Ruptured blood blister like aneurysm: does the best therapeutic option really exist?

Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3 months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3 months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.

MFI-11 Predicts Post-Operative Serious Complications in Patients Undergoing Surgery for Odontoid Fractures.

STUDY DESIGN: Retrospective Cohort. OBJECTIVES: The objective of this study was to analyze postoperative complications in different mFI-11 groups after surgery for odontoid fractures in a geriatric population. METHODS: A single center retrospective review of odontoid fractures surgery (between 2013 and 2022) in patients aged 65 years and older was conducted. The primary outcome was the occurrence of a major complication (Calvien-Dindo ≥4) within 30 days post-surgery. The secondary outcome was the occurrence of a major complication within 3 months after surgery, and death within 1-month post-surgery. Survival curve, multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated. RESULTS: There were 92 patients included in this study, with a mean age of 80.5 years. Serious complication occurred for 16 patients (17%) during hospitalization. Multivariate analysis demonstrated an mFI 11 >.27 was strongly and independently associated with serious complications within 1-month post-surgery (OR = 16.7, 95% CI = 4.50-83), as well as serious complications within 3 months post-surgery (OR = 11.8, 95% CI = 3.48-49.1) and death within 1 month post-surgery (OR = 11.7; 95% CI = 3.02-60.4). The Receiver Operator Characteristics (ROC) curves for the three models all have an Area Under the Curve (AUC) value greater than 0.7. CONCLUSIONS: The mFI-11 is a straightforward and validated tool that can be used during the preoperative period to identify the patient's level of frailty and assess their risk of postoperative complications. Patients with mFI-11 ≥.27 are at greater risk of serious complications within 1 and 3 months' post-surgery and death within 1 month post-surgery.

Management of delayed oesophagus perforation and osteomyelitis after cervical spine surgery: review of the literature.

Oesophagus perforation is a possible complication of anterior cervical spine surgery, which generally occurs during the first postoperative days. Delayed perforation is very rare and its management remains controversial. We report the successful management of a delayed oesophagus perforation associated with an osteomyelitis.

Combination of Percutaneous Screw Fixation and Cementoplasty for Lytic Bone Metastases: Feasibility, Safety and Clinical Outcomes.

OBJECTIVE: To evaluate feasibility, safety and efficacy of a combination of screw fixation and cementoplasty for pathologic bone fracture. METHODS: In this single-center prospective study, all consecutive percutaneous screw fixations under assisted CT guidance for palliation and fracture treatment of pathologic bone fracture were reviewed from July 2019 to February 2021. The primary outcome measure was the procedures' technical success, defined as the correct placement of the screw(s), without any complications. Secondary outcome measures were the safety, the procedures' early analgesic effects and impacts on quality of life at 4 weeks. RESULTS: Technical success was achieved in 11/11 procedures (100%) among 11 patients. No major complications attributable to the procedure were noted. The mean pain scored significantly decreased at the initial follow-up: 8.0 ± 2.7 versus 1.6 ± 2.5 (p < 0.05). Opioid doses were statistically lower after procedure: 70.9 ± 37 versus 48.2 ± 46 mg/day (p < 0.05). The mean EQ5D score had significantly increased by the early post-procedure consultation: 42.5 ± 13.6 vs 63.6 ± 10.3 (p < 0.05). CONCLUSION: Combination of percutaneous screw fixation and cementoplasty for pathologic bone fracture is feasible and safe. It is efficient to reduce pain, decrease the consumption of opioids and improve the quality of life at 4 weeks after the procedure.

Complications related to the placement of an intraventricular chemotherapy device.

Leptomeningeal meningitis occurs in 4-15% of patients with solid tumors. It is a severe disease which seriously affects patients' neurological status and quality of life. Intrathecal chemotherapy increases survival and improves quality of life. Administration of drugs by lumbar puncture causes pain and discomfort, reducing therapeutic compliance. Implantation of an intraventricular catheter fixed to a subcutaneous reservoir overcomes these drawbacks. To evaluate complications compared with implantation of an intraventricular chemotherapy device, between June 2006 and December 2009, 50 patients with a solid tumor underwent implantation of a catheter to treat leptomeningeal metastases. Clinical evaluation of all patients was performed every two weeks and magnetic resonance imaging at one month then every three months. Surgical data (operative time, blood loss) and all clinical and radiological complications were prospectively monitored. All patients underwent surgery with local anesthesia. The mean operative time was 15 min, with no complication during surgery. We report five complications (10%) during the follow-up; three required the removal of the device and another was lethal. There was no case of misplacement or obstruction of the catheter. Intraventricular chemotherapy is an effective treatment procedure which improves therapeutic compliance with acceptable morbidity.

Conservative versus Surgical Treatment for Odontoid Fracture: Is the Surgical Treatment Harmful? Systematic Review and Meta-Analysis.

BACKGROUND: Odontoid fracture is a common injury especially in elderly people. Despite some recent studies arguing in favor of surgery, the best treatment is still being debated. OBJECTIVE: We systematically review and analyze the comparative literature between surgical and conservative treatments of odontoid fractures. METHODS: We systematically searched Medline and the Cochrane Library for studies reported from January 1990 to May 2019 in English. Comparative studies evaluating the results of surgical and conservative treatments for odontoid fractures were eligible for inclusion. Combined relative risks (RRs) for mortality at last follow-up, union or nonunion rates, and complications were calculated. Methodological quality was assessed using the Newcastle-Ottawa Scale. Influence of age and year of publication on treatment effect was explored using a meta-regression analysis. RESULTS: A total of 1438 articles were identified, of which 30 articles with 2463 patients were eligible for inclusion. There was a trend toward lower mortality in the surgical group (RR, 0.80; 95% confidence interval [CI], 0.63-1.02). Nonunion rates (RR, 0.41; 95% CI, 0.28-0.6) were lower in the surgical group. Union rates were higher in the surgical group (RR, 1.26; 95% CI, 1.11-1.45). No significant influence of age or year of publication on treatment effect was found. CONCLUSIONS: Based on this meta-analysis of nonrandomized comparative studies, surgical treatment seems not to be inferior to conservative treatments. The conclusions of this study remain limited by the low quality of the evidence available. Randomized controlled studies are required.

Contribution of Dynamic Surgical Guidance to the Accurate Placement of Pedicle Screws in Deformity Surgery: A Retrospective Case Series.

OBJECTIVE: We assessed the contribution of a dynamic surgical guidance (DSG) probe in the accurate placement of thoracic and lumbar pedicle screws (PSs) in patients with spinal deformity. METHODS: A retrospective review was performed of 98 patients (104 procedures) with various spinal deformities, who had received posterior instrumentation with PSs inserted using either DSG or the conventional free-hand (FH) technique. A total of 882 PSs were inserted using DSG (DSG group) and 603 using the FH technique (FH group). The DSG probe was preferably chosen for large osteosyntheses and severe deformities. Two neurosurgeons, unaware of the surgical groups, reviewed all the intraoperative computed tomography scans and assessed all the PS placements. RESULTS: Of the PSs used, 95.4% in the DSG group and 92.2% in the FH group were correctly placed (P = 0.0136). The difference in screw placement accuracy was greater at the thoracic level (DSG group, 92.5%; vs. FH group, 87.0%; P = 0.0310) than at the lumbar level (DSG group, 98.0%; vs. FH group, 95.4%; P = 0.0385). Severe (>4 mm) lateral breaches occurred in 24 cases (4.0%) in the FH group but in only 5 (0.6%) in the DSG group (P < 0.0001). No severe medial breach was observed in either group. CONCLUSIONS: Despite having more patients with severe deformities in the DSG group, PS insertion was significantly more accurate with DSG. This technique also reduced the severe unacceptable lateral misplacement rate (>4 mm) and, consequently, the incidence of intraoperative screw revisions even in patients with severe deformities.

Interstitial 5-ALA photodynamic therapy and glioblastoma: Preclinical model development and preliminary results.

OBJECTIVE: Photodynamic therapy (PDT) has become a well-established modality for the treatment of many cancers. Photodynamic eradication of tumor cells depends on the presence of a photosensitizer, oxygen and light. However, oxygen depletion during PDT is a well known problem. Modulation of light delivery could address this issue by counteracting tumor hypoxia, thereby improving tumor cell killing. This preclinical study was designed to validate an animal model incorporating 5-aminolaevulinic acid (5-ALA)-PDT using U87 glioblastoma cells. We aimed to evaluate the effects of light modulation for inducing specific tumoral lesions in this model (i.e., necrosis or apoptosis). MATERIALS AND METHODS: U87 glioblastoma cells were stereotactically engrafted into the brains of male fox1 rnu/rnu rats. Light delivery was studied after 5-ALA injection (100 mg/kg i.p.). 26J of 635 nm light was interstitially delivered to U87 tumor-bearing rats at a radiant power of either 30 mW (high fluence rate) or 4.8 mW (low fluence rate). In each group, half of the population received illumination in 2 fractions with a refractory interval of 120 s, whereas the other half received continuous illumination. RESULTS: Twenty-two animals received 5-ALA-PDT, and the level of necrosis was scored. In the high-fluence-rate group, we observed a greater degree of tumor necrosis in rats receiving fractionated delivery than in rats receiving continuous illumination. Similar differences were not observed in the low-fluence-rate group, which exhibited only sparse necrosis. Higher morbidity and mortality rates were observed in the high-fluence-rate group. CONCLUSION: We have developed a reproducible and reliable rodent model for interstitial 5-ALA PDT. We found that the effects of 5-ALA-PDT are dependent on light delivery conditions. Although the low-fluence-rate treatment was better tolerated, 5-ALA-PDT induced more necrosis using fractionated delivery at a high fluence rate. These results require confirmation with further studies involving larger populations and additional fractionation schemes.

Experimental use of photodynamic therapy in high grade gliomas: a review focused on 5-aminolevulinic acid.

Photodynamic therapy (PDT) consists of a laser light exposure of tumor cells photosensitized by general or local administration of a pharmacological agent. Nowadays, PDT is a clinically established modality for treatment of many cancers. 5-Aminolevulinic acid (ALA) induced protoporphyrin IX (PpIX) has proven its rational in fluoro-guided resection of malignant gliomas due to a selective tumor uptake and minimal skin sensitization. Moreover, the relatively specific accumulation of photosensitizing PPIX within the tumor cells has gained interest in the PDT of malignant gliomas. Several experimental and clinical studies have then established ALA-PDT as a valuable adjuvant therapy in the management of malignant gliomas. However, the procedure still requires optimizations in the fields of tissue oxygenation status, photosensitizer concentration or scheme of laser light illumination. In this extensive review, we focused on the methods and results of ALA-PDT for treating malignant gliomas in experimental conditions. The biological mechanisms, the effects on tumor and normal brain tissue, and finally the critical issues to optimize the efficacy of ALA-PDT were discussed.