Bilateral Tapia's syndrome secondary to cervical spine injury: a case report and literature review.

A 24-year-old man presented with bilateral Tapia's syndrome (TS) after a traumatic cervical spine injury, manifested by apraxia of the hypoglossal and recurrent laryngeal nerves. The initial presentation was a profound inability to maintain upper respiratory airway patency due to bilateral vocal cord paralysis, accompanied by impairment of swallowing and loss of speech. The diagnosis was based on clinical grounds and verified by endoscopic laryngoscopy. A C7 corpectomy was performed for stabilizing the cervical spine, while conservative treatment with steroids was reserved for the TS. Over the following six months, there was complete resolution of the symptoms.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool.

OBJECTIVE: Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations. METHODS: A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS: A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis. CONCLUSIONS: These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Neuromonitoring in Severe Traumatic Brain Injury: A Bibliometric Analysis.

Traumatic brain injury (TBI) is the leading cause of mortality and disability among trauma-related injuries. Neuromonitoring plays an essential role in the management and prognosis of patients with severe TBI. Our bibliometric study aimed to identify the knowledge base, define the research front, and outline the social networks on neuromonitoring in severe TBI. We conducted an electronic search for articles related to neuromonitoring in severe TBI in Scopus. A descriptive analysis retrieved evidence on the most productive authors and countries, the most cited articles, the most frequently publishing journals, and the most common author's keywords. Through a three-step network extraction process, we performed a collaboration analysis among universities and countries, a cocitation analysis, and a word cooccurrence analysis. A total of 1884 records formed the basis of our bibliometric study. We recorded an increasing scientific interest in the use of neuromonitoring in severe TBI. Czosnyka, Hutchinson, Menon, Smielewski, and Stocchetti were the most productive authors. The most cited document was a review study by Maas et al. There was an extensive collaboration among universities. The most common keywords were "intracranial pressure," with an increasing interest in magnetic resonance imaging and cerebral perfusion pressure monitoring. Neuromonitoring constitutes an area of active research. The present findings indicate that intracranial pressure monitoring plays a pivotal role in the management of severe TBI. Scientific interest shifts to magnetic resonance imaging and individualized patient care on the basis of optimal cerebral perfusion pressure.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience.

BACKGROUND: It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping. MATERIAL AND METHODS: In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors. RESULTS: Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15th and the 60th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival. CONCLUSIONS: Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta.

BACKGROUND: The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms. METHODS: An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality. RESULTS: Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I2 = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I2 = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I2 = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I2 = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I2 = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I2 = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I2 = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I2 = 0%). CONCLUSIONS: ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.

Local complications of adjunct intrathecal antibiotics for nosocomial meningitis associated with gram-negative pathogens: a meta-analysis.

Direct delivery of antibiotics to the ventricular system offers an alternative for the management of nosocomial meningitis. However, the available literature frequently results in controversial findings regarding its safety. The present meta-analysis aimed at summarizing the risk of local complications after the administration of intraventricular/intrathecal (IVT/IT) antibiotics for the treatment of ventriculitis/meningitis (VM) associated with gram-negative pathogens. We systematically searched the medical literature from 1964 until July 2018, for clinical studies reporting on complications after the index treatment. The quality of the eligible studies was classified as "high," "moderated," and "low" for randomized controlled trials, observational studies, and case series, respectively. The results were summarized as pooled frequencies, estimated by the random- or fixed-effects models, according to the inter-study heterogeneity. The publication bias was visualized in trim-and-fill funnel plots. Τhe analysis included twenty-three primary studies with 229 patients. The overall complication rate was as high as 0.13 (95% CI 0.08; 0.19, I2 = 9%); chemical meningitis and seizures represented the majority of the complications, with an occurrence rate of 0.11 (95% CI 0.07; 0.17, I2 = 0%) and 0.07 (95% CI 0.04; 0.12; I2 = 0%), respectively. The meta-analysis was based on studies of "moderate" and "low" reporting quality, while the publication bias after inspecting of the funnel plots revealed significant asymmetry. The present review denotes the absence of large, high-quality studies in the field. Nevertheless, IVT/IT was associated with moderate morbidity, mainly attributed to chemical meningitis and seizures. Further high-quality studies are still required before this therapeutic modality becomes broadly established.

Assessment of TREM2 rs75932628 variant's association with Parkinson's disease in a Greek population and Meta-analysis of current data.

BACKGROUND: Α number of genetic variants are considered to confer susceptibility to Parkinson's disease (PD). Rs75392628 (R47H), a rare variant of TREM2 gene, has been linked to PD, although its role on PD remains conflicting. OBJECTIVE: Detection of a possible contribution of rs75392628 variant of TREM2 gene to PD risk. METHODS: A total of 358 PD patients and 358 healthy controls genotyped for rs75392628. In addition, a meta-analysis was performed by merging our results with those from previous studies. RESULTS: The rare variant of rs75932628 (47H) of TREM2 gene was not detected on cohort. Meta-analysis of a total of 9271 PD cases and 9777 controls across 14 independent PD data sets from 9 studies, including the present study, did not show any statistically significant effect of rs75392628 on PD risk (ORFE:1.54 95% CI:0.87-2.73. ORRE: 1.54, 95%CI: 0.71-3.32). CONCLUSIONS: Rs75392628 TREM2 variant is rather unlikely to be a major genetic risk contributor of PD.

Guidelines on the use of external ventricular drain and its associated complications: do we "AGREE II"?

Insertion of an external ventricular drain is a common procedure used in everyday practice by neurosurgeons all around the world. It consists of the placement of an external ventricular drain (EVD) into the ventricular system providing the ability to measure intracranial pressure, and also divert the flow of cerebrospinal fluid (CSF) in a variety of pathological conditions. The most common complication is infection, and it may result in devastating consequences and negatively affect the outcome of these patients. The Infectious Diseases Society of America (IDSA), the Neurocritical Care Society (NCS), and The Society for Neuroscience in Anesthesiology & Critical Care (SNACC) have published recommendations for the management of EVD-Associated Ventriculitis. The objective of this study was to assess the methodological quality and reporting clarity of these recommendations using the AGREE-II tool. We found that the overall quality of the published clinical practice guidelines is acceptable. However, continuous updates and external validation should be implemented.

Apremilast increases IL-10-producing regulatory B cells and decreases proinflammatory T cells and innate cells in psoriatic arthritis and psoriasis.

OBJECTIVES: Psoriatic arthritis (PsA) and psoriasis are immune-mediated inflammatory diseases sharing common immunological mechanisms. Regulatory B cells (Breg cells) producing IL-10 (B10 cells), a critical anti-inflammatory B-cell subset, were found to be decreased in both PsA and psoriasis. Apremilast, a phosphodiesterase-4(PDE4) inhibitor, increases IL-10 and therefore, we examined the effect of apremilast on Breg cells. METHODS: Fifty patients, including 20 with PsA and 30 with psoriasis, were included in the study. The effect of apremilast on Breg cells at 3, 6 and 12 months post-treatment, was examined by flow cytometry in ODN2006 (TLR9)-stimulated peripheral blood mononuclear cells and magnetically-isolated cells. Th1 cells, Th17 cells and NKT were also measured. RESULTS: Ex vivo stimulated cell analysis identified that post-apremilast (IL-10+CD19+) B10 cells were increased in all PsA and psoriasis patients and correlated with psoriatic skin and joint clinical improvement. Apremilast decreased IFNγ(+) T and NKT cells and IL-17(+)NKT cells. B10 cells also inversely correlated with Th1 cells, and IFNγ(+)NKT cells. CONCLUSION: These results suggest that Breg cells are a major target of apremilast in PsA and psoriasis and that apremilast-induced increase of Breg cells is associated with a decrease of Th1 cells, IFNγ-producing NKT cells and IL-17-producing NKT cells.

Complications after Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and Meta-Analysis.

BACKGROUND: The efficacy of surgery in the management of patients with longstanding temporal lobe epilepsy has been established. Anterior temporal lobectomy (ATL) is the most frequently implemented procedure. However, there is an obvious need to assess its perioperative safety. OBJECTIVE: We conducted a meta-analysis to estimate the postoperative mortality (Q1) and morbidity (Q2) associated with ATL for medically intractable epilepsy. In addition, we tried to identify the most frequent complications after ATL and assess their relative frequency (Q3) in children and adults. METHODS: Fixed- and random-effects model meta-analysis was conducted to assess the proportion estimate for each outcome individually. RESULTS: The postoperative mortality and cumulative morbidity were estimated to be as high as 0.01 (95% CI: 0.01, 0.02) and 0.17 (95% CI: 0.12, 0.24), respectively. Psychiatric disorders were the most common postoperative complications after ATL, with an estimated frequency as high as 0.07 (95% CI: 0.04, 0.10), followed by visual field defects (0.06; 0.03, 0.11), and cognitive disorders (0.05; 0.02, 0.10). Less frequent complications included hemiparesis and language disorders (0.03; 0.01, 0.06), infections (0.03; 0.02, 0.04), hemorrhage (0.02; 0.01, 0.05), cranial nerve deficits (0.03; 0.02, 0.05), extra-axial fluid collections (0.02; 0.01, 0.03), and medical complications (0.02; 0.01, 0.03). CONCLUSIONS: Even though the mortality after ATL is minimal, the overall morbidity cannot be ignored. Psychiatric disturbances, visual field defects, and cognitive disorders are the most common postoperative complications, and should be considered during the preoperative planning and consultation.

Effect of integrin AV and B8 gene polymorphisms in patients with traumatic brain injury.

Background: Α few genetic variants are associated with the outcome after traumatic brain injury (TBI). Integrins are glycoprotein receptors that play an important role in the integrity of microvasculature of the brain. Objective: To examine the role of integrin-AV (ITGAV) and integrin-B8 (ITGB8) tag single nucleotide polymorphisms (SNPs) on the outcome of patients with TBI. Methods: 363 participants were included and genotyped for 11 SNPs for ITGAV and 11 for ITGB8 gene. SNPs were tested for associations with the 6-month outcome after TBI, the presence of a hemorrhagic event after TBI, and the initial TBI severity after adjustment for TBI's main predictors. Results: The ITGAV rs3911239 CC and rs7596996 GG genotypes were associated with an unfavorable outcome after TBI, compared to the TT and AA genotypes, respectively. The ITGB8 rs10239099 CC and rs3757727 CC genotypes were associated with increased risk of any cerebral hemorrhagic event after TBI compared to GG and TT respectively. The ITGAV rs7589470 and rs7565633 were associated with the TBI's initial severity. Conclusions: ITGAV gene SNPs may be implicated in the outcome after TBI, as well as in the initial TBI severity, and also of ITGB8 gene SNPs in the risk of hemorrhagic event after a TBI.

Collagen type-I A2 gene polymorphisms and susceptibility to intracranial aneurysms: a meta-analysis of genetic association studies.

BACKGROUND: The development, evolution and rupture of intracranial aneurysms are in part related to genetic factors. The role of collagen type-I a2 genetic polymorphisms has not been clarified yet. MATERIAL AND METHODS: A meta-analysis was realized by means of a genotype model-fitting process (allele contrast, recessive, dominant, additive and co-dominant), and a model-free approach using the generalized odds ratio. The latter was assessed in association to the degree of dominance (h-index). RESULTS: No statistically significant association was documented between EX28 G>C collagen type-I a2 variant and intracranial aneurysms (generalized odds ratio = 1.23, 95% confidence interval = 0.57, 2.63). Significant associations between INT46 T>G collagen type I a2 variant and intracranial aneurysms were documented in three models, the dominant [0.52 (0.38, 069)], the co-dominant [0.50 (0.32, 0.78)] and the allele contrast models [0.63 (0.49, 0.82)]. The generalized odds ratio was estimated to be as high as 1.94 (1.23, 3.06). The degree of dominance (h-index = -1.54) indicated that the TG genotype was characterized by lower risk of developing intracranial aneurysms compared to the TT genotype. CONCLUSIONS: The available literature data demonstrated that there is no association of collagen type-(2a) and intracranial aneurysms, through EX28 G>C (rs42524) polymorphism according to the model-fitting process and the model-free approach. Regarding the INT46 T>G (rs2621215) polymorphisms, the latter models indicated that there could be a protective effect of the G-allele against the development of intracranial aneurysms. However, the majority of studies are from East Asia, therefore the results are applicable primarily to that patient population.

Variants of the elastin (ELN) gene and susceptibility to intracranial aneurysm: a synthesis of genetic association studies using a genetic model-free approach.

BACKGROUND: The presence of an intracranial aneurysm (IA) is thought to have a genetic origin. The genetic association studies (GAS) that investigated the association between IA and elastin gene (ELN) variants have produced contradictory or inconclusive results. MATERIALS AND METHODS: In order to decrease the uncertainty of estimated genetic risk effects, a meta-analysis of published GAS-related variants in the ELN gene (ELN INT20 1315T > C, EX20 1264G > A, INT23 1501 + 24T > C and INT4 196 + 71G > A) with susceptibility to IA was conducted using a genetic model-free approach. The risk effects were estimated using the generalized odds ratio (ORG) metric. RESULTS: The analysis showed significant association for the INT20 1315T > C variant [ORG = 0.66 (0.45-0.95)], indicating a protection effect. For the variants EX20 1264G > A, INT23 1501 + 24T > C and INT4 196 + 71G > A, no statistically significant association with IAs was found. CONCLUSION: There is evidence that the ELN variant INT20 1315T > C is implicated in the development of IA; however, the results should be interpreted with caution since the number of published studies is limited.

Endoscopic third ventriculostomy in the treatment of idiopathic normal pressure hydrocephalus: a review study.

Idiopathic normal pressure hydrocephalus is a hydrodynamic disorder whose etiology remains unclear. The diagnosis is mainly clinical and the traditional treatment is cerebrospinal fluid shunt diversion. With the introduction of modern management strategies, endoscopic third ventriculostomy has become a viable alternative to shunting and constitutes a well-established method of treatment for obstructive hydrocephalus. The new hydrodynamic concept of hydrocephalus suggests that endoscopic third ventriculostomy (ETV) may be an effective treatment for communicative hydrocephalus. In our current review, the authors focus on the up-to-date knowledge regarding the consideration of endoscopic third ventriculostomy as a safe surgical option in the management of idiopathic normal pressure hydrocephalus.

An evidence-based approach towards the cranio-cervical junction injury classifications.

PURPOSE: The cranio-cervical junction (CCJ) is an anatomically, functionally and biomechanically complex region. It is commonly involved in trauma of varying severity that can be managed with a multitude of treatment options and carry diverse prognosis. Our objective is to evaluate the quality of currently used CCJ injury classifications in an evidence-based approach. METHODS: We performed two consecutive literature reviews. In the first, we tried to find which classifications are currently used in CCJ injuries. In the second, we scrutinized the gathered classifications in terms of validity, reliability, severity grading, treatment guidance and prognosis assessment. RESULTS: Twenty classifications are currently used to describe the CCJ injuries and 72 individual injury patterns have been recognized. Almost a third of them can grade severity, guide treatment and assess prognosis. Only two classifications have been tested for validity and reliability. CONCLUSIONS: CCJ injuries are poorly described by the current classifications according to evidence-based criteria. There is an obvious need for a simple and reliable classification tool to guide patient management in the evidence-based medicine era.

Otogenic brain complications: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to form astute deductions regarding the presentation, treatment and mortality of otogenic brain complications. METHODS: A systematic literature search of four medical databases (PubMed, Embase, Web of Science and Scopus) was conducted. Studies associated with otogenic brain complications were considered eligible. Fixed- and random-effects model meta-analysis was developed to assess the proportion estimate for each outcome individually. RESULTS: Twenty-eight studies, with 1650 patients in total, were included. In 66 per cent of patients there was a known history of chronic otitis media. The most common symptoms were purulent otorrhoea (84 per cent), headache (65 per cent) and otalgia (45 per cent). A brain abscess was observed in 49 per cent of patients, followed by meningitis (34 per cent) and sinus thrombosis (22 per cent). A combination of surgical and conservative therapy was chosen in 84.3 per cent of cases and the mortality rate approached 11.1 per cent. CONCLUSION: Otogenic brain complications are a possibly life-threatening condition. Prompt imaging examination may set the final diagnosis and lead to an effective treatment.

Malignant character of an ossified posterior longitudinal ligament in a hyperflexion injury: A case report.

The present study reports the case of a 50-year-old obese male with ankylosing spondylitis, Scheuermann's kyphosis. The patient was asymptomatic concerning the ectopic ossification of the posterior longitudinal ligament (OPLL) at the cervical spine; he developed quadriparesis and respiratory insufficiency following minor head trauma. Even though trauma to the cervical spine in patients with OPLL is common, to the best of our knowledge, this is the first reported case of an extensive osteophyte with a lethal outcome after syncope. In rare occasions, it may be present with syncope and potentially lethal outcomes, particularly when precipitated by trauma. Therefore, the management of OPLL with significant canal stenosis should not be unnecessarily delayed.

The role of lobectomy in glioblastoma management: A systematic review and meta-analysis.

Introduction: Lobectomy has recently been employed in the management of glioblastoma (GB). Compared to subtotal, gross total and supramarginal resection, lobectomy provides maximum cytoreduction and improves overall survival (OS). Research question: The primary aim of this study is to compare lobectomy to other techniques for managing GB in terms of OS and progression-free survival (PFS). This study evaluated the association of the available surgical techniques for GB management with the reported relevant seizure outcome, operation time, length of stay, complication incidence, and Karnofsky performance status. Materials and methods: A PRISMA-compliant systematic review and meta-analysis was performed. We searched PubMed, Scopus, and Web of Science from January 2013 until April 2023. Random-effects models were employed. The Newcastle-Ottawa scale (NOS) and the GRADE approach were used for estimating risk of bias and quality of evidence. Results: We included six studies. Lobectomy demonstrated a mean OS of 25 months, compared to 13.72 months for gross total resection (GTR), and a PFS of 16.13 months, compared to 8.77 months for GTR. Comparing lobectomy to GTR, no statistically significant differences were observed regarding seizure management, length of stay, operation time, complications, and KPS due to limited amount of data. Discussion and conclusion: Our analysis demonstrated that lobectomy compared to GTR has a tremendous impact on the OS and the PFS, which seems to be improved almost by a year. Lobectomy, while demanding from a technical standpoint, constitutes a safe surgical procedure but further studies should assess its exact role in the management of GB patients.

Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis.

OBJECTIVE: Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics. DATA SOURCES: We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, ClinicalTrials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty. REVIEW METHODS: Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group. RESULTS: Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:-0.23; 95% CI: -0.61, 0.14, I2 = 33.42%), and air-bone gap improvement (pooled mean difference:-0.05; 95% CI:-0.23, 0.13, I2 = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: -1.72; 95% CI: -3.39, -0.04, I2 = 0%), dysgeusia (OR: -1.47; 95% CI: -2.47, -0.47, I2 = 0%), otitis externa development (OR: -1.96; 95% CI: -3.23, -0.69, I2 = 0%), auricular numbness (OR: -2.56; 95% CI: -3.93, -1.19, I2 = 0%), as well as surgical duration (OR: -1.86; 95% CI: -2.70, -1.02, I2 = 43.95%), when compared to the postauricular microscopic approach. CONCLUSION: Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3466-3476, 2024.

Determination of a 'point of no return' in refractory chronic subdural hematomas: A case report and review of the literature.

Recurrence following the surgical evacuation of a chronic subdural hematoma (CSDH) occurs in up to 33% of cases. Several clinical and radiologic factors have been identified that are associated with the recurrence of hematoma. However, the optimal treatment for recurrent CSDH has not yet been determined. The present study, based on a case report, reviews the predictors and treatment options for refractory CSDHs. An 85-year-old male patient presented with a symptomatic bilateral CSDH. The hematoma was initially removed through a burr hole and closed drainage system, resulting in clinical improvement and in the radiographic resolution of the hematoma. At the first recurrence, steroids were administered and the hematoma was re-evacuated. After 1 month, the patient returned comatose due to a massive right subdural hematoma and was treated with an ipsilateral craniotomy and a membranectomy. After 2 days, the patient succumbed due to massive intraparenchymal bleeding. The treatment of refractory CSDHs is challenging. The failure of brain re-expansion and senile atrophy appear to be the key predictors of recurrence. Patients who are at high-risk need to be identified promptly and treated with a multidisciplinary approach that considers adjuvant medications, middle meningeal artery embolization and repeat hematoma evacuation, probably with a membranectomy and an endoscope.