Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC ...anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques.
Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals 95%CI.
We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% 95%CI:1-3, 8% 95%CI:6-11, 17% 95%CI:12-23 and 2% 95%CI:2-3, respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 95%CI:0.36-2.69, 1.01 95%CI:0.52-1.88 for seizures, 1.66 95%CI:1.35-3.70 for new neurological dysfunction and 2.17 95%CI:1.22-3.85 for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies.
SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.
In recent years, argon has been shown to exert neuroprotective effects in an array of models. However, the mechanisms by which argon exerts its neuroprotective characteristics remain unclear. ...Accumulating evidence imply that argon may exert neuroprotective effects via modulating the activation and polarization of microglia/macrophages after ischemic stroke. In the present study, we analyzed the underlying neuroprotective effects of delayed argon application until 7 days after reperfusion and explored the potential mechanisms.
Twenty-one male Wistar rats underwent transient middle cerebral artery occlusion or sham surgery randomly for 2 h using the endoluminal thread model. Three hours after transient middle cerebral artery occlusion induction and 1 h after reperfusion, animals received either 50% vol Argon/50% vol O
or 50% vol N
/50% vol O
for 1 h. The primary outcome was the 6-point neuroscore from 24 h to d7 after reperfusion. Histological analyses including infarct volume, survival of neurons (NeuN) at the ischemic boundary zone, white matter integrity (Luxol Fast Blue), microglia/macrophage activation (Iba1), and polarization (Iba1/Arginase1 double staining) on d7 were conducted as well. Sample size calculation was performed using nQuery Advisor + nTerim 4.0. Independent t test, one-way ANOVA and repeated measures ANOVA were performed, respectively, for statistical analysis (SPSS 23.0).
The 6-point neuroscore from 24 h to d7 after reperfusion showed that tMCAO Ar group displayed significantly improved neurological performance compared to tMCAO N
group (p = 0.026). The relative numbers of NeuN-positive cells in the ROIs of tMCAO Ar group significantly increased compared to tMCAO N
group (p = 0.010 for cortex and p = 0.011 for subcortex). Argon significantly suppressed the microglia/macrophage activation as revealed by Iba1 staining (p = 0.0076) and promoted the M2 microglia/macrophage polarization as revealed by Iba1/Arginase 1 double staining (p = 0.000095).
Argon administration with a 3 h delay after stroke onset and 1 h after reperfusion significantly alleviated neurological deficit within the first week and preserved the neurons at the ischemic boundary zone 7 days after stroke. Moreover, argon reduced the excessive microglia/macrophage activation and promoted the switch of microglia/macrophage polarization towards the anti-inflammatory M2 phenotype. Studies making efforts to further elucidate the protective mechanisms and to benefit the translational application are of great value.
Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood ...pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO
) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances.
ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO
-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI).
PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35).
PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
Adrenomedullin (ADM) has been identified as a promising biomarker of mortality and outcome in sepsis, heart failure and after major surgery. A recently developed assay specific for bioactive ...adrenomedullin (bio-ADM) has not yet been assessed in aneurysmal subarachnoid hemorrhage (aSAH). The objective of this prospective trial was to assess the time course of bio-ADM after aSAH in relation to the development of delayed cerebral ischemia (DCI) and its association with clinical outcome.
Bio-ADM levels in plasma and cerebrospinal fluid (CSF) were measured during five predefined epochs, for up to 21 days in 30 aSAH patients: early, (day 0 to day 3); acute, (day 4 to day 8); early critical, (day 9 to day 12); late critical, (day 13 to day 15), and late (day 16 to day 21). DCI was diagnosed clinically or based on multimodal monitoring and imaging, and the occurrence of DCI-related cerebral infarction, and outcome after 12 months (extended Glasgow outcome scale), was noted.
Higher median bio-ADM levels in plasma during the acute phase were predictive of long-term unfavorable outcome (AUC = 0.97; 95% CI 0.91 to 1.00; p < 0.001). Early critical bio-ADM levels during DCI were lower in CSF and confirmed DCI occurrence (AUC = 0.80; 95% CI 0.59 to 1.00; p = 0.044).
The dynamics of bio-ADM levels in CSF present a fairly different course compared to plasma with observed higher bio-ADM concentrations in patients spared from DCI and/or developing favorable outcome.
•Adrenomedullin its role as an endogenous vasodilator has become more clear in recent years.•Adrenomedullin has proven to be an effective biomarker in monitoring the severity and the prognosis of a handful of diseases.•Adrenomedullin is detectable in cerebrospinal fluid and its levels differ clearly from plasma concentrations in patients who suffered from aneurysmal subarachnoid hemorrhage.•Patients spared from delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage tended to have higher levels of adrenomedullin in their cerebrospinal fluid.•Initial plasma levels of adrenomedullin reflect the severity of aneurysmal subarachnoid hemorrhage and carry a prognostic value towards long-term clinical outcome.
In a previous study from our group, argon has shown to significantly attenuate brain injury, reduce brain inflammation and enhance M
microglia/macrophage polarization until 7 days after ischemic ...stroke. However, the long-term effects of argon have not been reported thus far. In the present study, we analyzed the underlying neuroprotective effects and potential mechanisms of argon, up to 30 days after ischemic stroke. Argon administration with a 3 h delay after stroke onset and 1 h after reperfusion demonstrated long-term neuroprotective effect by preserving the neurons at the ischemic boundary zone 30 days after stroke. Furthermore, the excessive microglia/macrophage activation in rat brain was reduced by argon treatment 30 days after ischemic insult. However, long-lasting neurological improvement was not detectable. More sensorimotor functional measures, age- and disease-related models, as well as further histological and molecular biological analyses will be needed to extend the understanding of argon's neuroprotective effects and mechanism of action after ischemic stroke.
Cranioplasty is required after decompressive craniectomy (DC) to restore brain protection and cosmetic appearance, as well as to optimize rehabilitation potential from underlying disease. Although ...the procedure is straightforward, complications either caused by bone flap resorption (BFR) or graft infection (GI), contribute to relevant comorbidity and increasing health care cost. Synthetic calvarial implants (allogenic cranioplasty) are not susceptible to resorption and cumulative failure rates (BFR and GI) tend therefore to be lower in comparison with autologous bone. The aim of this review and meta-analysis is to pool existing evidence of infection-related cranioplasty failure in autologous versus allogenic cranioplasty, when bone resorption is removed from the equation.
A systematic literature search in PubMed, EMBASE, and ISI Web of Science medical databases was performed on three time points (2018, 2020 and 2022). All clinical studies published between January 2010 and December 2022, in which autologous and allogenic cranioplasty was performed after DC, were considered for inclusion. Studies including non-DC cranioplasty and cranioplasty in children were excluded. The cranioplasty failure rate based on GI in both autologous and allogenic groups was noted. Data were extracted by means of standardized tables and all included studies were subjected to a risk of bias (RoB) assessment using the Newcastle-Ottawa assessment tool.
A total of 411 articles were identified and screened. After duplicate removal, 106 full-texts were analyzed. Eventually, 14 studies fulfilled the defined inclusion criteria including one randomized controlled trial, one prospective and 12 retrospective cohort studies. All but one study were rated as of poor quality based on the RoB analysis, mainly due to lacking disclosure why which material (autologous vs. allogenic) was chosen and how GI was defined. The infection-related cranioplasty failure rate was 6.9% (125/1808) for autologous and 8.3% (63/761) for allogenic implants resulting in an OR 0.81, 95% CI 0.58 to 1.13 (Z = 1.24; p = 0.22).
In respect to infection-related cranioplasty failure, autologous cranioplasty after decompressive craniectomy does not underperform compared to synthetic implants. This result must be interpreted in light of limitations of existing studies. Risk of graft infection does not seem a valid argument to prefer one implant material over the other. Offering an economically superior, biocompatible and perfect fitting cranioplasty implant, autologous cranioplasty can still have a role as the first option in patients with low risk of developing osteolysis or for whom BFR might not be of major concern.
This systematic review was registered in the international prospective register of systematic reviews. PROSPERO: CRD42018081720.
•Cranioplasty is required after decompressive craniectomy to restore brain protection and cosmetic appearance.•Although cranioplasty is a straightforward procedure, complications are common.•Complications contribute to relevant comorbidity and increasing health care cost.•Autologous cranioplasty after decompressive craniectomy does not underperform compared to synthetic implants.•Risk of graft infection does not seem a valid argument to prefer one implant material over the other.
Introduction
Chronic subdural hematoma (cSDH) is becoming more prevalent due to population aging and the increasing use of antithrombotic drugs. Postoperative seizure in cSDH have a negative effect ...on outcome, and there currently no consensus regarding prophylactic anti-epileptic drug (AED) treatment. The objective of this study was to evaluate predisposing and triggering factors associated with postoperative epileptic seizure in patients with cSDH.
Methods
All patients, who were surgically treated for cSDH in a single tertiary care center between 2015 and 2019, were considered for inclusion. Relevant patient- and hematoma-specific characteristics were retrospectively extracted from hospital records. Paroxysmal events categorized by the treating physician as suspected postoperative seizures were noted. The clinical outcome was extracted from the last available follow-up visit and classified according to the Glasgow outcome scale (GOS).
Results
Of the included 349 patients, 54 (15.5%) developed suspected postoperative epileptic complications in the form of early seizure (≤ 7 days) in 11 patients (3.2%) and late seizure (>7 days) in 43 patients (12.3%). In the logistic regression analysis, solely depressed brain volume (supratentorial volume (ml) not filled with re-expanded brain) was independently associated with postoperative seizure (odds ratio
OR
1.006, 95%
CI
: 1.001–1.011;
p
= 0.034). The occurrence of postoperative seizure (
OR
6.210, 95%
CI
: 2.704–14.258;
p
< 0.001) and preoperative Markwalder grading (
OR
2.919, 95%
CI
: 1.538–5.543;
p
= 0.001) were independently associated with unfavorable (GOS
1−3
) outcome.
Conclusion
Larger postoperative depressed brain volume was the only factor independently associated with suspected postoperative seizure, and it could help identify a subgroup of patients with higher susceptibility to epileptic events. Based on our data, no formal recommendation can be made regarding the prophylactic use of anti-epileptic drugs. Nevertheless, the relative safety of new generation AEDs and the detrimental effect of postoperative seizure on outcome may justify its use in a selected patient population.
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