Postoperative CT scans after resection of brain metastases: neurosurgical routine or added value?

BACKGROUND: Metastasis is the most common brain tumor in adults. It is the standard of care at most North American centers to obtain an early postoperative imaging after their resection. However, the necessity of this practice in the absence of a new postoperative deficit remains unclear. METHODS: We retrospectively reviewed our surgical cohort of patients who underwent resection of brain metastases from July 2018 to June 2019. We collected demographic data and reviewed results of routine postoperative CT scans and neurological morbidities to examine the diagnostic and therapeutic yield of an early postoperative scan. In addition, we performed a systematic review of the topic. RESULTS: Our review included 130 patients, all of whom underwent gross total resection of one or more brain metastases. On postoperative CT, none had unexpected findings such as cavity hematoma or new ischemia; no changes in management resulted from postoperative imaging. One patient required a higher dose of dexamethasone on postoperative day 4 for delayed hemiparesis and aphasia due to cerebral edema. Three additional patients underwent a wound washout for delayed infection during a subsequent admission. Our systematic review identified three additional studies; in a combined cohort of 450 patients (including our own), no patients had clinically actionable findings on routine postoperative CT. CONCLUSIONS: Following resection of brain metastases, a routine postoperative CT scan has low diagnostic yield and did not change patient management in any cases examined in this work.

Traumatic penetrating head injury by crossbow projectiles: A case report and literature review.

Background: Low-energy penetrating head injuries caused by arrows are relatively uncommon. The objective of this report is to describe a case presentation and management of self-inflicted intracranial injury using a crossbow and to provide a relevant literature review. Case Report: A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow that he bought from a department store. The patient arrived neurologically intact at the hospital, fully awake and oriented. He was not able to verbalize due to immobilization of the jaw as well as fixation of his tongue to his hard palate secondary to the position of the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavity, along with the palate and, the skull base of the anterior cranial fossa, and the left frontal lobe, were all breached. No vascular injury was identified clinically or in imaging. The arrow was surgically removed in the operating room after establishing an elective surgical airway. The floor of the mouth, tongue, and palate was repaired next. A planned delayed cerebrospinal fluid leak repair was performed. The patient made a substantial recovery and was discharged home in good functional status. A systematic literature search was done using Medline for cases with intracranial injuries related to crossbows to review and appraise the available literature. Conclusion: A thorough assessment in a multidisciplinary trauma center and the availability of a subspecialty care team, including neurosurgery and otolaryngology, are paramount in such cases. The vascular imaging should be done before and after any planned surgical intervention. Emergent and elective surgical airway management should be considered and made available throughout the stabilization and care of the acute injury. Surgical management should be planned to remove the object with adequate exposure to facilitate visualization, removal, and the possible need for further intervention, including anticipating aerodigestive and vascular injuries on removal. Finally, access to weapons and the relation to psychiatric illness should not be overlooked, as many reported cases are self-harming in nature.

Image-Guided versus Freehand Ventricular Drain Insertion: Systematic Review and Meta-analysis.

BACKGROUND: Ventricular drain insertion is a common neurosurgical procedure, typically performed using a freehand approach. Use of image guidance during drain insertion could improve accuracy and reduce the incidence of drain failure. This review aims to assess the impact of image guidance on drain placement accuracy, failure rate, and number of ventricular cannulation attempts. METHODS: We searched MEDLINE, Embase, and Cochrane Library databases from inception to February 2021 for studies comparing image-guided versus freehand ventricular drain insertion. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias and quality of evidence. Pooled data were reported using random effects model. The ROBINS-I tool was used to assess risk of bias and the GRADE approach was used to assess quality of evidence. RESULTS: Of 1102 studies retrieved, 17 were included for a total of 3404 patients. All included studies were of non-randomized design. Pooled data on drain accuracy and drain failure rates showed favorable effect of image guidance, with risk ratio of 1.31 (95% confidence interval [CI] 1.13-1.51, low quality evidence) and 0.63 (95% CI 0.48-0.83, moderate quality evidence), respectively. Pooled data were equivocal for number of attempts with mean difference score of -0.14 times (95% CI -0.44 to 0.15, very low-quality evidence). Heterogeneity was substantial for drain accuracy and failure rate outcomes. CONCLUSIONS: In patients undergoing ventricular drain insertion, the use of image guidance may enhance drain accuracy and reduce drain failure rate. The use of image guidance probably does not decrease the number of drain insertion attempts.

Randomized controlled trials in neurosurgery.

Randomized controlled trials (RCTs) have become the standard method of evaluating new interventions (whether medical or surgical), and the best evidence used to inform the development of new practice guidelines. When we review the history of medical versus surgical trials, surgical RCTs usually face more challenges and difficulties when conducted. These challenges can be in blinding, recruiting, funding, and even in certain ethical issues. Moreover, to add to the complexity, the field of neurosurgery has its own unique challenges when it comes to conducting an RCT. This paper aims to provide a comprehensive review of the history of neurosurgical RCTs, focusing on some of the most critical challenges and obstacles that face investigators. The main domains this review will address are: (1) Trial design: equipoise, blinding, sham surgery, expertise-based trials, reporting of outcomes, and pilot trials, (2) trial implementation: funding, recruitment, and retention, and (3) trial analysis: intention-to-treat versus as-treated and learning curve effect.

Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience.

BACKGROUND: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. METHODS: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients' baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. RESULTS: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82-1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. CONCLUSION: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.

Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series.

BACKGROUND: Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear. OBJECTIVE: To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS. METHODS: A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma. RESULTS: A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported. CONCLUSION: Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.

Survey of lumbar discectomy practices: 10 years in the making.

BACKGROUND: Lumbar discectomy is a common spinal procedure. The purpose of this survey is to ascertain neurosurgeons' practices in the surgical management of one-level lumbar discectomies in the Canadian adult population and to determine changes over a 10-year period. METHODS: One-page questionnaire distributed electronically to neurosurgeons in Canada and results were compared with similarly completed survey from 2007. RESULTS: A total of 109 completed surveys were returned representing 43.8% response rate. This is compared to 112 completed surveys in 2007 reaching 64.4% response rate. Statistically significant differences between the two points in time were noted. There was an increase in spine fellowship training [26 (33.3%) 2017 vs. 15 (15.3%) 2007 (P=0.007)], use of pre-operative magnetic resonance imaging (MRI) [65 (83.3%) 2017 vs. 27 (27.6%) 2007] (P<0.001), use of intramuscular injection [58 (74.4%) 2017 vs. 43 (43.9%) 2007 (P<0.001)], use of both microscope and loupes [20 (25.6%) 2017 vs. 3 (3.1%) 2007 (P<0.001)], use of tubular retraction [26 (33.3%) 2017 vs. 12 (12.2%) 2007 (P=0.001)], use of fibrin glue for a durotomy [72 (92.3%) 2017 vs. 75 (76.5%) 2007 (P=0.007)]. There was an increased rate of same-day discharge in 2017 [46 (59.0%) vs. 18 (18.4%) 2007 (P<0.001)], and quicker return to work [62.8% in 6 weeks or less vs. 39.7% (P=0.003)]. No statistical differences were noted with pre-incision localization, pre-op antibiotics, pre-incision local anesthetic use, use of fat graft or epidural steroids. In either survey the majority would not perform lumbar discectomy on a patient whose primary complaint is back pain. CONCLUSIONS: Our survey identified changes in practice patterns amongst Canadian neurosurgeons with respect to performing one-level lumbar discectomy over the past 10 years. These changes include increased preference for minimally invasive surgical technique, same-day discharge and sooner return to work. Randomized trials would be helpful to provide evidence regarding which practices are associated with better outcomes.

Cerebellar Medulloblastoma in Middle-to-Late Adulthood.

Medulloblastoma is a malignant brain tumor that is typically seen in children. It is classified as an embryonal tumor, classically located within the posterior fossa. When it involves the fourth ventricle, the patient commonly presents with signs and symptoms of raised intracranial pressure secondary to obstructive hydrocephalus. It is exceedingly rare for Medulloblastoma to occur in middle and late adulthood. In this paper, we present a case of a 51-year-old man who presented with a posterior fossa mass that was diagnosed later as Medulloblastoma.