Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 79
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
World Neurosurg ; 2020 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-32525087

RESUMO

BACKGROUND: Mycobacterium avium complex (MAC) and Achromobacter xylosoxidans (AX) are uncommon sources of neurosurgical infections, particularly in immunocompetent hosts. We report the first published case of intracranial AX abscess and polymicrobial AX-MAC abscess, as well as the fourth MAC abscess in a non-immunocompromised patient. METHODS: This case report was conducted via retrospective chart review. A literature review was completed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Ten years following mucocele resection, a 60-year-old man presented with sinus congestion and headache. Head imaging revealed a left frontal lesion, abutting the cribriform plate and ethmoid roof. The patient had a left frontal craniotomy for abscess drainage. Intraoperative cultures demonstrated polymicrobial growth of AX and MAC, managed with antimicrobial therapy and staged skull base reconstruction. Three cases of MAC abscess and sixteen cases of AX ventriculitis or meningitis have been reported in immunocompetent patients. All MAC cerebral abscesses occurred in adults, one of whom succumbed to the infection. Of the nine AX meningitis cases, four occurred in neonates and two in pediatric patients. Six of the seven AX ventriculitis cases occurred after neurosurgical operations at the same hospital from contaminated chlorhexidine basins. Except for the neonates, AX ventriculitis or meningitis patients had undergone neurosurgery or had a history of cranial trauma. There were no reports of polymicrobial AX-MAC intracranial abscess. CONCLUSIONS: AX and MAC are rare causes of intracranial infection. Patients with these pathogens identified in the CNS require a multidisciplinary approach for successful management.

2.
J Clin Neurosci ; 2020 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-32507710

RESUMO

Spinal solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare mesenchymal malignancy. Radiographically, SFT/HPCs have a mutable appearance, with irregular borders, heterogeneous contrast enhancement, and variable but frequently hypointense T2 signal. We report a series of 5 neurosurgically managed spinal SFT/HPCs treated at our institution, with particular attention to 3 lesions demonstrating marked T2-hypointensity and differential diagnosis for the unusual finding of a "T2 dark" spinal lesion. Retrospective chart review of prospectively maintained surgical database, queried by diagnosis and site codes, 2002-2017. Retrospective radiographic review, with initial screening via keyword search of MR reports for "T2" and "hypointense." Four primary and one metastatic spinal SFT/HPCs were operatively treated during the study period (median follow-up 12 months; range 10-92). Three demonstrated marked T2 hypointensity on preoperative MRI, underwent primary resection-GTR in two, STR in one-and have remained progression-free on routine postoperative surveillance. Two patients with isointense lesions recurred within the follow-up period. Radiographic review identified a host of predominantly rare T2-hypointense lesions, including arteriovenous malformation, disk fragmentations, calcific arachnoiditis, calcifying pseudoneoplasm of the neuraxis, cavernoma, cord hemorrhage/acute blood, desmoid, granulocytic sarcoma, pigmented villonodular synovitis, Edheim-Chester, extramedullary hematopoiesis, IgG4-negative inflammatory pseudotumor, idiopathic hypertrophic pachymeningitis, B-cell lymphoma, primary melanoma neoplasm, melanotic schwannoma, meningioma, opacification of the posterior longitudinal ligament, osteoblastoma, osteochondroma, osteosarcoma, and synovial cyst. T2 hypointensity is associated with SFT/HPC, and may be an indicator relative indolence. "Dark" T2 spinal lesions are rare, with a narrow differential populated predominantly by rare entities.

4.
Spine (Phila Pa 1976) ; 45(13): E808-E812, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32539294

RESUMO

STUDY DESIGN: Review. OBJECTIVE: To provide practicing spine surgeons a primer with key insights for reading, interpreting, and clinically integrating systematic reviews and meta-analyses. SUMMARY OF BACKGROUND DATA: Evidence-based medicine (EBM) refers to a family of standardized techniques for critical appraisal of clinical research. Within the contemporary spine literature, EBM is most commonly encountered in the form of systematic reviews and meta-analyses. Although these analytic techniques are potentially useful when appropriately applied to well-formulated questions with adequate primary data in the literature, the rapid and somewhat indiscriminate increase in volume of systematic reviews and meta-analyses published may be associated with an overall dilution in their quality, as well as misperceptions regarding the applicability of particular EBM studies to spine surgery in general. METHODS: The collective experience of spine specialists with vested interests in advancing EBM and its utility was summarized into a primer. RESULTS: We emphasize components that are pertinent methodologically (search strategy, study number, meta-analysis, bias, and certainty), and pertinent clinically (outcomes) to interpreting, and clinically integrating systematic reviews and meta-analyses into spine surgery practice. CONCLUSIONS: Armed with these insights into these five perspectives, we anticipate that practicing spine surgeons will be better equipped to interpret systematic reviews and meta-analyses in a fashion that will meaningfully impact their patient care. LEVEL OF EVIDENCE: 2.

6.
Neurosurgery ; 2020 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-32267504

RESUMO

BACKGROUND: Stereotactic radiosurgery (SRS) is a safe and effective treatment for acromegaly. OBJECTIVE: To improve understanding of clinical and dosimetric factors predicting biochemical remission. METHODS: A single-institution cohort study of nonsyndromic, radiation-naïve patients with growth hormone-producing pituitary adenomas (GHA) having single-fraction SRS between 1990 and 2017. Exclusions were treatment with pituitary suppressive medications at the time of SRS, or <24 mo of follow-up. The primary outcome was biochemical remission-defined as normalization of insulin-like growth factor-1 index (IGF-1i) off suppression. Biochemical remission was assessed using Cox proportional hazards. Prior studies reporting IGF-1i were assessed via systematic literature review and meta-analysis using random-effect modeling. RESULTS: A total of 102 patients met study criteria. Of these, 46 patients (45%) were female. The median age was 49 yr (interquartile range [IQR] = 37-59), and the median follow-up was 63 mo (IQR = 29-100). The median pre-SRS IGF-1i was 1.66 (IQR = 1.37-3.22). The median margin dose was 25 Gy (IQR = 21-25); the median estimated biologically effective dose (BED) was 169.49 Gy (IQR = 124.95-196.00). Biochemical remission was achieved in 58 patients (57%), whereas 22 patients (22%) had medication-controlled disease. Pre-SRS IGF-1i ≥ 2.25 was the strongest predictor of treatment failure, with an unadjusted hazard ratio (HR) of 0.51 (95% CI = 0.26-0.91, P = .02). Number of isocenters, margin dose, and BED predicted remission on univariate analysis, but after adjusting for sex and baseline IGF-1i, only BED remained significant-and was independently associated with outcome in continuous (HR = 1.01, 95% CI = 1.00-1.01, P = .02) and binary models (HR = 2.27, 95% CI = 1.39-5.22, P = .002). A total of 24 patients (29%) developed new post-SRS hypopituitarism. Pooled HR for biochemical remission given subthreshold IGF-1i was 2.25 (95% CI = 1.33-3.16, P < .0001). CONCLUSION: IGF-1i is a reliable predictor of biochemical remission after SRS. BED appears to predict biochemical outcome more reliably than radiation dose, but confirmatory study is needed.

7.
Neurosurgery ; 2020 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-32348488

RESUMO

BACKGROUND: Central nervous system (CNS) germ cell tumors (GCT) are rare and complex pediatric neoplasms, the optimal management of which remains an area of active investigation. OBJECTIVE: To present an updated cohort study, with particular attention to novel diagnostic methods and posttreatment clinical phenotypes. METHODS: A single-institution cohort study of 80 primary, neurosurgically managed, CNS GCTs was conducted at Mayo Clinic, 1988-2017. RESULTS: Postchemotherapy resection (eg, second-look surgery) was frequently required (27.0%), especially after adjuvant therapies for nongerminomatous GCTs (NGGCTs; 14 of 28 cases, excluding mature teratoma) and significantly associated with pineal lesions, as compared to neurohypophyseal or bifocal lesions (43.6% vs 5.9% vs 6.7%, P = .004), a finding that retained statistical significance after adjusting for index extent of resection and histology (P = .04). Essentially every NGGCT case underwent at least 1 craniotomy, either on presentation, as second-look surgery, or following local recurrence. Mature teratomatous tissue was highly incident in second-look specimens (84.2%), even among lesions initially diagnosed as germinomas. Pretreatment cerebrospinal fluid (CSF) cell fraction analysis demonstrated an association between single lesions and neutrophil predominance, whereas nongerminomatous GCTs were associated with increased monocyte fractions. CONCLUSION: CNS GCTs are clinically heterogeneous lesions, resulting in numerous opportunities for improved understanding and clinical management via novel diagnostic and therapeutic protocols. Samples from second-look surgeries for recurrent germinomas frequently demonstrate teratomatous tissue, suggesting possible underdiagnosis of mixed GCTs-particularly among pineal lesions. GCT subtypes demonstrate differential cell fraction distributions on CSF analysis, a novel and perhaps diagnostically helpful finding that requires validation in external cohorts.

8.
World Neurosurg ; 139: 12-19, 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32251827

RESUMO

BACKGROUND: Ewing-like sarcoma with capicua transcriptional repressor (CIC) rearrangement is a unique class of undifferentiated round cell sarcomas characterized by CIC-double homeobox 4 gene fusion. Despite showing great histologic resemblance to Ewing sarcomas, they have proved to be a distinct pathological entity from the immunohistochemistry and genetic examinations and the response to treatment. We have presented a case of CIC-rearranged Ewing-like sarcoma with cerebral metastasis managed with operative resection and gamma knife radiosurgery. CASE DESCRIPTION: A 56-year-old woman had initially presented with an ulcerating lesion of the right fifth toe. The histological and immunohistochemical analysis revealed features consistent with CIC-rearranged Ewing-like sarcoma, which was confirmed with genetic analysis. Despite aggressive local control and a multidrug chemotherapy regimen, the patient developed multifocal metastases involving the lungs, femur, and cerebrum. The cerebral lesions were managed with surgery and gamma knife radiosurgery, with mixed results. CONCLUSION: CIC-rearranged Ewing-like sarcomas have recently been recognized as a distinct disease entity with a highly aggressive course. Treatment paradigms have yet to be defined to properly manage such an aggressive pathological process.

9.
World Neurosurg ; 2020 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-32339740

RESUMO

BACKGROUND: Departments of neurosurgery in the United States have had a long history of hosting international visitors for the advancement of their neurosurgical education. The goal of the present study was to determine the existence of a geographic profile of international visitors for education purposes, both students and graduates, to the United States through the anecdotal experience of 1 department to explore the reach and worth of hosting such opportunities. METHODS: Administrative records were retrospectively reviewed for international visitors over the preceding 10 years, 2009-2019, were surveyed at 1 institution. Visitors were grouped as either medical students or graduates, visiting for clinical or research purposes. Geographic trends were compared using the Pearson chi-squared test. RESULTS: We identified 128 visitors from 33 countries during the study period. The most common home countries were Italy (10%), China (9%), and India (7%). The cohort involved 62 (48%) students and 66 (52%) graduates, and 59 (46%) and 69 (54%) visited for clinical and research purposes, respectively. The geographic distribution of student versus graduate visitors was statistically significant by region (P < 0.01). However, the geographic distribution of clinical versus research visitors was not statistically different by region (P = 0.62). CONCLUSIONS: There appears to be international appeal worldwide to participate in neurosurgical education in the United States. At our institution, every geographic region was represented in our most recent decade of experience. International visitor profiles appear to be associated with particular geographic patterns depending on their status as either a medical student or graduate.

10.
Neurosurgery ; 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32140720

RESUMO

Systematic reviews and meta-analyses in the neurosurgical literature have surged in popularity over the last decade. It is our concern that, without a renewed effort to critically interpret and appraise these studies as high or low quality, we run the risk of the quality and value of evidence-based medicine in neurosurgery being misinterpreted. Correspondingly, we have outlined 4 major domains to target in interpreting neurosurgical systematic reviews and meta-analyses based on the lessons learned by a collaboration of clinicians and academics summarized as 4 pearls. The domains of (1) heterogeneity, (2) modeling, (3) certainty, and (4) bias in neurosurgical systematic reviews and meta-analyses were identified as aspects in which the authors' approaches have changed over time to improve robustness and transparency. Examples of how and why these pearls were adapted were provided in areas of cranial neuralgia, spine, pediatric, and neuro-oncology to demonstrate how neurosurgical readers and writers may improve their interpretation of these domains. The incorporation of these pearls into practice will empower neurosurgical academics to effectively interpret systematic reviews and meta-analyses, enhancing the quality of our evidence-based medicine literature while maintaining a critical focus on the needs of the individual patients in neurosurgery.

12.
J Neurosurg ; : 1-11, 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-32005022

RESUMO

OBJECTIVE: Central nervous system (CNS) germ cell tumors (GCTs) are rare malignant neoplasms that arise predominantly in adolescents and young adults. CNS GCTs demonstrate characteristic trends in national associations, with implications for both tumor incidence and genetics. Although the incidence of CNS GCTs is markedly higher in East Asia than Western countries, direct comparative analyses between these CNS GCT populations are limited. METHODS: In Japan, to facilitate the genomic analyses of CNS GCTs, the Intracranial Germ Cell Tumor Genome Analysis Consortium was established in 2011, and more than 200 cases of GCTs are available for both tumor tissue and clinical data, which is organized by the National Cancer Center (NCC) Japan. At the Mayo Clinic, there have been 98 cases of intracranial GCTs treated by the Department of Neurologic Surgery since 1988. In this paper, the authors compared the epidemiology, clinical presentation including location and histology, and prognosis between cases treated in the US and Japan. RESULTS: There was no significant difference in age and sex distributions between the databases. However, there was a significant difference in the tumor locations; specifically, the frequency of basal ganglia was higher in the NCC database compared with the Mayo Clinic (8.4% vs 0%, p = 0.008), and bifocal location (neurohypophysis and pineal gland) was higher at the Mayo Clinic than at the NCC (18.8% vs 5.8%, p = 0.002). There was no difference in histological subdivisions between the databases. There was no difference in progression-free survival (PFS) and overall survival (OS) of germinoma cases and OS of nongerminomatous GCT (NGGCT) cases treated with chemotherapy and radiation therapy covering whole ventricles. However, PFS of NGGCTs differed significantly, and was better in the NCC cohorts (p = 0.04). CONCLUSIONS: There appears to be a differential distribution of GCTs by neuroanatomical location between major geographic and national groups. Further study is warranted to better characterize any underlying genomic, epigenetic, or environmental factors that may be driving the phenotypic differences.

13.
World Neurosurg ; 137: e383-e388, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32032791

RESUMO

BACKGROUND: Neurosurgery residency in the United States is highly sought after by many international medical graduates (IMGs), and the geographic distribution of IMG candidates who have successfully matched has not been quantitatively explored to date. The aim of this study was to highlight the countries in which successfully matched IMG residents obtained their medical degrees and the states of their respective residency destinations. METHODS: All available resident lists of approved neurosurgical residency programs within the United States with at least 7 years of history were reviewed for IMGs in the most currently updated rosters. Demographic and geographic characteristics were summarized. RESULTS: A total of 1393 current neurosurgical residents in U.S. residency programs were identified from 99 programs across 39 states. Of 1393 residents, 87 were IMGs (6%). The IMG contingent originated from 39 countries, the most common of which was Lebanon (n = 14/87 [16%]). The Middle East was the most represented geographic region (n = 23/87 [26%]). The states with the highest number of IMGs were Kentucky, New York, and Texas (all n = 7/87 [8%]). CONCLUSIONS: IMGs constitute a small but appreciable portion of current neurosurgical residents in U.S. training programs. Particular countries have contributed more IMGs to neurosurgical programs than others, and particular states have higher counts and proportions of IMG residents than others. These outcomes are not geographically homogeneous, and the mechanisms by which IMG applicants successfully match to U.S. neurosurgery programs require more biographic granularity to elucidate.

14.
J Neurosurg ; : 1-9, 2020 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-32032947

RESUMO

OBJECTIVE: Intracranial germ cell tumors (iGCTs) often arise at the neurohypophysis, their second most common origination, following the pineal region. Neurohypophyseal iGCTs present with stereotypical symptoms, including pituitary dysfunction and visual field deficit, due to their suprasellar location. The goal of this study was to present a large, longitudinal single-institution experience with neurohypophyseal iGCTs to better understand their natural history and identify opportunities for further improvement in treatment outcomes. METHODS: This is a retrospective, single-institution cohort study of neurohypophyseal iGCTs treated between 1988 and 2017, with a focus on the epidemiology, presentation, natural history, and treatment. RESULTS: Thirty-five neurosurgically managed patients met inclusion criteria; the median age was 18 years (3 months to 49 years), and 74% of patients were male (n = 26). Thirty-one tumors were germinomas, and 4 were nongerminomatous iGCTs. Presenting symptoms included pituitary insufficiency in 76% (n = 25), visual deficit in 45% (n = 15), and diabetes insipidus (DI) in 61% (n = 20) of patients. Index symptoms included isolated DI in 10 (36%), isolated hormone deficiency in 14 (50%), and concomitant DI and hormone deficiency symptoms in 4 (14%). Radiographic diagnostic latency was common, occurring at a median of 363 days (range 9-2626 days) after onset of the first symptoms and was significantly associated with both DI and hormone deficiency as the index symptoms (no DI vs DI: 360 vs 1083 days, p = 0.009; no hormone deficiency vs hormone deficiency: 245 vs 953 days, p = 0.004). Biochemical abnormalities were heterogeneous; each pituitary axis was dysfunctional in at least 1 patient, with most patients demonstrating at least 2 abnormalities, and pretreatment dysfunction demonstrating a nonsignificant trend toward association with long-term posttreatment hormone supplementation. Among germinomas, whole-brain or whole-ventricle radiotherapy demonstrated significantly improved progression-free and overall survival compared with local therapy (p = 0.009 and p = 0.004, respectively). CONCLUSIONS: Neurohypophyseal iGCTs are insidious tumors that may pose a diagnostic dilemma, as evidenced by the prolonged latency before radiographic confirmation. Serial imaging and close endocrine follow-up are recommended in patients with a characteristic clinical syndrome and negative imaging, due to the propensity for radiographic latency. Pretreatment biochemical abnormalities may indicate higher risk of posttreatment pituitary insufficiency, and all patients should receive careful endocrine follow-up. Local radiotherapy is prone to treatment failure, while whole-ventricle treatment is associated with improved survival in germinomas.

15.
World Neurosurg ; 136: 172-177, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31958592

RESUMO

BACKGROUND: The College of Surgeons of East, Central, and Southern Africa (COSECSA) is a regional accrediting body for general and specialty surgical training programs that has recently expanded to include neurosurgery. As neurosurgical services expand in sub-Saharan Africa, the structure of training and accreditation has become a vital issue. METHODS: We review the founding and current structures of COSECSA neurosurgical training, identifying accomplishments and challenges facing the expansion of neurosurgical training in this region. RESULTS: The COSECSA model has succeeded in several countries to graduate qualified neurosurgeons, but challenges remain. Programs must balance the long duration of training required to promote surgical excellence against an overwhelming clinical need that seeks immediate solutions. CONCLUSION: Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons and is anticipated to dramatically improve on the markedly unmet need for neurosurgical care in sub-Saharan Africa.


Assuntos
Acreditação , Neurocirurgia/educação , Acreditação/organização & administração , África ao Sul do Saara , Humanos , Cirurgiões/educação
16.
Neurosurgery ; 86(2): 250-256, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30980077

RESUMO

BACKGROUND: Stereotactic radiosurgery (SRS) is a common treatment modality for vestibular schwannoma (VS), with a role in primary and recurrent/progressive algorithms. At our institution, routine magnetic resonance imaging (MRI) is obtained at 6 and 12 mo following SRS for VS. OBJECTIVE: To analyze the safety and financial impact of eliminating the 6-mo post-SRS MRI in asymptomatic VS patients. METHODS: A prospectively maintained SRS database was retrospectively reviewed for VS patients with 1 yr of post-treatment follow-up, 2005 to 2015. Decisions at 6-mo MRI were binarily categorized as routine follow-up vs clinical action-defined as a clinical visit, additional imaging, or an operation as a direct result of the 6-mo study. RESULTS: A total of 296 patients met screening criteria, of whom 53 were excluded for incomplete follow-up and 8 for NF-2. Nine were reimaged prior to 6 mo due to clinical symptoms. Routine 6-mo post-SRS MRI was completed by 226 patients (76% of screened cohort), following from which zero instances of clinical action occurred. When scaled using national insurance database-derived financials-which estimated the mean per-study charge for MRI of the brain with and without contrast at $1767-the potential annualized national charge reduction was approximated as $1 611 504. CONCLUSION: For clinically stable VS, 6-mo post-SRS MRI does not contribute significantly to management. We recommend omitting routine MRI before 12 mo, in patients without new or progressive neurological symptoms. If extrapolated nationally to the more than 100 active SRS centers, thousands of patients would be spared an inconvenient, nonindicated study, and national savings in health care dollars would be on the order of millions annually.

17.
Neurosurg Rev ; 43(2): 801-806, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31187343

RESUMO

Distal anterior cerebral artery (DACA) aneurysms are rare, accounting for 1-9% of all intracranial aneurysms. Previous systematic reviews have highlighted that given the markedly increased incidence of major complications after endovascular treatment, microsurgical clipping is the more attractive treatment option with generally excellent clinical outcomes. Subcallosal DACA aneurysms constitute a rare subset of these aneurysms, requiring special anatomic considerations-particularly with regard to the approach. The aim of this study is to review the technical nuances of microsurgical treatment of subcallosal DACA aneurysms, including review of contemporary techniques through presentation of a microneurosurgical operative video. This is a retrospective case series and intraoperative microsurgical videos review. Three subcallosal DACA aneurysms were identified via retrospective query of our institutional neurosurgical database from December 2017 to May 2018. Two were female; median age was 74 years (range 70-83); all 3 underwent bifrontal craniotomy via bicoronal skin incision for aneurysm clipping. Aneurysms were located in left pericallosal-callosomarginal artery junction, bifurcation of azygos A2, and pericallosal artery related with azygos A2, and the anterior interhemispheric approach was used in all 3 operations. No acute stroke, hemorrhage, or major complications occurred, and all patients remained neurologically intact at the time of last follow-up (median 3 months, range 1-6). Although DACA aneurysms are rare, they represent an important variant for cerebrovascular neurosurgeons where microsurgical clipping can have better angiographic outcomes than endovascular treatment. Detail-oriented anterior interhemispheric arachnoid dissection through bifrontal craniotomy with its lower margin sitting at the superior orbital rim maximizes safe and effective clipping of subcallosal DACA aneurysms.

18.
Neurosurg Rev ; 43(3): 957-966, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31041618

RESUMO

Rathke's cleft cysts (RCCs) are benign growths of the embryological Rathke's pouch. Surgical decompression provides effective symptomatic relief in most cases; however, the effect of gross total resection (GTR) of the cyst wall on recurrence, as well as pituitary function, is unclear. The aim of this meta-analysis was to pool the current literature and ascertain the recurrence control afforded by GTR of the cyst wall compared with subtotal resection (STR). Searches of seven electronic databases from inception to January 2019 were conducted following PRISMA guidelines, resulting in 476 articles to be screened. Outcomes were analyzed using meta-analysis of proportions. A total of 10 retrospective cohort studies satisfied selection criteria, describing 655 surgically managed RCC cases, with 254 (39%) and 401 (61%) achieving GTR and STR of the cyst wall, respectively. GTR was associated with significantly reduced overall RCC recurrence by fixed-effects (FE) modeling (RR, 0.66; 95% CI, 0.45-0.96), but not by random effects (RE) modeling (RR, 0.75; 95% CI, 0.51-1.12). Based on both models, GTR was associated with significantly reduced symptomatic recurrence (RE model, RR, 0.37, 95% CI, 0.14-0.95) and significantly increased postoperative diabetes insipidus (RE model, RR, 2.60; 95% CI, 1.34-5.03). There was insufficient data to evaluate other pituitary axes in this context. The current evidence indicates that GTR of the RCC cyst wall has the potential to affect the incidence of overall and symptomatic RCC recurrences, as well as drive postoperative DI incidence. However, expectations of clinical and pragmatic benefit following cyst wall resection should be titrated carefully against the potential for postoperative and pituitary morbidities which currently remain poorly defined. Greater granularity is required to understand all factors that can influence recurrence and quality of life when evaluating resection of RCC.

19.
Neurosurg Rev ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31845199

RESUMO

Post-traumatic hydrocephalus (PTH) is a potentially morbid sequela of decompressive craniectomy for traumatic brain injury (TBI). Subdural hygromas are commonly identified following decompressive craniectomy, but the clinical relevance and predictive relationship with PTH in this patient cohort is not completely understood. Survey of seven electronic databases from inception to June 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate hazard ratios (HRs) for PTH by the presence of subdural hygroma were extracted and pooled by meta-analysis of proportions with random effects modeling. We systematically identified nine pertinent studies describing outcomes of 1010 TBI patients managed by decompressive craniectomy. Of the overall cohort, there were 211 (21%) females and median age was 37.5 years (range 33-53). On presentation, median Glasgow Coma Scale was 7 (range, 5-8). In sum, PTH was reported in 228/840 (27%) cases, and subdural hygroma was reported in 449/1010 (44%) cases across all studies. Pooling multivariate-derived HRs indicated that subdural hygroma was a significant, independent predictor of PTH (HR, 7.1; 95% CI, 3.3-15.1). The certainty of this association was deemed low due to heterogeneity concerns. The presence of subdural hygroma is associated with increased risk of PTH after decompressive craniectomy among TBI patients based on the current literature and may mandate closer clinical surveillance when detected. Prospective studies, including those of intracranial hydrodynamics following decompressive craniectomy in the setting of TBI, will better validate the certainty of these findings.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA