Tranexamic acid in bleeding reduction and operative time of nasal surgeries: systematic review and meta-analysis.

PURPOSE: Our study goal is to review the efficacy of tranexamic acid in reducing blood loss and operative time in nasal surgeries. METHODS: We included randomized clinical trials using oral or intravenous tranexamic acid, excluded non-randomized studies, topic administration, coagulopathy, and using other drugs interfering in the coagulation cascade. Online databases, National Library of Medicine (MEDLINE-PubMED), Latin American and Caribbean Literature on Health Sciences (Lilacs), Cochrane Library, Embase and Google Scholar were used to perform the search. The review was registered in PROSPERO by no CRD42022310977. Two authors, independently, selected the articles meeting the inclusion criteria. They extracted the data and used RevMan 5 software to perform the meta-analysis. RESULTS: Our search resulted in 16 RCTs that were included in the meta-analysis totalizing 1108 patients. Studies were evaluated resulting in a low risk of bias for the five domains. The use of tranexamic acid resulted in significant reduction in duration of surgery (DOS) and intraoperative blood loss (IBL) had significant reduction. The level of evidence according to GRADE System was high in all studies and variables. CONCLUSION: Tranexamic acid has an important role in reducing intraoperative blood loss and duration of surgery. Our study has some limitations due to the low number of RCTs available in the literature.

Measuring pituitary tumor volume: a comparison of the simplified and non-simplified ellipsoid equation with the 3D planimetric volume assessment.

PURPOSE: The ellipsoid equation came in an attempt to facilitate the estimation of tumor volume, by measuring the height, width, and anteroposterior length of the lesion. The estimated tumor volume can sometimes be different between methods, thus, it is of extreme interest to evaluate if the methods are significantly different, as well as to discuss the main limitations of each one. METHODS: This is an observational, analytical, cross-sectional study. A systematic review of the literature was also performed in order to discuss the results observed in the present study. RESULTS: A total of 82 patients (43 males and 39 females) ranging in age from 15 to 78 years (mean 47.95 ± 14.76) were included in the study. Seven patients were classified as Knosp grade 0 (8.5%), 36 Knosp grade 1 (44%), 14 Knosp grade 2 (17%), 20 Knosp grade 3 (24.4%), 5 Knosp grade 4 (6.1%). The tumor volume estimated by 3D planimetric assessment, non-simplified ellipsoid equation, and simplified ellipsoid formula averaged 10.68 cm³, 10.36 cm³, and 9.9 cm³ respectively. CONCLUSION: A simplified form of the ellipsoid equation increases the divergence between the measurement obtained in planimetry, and should be discouraged, in view of the new automated methods of performing quick calculations using periodic digits. The non-simplified form underestimated the tumor volume by 2.9% on average but did so regularly. In clinical practice, measurement should be accompanied by an evaluation of tumor morphology.

A comparison of spinal laser interstitial thermotherapy with open surgery for metastatic thoracic epidural spinal cord compression.

OBJECTIVE: The proximity of the spinal cord to compressive metastatic lesions limits radiosurgical dosing. Open surgery is used to create safe margins around the spinal cord prior to spinal stereotactic radiosurgery (SSRS) but carries the risk of potential surgical morbidity and interruption of systemic oncological treatment. Spinal laser interstitial thermotherapy (SLITT) in conjunction with SSRS provides local control with less morbidity and a shorter interval to resume systemic treatment. The authors present a comparison between SLITT and open surgery in patients with metastatic thoracic epidural spinal cord compression to determine the advantages and disadvantages of each method. METHODS: This is a matched-group design study comprising patients from a single institution with metastatic thoracic epidural spinal cord compression that was treated either with SLITT or open surgery. The two cohorts defined by the surgical treatment comprised patients with epidural spinal cord compression (ESCC) scores of 1c or higher and were deemed suitable for either treatment. Demographics, pre- and postoperative ESCC scores, histology, morbidity, hospital length of stay (LOS), complications, time to radiotherapy, time to resume systemic therapy, progression-free survival (PFS), and overall survival (OS) were compared between groups. RESULTS: Eighty patients were included in this analysis, 40 in each group. Patients were treated between January 2010 and December 2016. There was no significant difference in demographics or clinical characteristics between the cohorts. The SLITT cohort had a smaller postoperative decrease in the extent of ESCC but a lower estimated blood loss (117 vs 1331 ml, p < 0.001), shorter LOS (3.4 vs 9 days, p < 0.001), lower overall complication rate (5% vs 35%, p = 0.003), fewer days until radiotherapy or SSRS (7.8 vs 35.9, p < 0.001), and systemic treatment (24.7 vs 59 days, p = 0.015). PFS and OS were similar between groups (p = 0.510 and p = 0.868, respectively). CONCLUSIONS: The authors' results have shown that SLITT plus XRT is not inferior to open decompression surgery plus XRT in regard to local control, with a lower rate of complications and faster resumption of oncological treatment. A prospective randomized controlled study is needed to compare SLITT with open decompressive surgery for ESCC.

Schizencephaly: A Review of 734 Patients.

BACKGROUND: Schizencephaly is a rare congenital cerebral malformation associated with serious neurological manifestations. The number of studies regarding schizencephaly is limited. METHODS: We conducted a literature review and extracted data from the case reports. Of 199 articles retrieved, 156 articles (734 patients) met our inclusion criteria. RESULTS: Patient characteristics included microcephaly (41.5% of patients), seizures (74.1%), bilateral cleft (41.4%), open lip (61.3%), septo-optic dysplasia (69.1%), and ventricular dilation (60.5%). The majority of clefts were in the frontal and parietal lobes. When these potential association factors were assessed by univariate logistic regression microcephaly (OR = 21.75, P < 0.001), corpus callosum agenesis (OR = 9, P < 0.001), motor impairments (OR = 6.21, P < 0.001), and bilateral clefts (OR = 6.31, P < 0.001) seems to have the strongest association, but also age at diagnosis <10 years (OR = 1.05, P < 0.001), right (OR = 1.85, P = 0.001) or left (OR = 2.71, P < 0.001) side clefts and septum pellucidum (OR = 3.7, P = 0.002) agenesis were associated with neurocognitive dysfunctions. CONCLUSIONS: We describe novel findings with practical implications for predicting neurocognitive outcomes in patients with schizencephaly. Most patients had neurological impairments including motor (90.0%) or cognitive (77.5%) dysfunctions. Bilateral clefts, motor impairment, microcephaly, and corpus callosum agenesis were strongly associated with neurocognitive impairment. A lack of large cohorts of patients with schizencephaly prevented comparison of our results; most previous studies are case reports or small case series.

Intrasphenoid septations inserted into the internal carotid arteries: a frequent and risky relationship in transsphenoidal surgeries.

INTRODUCTION: When an expanded endonasal transsphenoidal surgical approach is performed, intrasphenoid septations must be completely resected. If these structures are close to the internal carotid artery (ICA), then their manipulation might cause vascular injury. OBJECTIVE: The objective of this study is to describe the frequency of intrasphenoid septations in the internal carotid artery protuberance (ICAp). METHODS: Computed tomography (CT) scans of 421 patients were analysed. Intrasphenoid septations (classified as intersphenoid or accessory) and their relationship to the ICAp were described. Additionally, a sphenoid sinus classification was performed based on their degree of pneumatisation to determine whether a difference exists in the frequency of intrasphenoid septations inserted into ICAp with regard to sinus type. RESULTS: The patient mean age was 39±21.4 years. Overall, 219 patients (52%) had septations in the ICAp; 359 patients (85.3%) had intersphenoid septations; of the latter, 135 (37.6%) had septations in the ICAp. This frequency was higher among patients with sphenoid sinus type 4 or 5 (44.7% and 43.5%, respectively). Accessory septations were found in 255 patients (60.6%); 140 of these septations (54.9%) were in the ICAp. Among 351 patients with types 3, 4 or 5 sphenoid sinuses (i.e., only well-pneumatised sphenoid sinuses), 219 (62.4%) had septations in the ICAp. These frequencies are higher than those reported in most previous studies. CONCLUSION: The frequency of intrasphenoid septations in the ICAp found is considerable. It is higher among patients with more pneumatised sinuses. This finding justifies an appropriate pre-operative study, and careful attention must be paid during transsphenoidal surgery.

Anatomical Variations of the Anterior Clinoid Process: A Study of 597 Skull Base Computerized Tomography Scans.

BACKGROUND: The anterior clinoid process (ACP) is surrounded by a complex anatomy; variations include pneumatization and the formation of bone bridges with the middle and posterior clinoid, which complicate surgery. The key to avoiding microsurgical complications is a perfect understanding of this anatomy. OBJECTIVE: To explore the anatomic variations of the ACP. METHODS: Between January 1, 2013, and September 6, 2014, 597 skull base computed tomography scans were performed to evaluate inner ear disease in patients with no history of paranasal sinus disease or endonasal surgery. The base width and length of the ACP, complete carotid-clinoid foramen and sella turcica bridge, and sphenoid sinus pneumatization volume were assessed. ACP pneumatization was assessed with the use of a novel classification system. RESULTS: The scans were derived from a population of 343 female patients (57.5%), with a mean age of 38.6 years (0.2-90 years). ACP base width and length were 7.7 ± 1.73 and 10.31 ± 2.1 mm, respectively. Anatomic variations were present in 38.7% of scans. ACP pneumatization was present in 25.5% of scans, and carotid-clinoid foramen and sella turcica bridge were present in 14.2% and 14.4% of scans, respectively. There was no pneumatization of the ACP in patients <10 years of age and no progression of the pneumatization of the sphenoid sinus in patients >10 years old. CONCLUSION: At least 1 variation in ACP anatomy was found in 38.7% of cases with this simple method. Thus, a preoperative computed tomography scan could improve surgical procedures that involve removal of the anterior clinoid process.