Effect of preservation versus resection of turbinate on olfactory function in endoscopic trans-nasal trans-sphenoidal pituitary surgery: a systematic review and meta-analysis.

BACKGROUND: Utilizing endoscopes in surgery offers advantages and concerns, including potential nasal function impacts. Hyposmia following Transseptal Transsphenoidal hypophysectomy ranges from 0% to 2.2%. Debates persist about managing the M.T. in endoscopic sinus surgery due to its impact on nasal function. While preservation is recommended for sinonasal health, debates continue, as certain cases require resection. Our meta-analysis aims to compare turbinate resection and preservation effects on olfactory function. METHODS: We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled as standardized mean difference with 95% CI. Statistical analyses was done by RevMan. RESULTS: Our meta-analysis included four studies involving 235 patients (81 males). Evaluating changes in olfaction scores, two one-month studies (82 patients) revealed no significant difference between preservation and resection groups (Std.MD = 0.05[-0.39, 0.50], p = 0.81). For three-month assessments (146 patients), SNOT tests indicated no significant difference (Std.MD = 0.21, 95% CI[-0.11, 0.54], p = 0.20). Two studies used other tests on 70 patients at three months, yielding no significant difference (Std.MD = 0.13, 95% CI [-0.35, 0.62], p = 0.59). Two six-month studies (72 patients) similarly found no significant difference (Std.MD = 0.09, 95% CI [-0.39, 0.56], p = 0.72). CONCLUSION: Our meta-analysis involving 235 patients examined olfaction score changes over various time frames in trans-nasal trans-sphenoidal pituitary surgeries. No significant differences were observed between turbinate preservation and resection groups at one month, three months, or six months post-surgery.

Subcutaneous preservation versus cryopreservation of autologous bone grafts for cranioplasty: A systematic review and meta-analysis.

BACKGROUND: Cranioplasty corrects cranial bone defects using various bone substitutes or autologous bone flaps created during a previous craniectomy surgery. These autologous bone flaps can be preserved through subcutaneous preservation (SP) or cryopreservation (CP). AIM: We aim to compare outcomes and complications for both SP and CP techniques to enhance the current evidence about autologous bone flap preservation. METHODS: Five electronic databases were searched to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. We categorized surgical site infection (SSI) as either due to Traumatic brain injury (TBI) or not to reveal potential variations in SSI incidence. The double-arm meta-analysis utilized risk ratios (RR) and mean differences (MD) with corresponding confidence intervals (CI) to pool categorical and continuous outcomes, respectively. Proportions with their respective 95% CIs were pooled for single-arm meta-analyses to determine outcomes related to SP technique. RESULTS: Seventeen studies involving 1169 patients were analyzed. No significant difference in SSI rates was observed between SP and CP methods in patients with or without TBI. SP was linked to shorter hospital stays in two studies (194 patients). Single-arm analysis showed a 17% revision surgery rate across five studies (375 patients) and infection rates in 17 studies for SP. New bone formation occurred in 13.2% of patients, with 19.9% showing resorption. CONCLUSION: SP and CP methods showed similar SSI rates post-craniectomy in TBI and non-TBI patients. SP was associated with reduced hospitalization time, low infection rates, and a moderate need for revision surgery.

Ventriculoperitoneal shunt entry points in patients undergoing shunt placement: A single-center study.

Background: The ventriculoperitoneal (VP) shunt redirects cerebrospinal fluid flow, with the selection of entry points crucial for optimal outcomes. Anatomical landmarks and specific entry points, such as Kocher's, Frazier's, Keen's, and Dandy's points, have been utilized for shunt catheter placement. This study investigates the impact of various entry points on outcomes, particularly the necessity for revision procedures, in patients undergoing VP shunt placement. Methods: In this retrospective cohort study, we analyzed data from patients in our center's database, collected from October 2017 to October 2022. Participants were classified based on ventriculoperitoneal shunt entry points. The study followed STROBE guidelines. Continuous variables were presented as means with standard deviations (SD) and categorical variables as frequencies and percentages. Linear Model ANOVA and Pearson's Chi-squared tests were used for comparisons. Data analysis was conducted using Jamovi software. Results: Our study included 94 patients who underwent shunt procedures. The patients were categorized into four treatment groups: Dandy point (10), Frazier point (21), Keen point (43), and Kocher point (20). Conclusion: Our study found no significant differences in age, FOHR, and indication for shunt placement among catheter entry point subgroups. However, gender distribution, catheter length, and catheter tip location significantly varied. The proportion of patients requiring revision surgery varied among the groups, with the highest rate in the Dandy point group and the lowest in the Keen group; however, the difference among the entry groups was insignificant.

Ticagrelor Versus Clopidogrel in Endovascular Therapy for Cerebral Aneurysms: A Systematic Review and Meta-Analysis.

BACKGROUND: Antiplatelet therapy is pivotal in endovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our study important to cover these gaps. METHODS: We searched 5 databases to collect all relevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI. RESULTS: This comprehensive analysis of 18 studies involving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupture status, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentioned stratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events, hemorrhage, death, and favorable mRS scores, with associated confidence intervals (CIs). Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel. CONCLUSIONS: We found no significant differences in key outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality, and high rates of favorable mRS scores.

Subarachnoid Hemorrhage Caused by Supratentorial Cerebral Cavernous Malformation: A Case Report.

Cavernous malformations (CMs) are acquired vascular abnormalities of the central nervous system that are typically asymptomatic. Clinically symptomatic lesions may present with seizures, intracerebral hemorrhage, or focal neurological deficits. Very rarely, CMs have been described as the cause of subarachnoid hemorrhage. We report a case of a previously healthy 58-year-old man who presented with acute onset of severe headache associated with vomiting. Head computed tomography (CT) scan showed subarachnoid hemorrhage with intraventricular extension. Subsequent CT angiography (CTA) and digital subtraction angiography (DSA) studies showed no evidence of vascular abnormalities. The patient was initially managed conservatively but later required neurosurgical and radiological interventions due to a complicated hospital course and worsening clinical condition. During surgery, an incidental mass was found in the temporal lobe, and subsequent histopathological examination confirmed the diagnosis of cavernoma, which was likely the underlying cause of the subarachnoid hemorrhage. This report highlights the importance of considering CMs in the differential diagnoses of subarachnoid hemorrhage, especially in the absence of informative results from CTA and DSA studies. Timely detection and management of CMs may positively impact the clinical outcome, leading to reduced morbidity and mortality rates.

Incidence, clinical features, and outcomes of posterior circulation ischemic stroke: insights from a large multiethnic stroke database.

Background: Posterior cerebral circulation ischemic stroke (PCS) comprises up to 25% of all strokes. It is characterized by variable presentation, leading to misdiagnosis and morbidity and mortality. We aim to describe PCS in large multiethnic cohorts. Methods: A retrospective review of a large national stroke database from its inception on the 1st of January 2014 till 31 December 2020. Incidence per 100,000 adult population/year, demographics, clinical features, stroke location, and outcomes were retrieved. We divided the cohort into patients from MENA (Middle East and North Africa) and others. Results: In total, 1,571 patients were identified. The incidence of PCS was observed to be rising and ranged from 6.3 to 13.2/100,000 adult population over the study period. Men were 82.4% of the total. The mean age was 54.9 ± 12.7 years (median 54 years, IQR 46, 63). MENA patients comprised 616 (39.2%) while others were 954 (60.7%); of these, the majority (80.5%) were from South Asia. Vascular risk factors were prevalent with 1,230 (78.3%) having hypertension, 970 (61.7%) with diabetes, and 872 (55.5%) having dyslipidemia. Weakness (944, 58.8%), dizziness (801, 50.5%), and slurred speech (584, 36.2%) were the most commonly presenting symptoms. The mean National Institute of Health Stroke Score (NIHSS) score was 3.8 ± 4.6 (median 3, IQR 1, 5). The overall most frequent stroke location was the distal location (568, 36.2%). The non-MENA cohort was younger, less vascularly burdened, and had more frequent proximal stroke location (p < 0.05). Dependency or death at discharge was seen in 39.5% and was associated with increasing age, and proximal and multilocation involvement; while at 90 days it was 27.4% and was associated with age, male sex, and having a MENA nationality (p < 0.05). Conclusion: In a multiethnic cohort of posterior circulation stroke patients from the MENA region and South Asia, we noted a rising incidence over time, high prevalence of vascular risk factors, and poor outcomes in older men from the MENA region. We also uncovered considerable disparities between the MENA and non-MENA groups in stroke location and outcome. These disparities are crucial factors to consider when tailoring individualized patient care plans. Further research is needed to thoroughly investigate the underlying reasons for these variations.

Efficacy and safety of argatroban in the management of acute ischemic stroke: A systematic literature review and meta-analysis.

BACKGROUND: Acute ischemic stroke (AIS) is a leading cause of death and disability. AIS is caused by an embolus or thrombus that restricts blood flow to the brain tissue. Despite intravenous thrombolysis and endovascular thrombectomy, a substantial number of patients do not achieve effective reperfusion. Argatroban, a direct thrombin inhibitor, can potentially improve neurological outcomes in AIS patients. However, there are conflicting results in the medical literature regarding the efficacy and safety of argatroban in this context. OBJECTIVE: This study aims to evaluate the efficacy and safety of argatroban as monotherapy or adjunct therapy for acute ischemic stroke. METHODS: Five major databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched for randomized controlled trials (RCTs) that compared the efficacy and safety of using argatroban alone or in combination with recombinant tissue plasminogen activator (r-TPA) in the management protocol of the AIS. We used Review Manager Software (RevMan 5.4.1) for data analysis. RESULTS: We included 1393 patients from eight RCTs (of them, 726 were treated with argatroban alone or combined with r-TPA, while 667 received the placebo, standard therapy (standard treatments based on current guidelines including antihypertensive, antiplatelet agents, and statins) or endovascular r-TPA). Neither argatroban vs control nor argatroban with r-TPA vs r-TPA showed significant difference regarding the activity in daily living; (SMD= 1.69, 95% CI [-0.23, 3.61]; p = 0.09), (SMD= 0.99, 95% CI [-0.88, 2.86]; p = 0.30), respectively. Also, there was no significant difference in the National Institutes of Health Stroke Scale (NIHSS) score at seven days, the number of patients achieving modified Rankin Scale (mRS) of 0-1 or 0-2 at 90 days (p > 0.05). Argatroban did not significantly increase the risk of adverse events or symptomatic intracranial hemorrhage (ICH), or major systemic bleeding compared to control or r-TPA (p > 0.05) CONCLUSIONS: Argatroban does not demonstrate superior efficacy compared to placebo or standard therapy in terms of ADL, NIHSS and mRS outcomes. Importantly, argatroban does not significantly increase the incidence of adverse events, including symptomatic ICH and systemic bleeding.

General Anesthesia Versus Conscious Sedation for Acute Ischemic Stroke Endovascular Therapy: A Meta Analysis of Randomized Controlled Trials.

BACKGROUND: Endovascular thrombectomy (E.V.T.) is the primary treatment for acute ischemic stroke (AIS). Nevertheless, the optimal choice of anesthetic modality during E.V.T. remains uncertain. This systematic review and meta-analysis aim to summarize existing literature from randomized controlled trials (RCTs) to guide the selection of the most appropriate anesthetic modality for AIS patients undergoing E.V.T. METHODS: By a thorough search strategy, RCTs comparing general anesthesia (G.A.) and conscious sedation (C.S.) in E.V.T. for AIS patients were identified. Eligible studies were independently screened, and relevant data were extracted. The analysis employed pooled risk ratio for dichotomous outcomes and the mean difference for continuous ones. RCTs quality was assessed using the Cochrane Risk of Bias assessment tool 1. RESULTS: In the functional independence outcome (mRS scores 0-2), the pooled analysis did not favor either G.A. or C.S. arms, with an RR of 1.10 [0.95, 1.27] (P = 0.19). Excellent (mRS 0-1) and poor (≥3) recovery outcomes did not significantly differ between G.A. and C.S. groups, with RR values of 1.03 [0.80, 1.33] (P = 0.82) and 0.93 [0.84, 1.03] (P = 0.16), respectively. Successful recanalization significantly favored G.A. over C.S. (RR 1.13 [1.07, 1.20], P > 0.001). CONCLUSIONS: G.A. had superior recanalization rates in AIS patients undergoing endovascular therapy, but functional outcomes, mortality, and NIHSS scores were similar. Secondary outcomes showed no significant differences, except for a higher risk of hypotension with G.A. More trials are required to determine the optimal anesthesia approach for thrombectomy in AIS patients.

The Endoscopic-Assisted Supraorbital Approach for Resection of Anterior Skull Base Meningiomas: A Large Single-Center Retrospective Surgical Study.

Objective The endoscopic-assisted supraorbital approach (eSOA) constitutes a minimally invasive strategy for removing anterior skull base meningiomas (ASBM). We present the largest retrospective single-institution and long-term follow-up study of eSOA for ASBM resection, providing further insight regarding indication, surgical considerations, complications, and outcome. Methods We evaluated data of 176 patients operated on ASBM via the eSOA over 22 years. Results Sixty-five tuberculum sellae (TS), 36 anterior clinoid (AC), 28 olfactory groove (OG), 27 planum sphenoidale, 11 lesser sphenoid wing, seven optic sheath, and two lateral orbitary roof meningiomas were assessed. Median surgery duration was 3.35 ± 1.42 hours, being significantly longer for OG and AC meningiomas ( p <0.05). Complete resection was achieved in 91%. Complications included hyposmia (7.4%), supraorbital hypoesthesia (5.1%), cerebrospinal fluid fistula (5%), orbicularis oculi paresis (2.8%), visual disturbances (2.2%), meningitis (1.7%) and hematoma and wound infection (1.1%). One patient died due to intraoperative carotid injury, other due to pulmonary embolism. Median follow-up was 4.8 years with a tumor recurrence rate of 10.8%. Second surgery was chosen in 12 cases (10 via the previous SOA and two via pterional approach), whereas two patients received radiotherapy and in five patients a wait-and-see strategy was adopted. Conclusion The eSOA represents an effective option for ASBM resection, enabling high complete resection rates and long-term disease control. Neuroendoscopy is fundamental for improving tumor resection while reducing brain and optic nerve retraction. Potential limitations and prolonged surgical duration may arise from the small craniotomy and reduced maneuverability, especially for large or strongly adherent lesions.

Safety and efficacy of tirofiban in the management of stroke: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: About 30 % of stroke patients have experienced unsuccessful reperfusion following endovascular therapy. Mechanical thrombectomy instruments may contribute to this by stimulating platelet aggregation. Tirofiban is a selective and rapidly activated antagonist of the platelets nonpeptide glycoprotein IIb/IIIa receptors that can reversibly suppress platelet aggregation. But, data from the medical literature are conflicting regarding its safety and efficacy for stroke patients. Hence, this study was designed to assess the safety and efficacy of tirofiban in stroke patients. METHODS: Five major databases (PubMed, Scopus, Web of Science, Embase, and Cochrane library) were searched till December 2022. The Cochrane tool was used for risk of bias assessment, and the RevMan 5.4 was utilized for data analysis. RESULTS: Seven RCTs with 2088 stroke patients were included. Tirofiban significantly increased the number of patients with mRS 0 score after 90 days than control; RR= 1.39, 95 %CI [1.15, 1.69]; p = 0.0006. Additionally, it reduced the NIHSS score after seven days; MD= -0.60, 95 %CI [-1.14, -0.06]; p = 0.03. However, tirofiban increased the incidence of intracranial haemorrhage (ICH); RR= 1.22, 95 %CI [1.03, 1.44]; p = 0.02. Other assessed outcomes showed insignificant results. CONCLUSIONS: Tirofiban was associated with a higher mRS 0 score after three months and a lower NIHSS score after seven days. However, it is associated with higher ICH. Multicentric trials are required to provide more convincing proof of its utility.

The clinical aspects of septo-optic dysplasia: A narrative review with illustrative case report.

INTRODUCTION AND IMPORTANCE: Septo-optic dysplasia (SOD) is a rare congenital disorder characterized by abnormal development of the optic nerve, pituitary gland, hypothalamus, and midline brain structures, with heterogeneous presentation among cases. CASE PRESENTATION: We report a seven-month-old male infant presented with persistent vomiting and delayed developmental milestones. He had dysmorphic facial features, bilateral esotropia, a head circumference of 50 cm, and scoliosis. His muscle tone was high (clasp-knife spasticity) and his deep tendon reflexes were brisk in the four limbs. Clinical evaluation and brain MRI confirmed the diagnosis of SOD, for which, he was subjected for multidisciplinary evaluation. Genetic testing revealed an autosomal dominant TUBB gene mutation. On follow-up, at the age of three years, he presented with recurrent focal motor and generalized seizures, which were controlled with levetiracetam. CLINICAL DISCUSSION: The ophthalmic manifestations of SOD include optic nerve hypoplasia, which can lead to visual impairments such as nystagmus, strabismus, and reduced visual acuity. Midline brain anomalies involve structures like the corpus callosum and septum pellucidum, and can result in cognitive and neurological deficits. Hypothalamic-pituitary axis abnormalities can cause endocrine dysfunction and growth abnormalities. The clinical heterogeneity of SOD is attributed to variable phenotypic penetration and genetic mutations. Environmental risk factors may also contribute to the development of the syndrome. CONCLUSION: SOD is a complex disorder with diverse clinical manifestations. Early diagnosis and multidisciplinary management are crucial for optimizing patient outcomes. Further research is needed to understand the underlying genetic and environmental factors involved in SOD and to develop targeted treatments.

A rare case of pituicytoma-related hyperprolactinemia due to mass effect on infundibular stalk-Case report.

INTRODUCTION AND IMPORTANCE: Pituicytomas are extremely rare cancers of the sellar and suprasellar region that appear from the infundibulum or posterior pituitary. World Health Organization in 2007, described pituicytoma as a low-grade tumour (Grade I) in the taxonomy of CNS cancers. The tumour can frequently simulate a pituitary adenoma and is also linked with hormonal disorders. Distinguishing a pituitary adenoma from a pituicytoma can be challenging. We present a rare case report where an elderly female showed high levels of prolactin mainly due to mass effects along with diagnostic, imaging, and immunohistochemical characteristics of pituicytoma. CASE PRESENTATION: A 50-year-old female known case of hypothyroidism, complained of headache associated with dizziness and blurry vision. Her prolactin levels were high which led to the suspicion of pituitary involvement and underwent MRI. The imaging study revealed a well-defined, completely suprasellar, homogenously enhancing mass lesion arising from the left lateral aspect of the pituitary infundibulum. The initial differential diagnosis from the imaging included an ectopic pituitary gland, adenoma, pituicytoma, or hypothalamic glioma. She underwent a right supra-orbital craniotomy for debulking of the pituitary stalk lesion. The histopathological diagnosis was pituicytoma, WHO grade I. CLINICAL DISCUSSION: The clinical manifestations are mostly depended upon the tumour mass and position. They typically present due to mass effects leading to hormonal disorders. The imaging studies are the backbone of the clinical diagnosis along with the histopathological findings. Surgical resection is the preferred treatment for pituicytoma, with an exceptionally low recurrence rate (4.3 %) following complete removal. CONCLUSION: Pituicytomas are slow-growing, benign glial growths. It is challenging to diagnose before surgery as its clinical manifestations and imaging findings look like those of non-functional pituitary adenomas. The effective treatment for pituicytoma is gross total resection by the endoscopic method or transcranial technique.

Variants of the Anterior Subtemporal Approach to the Gasserian Ganglion and Related Structures: An Anatomical Study With Relevant Implications for Keyhole Surgery.

BACKGROUND: The advantages and limitations of different craniotomy positions and approach trajectories to the gasserian ganglion (GG) and related structures using an anterior subtemporal approach have not been studied systematically. Knowledge of these features is of importance when planning keyhole anterior subtemporal (kAST) approaches to the GG to optimize access and minimize risks. METHODS: Eight formalin-fixed heads were used bilaterally to assess temporal lobe retraction (TLR), trigeminal exposure, and relevant anatomical aspects of extra- and transdural classic anterior subtemporal (CLAST) approaches compared with slightly dorsally and ventrally allocated corridors. RESULTS: TLR to the GG and foramen ovale was found to be lower via the CLAST approach (P < 0.001). Using the ventral variant, TLR to access the foramen rotundum was minimized (P < 0.001). The overall TLR was maximal using the dorsal variant (P < 0.001) owing to interposition of the arcuate eminence. An extradural CLAST approach required wide exposure of the greater petrosal nerve (GPN) and middle meningeal artery (MMA) sacrifice. Both maneuvers were spared using a transdural approach. Using CLAST, medial dissection >39 mm can enter the Parkinson triangle, jeopardizing the intracavernous internal carotid artery. The ventral variant enabled access to the anterior portion of the GG and foramen ovale without the need for MMA sacrifice or GPN dissection. CONCLUSIONS: The CLAST approach provides high versatility to approach the trigeminal plexus, minimizing TLR. However, an extradural approach jeopardizes the GPN and requires MMA sacrifice. The risk of cavernous sinus violation exists when progressing medially beyond 4 cm. The ventral variant has some advantages to access the ventral structures and avoid MMA and GPN manipulation. In contrast, the usefulness of the dorsal variant is rather limited owing to the greater TLR required.

Diffusion tensor imaging with tractography in surgical resection of brainstem cavernous malformations: a systematic review and meta-analysis.

Brainstem cavernous malformations are benign subset of cerebral cavernous malformations, which need a special intervention owing to being vital and complex. The diffusion tensor imaging technique, a well-recognized neuroimaging tool, can visualize the white matter tracts and their surroundings and provide promising surgical outcomes. This systematic review and meta-analysis evaluated the effect of preoperative diffusion tensor imaging in patients undergoing surgical resection of brainstem cavernous malformations. Five databases, including PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, were searched using a comprehensive search strategy to find any article matching our inclusion criteria. We used Comprehensive Meta-Analysis (CMA) software to analyze the collected data, get the evidence, and report the results as event rate (ER), with their 95% confidence interval (CI). Twenty-eight studies involving 467 patients matched our criteria and 19 studies entered the analysis. Our analysis showed that, in patients undergoing surgical resection of brainstem cavernous malformations assisted by preoperative diffusion tensor imaging, 82.21% achieved total resection. About 12.4% of patients achieved partial resection, 65.65% improved, 8.07% worsened, 25.04% showed no change, 3.59% experienced postoperative re-bleeding, and 0.87% died. The utilization of preoperative diffusion tensor imaging significantly increased the proportion of improved patients and decreased the proportion of worsened patients. However, further controlled research is needed to draw a definite conclusion about the usefulness of its role.

Comparison of Burr-Hole Craniostomy versus Twist-Drill Craniostomy Operations for Patients with Chronic Subdural Hematoma: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Chronic subdural hematoma (CSDH) represents one of the most common neurologic disorders in the elderly. However, the optimum surgical option remains questionable. This study aims to compare the safety and efficacy of single burr-hole craniostomy (sBHC), double burr-hole craniostomy (dBHC), and twist-drill craniostomy (TDC) in patients with CSDH. METHODS: We searched PubMed, Embase, Scopus, Cochrane, and Web of Science until October 2022 for prospective trials. Primary outcomes comprised recurrence and mortality. The analysis was performed using R software, and the results were reported as risk ratio (RR) and 95% confidence interval (CI). RESULTS: Data from 11 prospective clinical trials were included in this network meta-analysis. We found that dBHC significantly decreased recurrence and reoperation rates compared with TDC (RR = 0.55, CI, 0.33-0.90 and RR = 0.48, CI, 0.24-0.94, respectively). However, sBHC showed no difference compared with dBHC and TDC. There was no significant difference among dBHC, sBHC, and TDC regarding the hospitalization duration, complication rates, mortality, and cured rates. CONCLUSIONS: dBHC seems to be the best modality for CSDH compared with sBHC and TDC. It showed significantly less recurrence and reoperation rates compared with TDC. On the other hand, dBHC showed no significant difference with the other comparators regarding complication, mortality, and cure rates in addition to the hospitalization duration.

Sinonasal Outcome After Endoscopic Transnasal Surgery-A Prospective Rhinological Study.

BACKGROUND: The sinonasal outcome after transnasal skull base surgery has often been neglected aside from major outcome criteria as extent of tumor resection, ophthalmological, and endocrinological parameters. OBJECTIVE: To analyze rhinological outcome after endoscopic transnasal neurosurgery. METHODS: Patients were treated using a middle turbinate-preserving transnasal endoscopic approach for sellar/parasellar lesions. As major variables, olfactory function and nose breathing ability were assessed. The study participants were investigated by odor testing ("Sniffin' sticks"), rhinomanometry, and endoscopic inspection of the nasal cavity before and 6 months after surgery. Furthermore, sinonasal-associated quality of life was measured before, immediately and 6 months after surgery with a standardized questionnaire (SNOT-20-GAV). RESULTS: Eighty-two patients (47 male, 35 female, median age 55 years) matched the inclusion criteria. Before surgery, the average odor was found to be 30.75 (≥31 = normosmia); in the postinterventional examination at 6 months, the average increased to 33.08 (n.s.). Rhinomanometric examination of binostril nasal airflow showed an average of 590.42 mL/s on inspiration before and an increase to 729.78 mL/s at 6 months after surgery. SNOT-20 symptom scores had a maximum score right after and no difference at 6 months after surgery (scores 23.76 and 14.91 vs 15.53 before surgery). CONCLUSION: Based on the study, the endoscopic transnasal technique preserving the middle turbinate has no significant negative effects on the rhinological outcome.

Risk Factors for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: A Tertiary Care Center Experience.

Objectives Cerebral vasospasm in subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. There is a lack of consensus on the risk factors leading to cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this retrospective study, our objective was to determine the association of risk factors for cerebral vasospasm aSAH. Methods A total of 259 charts of aSAH patients consecutively admitted to the surgical intensive care unit of Hamad General Hospital from January 2007 to December 2016 were reviewed and included. The patient's demographic data, including comorbidities like hypertension (HTN), was recorded. Variables of interest included measurements of the neurological deficit on admission, the severity of SAH, treatment modality, and the initial computerized tomography scan of the head for intraventricular hemorrhage, intracerebral hemorrhage, or hydrocephalus. Multivariate analysis and multiple logistic regression analyzed the relationship to identify the association of independent variables. Results Out of the 259 patients, 34% ( n = 87) suffered from cerebral vasospasm. The severity of SAH was associated with the development of cerebral vasospasm ( p < 0.05). The presence of HTN and neurological deficits on admission were associated with an increased risk of cerebral vasospasm ( p < 0.05, p < 0.01, respectively). Hydrocephalus requiring treatment using external ventricular drains decreased the risk of cerebral vasospasm ( p < 0.05). Intraventricular and intracerebral hemorrhage were not associated with cerebral vasospasm ( p = 0.25, p = 0.16). The endovascular treatment of cerebral aneurysms was associated with an increased risk of cerebral vasospasm ( p < 0.05). Conclusion Cerebral vasospasm is common among patients admitted with aSAH. It is significantly associated with the history of HTN, the neurological deficit on admission that corelates more strongly to the motor deficit on admission, the severity of hemorrhage (modified Fischer score), and endovascular treatment. External ventricular drainage was associated with a decrease in cerebral vasospasm. The present study's findings shed light on cerebral vasospasm's risk factors in the country and the region.

Spinal paraganglioma at the conus medullaris mimicking schwannoma: A case report.

BACKGROUND: Paragangliomas of the spine are extremely rare, and they should be considered in the differential diagnosis of spinal tumors due to its overlapping clinical and radiological features with many spinal tumors. CASE REPORT: In this article, we present a 30-year-old lady who presented with low back pain and radicular neuropathic pain at L1 dermatome which was intractable to medical surgery. Her magnetic resonance imaging (MRI) of the lumbosacral spine revealed a T1 isointense, T2 heterogeneously hyperintense intradural extramedullary lesion at the conus medullaris with strong homogenous enhancement on contrast administration. The lesion was surgically excised completely with L1 laminectomy, and the histopathological picture was suggestive of paraganglioma. The patient's complaints resolved fully postoperatively, and there was no evidence of recurrence on long-term follow-up. CONCLUSION: Due to the absence of pathognomonic clinical or radiological features of paragangliomas, they should be taken into consideration in the differential diagnosis of spinal tumors. They share similar clinical and radiological features of schwannomas, ependymomas, and hemangioblastomas. The diagnosis is usually made postoperatively based on histopathological examination.

Convexity Dura-Based Cerebral Cavernous Malformation Mimicking Meningioma: A Case Report and Literature Review.

Cavernous angioma, cavernoma, cavernous hemangioma, also called cerebral cavernous malformation (when present in the brain), are benign vascular malformations, usually intraparenchymal; however, a few reported cases are in the extra-axial location-as middle cranial fossa, near the cavernous sinuses, and in the cerebellopontine angle-and are rarely reported as dura-based convexity lesion resembling meningioma. We report a giant dura-based, convexity, a cerebral cavernous malformation. We wish to notify the case as occurring at a rare location and a large-sized cerebral cavernous malformation. A case of young female presented with a long-standing history of headache. Computed tomography scan and magnetic resonance imagings (MRIs) suggested right occipital dura-based large mass lesion of approximately 5 cm in diameter. The lesion was excised and pathology studies confirmed the diagnosis of a cerebral cavernous malformation. A follow-up MRI confirmed total resection of the lesion and the patient had a smooth postoperative recovery.

Lateral cervical approach for ventrally located upper cervical meningioma: experience of 14 cases with a narrative comparison with other surgical techniques.

BACKGROUND: Upper cervical meningioma represents a large portion of intradural extramedullary tumors that occur in the cervical spinal canal. Most of them are located ventrally or ventrolateral to the spinal cord. Reaching lesions at this location surgically is technically challenging. OBJECTIVES: The ideal approach to ventrally located upper cervical lesions continues to be controversial. The aim of this study was to discuss the advantage of the lateral cervical approach and compare it with other surgical routes. METHODS: This retrospective study was conducted on all cases of ventrally located upper cervical meningiomas (C1-C3) who have been operated on using the lateral cervical approach in a tertiary neurosurgery unit between 2006 and 2020. Demographic, clinical, surgical, and follow-up data were collected from hospital records. RESULTS: During the study period, fourteen patients (Nine females and five males, aged 42-73 years) were recruited. The follow-up period was 2-16 years. The most frequent presenting symptoms were neck pain, occipital headache, motor deficits, and sensory disturbances. Total excision was achieved in all patients. All patients who had preoperative motor deficits improved significantly postoperatively, and those who presented with sensory disturbance had partial recovery. There was neither mortality nor permanent neurological morbidity. CONCLUSION: A lateral cervical approach is a safe approach for ventrally located upper cervical lesions. In our series, it offered enough exposure for a safe dissection and total or extensive subtotal removal of the tumors. Retraction or rotation of the neuroaxis was avoided, and the incidence of complications (injury of neural or vascular structures, instability, infection) was very low.