Clinical Neurology and Neurosurgery

Transcalvarial brain herniation volume as a predictor of posttraumatic hydrocephalus after decompressive craniectomy Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Angelo R. Silva Neto, Marcelo M. Valença Abstract Objectives In patients undergoing decompressive craniectomy for traumatic brain injury(TBI) there has been reported an incidence of hydrocephalus between 0–45%. There are several radiological and clinical features described in association with development of hydrocephalus. For study the influence of these factors we conducted a retrospective observational single-center cohort study in a tertiary care center with special attention to the transcalvarial herniation(TCH) volume after decompressive craniectomy. Patients and methods: We selected 50 patients that underwent decompressive craniectomy after closed head injury between january 2014 and January 2015. Hydrocephalus was defined as a modified frontal horn index greater than 33%, presence of Gudeman CT scan criteria or insertion of ventriculoperitoneal Shunt. Variables analyzed were: age, post-resuscitation Glasgow coma scale (GCS) score, pupil reactivity, Zunkeller index, presence of hygroma, TCH volume, craniectomy diameter and distance of craniectomy from midline. Logistic regression was used with hydrocephalus as the primary outcome measure. Results 17 patients developed hydrocephalus (34%). TCH volume after decompression(p < 0.01), subdural hygroma (p < 0.01), lower admission Glasgow Coma Scale score (p = 0.015), unilateral pupil reactivity(p = 0.042) and higher Zumkeller index(p = 0.044) were significant risk factors for hydrocephalus. Logistic regression analysis showed that factors independently associated with the development of hydrocephalus was the TCH volume (odds ratio 11.08; 95%CI 2.10, 58.4; p = 0.0046), and presence of hygroma (odds ratio 49.59; 95%IC 4.1, 459; p = 0.002). Conclusions There was a clear association between severity of TBI, TCH volume and subdural hygroma with the development of hydrocephalus. Clinicians should follow closely patients with those findings in order to avoid late deterioration.

Cervical carotid pseudoaneurysm eroding the skin with impending blowout Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Abdelaziz Amllay, Ahmad Sweid, Stavropoula Tjoumakaris, Michael R. Gooch, Robert H. Rosenwasser, Pascal M. Jabbour

Two sisters with anti-MuSK-positive myasthenia gravis Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Erdal Kurt, Can Ebru Bekircan-Kurt, Bahadır Konuşkan, İrem Erkent, Ersin Tan, Banu Anlar

Predictability of vascular conflict by MRI in trigeminal neuralgia Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Patrick W. Hitchon, Girish Bathla, Toshio Moritani, Marshall T. Holland, Jennifer Noeller, Kirill V. Nourski Abstract Objective: Magnetic resonance imaging (MRI) has been investigated extensively in its success or failure to identify preoperative vascular compression in patients with trigeminal neuralgia (TN). To this end, we reviewed our case load to evaluate the concordance or discordance between preoperative MRI and intraoperative findings. Patients and Methods: Sixty-nine patients with Type 1 TN and retrievable MRI images, operative reports, and intraoperative photographs were retrospectively reviewed. Results: Our review shows that MRI predicted conflict (arterial or venous) in 58 cases that was confirmed at surgery in 55 cases. MRI predicted no conflict in 11 cases, whereas surgery revealed no conflict in a total of 6 cases. Thus, in predicting conflict at surgery, MRI had a sensitivity of 87%, and specificity of 50%, respectively. Conversely, MRI accurately predicted intraoperative conflict (positive predictive value) in 95% of cases, and the absence of conflict (negative predictive value) in 27%. These results reveal that MRI is more accurate in predicting conflict than the absence of conflict at surgery. Conclusion: Our results support the reliance on the clinical diagnosis of Type 1 TN to recommend microvascular decompression (MVD). The presence of vascular compression by MRI should encourage the surgeon to persevere in search of the offending vessel when it proves elusive. MRI positive and negative predictive values for conflict are expected to increase with better resolution imaging. The absence of neurovascular conflict on high-resolution MRI should not negate MVD in the treatment of a patient with classic TN.

Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Sumul Modi, Kavit Shah, Lonni Schultz, Rizwan Tahir, Muhammad Affan, Panayiotis Varelas Abstract Objective Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. Patients and methods Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. Results From 2002–2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11–23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40–59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60–79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost. Conclusion aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.

Nosocomial Infections among Patients with Intracranial Hemorrhage: A Retrospective Data Analysis of Predictors and Outcomes Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Roa'a W. Jaradat, Amro B. Lahlouh, Osama Y. Alshogran, Belal A. Aldabbour, Abedallah AK. Balusha Abstract Objective Intracranial hemorrhage is a critical medical emergency. Nosocomial infections may promote worse outcomes in these vulnerable patients. This study investigated microbial features, predictors, and clinical outcomes of nosocomial infections among patients with multiple subtypes of intracranial hemorrhage. Patients and methods We conducted a retrospective cohort study of patients that were hospitalized with intracranial hemorrhage between January 2015 and October 2018, and divided them into two groups based on the development of nosocomial infection. Within the cohort of patients with nosocomial infections, microbiology and resistance patterns were established across multiple sites of infection. Moreover, consequences of nosocomial infection such as mortality and length of hospital stay were determined. Results A total of 233 cases were identified that met our inclusion and exclusion criteria out of which were 94 cases of nosocomial infection (40.3%) versus 139 cases with no nosocomial infection (59.7%). The most common infections were pneumonia, urinary tract infections, and bacteremia. Resistance accounted for 70.2% of cultures. Multivariable analysis revealed significant association of nosocomial infections with hypertension (OR: 2.62, 95% CI: 1.11–6.16, p = 0.027), hospital LOS (OR: 1.08, 95% CI: 1.05–1.12, p < 0.001), levetiracetam (OR: 3.6, 95% CI: 1.41–0.922, p = 0.007), and GCS category (OR: 5.42, 95% CI: 1.67–17.55, p = 0.005 and OR: 7.63, 95% CI: 2.44–23.87, p < 0.001 for moderate and severe, respectively). Patients with nosocomial infections witnessed a significant increase in the length of hospital stay (23 versus 8 hospital days, p < 0.001). This finding was significant across most types of brain hemorrhage. Mortality was significantly associated with GCS category (OR: 10.1, 95% CI: 4–25.7, p < 0.001) and percutaneous endoscopic gastrostomy tube insertion (OR: 19.6, 95% CI: 4.1–91, p < 0.001). Conclusions Collectively, these findings suggest that nosocomial infections are common among patients with intracranial hemorrhage and can be predictable by considering certain risk factors. Future studies are warranted to evaluate the efficacy of implementing infection control strategies or protocols on these patients to achieve better therapeutic outcomes.

Cefazolin versus vancomycin for neurosurgical operative prophylaxis – A single institution retrospective cohort study Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Anthony V. Nguyen, William S. Coggins, Rishabh R. Jain, Daniel W. Branch, Randall Z. Allison, Ken Maynard, Brian Oliver, Rishi R. Lall Abstract Objectives Cefazolin and vancomycin are common choices for neurosurgical antimicrobial prophylaxis. Cefazolin is typically first-line due to its lower toxicity profile and specificity for gram-positives such as skin commensals, while vancomycin is often reserved for patients with cephalosporin or penicillin allergies. However, one randomized clinical trial demonstrated superiority of vancomycin for cerebrospinal fluid (CSF) shunt insertions at a hospital with a high prevalence of methicillin-resistance Staphylococcus aureus (MRSA). We aimed to evaluate the association of prophylaxis choice and incidence of surgical site infection (SSI) at our own institution. Patients and methods This was a retrospective cohort study of patients who underwent a neurosurgical operation from January 2013 to April 2016 at one particular hospital belonging to our institution. We included patients who received either only cefazolin or only vancomycin as their pre-incisional prophylaxis. Vancomycin was substituted for cefazolin in patients with known penicillin or cephalosporin allergy. Procedures requiring multiple attending surgeons were excluded. We defined a SSI as a confirmed culture isolated from the wound, implant (if pertinent), or CSF (if pertinent) within a year of surgery. Multivariable logistic regression was performed with consideration of antibiotic, operation performed, wound class, and procedure length. Results A total of 859 operations met study criteria; 664 patients received Cefazolin, and 195 received Vancomycin. We identified 22 SSIs, with 14 in the cefazolin (2.2%) and 8 in the vancomycin (4.1%) group. Upon logistic regression, there was no significant association of vancomycin substitution with incidence of SSIs between the two groups (odds ratio, 1.59; 95% CI, 0.42–6.00, p = .49). In the cefazolin group, 8/14 cultures were positive for S. aureus compared to 1/8 of the vancomycin group. Conclusions There was no significant difference in neurosurgical site infection incidence when vancomycin prophylaxis was substituted for cefazolin. S. aureus was isolated from patients who received cefazolin at a higher rate although this was not statistically significant. At our institution, S. aureus makes up 36% of isolated organisms from inpatient and intensive care units. Institutions should consider their own investigations into local antibiograms, SSI rates, and choice of prophylaxis.

Neuronavigation-assisted surgical treatments for medically refractory epilepsy: Single-hospital experience with 4 surgical approaches Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Jia-Sheng Pei, Peng-Fan Yang, Qiao Lin, Yan-Zeng Jia, Hui-Jian Zhang, Ming-Chao Shang, Zhong-Hui Zhong, Shou-Sen Wang Abstract Objective Surgical treatment should be considered for patients with medically refractory epilepsy, and neuronavigation may benefit and reduce the technical difficulties during surgery. In this study, we aimed to report our single-hospital experience of incorporating neuronavigation for treating patients with medically refractory epilepsy using 4 types of surgery. Patients and methods Patients who were diagnosed as medically refractory epilepsy and received neuronavigation-assisted surgery were included in this retrospective analysis. The type of surgery was decided by the surgery committee after careful evaluation and discussion, including temporo-parietal-occipital (TPO) disconnection, anterior subtotal callosal section, functional hemispherectomy and resection of the epileptogenic zone(s). Postoperative seizure outcome at the last visit was evaluated using Engel classification. Results A total of 173 patients with medically refractory epilepsy who were treated surgically under the assistance of neuronavigation were included. The majority type of surgery was resection of epileptic zone, n = 104 (60.12%). An excellent seizure outcome, Engel Class I was found in 50.86% of the patients, followed by 23.12% patients with a good outcome of Engel Class II. Conclusion Overall more than half of the patients could have excellent seizure outcome of Engel Class I, the postoperative complications were manageable. These results indicated that the applicability of neuronavigation, and the use of neuronavigation provides good efficacy and safety for all kinds of surgical procedures for patients with medically refractory epilepsy.

Predicting Functional Impairment in patients with chronic subdural hematoma treated with burr hole Trepanation—The FIT-score Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Nicolai Maldaner, Marketa Sosnova, Johannes Sarnthein, Oliver Bozinov, Luca Regli, Martin N. Stienen Abstract Objective It remains difficult to estimate prolonged functional impairment in patients with chronic subdural hematoma (cSDH) treated with burr hole trepanation. We aim to establish a score that reliably predicts postoperative functional impairment. Patients and methods Retrospectively analysis of a prospective institutional database. cSDH patients operated in 2013–2016 were identified. Clinical outcome was dichotomized into presence (modified-Rankin-Scale (mRS) ≥ 2) or absence of functional impairment (mRS 0–1) at discharge and last follow-up. A score was developed, based on the effect sizes of a set of outcome predictors. Its accuracy was tested using Area Under the Receiver-Operating Characteristic (AUROC) curve analysis. The 2017 cohort served for internal validation. Results A cohort of 253 patients (mean age 75 years, 75% male) was analyzed, of which 77 patients (30%) remained functionally impaired. In multivariate analysis, severe motor deficits at admission (OR 5.84, 95% CI 2.71–12.59, p < 0.001), age (≥85 years: 5.53, 2.14–14.32, p < 0.0001) and disorientation at admission (2.65, 11.39–5.05, p = 0.003) were associated with persistent functional impairment. Based on those variables, we created the "Functional Impairment after burr hole Trepanation" (FIT-score), which showed an AUROC of 0.77 (95% CI 0.70–0.83) for impairment at discharge and 0.76 (0.70–0.82) for impairment at follow-up. Internal validation confirmed the model with an AUROC of 0.79 (0.68–0.91) at discharge and 0.77 (0.64–91) at follow-up. Conclusions The FIT-score is likely to assist the physician when counseling patients and relatives pertaining to the need for postoperative rehabilitation and mid- to long-term supportive home care.

Blister aneurysms of the internal carotid artery: Surgical treatment and management outcome from a single center experience Publication date: July 2019 Source: Clinical Neurology and Neurosurgery, Volume 182 Author(s): Auricelio B. Cezar-Junior, Ubiratan Alves da Silva Viturino, Eduardo Vieira de Carvalho, Igor Vilela Faquini, Nivaldo S. Almeida, Hildo Rocha Cirne Azevedo-Filho Abstract Objective Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities, but clinically important cause of subarachnoid hemorrhage (SAH). Several surgical and endovascular strategies have been attempted for these heterogeneous lesions. In this study, the authors analyzed the treatment strategy and outcomes in a series of cases of ICA blister aneurysms treated microsurgically. Patients and methods We retrospectively reviewed 15 consecutive cases of patients harboring ruptured BBAs, microsurgically treated at our institution between 2014 and 2018. We performed an analysis of the clinical and surgical aspects, as well as post-operative angiograms and outcomes. Results Fifteen patients were identified; 9 (60%) were female. The mean age of presentation was 43,8 years. Most patients presented in good clinical conditions (Hunt-Hess 1–3 = 86%). The most common Fisher grade at presentation was 3 (60% of cases). All patients underwent digital subtraction angiography (DSA), revealing broad-based aneurysms at non-branching sites on the dorsal wall of the ICA. Intraoperatively, BBAs were confirmed in all cases. The lesions were approached through pterional (11–73%) or lateral supraorbital (4–27%) craniotomy. Direct clipping was performed in all but one lesion, in which case the clip-wrapping technique was used. Final angiographic control revealed complete occlusion in 14 cases. One patient required reoperation due to residual aneurysm filling. At discharge, a good outcome (Glasgow Outcome Scale [GOS] 4 or 5) was observed in 12 (80%) patients. Three patients were discharged with a GOS of 3. Conclusion Blood-blister-type aneurysms are rare and challenging lesions. Preoperative knowledge and careful surgical planning can prevent poor clinical outcomes. Surgical treatment remains an effective and safe option in this context.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com