The number of catastrophic head injuries recorded during the 2011 football season was the highest since data collection began in 1984—the vast majority of these cases were secondary to subdural ...hemorrhage (SDH). The incidence of catastrophic head injury continues to rise: the average yearly incidence from 2008 to 2012 was 238 % that of the average yearly incidence from 1998 to 2002. Greater than 95 % of the football players who suffered catastrophic head injury during this period were age 18 or younger. Currently, the helmet industry utilizes a standard based on data obtained at Wayne State University approximately 50 years ago that seeks to limit
severity index
—a surrogate marker of translational acceleration. In this manuscript, we utilize a focused review of the literature to better characterize the biomechanical factors associated with SDH following collisions in American football and discuss these data in the context of current helmet standard. Review of the literature indicates the rotational acceleration (RA) threshold above which the risk of SDH becomes appreciable is approximately 5,000 rad/s
2
. This value is not infrequently surmounted in typical high school football games. In contrast, translational accelerations (TAs) experienced during even elite-level impacts in football are not of sufficient magnitude to result in SDH. This information raises important questions about the current helmet standard—in which the sole objective is limitation of TA. Further studies will be necessary to better define whether helmet constructs and quality assurance standards designed to limit RA will also help to decrease the risk of catastrophic head injury in American football.
Cerebrospinal fluid rhinorrhea after temporal bone surgery involves drainage from the Eustachian tube (ET) into the nasopharynx, causing significant patient morbidity. Variable anatomy of the ET ...accounts for failures of currently used ET obliteration techniques.
To describe the surgical anatomy of the ET and examine possible techniques for ET closure through middle fossa (MF) and transmastoid approaches.
We described the surgical anatomy of the ET from the MF and transmastoid approaches in 5 adult cadaveric heads, measuring morphometric and surgical anatomy parameters and establishing targets for definite ET obliteration.
The osseous ET measured an average of 19.53 mm (±1.56 mm), with a mean diameter of 2.24 mm (±0.29 mm). The shortest distance between the greater superficial petrosal nerve and the ET junction was 6.61 mm (±0.61 mm). Shortest distances between the ET junction and the foramen spinosum and posterior border of the foramen ovale were 1.09 mm (±0.24 mm) and 2.03 mm (±0.30 mm), respectively. Closure of the cartilaginous ET may be performed by folding it in on itself, securing it by packing, suturing, or surgical clip ligation.
Definite obliteration of the cartilaginous ET appears feasible and the most definite approach to eliminate egress of cerebrospinal fluid to the nasopharynx using the MF approach. This technique may be used as an adjunct to skull base procedures where ET closure is planned.
INTRODUCTION The expanded endonasal approach has provided access and a relatively new visualization of the ventral skull base. Unfortunately, post-operative cerebrospinal fluid leakage has limited ...the use of this approach. Currently, existing methods for closing defects after such approach do not provide reliable results and dura suturing is one of the methodic shows high rate CSF prevention. However, the technique is time-consuming, making it an unfavorable closing procedure among surgeons. METHODS The training model was created using Ultimaker 2+ 3D printer. CT scan from real patient in DICOM format was used for skull modeling. Dura mater was mimicked by fresh chicken skin fixed by screws. Residents and attending were asked to perform suturing using 2D 0° endoscope without fixation and barbed sutures methodic. Participants were asked a series of questions after using the model regarding its usefulness in their endoscopic training and its potential to improve anatomic knowledge. RESULTS 26 participants took part in the research. They were divided in two main groups: Group A included 22 residents and fellows in training and Group B consisted of 2 otolaryngologists and 2 neurosurgeons with 10–20 years of experience. 68% of Group A believed that the model is useful in their endoscopic training while 45% said that the 3D skull model would enhance their dural suturing abilities. 3 experts in group B thought that the model was very similar to the real human anatomy which would enhance anyone's endoscopic surgical ability regardless of their training experience. CONCLUSION Our team thought by replicating a cheap and more readily available Skull model -specially for those in training- without the need to have costly cadaveric dissection laboratories would surely enhance the surgeons microsurgical skills and anatomic knowledge. Dural suturing model could potentially be used to enhance the residents and younger surgeons' endoscopic skills and endonasal suturing. Further replication and modification of the current model would serve better understanding of endoscopic surgery basics and enhance surgical.
Traumatic Brain Injury (TBI) is a significant global health concern, particularly in low- and middle-income countries (LMICs) where access to medical resources is limited. Decompressive craniectomy ...(DHC) is a common procedure to alleviate elevated intracranial pressure (ICP) following TBI, but the cost of subsequent cranioplasty can be prohibitive, especially in resource-constrained settings. We describe challenges encountered during the beta-testing phase of CranialRebuild 1.0, an automated software program tasked with creating patient-specific cranial implants (PSCIs) from CT images. Two pilot clinical teams in the Philippines and Ukraine tested the software, providing feedback on its functionality and challenges encountered. The constructive feedback from the Philippine and Ukrainian teams highlighted challenges related to CT scan parameters, DICOM file arrays, software limitations, and the need for further software improvements. CranialRebuild 1.0 shows promise in addressing the need for affordable PSCIs in LMICs. Challenges and improvement suggestions identified throughout the beta-testing phase will shape the development of CranialRebuild 2.0, with the aim of enhancing its functionality and usability. Further research is needed to validate the software’s efficacy in a clinical setting and assess its cost-effectiveness.
Background/aims
In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant ...may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals.
Methods
We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial.
Results
We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications.
Conclusion
Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.
Abstract Background Trigeminal neurovascular contact (NVC) is hypothesized to be the etiology of classical trigeminal neuralgia (TGN). We aimed to seek a correlation between types of NVCs and the ...presence of TGN as well as early surgical outcome in TGN patients treated with trigeminal microvascular decompression (MVD). Methods We blindly analyzed preoperative high-resolution MRIs with respect to the degree (‘none’, ‘touch’, or ‘compression’) and location of bilateral NVC in 57 retrospectively identified Burchiel Type 1 TGN patients treated by MVD. Location of NVC was noted as either at the root entry zone (REZ) or distal to it. Using a logistic regression model, the degree and location of trigeminal NVC was assessed for correlation with the symptomatic side. Further, the NVC characteristics on the symptomatic side were correlated with early postoperative pain relief. Results While the degree and location of NVC were not statistically correlative independently, a combined interaction analysis of both statistically correlated with the symptomatic side and with early postoperative pain relief. Conclusions We conclude that in TGN patients treated with MVD, MRI identified neurovascular compression at the REZ correlates with the affected side and early post-operative pain relief.
Color-labeling injections of cadaveric heads have revolutionized education and teaching of neurovascular anatomy. Silicone-based and latex-based coloring techniques are currently used, but ...limitations exist because of the viscosity of solutions used.
To describe a novel "triple-injection method" for cadaveric cranial vasculature and perform qualitative and semiquantitative evaluations of colored solution penetration into the vasculature.
After catheter preparation, vessel cannulation, and water irrigation of embalmed cadaveric heads, food coloring, gelatin, and silicone solutions were injected in sequential order into bilateral internal carotid and vertebral arteries (red-colored) and internal jugular veins (blue-colored). In total, 6 triple-injected embalmed cadaveric heads and 4 silicone-based "control" embalmed cadaveric heads were prepared. A qualitative analysis was performed to compare the vessel coloring of 6 triple-injected heads with that of 4 "control" heads. A semiquantitative evaluation was completed to appraise sizes of the smallest color-filled vessels.
Naked-eye and microscope evaluations of embalmed experimental and control cadaveric heads revealed higher intensity and more distal color-labeling following the "triple-injection method" compared with the silicone-based method in both the intracranial and extracranial vasculature. Microscope assessment of 1-mm-thick coronal slices of triple-injected brains demonstrated color-filling of distal vessels with minimum diameters of 119 μm for triple-injected heads and 773 μm for silicone-based injected heads.
Our "triple-injection method" showed superior color-filling of small-sized vessels as compared with the silicone-based injection method, resulting in more distal penetration of smaller caliber vessels.
Access to the anterolateral pontine lesions can be achieved through the peritrigeminal and supratrigeminal safe entry zones using Kawase, retrosigmoid, or translabyrinthine approaches. However, these ...approaches entail shallow extensive dissection, tangential access, and compromise vestibulocochlear function. We aimed to investigate infratentorial presigmoid retrolabyrinthine approach to access pontine lesions through the peritrigeminal zone.
We performed 10 presigmoid retrolabyrinthine suprameatal approach dissections in 5 cadaveric heads. Anatomic-radiological characteristics and variations were evaluated. Six morphometric parameters were measured and analyzed to predict surgical accessibility.
The pontine infratrigeminal area was accessible in all patients. The mean exposed area of the anterolateral pontine surface was 98.95 cm 2 (±38.11 cm 2 ). The mean length of the exposed trigeminal nerve was 7.9 cm (±2.9 cm). Preoperative anatomic-radiological parameters may allow to select patients with favorable anatomy that offers appropriate surgical accessibility to the anterior pontine cavernoma through a presigmoid retrolabyrinthine corridor.
Anterolateral pontine lesions can be accessed through a minimally invasive infratentorial presigmoid retrolabyrinthine approach by targeting the infratrigeminal safe entry zone. Further clinical studies should be conducted to evaluate the viability of this technique for treating these complex pathologies in real clinical settings.
Background Marginal zone B-cell lymphoma of the meninges is a rare pathologic subtype of central nervous system lymphoma that can mimic the radiologic appearance of meningioma. Case Description We ...present a unique case of a 57-year-old man who presented with neurologic symptoms of severe headache, memory loss, mental status changes, and depression. Subsequent magnetic resonance imaging of the brain demonstrated an enhancing mass tracking along the anterior falx and anterior skull base with extension into the ethmoid sinus, which was radiographically consistent with meningioma. However, pathologic examination revealed numerous sheets of plasma cells and plasmacytoid lymphocytes that were immunopositive for CD20. These combined features were indicative of marginal zone B-cell lymphoma. No evidence of systemic disease was found. Conclusions Although rare, marginal zone B-cell lymphoma must be considered in the differential diagnosis of an extra-axial enhancing mass. We review the contemporary literature and discuss preoperative radiologic differentiation of these 2 very different histopathologies.
Infection with SARS-CoV-2 is associated with an increased risk of arterial and venous thrombotic events, but the implications of vaccination for this increased risk are uncertain. With the approval ...of NHS England, we quantified associations between COVID-19 diagnosis and cardiovascular diseases in different vaccination and variant eras using linked electronic health records for ~40% of the English population. We defined a 'pre-vaccination' cohort (18,210,937 people) in the wild-type/Alpha variant eras (January 2020-June 2021), and 'vaccinated' and 'unvaccinated' cohorts (13,572,399 and 3,161,485 people respectively) in the Delta variant era (June-December 2021). We showed that the incidence of each arterial thrombotic, venous thrombotic and other cardiovascular outcomes was substantially elevated during weeks 1-4 after COVID-19, compared with before or without COVID-19, but less markedly elevated in time periods beyond week 4. Hazard ratios were higher after hospitalised than non-hospitalised COVID-19 and higher in the pre-vaccination and unvaccinated cohorts than the vaccinated cohort. COVID-19 vaccination reduces the risk of cardiovascular events after COVID-19 infection. People who had COVID-19 before or without being vaccinated are at higher risk of cardiovascular events for at least two years.
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