Subdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas.

PURPOSE: We present a series that describes the presenting features and clinical outcomes in patients with CSDH treated with a standardised technique and an open-drain placement. METHODS: We reviewed the medical records of 155 consecutive patients at a single centre who underwent CSDH evacuation by placing burr holes, accompanied by intraoperative irrigation and a subdural Penrose drain between 2014 and 2018. RESULTS: The mean age was 65.9 years, 81.9% were males. The most common clinical characteristics were an altered mental state (21.9%) and headache (12.9%). It was necessary to perform a second surgical intervention due to the evidence in the postoperative tomography of a residual hematoma in 10.3% of the cases; there were 2 cases of recurrence in 6 months (1.3%). Pneumonia (6.5%) and seizures (5.8%) were the most frequent medical complications. Intracranial infections accounted for 1.9%, and the mortality rate was 6.4% of cases. CONCLUSIONS: We provided our experience with a low-cost and less-commonly used technique in the management of CSDH. This technique showed similar recurrence, mortality and intracranial infection rates to those reported in the literature for closed drainage systems. Additional studies will be required to assess this technique.

3D-Printed Endoport vs. Open Surgery for Evacuation of Deep Intracerebral Hemorrhage.

BACKGROUND: Large-sized clinical trials have failed to show an overall benefit of surgery over medical treatment in managing spontaneous intracerebral hemorrhages (ICH); less invasive techniques have shown to decrease brain injury caused by surgical manipulation in the standard open approach improving the clinical outcomes of patients. Thereby, we propose a low-cost 3D-printed endoport for a less invasive ICH evacuation. In this study, the authors compare the clinical outcomes of early surgical evacuation using a 3D-printed endoport vs. a standard open surgery (OS). METHODS: A retrospective analysis was conducted comparing patients who underwent early evacuation of a deep hypertensive ICH through an endoport vs. OS at a single center from August 2017 to March 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were the 90-day post-stroke functional outcome and mortality. RESULTS: A total of 36 patients were included. The two cohorts (18 endoport; 18 OS) showed no statistically significant differences in demographic, clinical, and radiologic characteristics, including median admission hemorrhage volume, Glasgow Coma Scale, and ICH scores. At 90-day post-stroke, 44% of patients in the endoport group and 17% in the OS group had a favorable functional outcome (mRS 0-3) (p = 0.039); moreover, the endoport group showed lower mortality (33% vs. 72%, p = 0.019). CONCLUSIONS: This study suggests that an endoport-assisted ICH evacuation may have better functional outcomes and lower mortality than OS. The proposed device could provide a safe, low-cost alternative for ICH's surgical treatment. More rigorous research is hence needed to assess the potential benefits of this technique.

Frontal sulcotomy through 3D printed illuminated endoport for minimally invasive evacuation of a deep-seated intracerebral hematoma - A case report.

Spontaneous intracerebral hemorrhage carries high mortality and disability rates and usually affects deep brain structures. We have implemented a self-designed low-cost 3D-printed illuminated endoport for the surgical drainage of a deep spontaneous intracerebral hemorrhage in a patient who arrived with right hemiparesis and a GCS score of 10. A minimally invasive approach was made and our patient had a favorable functional outcome after surgery. Carrying out this approach with a low-cost 3D-printed endoport makes it possible to offer a safe and efficient treatment option to a low-income country population.

Decompressive Craniectomy for Hemispheric Infarction in a Low-Income Population.

BACKGROUND: Stroke is a worldwide leading cause of mortality and disability, and there are substantial economic costs for poststroke care. Disadvantaged populations show increased incidence, severity, and unfavorable outcomes. This study aimed to report the survival, functional outcome, and caregiver satisfaction of low-income patients diagnosed with a large hemispheric infarction (LHI) who underwent decompressive craniectomy (DC). METHODS: A retrospective analysis was conducted in consecutive adult patients with an LHI who underwent DC at a single center between October 2015 and September 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were 1-year survival and favorable functional outcome. RESULTS: Forty-nine patients were included; those <60 years of age showed a higher proportion of favorable functional outcomes (76% vs. 33%; P = 0.031) but similar survival (52% vs. 56%; P = 0.645) than older patients, respectively. Performing the craniectomy in <48 hours from stroke onset compared with ≥48 hours showed no statistically significant differences in survival (59% vs. 46%; P = 0.352) and favorable functional outcomes (56% vs. 70%; P = 0.683), respectively. In retrospective thinking, 79% of caregivers would decide to perform the surgery again. CONCLUSIONS: Age group and time from stroke onset to craniectomy were not associated with survival; notwithstanding, a higher proportion of patients <60 years of age were associated with a favorable functional outcome compared with older patients. Additionally, if given the option, most caregivers would decide to perform the surgery again, independently of the grade of disability of the patient.

Mobile application to analyse surgical experience. / Aplicación móvil para el análisis de la experiencia quirúrgica.

OBJECTIVE: To quantify the surgical experience acquired by residents in the neurosurgery specialisation programme over a 6-month period. MATERIALS AND METHODS: A total of 13 residents enrolled in the neurosurgery specialisation programme from February 2018 to July 2018. Over this period, the procedures residents were involved in and the role they played were documented in the Electronic Neurosurgical Register. Residents who withdrew from the specialisation program were excluded. RESULTS: A total of 530 procedures were performed during the study period. Observational learning and supervised practice are conducted primarily in the first and fifth years of residence, during which residents begin their training in emergency and elective surgeries, respectively. Residents are then able to independently perform emergency surgeries during the second and third years, and elective surgeries in the sixth year. Residents are able to instruct less experienced surgeons in the fourth year. CONCLUSIONS: The Electronic Neurosurgical Register is an innovative technological tool that supports the fields of care, teaching and research. It records the exact number of patients who have undergone surgery at a particular time, providing valuable information for the proper management of resources. The data obtained can be used to identify areas of opportunity in the training of residents, facilitating the development of continuous improvement strategies in the training of competent neurosurgeons.

Cranioplasty with a low-cost customized polymethylmethacrylate implant using a desktop 3D printer.

OBJECTIVECranioplasty implants should be widely available, low in cost, and customized or easy to mold during surgery. Although autologous bone remains the first choice for repair, it cannot always be used due to infection, fragmentation, bone resorption, or other causes, which led to use of synthetic alternatives. The most frequently used allogenic material for cranial reconstructions with long-term results is polymethylmethacrylate (PMMA). Three-dimensional printing technology has allowed the production of increasingly popular customized, prefabricated implants. The authors describe their method and experience with a customized PMMA prosthesis using a precise and reliable low-cost implant that can be customized at any institution with open-source or low-cost software and desktop 3D printers.METHODSA review of 22 consecutive patients undergoing CT-based, low-cost, customized PMMA cranioplasty over a 1-year period at a university teaching hospital was performed. Preoperative data included patient sex and age; CT modeling parameters, including the surface area of the implant (defect); reason for craniectomy; date(s) of injury and/or resections; the complexity of the defect; and associated comorbidities. Postoperative data included morbiditiy and complications, such as implant exposure, infection, hematoma, seroma, implant failure, and seizures; the cost of the implant; and cosmetic outcome.RESULTSIndications for the primary craniectomy were traumatic brain injury (16, 73%), tumor resection (3, 14%), infection (1, 4%), and vascular (2, 9%). The median interval between previous surgery and PMMA cranioplasty was 12 months. The operation time ranged from 90 to 150 minutes (mean 126 minutes). The average cranial defect measured 65.16 cm2 (range 29.31-131.06 cm2). During the recovery period, there was no sign of infection, implant rejection, or wound dehiscence, and none of the implants had to be removed over a follow-up ranging from 1 to 6 months. The aesthetic appearance of all patients was significantly improved, and the implant fit was excellent.CONCLUSIONSThe use of a customized PMMA was associated with excellent patient, family, and surgeon satisfaction at follow-up at a fraction of the cost associated with commercially available implants. This technique could be an attractive option to all patients undergoing cranioplasty.

Direct Endonasal Approach with Partial Upper Posterior Septectomy. A "Rescue Flap" Technique Modification.

Objective Report a modification of the "rescue flap" technique using a direct endonasal approach with a partial superior septectomy for approaching pituitary tumors developed in our institution. Design Prospective study. Setting Hospital Universitario "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León. Main Outcome Measures Since April 2015, we have performed 19 cases employing a direct endonasal approach with partial superior septectomy. Results and a technical note are described below. Results Nineteen patients were included in this report. Six patients presented transoperatory cerebrospinal fluid (CSF) leak, so a nasoseptal rescue flap was harvested. No patients developed postoperative CSF leak in this group. Two patients were submitted to a second surgical procedure. Nasoseptal flap was harvested without complications. In both patients, the size of the flap was enough to cover the dural defect and avoid CSF leak. Conclusion Direct endonasal approach with a partial posterior septectomy allows enough exposition of the sphenoidal sinus while preserving the nasoseptal septum with the possibility of a successful rescue flap when needed.