Purpose
This study aimed to establish the incidence of CSF leakage in children and associated complications after intradural spinal surgery in three tertiary neurosurgical referral centers and to ...describe the treatment strategies applied.
Methods
Patients of 18 years or younger who underwent intradural spinal surgery between 2015 and 2021 in three tertiary neurosurgical referral centers were included. Patients who died or were lost to follow-up within six weeks after surgery were excluded. The primary outcome measure was CSF leakage within six weeks after surgery, defined as leakage of CSF through the skin. Secondary outcome measures included the presence of pseudomeningocele (PMC), meningitis, and surgical site infection (SSI).
Results
We included a total of 75 procedures, representing 66 individual patients. The median age in this cohort was 5 (IQR = 0-13 years. CSF leakage occurred in 2.7% (2/75) of procedures. It occurred on days 3 and 21 after the index procedure, respectively. One patient was treated with a pressure bandage and an external lumbar drain on day 4 after diagnosis of the leak, and the other was treated with wound revision surgery on day 1 after the leak occurred. In total, 1 patient developed a PMC without a CSF leak which was treated with wound revision surgery. SSI occurred in 10.7%, which included both cases of CSF leak.
Conclusions
CSF leakage after intradural spinal surgery in the pediatric population is relatively rare (2.7%). Nevertheless, the clinical consequences with respect to secondary complications such as infection and the necessity for invasive treatment are serious.
Object
The proximal (anterior) transsylvian approach through a pterional craniotomy was developed by the senior author (M.G.Y.) in 1967 for the microsurgical treatment of saccular aneurysms of the ...circle of Willis, frontoorbital and temporobasal arteriovenous malformations, cavernomas, and extrinsic and intrinsic tumors. The acquired positive surgical experiences on this large series enabled the senior author, in 1973, to apply this approach for the selective amygdalohippocampectomy in patients with intractable mesial temporal lobe epilepsy.
Methods
The proximal (anterior) transsylvian-transamygdala approach to the mesial temporal structures permits the selective two-thirds resection of the amygdala and hippocampus-parahippocampus in an anteroinferior to posteroinferior exploration axis along the base of the semicircular temporal horn. This strategy ensures preservation of the overlying neopallial temporal convolutions such as the T1, T2, T3, and T4 gyri as well as the related subcortical connective fiber systems and other essential components of the temporal white matter.
The application of rigid brain self-retaining retractor systems was strictly avoided during the entire procedure. Computer-assisted navigation was never used. On routine postoperative CT scanning and MR imaging studies, infarction was not observed in any patient. The availability of tractography technology has proven that the connective fiber system around the resected mesial temporal area remains intact.
Results
The surgical outcome and results on neoplastic and vascular lesions of the mesiobasal temporal region have been presented in Volumes II, IIIB, and IVB of
Microneurosurgery
. The surgical outcomes and results in 102 patients with mesial temporal seizures who underwent surgery performed by the senior author in Zürich have been previously published.
In this paper, 73 patients who underwent surgery between 1994 and September 2006 in Little Rock, Arkansas, are presented, and 13 other patients are excluded who underwent surgery after September 2006. Altogether, among 188 patients who underwent surgery, there was no surgical mortality or morbidity, and no neurological deficits, new neurocognitive dysfunction, or impairments of the preoperative incapacities.
Conclusions
The surgical outcome in terms of seizures was rewarding in the majority of patients, particularly in those who exhibited the following irregularities on preoperative investigations: regular local dysfunctions on electroencephalography, dysmorphic changes in the mesiobasal temporal parenchyma on MR imaging studies, and hypometabolism in the anterior third of the temporal lobe on PET studies.
Decision-making for intracranial tumor surgery requires balancing the oncological benefit against the risk for resection-related impairment. Risk estimates are commonly based on subjective experience ...and generalized numbers from the literature, but even experienced surgeons overestimate functional outcome after surgery. Today, there is no reliable and objective way to preoperatively predict an individual patient's risk of experiencing any functional impairment.
The authors developed a prediction model for functional impairment at 3 to 6 months after microsurgical resection, defined as a decrease in Karnofsky Performance Status of ≥ 10 points. Two prospective registries in Switzerland and Italy were used for development. External validation was performed in 7 cohorts from Sweden, Norway, Germany, Austria, and the Netherlands. Age, sex, prior surgery, tumor histology and maximum diameter, expected major brain vessel or cranial nerve manipulation, resection in eloquent areas and the posterior fossa, and surgical approach were recorded. Discrimination and calibration metrics were evaluated.
In the development (2437 patients, 48.2% male; mean age ± SD: 55 ± 15 years) and external validation (2427 patients, 42.4% male; mean age ± SD: 58 ± 13 years) cohorts, functional impairment rates were 21.5% and 28.5%, respectively. In the development cohort, area under the curve (AUC) values of 0.72 (95% CI 0.69-0.74) were observed. In the pooled external validation cohort, the AUC was 0.72 (95% CI 0.69-0.74), confirming generalizability. Calibration plots indicated fair calibration in both cohorts. The tool has been incorporated into a web-based application available at https://neurosurgery.shinyapps.io/impairment/.
Functional impairment after intracranial tumor surgery remains extraordinarily difficult to predict, although machine learning can help quantify risk. This externally validated prediction tool can serve as the basis for case-by-case discussions and risk-to-benefit estimation of surgical treatment in the individual patient.
The risk of cerebrospinal fluid (CSF) leakage after cranial surgery and its associated complications in children are unclear because of variable definitions and the lack of multicenter studies. In ...this study, the authors aimed to establish the incidence of CSF leakage after intradural cranial surgery in the pediatric population. In addition, they evaluated potential risk factors and complications related to CSF leakage in the pediatric population.
The authors performed an international multicenter retrospective cohort study in three tertiary neurosurgical referral centers. Included were all patients aged 18 years or younger who had undergone cranial surgery to reach the subdural space during the period between 2015 and 2021. Patients who died or were lost to follow-up within 6 weeks after surgery were excluded. The primary outcome measure was the incidence of CSF leakage, defined as leakage through the skin, within 6 weeks after surgery. Univariable and multivariable logistic regression analyses were performed to identify risk factors for and complications related to CSF leakage.
In total, 759 procedures were identified, performed in 687 individual patients. The incidence of CSF leakage was 7.5% (95% CI 5.7%-9.6%). In the multivariate model, independent risk factors for CSF leakage were hydrocephalus (OR 4.5, 95% CI 2.2-8.9) and craniectomy (OR 7.6, 95% CI 3.0-19.5). Patients with CSF leakage had higher odds of pseudomeningocele (5.7, 95% CI 3.0-10.8), meningitis (21.1, 95% CI 9.5-46.8), and surgical site infection (7.4, 95% CI 2.6-20.8) than patients without leakage.
CSF leakage risk in children after cranial surgery, which is comparable to the risk reported in adults, is an event of major concern and has a serious clinical impact.
The postoperative functional status of patients with intracranial tumors is influenced by patient-specific factors, including age.
This study aimed to elucidate the association between age and ...postoperative morbidity or mortality following the resection of brain tumors.
A multicenter database was retrospectively reviewed. Functional status was assessed before and 3–6 months after tumor resection by the Karnofsky Performance Scale (KPS). Uni- and multivariable linear regression were used to estimate the association of age with postoperative change in KPS. Logistic regression models for a ≥10-point decline in KPS or mortality were built for patients ≥75 years.
The total sample of 4864 patients had a mean age of 56.4 ± 14.4 years. The mean change in pre-to postoperative KPS was −1.43. For each 1-year increase in patient age, the adjusted change in postoperative KPS was −0.11 (95% CI -0.14 - - 0.07). In multivariable analysis, patients ≥75 years had an odds ratio of 1.51 to experience postoperative functional decline (95%CI 1.21–1.88) and an odds ratio of 2.04 to die (95%CI 1.33–3.13), compared to younger patients.
Patients with intracranial tumors treated surgically showed a minor decline in their postoperative functional status. Age was associated with this decline in function, but only to a small extent.
Patients ≥75 years were more likely to experience a clinically meaningful decline in function and about two times as likely to die within the first 6 months after surgery, compared to younger patients.
•A multicenter database of patients with intracranial tumors is analyzed in this study.•Age is associated with a minor decline in the postoperative functional status & mortality.•Patients ≥75 years are more likely to experience a clinically meaningful decline in function and to die.
Aims/hypothesis The aim of this prospective trial was to compare the effect of different long-acting insulin preparations injected at bedtime on glucose concentrations in patients with type 2 ...diabetes omitting breakfast and lunch the next day. Methods Twenty patients (ten women) with type 2 diabetes who were on an intensified insulin therapy participated. Mean (±SD) age was 63 ± 10 years, diabetes duration 18 ± 9 years, BMI 32.5 ± 5 kg/m², and HbA₁c 7.3 ± 0.7%. Patients received neutral protamine Hagedorn (NPH) insulin, insulin detemir or insulin glargine for at least 2 months; doses were adjusted to achieve morning blood glucose levels of <7 mmol/l. At the end of the respective treatment period, the long-acting insulin was injected at bedtime (at 22:45 hours) as usual but patients refrained from breakfast and lunch the next day; glucose was measured by a continuous glucose monitoring system (CGMS). Results Comparable glucose target ranges were reached at midnight (5.8 to 6.1 mmol/l) and at 07:00 hours (6.7 to 6.9 mmol/l) with all three insulin preparations, using mean doses of 29 ± 10 U (NPH insulin), 33 ± 13 U (insulin detemir), and 32 ± 12 U (insulin glargine). Glucose levels between midnight and 07:00 hours were not significantly different for the three insulin preparations. Symptomatic hypoglycaemia did not occur from 08:00 to 16:00 hours; glucose concentrations during this time were slightly lower with NPH insulin than with insulin detemir (p = 0.012) and insulin glargine (p = 0.049). Conclusions/interpretation Following bedtime injection of NPH insulin or of the analogues insulin detemir or insulin glargine, fasting glucose <7 mmol/l was achieved in the morning, without subsequent hypoglycaemia when participants continued to fast during the day.
The proximal (anterior) transsylvian approach through a pterional craniotomy was developed by the senior author (M.G.Y.) in 1967 for the microsurgical treatment of saccular aneurysms of the circle of ...Willis, frontoorbital and temporobasal arteriovenous malformations, cavernomas, and extrinsic and intrinsic tumors. The acquired positive surgical experiences on this large series enabled the senior author, in 1973, to apply this approach for the selective amygdalohippocampectomy in patients with intractable mesial temporal lobe epilepsy.
The proximal (anterior) transsylvian-transamygdala approach to the mesial temporal structures permits the selective two-thirds resection of the amygdala and hippocampus-parahippocampus in an anteroinferior to posteroinferior exploration axis along the base of the semicircular temporal horn. This strategy ensures preservation of the overlying neopallial temporal convolutions such as the T1, T2, T3, and T4 gyri as well as the related subcortical connective fiber systems and other essential components of the temporal white matter. The application of rigid brain self-retaining retractor systems was strictly avoided during the entire procedure. Computer-assisted navigation was never used. On routine postoperative CT scanning and MR imaging studies, infarction was not observed in any patient. The availability of tractography technology has proven that the connective fiber system around the resected mesial temporal area remains intact.
The surgical outcome and results on neoplastic and vascular lesions of the mesiobasal temporal region have been presented in Volumes II, IIIB, and IVB of Microneurosurgery. The surgical outcomes and results in 102 patients with mesial temporal seizures who underwent surgery performed by the senior author in Zürich have been previously published. In this paper, 73 patients who underwent surgery between 1994 and September 2006 in Little Rock, Arkansas, are presented, and 13 other patients are excluded who underwent surgery after September 2006. Altogether, among 188 patients who underwent surgery, there was no surgical mortality or morbidity, and no neurological deficits, new neurocognitive dysfunction, or impairments of the preoperative incapacities.
The surgical outcome in terms of seizures was rewarding in the majority of patients, particularly in those who exhibited the following irregularities on preoperative investigations: regular local dysfunctions on electroencephalography, dysmorphic changes in the mesiobasal temporal parenchyma on MR imaging studies, and hypometabolism in the anterior third of the temporal lobe on PET studies.
The occurrence of a left ventricular anterograde flow velocity (maximal: 3.9 m.s-1) is demonstrated in a 32-year-old patient with hypertrophic cardiomyopathy and midventricular obstruction, beginning ...at early systole and persisting throughout the isovolumic relaxation. Cardiac catheterization with simultaneous dual high fidelity pressure measurements in the apical and basal chambers confirmed the presence of the Doppler maximal instantaneous pressure gradient of 60 mmHg. Contrast left ventricular angiography excluded apical dyskinesia. In the two intracavity compartments, isovolumic relaxation time and the time constant of pressure decay (tau) were abnormal whereby tau was more delayed in the apical than in the basal portion. The presence of an apical high pressure zone during systole with impeded and delayed emptying through the midventricular obstacle and the late onset and prolongation of relaxation are thought to be the cause of the intraventricular flow from apex to base lasting from early systole throughout isovolumic relaxation.
Microvascular angina is characterized by exercise-induced angina in patients with normal coronary arteries and reduced coronary flow reserve. Recently, a generalized disorder of abnormal vascular ...reactivity in microvascular angina has been postulated. Therefore, coronary flow reserve was determined by the coronary sinus thermodilution technique and compared with the cutaneous flux ratio in 6 control subjects (group 1) and 12 patients with microvascular angina (group 2).
Coronary flow reserve was calculated from maximal coronary flow after 0.5 mg/kg of dipyridamole divided by flow at rest. Cutaneous flow ratio was estimated by laser Doppler fluxmetry (right forearm) before and after 4 min of suprasystolic blood pressure occlusion. Coronary flow at rest was identical in the two groups, but after maximal vasodilation with dipyridamole, coronary flow was higher in group 1 than in group 2 (p < 0.05). Coronary flow reserve differed significantly between the two groups (2.9 in group 1 and 1.3 in group 2; p < 0.001). Cutaneous Doppler flux at rest was higher in group 1 than in group 2 (p < 0.05). However, the hyperemic response was identical in both groups.
It is concluded that the cutaneous flux ratio in patients with microvascular angina is not impaired. Local peripheral vasomotor tone appears to be increased in patients with microvascular angina because cutaneous flow at rest is reduced. Thus, a generalized disorder of abnormal vascular reactivity cannot be confirmed in patients with microvascular angina.
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