Early minimally invasive intracerebral hemorrhage evacuation: a phase 2a feasibility, safety, and promise of surgical efficacy study.

BACKGROUND: Surgical treatment of intracerebral hemorrhage (ICH) is unproven, although meta-analyses suggest that both early conventional surgery with craniotomy and minimally invasive surgery (MIS) may be beneficial. We aimed to demonstrate the safety, feasibility, and promise of efficacy of early MIS for ICH using the Aurora Surgiscope and Evacuator. METHODS: We performed a prospective, single arm, phase IIa Simon's two stage design study at two stroke centers (10 patients with supratentorial ICH volumes ≥20 mL and National Institutes of Health Stroke Scale (NIHSS) score of ≥6, and surgery commencing <12 hours after onset). Positive outcome was defined as ≥50% 24 hour ICH volume reduction, with the safety outcome lack of significant ICH reaccumulation. RESULTS: From December 2019 to July 2020, we enrolled 10 patients at two Australian Comprehensive Stroke Centers, median age 70 years (IQR 65-74), NIHSS score 19 (IQR 19-29), ICH volume 59 mL (IQR 25-77), at a median of 227 min (IQR 175-377) post-onset. MIS was commenced at a median time of 531 min (IQR 437-628) post-onset, had a median duration of 98 min (IQR 77-110), with a median immediate postoperative hematoma evacuation of 70% (IQR 67-80%). A positive outcome was achieved in 5/5 first stage patients and in 4/5 second stage patients. One patient developed significant 24 hour ICH reaccumulation; otherwise, 24 hour stability was observed (median reduction 71% (IQR 61-80), 5/9 patients <15 mL residual). Three patients died, unrelated to surgery. There were no surgical safety concerns. At 6 months, the median modified Rankin Scale score was 4 (IQR 3-6) with 30% achieving a score of 0-3. CONCLUSION: In this study, early ICH MIS using the Aurora Surgiscope and Evacuator appeared to be feasible and safe, warranting further exploration. TRIAL REGISTRATION NUMBER: ACTRN12619001748101.

Locally invasive giant spinal paraganglioma.

Cauda equina paragangliomas are neuroendocrine tumours rarely encountered in neurosurgical practice. Large cauda equina paragangliomas with an intradural and extradural component, dense adhesion to nerve roots and high vascularity are surgically challenging and mandate meticulous operative dissection. The presence of extensive bony erosion can lead to spinal instability requiring solid instrumentation and fixation. We recommend resection of large cauda equina paragangliomas in a staged fashion with the aim of gross total resection and spinal stabilisation.

Rare case of malignant transformation of a solitary spinal osteochondroma into recurrent metastatic chondrosarcoma.

Osteochondroma or osteocartilaginous exostosis is a commonly occurring primary tumor of the bone. Solitary spinal osteochondromas are, however, very rare, seen in only in 1-4% of all known cases and only few symptomatic cases have been reported in the literature so far. Further, while recurrence and malignant transformation are known to occur in osteochondroma, this is rare in the spine. We would like to report one such a case of an unusual presentation of recurrent, metastatic spinal chondrosarcoma in a patient with previous history of solitary cervical osteochondroma.

Outcomes of decompressive craniectomy in patients after traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) can result in cerebral oedema and vascular changes resulting in an increase in intracranial pressure (ICP), which can lead to further secondary damage. Decompressive craniectomy (DC) is a surgical option in the management of ICP. We aimed to investigate outcomes of DC after TBI. DESIGN: We performed a retrospective audit of 57 adult patients (aged > 15 years) who underwent DC after TBI, at the Royal Melbourne Hospital from 1 January 2005 to 30 June 2011. Our functional outcome measure was the Extended Glasgow Outcome Scale (GOSE). RESULTS: Patients had a median age of 30 years (range, 17- 73 years). The hospital mortality rate was 47% (27 patients). A higher postoperative median ICP was the most significant predictor of hospital mortality (OR, 1.1; 95% CI, 1-1.3). There was a mean decrease of 7.7mmHg in ICP between the mean preoperative and postoperative ICP values (95% CI, - 10.5 to - 5.0mmHg). There was a mean decrease of 3.5mmHg in the mean cerebral perfusion pressure (CPP) from preoperative to postoperative CPP values (95% CI, - 6.2 to - 0.8mmHg). At the 6-month follow-up, a poor outcome (GOSE score, 1-4) was seen in 39 patients (68%), while a good outcome (GOSE score, 5- 8) was noted in 15 patients (26%). A high APACHE II score on admission was the most significant predictor of a worse GOSE score at 6 months (OR, 1.3; 95% CI, 1.1-1.5). Analysis of the APACHE II and IMPACT scores as models for predicting mortality at 6 months showed an area under the curve (AUC) of 0.792 and 0.805, respectively, and for predicting poor outcome at 6 months, showed an AUC of 0.862 and 0.883, respectively. CONCLUSION: DC decreased ICP postoperatively. The IMPACT and APACHE II scores are good models for prediction of death and poor outcome at 6 months.

Central nervous system lymphoma associated with natalizumab.

Patients with primary central nervous system lymphoma (PCNSL) after treatment with natalizumab have been considered co-incidental. We report another case of PCNSL in a patient where the explosive onset suggests a causal link.

Clinical presentation and outcome of patients with intradural spinal cord tumours.

We aimed to retrospectively investigate the clinical presentation and outcome of surgical intervention of patients with intradural spinal cord tumours (IDSCT), and to assess the predictors of surgical outcome. A total of 109 patients with IDSCT (57 males and 52 females) (130 admissions; mean age, 45.9 years; range, 14-89 years) underwent surgery between 1 January 1994 and 30 June 2009 at The Royal Melbourne Hospital. Ninety per cent of tumours were classified as low grade. Pain was the most common symptom at presentation (60%) and the mean duration of symptoms was 37.8 weeks (0-4 years). Total resection was achieved in 72.3% of patients with IDSCT. An extramedullary location was the strongest predictor of greater extent of tumour resection (odds ratio [OR]=4.367, 95% confidence interval [CI]=1.876-10.204, p=0.001), whereas a rostral location was also a significant predictor of greater resection (OR=1.393, 95% CI=1.014-1.908, p=0.040). The surgical mortality rate was 0.92%. A good pre-operative clinical grade was the strongest predictor of a positive post-operative neurological status at discharge for IDSCT (OR=7.382, 95% CI=4.575-11.912, p<0.001). The mean follow-up was 37.9 months (16 days-165 months). A good post-operative clinical grade was the most significant predictor of a positive neurological outcome at short-term follow-up (OR=9.953, 95% CI=4.941-20.051, p<0.001), while a good pre-morbid clinical grade was the most significant predictor of a positive outcome at long-term follow-up (OR=9.498, 95% CI=2.780-32.451, p<0.001). We concluded that surgical outcome was influenced by pre-morbid, pre-operative and post-operative clinical grades, the extent of resection, tumour grade and tumour location with respect to the spinal parenchyma. Surgical intervention has a high success rate for tumour control and we recommend total resection where possible.

Extensive spinal epidural abscess as a complication of Crohn's disease.

A spinal epidural abscess is a neurosurgical emergency. Successful treatment frequently requires decompression of the spinal canal in combination with intravenous antibiotics. We report a patient with Crohn's disease who developed an extensive spinal epidural abscess communicating with an intra-abdominal collection.

Early detection of spinal sepsis.

Spinal sepsis (spinal epidural or subdural abscess) is a rare condition, which, if not diagnosed rapidly, can lead to paralysis or death. It is difficult to diagnose in its early stages as the symptoms are as yet non-specific. We aimed to identify predisposing factors and presenting symptoms that might aid in the early diagnosis of spinal sepsis. A case-control study was performed with non-pediatric patients who had been diagnosed with spinal sepsis from 1998 to 2007. Our control group comprised 80 randomly selected patients who had presented to the emergency department with back pain. We identified 72 patients with spinal sepsis. A multivariate analysis revealed that obesity (adjusted odds ratio [aOR] 21.4; 95% confidence interval [CI] 1.8-257.5) and alcoholism (aOR 6.5; 95% CI 1.3-32.8) were important predictive factors for spinal sepsis. To our knowledge, this is the first report that associates obesity and alcoholism with spinal sepsis.

Management and hospital outcome of the severely head injured elderly patient.

INTRODUCTION: Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population. MATERIALS AND METHODS: A retrospective review of all elderly patients (age >64 years) with a Glasgow Coma Scale (GCS) score of 8 or less, and confirmed intracranial pathology or fractured skull, was undertaken over a period of 40 months from July 2001 to September 2005. Data on patient demographics, injury cause, presenting clinical features and interventions were collected. In-hospital mortality was used as the primary outcome. RESULTS: There were 96 patients who met the inclusion criteria. One-third of the patients were managed palliatively, one-third supportively without surgery and another third underwent surgery. Overall mortality was 70.8% (n = 68). Older age and brainstem injuries were identified as independent predictors of mortality. Mortality was reported in all patients aged 85 years or older. CONCLUSIONS: Although overall outcomes were poor, careful consideration should be given to active treatment as favourable outcomes were possible even in the presence of extremely low GCS scores. Prediction of outcome on the basis of age and anatomical diagnoses may help in this decision-making.

Splenic angiosarcoma metastasis to the brain.

Angiosarcoma is a rare primary non-haematolymphoid malignant neoplasm of the spleen. This neoplastic process has a poor prognosis, with disease usually widespread by the time of presentation. In the literature there has been only six case reports of cerebral metastasis from splenic angiosarcomas. We report a 61-year-old woman who presented with a right occipital metastasis of a splenic angiosarcoma, 5 years after initial diagnosis, treated by stereotactic occipital craniotomy and resection of metastasis.

Intradural extramedullary spinal spread of oligoastrocytoma.

Spinal involvement from supratentorial oligoastrocytoma is rare, with only five previous case reports. We report a patient with a past history of a frontal oligoastrocytoma who presented 26 months post-primary resection with posterior fossa disease and spinal extension, in the absence of local recurrence or malignant transformation. The case and relevant literature review are instructive to those following patients with previously treated central nervous system tumours possessing seeding potential.

Acute atlanto-axial post-operative subluxation following posterior C1/2 fusion.

Two cases referred with acute post-operative C1/2 subluxation following posterior fusion are reported. Both cases had initial treatment for atlanto-axial instability with posterior cable (Brooks and interspinous) and graft techniques, and placed immediately in a Philadelphia collar. One case was found to have subluxed immediately post-operatively when failing to breathe following reversal of anaesthetic agents, and despite immediate realignment and reoperation was left with a significant quadriparesis. The other patient was noted to have subluxed on routine X-ray on day 4, and had no neurological deficit before or after reoperation. Risk factors for this dangerous complication are discussed and the techniques of C1/2 posterior fusion and stabilization are reviewed in detail. Surgeons performing atlanto-axial stabilization procedures should be familiar with and have expertize in the complete range of techniques described and choose the one most appropriate for the patient's individual requirements.

Spinal cord ischaemic stroke associated with vertebral body infarction.

Only eight cases of spinal cord ischaemic stroke causing paraplegia with associated vertebral body infarction have been previously described. We describe a ninth case with histopathology confirming the Magnetic Resonance Imaging (MRI) appearance of vertebral body infarction. We have reviewed the literature concerning this condition and discuss its diagnosis and aetiology.