Neurosurgery

Spinal cord stimulation in pregnant patients: Current perspectives of indications, complications, and results in pain control: A systematic review Bruno Camporeze, Renata Simm, Marcos Vinícius Calfat Maldaun, Paulo Henrique Pires de Aguiar Asian Journal of Neurosurgery 2019 14(2):343-355 Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

Diffuse low-grade glioma – Changing concepts in diagnosis and management: A review Rashid Jooma, Muhammad Waqas, Inamullah Khan Asian Journal of Neurosurgery 2019 14(2):356-363 Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from “wait and watch” of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical technologies allow more aggressive surgical resections with a reduction of morbidity. Many reports suggest the association of gross total resection with longer overall survival and progression-free survival in addition to better seizure control. The literature also shows the use of chemotherapeutics and radiation therapy as important adjuncts to surgery. The goals of management have has been increasing survival with increasing stress on quality of life. Our review highlights the recent advances in the molecular diagnosis and management of dLGG with trends toward multidisciplinary and multimodality management of dLGG with an aim to surgically resect the primary disease, followed by chemoradiation in cases of progressive or recurrent disease.

Simulation training methods in neurological surgery Louise Makarem Oliveira, Eberval Gadelha Figueiredo Asian Journal of Neurosurgery 2019 14(2):364-370 Simulation training plays a paramount role in medicine, especially when it comes to mastering surgical skills. By simulating, students gain not only confidence, but expertise, learning to apply theory in a safe environment. As the technological arsenal improved, virtual reality and physical simulators have developed and are now an important part of the Neurosurgery training curriculum. Based on deliberate practice in a controlled space, simulation allows psychomotor skills augment without putting neither patients nor students at risk. When compared to the master-apprentice ongoing model of teaching, simutation becomes even more appealing as it is time-efficient, shortening the learning curve and ultimately leading to error reduction, which is reflected by diminished health care costs in the long run. In this chapter we will discuss the current state of neurosurgery simulation, highlight the potential benefits of this approach, assessing specific training methods and making considerations towards the future of neurosurgical simulation.

The role of decompressive craniectomy in traumatic brain injury: A systematic review and meta-analysis Nida Fatima, Ghaya Al Rumaihi, Ashfaq Shuaib, Maher Saqqur Asian Journal of Neurosurgery 2019 14(2):371-381 The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75–1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40–0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26–0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.

Hypertonic solutions in traumatic brain injury: A systematic review and meta-analysis Nida Fatima, Ali Ayyad, Ashfaq Shuaib, Maher Saqqur Asian Journal of Neurosurgery 2019 14(2):382-391 This study aims to evaluate the efficacy of hypertonic saline versus crystalloids (normal Saline/lactated Ringers) in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and grey literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies and prospective cohort studies on decompressive craniectomy in TBI (>18-year-old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS), Extended GCOS, and mortality. Data were extracted to Review Manager Software. A total of 115 articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI who had hypertonic saline had no statistically significant likelihood of having a good outcome at discharge or 6 months than those who had crystalloid (odds ratio [OR]: 0.01; 95% confidence interval (CI): 0.03–0.05; P = 0.65). The relative risk (RR) of mortality in hypertonic saline versus the crystalloid at discharge or 6-month is RR: 0.80; 95% CI: 0.64–0.99; P = 0.04. The subgroup analysis showed that the group who had hypertonic solution significantly decreases the number of interventions versus the crystalloid group OR: 0.53; 95% CI: 0.48–0.59; P < 0.00001 and also reduces the length of intensive care unit stay (OR: 0.46; 95% CI: 0.21–1.01; P = 0.05). Hypertonic saline decreases the financial burden, but neither impacts the clinical outcome nor reduces the mortality. However, further clinical trials are required to prove if hypertonic saline has any role in improving the clinical and neurological status of patients with TBI versus the normal saline/lactated Ringers.

Impact of comorbidities on outcome following revision of recurrent single-level lumbar disc prolapse between revision microdiscectomy and posterior lumbar interbody fusion: A single-institutional analysis Chiazor U Onyia, Sajesh K Menon Asian Journal of Neurosurgery 2019 14(2):392-398 Objectives: Reports exist in the literature on the relationship between comorbid conditions and recurrence of lumbar disc herniation. Meanwhile, documented evidence abound on microdiscectomy and posterior lumbar interbody fusion (PLIF) as techniques of managing recurrent disc prolapse. Some surgeons would choose to perform PLIF instead of microdiscectomy for a first time re-herniation, because of the possibility of higher chances of further recurrence as well as increased likelihood of spinal instability following treatment with microdiscectomy. In this study, the authors sought to determine whether PLIF is better than microdiscectomy for first-time recurrent single-level lumbar disc prolapse and to compare the impact of comorbidities on outcome following revision. Patients and Methods: This was retrospective review of surgical treatment of patients with recurrent single-level disc prolapse with either microdiscectomy or PLIF at a tertiary health institution in India. Results: A total of 26 patients were evaluated. There was no statistically significant correlation between the presence of comorbidity and outcome in terms of improvement of pain (P > 0.05 at 95% degree of confidence; Spearman's ρ =0.239). Patients who had PLIF were neither more nor less likely to have a better outcome compared to those who had microdiscectomy, though this finding was not statistically significant (odds ratio = 0.263; P = 0.284). Conclusion: There was no significant relationship between the presence of comorbidity and outcome following revision. Microdiscectomy did not prove to be a better option than PLIF for surgical management of recurrent single-level disc prolapse. A quality randomized controlled study would help to validate these findings.

Endoscopic third ventriculostomy in children with failed ventriculoperitoneal shunt Bijan Heshmati, Zohreh Habibi, Mehdi Golpayegani, Farhad Salari, Mousarreza Anbarlouei, Farideh Nejat Asian Journal of Neurosurgery 2019 14(2):399-402 Context: Endoscopic third ventriculostomy (ETV) is an accepted procedure for the treatment of obstructive hydrocephalus. The role of endoscopic treatment in the management of shunt malfunction was not extensively evaluated. The aim of this study is to evaluate the success rate of ETV in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. Materials and Methods: Thirty-three patients with their first shunt failure and obstructive hydrocephalus in brain imaging between 2008 and 2014 were enrolled in this study. Results: The most common causes of hydrocephalus in these patients were aqueductal stenosis and myelomeningocele with or without associated shunt infection. Of these 33 cases, 20 ETV procedures were successful, and 13 cases needed shunt revision after ETV failure. There was no serious complication during ETV procedures. The follow-up period of patients with successful ETV was 6–50 months (mean 18 months). The time interval between ETV and new shunting subsequent to ETV failure was 24.4 days (10–95). Conclusions: ETV can be considered as an alternative treatment paradigm in patients with previous shunt or new shunt failure with an acceptable success rate of 6o%, although long-term follow-up is needed for these patients.

Predictive factors for seizures accompanying intracranial meningiomas Moamen Mohamed Morsy, Waleed Fawzy El-Saadany, Wael Mohamed Moussa, Ahmed Elsayed Sultan Asian Journal of Neurosurgery 2019 14(2):403-409 Objective: Seizures represent a common manifestation of intracranial meningiomas. Their predictive factors before and after excision merit studying. Materials and Methods: Patients having intracranial meningioma were prospectively studied. There were two groups; Group “A” with seizures and Group “B” with no preoperative epilepsy. Results: This study included 40 patients. Their ages ranged from 40 to 60 years old, and female-to-male ratio was 2.3:1 in both groups. In Group A, partial seizures were the most common pattern (60%). Manifestations other than fits included headache in most patients (97.5%), symptoms of increased intracranial pressure were found in 50% in Group A and 20% in Group B patients, peritumoral edema was present in 14 (70%) patients of Group A, compared to 6 (25%) patients of Group “B.” There was a statistically significant relation between peritumoral edema and presentation with fits (P < 0.1). Complication after surgery included nonsurgical hematoma in three patients and contusion in 7 patients. Following surgery for Group “A”, 8 (40%) patients had good seizure control. While, in Group “B” 3 (15%), patients developed new-onset seizures. Good seizure control in 7 (53%) patients with frontal, frontotemporal tumors than in other locations. In addition, better control was obtained in left sided, small tumors, and no peritumoral edema. Postoperative complication was significantly associated with new-onset epilepsy and poor seizure control (P < 0.05). Neither tumor size nor location had a significant relation to either pre or postoperative epilepsy. Conclusion: Predictive factors for epilepsy accompanying intracranial meningioma included males, elderly patients and patients with small lesions, frontal and left-sided locations but were statistically insignificant predictors. Peritumoral edema and postoperative complications are the most significant predictors.

Compound elevated skull fracture presented as a new variety of fracture with inimitable entity: Single institution experience of 10 cases Ashok Kumar, Vivek Kumar Kankane, Gaurav Jaiswal, Pavan Kumar, Tarun Kumar Gupta Asian Journal of Neurosurgery 2019 14(2):410-414 Background: Compound elevated Skull fracture (CESF) is a rare variety of fracture with rare presentation in comparison to other type of skull fracture. The mechanical force being applied is tangential causing high impact over skull as comparison to structure underlying the cranium. Objective: Aims of this study are bring attentiveness and management to deal this rare type of fracture and its outcomes. Materials and Methods: In this study, we demonstrated 10 cases of CESF in adult patients from January 2014 to January 2018 in the Department of Neurosurgery at RNT Medical College and M. B. Hospital, Udaipur, Rajasthan, India. Recorded documents were prospectively studied for age of distribution, sex, mode of injury, mechanism of injury, clinical profile, radiological investigations, neurosurgical management, and outcome asses by Glasgow outcome scale. Results: Totally 10 patients had CESF. Six are males and four are females. Male to female ratio was 3:2. Their age range was 20–45 years. The most common mode of injury was Road traffic accident in 60%. Wound exploration, cleaning, debridement, and reduction of fracture segment was done in eight cases, frontal bone craniotomy with evacuation of pneumocephalus done one case, frontal bone craniotomy, and extradural hematoma evacuation was done in one case. The postoperative course was uneventful, and outcome was good (GOS 5) in 8 (80%) cases. Conclusion: In compound elevated fracture, early recognition and immediate surgical intervention should be done to avoid related morbidity and mortality. Any delay in surgery may lead to a high possibility of wound infection and poor outcome.

Outcome analysis of surgical clipping for incidental internal carotid posterior communicating and anterior choroidal artery aneurysms Ameen Abdul Mohammad, Yamada Yasuhiro, Liew Boon Seng, Niranjana Rajagopal, Kato Yoko Asian Journal of Neurosurgery 2019 14(2):415-421 Introduction: Surgical outcome and ischemic complications of Internal carotid Posterior Communicating (IC PC) and anterior choroidal aneurysms have been questionable due to frequent occlusion of the anterior choroid artery and also due to low incidence of true anterior choroid artery aneurysms. The present series describes the postoperative outcome after clipping of such aneurysms at a single centre. Methods: A retrospective analysis of 73 cases with IC PC and Anterior choroidal aneurysms performed at a Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan from 2014 to 2018 have been studied and emphasis is made on the demography and ischemic complications. Results: A total of 73 patients with IC PC and anterior choroidal aneurysms were studied, out of which 57 patient had a true IC PC aneurysm, 14 patients had aneurysms involving the anterior choroidal artery and only 2 patients had aneurysms which involved both the IC PC and the anterior choroidal arteries. None of the patients had a permanent Anterior Choroidal Artery syndrome, whereas only 2 out of the 73 patients had postoperative complications in the form of transient hemiparesis. Conclusion: Ischemic complications following surgical clipping of IC PC and anterior choroidal aneurysms can be minimised by meticulous micro dissection to identify the anterior choroidal artery thus preserving the patency of the same.