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1.
J Neurosurg ; : 1-5, 2023 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-38064710

RESUMO

OBJECTIVE: Over the past several decades, the number of women applying to medical school has increased significantly. However, parallel recruitment and retention of women in the field of neurosurgery continues to lag. The aim of this study was to identify the ratio and trend of female neurosurgery residents to the total number of residents during the past 7 years across all US neurosurgery residency programs. METHODS: The authors conducted a cross-sectional demographic study investigating the ratio of female neurosurgery residents to the total number of neurosurgery residents across US neurosurgical programs from 2016 to 2022. Using the Fellowship and Residency Electronic Interactive Database, all neurosurgical residency programs in the US were collected. Data were further divided into postgraduate years 1-7 to dissect the data collection per residency year. One hundred fourteen programs were included in the study. RESULTS: The number of female neurosurgery residents was 71 (29.8%) in 2022, 58 (25.2%) in 2021, 65 (27.9%) in 2020, 62 (27.3%) in 2019, 46 (21.4%) in 2018, 33 (15.2%) in 2017, and 34 (15.9%) in 2016. The trend line showed a significant increase using the Mann-Kendall test (p = 0.035). The total number of international medical graduate (IMG) female neurosurgery residents was 3 (4.2%) in 2022, 4 (6.9%) in 2021, 3 (4.6%) in 2020, 1 (1.6%) in 2019, 1 (2.2%) in 2018, 1 (3%) in 2017, and 2 (5.9%) in 2016. CONCLUSIONS: The number of women matching into neurosurgery residency programs is modestly increasing, especially for IMG women. Future steps toward fewer gender disparities should focus on career advancement and leadership diversification in organized and academic neurosurgery.

2.
J Neuroimaging ; 32(5): 798-807, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35567418

RESUMO

Mechanical thrombectomy (MT) for ischemic stroke due to large vessel occlusion is standard of care. Evidence-based guidelines on eligibility for MT have been outlined and evidence to extend the treatment benefit to more patients, particularly those at the extreme ends of a stroke clinical severity spectrum, is currently awaited. As patient selection continues to be explored, there is growing focus on procedure selection including the tools and techniques of thrombectomy and associated outcomes. Artificial intelligence (AI) has been instrumental in the area of patient selection for MT with a role in diagnosis and delivery of acute stroke care. Machine learning algorithms have been developed to detect cerebral ischemia and early infarct core, presence of large vessel occlusion, and perfusion deficit in acute ischemic stroke. Several available deep learning AI applications provide ready visualization and interpretation of cervical and cerebral arteries. Further enhancement of AI techniques to potentially include automated vessel probe tools in suspected large vessel occlusions is proposed. Value of AI may be extended to assist in procedure selection including both the tools and technique of thrombectomy. Delivering personalized medicine is the wave of the future and tailoring the MT treatment to a stroke patient is in line with this trend.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Inteligência Artificial , Isquemia Encefálica/terapia , Humanos , Medicina de Precisão , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do Tratamento
3.
Neurosurg Rev ; 45(2): 925-936, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34480649

RESUMO

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.


Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
5.
Clin Neurol Neurosurg ; 206: 106677, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34020326

RESUMO

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.


Assuntos
COVID-19/complicações , Trombose das Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/cirurgia , Acidente Vascular Cerebral/etiologia , Trombectomia , Idoso , Trombose das Artérias Carótidas/diagnóstico , Trombose das Artérias Carótidas/etiologia , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/etiologia
6.
Clin Neurol Neurosurg ; 201: 106440, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33383464

RESUMO

BACKGROUND AND IMPORTANCE: Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes. CLINICAL PRESENTATION: We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery. CONCLUSION: This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.


Assuntos
COVID-19/diagnóstico por imagem , Oclusão da Artéria Retiniana/diagnóstico por imagem , Transtornos da Visão/diagnóstico por imagem , Visão Monocular/fisiologia , COVID-19/complicações , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/etiologia , Transtornos da Visão/etiologia
7.
World Neurosurg ; 146: e779-e785, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33181379

RESUMO

BACKGROUND: In patients with brain parenchyma extending beyond the craniectomy defect, cerebrospinal fluid diversion may be necessary to facilitate proper bone flap replacement during cranioplasty. In this study, we present our case series of patients who underwent ultrasound-guided ventricular puncture during cranioplasty and report periprocedural metrics and clinical outcomes. METHODS: A retrospective study of patients who presented for cranioplasty that required ultrasound-guided ventricular puncture was performed. We also describe our operative technique for safely and accurately performing ultrasound-guided ventricular puncture. RESULTS: Ten consecutive patients were included in the overall patient cohort, all of whom required intraoperative ventricular puncture to achieve brain relaxation. The mean time between decompressive hemicraniectomy and cranioplasty was 145.4 days (range 19-419). The mean duration of cranioplasty operation was 146 minutes (range 74-193). All patients underwent ultrasound-guided ventricular puncture, and 5 patients had an external ventricular drain left in place for postoperative intracranial pressure monitoring and possible cerebrospinal fluid drainage. There were no instances of pericatheter hemorrhage. One patient presented postoperatively with wound infection, and this same patient was the only one in the cohort who required subsequent ventriculoperitoneal shunt for symptomatic hydrocephalus. CONCLUSIONS: Ultrasound-guided ventricular puncture is safe, feasible, and efficacious for use during cranioplasty to help facilitate bone flap replacement in patients with "full" brains, with an overall low rate of associated periprocedural complications. Although further studies are needed in a larger patient cohort, this technique should be considered to help reduce the morbidity associated with cranioplasty.


Assuntos
Ventrículos Cerebrais/cirurgia , Craniectomia Descompressiva , Procedimentos de Cirurgia Plástica/métodos , Crânio/cirurgia , Ventriculostomia/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Punções/métodos , Estudos Retrospectivos , Cirurgia Assistida por Computador/métodos , Ultrassonografia/métodos
8.
World Neurosurg ; 146: 20-25, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33229309

RESUMO

The COVID-19 outbreak has led to fundamental disruptions of health care and its delivery with sweeping implications for patients and physicians of all specialties, including neurosurgery. In an effort to conserve hospital resources, neurosurgical procedures were classified into tiers to determine which procedures have to be performed in a timely fashion and which ones can be temporarily suspended to aid in the hospital's reallocation of resources when equipment is scarce. These guidelines were created quickly based on little existing evidence, and thus were initially variable and required refinement. As the early wave can now be assessed in retrospect, the authors describe the lessons learned and the protocols established based on published global evidence to continue to practice neurosurgery sensibly and minimize disruptions. These operational protocols can be applied in a surge of COVID-19 or another airborne pandemic.


Assuntos
COVID-19/epidemiologia , COVID-19/prevenção & controle , Procedimentos Neurocirúrgicos/normas , Guias de Prática Clínica como Assunto/normas , Humanos , Neurocirurgia/normas , Neurocirurgia/tendências , Procedimentos Neurocirúrgicos/tendências , Pandemias/prevenção & controle , Equipamento de Proteção Individual/normas , Equipamento de Proteção Individual/tendências
9.
Clin Neurol Neurosurg ; 198: 106121, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32818755

RESUMO

BACKGROUND: Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies. OBJECTIVE: To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions. METHODS: A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit. RESULTS: A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %). CONCLUSION: This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.


Assuntos
Encefalopatias/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/normas , Doenças da Medula Espinal/cirurgia , Vocabulário Controlado , Encefalopatias/epidemiologia , Bases de Dados Factuais , Humanos , Estudos Prospectivos , Padrões de Referência , Doenças da Medula Espinal/epidemiologia
10.
J Neurol Neurosurg Psychiatry ; 91(8): 846-848, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32354770

RESUMO

BACKGROUND: Emergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate. CASE DESCRIPTION: We present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease. CONCLUSION: Our report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/líquido cefalorraquidiano , Infecções por Coronavirus/complicações , Pneumonia Viral/líquido cefalorraquidiano , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/virologia , Adulto , COVID-19 , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Acidente Vascular Cerebral/líquido cefalorraquidiano
12.
Neurosurgery ; 86(1): 107-111, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30690608

RESUMO

BACKGROUND: Traumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality. OBJECTIVE: To assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system. METHODS: The data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017. RESULTS: Of 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005). CONCLUSION: This study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.


Assuntos
Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/cirurgia , Craniotomia/mortalidade , Craniotomia/tendências , Índice de Gravidade de Doença , Centros de Traumatologia/tendências , Adulto , Idoso , Lesões Encefálicas/cirurgia , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/tendências , Alta do Paciente/tendências , Pennsylvania/epidemiologia , Centros de Traumatologia/normas , Resultado do Tratamento
13.
Surg Neurol Int ; 10: 128, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31528464

RESUMO

BACKGROUND: Cerebral arteriovenous malformations (AVMs) are vascular lesions with a network of dysplastic vessels between an arterial and a venous tree with no intervening capillary bed. They most commonly present with an acute hemorrhage, seizures, or persistent headaches. CASE DESCRIPTION: The authors report the case of a 62-year-old male who presented with diplopia for 5 days. Magnetic resonance imaging and angiography demonstrated a Spetzler-Martin Grade 2 AVM located in the right frontal operculum with deep drainage into the basal vein of Rosenthal causing ipsilateral oculomotor neuropathy. The patient underwent staged embolizations of the feeding pedicles, which were derived from the internal as well as external carotid circulation. This was followed by a right pterional craniotomy for resection of the AVM. The patient reported complete resolution of the diplopia over 4 weeks with no recurrence at the 6-month follow-up appointment. CONLUSION: AVMs of the brain can present with atypical clinical symptoms that can be caused by the venous drainage pattern not the location. It is important to include vascular imaging studies in the work-up of patients who present with diplopia to rule out an AVM. Early diagnosis and treatment of the AVM can result in complete resolution of the diplopia.

14.
J Clin Neurosci ; 69: 261-264, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31481292

RESUMO

The distal transradial access in the anatomical snuffbox for neurovascular procedures is a modification of the radial access with an improved safety profile and patient comfort compared to the conventional transradial access. However, its use has been limited to diagnostic cerebral angiography, but not aneurysm treatment. We present the first case of a 53-year-old female whose work-up for headaches showed an anterior communicating artery aneurysm. The patient underwent distal transradial cerebral angiography and subsequent placement of a Woven EndoBridge (WEB) device for treatment of the aneurysm through the same access site. The procedure was uneventful and the patient was discharged home neurologically intact. Her hand remained warm, well-perfused, and with no visible or palpable hematoma. Our report illustrates the feasibility of the distal TRA for the treatment of cerebral aneurysms using the WEB device. Further studies are necessary to confirm the additional benefits of the distal TRA over TRA for neurovascular access.


Assuntos
Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Artéria Radial/cirurgia , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento
15.
World Neurosurg ; 130: e166-e171, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31203067

RESUMO

OBJECTIVE: Intracranial pressure (ICP)-guided therapy has been the mainstay of treatment of patients with severe traumatic brain injury (TBI), but recent data have questioned its efficacy. The aim of this study was to demonstrate trends in compliance to TBI guidelines and use of ICP-guided care in a mature trauma system. METHODS: A retrospective analysis was conducted of 36,915 patients with severe TBI collected by the Pennsylvania Trauma Systems Foundation. The registry includes all patients >18 years old with a diagnosis of TBI with a Glasgow Coma Scale score ≤8 who were admitted from January 2000 to December 2017. RESULTS: Of 36,915 patients, 73.6% were men with a median age of 43.0 ± 21.3 years. An ICP monitor was placed in 16.3% of all patients. The rate of ICP monitoring ranged from 17.8% of patients in 2000-2004 to 16.7% in 2005-2009, 16.4% in 2010-2014, and 12.8% in 2015-2017 (P < 0.001). The most statistically significant decrease was noted from 2014 (16.4%) to 2015 (14.1%, P = 0.042). The percent decrease in ICP monitoring from 2000-2014 to 2015-2017 was equivalent for patients with Glasgow Coma Scale scores of 3-5 (-4.0%) and 6-8 (-4.5%). CONCLUSIONS: As studies emerged that demonstrated unclear benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in the use of ICP monitoring after 2014 among all TBI subpopulations despite noteworthy limitations in the aforementioned studies and clear recommendations from the Brain Trauma Foundation guidelines.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/epidemiologia , Escala de Gravidade do Ferimento , Pressão Intracraniana/fisiologia , Monitorização Fisiológica/tendências , Adulto , Lesões Encefálicas Traumáticas/fisiopatologia , Humanos , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
16.
Brain Res ; 1718: 231-241, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31034813

RESUMO

BACKGROUND: The sphenopalatine ganglion (SPG) is a vasoactive mediator of the anterior intracranial circulation in mammals. SPG stimulation has been demonstrated to alter blood-brain barrier (BBB) permeability, although this phenomenon is not well characterized. OBJECTIVE: To determine the effect of SPG stimulation on the BBB using rat models. METHODS: Extravasation of fluorescent tracer 70 kDa FITC-dextran into rat brain specimens was measured across a range of stimulation parameters to assess BBB permeability. Tight junction (TJ) morphology was compared by assessing differences in the staining of proteins occludin and ZO-1 and analyzing ultrastructural changes on transmission electron microscopy (TEM) between stimulated and unstimulated specimens. RESULTS: SPG stimulation at 10 Hz maximally increased BBB permeability, exhibiting a 6-fold increase in fluorescent traceruptake (1.66% vs 0.28%, p < 0.0001). This effect was reversed 4-hours after stimulation (0.36% uptake, p = 0.99). High-frequency stimulation at 20 Hz and 200 Hz did not increase tracer extravasation, (0.26% and 0.28% uptake, p = >0.999 and p = 0.998, respectively). Stimulation was associated a significant decrease in the colocalization of occludin and ZO-1 with endothelial markers in stimulated brains compared to control (74.6% vs. 39.7% and 67.2% vs. 60.4% colocalization, respectively, p < 0.0001), and ultrastructural changes in TJ morphology associated with increased BBB permeability were observed on TEM. CONCLUSION: This study is the first to show a reversible, frequency-dependent increase in BBB permeability with SPG stimulation and introduces a putative mechanism of action through TJ disruption. Bypassing the BBB with SPG stimulation could enable new paradigms in delivering therapeutics to the CNS. Further study of this technology is needed.


Assuntos
Barreira Hematoencefálica/metabolismo , Fossa Pterigopalatina/inervação , Fossa Pterigopalatina/metabolismo , Animais , Estimulação Elétrica/métodos , Feminino , Ocludina/metabolismo , Permeabilidade/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Proteínas de Junções Íntimas/metabolismo , Junções Íntimas/efeitos dos fármacos , Proteína da Zônula de Oclusão-1/metabolismo
17.
World Neurosurg ; 103: 664-670, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28457929

RESUMO

BACKGROUND: Cervical spondylodiscitis is thought to carry a significant risk for rapid neurologic deterioration with a poor response to nonsurgical management. METHODS: A retrospective surgical case series of the acute surgical management of cervical spondylodiscitis is reviewed to characterize the neurologic presentation and postoperative neurologic course in a relatively uncommon disease. RESULTS: Fifty-nine patients were identified (mean age, 59 years [range, 18-83 years; SD ± 13.2 years]) from a single-institution neurosurgical database. The most common levels of radiographic cervical involvement were C4-C5, C5-C6, and C6-C7, in descending order. Overall, statistically significant clinical improvement was noted after surgery (P < 0.05). Spinal cord hyperintensity on T2-weighted magnetic resonance imaging was significantly associated with a worse preoperative neurologic grade (P = 0.036), but did not correlate with a relatively worse neurologic outcome by discharge. No significant difference was noted between potential preoperative predictors (organism cultured, presence of epidural abscess, tobacco use, early surgery within 24 hours of clinical presentation) and preoperative American Spinal Injury Association injury scale, with the exception of the duration between symptom onset and surgical intervention. A negative correlation between increased preoperative duration of symptoms and magnitude in motor improvement was observed. Relative to anteroposterior decompression and fusion, anterior treatment alone demonstrated a relatively greater effect in neurologic improvement. CONCLUSIONS: Cervical spondylodiscitis is a rare disease that typically manifests with preoperative motor deficits. Surgery was associated with a significant improvement in motor score by hospital discharge. Significant predictors of neurologic improvement were not observed. Prolonged symptomatic duration was correlated with a significantly lower likelihood of motor score improvement.


Assuntos
Vértebras Cervicais/cirurgia , Discite/cirurgia , Abscesso Epidural/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica , Discite/complicações , Discite/diagnóstico por imagem , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico por imagem , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Adulto Jovem
18.
Neurosurg Clin N Am ; 28(1): 147-155, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27886876

RESUMO

More than 50% of patients diagnosed with acute, traumatic spinal cord injury will experience at least 1 complication during their hospitalization. Age, severity of neurological injury, concurrent traumatic brain injury, comorbid illness, and mechanism of injury are all associated with increasing risk of complication. More than 75% of complications will occur within 2 weeks of injury. The complications associated with SCI carry a significant risk of morbidity and mortality; their early identification and management is critical in the care of the SCI patient.


Assuntos
Doenças Cardiovasculares/etiologia , Gastroenteropatias/etiologia , Infecções/etiologia , Pneumopatias/etiologia , Traumatismos da Medula Espinal/complicações , Lesões do Sistema Vascular/etiologia , Hospitalização , Humanos
19.
Neurosurg Focus ; 39(4): E8, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26424348

RESUMO

OBJECT Unintended durotomy is a common occurrence during lumbar spinal surgery, particularly in surgery for degenerative spinal conditions, with the reported incidence rate ranging from 0.3% to 35%. The authors performed a systematic literature review on unintended lumbar spine durotomy, specifically aiming to identify the incidence of durotomy during spinal surgery for lumbar degenerative conditions. In addition, the authors analyzed the incidence of durotomy when minimally invasive surgical approaches were used as compared with that following a traditional midline open approach. METHODS A MEDLINE search using the term "lumbar durotomy" (under the 2015 medical subject heading [MeSH] "cerebrospinal fluid leak") was conducted on May 13, 2015, for English-language medical literature published in the period from January 1, 2005, to May 13, 2015. The resulting papers were categorized into 3 groups: 1) those that evaluated unintended durotomy rates during open-approach lumbar spinal surgery, 2) those that evaluated unintended durotomy rates during minimally invasive spine surgery (MISS), and 3) those that evaluated durotomy rates in comparable cohorts undergoing MISS versus open-approach lumbar procedures for similar lumbar pathology. RESULTS The MEDLINE search yielded 116 results. A review of titles produced 22 potentially relevant studies that described open surgical procedures. After a thorough review of individual papers, 19 studies (comprising 15,965 patients) pertaining to durotomy rates during open-approach lumbar surgery were included for analysis. Using the Oxford Centre for Evidence-Based Medicine (CEBM) ranking criteria, there were 7 Level 3 prospective studies and 12 Level 4 retrospective studies. In addition, the authors also included 6 studies (with a total of 1334 patients) that detailed rates of durotomy during minimally invasive surgery for lumbar degenerative disease. In the MISS analysis, there were 2 prospective and 4 retrospective studies. Finally, the authors included 5 studies (with a total of 1364 patients) that directly compared durotomy rates during open-approach versus minimally invasive procedures. Studies of open-approach surgery for lumbar degenerative disease reported a total of 1031 durotomies across all procedures, for an overall durotomy rate of 8.11% (range 2%-20%). Prospectively designed studies reported a higher rate of durotomy than retrospective studies (9.57% vs 4.32%, p = 0.05). Selected MISS studies reported a total of 93 durotomies for a combined durotomy rate of 6.78%. In studies of matched cohorts comparing open-approach surgery with MISS, the durotomy rates were 7.20% (34 durotomies) and 7.02% (68), respectively, which were not significantly different. CONCLUSIONS Spinal surgery for lumbar degenerative disease carries a significant rate of unintended durotomy, regardless of the surgical approach selected by the surgeon. Interpretation of unintended durotomy rates for lumbar surgery is limited by a lack of prospective and cohort-matched controlled studies.


Assuntos
Degeneração do Disco Intervertebral/cirurgia , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Humanos , Estudos Longitudinais , Vértebras Lombares/cirurgia , MEDLINE/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos
20.
J Cereb Blood Flow Metab ; 35(2): 167-75, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25407267

RESUMO

Cerebral arteriovenous malformations (AVMs) entail a significant risk of intracerebral hemorrhage owing to the direct shunting of arterial blood into the venous vasculature without the dissipation of the arterial blood pressure. The mechanisms involved in the growth, progression and rupture of AVMs are not clearly understood, but a number of studies point to inflammation as a major contributor to their pathogenesis. The upregulation of proinflammatory cytokines induces the overexpression of cell adhesion molecules in AVM endothelial cells, resulting in enhanced recruitment of leukocytes. The increased leukocyte-derived release of metalloproteinase-9 is known to damage AVM walls and lead to rupture. Inflammation is also involved in altering the AVM angioarchitecture via the upregulation of angiogenic factors that affect endothelial cell proliferation, migration and apoptosis. The effects of inflammation on AVM pathogenesis are potentiated by certain single-nucleotide polymorphisms in the genes of proinflammatory cytokines, increasing their protein levels in the AVM tissue. Furthermore, studies on metalloproteinase-9 inhibitors and on the involvement of Notch signaling in AVMs provide promising data for a potential basis for pharmacological treatment of AVMs. Potential therapeutic targets and areas requiring further investigation are highlighted.


Assuntos
Malformações Arteriovenosas Intracranianas/genética , Malformações Arteriovenosas Intracranianas/metabolismo , Malformações Arteriovenosas Intracranianas/patologia , Animais , Moléculas de Adesão Celular/genética , Moléculas de Adesão Celular/metabolismo , Células Endoteliais/metabolismo , Células Endoteliais/patologia , Humanos , Inflamação/tratamento farmacológico , Inflamação/genética , Inflamação/metabolismo , Inflamação/patologia , Malformações Arteriovenosas Intracranianas/tratamento farmacológico , Leucócitos/metabolismo , Leucócitos/patologia , Metaloproteinase 9 da Matriz/biossíntese , Metaloproteinase 9 da Matriz/genética , Polimorfismo de Nucleotídeo Único , Receptores Notch/genética , Receptores Notch/metabolismo , Transdução de Sinais/genética , Regulação para Cima/efeitos dos fármacos
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