Emergency surgery for brainstem cavernoma haemorrhage with severe neurological presentation. Is it indicated and worthwhile?

Background: Brainstem Cavernoma (BSCM) haemorrhage is a complex condition, especially when patients present rapid neurological deterioration. Traditionally, these patients were initially treated by non-interventional means. Surgery was generally reserved for cases who presented a 'benign' evolution in a subacute/delayed fashion. Timing of surgery remains controversial. Since rebleeding is frequent and carries a high mortality, many of these patients do not tolerate this approach. Urgent/emergent surgery may be indicated and lifesaving.Methods: A single center experience is reported in which an aggressive approach was used with urgent/emergency surgery carried out on patients with BSCM haemorrhage and rapid neurological deterioration, ventilatory impairment and/or coma. A review of 5 consecutive cases where urgent/emergent surgery was performed is presented. The pre-operative status, pre- and post-operative examinations, surgical approach and neurological residual deficits/outcomes are reported.Results: Four females and one male with ages ranging from 36 to 66 years with rapid neurological deterioration, ventilatory impairment and/or coma were operated between 2011 and 2018. Favourable outcomes were observed with a modified Rankin Scale varying from 1 to 4. Cranial nerve deficits as well as motor and sensitive deficits were observed but all the patients recovered cognitive integrity.Conclusions: Our small series reveals an acceptable outcome with ultra-early surgery. This approach appears to be a valid option when there is rapid neurological deterioration, respiratory impairment and/or early onset coma. However, further studies are required to elucidate the optimal strategy.

Lobectomy in follicular thyroid neoplasms' treatment.

BACKGROUND: The purpose of this study is to evaluate the suitability of lobectomy with isthmectomy (LwI) in treatment of Follicular Thyroid Neoplasms (FTN), considering malignancy incidence and postoperative complications. METHODS: 192 patients (165 females; 27 males) who underwent LwI for FTN from 01/2005 to 12/2007 were retrospectively evaluated: clinical and pathological features, surgical complications and five year outcome. Inclusion criteria were cytological Bethesda category III and IV or histological follicular adenoma/carcinoma or follicular variant of papillary carcinoma). Metastatic disease or previous thyroidal surgery patients were excluded. RESULTS: Mean age was 48.68 ± 14.93 yrs. Overall malignancy occurred in 88 patients (45.83%) and 80 (41.67%) underwent thyroidectomy completion (TC), mainly by index lesion's malignancy. Forty-one (21.35%) in LwI and 31 (38.75%) in TC specimens had associated malignancy, mainly papillary microcarcinomas. High preoperative Thyroid-Stimulating Hormone (TSH), histological multinodularity and, in cytology category IV, younger age, were significantly associated to malignancy. Permanent recurrent laryngeal nerve lesion occurred in 0.58% in Lwl and 1.52% in TC, and temporary dysphonia occurred in 9.25% and 6.06% (LwI and TC respectively). No LwI patients presented hypoparathyroidism whereas 3.03% in TC had temporary symptoms. In LwI, 36.70% developed hypothyroidism. Higher preoperative TSH was associated with hypothyroidism development. CONCLUSIONS: LwI was inappropriate in 40.10% patients with malignancy who required TC and 23.12% had no functional benefit because post-LwI hypothyroidism. Nodular relapse was reported in at least 23/113 LwI patients (20.35%). We propose total thyroidectomy for patients with FTN preoperative TSH higher than 2.16 mU/L and, in Bethesda category IV, less than 39.5yrs.