Towards a common language in neurosurgical outcome evaluation: the NEON (NEurosurgical Outcome Network) proposal.

BACKGROUND: The aim of this study was to achieve a consensus on the minimum set of outcome measures and predictors to be used in the neurosurgical practice and on the timing of outcome assessment. METHODS: A consensus building approach was employed. All neurosurgical departments in Lombardy (Italy) were invited to participate by the Carlo Besta Neurologic Institute IRCCS Foundation. Three workshops were organized during which a multidisciplinary group called Neurosurgical Outcome Network (NEON) was created and the methodology to select outcome measures, predictors, and timing of outcome assessment was established. Eight working groups were created for the different neurosurgical diseases (neuro-oncological, skull base, vascular, traumatic, spinal, peripheral nervous system, malformation, functional) and 8 workshops were organized to identify the outcome measures and predictors specific for each of the neurosurgical diseases based on the experts' clinical practice and the existing literature. RESULTS: A total of 20 neurosurgical departments participated in this study. Specific outcome measures, predictors and the timing of outcome assessment were identified for each of the 8 neurosurgical diseases. Moreover, a list of variables common to all pathologies were identified by the NEON group as further data to be collected. CONCLUSIONS: A consensus on the minimum set of outcome measures and predictors and the timing of outcome assessments for 8 neurosurgical diseases was achieved by a group of neurosurgeons of the Lombardy region, called NEON. These sets could be used in future studies for a more homogeneous data collection and as a starting point to reach further agreement also at national and international level.

Posttraumatic Vertebral Arteriovenous Fistula: A Lifeline from Tetraplegia?

BACKGROUND: Vertebral artery (VA) rupture is a rare condition that occurs about in 0.5% of cervical trauma. The management of our case was complicated by a spinal epidural hematoma (SEH) leading to worsening neurologic deficits. Only 1 similar case has been reported before in the literature. CASE DESCRIPTION: We report the case of a 37-year-old victim of a serious car accident. Shortly after admission to the emergency department, she developed weakness in all 4 limbs and sensory deficit below T6 level. Cervical spine computed tomography scan revealed an SEH from C1 to T3. Computed tomography angiography scan showed rupture of the left VA at C3 level, with a posttraumatic vertebral arteriovenous fistula at the same level, draining in the epidural venous plexus and to the right jugular internal vein. Immediately after embolization of the left VA, we performed a cervical decompression from C2 to C7. Three months after surgery the patient had a full recovery. CONCLUSIONS: No guidelines exist to treat this situation. We propose consequential steps to treat a posttraumatic cervical SEH with evidence of VA rupture.

Snake-Eye Myelopathy and Surgical Prognosis: Case Series and Systematic Literature Review.

The prognostic value of "snake-eyes" sign in spinal cord magnetic resonance imaging (MRI) is unclear and the correlation with different pathological conditions has not been completely elucidated. In addition, its influence on surgical outcome has not been investigated in depth. A literature review according to PRISMA (Preferred reporting items for systematic review and meta-analysis protocols) guidelines on the prognostic significance of "snake-eyes" sign in operated patients was performed. Clinical, neuroradiological, and surgical data of three institutional patients, were also retrospectively collected. The three patients, with radiological evidence of "snake-eyes" myelopathy, underwent appropriate surgical treatment for their condition, with no new post-operative neurological deficits and good outcome at follow-up. The literature review, however, reported conflicting results: the presence of "snake-eyes" sign seems a poor prognostic factor in degenerative cervical myelopathy, even if some cases can improve after surgery. "Snake-eyes" myelopathy represents a rare form of myelopathy; pathophysiology is still unclear. The frequency of this myelopathy may be greater than previously thought and according to our literature review it is mostly a negative prognostic factor. However, from our experience, prognosis might not be so dire, especially when tailored surgical intervention is performed; therefore, surgery should always be considered and based on the complete clinical, neurophysiological, and radiological data.

Dorsal paddle leads implant for spinal cord stimulation through laminotomy with midline structures preservation.

BACKGROUND: Pain relief obtained with spinal cord stimulation (SCS) in failed back surgery syndrome (FBSS) has been shown to be more effective with paddle leads than with percutaneous catheters. A laminectomy is generally required to implant the paddles, but the surgical approach may lead to iatrogenic spinal instability in flexion. In contrast, clinical and experimental data showed that a laminotomy performed through flavectomy and minimal resection of inferior and superior lamina with preservation of the midline ligamentous structures allowed to prevent iatrogenic instability. Aim of the study was to assess degree of instability and pain level in patients operated for SCS through laminectomy or laminotomy with midline structures integrity. The surgical technique is described and our preliminary results are discussed. METHODS: Nineteen patients with FBSS underwent SCS, 12 through laminectomy and 7 through uni- or bilateral interlaminotomy with supraspinous ligament preservation. Postoperative local pain was evaluated at 15, 30, and 60 days. Static and dynamic X-rays were performed after 2 months. RESULTS: The techniques allowed implanting the paddle leads in all cases. No intraoperative complications occurred. Local pain was higher and recovery time was longer in patients with laminectomy. We did not observe radiological signs of postoperative iatrogenic vertebral instability. Nevertheless, two patients who underwent laminectomy showed persistence of local pain after 2 months probably due to pathologic compensatory stability provided by the paraspinal musculature. CONCLUSIONS: The laminotomy is a minimally invasive approach that ensures rapid recovery after surgery, spinal functional integrity, and complete reversibility. Further studies are needed to confirm our preliminary results.

Chemokine detection in the cerebral tissue of patients with posttraumatic brain contusions.

OBJECT: The clinical outcome of patients with severe head injuries is still critically dependent on their secondary injuries. Although hypoxia and hypotension appear to mediate a substantial proportion of secondary injuries, many studies associate secondary brain injury with neuroinflammatory responses. Chemokines have been detected in the cerebrospinal fluid but not in the brain tissue of patients with head trauma. This study was performed to determine if chemokines were expressed in pericontusional brain tissue in patients with moderate or severe head trauma who underwent surgical evacuation of their brain contusions. METHODS: Twelve patients with posttraumatic cerebral contusion requiring a surgical evacuation were studied. A 20- to 40-mg sample of white matter was removed from the surgical cavity in the pericontusional area. Two patients undergoing elective surgery for clip ligation of an unruptured aneurysm were used as controls. The median interval from trauma to biopsy procedure was 44 hours (range 3-360 hours). Total RNA was isolated from these samples and a ribonuclease protection assay was performed to measure the mRNA levels of several chemokines: CCL2, CCL3, CCL4, CCL5, CXCL8, CXCL10, and XCL1. RESULTS: The CCL2, a monocyte chemoattractant produced by activated astrocytes, was the most strongly expressed chemokine, followed by CXCL8, CCL3, and CCL4. The chemokines CXCL10 and CCL5 were expressed at very low levels, and XCL1 was not detected. CONCLUSIONS: Chemokine activation occurs early after moderate or severe head trauma and is maintained for several days after trauma. This event may contribute to neuroinflammatory exacerbation of posttraumatic brain damage in the pericontusional brain tissue.

Uncommon presentation of ruptured intracranial aneurysm during surgical evacuation of chronic subdural hematoma: case report.

BACKGROUND: There are many factors that predispose an aneurysm to rupture, but there are few real, demonstrable causes that lead to rupture of the aneurysmal sac with a precise cause-effect mechanism. CASE DESCRIPTION: We report a 74-year-old male patient with chronic subdural hematoma after head trauma, who underwent surgery for evacuation of the hematoma. During surgery, there was sudden copious loss of blood from the drainage tubes that were positioned subdurally. Immediate cerebral computed tomography scan and angiography revealed a subarachnoid hemorrhage at the level of the basal cisterns from a ruptured basilar apex aneurysm. We discuss the cause-effect relationship between the surgery with its positioning of subdural drains and the rupture of a previously unrecognized cerebral aneurysm. CONCLUSIONS: The rupture of an unknown, previous "unruptured" aneurysm after craniotomy with subdural positioning of drainage, must be considered a possible complication.

Linezolid for the treatment of central nervous system infections in neurosurgical patients.

We report our experience with linezolid in the treatment of 5 patients with central nervous system infections subsequent to neurosurgical interventions. In all cases, initial antimicrobial treatment regimens, including a glycopeptide, either failed or were associated with significant adverse events. The good clinical outcome and the absence of significant side-effects associated with linezolid suggest that it may be an attractive alternative for the treatment of central nervous system infections, particularly in settings characterized by a high incidence of multiresistant Gram-positive pathogens.