Sex differences in aneurysmal subarachnoid haemorrhage (aSAH): aneurysm characteristics, neurological complications, and outcome.

BACKGROUND: Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes. METHODS: In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke < 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders. RESULTS: Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models. CONCLUSION: The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.

Subdural Versus Subgaleal Drain Placement After Minicraniotomy for Chronic Subdural Hematoma.

BACKGROUND AND OBJECTIVES: Surgical evacuation with placement of a postoperative drain is the standard treatment for symptomatic chronic subdural hematoma (cSDH). Subdural and subgaleal drains are equally effective after burrhole craniostomy, but the optimal location of the drain after craniotomy is not clear. We sought to compare the clinical and radiological outcomes of subdural and subgaleal drain placement in patients undergoing minicraniotomy for cSDH. METHODS: A retrospective review of 137 consecutive patients undergoing minicraniotomy for cSDH at a single institution was performed. Cases were stratified by location of postoperative drain. The primary outcome was change in functional status (modified Rankin Score, mRS) at 3 months from preoperative baseline. RESULTS: Among the patient cohort, 24.6% received subgaleal drain placement. After a median follow-up of 105 days, 79.4% (27/34) in the subgaleal group and 57.3% (59/103) in the subdural group (P = .02) had been discharged home. Worse premorbid mRS (P = .002), subdural drain location (P = .004), and decreased consciousness at presentation (Glasgow Coma Scale<15) (P < .002) were independent predictors of a discharge destination other than home. At the 3-month follow-up, the subgaleal group exhibited a mean improvement of 0.77 ± 1.2 points, while the subdural group had a deterioration of 0.14 ± 0.8 points (P < .01). Subgaleal drain location (P < .0001), better preoperative Glasgow Coma Scale (P = .01), and worse premorbid mRS (P = .0003) were independent predictors of improved mRS at 3 months. Recurrence requiring repeat surgery were more common in the subdural (13.6% (14/103) than the subgaleal 2.9% (1/34) group, P = .12), although the absolute incidence rates remained low. CONCLUSION: In patients undergoing minicraniotomy for cSDH, subgaleal drains are associated with shorter hospitalization, greater chance of discharge home, and better functional outcomes than subdural drains.

The utility of internal spinal marking for intraoperative localisation: A systematic review.

BACKGROUND: Incorrect level spinal surgery is an avoidable complication, with significant ramifications. Several pre-operative spinal marking techniques have been described to aid intraoperative localisation. METHODS: A systematic search of Ovid MEDLINE, and EMBASE was performed from inception to July 2022. All publications describing cases of internal spinal marking were included for further analysis. 22 articles describing 503 patients satisfied our eligibility criteria. RESULTS: A number of localisation techniques, including endovascular coiling (n = 16), fiducials (n = 177), dye (n = 109), needle/fixed wire (n = 199), cement (n = 4), and gadolinium tubes (n = 1) were described. The highest rates of technical success were observed with endovascular coiling, fiducials, cement and dye (100 %), and complication rates were lowest with endovascular coiling, fiducials and cement (0 %). CONCLUSIONS: Overall, internal spinal marking was effective and safe. When considering practicality and efficacy, fiducial marking appears the optimal technique, as it can be performed in the outpatient setting under local anaesthesia. This review demonstrates the need for more targeted investigation into localisation methods in spinal surgery.

Recurrent haemorrhagic pontine cavernoma resection via a retrosigmoid microsurgical approach.

BACKGROUND: Brainstem cavernomas occasionally require surgical treatment. Appropriate patient selection and thorough understanding of the anatomy and technical nuances involved in microsurgical resection is a pre-requisite in undertaking these challenging cases. CASE DESCRIPTION: We present a video case of a patient with a recurrent haemorrhagic pontine cavernoma. A step-by-step commentary of surgical footage is provided along with clinical, anatomical and technical learning points pertinent to the safe surgical management of these lesions.

Microsurgical clipping of ruptured supraclinoid internal carotid artery aneurysm with extradural clinoidectomy.

BACKGROUND: Supraclinoid Internal Carotid Artery (ICA) aneurysms require additional access to standard pterional craniotomy via extradural clinoidectomy. Existing texts and surgical videos lack clarity, explanation and a clear step by step process. CASE DESCRIPTION: We present a case of a ruptured supraclinoid ICA aneurysm and extradural clinoidectomy along with 3D reconstructed imaging of the case anatomy to guide its resection. Real-time unedited on table rerupture provides an example of management. CONCLUSION: Extradural Anterior Clinoidectomy is a key maneuver in cerebrovascular surgical armamentarium for clipping of supraclinoid aneurysms. Stereotypical Pathological or Surgical Anatomy, its application, and availability with 3D imaging should be facilitates the framing and learning of normal physiological anatomy.

Microsurgical disconnection of a T12/L1 ventral intradural perimedullary arteriovenous fistula (type IV) via instrumented trans-pedicular approach.

CASE DESCRIPTION: We present a case of microsurgical disconnection of a PMAVF supplied by the artery of Adamkiewicz with fistulation at the ventral spinal cord.

Cranial fat dissemination following fat grafting for lumbar dural tear: First case report in the literature.

INTRODUCTION AND IMPORTANCE: Dural tear and cerebrospinal fluid (CSF) leak is among the most common complications in lumbar spine surgery. Although primary dural suturing is the preferred method for repair, this is not always achievable specially with ventrolateral tears. Autologous fat grafting is one of the oldest and effective methods for dural repair which can also be used along with other methods of repair. This case report highlights a unique post spinal surgery complication with comment on how to avoid it. To our knowledge, this has not been previously reported in the literature. CASE PRESENTATION: The authors report a sixty-seven-year-old male with lumbar pseudomeningocele and cranial fat dissemination following fat grafting for non suturable lumbar dural tear. This was demonstrated on magnetic resonance imaging (MRI) after her presented with low-pressure headache. CLINICAL DISCUSSION: Intraoperative dural tear is one of the most common complications in spinal surgery. Methods for optimal dural repair including fat grafting have been described but the choice still heavily dependent on the surgeon's preference and experience. Fat graft can migrate leading to potential undesirable further complications like hydrocephalus and aseptic meningitis. CONCLUSION: Cranial fat dissemination following fat grafting for lumbar dural tear should be recognized as a post-operative complication in lumbar spine surgery. It should be considered in case of hydrocephalus or aseptic meningitis post dural fat grafting. Surgeons should utilize adjunct methods to minimize its incidence.

Predictive Relevance of Early Temperature Elevation on the Risk of Delayed Cerebral Ischemia Development Following Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Fever in aneurysmal subarachnoid hemorrhage (aSAH) has been associated with delayed cerebral ischemia (DCI), but its relevance in risk stratification has not been explored. This study investigated whether early temperature elevation following aSAH predicts impending clinical deterioration caused by DCI. METHODS: Relevant cases were identified from a prospectively maintained database for consecutive patients with aSAH treated at our center between July 2015 and January 2020. Temperature readings obtained every 2 hours for individual patients from admission through day 14 were recorded and analyzed. Demographic, clinical, treatment, and angiographic data were extracted from the electronic medical record. The primary end point was the occurrence of DCI (clinical and radiographic vasospasm). Multivariate logistic regression analyses were performed to account for patient age, smoking status, and VASOGRADE classification. RESULTS: The study included 175 patients (124 women) with aSAH. The median age at diagnosis was 55.4 years (range, 20.5-87.2 years). Clinical DCI occurred in 58 patients; 2 (1.1%) responded to hemodynamic augmentation, and 56 (32.0%) required intra-arterial therapy. Temperature graphs showed a marked divergence on day 4 between clinical DCI and non-DCI groups (1.12°C ± 0.15°C and 0.76°C ± 0.08°C, respectively, P = 0.007). Patients with temperature elevation ≥2.5°C on day 4 or 5 compared with their admission temperature were more likely to clinically deteriorate owing to DCI (odds ratio 4.55, 95% confidence interval 1.31-15.77, P = 0.017). CONCLUSIONS: Temperature elevation of ≥2.5°C on day 4 or 5 compared with baseline suggests a greater risk of clinical deterioration owing to DCI.

Bleeding from the pancreatic cut surface post pancreaticoduodenectomy: a review of a tertiary referral centre.

BACKGROUND: Haemorrhage from the pancreatic cut surface after pancreaticoduodenectomy is uncommon. The optimal treatment for post-pancreatectomy haemorrhage (PPH) from the pancreatic cut surface remains controversial. METHODS: We performed a retrospective analysis including all patients who underwent a pancreatiocoduodenectomy between 2008 and 2018 at a single tertiary institution in Melbourne, Australia, to analyse the incidence, potential risk factors, treatment and outcomes of cut surface PPH. RESULTS: A total of 168 pancreaticoduodenectomies were performed during the study period with pancreaticogastrostomy being the most common method of reconstruction at our institution (84.5%). There were 12 instances of cut surface PPH (7.1%). The majority of cases of cut surface PPH occurred within 48 h following pancreaticoduodenectomy (67%) with 41.7% occurring in the first 24 h. All but one patient required surgical intervention but length of stay did not appear to be increased compared to those without cut surface PPH. There was a trend towards patients with cut surface PPH being more likely to have a non-dilated pancreatic duct (75% versus 49%; P = 0.079). No significant differences were noted between patient with and without cut surface PPH with regards to abnormalities in platelet counts (3.2% versus 0%; P = 0.529), international normalized ratio (4.5% versus 8.3%; P = 0.694) and prophylactic anticoagulant administration or continuing antiplatelet use (28.2 versus 16.7%; P = 0.630). CONCLUSION: We believe that an unobstructed pancreas, in combination with the acidic environment associated with a dunking pancreaticogastrostomy anastomosis, may predispose to bleeding from the cut surface of the pancreas.

Spinal Pleomorphic Xanthoastrocytoma: Case Report and Literature Review.

Pleomorphic xanthoastrocytoma (PXA) is an uncommon central nervous system neoplasm with an overall favorable survival prognosis. Metastatic spread of PXA to the spinal cord and the cauda equina is rare and may have a different clinicopathologic course. Treatment and prognostic outcomes, in this context, are not well defined. We discuss a case of a 30-year-old patient with known cerebral PXA presenting with metastatic spinal anaplastic PXA and present a literature analysis of treatment outcomes.

The Role of Laparoscopic Cholecystectomy After Severe and/or Necrotic Pancreatitis in the Setting of Modern Minimally Invasive Management of Pancreatic Necrosis.

OBJECTIVES: The trend toward minimally invasive procedures (MIP) in necrotizing pancreatitis is increasing. The optimal timing and technique of cholecystectomy in severe/necrotizing pancreatitis is unclear. This study aims to determine the role of laparoscopic cholecystectomy after severe/necrotizing pancreatitis in the context of MIP. METHODS: Retrospective analysis of a prospective database was performed for consecutive patients after cholecystectomy for gallstone pancreatitis between January 2011 and January 2018 at Monash Health, Melbourne, Australia. RESULTS: Three hundred fifty-five patients with gallstone pancreatitis underwent laparoscopic cholecystectomy with 2 conversions. Patients with severe pancreatitis were older (P = 0.002), with a more even sex distribution when compared with mild pancreatitis. Females predominated in the mild pancreatitis group.Patients with moderate/severe pancreatitis (P = 0.002) and necrosis (P > 0.001) were more likely to have delayed cholecystectomy compared with mild pancreatitis. There was no increase in biliary presentations while awaiting cholecystectomy. Length of stay for patients with severe/necrotizing pancreatitis (P = 0.001) was increased, surgical complications appeared similar. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely and effectively for pancreatitis, irrespective of severity. The paradigm shift in the management of severe necrotizing pancreatitis away from open necrosectomy toward MIP can be extended to encompass laparoscopic cholecystectomy.

Buccal space tumours.

OBJECTIVE: To review the available literature as it pertains to the buccal space with a specific focus on the pathologies encountered within this space. Clinical presentation, investigations, and surgical approaches to the region are also reviewed. METHODS: A systematic review of the available literature was performed on buccal space tumours from 1980 to 2017. Data was extracted on clinical presentation, investigations and surgical approaches to the buccal space. The pathologies encountered in the buccal space were reviewed and presented. RESULTS: Forty-nine unique articles were reviewed, with a total 217 patients. The age of the patients ranged from 0 to 83 with a mean age of 45.8. A total of 51 pathologies were reported. The majority of these were vascular and salivary gland pathologies. The majority of salivary gland neoplasms were malignant. However a wide variety of benign and malignant soft tissue tumours were also reported to occur in this region. CONCLUSIONS: The buccal space is a small and complex region with a variety of pathologies occurring within it. This review clarifies the differential diagnosis of a mass which presents in this area and the pathologies which occur within it.

Glioblastoma Presenting as Spontaneous Subarachnoid Hemorrhage: Technical Case Note of Combined Endovascular and Microsurgical Vision-Sparing Treatment.

BACKGROUND: Clinical utility of endovascular adjunct for tumor resection is well established, but its role in acute subarachnoid hemorrhage secondary to neoplastic pseudoaneurysm rupture has not been reported. CASE DESCRIPTION: We discuss a 46-year-old patient presenting with a World Federation of Neurological Surgeons grade 1 subarachnoid hemorrhage from a ruptured posterior cerebral artery pseudoaneurysm due to glioblastoma tumor invasion. CONCLUSIONS: A combined targeted endovascular embolization with microsurgical resection to spare the calcarine artery was used to avoid disruption to the optic radiation fiber pathway.

Primary intradural extramedullary Ewing sarcoma of the cervical spine: A case report and review of the literature.

Spinal intradural Ewing sarcoma (ES) of the cervical region is not common. Few cases have been reported and optimal management remain poorly defined. We described a case of a young woman with extensive primary leptomeningeal spinal ES and conducted a review of the literature.