Awake surgery in sitting position for chronic subdural hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD: This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS: Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS: In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.

A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case.

BACKGROUND: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. CASE REPORT: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions.

Fatal Acute Pneumocephalus after Bilateral Drainage for Chronic Subdural Hematomas: Case Report.

BACKGROUND: Pneumocephalus is a well-known complication in the surgical treatment of chronic subdural hematomas; however, its influence remains controversial. The amount of subdural air may vary, and it may cause worsening of symptoms, increase reoccurrence rates, and worsen the outcomes. Lethal outcome following acute onset of massive pneumocephalus was not previously reported. CASE REPORT: An 81-year-old man with bilateral hematomas underwent surgery under local anesthesia. Both hematomas were approached in the same surgery, and the drains were placed subdurally. After initial improvement, severe hypertension developed, followed by vital function and neurologic deterioration. Massive pneumocephalus with subarachnoid and contralateral intracerebral hemorrhage was revealed, causing a severe midsagittal shift. Emergency irrigation to evacuate subdural air was performed. However, there was no improvement. Further computed tomography confirmed subdural air collection, but it also revealed hemorrhage progression and intraventricular propagation. No further surgery was indicated. CONCLUSION: Pneumocephalus is an underestimated but potentially devastating complication. Both intraoperative avoidance and postoperative prevention should be utilized to avoid subdural air ingress, and thus evade potentially fatal complications.

Analysis of the factors affecting outcome after combat-related cranial defect reconstruction.

INTRODUCTION: Reports on the outcomes of cranioplasty after combat-related injuries are relatively rare in the current literature. We present our results on the reconstruction of cranial defects resulting from injuries sustained in combat, comparing outcomes using autologous (iliac bone) grafts or (acrylate) allografts, and analysis of other factors that may influence the final outcome. MATERIAL AND METHODS: The study comprised 207 patients with cranial defects resulting from combat-related injuries, repaired with autografts or allografts. The final outcome was defined at least 5 years postoperatively on the basis of cosmetic restoration and the existence of complications as successful (acceptable cosmetic restoration + absence of complications) or unsuccessful (poor cosmetic restoration or acceptable cosmetic restoration + complications). RESULTS: Successful outcomes were achieved in 83.6% of patients; there was no operative mortality. There were 25 instances of complications: postoperative infection (n = 15, allograft (7/53), autograft (8/154)), autograft resorption (n = 8), and in two cases, graft luxation. Poor cosmetic restoration was noted in 9 (4.3%) patients who had received an autograft. CONCLUSIONS: Thin and poorly vascularized skin, a surface area of the defect larger than 88 cm2, previous local infection and communication with paranasal cavities significantly influenced outcomes after combat-related cranioplasty, the final three being independent predictors of an unsuccessful outcome.

Missile-induced complete lesions of the tibial nerve and tibial division of the sciatic nerve: results of 119 repairs.

OBJECT: Very few extensive studies regarding the repair of missile-induced tibial nerve or tibial division complete lesions have been published to date. In this prospective study, the outcomes of such repairs as well as factors influencing them are presented. METHODS: Between 1991 and 1994, 119 patients with missile-induced complete lesions of the tibial nerve or tibial division were treated in the neurosurgical department of the Military Medical Academy, Belgrade. After at least 4 years of follow up, the final outcome was defined as poor, insufficient, good, or excellent, based on sensorimotor recovery, electromyoneurography-demonstrated recovery, and patient judgment. Good and excellent outcomes were considered to be successful. The influence of the repair level, length of the defect, and preoperative interval on final outcome was also tested. A successful outcome was obtained in 30.3% of high-level, 50% of intermediate-level, and 85.7% of low-level repairs (p < 0.001). On average, the nerve defect and preoperative interval were significantly shorter in patients with a successful outcome. Significant worsening of the outcome was related to a nerve defect longer than 5 cm and a preoperative interval longer than 4 months. Repair level, preoperative interval, and length of the defect were independent predictors of a successful outcome. CONCLUSIONS: A successful outcome is most probable following the low-level repairs, within the first 4 months after injury, and using grafts shorter than 5 cm. Other repairs can also be beneficial in preventing dangerous anesthesia of the sole of the foot and enabling almost normal walking.

Multiple lateral sinus pericranii--A case report.

INTRODUCTION: Sinus pericranii is a rare vascular anomaly. It is characterized by abnormal communication between the extracranial and intracranial venous system, usually involving the superior sagittal sinus and occasionally the transverse sinus. Off the midline lesions are extremely rare. Multiplicity, associated venous lakes, venous angioma and lateral location are unusual and unique presentation of sinus pericranii. CASE REPORT: A case of multiple congenital off-midline sinus pericranii in the left frontotemporal and parietal region is presented. Magnetic resonance imaging showed an extracranial vascular anomaly connected with the intracranial venous system through abnormal diploic or emissary veins. The lesions were removed completely by surgery. CONCLUSION: Sinus pericranii is a rare vascular malformation with unique clinical and radiological features. Sinus pericranii may cause fatal complications, and it must be treated by surgical or endovascular procedures.

Difference in recovery potential of peripheral nerves after graft repairs.

OBJECTIVE: To our knowledge, few studies have been published regarding differences in nerve recovery potentials. In this study, sensory and motor recovery potentials were compared between different nerves. METHODS: A prospective study of a homogenous group of 393 graft repairs of the median, ulnar, radial, tibial, peroneal, femoral, and musculocutaneous nerves, with the scoring of motor and sensory recoveries. Sensory and motor recovery potentials, defined on the basis of average scores and rates of useful recovery, were compared between the different nerves, and separately for high-, intermediate-, and low-level repairs. RESULTS: Sensory recovery potential was similar for all nerves tested (P > 0.05), but motor recovery potential differed significantly. After high-level repairs, motor recovery potential was significantly better for the radial and tibial nerves (useful recovery in 66.7 and 54.5% of patients, respectively), than for the ulnar and peroneal nerves (useful recovery in 15.4 and 13.8% of patients, respectively; P < 0.05). After intermediate-level repairs, motor recovery potential was better for the musculocutaneous, radial, and femoral nerves (useful recovery in 100, 98.3, and 87.5% of repairs, respectively), than for the tibial, median and ulnar nerves (useful recovery in 63.9, 52, and 43.6% of repairs, respectively; P < 0.05). In addition, motor recovery potential was significantly the worst with peroneal nerve repairs (useful recovery in 15.2% of patients; P < 0.05). After low-level repairs, motor recovery potential was similar for all nerves (useful recovery in the range of 88.9-100% of patients and in 56.3% of peroneal nerve repairs). CONCLUSION: Sensory recovery potential is similar for the median, ulnar, and tibial nerves. The expression of motor recovery potential depends on the repair level. With low- and high-level repairs, it does not stand out in an obvious way, but it is fully expressed with intermediate-level repairs, classifying nerves into three categories with excellent, moderate, and poor recovery potential.

[Intraoperative rupture of cerebral aneurysms and use of temporary arterial occlusion]. / Intraoperativna ruptura mozdane aneurizme i primena privremene arterijske okluzije.

OBJECTIVES: The aim was to analyze the risk factors for intraoperative rupture (IR) of cerebral aneurysm and for temporary clips (TC) use, as well as their influence on the final postoperative outcome. METHODS: Retrospective study was done 72 IR patients, and on 75 TC patients. For patients with or without IR, as well as for the patients with or without TK, outcome of the treatment, aneurysm size and localization, preoperative clinical state and operative timing was analyzed, and statistical significance of obtained differences was tested. RESULTS: IR occurred in 40% of anterior cerebral artery aneurysms and in 16.7% of internal carotid artery aneurysms (p > 0.05), while TCs were used in 52% of middle cerebral artery aneurysms and 34.8% of internal carotid artery aneurysms (p > 0.05). Average size was 17.3 mm for aneurysms with IR and 11.7 mm for those without IR (p > 0.05). Aneurysms were significantly larger in patients with TCs, than in patients without TCs (16.7 mm and 9.4 mm respectively, p < 0.05). Preoperative period was 10.2 days for patients with IR, and 16.8 days for patients without IR (p < 0.05). Favorable outcome was observed in 71.4% of patients with IR and in 70.6% of those without IR, as well as in 76.4% of patients who required TC and in 75.6% of cases without TC (p > 0.05). Average duration of temporary occlusion was 5.8 min for patients with favorable outcome and 15 min for patients with poor outcome (p < 0.05). CONCLUSIONS: Incidence of IR mostly depended on the duration of preoperative interval, while the frequency of TC use depended mostly on aneurysm size. IR did not influence the surgical outcome, as well as TC use, if the occlusion was shorter than 8-10 min.

[Outcome of surgical treatment of malignant astrocytoma of the brain]. / Ishod hirurskog lecenja malignih astrocitoma mozga.

BACKGROUND: The aim of this study was to analyze the outcome after the surgical treatment of patients with malignant brain astrocytomas, as well as the factors influencing the outcome. Retrospective study was performed on 145 operated patients (102 with glioblastoma multiforme, and 43 with anaplastic astrocytomas). METHODS: Clinical state was graded according to the Yasargil scale (grades I-IV) and the Karnofski score, and the outcome was defined either as good (better or unchanged clinical state) or as poor (deteriorated state or death). The outcome was correlated with patients age and preoperative clinical condition, as well as with the localization, extensiveness and the extent of resection of the tumor. RESULTS: Preoperative clinical state of patients most frequently corresponded to grades II-III (75.9%). Radical resection was done in 48.3%, subtotal in 15.2%, partial in 30.3%, and biopsy was performed in 6.2% of patients, with the total operative mortality of 16.5%, morbidity of 9.7%, and good postoperative outcome in 73.8% of the patients. The incidence of good postoperative outcome did not significantly depend on the tumor location (42.6-78.3%), cortical presentation, the extent of resection (68.2-75.7%), and preoperative clinical state (67.8-81.5%). Good outcome was seen in 82.7% of patients with one, and in 53.8% of patients with three or more infiltrated lobes (p < 0.01). Patients with poor outcome were significantly older in average than the patients with good outcome (58.9 +/- 12.1 and 50.9 +/- 13.4 years of age, respectively; p < 0.05). Operative mortality was 7.4%, and 27.3% for clinical grades II and IV (p < 0.05), namely 11% and 23.8% for the patients with the Karnofski score above and under 50 (p < 0.05), respectively. CONCLUSION: The outcome after the operative treatment of malignant cerebral astrocytomas significantly depended on patients age and the extensity of the tumor. For such patients operative mortality was also significantly influenced by clinical preoperative state.

[Complications and mortality in surgery of cerebral aneurysms]. / Komplikacije i smrtnost u hirurgiji mozdanih aneurizmi.

AIM: To establish the risk factors for complications and fatal outcome after the operative occlusion of cerebral aneurysms. METHODS: Retrospective study on 91 (lethality rate) and on 72 operated patients (complications). For survived and dead patients, as well as for patients with and without complications, following parameters were compared: gender, age, clinical condition, preoperative interval, use of temporary clips, vasospasm, outcome, as well as localization, size and intraoperative rupture of the aneurysm. RESULTS: Complications existed: in 54.5% of aneurysms of middle cerebral and 13.6% of aneurysms of internal carotid artery (p < 0.01); in 18.2% of patients in the first and 45.8% of patients in the third clinical Hunt and Hess group (p < 0.05); in 57.9% of patients with and 20.5% of patients without intraoperative rupture (p < 0.01); in 50% of patients with and 18.7% of patients without vasospasm (p < 0.05). Average aneurysmal size was 18 mm in group with complications and 10.8 mm in patients with no complications (p < 0.05), while average preoperative intervals in these two groups were 20 and 8.7 days (p < 0.05). Lethality rate was 25% for the third and 83.3% for the fourth and fifth clinical group (p < 0.01), and the existence of complications significantly increased mortality (from 15.7% to 50%, p < 0.01). Good outcome existed in 19.2% of operated patients with complications and in 78.3% of those without complications (p < 0.01). CONCLUSIONS: Incidence of complications depended significantly on preoperative clinical condition, duration of preoperative interval, size, localization and intraoperative rupture of aneurysm. Complications significantly minimized the surgical treatment outcome and increased the lethality rate mortality.

[Multiple cerebral aneurysms]. / Multiple mozdane aneurizme.

BACKGROUND: To define risk factors for the multiplicity of cerebral aneurysms, as well as clinical and therapeutical characteristics of patients with single aneurysms (SA) and multiple aneurysms (MA). METHODS: Retrospective study on 95 patients with SA and 22 patients with MA. For patients with SA and MA the following parameters were compared: gender, age, clinical state, aneurysmal localization and size, incidence of rebleeding and vasospasm, manner and outcome of treatment, preoperative interval, intraoperative rupture and postoperative complications. RESULTS: Aneurysms on anterior communicating artery existed in 37.4% of SA and in 17.8% of all MA (p < 0.05). As much as 44.2% of all aneurysms on middle cerebral artery and only 19% of all aneurysms on anterior communicating artery were associated with some other aneurysm (p < 0.02). The average size of SA was 15.4 +/- 11.8 mm, and 9.8 +/- 9 mm for MA (p < 0.05). Surgery was performed in 77.3% of patients with MA and 78.9% of patients with SA (p > 0.05), but complete surgical clipping was performed in 89.3% of patients with SA and in 47.1% of patients with MA (p < 0.01). Among operated patients with MA and SA, intraoperative rupture occurred in 36% and 17.6% of cases, respectively (p < 0.05) and ischemic postoperative complications were found in 29.4% and 17.3% of the cases (p > 0.05). Among 72.7% of all patients with MA and in 69.5% of all patients with SA the outcome was good, while among surgically treated patients it was good in 76.5% and 70.7% of cases, respectively. CONCLUSION: The treatment outcome was similar for patients with MA and SA, but complete operative treatment is significantly more frequent for SA. Multiple aneurysms were considerably smaller and with different anatomical distribution in relation to solitary aneurysms.

Factors influencing the outcome after the operative treatment of cerebral aneurysms of anterior circulation.

BACKGROUND: The influence of various factors on the outcome after the operative occlusion of the cerebral aneurysm was to be defined through the retrospective study on 111 surgically treated patients with aneurysm of anterior cerebral circulation. METHODS: Preoperative clinical condition was graded from 0 to V, according to Hunt & Hess. Postoperative outcome, defined as good or bad according to modified Glasgow Outcome Scale, was correlated in homogenous experimental groups with the following factors: gender, age, aneurysmal size, preoperative interval, nimodipine therapy, experience of surgical team and existence of chronic vascular diseases. RESULTS: Surgical outcome was good in 74.4% of males and 71.4% of females (p > 0.05); in 83.3% of patients with and 41.2% of patients without chronic diseases (p < 0.01); in 71.4% of patients underwent early, 83.3% of ones underwent postponed and 85% of those underwent late surgery (p > 0.05); in 81.5% of patients treated by nimodipine and in 41.7% of those untreated by the same drug (p < 0.01); in 78.9% of patients operated by the experienced surgical team and in 40% of those operated by less experienced surgical team (p < 0.01). In patients with both good and bad outcome, the mean age was 50.6 and 47.6 years (p > 0.05), and the mean aneurysmal size was 12.3 mm and 13.3 mm, respectively (p > 0.05). Before rupture, the mean size for aneurysms on the bifurcation of the middle cerebral artery was 14.3 mm, and for posterior communicating artery aneurysms only 9.7 mm (p < 0.05). CONCLUSION: Surgical outcome was significantly influenced by the existence of chronic diseases, nimodipine therapy and experience of surgical team, whereas gender, age, timing for surgery and aneurysmal size were not of significant influence.

[Treatment of aneurysms in the anterior cerebral circulation]. / Tretman arterijskih aneurizmi prednje mozdane cirkulacije.

OBJECTIVES: To analyze the outcome of either surgical or conservative treatment of patients with aneurysms on cerebral arteries. DESIGN: Retrospective study on 114 patients (89 operated and 25 not operated). METHODS: Clinical state was graded from 0 to V, according to Hunt & Hess (HHG), and the treatment outcome was defined as favorable or poor, according to the modified Glasgow Outcome Score. The outcome was correlated with the type of treatment (operative or conservative), clinical state and aneurysmal localization. RESULTS: Aneurysm was localized mostly on the anterior communicating (33.6%) and middle cerebral arteries (32.8%) and the patients were mostly in HHG II or III (34.4% and 25.2%). HHG after the aneurysmal rupture did not depend on the aneurysmal location (p > 0.05). Favorable treatment outcome was noted: in 74.1% of all operated and in 60% of all conservatively treated patients (p > 0.05); in 81.6% of operated and in 33.3% of not operated patients with HHG = II-III (p < 0.01); in 78.8% of aneurysms of the middle cerebral artery and in 66.7% of those of the anterior communicating artery (p > 0.05); in 73.1% of patients with HHG = III and in 25% of patients with HHG = IV (p < 0.01). CONCLUSIONS: Clinical state after the aneurysmal rupture did not depend on its localization. Results were better after the surgical, than after the conservative treatment. Outcome after the surgery depended on the clinical state of the patient, but not on the aneurysmal localization.