cost-effective tools available to assess the severity and prognosis of pediatric TBI. The systemic immune-inflammation index (SII), neutrophilto-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) serve as inflammatory biomarkers that may assist in predicting the outcome of pediatric TBI. This research aims to assess the utility of SII, NLR, and PLR as a predictive biomarker in children with TBI.

Methods: A retrospective analysis was conducted on SII, NLR, and PLR by reviewing the medical records of all pediatric (age ≤18 years) TBI cases who came to the emergency department in the period from January 2023 to August 2024. Patients were categorized according to 28-day mortality and the severity of TBI. The correlation between the biomarkers and outcomes was analyzed.

Results: A total of 206 patients were included in this study. The mean age was 13.81 (1-18). The 28-day mortality rate was 5.3% (n = 11). There were no significant differences in SII, NLR, and PLR between the survivor and mortality groups (P = 0.317, P = 0.288, and P = 0.200, respectively). Based on the TBI severity, there was a significant difference in the SII, NLR, and PLR across mild, moderate, and severe TBI (P = 0.006, P = 0.002, P = 0.001, respectively).

Conclusion: The findings of our study did not reveal a significant predictive relationship between SII, NLR, and PLR to 28-day mortality. Nonetheless, there were significant differences in SII, NLR, and PLR among mild, moderate, and severe TBI groups. Further research under more controlled conditions is essential to facilitate the use of SII, NLR, and PLR as predictive biomarkers in pediatric TBI.

Background: Intracranial chondrosarcomas are malignant tumors that most commonly affect the clivus region. For tumors in this location, the extended endoscopic endonasal approach could offer an alternative route. We present a case of pons herniation after this technique.

Case description: A 55-year-old female presented with a 6-month history of difficulty walking. The neurological evaluation showed asymmetric tetra paresis and involvement of the IX cranial nerve on the right side. Imaging exams showed a lesion at the upper clivus, with a possible diagnosis of chondrosarcoma. An extended transclival approach with partial resection and a multilayer closure were performed. The patient had a slight immediate improvement in muscle strength, and she was discharged home 5 days after surgery. Four weeks later, she evolved with worsening strength on the left side. A new image examination revealed an atypical protrusion of the pontine tissue through the bone defect at the opening of the clivus; a surgical revision was proposed, but the patient chose conservative management.

Conclusion: Pontine herniation is a rare complication with no defined cause. The use of a rigid material for closure could reduce the chances of this complication, but futher studies are necessary to reinforce that hypothesis.