Comparison of craniotomy and decompressive craniectomy for acute subdural hematoma -a Meta-Analysis of comparative study.

BACKGROUND: Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures. MATERIALS AND METHODS: We performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513, Supplemental Digital Content 2, http://links.lww.com/JS9/C514) Statement protocol and AMSTAR, Supplemental Digital Content 3, http://links.lww.com/JS9/C515 (Assessing the methodological quality of systematic reviews) guideline. The PubMed, Embase, Web of Science and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included. RESULTS: A total of 15 articles with 4853 patients (2531 [52.2%] receiving CO and 2322 [47.8%] receiving DC) were included in this meta-analysis. DC was associated with higher mortality (31.5% vs. 40.6%, odds ratio [OR]=0.58, 95% confidence interval [CI] 0.43 to 0.77) and rate of patients with poorer neurological outcomes (54.3% vs. 72.7%; OR=0.43, 95% CI 0.28 to 0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5% vs. DC 38.1%, OR=0.80, 95% CI 0.62 to 1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8% vs. DC 66.0%; OR=0.82, 95% CI 0.57 to 1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1% vs. DC 16.0%; OR=0.95, 95% CI 0.61 to 1.48). CONCLUSION: Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.

Surgical management of spinal "Subpial" lipomas.

BACKGROUND: This study reports five cases of subpial lipomas via a new grouping method with respect to the cases' distinctive magnetic resonance imaging characteristics to provide insight into the management of this entity. METHOD: From January 2013 to December 2014, five cases of pathologically diagnosed subpial lipomas that received surgical treatment in our department were included. The clinical histories and medical records were carefully reviewed, and the radiological characteristics were periodically inspected after surgery. The preoperative radiology and symptoms were reviewed with regard to outcome. RESULTS: All five patients were confirmed as having lipomas based on their histological results. Total removal was achieved in one patient only, with partial removal in the other four patients. Neurological deterioration was observed in all patients immediately after surgery, with a typically lower McCormick score. Two of the patients returned to preoperative level one year later. Based on radiological traits, the lipomas could be divided into "simple" and "invasive." The syrinx formation and neurological recovery were different between these two kinds of lipoma. CONCLUSION: Surgery for subpial lipomas without dysraphisms is frequently accompanied by neurological deterioration, temporally or permanently. Thus, this new classification of subpial lipomas into "simple" and "invasive" based on radiological traits may be valuable for making better surgical decisions.

Clinical presentation and long-term outcome of primary spinal peripheral primitive neuroectodermal tumors.

Primary spinal peripheral primitive neuroectodermal tumors (pPNETs) are extremely rare entities that predominantly occur in children and young adults. Few studies have reported more than three cases. There are no current optimum treatment strategies due to the paucity of data. Here, we present 13 patients (nine females and four males) with primary intraspinal pPNETs who were surgically treated from April 2008 to February 2014. Histopathologic findings revealed the expression of CD99 in all cases. Limb weakness was the most common initial symptom (11/13, 85 %). The tumors were located mainly at the cervical level (6/13, 46 %) and in the epidural space (10/13, 77 %). The radiological diagnosis was neurinoma or meningioma in most cases (10/13, 77 %). Gross total resection was achieved in 77 % (10/13) of patients. During a mean follow-up of 25.5 months, local relapse occurred in 8 (61.5 %) patients and distant metastases occurred in 8 (61.5 %) patients. The overall 1-year survival rate was 77 % (10/13), and the overall 2-year survival rate was 54 % (7/13). The 2-year survival rate was 57.1 % in patients with adjuvant chemotherapy and 50 % in those without chemotherapy. Gross total resection and adjuvant radiotherapy with or without chemotherapy demonstrated a longer survival period (1-year survival rate: 100 %; 2-year survival rate: 86 %). Our data showed that primary spinal pPNETs are extremely rare and aggressive tumors with a poor prognosis. Radical resection is advocated. Gross total resection combined with adjuvant radiation may help to significantly improve patient survival period. Chemotherapy may also help to slightly prolong patient life.

Quantification of Corticospinal Tracts with Diffusion Tensor Imaging in Brainstem Surgery: Prognostic Value in 14 Consecutive Cases at 3T Magnetic Resonance Imaging.

OBJECTIVE: In this study, we investigated the potential prognostic role of morphologic and quantitative diffusion tensor imaging (DTI) in patients with brainstem cavernoma (BSC) in terms of postoperative outcome. METHODS: In this retrospective study of 14 brainstem cavernoma patients, we analyzed pre- and postoperative DTI data. White matter tractography of corticospinal tracts (CSTs) was performed with the Fiber Assignment by Continuous Tracking algorithm, and morphologic characteristics of CSTs were compared with clinically assessed motor strength. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were measured in ipsi- and contralesional regions of interest at the lesion level, as well as levels caudal and rostral to the lesion. Correlation analysis was performed between lateral index (LI) of ipsi-/contralateral FA and ADC values and patients' motor function. RESULTS: Preoperatively, normal morphologic features of CSTs corresponded to normal motor function in 4 patients. The other 10 morphologically abnormal preoperative CSTs didn't show corresponding motor impairment either in pre- or postoperative follow-up period. The sensitivity, specificity, positive predictive, and negative predictive values of white matter tractographic morphology on preoperative motor function were 100%, 57.1%, 70%, and 100%, respectively. The corresponding values on follow-up motor function were 100%, 33.3%, 20%, and 100%, respectively. The mean FA at lesion level was significantly lower than the corresponding FA at the contralateral hemisphere (P = 0.009). In areas caudal to the lesion the same trend yet without statistic significance was observed (P = 0.23). There was no significant laterality difference of mean FAs rostral to the level of the lesion. No correlation in LI of FA or ADC in the 3 anatomic levels with simultaneous and long-term follow up motor function was observed. Restoration of the morphology of the affected CST postoperatively was associated with a trend for decreasing ADC compared with the preoperative measurements. CONCLUSION: Intact CST morphology in DTI predicts a favorable postoperative outcome in patients with BSC. Interrupted CSTs and decreased FA values correlate well within BSC lesion level; nevertheless, morphologic characteristics and diffusion parameter changes at lesion level cannot predict poor prognosis. Caudal and rostral diffusion parameters can provide more information of the integrity of CSTs compared with morphologic study alone.