Migration of the anal distal end due to ventriculoperitoneal shunt placement: an atypical case report of a 9-month-old infant with tuberculous meningitis and review of the literature.

BACKGROUND: Ventriculoperitoneal shunt (VPS) represents one of the most classic and widely used treatments for hydrocephalus in pediatric patients. Migration and externalization of the distal end of the catheter through the rectum are extremely rare complications of intestinal perforation with devastating consequences such as meningitis or peritonitis due to enteric bacteria that are significantly life-threatening. Besides, one of the biggest topics with that is that it can happen without producing symptoms, like the patient we present in this case report, which further masks the condition and puts the patient's life more at risk. CASE PRESENTATION: We present a case of a 9-month-old infant patient, with a history of prematurity, tuberculous meningitis (TBM), and hydrocephalus, who came to ED with a functional VPS and the distal end of the catheter protruding outside the rectum for 7 days, without presenting neurological or intestinal symptoms accompanying. One of the parameters that guided the diagnosis and made us suspicious of asymptomatic intestinal perforation (IP) was the background of TMB. The patient was immediately transferred to the OR where both ends of the shunt were removed: in the first instance, the shunt tube was disconnected through the abdomen, thus withdrawing through the anus, and subsequently, the proximal end of the catheter was exteriorized. In turn, the intestinal fistula was successfully repaired laparoscopically, and prophylactic antibiotic treatment was early administered. On the 6th postop day, a shunt was internalized, and a child was discharged on postop day 15 without complications with alarm guidelines. CONCLUSIONS: The authors of this article strongly suggest that (1) anal extrusion of catheters is an uncommon complication but real: for this reason, its development should be considered in all patients with VPS, especially in infants. (2) The patients are often asymptomatic since false tracts can form around the catheter protecting it from spillage, and thus can be removed without complications. (3) Special care should be taken in patients with conditions that increase the risk of developing IP, such as TMB.

Supraorbital keyhole approaches in the first 3 years of practice: outcomes and lessons learned. Patient series.

BACKGROUND: Supraorbital keyhole approaches (SKAs) have garnered criticism for a limited surgical exposure, restrictive surgical freedom, blind spots, and the learning curve. This retrospective study of patients who underwent SKA aims to explore the outcomes, technical nuances, and the learning curve reflected in a single surgeon's experience in the initial 3 years of practice. OBSERVATIONS: A total of 20 SKA operations were performed in 19 patients. Gross- or near-total resection was achieved in 14 of 17 tumor cases. The mean blood loss was 80.5 mL, the mean duration of surgery was 5 hours, and the median stay was 3 days. Endoscopic augmentation was used in 11 cases in which additional tumor removal occurred in 8 of the 11 cases. There were no cases of cerebrospinal fluid leakage or wound infection. A 30-day readmission and typical narcotics after discharge were seen in one patient each. When comparing two halves of a neurosurgery practice over 3 years, the duration of surgery was significantly longer in the later year, which is likely due to operating on a larger tumor size as the years progressed. No cases required static retractors or conversion to larger craniotomies. LESSONS: Careful case selection and respecting the learning curve allows the safe incorporation of SKA in the early stages of neurosurgical practice.

Construction and Validation of a Benchtop Model for Testing of Mechanical Thrombectomy Devices for Pulmonary Embolism.

PURPOSE: This study aims to define the process of designing and manufacturing 3D printed and glass models of the pulmonary artery (PA) and utilizing them in a test bed for evaluation of devices for mechanical thrombectomy of pulmonary embolism (PE). MATERIALS AND METHODS: Patient derived computed tomography angiography (CTA) images of the PA were digitally converted into a hollowed-out structure and translated into clear 3D printed and glass models. A test bed was created using a peristaltic pump and silicone tubing connected to the models. Human clot analogs were then prepared and injected within the models. Thrombectomy testing was done using clinically used predicates and baseline characteristics of the models were evaluated by independent interventionalists. RESULTS: The mean sizes of the main pulmonary artery (MPA) for the 3D printed model and glass model were 30.4 mm and 29.2 mm, mimicking those of the patient's PA obtained on CTA. Heterogeneous human clot analogs were created with fibrin composition ranging from 60 to 30%. Mechanical thrombectomy was successfully attempted by independent interventionalists. Both the 3D printed, and glass model were appraised as very good for multiple attributes. CONCLUSION: A complete test bed using 3D printed and glass models of the PA with human clot analogs was created for testing of mechanical thrombectomy devices for PE.

Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis.

BACKGROUND AND AIM: First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome. METHODS: A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass. RESULTS: Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more. CONCLUSION: Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.

"Tocilizumab-an option for patients with COVID-19 associated cytokine release syndrome: A single center experience", a retrospective study-original article.

BACKGROUND: The first case of Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was diagnosed in Wuhan, China in 2019. In the first half of 2020, this disease has already converted into a global pandemic. This study aimed to find that treatment of patients with COVID-19 pneumonia with Tocilizumab or steroids was associated with better outcomes. Objectives: To analyze the effectiveness of Tocilizumab in moderate to severe Covid-19 patients based on predefined assessment criteria . Study Settings: Single-center, Fatima Memorial Hospital, Lahore. STUDY DESIGN: Quasi-experimental. DURATION OF STUDY: From May 12, 2020 to June 12, 2020. PATIENTS & METHODS SAMPLE SIZE AND TECHNIQUE: Sample size was 93; 33 patients were kept in the experimental group, given Tocilizumab, 8 mg/kg intravenously or 162 mg subcutaneously, and the rest of the 60 patients were given corticosteroids, methylprednisolone 80 mg/day. Consecutive sampling. Failure of therapy was labeled when patients were intubated or died, and the endpoints were failure-free survival which was the primary endpoint, and overall survival secondary at the time of discharge. RESULTS: A total of 93 patients were enrolled, the Tocilizumab (TCZ) group (case) and Corticosteroid (CS) group (Control). The median age was 58 years (IQR-21), 37 (39.8%) patients with diabetes mellitus, 11 (11.8%) in the TCZ group, and 26 (28%) in the CS group. On the whole, the total median hospital stay in days was 7 with IQR (4), a total of 83 (89.2%) patients recovered successfully and discharged, 27 (29%) in the TCZ group and 56 (60.2%) in the CS group. Total 10 (10.8%) patients died, out of which 6 (6.5%) belonged to the TCZ group and 4 (4.3%) belonged to the CS group The median Oxygen requirement with IQR was 8 (9) in both the groups and in total as well, p-value (0.714). CONCLUSIONS: Tocilizumab is a quite effective treatment option for critically sick patients of Covid-19 by reducing their oxygen requirement drastically and so the ICU stay, median hospital stay and so the mortality as well. CLINICALS TRIALS REGISTRATION: UIN # NCT04730323.

Cognitive Impairments After Clipping of Ruptured Anterior Circulation Aneurysms.

BACKGROUND: The cognitive impairments after treatment of ruptured aneurysms have often been underestimated. This study sought to assess their prevalence and analyze various associated factors. METHODS: Patients who were operated on for ruptured anterior circulation aneurysms and discharged with a Glasgow Outcome Scale score of 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual, and overall memory), verbal fluency (phonemic and category fluency), and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS version 21. RESULTS: A total of 87 patients were included in our study. Phonemic fluency was the most affected, noted in 66% of patients. Although 56% had some memory-related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory, respectively. Patients operated on for anterior cerebral artery (ACA) aneurysms had significantly greater impairments in recent (34% vs. 8%) and remote memory (43% vs. 28%) compared with the rest, both in univariate (P = 0.01 and 0.002, respectively) and multivariate analyses (P = 0.01 and 0.03, respectively). ACA-related aneurysms also had significantly greater independent impairments in phonemic fluency (P = 0.04), compared with others. The clinical grade had a significant independent impact only on remote memory (P = 0.01). CONCLUSIONS: Cognitive impairments are frequent after treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater after treatment of ACA-related aneurysms, compared with others, independent of other factors.

The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome.

OBJECTIVE Decompressive craniectomy is an established therapy for refractory intracranial hypertension. Cranioplasty following decompressive craniectomy not only provides protection to the brain along with cosmetic benefits, but also enhances rehabilitation with meaningful functional recovery of potentially reversible cortical and subcortical damaged areas of the affected as well as the contralateral hemisphere. The aim of the study was to assess neurological and cognitive outcome as well as cerebral blood flow after cranioplasty. METHODS Thirty-four patients admitted for replacement cranioplasty after decompressive craniectomy for head injury were studied prospectively. Clinical, neurological, and cognitive outcomes were assessed by the Glasgow Outcome Scale (GOS), the Glasgow Coma Scale, and a battery of cognitive tests, respectively. Simultaneously, cerebral blood perfusion was assessed by technetium-99m ethyl cysteinate dimer (99mTc-ECD) brain SPECT imaging 7 days prior to and 3 months after cranioplasty. RESULTS Prior to cranioplasty 9 patients (26.5%) had GOS scores of 5 and 25 patients (73.5%) had GOS scores of 4, whereas postcranioplasty all 34 patients (100%) improved to GOS scores of 5. Approximately 35.3%-90.9% patients showed cognitive improvement postcranioplasty in various tests. Also, on comparison with brain SPECT, 94% of patients showed improvement in cerebral perfusion in different lobes. CONCLUSIONS Cranioplasty remarkably improves neurological and cognitive outcomes supported by improvement in cerebral blood perfusion.