Risk of Deep vein thrombosis in neurosurgery: State of the art on prophylaxis protocols and best clinical practices

Surgeon-led improvement in compliance with use of sequential compression devices in a neurosurgery patient population

INTRODUCTION

Sequential compression devices (SCDs) are the mainstay of mechanical prophylaxis for venous thromboembolism in perioperative neurosurgical patients and are especially crucial when chemical prophylaxis is contraindicated.

OBJECTIVES

This study aimed to characterise and improve SCD compliance in neurosurgery stepdown patients.

METHODS

SCD compliance in a neurosurgical stepdown unit was tracked across 13 months (August 2022-August 2023). When not properly functioning, the missing element was documented. Compliance was calculated daily in all patients with SCD orders, and then averaged monthly. Most common barriers to compliance were identified. With nursing, we implemented a best practice alert to facilitate nursing education at month 3 and tracked compliance over 9 months, with two breaks in surveillance. At month 12, we implemented a patient-engagement measure through creating and distributing a patient-directed infographic and tracked compliance over 2 months.

RESULTS

Compliance averaged 19.7% (n=95) during August and 38.4% (n=131) in September. After implementing the best practice alert and supply chain upgrades, compliance improved to 48.8% (n=150) in October, 41.2% (n=104) in March and 45.9% (n=76) in April. The infographic improved compliance to 51.4% (n=70) in July and 55.1% (n=34) in August. Compliance was significantly increased from baseline in August to October (z=4.5838, p<0.00001), sustained through March (z=3.2774, p=0.00104) and further improved by August (z=3.9025, p=0.0001).

CONCLUSION

Beyond an initial Hawthorne effect, implementation of the best practice nursing alert facilitated sustained improvement in SCD compliance despite breaks in surveillance. SCD compliance nonetheless remained below 50% until implementation of patient-engagement measures which were dependent on physician involvement.

The effect of intraoperative intermittent pneumatic compression on deep venous thrombosis prophylaxis in patients undergoing elective craniotomy

Objective

Postoperative deep venous thrombosis (DVT) is commonly observed in patients undergoing craniotomy and is associated with a high incidence of pulmonary embolism and poor clinical outcomes. Herein, we investigated the prophylactic effect of DVT of intraoperative intermittent pneumatic compression (IPC) in patients undergoing craniotomy.

Methods

A total of 516 patients who underwent elective craniotomy between December 2021 and December 2022 were enrolled in this study. Patients were randomly assigned to the intervention group (received intraoperative IPC) or control group (without IPC). Lower extremity ultrasound was performed on both legs before and after surgery (1 h, 24 h, and 7 days post-intervention). DVT was defined as the visualization of a thrombus within the vein lumen of the leg. Coagulation and platelet function were measured at the start and end of the craniotomy.

Results

A total of 504 patients (251 in the intervention group and 253 in the control group) completed the study. Among these patients, 20.4% (103/504) developed postoperative DVT within the first week after surgery, with 16.7% occurring within 24 h. The incidence of postoperative DVT in the intervention group (9.6%, 24/251) was significantly lower than that in the control group (22.9%, 58/253, p < 0.001). Intraoperative IPC reduced the risk of DVT by 64.6% (0.354, 95% CI, 0.223-0.564, p < 0.001). There was no significant difference in coagulation and platelet function between the two groups (all p > 0.05).

Conclusion

DVT may develop within 24 h after the craniotomy. Intraoperative application of IPC reduces the incidence of postoperative DVT.

Intermittend pneumatic venous thrombembolism (VTE) prophylaxis during neurosurgical procedures

BACKGROUND

The management of perioperative venous thrombembolism (VTE) prophylaxis is highly variable between neurosurgical departments and general guidelines are missing. The main issue in debate are the dose and initiation time of pharmacologic VTE prevention to balance the risk of VTE-based morbidity and potentially life-threatening bleeding. Mechanical VTE prophylaxis with intermittend pneumatic compression (IPC), however, is established in only a few neurosurgical hospitals, and its efficacy has not yet been demonstrated. The objective of the present study was to analyze the risk of VTE before and after the implementation of IPC devices during elective neurosurgical procedures.

METHODS

All elective surgeries performed at our neurosurgical department between 01/2018-08/2022 were investigated regarding the occurrence of VTE. The VTE risk and associated mortality were compared between groups: (1) only chemoprophylaxis (CHEMO; surgeries 01/2018-04/2020) and (2) IPC and chemoprophylaxis (IPC; surgeries 04/2020-08/2022). Furthermore, general patient and disease characteristics as well as duration of hospitalization were evaluated and compared to the VTE risk.

RESULTS

VTE occurred after 38 elective procedures among > 12.000 surgeries. The number of VTEs significantly differed between groups with an incidence of 31/6663 (0.47%) in the CHEMO group and 7/6688 (0.1%) events in the IPC group. In both groups, patients with malignant brain tumors represented the largest proportion of patients, while VTEs in benign tumors occurred only in the CHEMO group.

CONCLUSION

The use of combined mechanical and pharmacologic VTE prophylaxis can significantly reduce the risk of postoperative thromboembolism after neurosurgical procedures and, therefore, reduce mortality and morbidity.

Venous thromboembolism chemical prophylaxis after skull base surgery

PURPOSE

There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.

METHODS

Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.

RESULTS

One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.

CONCLUSION

Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Safety and timing of early therapeutic anticoagulation therapy after craniotomy

Background

To date, there are few guidelines and studies to guide the timing of initiation of therapeutic anticoagulation (AC) after craniotomy. The goal of this study was to assess the timing, safety, and outcomes of patients following the administration of therapeutic AC after craniotomy.

Methods

A retrospective case-control study was performed evaluating all craniotomy patients from August 2017 to July 2021. Cases were selected if they received therapeutic AC within ten days of craniotomy. Nineteen out of 1013 craniotomy patients met the inclusion criteria. Indications for therapeutic AC were diverse, including deep venous thrombosis, pulmonary embolism, dural venous sinus thrombosis, mechanical heart valve, and left ventricular thrombus.

Results

The mean and median time to therapeutic AC were 5.35 and 5 days, respectively. Three patients developed intracerebral hemorrhage (ICH) that was stable on repeat imaging and did not require any surgical intervention or result in new neurologic deficits. There was no significant association between therapeutic AC and postoperative ICH (P = 0.067).

Conclusion

This study demonstrated that the initiation of therapeutic AC in postoperative craniotomy patients from postoperative days 2 to 10 did not result in any major complications. A prospective study is warranted to clarify the indications and safety of therapeutic AC after craniotomy.

Risk prediction models for deep venous thrombosis in patients with acute stroke: A systematic review and meta-analysis

BACKGROUND

The number of risk prediction models for deep venous thrombosis (DVT) in patients with acute stroke is increasing, while the quality and applicability of these models in clinical practice and future research remain unknown.

OBJECTIVE

To systematically review published studies on risk prediction models for DVT in patients with acute stroke.

DESIGN

Systematic review and meta-analysis of observational studies.

METHODS

China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal Database (VIP), SinoMed, PubMed, Web of Science, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Embase were searched from inception to November 7, 2022. Data from selected studies were extracted, including study design, data source, outcome definition, sample size, predictors, model development and performance. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was used to assess the risk of bias and applicability.

RESULTS

A total of 940 studies were retrieved, and after the selection process, nine prediction models from nine studies were included in this review. All studies utilized logistic regression to establish DVT risk prediction models. The incidence of DVT in patients with acute stroke ranged from 0.4 % to 28 %. The most frequently used predictors were D-dimer and age. The reported area under the curve (AUC) ranged from 0.70 to 0.912. All studies were found to have a high risk of bias, primarily due to inappropriate data sources and poor reporting of the analysis domain. The pooled AUC value of the five validated models was 0.76 (95 % confidence interval: 0.70-0.81), indicating a fair level of discrimination.

CONCLUSION

Although the included studies reported a certain level of discrimination in the prediction models of DVT in patients with acute stroke, all of them were found to have a high risk of bias according to the PROBAST checklist. Future studies should focus on developing new models with larger samples, rigorous study designs, and multicenter external validation.

REGISTRATION

The protocol for this study is registered with PROSPERO (registration number: CRD42022370287).

Venous thromboembolism and intracranial hemorrhage in patients undergoing glioblastoma surgery

In the perioperative management of patients with glioblastoma (GBM), physicians face the question of whether and when to administer prophylactic or therapeutic anticoagulation (AC). In this study, we investigate the effects of the timing of postoperative heparinization on thromboembolic events (TE) and postoperative hemorrhage (bleeding, PH) as well as the interactions between the two in the context of an underlying intracerebral malignancy. For this retrospective data analysis, 222 patients who underwent surgery for grade IV glioblastoma, IDH-wildtype (2016 CNS WHO) between 01/01/2014 and 31/12/2019 were included. We followed up for 12 months. We assessed various biographical and clinical data for risk factors and focused on the connection between timepoint of AC and adverse events. Subgroup analyses were performed for pulmonary artery embolism (PE), deep vein thrombosis, and postoperative intracranial hemorrhage (PH) that either required surgical intervention or was controlled radiologically only. Statistical analysis was performed using Mann-Whitney U-Test, Chi-square test, Fisher's exact test and univariate binomial logistic regression. p values below 0.05 were considered statistically significant. There was no significant association between prophylactic AC within 24 h and more frequent major bleeding (p = 0.350). AC in patients who developed major bleeding was regularly postponed by the physician/surgeon upon detection of the re-bleeding; therefore, patients with PH were anticoagulated significantly later (p = 0.034). The timing of anticoagulant administration did not differ significantly between patients who experienced a thromboembolic event and those who did not (p = 0.634). There was considerable overlap between the groups. Three of the six patients (50%) with PE had to be lysed or therapeutically anticoagulated and thereafter developed major bleeding (p < 0.001). Patients who experienced TE were more likely to die during hospitalization than those with major bleeding (p = 0.022 vs. p = 1.00). Prophylactic AC within 24 h after surgery does not result in more frequent bleeding. Our data suggests that postoperative intracranial hemorrhage is not caused by prophylactic AC but rather is a surgical complication or the result of antithrombotic therapy. However, thromboembolic events worsen patient outcomes far more than postoperative bleeding. The fact that bleeding may occur as a complication of life-saving lysis therapy in the setting of a thromboembolic event should be included in this cost-benefit consideration.

Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord

This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.

Sonographic Evaluation of Deep Vein Thrombosis in Hospitalized Neurosurgical Trauma Patients in Ibadan, Nigeria

BACKGROUND

Deep vein thrombosis (DVT) is a major cause of morbidity and mortality in hospitalized trauma patients. Ultrasonography (US) has replaced venography as the initial diagnostic tool for DVT.

AIMS

The study aimed to determine the incidence of lower limb DVT in hospitalized neurosurgical trauma patients in hospitalized neurosurgical patients. It also aimed to determine the effect of combined thrombo-prophylaxis on the incidence of lower limb deep DVT relative to a single regimen.

PATIENTS AND METHODS

This was a prospective study of 154 adult neurotrauma patients who consecutively had lower limb Doppler ultrasound, initially within 72 hours of admissions and subsequently weekly or when DVT was suspected for the first 3 weeks of admission. The study spanned a 12-month period. The data generated were analyzed using the statistical package for social sciences software version 20, Chicago IL. Inc. Chi-square test was used to compare the outcome (DVT incidence) between single and combined prophylaxis groups.

RESULTS

The study participants consisted of 116 (75.3%) and 38 (24.7%) cases of head and spine injuries, respectively, with a mean age of 38.8 ± 6.3 years and 85.1% being males. A total of four cases of DVT were detected during the study period, with the majority of the cases (3) detected within the first week of admission, giving an incidence of 2.6%. All four cases of DVT were detected in patients on single thrombo-prophylaxis (4/55 = 7.3%), while none was found in those on a combined regimen (0/34, P = 0.046).

CONCLUSION

Most cases of DVT developed in the first week of hospitalization. Combined thrombo-prophylaxis was more effective than single regimen at reducing rate of DVT in neurosurgical trauma patients. Routine Doppler ultrasound DVT surveillance should be part of the management protocol for neurosurgical trauma patients on admission to increase DVT detection and prevent possible fatal pulmonary embolism.

Prognostic nomogram for predicting lower extremity deep venous thrombosis in ruptured intracranial aneurysm patients who underwent endovascular treatment

Background

Lower extremity deep vein thrombosis (DVT) is one of the major postoperative complications in patients with ruptured intracranial aneurysms (RIA) who underwent endovascular treatment (EVT). However, patient-specific predictive models are still lacking. This study aimed to construct and validate a nomogram model for estimating the risk of lower extremity DVT for RIA patients who underwent EVT.

Methods

This cohort study enrolled 471 RIA patients who received EVT in our institution between 1 January 2020 to 4 February 2022. Perioperative information on participants is collected to develop and validate a nomogram for predicting lower extremity DVT in RIA patients after EVT. Predictive accuracy, discriminatory capability, and clinical effectiveness were evaluated by concordance index (C-index), calibration curves, and decision curve analysis.

Result

Multivariate logistic regression analysis showed that age, albumin, D-dimer, GCS score, middle cerebral artery aneurysm, and delayed cerebral ischemia were independent predictors for lower extremity DVT. The nomogram for assessing individual risk of lower extremity DVT indicated good predictive accuracy in the primary cohort (c-index, 0.92) and the validation cohort (c-index, 0.85), with a wide threshold probability range (4-82%) and superior net benefit.

Conclusion

The present study provided a reliable and convenient nomogram model developed with six optimal predictors to assess postoperative lower extremity DVT in RIA patients, which may benefit to strengthen the awareness of lower extremity DVT control and supply appropriate resources to forecast patients at high risk of RIA-related lower extremity DVT.

Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review

Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.

Is it safe for the spinal metastasis patients with preoperative deep vein thrombosis to use low-molecular-weight heparin before surgery? A prospective study

Spine surgeons should weigh the risks of anticoagulants against their benefits in preventing deep venous thrombosis (DVT), as they may increase the risk of bleeding. Spinal metastasis patients undergoing decompression with fixation are at a high risk for DVT, which may occur preoperatively. Therefore, anticoagulants should be administered preoperatively. This study aimed to evaluate the safety of the administration of anticoagulants in treating spinal metastasis patients with preoperative DVT. Therefore, we prospectively investigated the prevalence of DVT in these patients. Patients who were diagnosed with preoperative DVT were included in an anticoagulant group. Subcutaneous low-molecular-weight heparin (LMWH) was administered. Patients without DVT were included in a non-anticoagulant group. Data on patient information, clinical parameters, blood test results, and bleeding complications were also collected. Moreover, the safety of anticoagulants was analyzed. The prevalence of preoperative DVT was 8.0%. None of the patients developed pulmonary thromboembolism. Furthermore, no significant differences in blood loss, drainage volume, hemoglobin levels, number of transfusions, or preoperative trans-catheter arterial embolization were observed between the two groups. None of the patients developed major bleeding. However, two patients experienced wound hematoma and one experienced incisional bleeding in the non-anticoagulant group. Therefore, LMWH is safe for spinal metastasis patients. Future randomized controlled trials should be conducted to evaluate the validity of perioperative prophylactic anticoagulation therapy in these patients.

Stratifying the risks of venous thromboembolism in the lateral skull base surgery using Caprini risk assessment model

PURPOSE

To analyze and stratify the possible risk factors of venous thromboembolism (VTE) in lateral skull base surgery (LSBS) using the Caprini risk assessment model.

METHODS

In a single center, a retrospective study was conducted with patients who underwent LSBS from June 2016 to August 2021. The clinical characteristics and blood chemistry tests were collected. The incidence of VTE within 30 days of surgery was recorded. The Caprini risk score was calculated to assess the postoperative VTE risk.

RESULTS

Among the 123 patients in this study, the VTE incidence within 30 postoperative days was 8.9%. The total Caprini risk score in VTE patients (5.6 ± 1.9 points) was significantly higher than that of non-VTE patients (4.6 ± 1.4 points; p = 0.028). The binary logistic regression showed the total Caprini score as the only independent indicator of postoperative VTE. The receiver operating characteristic curve analysis showed that the Caprini score at 6.5 points had low sensitivity (36.4%) but high specificity (91.1%), with the largest area under the curve being 0.659. The VTE rate was significantly higher in patients with a total Caprini score ≥ 7 points (28.6%) compared to those with a total Caprini score ≤ 6 points (7.3%; p = 0.022).

CONCLUSION

LSBS patients have a high risk of developing postoperative VTE. Patients with a Caprini score ≥ 7 points had a significantly higher risk of developing VTE after LSBS. The Caprini risk system was useful in assessing the VTE risk in LSBS. However, more data, calibration, and validation are necessary to establish an exclusive Caprini risk system for LSBS.

Incidence and risk factors of deep vein thrombosis in patients with spinal cord injury: a systematic review with meta-analysis

Background

Spinal cord injury (SCI) is a highly disabling disease with huge public health burden. The complications associated with it, especially deep vein thrombosis (DVT), further aggravate the disability.

Objective

To explore the incidence and risk factors of DVT after SCI, in order to provide guidance for disease prevention in the future.

Methods

A search was performed on PubMed, Web of Science, Embase, and Cochrane database up to November 9, 2022. Literature screening, information extraction and quality evaluation were performed by two researchers. The data was later combined by metaprop and metan commands in STATA 16.0.

Results

A total of 101 articles were included, including 223,221 patients. Meta-analysis showed that the overall incidence of DVT was 9.3% (95% CI: 8.2%-10.6%), and the incidence of DVT in patients with acute and chronic SCI was 10.9% (95% CI: 8.7%-13.2%) and 5.3% (95% CI: 2.2%-9.7%), respectively. The incidence of DVT decreased gradually with the accumulation of publication years and sample size. However, the annual incidence of DVT has increased since 2017. There are 24 kinds of risk factors that may contribute to the formation of DVT, involving multiple aspects of the baseline characteristics of the patient, biochemical indicators, severity of SCI, and comorbidities.

Conclusions

The incidence of DVT after SCI is high and has been gradually increasing in recent years. Moreover, there are numerous risk factors associated with DVT. Comprehensive preventive measures need to be taken as early as possible in the future.

Systematic Review Registration

www.crd.york.ac.uk/prospero, identifier CRD42022377466.

Endoscopic-enhanced supra-cerebellar trans-tentorial (SCTT) approach to temporo-mesial region: a multicenter study

Surgical access to the temporo-mesial area may be achieved by several routes such as the sub-temporal, the temporal trans-ventricular, the pterional/trans-sylvian, and the occipital interhemispheric approaches; nonetheless, none of them has shown to be superior to the others. The supra-cerebellar trans-tentorial approach allows a great exposure of the middle and posterior temporo-mesial region, while avoiding temporal lobe retraction. A prospective multicenter study was designed to collect data on patients undergoing endoscopic-enhanced SCTT approach to excise left temporo-mesial lesions. The study involved 5 different neurosurgical European centers and ran from 2015 to 2020. All patients had preoperative as well as postoperative brain MRI and ophthalmology evaluation. A total of 30 patients were included in this study, the mean follow-up was 44 months (range 18 to 84 months), male/female ratio was 16/14, and mean age was 39 years. A gross total resection was achieved in 29/30 (96.7%) cases. All surgical procedures were uneventful, without transient or permanent neurological deficits thanks to the preservation of the posterior cerebral artery. The endoscopic-enhanced SCTT approach provides satisfactory exposure to the left temporo-mesial region. Its minimally invasive nature helps minimize the surgical risks related to vascular and white tract manipulation, which represent known limitations of open microsurgical as well as other approaches.

Pilot Study of Effects of Intermittent Pneumatic Compression in the Immediate Peri-Operative Period on Hemodynamic Parameters in Patients After Laparoscopic Gynecologic Surgery

The randomized controlled study investigated the impacts of immediate peri-operative Intermittent pneumatic compression (IPC) on hemodynamic indicators in patients undergoing laparoscopic gynecologic surgery. Patients scheduled for elective laparoscopic gynecologic surgery were randomized to control (IPC not used), pre-operative IPC, post-operative IPC, and peri-operative IPC (performed both before and after surgery) groups. Systolic blood pressure (SBP), mean blood pressure (MBP) cardiac output (CO), heart rate (HR) and systemic vascular resistance (SVR) were measured at different time points. The results showed that SBP changes not obviously over time in the control and peri-operative IPC group. Compared with values before surgery, the pre-operative IPC group had a lower SBP (P < 0.01) at the end of PACU stay, whereas the post-operative IPC group had a higher SBP (P < 0.01) after surgery. All groups exhibited little or no variation in HR, CO and SVR. Conclusion is peri-operative IPC has no major adverse effects on hemodynamic parameters.

A scoping review on the challenges, improvement programs, and relevant output metrics for neurotrauma services in major trauma centers

Background:

For a neurotrauma unit to be defined as a structured neurotrauma service (NS) the following criteria must be satisfied: A dedicated neurointensive care unit, endovascular neuroradiology, in-hospital neurorehabilitation unit and helicopter platform within the context of a Level I trauma center. Designing an effective NS can be challenging, particularly when considering the different priorities and resources of countries across the globe. In addition the impact on clinical outcomes is not clearly established.

Methods:

A scoping review of the literature spanning from 2000 to 2020 meant to identify protocols, guidelines, and best practices for the management of traumatic brain injury (TBI) in NS was conducted on the US National Library of Medicine and National Institute of Health databases.

Results:

Limited evidence is available regarding quantitative and qualitative metrics to assess the impact of NSs and specialist follow-up clinics on patients’ outcome. Of note, the available literature used to lack detailed reports for: (a) Geographical clusters, such as low-to-middle income countries (LMIC); (b) clinical subgroups, such as mild TBI; and (c) long-term management, such as rehabilitation services. Only in the last few years more attention has been paid to those research topics.

Conclusion:

NSs can positively impact the management of the broad spectrum of TBI in different clinical settings; however more research on patients’ outcomes and quality of life metrics is needed to establish their efficacy. The collaboration of global clinicians and the development of international guidelines applicable also to LMIC are warranted.

Prognostic Nomogram for Predicting Lower Extremity Deep Venous Thrombosis in Neurointensive Care Unit Patients: A Prospective Observational Study

Background

Deep venous thrombosis (DVT) of the lower extremities is one of the common complications for neurointensive care unit patients, which leads to increased morbidity and mortality. The purpose of our study was to explore risk factors and develop a prognostic nomogram for lower extremity DVT in neurointensive care unit patients.

Methods

We prospectively collected and analyzed the clinical data of 420 neurointensive care unit patients who received treatment in our institution between January 2018 and September 2019. Stepwise logistic regression was used to select predictors. R software was used to develop the prognostic nomogram. The performance of the nomogram was validated using a validation cohort of patients with data collected between October 2019 and March 2020.

Results

Among 420 patients, 153 (36.4%) had lower extremity DVT and five (1.2%) had both DVT and pulmonary embolism (PE) in our study. Logistic regression analysis indicated that age [odds ratio (OR): 1.050; 95% confidence interval (CI): 1.029–1.071; P < 0.001], Glasgow Coma Scale (GCS) score (OR: 0.889; 95% CI: 0.825–0.959; P = 0.002), D-dimer level (OR: 1.040; 95% CI: 1.008–1.074; P = 0.014), muscle strength (OR: 2.424; 95% CI: 1.346–4.366; P = 0.003), and infection (OR: 1.778; 95% CI: 1.034–3.055; P = 0.037) were independent predictors for lower extremity DVT. These predictors were selected to be included in the nomogram model. The area under the curve values in the primary cohort and validation cohort were 0.817 (95% CI: 0.776–0.858) and 0.778 (95% CI: 0.688–0.868), respectively, and respective Brier scores were 0.167 and 0.183.

Conclusion

Age, GCS score, D-dimer level, muscle strength, and infection are independent predictors for lower extremity DVT. The nomogram is a reliable and convenient model to predict the development of lower extremity DVT in neurointensive care unit patients.

Hereditary Antithrombin Deficiency: A Balancing Act of Perioperative Hemostasis and Thromboprophylaxis-A Case Report

Hereditary deficiency of antithrombin (AT) is associated with increased risk of venous thromboembolism (VTE), especially under the circumstances of stress, vascular injury, and immobilization associated with surgery. To date, there is no consensus on the use of perioperative anticoagulant bridging in the setting of hereditary thrombophilia. Balancing hemorrhagic and thrombotic risks associated with anticoagulant bridging and AT deficiency can be challenging to perioperative physicians. We present a case of a 65-year-old woman with inherited AT deficiency with history of multiple VTEs who was admitted for presurgical anticoagulant bridging before microvascular decompression craniotomy for trigeminal neuralgia.

Venous thromboembolism rates and risk factors following endoscopic skull base surgery

BACKGROUND

Venous thromboembolism (VTE) is a potentially fatal perioperative complication. The objective of this study was to assess the rate and risk factors for VTE in endoscopic skull base surgery (ESBS).

METHODS

This was a retrospective review of adults undergoing ESBS at a tertiary academic center. Incidence of VTE in the 30-day postoperative period was recorded. Logistic regression analyses identified factors associated with VTE.

RESULTS

1122 ESBS cases between 2009 and 2019 were studied. Almost no cases (96.1%) employed perioperative VTE chemoprophylaxis. The overall incidence of VTE was 2.3% (26/1122). Malignant pathologies had a higher rate of VTE compared to nonmalignant pathologies (4.5% vs 2.0%, OR 2.85, 95%CI 1.22-6.66). Factors associated with an increased risk of VTE included a Caprini score greater than 5 (OR 1.53, 95% CI 1.28-1.83); multiple preoperative endocrinopathies such as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (OR 22.48, 95% CI 3.93-128.70), adrenal insufficiency (OR 5.24, 95% CI 1.82-15.03), hypercortisolism (OR 4.46, 95% CI 1.47-13.56), and hypothyroidism (OR 3.69, 95% CI 1.66-8.20), each 10-hour increment of lumbar drain duration (OR 1.16, 95%CI 1.08-1.25), and each 10-hour increment for duration of hospitalization (OR 1.05, 95% CI 1.03-1.06).

CONCLUSIONS

The incidence of VTE following ESBS is relatively low. Factors with a higher association with VTE include malignancy, preoperative endocrinopathies, higher Caprini score, prolonged lumbar drain duration, and prolonged hospitalization. Further study is needed to validate these findings and to refine clinical decision making around perioperative VTE prophylaxis. This article is protected by copyright. All rights reserved.

Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience

Simple Summary

Giant pituitary adenomas are highly invasive tumors whose treatment is challenging. Surgery is their management mainstay. However, there is no consensus about the type of approach. Open transcranial, microscopic, and endoscopic trans-sphenoidal approaches have all been employed, alone or in combination. Extended endoscopic endonasal techniques may represent a versatile and safe one-stage approach. Our research aimed at evaluating prospectively their applicability, effectiveness, and safety in a multicenter series, to acquire further evidence toward its use in the treatment of those challenging lesions. Ninety-six patients were recruited and followed-up for 52.4 months on average. Most of them (81.2%) presented with visual deficits and >50% had various degrees of adenohypophysis insufficiency. Resection of at least 75% of initial volume was achieved in all cases, with 98.7% visual improvement, >50% endocrine deficit recovery and a permanent complication rate of 4.2%, indicating extended endoscopic endonasal approaches as a valuable treatment option.

Abstract

Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.

Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.

Pharmacologic thromboprophylaxis in adult patients undergoing neurosurgical interventions for preventing venous thromboembolism

The impact of pharmacologic prophylaxis for venous thromboembolism in patients undergoing neurosurgical intervention remains uncertain. We reviewed the efficacy and safety of pharmacologic compared with nonpharmacologic thromboprophylaxis in neurosurgical patients. Three databases were searched through April 2018, including those for randomized controlled trials (RCTs) and for nonrandomized controlled studies (NRSs). Independent reviewers assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Seven RCTs and 3 NRSs proved eligible. No studies reported on symptomatic proximal and distal deep vein thrombosis (DVT). Two RCTs reported on screening-detected proximal and distal DVTs. We used the findings of these 2 RCTs as the closest surrogate outcomes to inform the proximal and distal DVT outcomes. These 2 RCTs suggest that pharmacologic thromboprophylaxis may decrease the risk of developing asymptomatic proximal DVT (relative risk [RR], 0.50; 95% confidence interval [CI], 0.30-0.84; low certainty). Findings were uncertain for mortality (RR, 1.27; 95% CI, 0.57-2.86; low certainty), symptomatic pulmonary embolism (PE) (RR, 0.84; 95% CI, 0.03-27.42; very low certainty), asymptomatic distal DVT (RR, 0.54; 95% CI, 0.27-1.08; very low certainty), and reoperation (RR, 0.43; 95% CI, 0.06-2.84; very low certainty) outcomes. NRSs also reported uncertain findings for whether pharmacologic prophylaxis affects mortality (RR, 0.72; 95% CI, 0.46-1.13; low certainty) and PE (RR, 0.18; 95% CI, 0.01-3.76). For risk of bleeding, findings were uncertain in both RCTs (RR, 1.57; 95% CI, 0.70-3.50; low certainty) and NRSs (RR, 1.45; 95% CI, 0.30-7.12; very low certainty). In patients undergoing neurosurgical procedures, low certainty of evidence suggests that pharmacologic thromboprophylaxis confers benefit for preventing asymptomatic (screening-detected) proximal DVT with very low certainty regarding its impact on patient-important outcomes.

Venous Thromboembolism Prophylaxis in Elective Neurosurgery: A Survey of Board-Certified Neurosurgeons in the United States and Updated Literature Review

BACKGROUND

Venous thromboembolism (VTE) remains the single most important preventable cause of morbidity and mortality following neurosurgical procedures, with an incidence of approximately 16%. In the absence of stringent guidelines, the variation in current practice patterns could be considerable and was the underlying basis for this study.

OBJECTIVES

Our objective is to evaluate the modality of thromboprophylaxis used by neurosurgeons.

METHODS

In line with "CHERRIES" (Checklist for Reporting Results of Internet E-Surveys) guidelines, an online survey regarding postoperative VTE prophylaxis following elective neurosurgical procedures was created using Google Forms and distributed to 1500 board-certified neurosurgeons in the United States.

RESULTS

A total of 370 board-certified neurosurgeons (24.7%) responded to the survey. Sequential compression device was the only primary method of thromboprophylaxis used by 27.2% and 26.5% of respondents after elective craniotomy for tumor resection and spine surgery, respectively. Of the chemical prophylaxis, subcutaneous heparin 5000 U every 8 hours was the most commonly used medication followed by enoxaparin 40 mg daily. Most responders were comfortable starting chemical prophylaxis on postoperative day 1, followed by day 2 and day 3 in both types of surgeries. The mean postoperative time of chemical prophylaxis initiation was significantly more delayed by respondents with longer years in practice.

CONCLUSIONS

This study highlights the variation in practice between neurosurgeons in managing postoperative VTE prophylaxis after elective spine and cranial surgeries. In lieu of this variation, our results showed that most neurosurgeons are comfortable starting chemical prophylaxis as soon as postoperative day 1 following both types of procedures.

Managing Incomplete and Complete Thoracolumbar Burst Fractures (AO Spine A3 and A4). Results from a Prospective Single-Center Study Comparing Posterior Percutaneous Instrumentation plus Mini-Open Anterolateral Fusion versus Single-Stage Posterior Instrumented Fusion

OBJECTIVE

The treatment strategy for thoracolumbar burst fractures is still debated. The aim of this study is to evaluate clinical and radiologic outcomes of a 2-stage strategy with immediate posterior percutaneous instrumentation and delayed anterolateral fusion (group A) versus a single-stage open posterior instrumented fusion (group B).

METHODS

Demographics and clinical and surgical data of patients operated for AO Spine A3 and A4 fractures were prospectively collected. Vertebral height and deformity were evaluated before and after surgery. Visual analog scale score for back pain, Oswestry Disability Index, and 12-Item Short Form Health Survey results for quality-of-life assessment were collected during follow-up.

RESULTS

Among the 110 patients enrolled, 66 were allocated to group A and 44 to group B; the most common fractured level was T12 (34%). Postoperative complications were higher in group B, especially the wound infection rate (18% vs. 3%), and pseudomeningocele (14% vs. 0%). The 2-stage approach allowed an average long-term gain of 15.8° at the local kyphosis of fractured vertebra and 5.8° at the regional level (Cobb angle), versus 15.4° and 5.5° in group B. At 2 years follow-up, both groups showed significant functional improvements; however, the visual analog scale and Oswestry Disability Index metrics seemed more favorable for group A patients (P < 0.0001 vs. P < 0.003). A complete fusion rate was obtained in 100% of group A vs. 65% of group B.

CONCLUSIONS

Our study indicates that percutaneous instrumentation and anterior fusion or an expandable cage lead to excellent long-term clinical and radiologic outcomes with a lower complication rate and higher fusion rate than those of open posterior approaches.

Management Challenges of Metastatic Spinal Cord Compression in Pregnancy

Primary and secondary spinal tumours with cord compression often represent a challenging condition for the patient and clinicians alike, even more so during pregnancy. The balance between safe delivery of a healthy baby and management of the mother's disease bears many clinical, psychological, and ethical dilemmas. Pregnancy sets a conflict between the optimal surgical and oncological managements of the mother's tumour and the well-being of her foetus. We followed the CARE guidelines from the EQUATOR Network to report an exemplificative case of a 39-year-old woman with a 10-year history of breast cancer, presenting in the second trimester of her first pregnancy with acute onset severe thoracic spinal instability, causing mechanical pain and weakness in lower limbs. Neuroradiological investigations revealed multilevel spinal deposits with a pathological T10 fracture responsible for spinal cord compression. The patient was adamant that she wanted a continuation of the pregnancy and her baby delivered. After discussion with her oncologist and obstetrician, we agreed to perform emergency spinal surgery—decompression and instrumented fixation. The literature search did not reveal a similar case of spinal metastatic breast cancer undergoing spinal instrumentation and delivery of a healthy baby a few months later. Following the delivery, the patient had further oncological treatment, including chemotherapy and radiotherapy. The paucity of such reports prompted us to present this case and highlight the relevance of a multidisciplinary approach involving obstetrician, oncologist, spinal surgeon, and radiologist to guide the optimal decision-making process.

Prolonged activated partial thromboplastin time after prophylactic-dose unfractionated heparin in the post-operative neurosurgical setting: case series and management recommendations

Primary brain tumors, both benign and malignant, pose a high risk of perioperative venous thromboembolism (VTE) due to the development of a prothrombotic state. Perioperative pharmacologic thromboprophylaxis with subcutaneous (SC) unfractionated heparin (UFH) has significantly reduced VTE associated morbidity. Recent reports suggest an association between prolonged activated partial thromboplastin time (aPTT) due to prophylactic SC UFH and increased bleeding risk. We present three patients with normal baseline coagulation parameters in whom pharmacologic thromboprophylaxis with SC UFH resulted in a marked prolongation of the aPTT, leading to adverse outcomes in two patients. These cases demonstrate the uncertain kinetics of SC UFH and effect on aPTT, suggesting the significance of routine aPTT monitoring in high-risk settings. Given the wide variation in presentations of therapeutic or supratherapeutic values of aPTT in the perioperative neurosurgical setting, we propose a practical standardized approach to the evaluation and management of aPTT prolongation following prophylactic SC UFH administration.

Early and Ultraearly Administration of Tranexamic Acid in Traumatic Brain Injury: Our 8-Year-Long Clinical Experience

Introduction

The most important result of head trauma, which can develop with a blunt or penetrating mechanism, is traumatic brain injury. Tranexamic acid (TXA) can be used safely in multiple trauma. Recent studies showed that TXA can be useful in management of intracerebral hemorrhage, especially in reducing the amount of bleeding. The TXA given in the first 3 hours has been shown to reduce mortality. The aim of our study was to evaluate the effectiveness of tranexamic acid used in patients with traumatic brain injury.

Method

Patients with trauma in the emergency room between January 2012 and January 2020 were screened in this retrospective study. The inclusion criteria were being over the age of 18 years, tranexamic acid administration in the emergency department, and traumatic brain injury on brain computerized tomography (CT) and control CT imaging after 6 hours.

Results

The number of study patients was 51. The median score of GCS was 12.00 (8.00–15.00). Subdural hemorrhage and subarachnoid hemorrhage were the most common findings on brain CT scans. In the group TXA treatment for less than 1 hour, the arrival MAP was low and the pulse was high (p=0.022 and p=0.030, respectively). All the patients were admitted with multiple trauma. None of the 51 patients had thrombotic complications and died due to head injury.

Conclusion

TXA appears to be a safe drug with few side effects in the short term in head injuries. According to our experience, it comes to mind earlier in multiple trauma, especially in head trauma with pelvic trauma.

Perioperative anticoagulation in patients with intracranial meningioma: No increased risk of intracranial hemorrhage?

OBJECTIVE

Anticoagulation (AC) is a critical topic in perioperative and post-bleeding management. Nevertheless, there is a lack of data about the safe, judicious use of prophylactic and therapeutic anticoagulation with regard to risk factors and the cause and modality of brain tissue damage as well as unfavorable outcomes such as postoperative hemorrhage (PH) and thromboembolic events (TE) in neurosurgical patients. We therefore present retrospective data on perioperative anticoagulation in meningioma surgery.

METHODS

Data of 286 patients undergoing meningioma surgery between 2006 and 2018 were analyzed. We followed up on anticoagulation management, doses and time points of first application, laboratory values, and adverse events such as PH and TE. Pre-existing medication and hemostatic conditions were evaluated. The time course of patients was measured as overall survival, readmission within 30 days after surgery, as well as Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS). Statistical analysis was performed using multivariate regression.

RESULTS

We carried out AC with Fraxiparin and, starting in 2015, Tinzaparin in weight-adapted recommended prophylactic doses. Delayed (216 ± 228h) AC was associated with a significantly increased rate of TE (p = 0.026). Early (29 ± 21.9h) prophylactic AC, on the other hand, did not increase the risk of PH. We identified additional risk factors for PH, such as blood pressure maxima, steroid treatment, and increased white blood cell count. Patients' outcome was affected more adversely by TE than PH (+3 points in modified Rankin Scale in TE vs. +1 point in PH, p = 0.001).

CONCLUSION

Early prophylactic AC is not associated with an increased rate of PH. The risks of TE seem to outweigh those of PH. Early postoperative prophylactic AC in patients undergoing intracranial meningioma resection should be considered.

Prophylactic unfractionated heparin and hemorrhage in neurocritically ill underweight patients: A case series and review of the literature

PURPOSE

Three cases of major bleeding associated with thromboprophylactic unfractionated heparin (UFH) therapy in underweight neurocritically ill patients are reported.

SUMMARY

Three underweight patients (body mass index of <18.5 kg/m2) were treated in the intensive care unit with major bleeds associated with UFH thromboprophylaxis. Two of the patients, a 76-year-old female and a 56-year-old female, had hemorrhages on presentation; the third patient, a 29-year-old male, developed bleeding during his admission. All 3 patients had past medical histories consisting of acute neurologic conditions within 6 weeks of presentation, including subdural hematoma, subarachnoid hemorrhage, and obstructive hydrocephalus secondary to a brain mass. All hemorrhages developed following the receipt of prophylactic UFH at doses of 5,000 units every 8 to 12 hours, which translated to high weight-based dosages (>300 units/kg/d). Additionally, hemorrhages were associated with prolonged activated partial thromboplastin time, which declined following heparin discontinuation. The major bleeds following UFH administration included an acute on chronic subdural hematoma, acute rectus sheath hematoma, and cerebellar hematoma. Stabilization of the subdural hematoma was achieved without the use of protamine and the patient was discharged in stable condition. The other 2 patients expired secondary to their hemorrhagic events. Naranjo nomogram scores for the patients indicated that heparin was the probable cause of bleed in 2 cases and a possible cause in 1 case.

CONCLUSION

Three major hemorrhages developed following the administration of UFH. Underweight patients with neurologic injury may require increased clinical vigilance, reduced doses, and pharmacodynamic monitoring to improve safety outcomes associated with thromboprophylaxis.

Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review

Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.

The Effects of Patient Positioning on the Outcome During Posterior Cranial Fossa and Pineal Region Surgery

Background: Surgery on posterior cranial fossa (PCF) and pineal region (PR) carries the risks of intraoperative trauma to the brainstem structures, blood loss, venous air embolism (VAE), cardiovascular instability, and other complications. Success in surgery, among other factors, depends on selecting the optimal patient position. Our objective was to find associations between patient positioning, incidence of intraoperative complications, neurological recovery, and the extent of surgery.

Methods: This observational study was conducted in two medical centers: The Ohio State University Wexner Medical Center (USA) and The Burdenko Neurosurgical Institute (Russian Federation). Patients were distributed in two groups based on the surgical position: sitting position (SP) or horizontal position (HP). The inclusion criteria were adult patients with space-occupying or vascular lesions requiring an open PCF or PR surgery. Perioperative variables were recorded and summarized using descriptive statistics. The post-treatment survival, functional outcome, and patient satisfaction were assessed at 3 months.

Results: A total of 109 patients were included in the study: 53 in SP and 56 in HP. A higher proportion of patients in the HP patients had >300 mL intraoperative blood loss compared to the SP group (32 vs. 13%; p = 0.0250). Intraoperative VAE was diagnosed in 40% of SP patients vs. 0% in the HP group (p < 0.0001). However, trans-esophageal echocardiographic (TEE) monitoring was more common in the SP group. Intraoperative hypotension was documented in 28% of SP patients compared to 9% in HP group (p = 0.0126). A higher proportion of SP patients experienced a new neurological symptom compared to the HP group (49 vs. 29%; p = 0.0281). The extent of tumor resection, postoperative 3-months survival, functional outcome, and patient satisfaction were not different in the groups.

Conclusions: The SP was associated with, less intraoperative bleeding, increased intraoperative hypotension, VAE, and postoperative neurological deficit. More HP patients experienced macroglossia and increased blood loss. At 3 months, there was no difference of parameters between the two groups.

Clinical Trial Registration:ClinicalTrials.gov: registration number NCT03364283.

Incidence and Risk Factors for Venous Thromboembolism Following Craniotomy for Intracranial Tumors: A Cohort Study

Context:

Venous thromboembolism (VTE) is a devastating complication of intracranial tumor surgery. The present study helps identify patients at the greatest risk of developing VTE.

Aims:

The aim of the study was to evaluate the incidence of and risk factors for VTE following craniotomy for intracranial tumors.

Setting and Designs:

This was a retrospective cohort study.

Methods:

Data from the institutional database (between January 2017 and December 2018) were reviewed. Consecutive patients with intracranial tumors who underwent craniotomy were included.

Statistical Analysis Used:

Patient characteristics were reported as descriptive data, and factors associated with VTE development were analyzed by the Cox regression model.

Results:

The study identified 177 patients. The incidence of VTE was 10.2% (deep-vein thrombosis [DVT], 8.5%; pulmonary embolism [PE] 1.7%; and simultaneous DVT and PE, 1.7%). In univariate analysis, VTE development was associated with diabetes mellitus (DM), operative duration of >420 min, blood transfusion, and new-onset postoperative motor deficits. DM and new-onset postoperative motor deficits were statistically significant factors in multivariable analysis, with hazard ratios of 4.52 (95% confidence interval [CI] = 1.38–14.82) and 3.46 (95% CI = 1.17–10.23), respectively.

Conclusions:

Postcraniotomy VTE was detected in 10.2% of patients with intracranial tumors. Risk factors for VTE included DM and new-onset postoperative motor deficits. Hence, intracranial tumor patients with these risk factors are the most likely to require VTE prophylaxis with an anticoagulant.

A novel neuroimaging assessment of predictive risk factors associated with intraoperative massive hemorrhage in intracranial solid hemangioblastoma

Background

A solid hemangioblastoma (SH) is a benign and highly vascularized tumor. Microsurgical treatment of SH is still challenging due to excessive intraoperative bleeding.

Methods

Sixty-six consecutive patients with SH were retrospectively analyzed. The volume of intraoperative blood loss (IBL) and the features detected by magnetic resonance imaging (MRI) were evaluated by a neurosurgeon and multiple neuroradiologists.

Results

Four striking MRI features-peritumoral edema, the flow-void effect, large draining veins, and a visible feeding artery-were related to excessive IBL. Regarding the weighted values of these risk factors, the flow-void effect was the factor most significantly correlated with IBL (P<0.01, R=0.418). The feeding artery also contributed substantially to excessive IBL (P<0.05, R=0.412). The next most influential factor was the presence of large draining veins (P<0.05, R=0.350), followed by peritumoral edema (P<0.05, R=0.308). The four major risk factors-the flow-void effect, feeding arteries, large draining veins, and peritumoral edema-were assigned point values of 3, 3, 2, and 1, respectively, for a maximum total score of 9 points. A higher total score indicates that a higher volume of bleeding is more likely to occur during surgery.

Conclusions

This study reports the potential neuroimaging-based risk factors leading to abundant IBL in SH by neuroimaging assessment. The study proposes a novel scoring system to predict IBL, potentially decreasing the risk involved in the surgical treatment of SH.

Neurosurgical Care of Nonpowder Firearm Injuries: A Narrative Review of the Literature

Background

Nonpowder firearms discharge a projectile using compressed gases. Unlike traditional firearms, there is a perception that nonpowder guns do not cause serious injury. However, intracranial injury disproportionally affects children and can cause significant neurological disabilities and mortality. Management of nonpowder firearm injuries has received little attention in the literature and presents unique surgical challenges.

Materials and Methods

We conducted a narrative review of the literature of the management of nonpowder firearm injuries with particular emphasis on intracranial injury.

Results

Modern nonpowder firearms have muzzle velocities which are capable of penetrating the skin, eyes, and bone. Direct intracranial injury commonly results from entrance of projectile through thinner portions of the skull. Operative intervention is needed to debride and safely explore the trajectory to remove fragments which can easily cause neurovascular injury.

Conclusions

Neurosurgeons play a crucial role in managing serious nonpowder firearm injuries. A multidisciplinary team is needed to manage the direct results of penetrating injury and long-term sequalae.

Deep Vein Thrombosis and the Neurosurgical Patient

Background

Neurosurgical patients are varied, encompassing cranial and spinal diseases and trauma, and are admitted under both elective and emergency settings. In all settings, neurosurgery patients are at risk of deep vein thrombosis. D-dimer and ultrasound Doppler have long been good screening and confirmatory tools for the diagnosis of deep vein thrombosis (DVT). We conducted a study to identify the factors associated with DVT among neurosurgical patients, and the overall rate of occurrence at our centre. We aimed to also compare our results to the incidence in similar studies elsewhere in which more judicious use of pharmacological prophylaxis was undertaken. We also included the Well’s score to validate its usefulness in screening for DVT in our local setting.

Methods

All patients admitted into our centre were screened for eligibility and those who underwent surgery from September 2016 to September 2017 had a D-dimer screening after surgery, followed by an ultrasound Doppler if the former was positive. The choice of anticoagulant therapy was not influenced by this study, and observation of the use was in keeping with usual practices in our centre was done.

Results

A total number of 331 patients were recruited in this study, however, after the inclusion and exclusion criteria had been met, 320 patients remained eligible, i.e. suitable for analysis. The mean age of our patients was 46 years, with 66% being male patients. A majority of the cases in this study were cranial related, with only 5% being spine surgeries. On the multivariate analysis, the Well’s score and the number of days in bed remained statistically significant, after adjusting for age group, gender, ethnicity, type of central venous access and type of DVT prophylaxis with an adjusted odd’s ratio, and a confidence interval of 95%, and P < 0.05 for each.

Conclusion

Well’s scoring and number of days in bed were independent factors affecting the rate of DVT in patients undergoing neurosurgical procedures in our centre.

Outcomes of Total Hip Arthroplasty in Patients with Osteonecrosis of the Femoral Head Following Surgical Treatment of Brain Tumors

Corticosteroids have been widely used in patients with brain tumors to reduce tumor-associated edema and neurological deficits. This study examined the outcomes of total hip arthroplasty (THA) in patients with osteonecrosis of the femoral head (ONFH) following brain tumor surgery. We identified 34 THAs performed in 26 patients with steroid-induced ONFH among 9254 patients undergoing surgical treatment for primary brain tumors. After propensity score matching with demographics, 68 THAs (52 patients) in ONFH unrelated to brain tumors were selected as the control group. At the time of THA, 54% of brain tumor patients had neurological sequelae and 46% had adrenal insufficiency. After THA, patients with brain tumor required longer hospital stay, reported a lower functional score, and showed a higher rate of heterotopic ossification compared to the control group. However, hip pain score improved significantly after THA in the brain tumor group, and did not differ from that of the control group (P-value = 0.168). Major complication rates were similar (2.9% and 1.5% for the brain tumor and control groups, respectively; P-value = 1.000), and implant survivorships were not different at 7 years (100% and 98.1% for the brain tumor and control groups, respectively; P-value = 0.455). Our findings suggest that THA can be safely performed to reduce hip pain in patients with steroid-induced ONFH after surgical treatment of primary brain tumors.

Evaluation of a D-Dimer Protocol for Detection of Venous Thromboembolism

BACKGROUND

The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism.

METHODS

We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE.

RESULTS

In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE.

CONCLUSIONS

The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner.

Primary Gliosarcoma of the Cerebellum in a Young Pregnant Woman: Management Challenges and Immunohistochemical Features

Background

Gliosarcoma (GS) represents a rare, high-grade (WHO Grade IV), central nervous system neoplasm, characterized by a very poor prognosis. Similar to other high-grade gliomas, GS affects mainly adults in the 5^th-7^th decade of life and presents a higher incidence in males. The most reported locations of GS are the temporal lobe and the frontal lobe, while only eight cases of GS originating from the posterior cranial fossa are reported in the literature.

Case Description

We report the first case occurring during pregnancy in a 33-year-old patient. Diagnosis was obtained on the 15^th week of gestation when patient presented with signs and symptoms of life-threatening raised intracranial pressure. Surgical excision was followed by early recurrence and eventually disease progression because the patient refused adjuvant treatment to save her fetus.

Conclusions

GS should be considered in the differential diagnosis of posterior cranial fossa tumors with radiological features of meningioma or glioblastoma, even in young patients. To this regard, sarcomas, solitary fibrous tumors, and even metastases should be considered, especially in light of the tendency of GS to give rise to extracranial localizations. Whenever an aggressive management with radical excision and adjuvant treatment is not safely achievable, disease progression is likely to be unavoidable.

A Pilot Study of Percutaneous Interlaminar Endoscopic Lumbar Sequestrectomy: A Modern Strategy to Tackle Medically-Refractory Radiculopathies and Restore Spinal Function

Objective

Angled scopes allow 360° visualization, which makes percutaneous endoscopic techniques (percutaneous endoscopic lumbar discectomy, PELD) particularly attractive for sequestrectomies, which entail the removal of extruded lumbar disc fragments that have migrated caudally or cranially between the ligaments, foramina, and neural structures, while preserving the disc. Although many different PELD techniques are currently available, not all of them are suitable for sequestrectomies; furthermore, long-term follow-up data are unfortunately lacking.

Methods

A pilot study was conducted on a cohort of 270 patients with lumbar radiculopathy undergoing minimally invasive spine surgery (PELD or microdiscectomy), of whom only 7 were eligible for endoscopic interlaminar sequestrectomy with disc preservation. The patients’ baseline conditions and clinical outcomes were measured with the Oswestry Disability Index and a visual analogue scale. Long-term follow-up was conducted using satisfaction questionnaires that were based on the MacNab criteria and administered by medical/nursing personnel not involved in their primary surgical management.

Results

EasyGo system was eventually used in 5 PELD cases. No dural tears, infections, or nerve root injuries were recorded in patients undergoing sequestrectomy. Surgical events, including blood loss and overall length of hospital stay, did not differ significantly among the 270 patients. In the group treated with endoscopic sequestrectomy, no recurrences or complications were noted during a follow-up of 3 years, and an excellent degree of satisfaction was reported.

Conclusion

We provide OCEBM (Oxford Centre for Evidence-Based Medicine) level 3 evidence that interlaminar endoscopic sequestrectomy is a tailored and well-tolerated surgical option; nonetheless, a cost-effectiveness analysis assessing the interval until return to working activities and long-term benefits is warranted.