Hemithyroidectomy, does the indication influence the outcome?

PURPOSE: Hemithyroidectomies are mainly performed for two indications, either therapeutically to relieve compression symptoms or diagnostically for suspicious nodule(s). In case of the latter, one could consider the approach to be rather extensive since the majority of patients have no symptoms and will have benign disease. The aim of this study is to investigate the complication rates of diagnostic hemithyroidectomy and to compare it with the complication rates of compressive symptoms hemithyroidectomy. METHODS: Data from patients who had undergone hemithyroidectomy either for compression symptoms or for excluding malignancy were extracted from a well-established Scandinavian quality register (SQRTPA). The following complications were analyzed: bleedings, wound infections, and paresis of the recurrent laryngeal nerve (RLN). Risk factors for these complications were examined by univariable and multivariable logistic regression. RESULTS: A total of 9677 patients were included, 3871 (40%) underwent surgery to exclude malignancy and 5806 (60%) due to compression symptoms. In the multivariable analysis, the totally excised thyroid weight was an independent risk factor for bleeding. Permanent (6-12 months after the operation) RLN paresis were less common in the excluding malignancy group (p = 0.03). CONCLUSION: A range of factors interfere and contribute to bleeding, wound infections, and RLN paresis after hemithyroidectomy. In this observational study based on a Scandinavian quality register, the indication "excluding malignancy" for hemithyroidectomy is associated with less permanent RLN paresis than the indication "compression symptoms." Thus, patients undergoing diagnostic hemithyroidectomy can be reassured that this procedure is a safe surgical procedure and does not entail an unjustified risk.

Usefulness of Transcranial Motor Evoked Potential in Clipping Surgery for Cerebral Aneurysms-Introduction of a New Protocol for Stable Monitoring.

The usefulness of transcranial motor evoked potentials (Tc-MEPs) in clipping surgery has been reported. However, numerous false positive and false negative cases were reported. We report the usefulness of a new protocol compared with direct cortical MEP (Dc-MEP).Materials were 351 patients who underwent aneurysmal clipping under simultaneous monitoring of Tc- and Dc-MEPs. A total of 337 patients without hemiparesis and 14 with hemiparesis were separately analyzed. Intraoperative changes of Tc-MEP thresholds were examined in the first 50 patients without hemiparesis. The stimulation strength of Tc-MEP was set at +20% of the stimulation threshold. As thresholds changed intraoperatively, thresholds were examined every 10 min and changed stimulation strength.Stimulation thresholds of Tc-MEP were significantly decreased after craniotomy and significantly increased after CSF aspiration. The recording ratios of Tc- and Dc-MEPs were 98.8% and 90.5%, respectively. Out of 304 patients without MEP change, 5 patients developed transient or mild hemiparesis with infarction of the territory of the perforating artery arising from the posterior communicating artery. Out of 31 patients whose MEP transiently disappeared, 3 patients developed transient or mild hemiparesis. The other two patients without MEP recovery manifested persistent hemiparesis. In 14 patients with preoperative hemiparesis, 3 patients whose healthy/affected ratio of Tc-MEP was large developed severe persistent hemiparesis.We clarified the intraoperative changes of Tc-MEP thresholds for the first time. A new protocol of Tc-MEP that followed thresholds and changed stimulation strength to +20% of thresholds is useful for stable monitoring. The usefulness of Tc-MEP is the same as that or better than that of Dc-MEP.

Application of tenotomy on Korean native cattle (Hanwoo) with spastic paresis symptoms in the field.

Bovine spastic paresis (BSP) is a neuromuscular disorder characterized by hypertension and stiffness of hindlimb. Two Korean native cattle (Hanwoo) calves developed BSP or BSP-like symptoms, and a tenotomy of superficial tendon of medial head and deep tendon of lateral head of gastrocnemius muscle was performed for treatment. A cast was applied postoperatively to prevent muscle rupture and was removed three weeks later. The prognosis was evaluated at 3 weeks, 6 and 18 months postoperatively. Neither calf showed any other postoperative sequelae. This is the first case study to report the diagnosis, treatment, and prognosis of BSP in Hanwoo.

The phrenic nerve; the forgotten nerve in head and neck surgery.

BACKGROUND: Neck dissection is a commonly performed procedure for oncologic control of head and neck malignancy. With contemporary modified radical and selective neck dissections, haematoma, wound infection, tissue necrosis, chyle leak and injury involving the marginal mandibular, hypoglossal, vagus or accessory nerves are commonly described complications. Although the phrenic nerve courses within the surgical planes explored during a neck dissection and has a vital function in innervating the diaphragm, few studies have been performed to investigate the exact incidence of post-operative phrenic nerve paresis. This study aims to review the literature as to the rate of phrenic nerve injury following neck dissection. METHODS: A systematic literature review was conducted from 2000 to 2022 including studies reporting on phrenic nerve paresis following neck dissection. RESULTS: In total, 11 studies were included. The reported rate of immediate post-operative phrenic nerve paresis ranged from 0% to 5.3%, with an average rate of 0.613% (12/1959). The reported rate of phrenic nerve paresis at follow-up (1 month-127 months) ranged from 0% to 4.7%, with an average rate of 1.035% (5/483). There were no cases of bilateral phrenic nerve paresis reported in this period. CONCLUSIONS: Phrenic nerve paresis is an uncommon complication following neck dissection, often asymptomatic and potentially underreported. Bilateral phrenic nerve paresis is exceedingly rare. Injury can be avoided by staying superficial to the prevertebral fascia when dissecting around the anterior scalene muscle. Routine phrenic nerve integrity monitoring is not commonly utilized but may aid intra-operative phrenic nerve identification or confirmation of function.

Isolated inferior oblique pareses.

PURPOSE: To describe etiology, clinical characteristics, radiological features and management of isolated inferior oblique pareses. METHODS: A diagnosis of inferior oblique paresis was made after a thorough strabismus examination and neuroimaging. The patients were managed surgically with adjustable strabismus surgery, or conservatively. Surgical success was defined as average horizontal deviation within ≤ 10 prism diopters [PD] post-operatively and for vertical deviation, it was ≤ 5 PD, at last follow-up. RESULTS: Seven cases were congenital, 6 cases were bilateral, with esotropia in 6 cases; 'A' pattern in 7 cases and hypotropia in 3 cases. The mean preoperative horizontal deviation was 52.5 PD, and the mean postoperative horizontal deviation was 2.37 PD (p = 0.028). The pre-operative vertical deviation was 18 PD and post-operative vertical deviation was 5 PD. MRI showed reduced IO muscle size; average area being 11.27 mm2 in the affected eyes, with normal sized inferior recti (average: 24.63 mm2) and medial recti muscles (average: 30.08 mm2). Surgical success was seen in all six cases. Average follow-up was 265 days. The Parks' three step test was not valid, except for one acquired unilateral case. CONCLUSION: Isolated pareses of inferior oblique muscle exhibit defective elevation in adduction of the affected eye, 'A' pattern and fundus intorsion, and is confirmed by neuroimaging. These can be successfully managed surgically to correct the deviation.

Resection of Giant Remote Recurrence of Ependymoma After 41 Years.

Ependymomas are rare primary tumors of the brain and spinal cord that arises from the ependymal cell layer. Cranial ependymomas commonly occur in the posterior fossa; however, approximately 30% of all tumors can be found in the supratentorial region. Supratentorial ependymomas have a shorter progression-free and overall survival than their infratentorial counterparts. We present the case of a 47-year-old man who presented with mild left-sided hemiparesis and confusion secondary to a right-sided 8.5 × 6.0 × 6.0 cm frontotemporal neoplasm encasing the ipsilateral internal and middle cerebral arteries. The patient had undergone a suboccipital craniectomy for resection of a posterior fossa ependymoma at 6 years of age (41 years ago). After multidisciplinary discussion, we performed a right frontotemporal craniotomy for tumor resection (Video) using intraoperative navigation, ultrasound, and intraoperative neurophysiological monitoring. While skeletonizing branches of the middle cerebral artery, an M3 branch was injured inadvertently and repaired immediately. Histopathologic specimens were consistent with ependymoma (World Health Organization grade II). A near-total resection was achieved. The patient developed a transient left-sided hemiparesis but improved to full strength on discharge from the hospital.

The Clinical Utility of Surgical Histopathology in Predicting Seizure Outcomes in Patients with Rasmussen Encephalitis Undergoing Hemispherectomy.

OBJECTIVE: The objectives of this study were to determine the relationship between the severity of pathology and seizure outcomes in patients who underwent hemispherectomy for Rasmussen encephalitis (RE) and to investigate which clinical factors correlated with severity of pathology. METHODS: In this retrospective cohort study, we collected and reviewed pathology and clinical variables. We ascertained seizure outcomes using Engel's classification, and Pardo stages were used to grade pathology. RESULTS: We included 29 unique patients who underwent 34 hemispherectomy procedures for analysis. There was no statistically significant correlation between Pardo stage and seizure outcome (P = 1). Increasing duration of epilepsy (ß = 0.011, P = 0.02) and duration of hemiparesis (ß = 0.024, P = 0.01) were significantly associated with a more severe Pardo stage. In contrast, the presence of epilepsia partialis continua had a negative relationship with Pardo stage (ß = -0.49, P = 0.04). Twenty-six (89.75%) patients were Engel class I at the last follow-up, including all 5 patients who underwent redo hemispherectomy in our cohort. CONCLUSIONS: Consistent with the progressive nature of RE, more severe pathology was associated with a longer duration of epilepsy and longer duration of hemiparesis, while the presence of epilepsia partialis continua was associated with less severe pathology. Results from this series suggest the degree of cortical involvement with RE as assessed on surgical histopathology does not correlate with seizure outcome after hemispherectomy, which appears to be more dependent on surgical technique/complete disconnection.

Preoperative and Postoperative Gait Analysis and Video for Selective Dorsal Rhizotomy in Focal Hemiplegic Spasticity: 2-Dimensional Operative Video.

Selective dorsal rhizotomy (SDR) has been a well-established neurosurgical treatment option for ambulatory children with spastic diplegic cerebral palsy to reduce spasticity. Outcomes for SDR for spastic lower extremity hemiparesis has been less well described. In our experience, hemi-SDR has been an excellent intervention for children with suboptimal spasticity control despite maximizing pharmacologic and chemodenervation treatments. In Video 1, we demonstrate a focal segmental hemi-SDR at the L5-S1 level in a 7-year-old male patient with spastic hemiparesis secondary to a dysembryoplastic neuroepithelial tumor in the right inferior frontoparietal area. Rhizotomy was performed with identification and selective sectioning of dorsal nerve roots with abnormal stimulation patterns as determined by electrophysiology and clinical correlation. Dorsal nerve root fibers with unsustained discharges were spared. Postoperatively, the patient participated well in inpatient and outpatient therapies with significant progress in his mobility and activities of daily living. The patient showed improvement in gait velocity (51%), internal pressure ratio (+0.05), and step length (41% on the left and 27% on the right) 20 months after hemi-SDR. He also demonstrated a step length ratio closer to 1 (0.89) showing a more equal step length bilaterally and improved weight acceptance on the affected side. There were no changes observed on the left upper extremity. This positive outcome on spasticity control and function supports the need for further prospective studies for hemi-SDR as a treatment option for children with spastic hemiparesis.

Application Experience and Patient Feedback Analysis of 3D Printed AFO with Different Materials: A Random Crossover Study.

PURPOSE: This study is aimed at analyzing the application experience and feedback of the patients with poststroke ankle dorsiflexion disorders for 3D printed AFO with three different materials. METHODS: 15 patients were randomly divided into three groups; 3D printed AFO with 3 different materials (PA2200, Somos NeXt, and PA12) was used to each group, according to the crossover study design, in order to ask the three groups of patients to use three different materials of 3D printed AFO. Assessment was taken by the end of each test round. Through statistical processing, the patient feedback data of the three groups of materials of 3D printed AFO were obtained. RESULTS: In the material comfort assessment of the AFO, Somos NeXt was compared with PA2200, and the p value was <0.05; in the item of surface smoothness of the AFO, Somos NeXt was compared with PA2200, and the p value was <0.01; at the same time, PA12 was compared with PA2200, and the p value was <0.05. CONCLUSION: The 3 different materials of 3D printing AFO bring different experience, and we also have sufficient reason to believe that there will be differences in the auxiliary effect of this on patients, which leads the patient's selection too. The material Somos NeXt is much popular and has certain clinical advantages.

Uncrossed corticospinal tracts presenting as transient tumor-related symptomatology.

Ipsilateral corticospinal innervation is rare. No prior cases have described ipsilateral tumor-associated symptoms as the presentation of an uncrossed corticospinal tract. Herein, we describe a case associated with a left frontal tumor, presenting with transient ipsilateral hemiparesis and aphasia. Due to the fluctuating symptomatology, we suspected a cerebrovascular cause and initially performed a workup for stroke. Ipsilateral motor innervation was discovered with intraoperative monitoring during the resection of the tumor, and confirmed with postoperative diffusion tensor imaging (DTI). Neurosurgeons should be aware of uncrossed motor system, and include it in the differential of ipsilateral deficit in patients with intracranial tumors.

Improvement of Hemichorea Following Surgical Resection of a Putaminal Cavernous Angioma: Case Report and Review of Literature.

BACKGROUND: Hemichorea may point to a structural lesion in the contralateral basal ganglia with a large list of possible causes. Cavernous angioma may be rarely a possible cause for acute appearance of this movement disorder. CASE DESCRIPTION: We present a rare case of a 32-year-old female patient with hemichorea caused by a cavernoma (or cavernous angioma) in the contralateral insula and putamen with complete improvement of symptoms with surgical resection of the lesion. CONCLUSIONS: We believe that surgical resection of basal ganglia cavernomas may be feasible with minor risks and resolution of clinical symptoms in the immediate postoperative period.

Parasagittal hemispherotomy in hemispheric polymicrogyria with electrical status epilepticus during slow sleep: Indications, results and follow-up.

PURPOSE: Polymicrogyria (PMG), although the most common brain malformation, represents a low percentage among patients operated on for epilepsy. In cases of hemispheric PMG, electrical status epilepticus during slow sleep (ESESS) may occur leading to an aggravation of the neurological condition and a risk of drug resistance. In such cases, surgical treatment can be offered. METHODS: From a population of 230 children who underwent hemispherotomy for epilepsy, we retrospectively reviewed the patients with unilateral PMG and drug-resistant ESESS focusing on clinical charts, electrophysiological data and post-surgical outcome. RESULTS: Eighteen patients were operated on at a mean age of 7.2 years. The average age was 2 years at seizure onset and 4.4 years at diagnosis of ESESS. All the patients preoperatively had some degree of developmental delay associated with a hemiparesis. During ESESS all of them evidenced a cognitive decline and eight experienced a worsening of the hemiparesis; ESESS was resistant to at least three antiepileptic drugs. The outcome of epilepsy, with a mean follow-up of 12.8 years showed that ESESS disappeared in all patients while 16 of 18 became seizure-free. An improvement of behavior and cognitive condition was observed in all. CONCLUSION: Hemispherotomy can be helpful in patients with drug-resistant ESESS and hemispheric PMG while keeping in mind that more often an accurate medical treatment can be sufficient. The main benefit of surgery is to definitively stop the seizures and to withdraw the medical treatment while keeping in mind the risk of motor aggravation.

Acute cholecystitis in patients with stroke.

BACKGROUND: Although acute cholecystitis after stroke is rare, an immediate diagnosis and treatment is required. MATERIAL AND METHODS: In the past five years, we observed six patients with acute cholecystitis during the initial hospitalization for stroke. RESULTS: Three patients had cardiac embolism, two had subarachnoid hemorrhage, and one had intra-cerebral hemorrhage. Four had calculous cholecystitis and two had acalculous cholecystitis. One of the patients with acalculous cholecystitis had hemorrhagic cholecystitis. The most commonly presented symptom was fever (50%), whereas only one patient (17%) had abdominal pain. Three patients (50%) were completely asymptomatic. CONCLUSIONS: Acute cholecystitis and stroke are closely associated, and anti-thromboembolic drugs may cause hemorrhagic cholecystitis. Stroke patients tend to have atherosclerotic risk factors resulting in ischemic injury of the gallbladder. Furthermore, severe hemiparesis, a fasting state, dehydration, or bacteremia, which are occasionally exhibited by stroke patients, are known risk factors for acalculous cholecystitis. Stroke patients, especially patients with aphasia and consciousness disturbance, require immediate abdominal examination, if acute cholecystitis is suspected.

Antegrade versus retrograde facial nerve dissection in benign parotid surgery: Is there a difference in postoperative outcomes? A meta-analysis.

OBJECTIVE: The primary aim of this meta-analysis was to test the null hypothesis of no difference in facial nerve dysfunction in studies that compared classical antegrade facial nerve dissection (AFND) versus retrograde facial nerve dissection (RFND) during benign parotid surgery. METHODS: A comprehensive search of PubMed, the Cochrane Central Register of Controlled Trials, Scopus, Google Scholar, Science Direct and relevant journals was undertaken up to June 27, 2018. Randomized controlled clinical trials (RCTs), controlled clinical trials (CCTs), and retrospective studies aimed at comparing the effect of AFND vs. RFND during parotidectomy were included. The outcome measures included facial nerve dysfunction, Frey's syndrome, recurrence, silaocele, salivary fistula, operating time length of hospital stay, and estimated blood loss. Pooled risk ratio (RR) and weighted mean differences (MD) with 95% confidence intervals were calculated using either a fixed-effects or random-effects model. RESULTS: Ten studies; four RCTs and five retrospective studies were included. There were 570 patients (319 in RFND group and 251 in AFND group). 481 patients in 9 studies reported the incidence rate of facial nerve dysfunction. No statistical significant difference was observed between both groups concerning the occurrence of transient or permanent facial nerve paralysis (p = 0.44 and 0.11 respectively). One out 10 studies reported the incidence rate of sialocele, however no statistical difference was observed between the two techniques. There was reduction in the operative time (19.30 min), amount of blood loss (25.08 ml) and amount of healthy salivary tissues removed (12.20 mm) in RFND compared with AFND. CONCLUSIONS: According to the results of the current review there is no evidence demonstrating a significant advantage of one approach over another, therefore, well-designed standardized RCTs are required.

Subdural Tension on the Brain in Patients with Chronic Subdural Hematoma Is Related to Hemiparesis but Not to Headache or Recurrence.

BACKGROUND: Hemiparesis is a major symptom of chronic subdural hematoma (CSDH). Its severity does not always correlate with hematoma size. The authors analyzed hematoma thickness, pressure, and tension to clarify the mechanism of hemiparesis in CSDH patients. METHODS: A burr-hole surgery was performed on 124 CSDHs in 102 patients. Hematoma thickness and midline shift were measured by computed tomography, and hematoma pressure was measured in surgery. According to Laplace law, tension was calculated as follows: (half the hematoma thickness × hematoma pressure)/2. Student t test and Pearson correlation coefficient (r) were applied in statistical analysis of findings. RESULTS: Motor weakness was identified in 76.5% of our cases. Tension was strongly related to hemiparesis (r = -0.747, P < 0.01), whereas hematoma thickness (r = -0.458, P < 0.01) and pressure (r = -0.596, P < 0.01) were moderately correlated. Mean age of 14 patients (13.7%) with headache was much younger than those without headache (P < 0.01). Stronger midline shift (P < 0.01) and greater ratio of midline shift to hematoma thickness (P < 0.01) were statistically correlated with headache. Recurrence was recognized in 8 patients (7.8%), and stronger midline shift (P < 0.05) and greater ratio of midline shift to hematoma thickness (P < 0.05) were statistically associated with recurrence. CONCLUSIONS: Tension is the most influencing factor to hemiparesis in CSDH patients. This study also elucidates the mechanism for quick recovery from hemiparesis after surgery in that tension on the motor cortex is decreased immediately by drainage.

Acute Supratentorial Ischemic Stroke with Ipsilateral Hemiparesis: Pathomechanism and Management Challenges.

BACKGROUND: Supratentorial stroke manifesting as ipsilateral hemiparesis is rare. Multiple pathophysiologic mechanisms are possible for this unusual phenomenon and has been previously described. Its implication in therapeutic decision making in a patient with an acute emergent condition has never been discussed. We describe our experience with a patient with this unusual presentation. CASE DESCRIPTION: A 44-year-old woman presented with acute-onset right hemiparesis and left facial weakness. Evaluation with computed tomography angiography showed right M3 segment occlusion. Her National Institutes of Health Stroke Scale score on arrival was 9. Urgent magnetic resonance imaging was performed, which showed ongoing ischemia in the right frontotemporal cortex. She underwent endovascular thrombectomy, and complete revascularization was achieved. Postoperatively, the patient experience complete neurologic recovery. Further diffusion tractography imaging showed near-complete nondecussation of corticospinal fibers. CONCLUSIONS: Discordance between clinical and initial computed tomography angiography findings in a patient with acute ischemic stroke poses a management challenge. Additional imaging to correlate clinical findings in equivocal cases may help in decision making but may significantly delay intervention, and therefore its utility during the short therapeutic window period needs careful consideration. Considering the risks and benefits, timely intervention should be balanced judiciously against appropriate intervention to achieve a positive patient outcome.

Cephalad Migration of Intradural Bullet from Thoracic Spine to Cervical Spine.

BACKGROUND: There are few reported instances of intraspinal migration of a bullet fragment. The majority of these migrations occur caudally, typically below the level of T10. Even fewer cases demonstrate cephalad migration from the sacral spine to the lumbar spine. We report here for the first time a case of a cephalad migration intradurally from the thoracic spine to cervical spine. CASE DESCRIPTION: A 31-year old man presented to the emergency department with a suspected spinal cord injury following a GSW sustained to the left shoulder. A penetrating gunshot injury to the thoracic spine at the level of T2 was observed, and CT angiography revealed a cephalad migration of the bullet fragment to the level of C6. The patient had marked weakness of the bilateral upper extremities, with paraplegia of the lower extremities. There was a sensory deficit beginning at a level 1 cm below the clavicle, as well as a decrease in rectal tone. We performed a laminectomy at C6 with dural incision and removal of the main bullet fragment. Following the surgery, significant improvement in strength and sensation in the bilateral upper extremities was noted, but paraplegia and sensory loss below the level of T2 persisted. CONCLUSIONS: In this report, we review the previously reported cases in which intraspinal migration of bullets have occurred, and discuss the unique finding in this study of cephalad migration of a bullet within the dura. In addition, we detail considerations in the management of such injuries.

The prognostic value of concurrent Horner syndrome in surgical decision making at 3 months in total-type neonatal brachial plexus palsy.

We investigated the prognostic value of concurrent Horner syndrome for predicting spontaneous motor recovery in surgical decision making at 3 months with neonatal brachial plexus palsy. Medical records of 129 neonates with total-type brachial plexus palsy were reviewed, and clinical and follow-up data of patients with or without Horner syndrome were compared. Twenty-seven of 129 newborn babies with total-type palsy (21%) had concurrent Horner syndrome. Poor spontaneous motor recovery was observed in 21 (78%) neonates with concurrent Horner syndrome and in 84 (82%) without concurrent Horner syndrome. Concurrent Horner syndrome in neonates with brachial plexus palsy has no prognostic value in predicting poor spontaneous motor recovery of the brachial plexus in patients with total-type palsy. LEVEL OF EVIDENCE: III.