Surgical Management of Large (≥3 cm) Trigeminal Schwannomas: Functional Outcomes and Approach Selection in Multicompartmental Schwannomas.

Introduction Trigeminal schwannoma surgery has shown a remarkable improvement in functional recovery and tumor resection. In the era of radiosurgery, these outcomes need to be characterized for tumors which are outside the realm of being treated with radiosurgery. We present a series of trigeminal schwannomas larger than 3 cm, surgical approaches used, and outcomes with an emphasis on functional recovery in a high-volume center with radiosurgery facilities. Method All consecutive cases of trigeminal schwannoma from January 2012 to May 2021 which were more than 3 cm in size and underwent microsurgery were included in this series. The surgical approach, neurological outcomes, and extent of resection were defined objectively with pre/postoperative magnetic resonance imaging. Results A total of 83 such cases (>3 cm) were found, with cranial nerve symptoms (5th most common) being the commonest. Twenty three percent cases had blindness due to secondary optic atrophy and eighteen percent had long tract motor symptoms signifying the tumor burden in our series. Radiological gross total excision was achieved in 75.9% cases. Conclusion Large-volume schwannomas present with cranial nerve involvement and may need extensive skull base approaches. Functional outcomes need to be prioritized and can be achieved albeit with lesser gross resection rates. Hearing and facial preservation in addition to relief of trigeminal symptoms should be the goal of resection with minimal additional morbidity.

Predictors of Remission of Acromegaly following Surgical Treatment in Growth Hormone-Secreting Pituitary Adenoma.

Background and Objective Surgery is the treatment of choice for growth hormone (GH)-secreting pituitary adenoma. The remission of random GH depends on various factors. We aimed to evaluate the predictors related to remission of random GH following surgical treatment. Methods We collected the data retrospectively from the chart review from a single unit of neurosurgery. The diagnostic criteria for remission were a random GH < 1 ng/mL or nadir GH < 0.4 ng/mL after an oral glucose tolerance test. Results Data from a total of 110 (females 62 [56.4%]) patients were available for follow-up and were analyzed. The mean age was 36.5 years (14-69 years). Vision impairments were seen in 39 (35.5%) patients. The mean duration of symptoms before surgery was 34 months. The mean volume of the tumor was 7.2 mL (0.44-109.8 mL). Knosp grade 3 and 4 tumors were seen in 41.5% of cases. The mean preoperative random GH level was 68.9 ng/mL. Transsphenoidal surgery was done in 107 (97.3%) cases. The gross total resection could be done in 36 (32.7%) cases. At 3 months, 25 (26%) patients had a biochemical remission. In univariable analysis, lower Knosp grade, preoperative GH level < 40 ng/mL, gross total resection, and male gender were associated with remission at 3 months. In regression analysis, preoperative GH and male gender were related to remission at 3 months. Conclusion The preoperative GH level < 40 ng/mL is associated with higher chances of remission after surgery for GH-secreting pituitary adenoma.

Suprasellar Multiple Neurocysticercal Cyst Presenting with Visual Loss.

Suprasellar cysticercosis is a rare entity. Only a few cases are reported in the literature.1 Clinically, present with visual loss and endocrinopathy and radiologically mimic craniopharyngioma, cystic pituitary adenoma, and Rathke cleft cyst.2 We present the case of a 34-year-old woman with a history of diminution of vision for 2 months. On examination, her visual acuity was 6/9 bilaterally, per the Snellen chart. The visual field showed incomplete temporal hemianopia in the right eye and a severely depressed field in the left eye. She was evaluated with magnetic resonance imaging (MRI) of the brain, which showed multiple well-defined enhancing cystic lesions in the suprasellar cistern splaying the optic chiasm. Enzyme-linked immunoelectrotransfer blot testing was not done due to the lack of availability at our center. She underwent left pterional craniotomy and excision of the cysts. Multiple cysts were noted during surgery, and all were dissected from the surrounding structures. However, there was a spillage of cystic contents during excision, and they are not associated with any adverse reactions, unlike hydatid cysts.3 She recovered well. Histopathology suggestive of cysticercal cyst, no scolexes. As per Infectious Diseases Society of America, non-operated subarachnoid neurocysticercosis requires prolonged antiparasitic agents along with steroids.4 She received 6 weeks of albendazole 15 mg/kg/day and steroids tapered over 3 weeks. At 2 years of follow-up, her visual acuity improved to 6/6 with a normal visual field. Follow-up MRI showed complete removal of all cysts with no relapse. Early surgery is safe and effective. Visual outcome depends on the timing of the diagnosis and prompt intervention.

Role of substance P in cerebral edema and association with an estimated specific gravity of the brain and an outcome prediction in post-traumatic cerebral edema.

Purpose: The study aims to evaluate the role of substance P in cerebral edema and outcomes associated with acute TBI. Method: Patients with acute TBI who presented within 6 h and a CT scan showed predominantly cerebral edema were included in the study. Substance P level was assessed from a serum sample collected within 6 h of trauma. We also evaluated the brain-specific gravity using the Brain View software. Result: A total of 160 (128 male) patients were recruited. The median serum substance P concentration was 167.89 (IQR: 101.09-238.2). Substance P concentration was high in the early hours after trauma (p = 0.001). The median specific gravity of the entire brain was 1.04. Patients with a low Glasgow coma scale (GCS) at admission had a high concentration of the substance P. In the univariate analysis, low GCS, elevated serum concentrations of substance P level, high Rotterdam grade, high cerebral edema grade, a high international normalized ratio value, and high blood sugar levels were associated with poor outcomes at six months. In logistic regression analysis, low GCS at admission, high cerebral edema grade, and elevated blood sugar level were strongly associated with poor outcomes at six months. The area under the receiver operating characteristic curve was 0.884 (0.826-0.941). Conclusion: Serum substance P is strongly associated with the severity of cerebral edema after TBI. However, brain-specific gravity does not directly correlate with posttraumatic cerebral edema severity. Serum substance P does not influence the clinical outcome of traumatic brain injury.

A randomized controlled trial of nurse-led Brief Focused Intervention for patients with alcohol use-related mild traumatic brain injury in the emergency and casualty services of a tertiary hospital.

Objectives: Driving under the influence of alcohol is one of the leading causes of road traffic accidents in India. Individuals with acute injuries often present to emergency hospital services. Carrying out brief interventions in the emergency can prevent further injury and even progression to severe patterns of drinking. However, there are no known studies from India examining the effectiveness of such interventions in emergency settings. Against this background, the objective of this randomized controlled trial was to evaluate the effectiveness of a nurse-led Brief Focused Intervention (BFI) in comparison with the minimal intervention for patients with mild Traumatic Brain Injury (TBI) reporting to the emergency and casualty services of a tertiary hospital in Bengaluru, South India, who screened positive for alcohol use. Materials and Methods: The BFI comprised a video portraying the effects of alcohol on the brain and muscles and brief advice on how to reduce or avoid alcohol use. Subjects (N = 90) were randomly allocated to two groups: BFI (n = 45) or Minimal Intervention Group (MIG) (n = 45). Standardized tools were used to assess both groups on specific outcomes for up to six months following discharge from the emergency and casualty services. At the end of six months, complete data wasavailable for 73 patients. Results: Participants' (N = 73) mean age was 35 years (standard deviation [SD]-11). Over the six-month follow-up, the BFI group reported significantly lesser quantity of alcohol consumption (Alcohol Use Disorder Identification Test [AUDIT] Score - 5.03, SD 4.09, 95% confidence interval [CI] = 3.70, 6.35) compared to MIG (AUDIT Score - 9.76, SD 2.96, 95% CI = 8.73, 10.80), and fewer alcohol use-related problems in BFI group (Mean - 4.18, SD 3.21, 95% CI = 3.14, 5.22) compared to MIG (Mean - 5.88, SD 2.59, 95% CI = 4.98, 6.79). Results of logistic regression showed that being in MIG as well as baseline hazardous use of alcohol were associated with unfavorable outcomes at the end of six months follow-up. Conclusion: Findings provide the first known evidence from India for the effectiveness of nurse-led BFI in the emergency and casualty services in improving post-discharge outcomes for patients with alcohol use-related mild TBI. While the findings of the study are statistically significant, these findings also have significant clinical relevance, as they have shown that the BFI improved clinical outcomes. Thus, brief interventions should be implemented for these patients whenever possible in the Emergency setting.

Post-operative anemia in children undergoing elective neurosurgery: An analysis of incidence, risk factors, and outcomes.

Objectives: Pediatric neurosurgeries carry a considerable risk of intraoperative bleeding and, subsequently, anemia in the post-operative period. Postoperative anemia is often multifactorial with several factors contributing to its occurrence. The present study aims to quantify the incidence of postoperative anemia, identify potential risk factors, and assess the impact of post-operative anemia on clinical outcomes in the pediatric neurosurgery population. Materials and Methods: This was a single-center and retrospective cohort study which included children <18 years of age undergoing elective neurosurgery. The data were extracted from the electronic and physical patient health records. Post-operative anemia was defined for this study as a hemoglobin value below 10 g/dL at any time up to 3 days after surgery. Results: A total of 300 children were recruited during the study period. The incidence of post-operative anemia after elective pediatric neurosurgery was 21.33%. Children in the post-operative anemia group were younger (P = 0.004), had lower pre-operative hemoglobin values (P < 0.001), belonged to higher American Society of Anesthesiologists (ASA) physical status (P = 0.023), underwent predominantly supratentorial (P = 0.041) and non-tumor surgeries (0.004), and received lesser intraoperative blood transfusion (P = 0.010) compared to no post-operative anemia group. The factors that remained predictive of post-operative anemia on multivariate analysis were ASA physical status (P = 0.018, odds ratio [OR] = 1.94, 95% confidence interval [CI] of 1.12-3.36), pre-operative hemoglobin (P < 0.001, OR = 0.64, 95% CI of 0.50-0.82), and intraoperative transfusion (P = 0.028, OR = 0.45, 95% CI of 0.22-0.92). Conclusion: Optimization of modifiable risk factors is essential to reduce the occurrence of post-operative anemia and improve outcomes in pediatric neurosurgical patients.

Incidence, risk factors and impact of anemia after elective neurosurgery: A retrospective cohort study.

Objectives: Anemia after surgery is common and is associated with adverse clinical outcomes. Understanding the incidence and risk factors for postoperative anemia is important to reduce anemia-related complications and blood transfusion. There is lack of data regarding postoperative anemia and its contributing factors in neurosurgery. This study evaluates the incidence and risk factors of postoperative anemia, and its impact on clinical outcomes. Methods: This was a single centre, retrospective study of patients who underwent elective neurosurgery over seven months. Data regarding age, gender, body mass index, American Society of Anesthesiologists (ASA) physical status, diagnosis, surgery, preoperative hemoglobin, surgery duration, intraoperative blood loss and red blood cell (RBC) transfusion, dose of tranexamic acid, intraoperative fluid balance, years of surgeon's experience, postoperative hemoglobin, postoperative RBC transfusion, Glasgow Coma Scale (GCS) score at hospital discharge, and duration of postoperative intensive care unit and hospital stay were collected. Logistic regression was used to identify predictors of postoperative anemia. Results: The incidence of postoperative anemia was 11.3% (116/1025). On univariate analysis; age, preoperative hemoglobin, surgery duration, gender, ASA grade, surgery type, and surgeon's experience were associated with postoperative anemia. Lower preoperative hemoglobin (p<0.001) and non-tumor surgery (p<0.001) were predictive of postoperative anemia on multivariate analysis. Postoperative anemia resulted in increased RBC transfusion (p<0.001) and lower GCS score at discharge (p=0.012). Conclusions: Atleast one in ten patients undergoing elective neurosurgery develop postoperative anemia. Lower preoperative hemoglobin and non-tumor surgery predict anemia. Anemia results in increased RBC transfusion and lower discharge GCS score.

Factors That Predict Recurrence Following Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea.

BACKGROUND: The endoscopic approach has gained popularity in cerebrospinal fluid (CSF) rhinorrhea repair with high success rates, yet recurrence is frequent. We analyzed our cases to determine the outcomes of endoscopic repair of CSF rhinorrhea and the effect of several perioperative factors on the success of repair. METHODS: A retrospective review of 50 patients who underwent endoscopic repair of CSF rhinorrhea between January 2013 and July 2023 was performed, collecting details of presentation, surgery, and postoperative period. RESULTS: The most frequent etiology was nontraumatic CSF rhinorrhea (76%), in which the defect was most commonly located at the left cribriform plate, followed by traumatic CSF rhinorrhea (24%), in which sphenoid defects were most frequent. Traumatic CSF rhinorrhea was more common among male patients and was significantly associated with anosmia. Success rate at first repair attempt was 84%. Persistent CSF rhinorrhea was present in 3 patients (6%), and 5 patients (10%) developed recurrence of CSF rhinorrhea. Overall, 7 patients required reoperation, with 100% success rate after the second surgery. The use of 3-layered repair with fat, fascia lata, and mucosal flap was protective against repair failure, whereas bilateral defects and duration of symptoms >1 year were significantly associated with repair failure. The use of lumbar drain did not demonstrate a difference in repair success rate. CONCLUSIONS: Endoscopic repair of CSF rhinorrhea appears to be safe and effective when performed with accurate localization of the site of the lesion and multilayered repair. Potential predictors of recurrence include bilateral and long-standing defects.

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience.

INTRODUCTION: Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation. METHODS: We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence. RESULTS: A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases. CONCLUSIONS: Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Evaluating CAPO®: A biocompatibility, transparency, and fitment assessment for use with CEREBO® in traumatic intracranial injury detection.

Healthcare-associated infections (HAIs) are a global concern affecting millions of patients, requiring robust infection prevention and control measures. In particular, patients with traumatic brain injury (TBI) are highly susceptible to nosocomial infections, emphasizing the importance of infection control. Non-invasive near infrared spectroscopy (NIRS) device, CEREBO® integrated with a disposable component CAPO® has emerged as a valuable tool for TBI patient triage and this study evaluated the safety and efficacy of this combination. Biocompatibility tests confirmed safety and transparency assessments demonstrated excellent light transmission. Clinical evaluation with 598 enrollments demonstrated high accuracy of CEREBO® in detecting traumatic intracranial hemorrhage. During these evaluations, the cap fitted well and moved smoothly with the probes demonstrating appropriate flexibility. These findings support the efficacy of the CAPO® and CEREBO® combination, potentially improving infection control and enhancing intracranial hemorrhage detection for TBI patient triage. Ultimately, this can lead to better healthcare outcomes and reduced global HAIs.

Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for paediatric hydrocephalus due to primary aqueductal stenosis.

PURPOSE: The purpose of this study was to compare outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in children with symptomatic triventricular hydrocephalus due to primary aqueductal stenosis. METHOD: This is a retrospective analytical study. Patients who underwent either ETV or VPS as the first procedure for hydrocephalus due to primary aqueductal stenosis were included in the study. RESULT: A total of 89 children were included in the study for analysis. The mean age was 8.4 years. Forty-four (49.4%) had their first surgery as ETV and 45 (50.6%) had their first surgery as VPS. Overall, 34 (38.2%) patients required a second surgery (either ETV or VPS) for persistent or recurrent hydrocephalus. The mean follow-up duration was 832.9 days. The overall complication rate was 13.5%. The mean timing of the second surgery after index surgery was 601.35 days. Factors associated with a second surgery were the presence of complications, high protein in cerebrospinal fluid, the relative change of frontal-occipital horn ratio (FOHR) and Evans' index. The survival of the first surgery was superior in ETV (751.55 days) compared to VPS (454.49 days), p = 0.013. The relative change of fronto-occipital horn index ratio (FOIR) was high in the VPS (mean 7.28%) group compared to the ETV (mean 4.40%), p = 0.001 group. CONCLUSION: Overall procedural survival was better after ETV than VPS for hydrocephalus due to aqueductal stenosis. VPS causes more reduction in linear indices of ventricles as compared to ETV, however, is not associated with the success or complication of the procedure.

Pediatric shunt failure: finding predictability in the sea of uncertainty.

OBJECTIVE: Shunt malfunction is a complication that can have devastating implications. In this study, the authors aimed to evaluate the rate of shunt revision in a single institution over 5 years and to determine the factors associated with shunt revision in the pediatric population. METHODS: This retrospective report assimilated data from all patients ≤ 18 years old who underwent shunt surgery between January 2015 and April 2021 at the authors' institute with a minimum of 3 months of follow-up. Patient data regarding demographic characteristics, indications, clinical status, point of entry, operative and CSF findings, revision interval, and cause of failure were collected. RESULTS: Between January 2015 and April 2021, 1112 pediatric patients underwent initial shunt surgery at the authors' institute, among whom 934 patients met the inclusion criteria. Ninety-five patients underwent revision (shunt revision rate 10.2%). The cohort comprised 562 male and 368 female patients (no sex was recorded in 4 cases), with infratentorial tumors (37.8%) being the most common indication for the shunt. Multivariate analyses revealed that younger patient age, right-sided shunt, single surgeon, and shunt placement done in the evening and night were significantly associated with shunt failure. Among all the factors analyzed, female sex had the greatest risk of early shunt failure (OR 2.90 [95% CI 1.09-8.16], p = 0.037). The presence of prior external ventricular drainage was associated with an increased risk of multiple revisions (OR 6.67 [95% CI 1.60-32.52], p = 0.012). The most common cause of failure was obstruction, usually at the cranial end. The most common cause of distal failure was malposition of the abdominal end. CONCLUSIONS: This study identifies various factors associated with shunt failure. Various goal-directed strategies toward modifiable risk factors can significantly improve shunt survival.

Surgical Management of Vision Loss in Cerebral Venous Thrombosis: Case Series from a Tertiary Care Stroke Center.

Background and Purpose: Cerebral venous thrombosis (CVT) presenting as vision loss is uncommon. Raised intracranial tension in CVT is proposed as one of the mechanisms (13.2%). There are still unknown underlying mechanisms to explain vision loss in CVT. The safety and outcome of the surgery (optic nerve sheath fenestration [ONSF] or theco-peritoneal shunt [TPS]) to reduce intracranial hypertension and prevent vision loss has not been studied. Methods: A retrospective case record review of CVT patients with impending vision loss who underwent ONSF/TPS from 2007 to 2019 was performed from the stroke registry. All patients had formal neuro-ophthalmological evaluation and documentation of visual acuity, supplemented by visual field assessments by perimetry in a subset of patients. Safety and outcomes were assessed based on vision improvement and adverse effects after the surgery. Results: Among approximately 1400 patients with CVT admitted in the stroke ward over 12 years, surgery for rescuing vision was done in 18. Among these, the males were 6, and the females were 12. The mean age of presentation was 24 (range 18-52 years). All of them had headaches and progressive blurring of vision with papilledema. The number of patients who underwent TPS was 13, ONSF was 1, and both were 4. In the TPS group (26 eyes), vision improved in 15 eyes (57.7%), remained status-quo in 8 eyes (30.7%), and worsened in 3 eyes (11.5%). Four patients underwent both surgeries; three eyes improved, two remained status quo, and three worsened. One patient underwent ONSF, and his vision remained status quo (no perception of light). Three patients (17.6%) of the TPS group had minor complications (low-pressure headache, subdural hygroma), and five (29.4%) had major complications like subdural hemorrhage, abdominal wound infection, and meningitis. Conclusion and Implications: In patients with CVT, adequate vision monitoring is mandatory. Shunt surgeries (especially TPS) may help in stabilizing/improving vision in CVT patients with impending vision loss, despite adequate anti-edema measures (53.8% improved). Early diagnosis and precise decisions in referring for surgery are crucial.

Transventricular Endoscopic Approach for Cystic Craniopharyngioma: Case Series.

Background and Study Aims The treatment of craniopharyngioma is varied. The treatment ranges from radical excision to direct radiotherapy. As the morbidity of excision is high, more conservative approaches are used. Transventricular endoscopy is a minimally invasive treatment for cystic craniopharyngiomas. The objective of this study is to describe a personal experience with this method of treatment. Material and Methods This is a retrospective review of a series of patients managed with endoscopic catheter and reservoir placement for cystic craniopharyngiomas. Results Twenty-nine patients presented with clinical features of raised intracranial features. Imaging showed a predominantly cystic craniopharyngioma extending into the third ventricle with hydrocephalus. All patients underwent transcortical transventricular endoscopic biopsy, and catheter placement connected to a reservoir. There was no morbidity ascribed to the endoscopic procedure when fenestration and aspiration or fenestration and reservoir were placed. Twelve patients underwent radiotherapy. The median duration of follow-up was 18 months (3-72 months). Eight (27.5%) cases had recurrences. Five (17.2%) could be managed with only reaspiration, two (6.8%) required craniotomy and resection, and one (3.4%) could be managed only with ventriculoperitoneal shunt. Conclusion The neuroendoscopic fenestration, aspiration of cyst, and placement of catheter reservoir followed by radiation is an optional treatment for predominantly cystic craniopharyngiomas arising within or extending into the third ventricle causing hydrocephalus.

Neuroanatomical zones of human traumatic brain injury reveal significant differences in protein profile and protein oxidation: Implications for secondary injury events.

Traumatic brain injury (TBI) causes significant neurological deficits and long-term degenerative changes. Primary injury in TBI entails distinct neuroanatomical zones, i.e., contusion (Ct) and pericontusion (PC). Their dynamic expansion could contribute to unpredictable neurological deterioration in patients. Molecular characterization of these zones compared with away from contusion (AC) zone is invaluable for TBI management. Using proteomics-based approach, we were able to distinguish Ct, PC and AC zones in human TBI brains. Ct was associated with structural changes (blood-brain barrier (BBB) disruption, neuroinflammation, axonal injury, demyelination and ferroptosis), while PC was associated with initial events of secondary injury (glutamate excitotoxicity, glial activation, accumulation of cytoskeleton proteins, oxidative stress, endocytosis) and AC displayed mitochondrial dysfunction that could contribute to secondary injury events and trigger long-term degenerative changes. Phosphoproteome analysis in these zones revealed that certain differentially phosphorylated proteins synergistically contribute to the injury events along with the differentially expressed proteins. Non-synaptic mitochondria (ns-mito) was associated with relatively more differentially expressed proteins (DEPs) compared to synaptosomes (Syn), while the latter displayed increased protein oxidation including tryptophan (Trp) oxidation. Proteomic analysis of immunocaptured complex I (CI) from Syn revealed increased Trp oxidation in Ct > PC > AC (vs. control). Oxidized W272 in the ND1 subunit of CI, revealed local conformational changes in ND1 and the neighboring subunits, as indicated by molecular dynamics simulation (MDS). Taken together, neuroanatomical zones in TBI show distinct protein profile and protein oxidation representing different primary and secondary injury events with potential implications for TBI pathology and neurological status of the patients.

Endovascular Management of a Basilar Artery Pseudoaneurysm After Iatrogenic Injury During Endoscopic Third Ventriculostomy: Case Report.

Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.

Impact of perioperative factors on short-term outcomes after emergency surgery for acute traumatic extradural hematoma - A retrospective cohort study.

BACKGROUND: Preoperative clinical and imaging findings predict neurological outcomes in patients with traumatic brain injury (TBI). Similarly, intraoperative factors such as blood loss and hypotension can also affect outcomes. However, there is not much data regarding the influence of perioperative variables on clinical outcomes in patients with extradural hematoma (EDH). This study aimed to understand the effect of perioperative factors on short-term neurological outcomes in patients operated for acute traumatic EDH. METHODS: After obtaining institutional ethical approval, we collected data retrospectively from records of patients who underwent emergency surgery for acute traumatic EDH over a two-year period. Data regarding age, gender, preoperative Glasgow coma scale (GCS) score, clinical and imaging findings, surgical and anesthetic details, blood loss and transfusion, duration of hospital stay, and GCS score at discharge were collected. Patients with discharge GCS score of 14-15 were considered to have favorable outcome and <14 as unfavorable outcome. Regression analysis was performed to examine the association between predictors and outcomes. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated. RESULTS: Data of 501 patients were analyzed. Outcome was favorable in 343 (68.5 %) and unfavorable in 158 (31.5 %) patients. On multivariate logistic regression analysis (OR, 95 % CI, p value), age (1.03, 1.01-1.05, 0.01), preoperative GCS score (0.68, 0.61-0.76, <0.001), signs of basal skull fracture (1.9, 1.02-3.61, 0.043) and intraoperative blood loss (2.23, 1.2-4.16, 0.01) were independently associated with unfavorable outcome. Pneumonia, neurological deficits, inotrope use and duration of hospital stay was more in this group. CONCLUSIONS: Older age, poor pre-operative GCS score, signs of basal skull fracture, and intraoperative blood loss were associated with lower discharge GCS score, increased neurological deficits and longer hospital stay in patients operated for acute traumatic EDH.