Tuesday, January 8, 2013

Clinical, radiological and microbiological profile of patients with autogenous cranioplasty infectio

Available online 5 January 2013
Publication year: 2013
Source:World Neurosurgery

Introduction Bone flap infections following autogenous cranioplasty can present a diagnostic and management challenge. Little is known about the clinical, radiological and microbiological profile of these patients. Methods Patients who developed bone flap infective complications requiring explantation following autogenous cranioplasties between 1999 and 2009 were identified. Their prospectively collected demographic details, clinical presentation, radiological features, surgical intervention, microbiological profile and treatment outcomes were retrospectively reviewed. Results During the study period, 179 cranioplasties were performed using frozen autogenous skull flaps. Seventeen patients (10%, median age 25 years) were complicated by deep infection necessitating flap removal and antimicrobial treatment. While fever, scalp swelling and local inflammation were present in majority of patients (76.5%), inflammatory markers were abnormal only in 33%. CT imaging features included: extra-axial collection (76.5%), subgaleal collection or galeal swelling (70.6%), cerebritis (37.5%) and osteomyelitis (23.5%). Positive bacterial cultures were obtained from all (100%) explanted bone-flaps, including gram positive (82.3 %) and negative (17.7%) organisms. Significant proportion (29.4%) of patients presented late (>6 weeks), 60% of these were due to Propionibacterium acnes infection. Conclusions Clinical assessment is critical to the diagnosis of bone flap infection. A high index of suspicion is necessary as late presentations are possible. Empirical antimicrobial treatment should include gram-negative coverage.






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Hypothermia for Acute Spinal Cord Injury - A Review

Available online 5 January 2013
Publication year: 2013
Source:World Neurosurgery

Objectives Spinal cord injury (SCI) is a catastrophic neurological event with no proven treatments that protect against its consequences. Potential benefits of hypothermia in preventing/limiting central nervous system (CNS) injury are now well known. There has been an interest in its potential use after SCI. This article reviews the current experimental and clinical evidence on the use of therapeutic hypothermia in patients with SCI. Method Review of literature. Results There are various mechanisms by which hypothermia is known to protect the CNS. Modest hypothermia (32-34 °C) can deliver the potential benefits of hypothermia without incurring the complications associated with deep hypothermia. Several recent experimental studies have repeatedly shown that the use of hypothermia provides the benefit of neuroprotection after SCI. While older clinical studies were often focused on local cooling strategies and demonstrated mixed results, more recent data from systemic hypothermia use demonstrates its safety and its benefits. Endovascular cooling is a safe and reliable method of inducing hypothermia. Conclusion There is robust experimental and some clinical evidence that hypothermia is beneficial in acute SCI. Larger, multicenter trials should be initiated to further study the usefulness of systemic hypothermia in SCI.






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Venous Thromboembolism in Subarachnoid Hemorrhage

Available online 5 January 2013
Publication year: 2013
Source:World Neurosurgery

Objective Venous thrombembolism is a significant cause of mortality in patients after subarachnoid hemorrhage (SAH). After screening a cohort of SAH for this complication, we proposed a refinement for risk stratification of venous thromboembolism. Methods Our retrospective study included patients admitted to our academic medical center (2005-2007) for SAH from ruptured aneurysm and having survived beyond 72 hours. The 196 patients then underwent screening (i.e., duplex scans of the lower extremities) for deep vein thrombosis (DVT); ultrasounds were obtained when there was a clinical suspicion of DVT. Patient demographics and clinical variables were assessed as risk factors for DVT by logistic regression analysis. Results Among 196 patients, the incidence of DVT was 9.7% and pulmonary embolism was 2%. In univariate analysis, factors significantly associated with DVT were absence of tobacco smoking, black race, male sex, poor admission Glasgow Coma Scale or World Federation of Neurological Surgeons grading scale for SAH, tall height, long hospital stay, and heavier body weight (p < .05). In multivariate analysis, only smoking, race, and length of stay were significant independent predictors of DVT; aneurysm securing method and hypertension had no association with DVT. Conclusions Finding our SAH patients to be the largest group screened for DVT on the basis of our literature review, we confirmed many known risk factors for DVT and observed that smokers who abruptly quit lowered their risk of DVT. Our findings may be used for risk stratification when determining DVT chemoprophylaxis after SAH.






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Neurologic Grading in Traumatic Spinal Cord Injury

Available online 5 January 2013
Publication year: 2013
Source:World Neurosurgery

Quantifying the clinical neurological impairment of individuals with traumatic spinal cord injury (SCI) is of great importance in managing the population. The current gold standard is the International Standards for Neurological Classification (ISNCSCI) of SCI. Administered in isolation, this measure is not sensitive or specific enough to quantify impairment for the whole SCI population with the detail required for clinical trials and interventional studies. This review outlines a broader range of outcome measures which have the potential to assess neurological impairment and function in the traumatic SCI population. We describe recent developments in new, more sensitive outcomes traditionally used in the laboratory; and the efforts being made to validate and encourage their clinical use. However, the use of impairment measures alone will not provide clinicians with enough information regarding the individual's abilities. Thus, the use of functional outcomes such as the Spinal Cord Independence Measure, Functional Independence Measure and other functional tests alongside the neurological impairment measures, such as the ISNCSCI and the electrophysiological measures are required for adequate characterization of the deficits and abilities in the traumatic SCI population.






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Friday, January 4, 2013

Surgical results of the Carotid Occlusion Surgery Study

Journal of Neurosurgery, Volume 118, Issue 1, Page 25-33, January 2013.
Object The Carotid Occlusion Surgery Study (COSS) was conducted to determine if superficial temporal artery–middle cerebral artery (STA-MCA) bypass, when added to the best medical therapy, would reduce subsequent ipsilateral stroke in patients with complete internal carotid artery (ICA) occlusion and an elevated oxygen extraction fraction (OEF) in the cerebral hemisphere distal to the occlusion. A recent publication documented the methodology of the COSS in detail and briefly outlined the major findings of the trial. The surgical results of the COSS are described in detail in this report. Methods The COSS was a prospective, parallel-group, 1:1 randomized, open-label, blinded-adjudication treatment trial. Participants, who had angiographically demonstrated complete occlusion of the ICA causing either a transient ischemic attack or ischemic stroke within 120 days and hemodynamic cerebral ischemia indicated by an increased OEF measured by PET, were randomized to either surgical or medical treatment. One hundred ninety-five patients were randomized: 97 to the surgical group and 98 to the medical group. The surgical patients underwent an STA-MCA cortical branch anastomosis. Results In the intention-to-treat analysis, the 2-year rates for the primary end point were 21% for the surgical group and 22.7% for the medical group (p = 0.78, log-rank test). Fourteen (15%) of the 93 patients who had undergone an arterial bypass had a primary end point ipsilateral hemispheric stroke in the 30-day postoperative period, 12 within 2 days after surgery. The STA-MCA arterial bypass patency rate was 98% at the 30-day postoperative visit and 96% at the last follow-up examination. The STA-MCA arterial bypass markedly improved, although it did not normalize, the level of elevated OEF in the symptomatic cerebral hemisphere. Five surgically treated and 1 nonsurgically treated patients in the surgical group had a primary end point ipsilateral hemispheric stroke after the 30-day postoperative period. No baseline characteristics or intraoperative variables revealed those who would experience a procedure-related stroke. Conclusions Despite excellent bypass graft patency and improved cerebral hemodynamics, STA-MCA anastomosis did not provide an overall benefit regarding ipsilateral 2-year stroke recurrence, mainly because of a much better than expected stroke recurrence rate (22.7%) in the medical group, but also because of a significant postoperative stroke rate (15%). Clinical trial registration no.: NCT00029146.





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