This case report presents the unique clinical presentation of an 18-year-old female patient with an 8-year history of a progressively enlarging pulsatile mass in the left parieto-occipital region of ...her scalp. Remarkably, there was no history of trauma, headache, or other associated neurological deficits. Advanced imaging techniques, including computed tomography angiography and magnetic resonance imaging, revealed a vascular lesion consistent with an arteriovenous malformation beneath the scalp. Notably, the arteriovenous malformation's nidus was primarily supplied by branches of bilateral superficial temporal and occipital arteries, with a more pronounced involvement on the left side. Further magnetic resonance imaging characterization confirmed the diagnosis as a high parieto-occipital arteriovenous malformation/dural arteriovenous fistula. This case underscores the importance of a multidisciplinary approach involving neurosurgery and interventional radiology to the diagnosis and management of complex vascular lesions, particularly when they occur in unusual anatomical locations, like in our patient. The long-term clinical course and outcomes of such cases warrant continued investigation.
Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in surgical cases. The aim of our ...study was to validate a modified 15-variable EGS-specific frailty index (EGSFI).
We prospectively collected geriatric (age older than 65 years) EGS patients for 2 years. Postoperative complications were collected. Frailty index was calculated for 200 patients based on their preadmission condition using 50-variable modified Rockwood frailty index. Emergency general surgery-specific frailty index was developed based on the regression model for complications and the most significant factors in the frailty index. Receiver operating characteristic curve analysis was performed to determine cutoff for frail status. We validated our results using 60 patients for predicting complications.
A total of 260 patients (developing, 200; validation, 60) were enrolled in this study. Mean age was 71 ± 11 years, and 33% developed complications. Most common complications were pneumonia (12%), urinary tract infection (9%), and wound infection (7%). Univariate analysis identified 15 variables significantly associated with complications that were used to develop the EGSFI. A cutoff frailty score of 0.325 was identified using receiver operating characteristic curve analysis for frail status. Sixty patients (frail, 18; nonfrail, 42) were enrolled in the validation cohort. Frail patients were more likely to have postoperative complications (47% vs. 20%; p < 0.001) compared to nonfrail patients. Frail status based on EGSFI was a significant predictor of postoperative complications (odds ratio, 7.3; 95% confidence interval, 1.7-19.8; p = 0.006). Age was not associated with postoperative complications (odds ratio, 0.99; 95% confidence interval, 0.92-1.06; p = 0.86).
The 15-variable validated EGSFI is a simple and reliable bedside tool to determine the frailty status of patients undergoing EGS. Frail status as determined by the EGSFI is an independent predictor of postoperative complications and mortality in geriatric EGS patients.
Prognostic study, level II.
Background
We examined the value of indocyanine green (ICG) fluorescence angiography in predicting parathyroid vascularization following thyroid and central compartment surgeries.
Methods
Data were ...prospectively collected on adult patients undergoing thyroid and/or central compartment surgeries. Outcomes were compared in surgeries performed with and without ICG use. ICG scoring was used to quantify the vascularity of parathyroid glands.
Results
One hundred eleven patients were included; 43 (38.7%) patients underwent ICG injections. There was no significant difference in mean parathyroid hormone (PTH) changes at the end of surgery (29.24 vs 23.48 pg/mL, P = .38), symptomatic hypocalcemia (7.9% vs 3.9%, P = .37), or length of stay (1.095 ± 0.22 vs 0.912 ± 0.07 days, P = .51) between surgeries performed with and without ICG. The average vascularization score among individuals undergoing ICG angiography was 2.89 out of a maximum of 8 points.
Conclusion
Low‐flow ICG patterns are not associated with postoperative PTH changes or transient hypocalcemia and may lead to unnecessary parathyroid autotransplantation.
The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special ...consideration. We hypothesized that physical examination can safely guide CTA use in a “no zone” approach.
An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries).
A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs (P = 0.23) or soft signs (P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE.
Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking.
Objectives
To evaluate the safety and efficacy of percutaneous ethanol ablation (PEA) on indeterminate thyroid nodules (Bethesda III and IV) based on ultrasound (US) elastography by assessing the ...volume reduction rate (VRR), relative reduction in size, resolution of compressive symptoms, and post-procedural complications.
Materials and Methods
This is a retrospective cohort study of all thyroid nodules treated with PEA by a single surgeon at a North American tertiary referral center. Study variables included demographics, nodule characteristics, Bethesda classification, US elastography, presence of compressive symptoms, thyroid function, and post-procedural complications. Relative volume reductions and VRR were calculated at 3- and 6-month follow-ups.
Results
Thirty-four thyroid nodules were evaluated in 22 patients. All thyroid nodules underwent a fine needle aspiration prior to PEA. After 6 months, 45% of all thyroid nodules exhibited a VRR of ≥50%. A significant VRR was achieved in the soft thyroid nodules at 6 months (42.15% ± 31), compared to the stiff nodules with 30.92% ± 91.53, P < .05. Post-PEA thyroid stimulating hormone levels did not significantly change after the procedure. Compressive symptoms resolved in all 5 patients who reported it. One patient developed transient vocal cord paresis that resolved in 3 months.
Discussion
To the best of our knowledge, this is the largest series of PEA for thyroid nodules in North America. Ultrasound elastography is a useful adjunct in predicting the success of PEA for nonmalignant thyroid nodules. Percutaneous ethanol ablation is both a safe and effective alternative to surgery for relief of compressive symptoms in select patients.
Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries ...in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT.
We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017.
A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%.
This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients.
Systematic review, level IV.
Obesity is associated with numerous complications after elective general surgeries. The aim is to compare surgical outcomes and local specific complications in obese and non-obese patients after ...thyroid surgery.
Retrospective study over a 3-year period at a North American academic institution. Outcome measures were operative time, estimated blood loss, hospital length of stay, and local specific complications (hypocalcemia, recurrent laryngeal nerve injury, wound hematoma, wound seroma, and chyle leakage).
A total of 469 patients were included (mean SD age, 50.11 15.01 years; mean SD BMI, 30.5 8.3 kg/m2; 207 44.14% obese). There was no difference in operative time (125.7 vs. 129.6, p = 0.52), estimated blood loss (16.88 vs. 14.56, p = 0.28), or hospital length of stay (0.95 vs. 0.95, p = 0.96). Overall, there was no difference in the rates of local specific complications between the two groups.
Obesity is not associated with adverse outcomes in patients undergoing thyroid surgery.
•Obesity is considered by many surgeons as a challenge associated with complications.•The local specific complications in the obese were comparable to those in the non-obese.•The more familiarity with operating on obese patients, the less operative time.•No difference between obese and non-obese regarding hospital length of stay.
