Managing Complications Related to Peripheral Nerve Surgery: Selected Illustrative Cases.

Peripheral nerve surgery mostly involves elective procedures; thus, the associated complications are of great clinical, social, and medicolegal importance. Apart from the general perioperative morbidity, complications during interventions on peripheral nerves are extremely rare. However, iatrogenic peripheral nerve injuries during unrelated surgical procedures performed by those not specialised in peripheral nerve surgery remain the most significant group of complications, accounting for up to approximately 17% of all cases. The aims of this review are to provide better insight into the multifaceted nature of complications related to peripheral nerve surgery-from the perspective of their causes, treatment, and outcome-and to raise surgeons' awareness of the risks of such morbidity. It should be emphasized that intraoperative complications in peripheral nerve surgery are largely "surgeon-related" rather than "surgery-related"; therefore, they have great potential to be avoided.

Reversible splenial lesion after surgery for distant arteriovenous malformation: a case report.

Isolated lesions of the corpus callosum are rare and may represent permanent but also transient responses to various pathology termed "reversible splenial lesion syndrome" (RESLES) when in light of relevant clinical presentation. We present the first case of the RESLES after elective surgery for distant arteriovenous malformation (AVM), followed by a slight speech disturbance and MRI verified small, oval, well-circumscribed area of apparent cytotoxic edema in the center of the corpus callosum splenium, which completely resolved within 15 days. Surgery for AVM is followed by the complex adaptation to a new vascular pattern, RESLES might develop, and should be suspected.

CLINICAL CHARACTERISTICS AND MORPHOLOGICAL PARAMETERS ASSOCIATED WITH RUPTURE OF ANTERIOR COMMUNICATING ARTERY ANEURYSMS.

We analyzed aneurysm morphology, demographic and clinical characteristics in patients with anterior communicating artery (ACoA) aneurysms to investigate the risk factors contributing to aneurysm rupture. A total of 219 patients with ACoA aneurysms were admitted to our hospital between January 2016 and December 2020, and morphological and clinical characteristics were analyzed retrospectively in 153 patients (112 ruptured and 41 unruptured). Medical records were reviewed to obtain demographic and clinical data on age, gender, presence of hemorrhage, history of hypertension, diabetes, heart disease, and kidney disease. Morphological parameters examined on 3-dimensional digital subtraction angiography included aneurysm size, neck diameter, aspect ratio, size ratio, bottleneck ratio, height/width ratio, aneurysm angle, (in)flow angle, branching angle, number of aneurysms per patient, shape of the aneurysm, aneurysm wall morphology, variation of the A1 segment, and direction of the aneurysm. Male gender, aspect ratio, height/width ratio, non-spherical and irregular shape were associated with higher odds of rupture, whilst controlled hypertension was associated with lower odds of rupture, when tested using univariate logistic regression model. In multivariate model, controlled hypertension, presence of multiple aneurysms, and larger neck diameter reduced the odds of rupture, while irregular wall morphology increased the risk of rupture. Regulated hypertension represented a significant protective factor from ACoA aneurysm rupture. We found that ACoA aneurysms in male patients and those with greater aspect ratios and height/width ratios, larger aneurysm angles, presence of daughter sacs and irregular and non-spherical shapes were at a higher risk of rupture.

Awake surgery in sitting position for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD: This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS: Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS: In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.

GIANT CAVERNOUS MALFORMATION WITH UNUSUALLY AGGRESSIVE CLINICAL COURSE: A CASE REPORT.

Giant cavernomas (GC) are rare lesions, with less than 50 cases reported so far. Clinical presentation usually involves epileptic seizures and less typically focal neurological deficit, due to repeated hemorrhages and GC mass effect and consequentially increased intracranial pressure. Although individual cases have been reported, due to the rarity and variable imaging appearance, GCs are usually not considered in the differential diagnosis of large hemorrhagic lesions, especially when significant mass effect is present. A 17-year-old boy presented due to severe headache, right-sided weakness, and slurred speech. Symptoms started three days before with occasional headaches, which intensified gradually. Emergency computed tomography revealed a left frontal massive heterogeneous lesion. Soon after, right-sided hemiparesis and speech impairment progressed, and the patient became drowsy with the slightly dilated left pupil. Emergency surgery was performed, and the lobed grayish lesion was entirely removed. Based on the macroscopic appearance, the surgeon assumed it was a metastasis of melanoma. Histopathologic analysis result was cavernoma. GC should be considered as an option in hemorrhagic lesions, especially in the young age population. Emergency surgery for mass lesions is not uncommon in neurosurgery; however, bleeding cavernomas are usually planned for elective surgery due to the specific approach and complications.

A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case.

BACKGROUND: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. CASE REPORT: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions.

Ultrasonographic assessment of the maxillary artery and middle meningeal artery in the infratemporal fossa.

PURPOSE: To investigate with Doppler ultrasonography the maxillary and middle meningeal arteries in the infratemporal fossa, and describe their hemodynamic characteristics. METHODS: We included 24 female and 11 male volunteers without vascular diseases, with a median age of 43 years. We used the acoustic window, enlarged by subjects half-opening their mouth, located below the zygomatic arch, in front of temporo-mandibular joint, to reach the maxillary and middle meningeal arteries. RESULTS: In the 35 subjects, 112 arteries were visualized successfully: 60 maxillary (85.7%), and 52 middle meningeal arteries (74.3%), at a depth of 2.40 and 2.50 cm, respectively. Their blood flow was directed anteriorly and away from the probe. While all the measured hemodynamic characteristics differed significantly between the maxillary and the middle meningeal artery (P < 0.001), there was no significant difference between male and female subjects, nor between the left or the right side. CONCLUSIONS: The maxillary and middle meningeal arteries can be insonated in the infratemporal fossa through the easily accessible acoustic window below the zygomatic arch, when the patient holds his mouth half open. They can be differentiated by their ultrasonographic characteristics and blood flow features.

Environmental and take-home lead exposure in children living in the vicinity of a lead battery smelter in Serbia.

Blood lead levels (BLLs) have been falling steadily worldwide due to restricted use of lead (Pb) and its compounds. although they remain above preindustrial Pb levels. Elevated BLL can still be found in children living near secondary Pb smelters that represent around 50% of Pb production. There have been no studies on Pb exposure in children living in Serbia ever since the 1980s. The aim of this study was to evaluate the BLLs in children living in two villages in Serbia (Zajaca, the location of a secondary lead smelter, and Paskovac, 5 km away), identify the primary determinants of children's BLLs, and investigate the impact of BLLs on children's health symptoms and school achievement. The study was conducted in 2011 on 127 children, aged 1-18 years, whose BLLs were measured using inductively coupled argon plasma mass spectrometry (ICP-MS). The median BLL in children was 12 µg/dl, with a significantly higher value of 17.5 µg/dl in Zajaca, compared to 7.6 µg/dl in Paskovac. Only 1 out of 75 and 12 out of 52 children from Zajaca and Paskovac, respectively, had BLLs below the CDC recommended 5 µg/dl level. Living near the smelter resulted in 19 times, and having a father who works in the plant 4 times higher odds of elevated BLLs. No significant effects of elevated BLLs health symptoms were seen in this study. BLLs of children living near a battery recycling plant in Serbia, an upper-middle income European country, were in the range and even higher than those of children living in developing countries. For the first time, the contribution of environmental and take-home lead exposure was quantified using mixed-effect modeling, and our results indicate a contribution of 25-40% of the take-home lead exposure to the BLLs of children living in the vicinity of a secondary lead smelter.

MANAGEMENT OF BRACHIAL PLEXUS MISSILE INJURIES.

- Missile injuries are among the most devastating injuries in general traumatology. Traumatic brachial plexus injuries are the most difficult injuries in peripheral nerve surgery, and most complicated to be surgically treated. Nevertheless, missile wounding is the second most common mechanism of brachial plexus injury. The aim was to evaluate functional recovery after surgical treatment of these injuries. Our series included 68 patients with 202 nerve lesions treated with 207 surgical procedures. Decision on the treatment modality (exploration, neurolysis, graft repair, or combination) was made upon intraoperative finding. Results were analyzed in 60 (88.2%) patients with 173 (85.6%) nerve lesions followed-up for two years. Functional recovery was evaluated according to functional priorities. Satisfactory functional recovery was achieved in 90.4% of cases with neurolysis and 85.7% of cases with nerve grafting. Insufficient functional recovery was verified in ulnar and radial nerve lesions after neurolysis, and in median and radial nerve lesions when graft repair was done. We conclude that the best time for surgery is between two and four months after injury, except for the gunshot wound associated with injury to the surrounding structures, which requires immediate surgical treatment. The results of neurolysis and nerve grafting were similar.

Outcome after brachial plexus injury surgery and impact on quality of life.

BACKGROUND: The aim of this study was to investigate outcomes after surgery for brachial plexus injury (BPI), not only motor outcomes but also the quality of life of the patients. METHODS: We operated on 128 consecutive patients with BPI from 1992 to 2012. We documented the information on the injured nerve, level of injury, type of treatment used, timing of surgery, patient age, and preoperative and postoperative motor deficits. In 69 patients who agreed to participate in a quality of life study, additional assessments included functionality, pain, quality of life, patient satisfaction, and psychosocial health. RESULTS: Of patients who underwent only exploration and neurolysis, 35.3% showed a good quality of recovery. Patients who underwent nerve reconstruction using nerve grafting showed a better rate of good quality recovery (56.7%), and the results following nerve transfer depended on the type of transfer used. After surgery, 82.6% of patients showed significant improvement, 82.6% were satisfied, and 81.2% responded positively when asked if they would undergo surgery again if they knew the current result beforehand. Overall, 69.6% patients continued working after surgery. The mean DASH disability score was high (58.7) in the study group. Patients who had early surgery showed a consistently higher DASH score. About 76% of patients reported having pain regularly, and 18.8% reported depression or anxiety. CONCLUSIONS: We consider that it is important to report not only muscle recovery, but also other aspects of recovery.

Cranial Reconstruction Using Autologous Bone and Methylmethacrilate.

BACKGROUND: Having in mind the importance of reconstruction of the calvaria, our goal was to compare the complication rates following the use of autologous bone and methylmethacrilate grafts, and explain the factors influencing them. METHODS: The authors collected information of all the patients undergoing cranial reconstructive surgery (N = 149) at the Military Medical Academy in Belgrade. Procedures were performed either using a craniotomy bone flap, removed and replaced in the same act, or using methylmethacrilate. These 2 groups were compared using the Chi-squared test, controlling for the confounding influence of the size of the defect. RESULTS: Intracranial neoplasms were the cause for the reconstruction in 71.1% of patients. The total complication rate was 7.4%, while the infection rate was 5.4%. The infection rate was significantly higher in those procedures done using methylmethacrilate (11.3% compared with 2.1%, P = 0.017), but when controlling for the confounding effect of the size of the defect treated, the difference in infection rate was significant only in large defects (13.9% compared with 2%, P = 0.031), while for small defects the difference was not statistically significant. CONCLUSIONS: Our study suggests that the material used for reconstruction of calvaria influences the infection rate only in large and complicated defects. Considering the importance of the reconstruction, further studies should explore and confirm the role of material type on the rate of complications.

Combined Treatment of Ruptured Middle Cerebral Artery Aneurysm Followed by Subarachnoid Hemorrhage and Acute Subdural Hematoma in Multiple Aneurysm Disease of Cerebral Blood Vessels: Case Report

Aneurysms of blood vessels at the base of the brain are pathological focal out-pouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.

Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note.

BACKGROUND AND IMPORTANCE: Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy. CLINICAL PRESENTATION: A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved. CONCLUSION: Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.

Effect of revascularization surgery on cerebral hemodynamics in adult moyamoya disease.

OBJECTIVE: Few studies have reported local hemodynamic changes after revascularization surgery. This study aimed to identify regional hemodynamic changes after combined revascularization surgery for moyamoya disease using single-photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine. METHODS: A total of 46 adults with moyamoya disease who underwent combined revascularization surgery from August 2009 to July 2021 at our facility were enrolled. The combined bypass procedure comprised a single direct bypass to the motor area and encephalo-duro-arterio-myo-synangiosis. The preoperative and postoperative cerebral blood flow (CBF) and cerebral vascular reserve (CVR) in the genu; precentral, central, parietal, angular, temporal, and posterior regions; splenium; hippocampus; and cerebellum were measured. To modify the examination variability, the cerebral-to-cerebellar activity ratio (CCR) was calculated by dividing the counts in the region by those in the cerebellum (CBF-CCR and CVR-CCR). RESULTS: Postoperatively, asymptomatic cerebral infarction occurred in three (6.5%) patients. The CBF-CCR and CVR-CCR improved in the precentral, parietal, and temporal regions and in the overall middle cerebral artery (MCA) territory. Sub-analysis of anterior cerebral artery (ACA) and posterior cerebral artery (PCA) territory hemodynamics revealed that patients with normal preoperative hemodynamics showed no changes in the CBF-CCR and CVR-CCR postoperatively, whereas patients with preoperative perfusion impairment exhibited improved CVR-CCR in the ACA territory (0.13-0.3, p=0.019) and CBF-CCR in the PCA territory (0.93-0.96, p=0.0039). CONCLUSION: Combined revascularization surgery with single bypass to the motor area improved hemodynamics in the primary targeted MCA territory and in the ACA and PCA territories among patients with preoperative hemodynamic impairment.

Frontal Sinus Mucosa Bacteriological Features: Evaluation after Unintentional Opening in Neurosurgery.

Objectives The bacteriological features of the frontal sinus mucosa may impose significant complications in neurosurgery, when breached unintentionally. This study aimed to investigate the bacterial flora in patients undergoing frontal craniotomy for cerebrovascular substrate surgery. Design This is a single-center prospective study. Setting When mucosal laceration occurred, the patients underwent frontal sinus reconstruction with mucosa reconstruction, preserving the nasofrontal duct. Participants We enrolled eight consecutive patients who underwent bifrontal craniotomy associated with frontal sinus mucosa laceration. Main Outcome Measures A portion of the mucosa was extracted during the reconstructive procedure and was sent for microbiological analysis. Results None of the patients presented with the bacterial flora in the mucosal cultures. No patient experienced postoperative cerebrospinal fluid leakage or meningitis. One patient with a clinical history of chronic maxillary sinusitis presented with a subcutaneous abscess around the forehead at 9 months postoperatively. The patient rapidly recovered after receiving oral administration of antibiotics. Conclusions Our findings demonstrated that the frontal sinuses were maintained in an aseptic environment in all cases. The results may encourage the development and wider use of transfrontal sinus approaches.

A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Background: Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Methods: Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. Results: The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. Conclusion: The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

The prevalence of imposter syndrome among neurosurgeons in Europe: An EANS YNC survey.

Introduction: Imposter syndrome (IS), characterized by persistent doubts about one's abilities and fear of exposure as a fraud, is a prevalent psychological condition, particularly impacting physicians. In neurosurgery, known for its competitiveness and demands, the prevalence of IS remains high. Research question: Recognizing the limited literature on IS within the neurosurgical community, this European survey aimed to determine its prevalence among young neurosurgeons and identify associated factors. Material and methods: The survey, conducted by the Young Neurosurgeon Committee of the European Association of Neurosurgical Societies, gathered responses from 232 participants. The survey included demographics, the Clance Imposter Phenomenon Survey (CIPS), and an analysis of potential compensatory mechanisms. Results: Nearly 94% of respondents exhibited signs of IS, with the majority experiencing moderate (36.21%) or frequent (40.52%) symptoms. Analyses revealed associations between IS and factors such as level of experience, sex, and board-certification. Discussion and conclusion: The findings suggest a significant prevalence of IS among young neurosurgeons, with notable associations with sex and level of experience. Compensatory mechanisms, such as working hours, article reading, and participation in events, did not show significant correlations with IS. Notably, male sex emerged as an independent protective factor against frequent/intense IS, while reading more than five articles per week was identified as a risk factor. The identification of protective and risk factors, particularly the influence of gender and reading habits, contributes valuable insights for developing targeted interventions to mitigate IS and improve the well-being of neurosurgeons.

A Brief History of Peripheral Nerve Surgery in Serbia.

Peripheral nerve surgery in Serbia has become the most fruitful subsection of national neurosurgery, with international recognition of Serbian surgeons and institutions. We chronicle landmark events in the history of the field in Serbia, highlighting the development of the field over time and outlining future prospects. This manuscript provides an example of the development of peripheral nerve surgery and associated training in a challenging social, political, and economic context and may guide the development of peripheral nerve surgery care and training in other settings.

Disappearance of hemichorea as the initial presentation of moyamoya disease after revascularization surgery regardless of residual hypoperfusion evaluated by quantitative N-isopropyl-p-123I-iodoamphetamine SPECT.

BACKGROUND AND IMPORTANCE: Although hypoperfusion of the basal ganglia or the frontal subcortical matter is suspected, the pathology of chorea in moyamoya disease remains unclarified. Herein, we report a case of moyamoya disease presenting with hemichorea and evaluate pre- and postoperative perfusion using single photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine (123I-IMP SPECT). CLINICAL PRESENTATION: An 18-year-old woman presented with choreic movement of her left limbs. Magnetic resonance imaging revealed an ivy sign, and 123I-IMP SPECT demonstrated decreased cerebral blood flow (CBF) and cerebral vascular reserve (CVR) values in the right hemisphere. The patient underwent direct and indirect revascularization surgery to improve cerebral hemodynamic impairment. The choreic movements entirely resolved immediately after surgery. Although CBF and CVR values in the ipsilateral hemisphere demonstrated by quantitative SPECT increased, these did not reach the normal values threshold. CONCLUSION: Choreic movement in moyamoya disease may be related to cerebral hemodynamic impairment. Further studies are required to elucidate its pathophysiological mechanisms.