Asian journal of neurosurgery最新文献

Primary intracranial melanomas are an extremely rare entity and are a diagnosis of exclusion. Malignant melanoma represents the third most common site for cerebral metastasis. We hereby narrate a comprehensive and detailed case of metastatic intracranial melanomas with BRAF mutation, which later on had an extensive systemic spread. The imaging differentials include metastasis, intracranial hemorrhage, or granuloma. The final and definitive diagnosis was attained by detailed clinical, histological, and immunohistochemical evaluation as metastatic malignant pigmented tumor consistent with intracranial melanoma.

Objective: Mechanical thrombectomy (MT) alone or with intravenous thrombolysis (IVT) avoids disabilities in patients with acute ischemic stroke. The purpose of this study is to assess the outcome in two different age groups by combined technique (simultaneous stent retriever plus syringe aspiration) following thrombolysis in anterior circulation stroke and to analyze predictive factors.

Materials and methods: We retrospectively studied all patients ( n  = 500) who had ≥ modified thrombolysis in cerebral infarction (mTICI)2b following Solitaire stent retriever MT following IVT. Patients with anterior circulation stroke were dichotomized based on whether younger or older than 50 years. We analyzed predictive factors for favorable clinical outcome and also evaluated the age-related adverse results, with focus on symptomatic intracerebral hemorrhage within 7 days, favorable outcome (modified Rankin scale [mRS] 0-2), and mortality at 3 months following procedure.

Results: Among a total of 500 patients, 144 patients were in the young age group (≤50 years) with a mean age of 37.10 years, and 356 patients were in the old age group (>50 years) with a mean age of 63.55 years. There was a significant association between these two groups in the etiologies, medical history, age, puncture to recanalization time, and adverse results. Similarly, patient age ≤50 years, National Institute of Health Stroke Scale score at admission < 15, Alberta Stroke Program Early CT Score >5, mTICI3, and onset to recanalization time < 4 hours were significantly predictive factors for a favorable outcome.

Conclusion: Our study shows that the combined technique after IVT for anterior circulation stroke in large vessels is safe and effective; however, younger age has a higher rate of favorable outcome with a lower mortality rate.

Objective: Preoperative embolization of meningiomas with n-butyl 2-cyanoacrylate (NBCA) is problematic as its adhesive nature may force termination prior to achieving adequate embolization of intratumoral vessels. Herein, we report the use of ultralow concentration NBCA embolization to address this issue.

Materials and methods: Seventeen patients with meningiomas underwent embolization with ultralow concentration NBCA. Twenty-four tumor-feeding vessels were embolized with 5% NBCA to allow infiltration of the intratumoral vessels. Overall, this method achieved a reduced operative time and blood loss during the resection as compared with those of the nonembolized group.

Results: Embolization was achieved in all patients at ultralow concentrations. Additionally, 20 vessels (83.3%) were embolized up to the intratumoral level. Warmed 5% NBCA aided in the embolization of intratumoral vessels. Embolization effectively controlled bleeding in all patients, while in 15 patients (88.2%), some form of tumor necrosis or softening was observed, predominantly in the area of dural attachment, demonstrating the efficacy of embolization in tumor removal. No embolization-related complications were observed. The mean operative time for resection was significantly different between the embolization (17 patients) and nonembolization (9 patients) groups (316 vs. 412 minutes, p  = 0.0271). In these two groups, the mean blood loss was 349 versus 575 mL, the mean maximum tumor diameter was 56.8 versus 35.4 mm ( p  = 0.0089), and the mean age was 73.3 versus 72.3 years, respectively, with the significantly larger embolization group having shorter operation time and less blood loss.

Conclusion: Embolization of meningiomas with ultralow concentrations of NBCA can help to reach intratumoral vessels.

Background: Accurate prediction of outcomes in traumatic brain injury (TBI) is crucial for optimizing therapeutic interventions and improving patient survival rates.

Objectives: This article determines the diagnostic accuracy of Madras Head Injury Prognostication Scale (MHIPS) in predicting mortality among patients with TBI, and compares the performance of MHIPS scores with that of Corticosteroid Randomisation after Significant Head Injury (CRASH) and International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) scores.

Materials and methods: This was a prospective observational study conducted among patients ( n  = 100) with clinical evidence of TBI presenting to the Department of Emergency Medicine, R. L. Jalappa Hospital and Research Centre, Tamaka, Karnataka, India, between August 2023 and July 2024.

Results: Of the 100 patients, 92 patients (92.0%) were survivors of which 4 patients (4.0%) had disability and 8 patients died/nonsurvivors (8.0%). Age more than 40 years, higher heart rate, lower Glasgow Coma Scale scores, lower MHIPS scores, higher CRASH scores, and higher IMPACT scores were significantly ( p  < 0.05) associated with mortality among patients with TBI. However, gender, mode of injury, diagnosis, time to presentation, systolic blood pressure (BP), diastolic BP, and respiratory rate did not vary significantly between nonsurvivors and survivors in the present study ( p  > 0.05). The mean (standard deviation) duration of ventilation among nonsurvivors was 3.3 (2.2), and that among survivors was 0.5 (1.1)-the difference was statistically significant ( p  < 0.05). The area under the curve of MHIPS scores was 0.912, in comparison with 0.893 for CRASH scores and 0.927 for IMPACT scores ( p  < 0.05). The MHIPS scores, with a cutoff of 13.5, showed a sensitivity of 87.5%, specificity of 81.5%, positive predictive value (PPV) of 29.2%, and negative predictive value (NPV) of 98.7%. The CRASH scores, with a cutoff of 5.5, demonstrated a sensitivity of 87.5%, specificity of 53.3%, PPV of 14.0%, and NPV of 98.0%. The IMPACT scores, with a cutoff of 8.5, had a sensitivity of 87.5%, specificity of 91.3%, PPV of 46.7%, and NPV of 98.8%. All three scoring systems showed statistically significant predictive accuracy.

Conclusion: MHIPS, CRASH, and IMPACT are effective tools for prognosticating mortality in TBI patients. MHIPS score offers simplicity and ease of use, making it valuable in resource-limited environments.

Introduction: The evaluation of clipped intracranial aneurysms postoperatively is crucial for successful surgical treatment and minimizing risks such as residual aneurysms and complications. Fluorescein sodium videoangiography (FL-VA) has been introduced to aid in this assessment, but comparative studies with postoperative imaging remain limited.

Materials and methods: A prospective observational study was conducted on 57 patients with 64 intracranial aneurysms who underwent surgery between December 2021 and September 2022. FL-VA was performed, followed by postoperative computed tomography angiography (CTA). Discordance between FL-VA and CTA findings was analyzed statistically.

Results: FL-VA showed complete occlusion in 57 out of 61 aneurysms (93.4%), with 10 cases of discordance identified in postoperative CTA. One patient showed a neck remnant in FL-VA, but CTA revealed a residual aneurysm. Another patient displayed neck remnant and stenosis in branching vessels on CTA, not identified by FL-VA. Additionally, five aneurysms had neck remnants, and three had stenosis in branching vessels, detected in CTA but missed in FL-VA. Statistical analysis did not reveal significant associations between discordance and studied factors.

Conclusion: FL-VA shows potential as an effective intraoperative assessment tool for clipped intracranial aneurysms, although further research is needed to establish its definitive efficacy and reliability compared with other modalities.

Low-grade fibromyxoid tumors are very uncommon in children. A tumor of this type has never been reported in the posterior fossa to date. Such lesions may mimic more common lesions of the posterior fossa. Awareness of this entity and its subsequent behavior may guide better management and outcomes. We describe the case of a previously unreported low-grade angiomyxofibromatous tumor of the falx cerebelli in a 10-year-old female, whose presentation mimicked cystic lesions of the posterior fossa causing obstructive hydrocephalus. Microscopic examination revealed stellate cells set in myxoid and edematous stroma, along with a plexiform vasculature pattern. The tumor cells were diffusely immunopositive for vimentin and focally positive for S-100 protein, but negative for epithelial membrane antigen, CD34, MIC2, Bcl-2, glial fibrillary acidic protein, cytokeratin, CAM 5.2, desmin, and smooth muscle actin. This lesion could not be categorized according to the current World Health Organization classification of tumors of the nervous system. Therefore, there is a need for a better understanding of the central nervous system (CNS) myxoid neoplasms and a reassessment of the classification of CNS tumors.

Objectives: Postoperative meningitis following endoscopic endonasal transsphenoidal surgery (TSS) is a critical outcome metric. Meningitis is one of the most severe complications in neurosurgery, particularly with transsphenoidal procedures, due to the potential for bacterial contamination from the nasal or sinus cavities. Identifying the risk factors associated with postoperative meningitis is crucial for preventing and minimizing this risk in future surgeries.

Materials and methods: The study reviewed admission forms, operative notes, and the occurrence of various complications in patients who underwent the TSS approach between 2010 and 2024, focusing on variations in health care access and surgical practices.

Statistical analysis: Descriptive statistics will summarize demographic, surgical, and clinical characteristics. Univariate analysis: risk factors for meningitis could be evaluated through chi-square tests for categorical variables (e.g., presence of a cerebrospinal fluid [CSF] leak) and t -tests or analysis of variance for continuous variables (e.g., age, surgery duration). Multivariate logistic regression: to identify independent predictors of meningitis, logistic regression could be used.

Results: A total of 237 patients who underwent TSS between 2010 and 2024 were included in the final analysis. The overall incidence of postoperative meningitis was 23%. Intra- and postoperative CSF leakage, diabetes mellitus, obesity, and previous sinus or nasal infection were found to be a significant factor associated with postoperative meningitis.

Conclusion: Understanding the risk factors for meningitis following TSS is crucial for improving patient outcomes. While preoperative nares cleaning with normal saline may reduce nasal congestion, our findings indicate that it does not significantly affect the rate of postoperative meningitis compared with Hibitane-only cleaning.

Nimodipine, a calcium channel blocker of the dihydropyridine class, is used prophylactically in ruptured aneurysmal subarachnoid hemorrhage (aSAH) patients to reduce the incidence of poor outcome, delayed cerebral ischemia, and delayed ischemic neurological deficits. This case series reports nine instances of normal anion gap metabolic acidosis (NAGMA) in patients with aSAH following intravenous nimodipine administration in a neuro-intensive care unit (NICU) over 2 months. The patients, aged 4 to 68 years (seven male, two female), presented with acute headaches and were diagnosed with intracranial aneurysms, managed with aneurysmal clipping or coiling. Intravenous nimodipine (1-2 mg/hour) was initiated as per protocol, along with standard NICU care. After 48 to 72 hours, patients developed hyperventilation, respiratory alkalosis, and a significant decrease in bicarbonate, leading to NAGMA. Despite ruling out common causes like gastrointestinal losses and nephrotoxic drugs, renal tubular acidosis was suspected. The NAGMA resolved spontaneously 6 to 7 days postsurgery, coinciding with the discontinuation of intravenous nimodipine. A retrospective audit revealed a common factor: using a specific brand of intravenous nimodipine, a new arrival from the hospital supply. This phenomenon was later corroborated in a similar case from another hospital. The case highlights the importance of pharmacovigilance, postmarketing surveillance, and regulatory oversight in identifying rare drug-related adverse events, particularly in high-acuity settings like NICU.

Calvarial lesions are uncommonly encountered and are often a slow and progressive process. Biopsies of calvarial lesions can be uniquely challenging due to its proximity to critical structures. Augmented reality (AR) offers a potential alternative to computed tomography guidance that reduces radiation exposure and provides hands-free intraoperative guidance through complex and challenging surgical approaches. The patient is an 86-year-old female with significant past medical history of coronary heart disease. The patient underwent imaging which demonstrated a left parietal lytic skull lesion with extracranial extension. Using Surgical AR (Medivis, New York, New York, United States), a trajectory was planned centered on the lesion. Surgical AR was registered using point-to-point registration reliant on four anatomic fiducials. We used a ground truth, which is a bi-faced adhesive tag that measures 2 cm × 1 cm, with a QR code on each side that the Surgical AR system recognizes. This ground truth was placed on the patient's forehead, which linked to the registered holographic overlay. A small incision was made and after removal of a small portion of the overlying skull, multiple pieces of the lytic skull lesion were sampled. A specimen was obtained for frozen sectioning. Intra-operative pathology was consistent with metastatic carcinoma. Total surgical time was 35 minutes from incision to closure. The frameless AR navigation system successfully allowed accurate location, visualization, and biopsy of a calvarial lesion that had minimal surface landmarks. More so, this was completed without obscuring the surgical field or requiring time-consuming setup or registration.