Background Insular gliomas (INGs) remain a surgically intimidating glioma subgroup encased by eloquent cortical parcels and white matter language tracts, and traversed by multiple middle cerebral artery branches. The predictive power of prognostic factors affecting overall survival (OS), progression-free survival (PFS), and resectability of INGs remain disputed. This comprehensive systematic review analyses prognostic factors and resectability predictors of INGs substantiating pragmatic management options. Materials and Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and the Cochrane Handbook of Systematic Reviews of Interventions guidelines. The PubMed, MEDLINE, and Embase databases were searched in April 2022. All clinical studies with ≥10 patients harboring INGs with any intervention and reporting predictors of OS, PFS, and tumor resectability in INGs were included. Molecular ING prognosticators were also included. Studies combining insular and other gliomas analysis, case studies, experimental and animal studies, conference abstracts, letters to the editor, and articles in other languages were excluded. Results Of the 2,384 articles returned, 27 fulfilled the inclusion criteria totaling 1,985 patients. The review yielded 18 OS and 17 PFS prognosticators. These were classified as preoperative (radiologic; clinical), intraoperative, and postoperative (molecular; histopathologic; clinical) prognosticators. In addition, 21 resectability predictors were categorized as preoperative (radiologic; clinical), intraoperative (surgical approach and assistive technology), and postoperative (histopathologic; clinical). The quality assessment revealed 24/27 studies had low risk of bias. One study with moderate and two studies with high risk of bias were included. Conclusion Negative prognosticators reported in ≥2 studies included putaminal or paralimbic involvement and higher tumor grade, while seizures at presentation, isocitrate dehydrogenase (IDH) mutation, increased extent of resection, and higher Karnofsky Performance Status preoperatively and at 3 months postoperation were positive prognosticators. Resectability predictors reported in ≥2 studies included the positive predictors of zone I/zone IV tumor location and intraoperative imaging use and the negative predictor of encased lenticulostriate arteries. Paralimbic INGs are not a single entity with homogeneous prognosis. Integration of identified prognosticators in a prospective trial to devise a grading system for INGs can improve clinical decision-making.
BACKGROUND:Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution. METHODS:Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details. RESULTS:There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging. CONCLUSIONS:Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.
BACKGROUND:The COVID-19 pandemic has significantly affected acute ischemic stroke (AIS) care. In this study, we examined the effects of the pandemic on neurosurgical AIS care by means of decompressive surgery (DS). METHODS:In this retrospective observational study, we compared the characteristics, in-hospital processes, and in-hospital mortality rates among patients hospitalized for AIS during the first four waves of the pandemic (between January 1, 2020 and October 26, 2021) versus the corresponding periods in 2019 (prepandemic). We used administrative data from a nationwide hospital network in Germany. RESULTS:Of the 177 included AIS cases with DS, 60 were from 2019 and 117 from the first four pandemic waves. Compared with the prepandemic levels, there were no changes in weekly admissions for DS during the pandemic. The same was true for patient age (range: 51.7-60.4 years), the number of female patients (range: 33.3-57.1%), and the prevalence of comorbidity, as measured by the Elixhauser Comorbidity Index (range: 13.2-20.0 points). Also, no alterations were observed in transfer to the intensive care unit (range: 87.0-100%), duration of in-hospital stay (range: 14.6-22.7 days), and in-hospital mortality rates (range: 11.8-55.6%). CONCLUSION:In Germany, compared with the prepandemic levels, AIS patients undergoing DS during the first four waves of the pandemic showed no changes in demographics, rates of comorbidity, and in-hospital mortality rates. This is in contrast to previous evidence on patients with less critical types of AIS not requiring DS and underlines the uniqueness of the subgroup of AIS patients requiring DS. Our findings suggests that these patients, in contrast to AIS patients in general, were unable to forgo hospitalization during the COVID-19 pandemic. Maintaining the delivery of DS is an essential aspect of AIS care during a pandemic.
BACKGROUND:Pituitary adenoma (PA) is a common intracranial endocrine tumor, but no precise target has been found for effective prediction and treatment of PA. METHODS:Quantitative reverse transcription polymerase chain reaction (qRT‒PCR) analysis showed that circMFN2 could affect the expression of miR-146a-3p in PA samples. Moreover, we used Western blotting to evaluate the expression levels of TRAF6 and NF-κB markers. The EdU assay, scratch wound healing assay, and Matrigel invasion assay were performed to assess the potential function of this pathway in PA cells. Based on the bioinformatic analysis including KEGG, gene ontology (GO) analysis, and microarray analysis, we evaluated the efficacy of circMFN2 as a potential biomarker for diagnosing PA, and we aimed to determine the mechanism of action in PA cells. RESULTS:Our findings indicate that there is a significant increase in the expression of circMFN2 in tissues, serum, and exosomes in the invasive group compared with the noninvasive and normal groups. Furthermore, this difference was statistically significant both preoperatively and postoperatively. To clarify its function, we downregulated this gene, and the experimental results suggested that the motility and proliferative capacity were reduced in vitro. In addition, rescue assays showed that miR-146a-3p could successfully reverse the inhibitory effect of circMFN2 knockdown on motility and proliferation in PA cells. Moreover, downregulation of circMFN2 and miR-146a-3p significantly changed the expression of TRAF6 and NF-κB. CONCLUSION:This study identified that circMFN2 regulates miR-146a-3p to promote adenoma development partially via the TRAF6/NF-κB pathway and may be a potential therapeutic target for PA.
BACKGROUND:Delayed cerebral ischemia (DCI) is usually caused by cerebral vasospasm (CVS). To detect DCI and CVS, a cranial computed tomography (CT) scan will be performed, but cervical vessels are not necessarily displayed. METHODS:A 63-year-old female patient who suffered from aneurysmal subarachnoid hemorrhage (SAH) was treated at the authors' institution. After an initially unremarkable clinical course, she developed aphasia on day 11. CT angiography (CTA) and perfusion imaging revealed significant hypoperfusion of the left hemisphere. In addition, the CTA showed a subtotal stenosis of the internal carotid artery (ICA) at the level of the petrous segment, suspicious for a dissection. This was not detectable angiographically in the final control of the intervention and was also not clinically evident until day 11. RESULTS:Cerebral perfusion as well as the clinical symptoms normalized rapidly after stent reconstruction of the ICA. CONCLUSION:Even though CVS is the most common cause of hypoperfusion in patients after an SAH, a peri-interventional dissection can also lead to relevant stenosis and thus to a disturbed cerebral perfusion and corresponding neurologic deficits. The time delay between the intervention and the clinical and CTA manifestation in our case is remarkable.
BACKGROUND:Endovascular therapy has revolutionized the treatment of cerebral aneurysms in recent years and decades. So-called intrasaccular devices (i.e., Woven EndoBridge [WEB], MicroVention, Aliso Viejo, California, United States; or Contour, Cerus Neurovascular, Fremont, California, United States) are a promising endovascular technology, especially for wide-based aneurysms. However, long-term outcome data are currently particularly scarce for Contour and strategies for failed Contour cases are lacking. Here, we report the feasibility of microsurgical clipping after failed Contour device embolization.METHODS:Feasibility of microsurgical clipping after failed aneurysm embolization with a Contour intrasaccular device was assessed in a patient.RESULTS:We present the case of a 36-year-old male patient diagnosed with Hunt and Hess grade 1 subarachnoid hemorrhage from an anterior communicating artery aneurysm. The ruptured aneurysm was initially treated with the Contour device. After 3 months, angiographic imaging showed a clear aneurysm residual deemed not endovascularly accessible. The patient was then successfully clipped using microsurgical techniques. The patient was discharged with no neurologic abnormalities.CONCLUSION:After thorough bibliographical research, this presents the first published case report of microsurgical clipping after failed embolization with Contour. The main insights gained after clipping were that the Contour does not significantly disturb or hinder clipping. In contrast to coils in aneurysms to be clipped, the Contour can be easily compressed by the clip blades and does not have to be removed. In addition, the Contour had not migrated into the subarachnoid space and there was no abnormal scarring. Clipping appears to be a reasonable treatment strategy for failure of embolization with Contour if endovascular means are not suitable.
BACKGROUND:High-frequency oscillations (HFOs) are spontaneous electroencephalographic (EEG) events that occur within the frequency range of 80 to 500 Hz and consist of at least four distinct oscillations that stand out from the background activity. They can be further classified into "ripples" (80-250 Hz) and "fast ripples" (FR; 250-500 Hz) based on different frequency bands. Studies have indicated that HFOs may serve as important markers for identifying epileptogenic regions and networks in patients with refractory epilepsy. Furthermore, a higher extent of removal of brain regions generating HFOs could potentially lead to improved prognosis. However, the clinical application criteria for HFOs remain controversial, and the results from different research groups exhibit inconsistencies. Given this controversy, the aim of this study was to conduct a meta-analysis to explore the utility of HFOs in predicting postoperative seizure outcomes by examining the prognosis of refractory epilepsy patients with varying ratios of HFO removal. METHODS:Prospective and retrospective studies that analyzed HFOs and postoperative seizure outcomes in epilepsy patients who underwent resective surgery were included in the meta-analysis. The patients in these studies were grouped based on the ratio of HFOs removed, resulting in four groups: completely removed FR (C-FR), completely removed ripples (C-Ripples), mostly removed FR (P-FR), and partial ripples removal (P-Ripples). The prognosis of patients within each group was compared to investigate the correlation between the ratio of HFO removal and patient prognosis. RESULTS:A total of nine studies were included in the meta-analysis. The prognosis of patients in the C-FR group was significantly better than that of patients with incomplete FR removal (odds ratio [OR] = 6.62; 95% confidence interval [CI]: 3.10-14.15; p < 0.00001). Similarly, patients in the C-Ripples group had a more favorable prognosis compared with those with incomplete ripples removal (OR = 4.45; 95% CI: 1.33-14.89; p = 0.02). Patients in the P-FR group had better prognosis than those with a majority of FR remaining untouched (OR = 6.23; 95% CI: 2.04-19.06; p = 0.001). In the P-Ripples group, the prognosis of patients with a majority of ripples removed was superior to that of patients with a majority of ripples remaining untouched (OR = 8.14; 95% CI: 2.62-25.33; p = 0.0003). CONCLUSIONS:There is a positive correlation between the greater removal of brain regions generating HFOs and more favorable postoperative seizure outcomes. However, further investigations, particularly through clinical trials, are necessary to justify the clinical application of HFOs in guiding epilepsy surgery.
Background: The 12-year collaboration between Greifswald and Cairo Universities in Neurosurgery has recently reached stable steps in post-graduate education represented in the bi-institutional fellowship of Neuro-endoscopy. Aim: We present our new experience of upgrading the level of bi-institutional collaboration to serve for highly skilled undergraduate training. Methods: we started a summer school program for the Egyptian medical students, with the target of allowing better orientation with the specialty Results: 10 candidates (6 males and 4 females) were selected to participate in the program. All candidates successfully finished the summer school and stated they would recommend this activity to their colleagues. Conclusion: We recommend the summer school activities either within the host university or abroad in a collaborate university to the students that would be preselected to fit in the planned program. It is our opinion this would assist the young generations in choosing the suitable career and help in improving the quality of the working teams in Neurosurgery in the future.
Abstract Background Spinal cord hemangioblastomas are rare benign and highly vascular tumors that develop either sporadically or as part of von Hippel–Lindau (VHL) disease. Generally, complete resection without significant neurologic deficit remains considerably challenging due to the risk of massive bleeding. The current study therefore aimed to describe en bloc resection of spinal cord hemangioblastomas according to the typical anatomical structures of peripheral lesions and evaluate the neurofunctional prognosis of this technique. Methods A total of 39 spinal cord hemangioblastomas from a series of 19 patients who underwent en bloc resection were retrospectively analyzed. In all cases, clinical and radiologic characteristics, as well as surgical tenets, were retrospectively determined and analyzed. Short- and long-term outcomes were analyzed using the McCormick grade and Odom's criteria. Factors significantly associated with poor neurologic function after en bloc resection were also determined. Results All 39 spinal cord hemangioblastomas, including 28 intramedullary, 2 intramedullary–extramedullary, and 9 extramedullary lesions, were located dorsally or dorsolaterally (100.0%). The most common lesion location was the thoracic segment (53.8%), with most of the lesions being accompanied by syringomyelia (94.7%). Long-term follow-up (mean: 103 ± 50.4 months) for prognosis determination revealed that 88.2% (15/17) of all cases had stable or improved neurofunctional outcomes according to the McCormick grade and Odom's criteria. Only one case with VHL disease developed recurrence 4 years after surgery. Additionally, statistical analysis showed that VHL disease was an independent prognostic factor associated with deteriorating neurologic function ( p = 0.015). Conclusions En bloc resection facilitated satisfactory long-term functional outcomes in patients with spinal cord hemangioblastomas. Given that VHL disease was identified as a predictor of poor long-term outcomes, regular long-term follow-up of patients with VHL-associated spinal cord hemangioblastoma seems necessary.
Abstract Background Transforaminal endoscopic lumbar diskectomy (TELD) is considered an effective treatment for lumbar disk herniation (LDH). There is a paucity of studies comparing in detail the costs and long-term clinical outcomes of TELD and open microdiskectomy (MD), especially in developing countries. Thus, we sought to provide a multidimensional insight into this matter by comparing the direct costs and long-term outcomes of TELD with those of MD. Methods The electronic health records of 434 patients with LDH who underwent either TELD or MD were collected from February 2011 to October 2014. Within a 7-year follow-up period, 412 patients, comprising 203 patients treated with TELD and 209 patients treated with MD, were fully evaluated. Patient characteristics, operative time, intraoperative blood loss (IBL), postoperative hospital stay, time to return to work (RTW), perioperative complications, and direct costs were collected. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. Results The postoperative ODI and VAS scores improved significantly in both groups ( p < 0.001). In accordance with the modified MacNab criteria, the rate of excellent and good outcomes was 88.67 and 88.03% in the TELD and MD groups, respectively. There were no significant differences between the groups in the clinical outcomes and perioperative complications. However, IBL, hospital stay, and RTW were significantly reduced in the TELD group ( p < 0.05). Twenty-one cases in the TELD group and nine in the MD group underwent reoperation due to recurrence ( p < 0.05). Total inpatient cost per patient was $1,596 in the TELD group and $1,990 in the MD group ( p < 0.05). Conclusion TELD for the treatment of symptomatic LDH could be an affordable strategy, providing certain advantages of minimally invasive procedures such as shorter hospital stay and earlier recovery along with comparable clinical outcomes to the conventional surgical method.
Background: Brain abscess is a major health problem with a reasonable morbidity and mortality rate. Objective: The objective of this study was to compare the efficacy between endoscope-assisted evacuations of brain abscess with burr hole aspiration method in a tertiary health care center. Methodology: This non-randomized clinical trial was conducted in the Department of Neurosurgery at Dhaka Medical College Hospital, Dhaka, Bangladesh during the period of July 2016 to December 2017. Patients with the age group of more than or equal to 18 years of both gender presented with brain abscess were enrolled in this study. The endoscope-assisted evacuation of abscess was done on group A patients and burr hole aspiration was done on group B patients. Outcome of the patients was assessed using GCS and MRC muscle power grading and by GOS. Patients were evaluated by contrast enhanced CT scan of head at pre-operative, 1st and 30th postoperative day. Both groups received best available medical treatment along with surgery. Results: The mean age of was 13.0 ± 6.3 years in burr hole group and is 13.1 ± 6.4 years in endoscope-assisted group. The patients presented with GCS was 66.7% in burr hole group and 93.3% in endoscope assisted group. The study showed e”75.0% evacuation of brain abscess at 1st post-operative day in 13(92.9%) patients in endoscope-assisted group and 5(33.3%) patients in burr hole group. The study showed mortality rate of 6.7% in both the groups. Mean residual volume at 30th post operative day was 0.75ml in endoscope-assisted group and 1.75ml in burr hole aspiration group. Conclusion: In conclusion endoscope-assisted procedure has better rate of abscess evacuation, less chance of residual and repeated surgeries than conventional burr hole. Bang. J Neurosurgery 2023; 13(1): 14-19
BACKGROUND:Ventriculoperitoneal (VP) shunt infections are a fairly common complication in both the early and late postoperative periods. Sometimes diagnosis is difficult despite the fact that infection is often accompanied by clinical symptoms. Furthermore, pathogenic bacteria can be detected in the cerebrospinal fluid. METHOD:We describe a case of chronic VP shunt infection in a 24-year-old female patient who was operated on for posterior fossa pilocytic astrocytoma and needed a VP shunt. The infection revealed itself 5 years after shunt implantation with nonspecific symptoms, and it took approximately 2 years to make a correct diagnosis. Meanwhile, the patient's condition became critical. The infection was caused by Propionibacterium acnes, which is capable of forming biofilms on implants, and which is difficult to identify due to the peculiarity of its cultivation. RESULT:When the bacterium was identified, the shunt was replaced and antimicrobial therapy was performed, after which the patient's condition improved dramatically and she got back to her normal life. CONCLUSIONS:This case shows how difficult the diagnosis of VP shunt infection can be and what clinical significance it can have for the patient.
Gregor Antoniadis, Leila Harhaus, Hans Assmus. Chirurgie peripherer Nerven kompakt. Berlin, Heidelberg: Springer; 2021 (XVI, 399 pages) ISBN 978-3-662-62503-3.
The idea of publishing special issues on “hot topics” twice a year was born at the end of the last decade. However, this plan turned out to be too ambitious. Collecting high-quality manuscripts with a specific focus requires more time than only a few months. The first special issue on “brain mapping” was published in March 2020. This was followed by a special issue on “intraoperative neurophysiological monitoring” in July 2021. For these two issues, well-known experts in the field were invited to share their latest research results with the readers of the “Central European Neurosurgery/Journal of Neurological Surgery – Part A.” Spinal infection had already been identified as another “hot topic” during this time. The incidence of spinal infections, especially the incidence of spondylodiskitis, increased steadily over the last two decades. This was probably linked to the aging population with more comorbidities and the popularity of injection therapies in the management of back pain. The increase in the incidence of spinal infections was followed by the intensification of mostly clinical research in this field, making the task of the guest editors to put together a special issue on spinal infections easier. They could select the best manuscripts on the topic submitted to the “Central European Neurosurgery/Journal of Neurological Surgery – Part A,” garnished by a few invited papers. This special issue, the fruit of more than a year's work, which includes original contributions, a review, and educative case reports, covers many aspects of spinal infections and reflects the research trends in this field. I hope that the issue gives you new insights, has the potential to influence your daily clinical practice, and stimulates your research plans.
Abstract Background Revision lumbar spine surgery via a posterior approach is more challenging than primary surgery because of epidural or perineural scar tissue. It demands more extensive removal of the posterior structures to confirm intact bony landmarks and could cause iatrogenic instability; therefore, fusion surgery is often added. However, adjacent segment disease after fusion surgery could be a problem, and further exposure of the posterior muscles could result in multiple operated back syndrome. To address these problems, we now perform transforaminal full-endoscopic spine surgery (TF-FES) as revision surgery in patients who have previously undergone posterior lumbar surgery. There have been several reports on the advantages of TF-FES, which include feasibility of local anesthesia, minimal invasiveness to posterior structures, and less scar tissue with fewer adhesions. In this study, we aim to assess the clinical outcomes of revision TF-FES and its advantages. Methods We evaluated 48 consecutive patients with a history of posterior lumbar spine surgery who underwent revision TF-FES (at 60 levels) under local anesthesia. Intraoperative blood loss, operating time, and complication rate were evaluated. Postoperative outcomes were assessed using the modified Macnab criteria and visual analog scale (VAS) scores for leg pain, back pain, and leg numbness. We also compared the outcome of revision FES with that of primary FES. Results Mean operating time was 70.5 ± 14.4 (52–106) minutes. Blood loss was unmeasurable. The clinical outcomes were rated as excellent at 16 levels (26.7%), good at 28 (46.7%), fair at 10 (16.7%), and poor at 6 (10.0%). The mean preoperative VAS score was 6.0 ± 2.6 for back pain, 6.8 ± 2.4 for leg pain, and 6.3 ± 2.8 for leg numbness. At the final follow-up, the mean postoperative VAS scores for leg pain, back pain, and leg numbness were 4.3 ± 2.5, 3.8 ± 2.6, and 4.6 ± 3.2, respectively. VAS scores for all three parameters were significantly improved ( p < 0.05). There was no significant difference in operating time, intraoperative blood loss, or the complication rate between revision FES and primary FES. Conclusions Clinical outcomes of revision TF-FES in patients with a history of posterior lumbar spine surgery were acceptable (excellent and good in 73.4% of cases). TF-FES can preserve the posterior structures and avoid scar tissue and adhesions. Therefore, TF-FES could be an effective procedure for patients who have previously undergone posterior lumbar spine surgery.
AbstractLumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage–assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage–induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.
Background We previously reported that normalization of motor evoked potential (MEP) monitoring amplitude by compound muscle action potential (CMAP) after peripheral nerve stimulation prevented the expression of anesthetic fade (AF), suggesting that AF might be due to reduced synaptic transfer in the neuromuscular junction.Methods We calculated the time at which AF began for each of craniotomy and spinal cord surgery, and examined whether AF was avoided by CMAP after peripheral nerve stimulation normalization in each. Similar studies were also made with respect to the upper and lower limb muscles.Results AF was observed in surgery lasting 160 minutes for craniotomy and 260 minutes or more for spinal surgery, and 195 minutes in the upper limb muscles and 135 minutes in the lower limb muscles. In all the series, AF could be avoided by CMAP after peripheral nerve stimulation normalization.Conclusion AF of MEP occurred in both craniotomy and spinal cord surgery, and it was also corrected by CMAP after peripheral nerve stimulation. AF is considered to be mainly due to a decrease in synaptic transfer of the neuromuscular junction due to the accumulation of propofol because of the avoidance by CMAP normalization. However, it may be partially due to a decrease in the excitability of pyramidal tracts and alpha-motor neurons, because AF occurred earlier in the lower limb muscles than in the upper limb muscles.
Background Open-door laminoplasty is a classical decompression method used to treat cervical spondylotic myelopathy. However, hinge fracture displacement (HFD) is a common occurrence during this procedure. The current study aimed to investigate the safety and efficacy of a combined imbrication axle reconstruction and Z-type titanium plate fixation method for HFD during open-door laminoplasty.Methods In total, 617 patients with cervical spondylotic myelopathy who underwent C3-C7 open-door laminoplasty from March 2015 to October 2018 were included in this retrospective study. Overall, 73 patients developed HFD during surgery. Of these, 43 underwent combined imbrication axle reconstruction and Z-type titanium plate fixation (IRZF group) and 30 underwent traditional titanium plate fixation (TF group). Data such as the operative time, intraoperative blood loss volume, and distribution of fractured hinges were recorded. Both groups were compared in terms of improvement in neurologic function, cervical curvature index, hinge fusion rate, incidence of C5 palsy, severity of axial symptoms, and development of complications.Results The operative time and intraoperative blood loss were slightly higher in the IRZF group than in the TF group; however, the differences were not significant ( p > 0.05). Furthermore, there was no significant difference between the groups in terms of the number of fractured segments and the distribution of fractured hinges ( p > 0.05). The cervical curvature index did not decline in the two groups ( p > 0.05). The IRZF group had a higher hinge fusion rate than the TF group at 3 (79.6 vs. 57.1%) and 12 (93.9 vs. 74.3%) months postoperatively ( p < 0.05). There was no significant difference in the incidence of C5 palsy between the two groups (9.3 vs. 6.7%; p > 0.05). However, the TF group had more severe axial symptoms than the IRZF group ( p < 0.05). The neurologic function of the two groups increased postoperatively as per the Japanese Orthopaedic Association scoring system ( p < 0.05). Nevertheless, there was no significant difference in terms of neurologic function at any observational time point ( p > 0.05). One patient in the TF group with hinge nonunion underwent laminectomy due to lamina displacement into the spinal canal and nerve root compression.Conclusion In patients with HFD, IRZF facilitates a more intimate contact between the lamina and the lateral mass and, therefore, achieves fractured hinge fusion without additional surgical trauma. This technical improvement can significantly promote neurologic recovery, decrease the severity of axial symptoms, and prevent the development of spinal cord or nerve root recompression.
Abstract Background Between 3 and 15% of winter sports–related injuries are related to head injuries, which are the primary cause of mortality and disability among skiers. Despite the widespread adoption of helmets in winter sports, which has reduced the incidence of direct head injury, there is a paradoxical trend of an increasing number of individuals wearing helmets sustaining diffuse axonal injuries (DAI), which can result in severe neurologic sequelae. Methods We retrospectively reviewed 100 cases collected by the senior author of this work from 13 full winter seasons during the period from 1981 to 1993 and compared them with 17 patients admitted during the more shortened 2019 to 2020 ski season due to COVID-19. All data analyzed come from a single institution. Population characteristics, mechanism of injury, helmet use, need for surgical treatment, diagnosis, and outcome were collected. Descriptive statistics were used to compare the two databases. Results From February 1981 to January 2020, most skiers with head injuries were men (76% for the 1981–1993 and 85% for 2020). The proportion of patients aged over 50 increased from <20% in 1981 to 65% in 2020 ( p < 0.01), with a median age of 60 years (range: 22–83 years). Low- to medium-velocity injuries were identified in 76% (13) of cases during the 2019 to 2020 season against 38% (28/74) during the 1981 to 1993 seasons ( p < 0.01). All injured patients during the 2020 season wore a helmet, whereas none of the patients between 1981 and 1993 wore one ( p < 0.01). DAI was observed in six cases (35%) for the 2019 to 2020 season against nine cases (9%) for the 1981 to 1993 season ( p < 0.01). Thirty-four percent (34) of patients during the 1981 to 1993 seasons and 18% (3) of patients during the 2019 to 2020 season suffered skeletal fractures ( p = 0.02). Among the 100 patients of the 1981 to 1993 seasons, 13 (13%) died against 1 (6%) from the recent season during care at the hospital ( p = 0.15). Neurosurgical intervention was performed in 30 (30%) and 2 (12%) patients for the 1981 to 1993 and 2019 to 2020 seasons, respectively ( p = 0.003). Neuropsychological sequelae were reported in 17% (7/42) of patients from the 1981 to 1993 seasons and cognitive evaluation before discharge detected significant impairments in 24% (4/17) of the patients from the 2019 to 2020 season ( p = 0.29). Conclusion Helmet use among skiers sustaining head trauma has increased from none in the period from 1981 to 1993 to 100% during the 2019 to 2020 season, resulting in a reduction in the number of skull fractures and deaths. However, our observations suggest a marked shift in the type of intracranial injuries sustained, including a rise in the number of skiers experiencing DAI, sometimes with severe neurologic outcomes. The reasons for this paradoxical trend can only be speculated upon, leading to the question of whether the perceived benefits of helmet use in winter sports are actually misinterpreted.
BACKGROUND:Flow-related aneurysms (FRAs) associated with cerebral arteriovenous malformations (AVMs) pose a significant therapeutic challenge. Both their natural history and management strategy are still unclear and underreported. FRAs generally increase the risk of brain hemorrhage. However, following AVM obliteration these vascular lesions are expected to disappear or remain stable. METHODS:We present two cases where growth of FRAs was detected following complete obliteration of an unruptured AVM. RESULTS:The first patient presented with proximal middle cerebral artery (MCA) aneurysm growth after spontaneous and asymptomatic thrombosis of the AVM. In our second case, a very small aneurysmal-like dilation located at the basilar apex enlarged to a saccular aneurysm following complete endovascular and radiosurgical obliteration of the AVM. CONCLUSION:The natural history of flow-related aneurysms is unpredictable. In the cases where these lesions are not managed first, there should be close follow-up. When aneurysm growth is evident, active management strategy seems mandatory.
