OBJECTIVE: Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular spinal malformations. According to the reported data, surgery seems to result in better occlusion rates than endovascular treatment. However, the post-treatment evolution of neurological symptoms stratified by the treatment remains unknown. The main objective of the present study was to compare the clinical outcomes for patients according to the treatment method. METHODS: The data from 63 patients with SDAVFs from 2000 to 2017 at 4 academic neurosurgical departments were retrospectively analyzed. Preoperative and postoperative examination neurological status was assessed using the Aminoff-Logue scale (ALS), which evaluates gait and micturition disturbances. Initial occlusion, late recurrence, and complications of the 2 techniques were also reviewed. RESULTS: Patients who had undergone surgery and embolization improved clinically on the ALS (P = 0.0009), and no significant differences were found between the 2 techniques. Subgroup analysis using the ALS showed that patients who had undergone surgery and embolization without late recurrence improved (P < 0.0001 and P = 0.0334, respectively) and that patients who had undergone surgery or embolization with late recurrence did not improve. The initial occlusion rate was in favor of surgery, with 91.3% versus 70% for endovascular treatment (P = 0.050). The late recurrence rate was higher for embolization (21.4% vs. 9.1% for surgery; P = 0.28). CONCLUSIONS: Surgery can be proposed as first-line treatment of SDAVFs after multidisciplinary discussion between neurosurgeons and neuroradiologists. The development of late recurrence negatively affects the neurological outcome of patients.

BACKGROUND:Undesirable events in the neurosurgery operating theater have less often been the result of a technical error than of a dysfunction linked to nontechnical skills (NTSs). The essential aim of our study was to perform a systematic review of the reported data on NTS in neurosurgery. Our secondary objective was to identify the NTSs more specific to neurosurgery to define the training needs of neurosurgery trainees.METHODS:The MEDLINE and Cochrane Database of Systematic Reviews were searched according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) guidelines. The search initially identified 2132 reports, of which 21 were eligible for systematic study. Data were extracted from the report regarding study design, sample size, NTSs assessed, and assessment tools, and the key results were collected.RESULTS:Interpersonal skills (communication, teamwork), cognitive skills (decision making, situational awareness), and personal resource factors (coping with stress or fatigue) were specifically identified. No study had used assessment tools such as NOTECHS (nontechnical skills), NOTSS (nontechnical skills for surgeons), or OTAS (observational teamwork assessment for surgery). They were performed in a real environment in 11 cases, in a simulated environment in 9, and during theoretical teaching in 1 case.CONCLUSIONS:Very few studies have been performed concerning neurosurgical NTSs, despite the increasing the number of studies during the past few years on NTSs in other domains of surgery. Society has been concentrating more and more on the quality and safety of medical care. The development and application of NTS assessment tools is, therefore, essential to provide assistance in the training of future neurosurgeons.

OBJECTIVE:Meningiomas that compress the optic nerve (ON) can lead to different visual outcomes depending on the segment of ON affected (intraorbital, canalicular, and intracranial). In this study, we performed a comprehensive comparison of the management options (surgery, radiation, or observation alone) for meningiomas compressing the ON, categorized by location and relation to the ON.METHODS:MEDLINE, EMBASE, Web of Science, and the Cochrane Database of Systematic reviews databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Data were extracted from the articles regarding anatomic location, initial visual impairment, surgical procedure, visual outcome, morbidity and mortality, gross total removal, and requirement for postoperative radiotherapy.RESULTS:Of the 47 articles eligible for full-text reading, 9 surgical studies met our inclusion criteria. Data from 317 patient cases were extracted. In patients in whom the intracranial segment of the ON was impaired in isolation, 49% experienced visual improvement after surgery. When the meningioma affected the canalicular segment or intraorbital segment, visual improvement after surgery was 31% and 11%, respectively. Of patients who underwent surgery for the intraorbital segment of the ON, 56% experienced a decline in visual outcome.CONCLUSIONS:When a neurosurgeon deals with a meningioma compressing the ON, opening the optic canal is suggested if invasion is suspected on the preoperative imaging. Extra caution should be used when operating on meningiomas with ON sheath adhesion, given the higher evidence of postoperative visual worsening.

PURPOSE:Surgery is one of the riskiest and most important medical acts that are performed today. The need to improve patient outcomes and surgeon training, and to reduce the costs of surgery, has motivated the equipment of operating rooms with sensors that record surgical interventions. The richness and complexity of the data that are collected call for new methods to support computer-assisted surgery. The aim of this paper is to support the monitoring of junior surgeons learning their surgical skill sets.METHODS:Our method is fully automatic and takes as input a series of surgical interventions each represented by a low-level recording of all activities performed by the surgeon during the intervention (e.g., cut the skin with a scalpel). Our method produces a curve describing the process of standardization of the behavior of junior surgeons. Given the fact that junior surgeons receive constant feedback from senior surgeons during surgery, these curves can be directly interpreted as learning curves.RESULTS:Our method is assessed using the behavior of a junior surgeon in anterior cervical discectomy and fusion surgery over his first three years after residency. They revealed the ability of the method to accurately represent the surgical skill evolution. We also showed that the learning curves can be computed by phases allowing a finer evaluation of the skill progression.CONCLUSION:Preliminary results suggest that our approach constitutes a useful addition to surgical training monitoring.

BACKGROUND:Spheno-orbital meningiomas (SOMs) are complex tumors involving the sphenoid wing, the orbit, and sometimes the cavernous sinus with bone hyperostosis and sheet-like dural involvement. Optimal removal, proptosis cure, and visual preservation remain a challenge. OBJECTIVE:To study the management of surgically treated SOMs. METHODS:The clinical records of 130 consecutive patients undergoing surgery for SOMs were retrospectively collected in a database during a 20-year period to analyze symptoms, surgical technique, clinical outcome, and follow-up. RESULTS:Among the 130 patients (mean age 51.2 ± 9.5 years), 91.5% were female. The most typical symptoms recorded were proptosis in 94.6%, visual impairment in 37.7%, and oculomotor paresis in 10.0%. Simpson grade I-II removal was achieved in 97 patients (74.6%). After 1 year, proptosis was improved in 60% of cases. A total of 44.9% of the patients with preoperative visual acuity impairment were improved. Periorbital excision was statistically linked to proptosis decreasing (P = 0.0001) and optic canal decompression was linked to visual stabilization (P = 0.03). Bone reconstruction prevented temporal muscle atrophy (P = 0.01) and unaesthetic results (P = 0.0001). Mean follow-up was 76.5 months (range 3-288 months), and the mean time for recurrence was 54.2 months. CONCLUSIONS:A single-stage optimal surgery with bone reconstruction appears to be the best first-line treatment, on a case-by-case analysis. Optic canal decompression and periorbital excision have to be performed in case of visual disturbance and proptosis. SOMs require a long-term follow-up because of a delayed high rate of recurrence.

Brain arteriovenous malformations (AVM) are complex and highly challenging lesions, for which intra-operative indocyanin green fluorescence video angiography is widely used. Fluorescein video angiography (FVA) recently appeared as an alternative technique but the feasibility and usefulness of this technique is yet uncertain. This short series reports our preliminary experience of FVA in intracranial AVM surgery. We retrospectively studied the cases of seven patients who had FVA for an AVM surgery. The primary objective of this study was to assess the utility of FVA as judged by the surgeon. Secondary objectives were the evaluation of the tolerance of bolus injection of fluorescein in the context of cranial surgery, the comparison with ICG and the rate of complete removal. For each of the seven patients, FVA was performed after exposure of the AVM and before the resection; it was visualized directly through the eyepieces of the microscope and helped in the identification of arterial feeders and draining veins. In one case, post-resection FVA allowed the visualization of a residual shunt and the resection was completed. In two cases, ICG and FVA brought comparable information. The resection was complete in all cases, confirmed by post-operative imaging. There was no anaphylactic complication. This preliminary work suggests that FVA is a simple and well tolerated technique, comparable to ICG angiography. Prospective and larger studies are needed to confirm the clinical benefit of this tool.

BACKGROUND:Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD.METHODS:We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity.RESULTS:9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN.CONCLUSIONS:The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

Objective: Surgery is one of the riskiest and most important medical acts that is performed today. Understanding the ways in which surgeries are similar or different from each other is of major interest to understand and analyze surgical behaviors. This article addresses the issue of identifying discriminative patterns of surgical practice from recordings of surgeries. These recordings are sequences of low-level surgical activities representing the actions performed by surgeons during surgeries.Materials and method: To discover patterns that are specific to a group of surgeries, we use the vector space model (VSM) which is originally an algebraic model for representing text documents. We split long sequences of surgical activities into subsequences of consecutive activities. We then compute the relative frequencies of these subsequences using the tridf framework and we use the Cosine similarity to classify the sequences. This process makes it possible to discover which patterns discriminate one set of surgeries recordings from another set.Results: Experiments were performed on 40 neurosurgeries of anterior cervical discectomy (ACD). The results demonstrate that our method accurately identifies patterns that can discriminate between (1) locations where the surgery took place, (2) levels of expertise of surgeons (i.e., expert vs. intermediate) and even (3) individual surgeons who performed the intervention. We also show how the tfidf weight vector can be used to both visualize the most interesting patterns and to highlight the parts of a given surgery that are the most interesting.Conclusions: Identifying patterns that discriminate groups of surgeon is a very important step in improving the understanding of surgical processes. The proposed method finds discriminative and interpretable patterns in sequences of surgical activities. Our approach provides intuitive results, as it identifies automatically the set of patterns explaining the differences between the groups. (C) 2017 Elsevier B.V. All rights reserved.

Chronic subdural hematoma (CSDH) is a common neurological pathology, especially in older patients. The actual “gold standard” of treatment is surgical evacuation, with various techniques used across neurosurgical teams. Over the years, there has been growing evidence that inflammatory processes play a major role in the pathogenesis of CSDH. In that context, the use of corticosteroids has been proposed alone or as an adjuvant treatment to surgery. However, this practice remains very empirical and there is a need for high-quality-of-evidence studies to clarify the role of corticosteroids in the management of CSDH.

Purpose A rare case of intradiploic growing fracture of the occipital bone is presented. Examination of this case and literature review was carried out to find significant specific features of such a rare condition. Case A 4-year-old boy was operated on for a huge occipital intradiploic growing skull fracture. His medical history, surgical management, and postoperative course are presented. Literature review A computer literature search using the Medline database revealed 31 well-documented cases. Conclusions Special attention must be paid to skull fractures in childhood when occurring near CSF large spaces, especially if ventricle enlargement, suggesting that hydrocephalus is present. Surgeons should evaluate hydrocephalus before treating such lesions in order to improve surgical result and postoperative clinical evolution.

Here we report in a human, a renal transplant patient, the first disseminated infection with Nocardia cerradoensis, isolated after a brain biopsy. Species identification was based on 16S rRNA, gyrB, and hsp65 gene analyses. Antibiotic treatment was successful by combining carbapenems and aminoglycosides and then switching to oral trimethoprim-sulfamethoxazole.

1. Patients with dynamic cervical myelopathy had a clinical instability. All of them had a cervical pain and consecutive loss of mention stiffness. Three of them had in addition Lhermitte’s sign. 2. They had also a radiological instability because anterior impingement with medullary compression was always observed in extension in this population of patients. In a physiologic condition, cervical disc budge in flexion and not in extension [1]. 3. Last, during the surgery, we observed in all cases a degenerative disc with an excessive motion between the two adjacent vertebrae corroborating chronic joint instability.

Background The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery.Methods Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model.Results The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model.Conclusion This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery.

PURPOSE:Non-traumatic cervical chronic joint instability in young adults is a rare and underexplored entity. We assessed the diagnostic relevance of dynamic MRI, and the clinical and radiological outcome after anterior cervical interbody fusion (ACIF) in these cases.METHODS:Six young patients (mean age 34 years) with cervical myelopathy without compression on static imaging had a dynamic MRI. Joint instability was defined by a reduction of the canal diameter on dynamic sequences. Clinical and radiological outcomes were assessed after surgery by examination, cervical X-rays, static and dynamic MRI.RESULTS:All the patients had joint instability. Four patients underwent surgery. Clinical status improved 1 year after surgery. All patients had a satisfactory fusion at 6-month follow-up and no residual compression at 1 year.CONCLUSION:Dynamic MRI can help detect a joint instability in young patients with cervical myelopathy without compression. ACIF seems to be efficient in these cases.

Haemangioblastomas are benign vascular tumours that may appear sporadically or in von Hippel-Lindau disease. Despite their higher incidence, sporadic haemangioblastomas have been less studied than syndromic ones. In this article, we evaluate the specific features, outcome and quality of life of patients with intracranial sporadic haemangioblastomas (ISHs) operated on in our institution.

Cauda equina tumours (CET) are rare and usually benign. Treatment of schwannomas and benign ependymomas, which are the most frequent histopathological types of CET, is now well established. However, management of other presumed histopathological types of CET is still a matter of debate. The aim of this study was to assess the incidence and the surgical treatment of rare CET.

In order to determine sources and metabolism of melatonin in human cerebrospinal fluid (CSF), melatonin and 6-sulfatoxymelatonin (aMT6S) concentrations were measured in CSF sampled during neurosurgery in both lateral and third ventricles in patients displaying movement disorder (Parkinson's disease, essential tremor, dystonia or dyskinesia) and compared with their plasma levels. Previous determinations in nocturnal urine had showed that the patients displayed melatonin excretion in the normal range, compared with healthy controls matched according to age. A significant difference in melatonin concentration was observed between lateral and third ventricles, with the highest levels in the third ventricle (8.75 ± 2.75 pg/mL vs. 3.20 ± 0.33 pg/mL, P = 0.01). CSF aMT6s levels were similar in both ventricles and of low magnitude, less than 5 pg/mL. They were not correlated with melatonin levels or influenced by the area of sampling. Melatonin levels were significantly higher in third ventricle than in the plasma, whereas there was no difference between plasma and lateral ventricle levels. These findings show that melatonin may enter directly the CSF through the pineal recess in humans. The physiological meaning of these data remains to be elucidated.Afin de déterminer les sources et le métabolisme de la mélatonine dans le liquide cérébrospinal (LCS) chez l’homme, nous avons déterminé les concentrations de mélatonine et de 6-sulfatoxymélatonine (aMT6S) dans des échantillons de LCS (ventricule latéral et troisième ventricule) prélevées durant la neurochirurgie chez des patients présentant un trouble des mouvements (maladie de Parkinson, tremblement essentiel, dystonie or dyskinésie) and comparé ces valeurs à celles des concentrations plasmatiques. Des dosages pratiqués préalablement sur les urines nocturnes avaient montré que les patients présentaient une excrétion normale de mélatonine, comparé aux valeurs de sujets normaux dans des mêmes tranches d’âge. Une différence significative était observée entre les concentrations de mélatonine dans le ventricule latéral et le troisième ventricule, avec les valeurs les plus élevées dans le troisième ventricule (8,75 ± 2,75 pg/mL vs. 3,20 ± 0,33 pg/mL, p = 0,01). Les concentrations d’aMT6s étaient semblables et très faibles dans les deux prélèvements de LCS, moins de 5 pg/mL. Ces valeurs n’étaient pas corrélées avec celles de mélatonine. Les concentrations de mélatonine étaient significativement plus élevées dans le troisième ventricule que dans le plasma et identiques dans le plasma et le ventricule latéral. Ces données suggèrent que la mélatonine peut pénétrer directement dans le LCS à partir du récessus pinéal chez l’homme. La signification physiologique de ces données reste à élucider.

Objective: This study analyzes decision making during preoperative surgical planning through two cognitive indicators: conflict and cognitive control. Background: Planning is a critical stage in naturalistic decision making, and there is some evidence suggesting that this activity depends on the level of expertise and the demands of the task. The specificity of surgery resides in the necessity to cope with (potential) conflicts between the purpose of the surgical intervention and the biological laws governing the patient's body. Method: Six neurosurgeons (two board-certified neurosurgeons, two chief residents, and two residents) described the operative procedure envisaged on nine surgical cases of increasing surgical complexity. A detailed analysis of one surgical case described by one expert was performed. Moreover, we measured the number of conflicts and controls reported by each surgeon. Results: Two experts were the only ones for which the report of conflicts increased with surgical complexity (respectively, 75% and 73% of the conflict variance predicted by complexity). The two experts significantly activated a higher proportion of knowledge-based control (respectively, 43% and 38%) than did intermediates and residents. The residents significantly activated more motor skill—based controls (respectively, 40% and 44%) than did intermediates and experts. Conclusion: It seems that expert surgical decision making to cope with task demands is significantly associated with conflict monitoring. Knowledge-based control to regulate conflict is mainly produced by experts. Application: Conflicts and controls analyzed through verbal reports can be used as relevant indicators to highlight critical moments in decision making that potentially require assistance from information systems.

The authors present the case of a 13-year-old boy who experienced frequent disabling episodes of typical postural induced headaches, which revealed a Chiari I malformation, syringomyelia and cervical spinal cord edema. This boy had received a valveless lumboperitoneal (LP) shunt at the age of 18 months for macrocephaly. At this time, cranial CT scan showed moderate enlargement of the subarachnoid spaces without hydrocephalus or tonsillar herniation. The LP shunt was clamped but the patient experienced signs of brain stem dysfunction and increased intracranial pressure. Finally, an adjustable valve (110 mm Hg) was inserted and all the symptoms resolved. Although some authors consider LP shunt as a safe and effective procedure even in the pediatric population, our case reminds us that these shunts, especially when valveless, may expose the patient to the risk of symptomatic acquired Chiari I malformation and syringomyelia consecutive to a chronic spinal CSF leakage.

Intracerebral haemorrhage remote from the site of surgery is an uncommon and poorly understood complication after neurosurgical procedures. Although patients under anticoagulant therapy or with perioperative elevated blood pressure are usually considered potentially at high risk of postoperative intracerebral haemorrhage, the aetiology is still unclear for patients without these predisposing factors. In this paper, we suggest that brain shift, unavoidably occurring during all neurosurgical procedures, might play a central role in the aetiology of postoperative remote intracerebral haemorrhage. Brain shift is mainly caused by gravity, aggressive intraoperative dehydration, and cerebrospinal fluid aspiration. Brain shift produces stretching and transient occlusion of the corticodural bridging veins draining into the peripheral dural sinus. Consequently, venous infarcts occur in the venous drainage territories and haemorrhagic transformation results when perfusion is re-established within ischemic tissue. To minimize brain shift and consequent risk of remote intracerebral haemorrhage, we recommend avoiding the use of hyperosmotic agents and cerebrospinal fluid drainage systems during neurosurgical procedures. Moderate head elevation during and immediately after surgery may improve cerebral venous drainage and reduces the risks of this life-threatening complication.