Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Pathogenesis of spinal intramedullary lipomas: two case reports.

BACKGROUND: Spinal lipomas not associated with dysraphism are rare and have an unknown natural history. In this report, we describe two cases; they showed recurrence during long-term follow-up, which makes us doubt a benign malformative etiology. CASE REPORTS: Two patients, a 19-year-old South American woman and a 14-year-old boy with spinal lipomas, underwent surgical resection. The lipomas were not associated with dysraphism and were located in the cervicothoracic and craniocervical junctions. In both cases, we decided to operate due to clinical progression; the former had a progressive natural course, and the latter experienced clinical worsening after recurrence from previous surgeries. The surgery took place with the assistance of neurophysiological monitoring and intraoperative ultrasound; a partial resection and medullary decompression were done, following the more recent recommendations. DISCUSSION: The natural history of these lesions is currently unknown due to their rarity and the heterogeneity in the long-term follow-up of previously reported cases. Although previous reports describe good outcomes after surgical resection, long follow-ups, especially in young subjects, may show differences in these outcomes with progression and recurrence. We contribute to this last piece of evidence by describing two more cases of progression and recurrence. LESSONS: Long-term close follow-up should be done in young subjects with spinal lipomas, as they are more prone to an aggressive course. Metabolism and hormonal changes may be behind this progression. Reoperation must be considered if neurological decline is detected.

Variability in the indication of brain CT scan after mild traumatic brain injury. A transnational survey.

PURPOSE: Clinical guidelines have been developed to standardize the management of mild traumatic brain injury (mTBI) in the emergency room, in particular the indication of brain CT scan and the use of blood biomarkers. The objective of this study was to determine the degree of adherence to guidelines in the management of these patients across four countries of Southern Europe. METHODS: An electronic survey including structural and general management of mTBI patients and six clinical vignettes was conducted. In-charge physicians from France, Spain, Greece and Portugal were contacted by telephone and email. Differences among countries were searched using an unconditional approach test on contingency tables. RESULTS: One hundred and eighty eight physicians from 131 Hospitals (78 Spain, 36 France, 12 Greece and 5 Portugal) completed the questionnaire. There were differences regarding the in-charge specialist across these countries. There was variability in the use of guidelines and their adherence. Spain was the country with the least guideline adherence. There was a global agreement in ordering a brain CT for patients receiving anticoagulation or platelet inhibitors, and for patients with seizures, altered consciousness, neurological deficit, clinical signs of skull fracture or signs of facial fracture. Aging was not an indication for CT in French centres. Loss of consciousness and posttraumatic amnesia were considered as indications for CT more frequently in Spain than in France. These findings were in line with the data from the 6 clinical vignettes. The estimated use of CT reached around 50% of mTBI cases. The use of S100B is restricted to five French centres. CONCLUSIONS: There were large variations in the guideline adherence, especially in the situations considered to order brain CT after mTBI.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain.

OBJECTIVE: To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. SETTINGS: The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. PARTICIPANTS: This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. INTERVENTIONS: An exploratory factorial analysis was performed to select the most relevant variables of the sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. RESULTS: Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/105 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/105 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. CONCLUSIONS: Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/105 people/week) was a statistically independent predictor of mortality. TRIAL REGISTRATION NUMBER: CEIM 20/217.

Dexamethasone for the treatment of traumatic brain injured patients with brain contusions and pericontusional edema: Study protocol for a prospective, randomized and double blind trial.

BACKGROUND: Traumatic brain injury (TBI) constitutes a leading cause of death and disability. Patients with TBI and cerebral contusions developing pericontusional edema are occasionally given dexamethasone on the belief that this edema is similar to that of tumors, in which the beneficial effect of dexamethasone has been demonstrated. METHODS: The DEXCON TBI trial is a multicenter, pragmatic, randomized, triple-blind, placebo controlled trial to quantify the effects of dexamethasone on the prognosis of TBI patients with brain contusions and pericontusional edema. Adult patients who fulfill the elegibility criteria will be randomized to dexamethasone/placebo in a short and descending course: 4 mg/6 h (2 days); 4 mg/8 hours (2 days); 2 mg/6 hours (2 days); 2 mg/8 hours (2 days); 1 mg/8 hours (2 days); 1 mg/12 hours (2 days). The primary outcome is the Glasgow Scale Outcome Extended (GOSE) performed 1 month and 6 months after TBI. Secondary outcomes are: number of episodes of neurological deterioration; symptoms associated with TBI; adverse events; volume of pericontusional edema before and after 12 days of treatment; results of the neuropsychological tests one month and 6 months after TBI. The main analysis will be on an "intention-to-treat" basis. Logistic regression will estimate the effect of dexamethasone/placebo on GOSE at one month and at 6 months, dichotomized in unfavorable outcome (GOSE 1-6) and favorable outcome (GOSE 7-8). Efficacy will also be analyzed using the 'sliding dichotomy'. An interim and safety analysis will be performed including patients recruited during the first year to calculate the conditional power. A study with 600 patients would have 80% power (2 sided alpha = 5%) to detect a 12% absolute increase (from 50% to 62%) in good recovery. DISCUSSION: This is a confirmative trial to elucidate the therapeutic efficacy of dexamethasone in a very specific group of TBI patients: patients with brain contusions and pericontusional edema. This trial could become an important milestone for TBI patients as nowadays there is no effective treatment in this type of patients. TRIAL REGISTRATION: eudraCT: 2019-004038-41; Clinical Trials.gov: NCT04303065.

Snorting the Brain Away: Cerebral Damage as an Extension of Cocaine-Induced Midline Destructive Lesions.

Cocaine consumption is associated with a variety of clinical manifestations. Though cocaine intranasal inhalation always determines nasal mucosal damages, extensive septum perforations, and midline destructions-known as cocaine-induced midline destructive lesions (CIMDL)-affect only a limited fraction of patients. CIMDL is viewed as a cocaine-associated autoimmune phenomenon in which the presence of atypical anti-neutrophil cytoplasmic antibody (ANCA) promotes and/or defines the disease phenotype. A 51-year-old man presented with an intracranial tumor-like lesion by its space-occupying effect. CT also revealed the destruction of the nasal septum and skull base. A diagnosis of CIMDL was made in light of the patient's history as well as findings of the physical and endoscopic examinations, imaging studies, and laboratory testing. There was no evidence of other pathologies. Histopathological results from cerebral biopsy led us to consider the intracranial pathology as an extension of the CIMDL. CIMDL is the result of a necrotizing inflammatory tissue response triggered by cocaine abuse in a subset of predisposed patients. The reported case is the first CIMDL consistent with brain extension mimicking a tumor-like lesion. While the presence of atypical ANCA seems to promote and/or define the disease phenotype, the specific role of these and other circulating autoantibodies needs further investigation.

Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study.

BACKGROUND: Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria. METHODS: The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared. RESULTS: One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized. CONCLUSIONS: A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.

True Dural Spinal Epidural Cysts: Report of 5 Cases.

BACKGROUND: Spinal arachnoid cysts are a rare cause of compressive myelopathy. Spinal extradural arachnoid cysts (SEACs) are even rarer. METHODS: We retrospectively reviewed the SEACs operated on in our hospital between 2015 and 2019, according to their clinical and radiologic findings, treatments performed, and outcomes. RESULTS: We identified 5 cases (2 males and 3 females), ranging in age from 21 months to 78 years. Except for the pediatric case, all patients presented with pain and 3 had some grade of neurologic impairment. Preoperative magnetic resonance imaging showed multiloculated cyst in 4 cases, and the communication with the dura was properly identified in only 1 case. The patients were operated through a laminectomy or laminoplasty and total removal of the cyst, and the communication with the dura was identified and repaired in all cases. In all cases, the defect was near the exit of a nerve root, and rootlets were seen through it, producing a ball-like valve mechanism. Histology of the cyst wall showed true dura in every case. One patient needed a reoperation for evacuation of a fluid collection (related to the dural sealant). Following Odom's criteria, 3 patients had an excellent outcome and 2 had a fair outcome. CONCLUSIONS: Total excision of a symptomatic SEAC through either laminectomy or laminoplasty is a safe and effective treatment option. Although isolated repair of the dural communication without cyst removal may seem appealing, we have found it very difficult to identify the point of communication preoperatively.

Chitinase-3-Like Protein 1, Serum Amyloid A1, C-Reactive Protein, and Procalcitonin Are Promising Biomarkers for Intracranial Severity Assessment of Traumatic Brain Injury: Relationship with Glasgow Coma Scale and Computed Tomography Volumetry.

OBJECTIVE: The volume and location of intracranial hematomas are well-known prognostic factors for traumatic brain injury. The aim of this study was to determine the relationship of serum biomarkers S100ß, glial fibrillary acidic protein, neuron-specific enolase, total tau, phosphorylated neurofilament heavy chain, serum amyloid A1 (SAA1), C-reactive protein, procalcitonin (PCT), and chitinase-3-like protein 1 (YKL-40) with traumatic brain injury severity and the amount and location of hemorrhagic traumatic lesions. METHODS: A prospective observational cohort of 115 patients with a Glasgow Coma Scale (GCS) score of 3-15 were evaluated. Intracranial lesion volume was measured from the semiautomatic segmentation of hematoma on computed tomography using Analyze software. The establishment of possible biomarker cutoff points for intracranial lesion detection was estimated using the Youden Index (J) obtained from the area under the receiver operating characteristic curve. RESULTS: SAA1, YKL-40, PCT, and S100ß showed the most robust association with level of consciousness, both with total GCS and motor score. Biomarkers significantly correlated with volumetric measurements of subdural hematoma, traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage, intraventricular hemorrhage, and total amount of bleeding. The type of intracranial hemorrhage was associated with various release patterns of neurobiochemical markers. CONCLUSIONS: YKL-40, SAA1, C-reactive protein, and PCT combined with S100ß were the most promising biomarkers to determine the presence, location, and extent of traumatic intracranial lesions. Combination of biomarkers further increased the discriminatory capacity for the detection of intracranial bleeding.

Call to participate in the international study of traumatic brain injury results (Global Neurotrauma Outcomes Study). / Llamada para participar en el estudio internacional de resultados del traumatismo craneoencefálico (Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. The GNOS is a multi-centre international, prospective cohort study. This study is the first global neurosurgical study that aims to provide a comprehensive picture of the management and outcomes of patients undergoing emergency surgery for TBI worldwide.

Single Case Study: Neuropsychological Functioning in a Patient Diagnosed with Intermittent Explosive Disorder Pre and Post Neurosurgery.

Intermittent explosive disorder (IED) is characterized by a difficulty to resist the urge to carry out a recognized harmful behavior. The central symptom is aggressiveness, expressed in isolated episodes. Executive function impairments are habitually found in impulse control disorders. Neuropsychology of impulsivity is related to dysfunctions in the orbito-frontal cortex, dorsolateral cortex and anterior-cingulated regions, being consequently involved in cognitive mechanisms of inhibition. Lesions in those areas are common in IED. In the most severe cases of IED, surgical procedures are required for treatment. In this study, we examined JML; a patient suffering from a severe case of IED. He experienced frequent episodes of auto and heteroaggression and multiple psychiatric admissions, and thus stereotactic surgery was the recommended treatment. The procedure consisted of an electrode situated lateral to the lateral ventricle, targeting the projections between frontal and subcortical affected regions. We aimed to study the neuropsychological functioning of JML, before and after electrode implantation. Our results suggested that surgery in IED improves cognitive performance at some levels. JML significantly improved his cognitive flexibility, measured with WCST, and alternate attention assessed with CPT and TMT-B tests, after electrode implantation. Cognitive flexibility deficits may be also related to increased aggressiveness. Therefore, improvements at this level may involve a reduction of impulsivity and aggressive behavior.

Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement.

BACKGROUND: Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty. METHODS: We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72 h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement. RESULTS: Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5-149.5) cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25-1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel≤70 (Odds ratio [OR] 22; 2.5-192; P=0.005), age over 45 years (OR 13.5; 1.5-115; P=0.01) and early surgery (≤85 days; OR 8; 1.69-37.03, P=0.004). After multivariate analysis, Barthel≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (<85 days) increased the likelihood of improvement (OR 4.67; 1.05-20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6 cm2; P=0.1). CONCLUSIONS: The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.

[Intracranial dural arteriovenous fistulae. Experience after 81 cases and literature review]. / Fístulas durales arteriovenosas intracraneales. Experiencia con 81 casos y revisión de la literatura.

OBJECTIVES: To analyse the clinical, radiological and therapeutic variables of intracranial dural arteriovenous fistulae (DAVF) treated at our institution, and to assess the validity of the Borden and Cognard classifications and their correlation with the presenting symptoms. MATERIAL AND METHODS: The DAVF identified were retrospectively analysed. They were classified according to their location, drainage pattern and the Borden and Cognard classifications. We recorded the different treatments, their complications and efficacy. RESULTS: There were 81DAVF identified between 1975 and 2012. The cavernous sinus (CS) location was the most frequent one. The Borden and Cognard classifications showed an interobserver Kappa index of 0.72 and 0.76 respectively. The odds ratio of aggressive presentation in the presence of cortical venous drainage (CVD) was 19.3 (2.8-132.4). No location, once adjusted by venous drainage pattern, showed significant association with an aggressive presentation. Endovascular transarterial treatment of cavernous sinus DAVF achieved symptomatic improvement of 78%, with a complication rate of 5%. The DAVF of non-CS locations, with CVD, treated surgically were angiographically shown cured in 100% of the cases, with no treatment-related complications. CONCLUSIONS: The presence of CVD was significantly associated with aggressive presentations. The Borden and Cognard classifications showed little interobserver variability. Endovascular treatment for CS DAVF is safe and relatively effective. Surgical treatment of non-CS DAVF with CVD is safe, effective and the first choice treatment in our environment.