1
|
Eaton JC, Meyer RM, Lim DH, Greil ME, Williams JR, Young CC, Barber JK, Temkin NR, Bonow RH, Chesnut RM. Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals. World Neurosurg 2023; 179:e523-e529. [PMID: 37683917 DOI: 10.1016/j.wneu.2023.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients. METHODS We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury. RESULTS Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted). CONCLUSIONS Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.
Collapse
Affiliation(s)
- Jessica C Eaton
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - R Michael Meyer
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Do H Lim
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Madeline E Greil
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention Research Center, University of Washington, Seattle, WA, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; School of Global Health, University of Washington, Seattle, WA, USA.
| |
Collapse
|
2
|
Greil ME, Bergquist J, Kashlan ON, Kwon WK, Durfy S, Hofstetter CP. Incidence and management of dural tears in full-endoscopic unilateral laminotomies for bilateral lumbar decompression. Eur Spine J 2023; 32:2889-2895. [PMID: 37264093 DOI: 10.1007/s00586-023-07749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/20/2023] [Accepted: 04/25/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE To report incidence of dural lacerations in lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) and to describe patient outcomes following a novel full-endoscopic bimanual durotomy repair. METHODS Retrospective review of prospectively collected database including 5.5 years of single surgeon experience with LE-ULBD. Patients with no durotomy were compared with patients who experienced intraoperative durotomy, including demographics, ASA score, prior surgery, number of levels treated, procedure time, hospital length of stay (LOS), visual analogue scale, perioperative complications, revision surgeries, use of analgesics, and Oswestry Disability Index (ODI). RESULTS In total, 13/174 patients (7.5%) undergoing LE-ULBD experienced intraoperative durotomy. No significant differences in demographic, clinical or operative variables were identified between the 2 groups. Sustaining a durotomy increased LOS (p = 0.0019); no differences in perioperative complications or rate of revision surgery were identified. There was no difference in minimally clinically important difference for ODI between groups (65.6% for no durotomy versus 55.6% for durotomy, p = 0.54). CONCLUSION In this cohort, sustaining a durotomy increased LOS but, with accompanying intraoperative repair, did not significantly affect rate of complications, revision surgery or functional outcomes. Our method of bimanual endoscopic dural repair provides an effective approach for repair of dural lacerations in interlaminar ULBD cases.
Collapse
Affiliation(s)
- Madeline E Greil
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA, 98104, USA
| | - Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Osama N Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Woo-Keun Kwon
- Department of Neurosurgery, College of Medicine, Korea University Guro Hospital, Korea University, Seoul, Republic of Korea
| | - Sharon Durfy
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA, 98104, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA, 98104, USA.
| |
Collapse
|
3
|
Greil ME, Ogunlade JI, Bergquist J, Williams JR, Kashlan ON, Hofstetter CP. Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy. Eur Spine J 2023:10.1007/s00586-023-07698-1. [PMID: 37166550 DOI: 10.1007/s00586-023-07698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.
Collapse
Affiliation(s)
- Madeline E Greil
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - John I Ogunlade
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - John R Williams
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christoph P Hofstetter
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA.
| |
Collapse
|
4
|
Bergquist J, Greil ME, Khalsa SSS, Sun Y, Kashlan ON, Hofstetter CP. Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression. Eur Spine J 2023:10.1007/s00586-023-07705-5. [PMID: 37169883 DOI: 10.1007/s00586-023-07705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE Obesity is associated with increased surgical complexity and postoperative complications in spine surgery. Minimally invasive procedures have been shown to lessen some of the increased risk in obese patients. This study investigated whether utilization of a working channel endoscope can further mitigate obesity-associated challenges in spinal surgery. METHODS A retrospective review of a single-surgeon database was conducted for all adult patients undergoing full-endoscopic unilateral laminotomies for bilateral decompression between November 2015 and March 2021. Data collected included body mass index, in operating room preparation time, procedure time, length of hospital stay, use of analgesics, complications, and quality of life measured by Oswestry Disability Index. RESULTS Our cohort included 174 patients. Of these, 74 (42.5%) were obese. The average age was 63.6 years. In-operating room preparation time was 70.0 ± 1.7 min for obese patients and 64.4 ± 1.5 min for non-obese patients (p = 0.02). There was no difference in operative time, durotomy rates or other perioperative complications between obese and non-obese patients. Hospital length of stay trended toward longer in the obese group, but did not reach significance. A greater percentage of obese patients were still using both narcotic and non-narcotic pain medications 2 weeks after surgery. There was no significant difference in functional outcomes between groups. CONCLUSION Full-endoscopic unilateral laminotomies for bilateral decompression are safe and effective in both non-obese and obese patients. The use of an endoscope can partially mitigate obesity-related morbidity in lumbar decompression. However, obesity is significantly related to increased postoperative analgesic use.
Collapse
Affiliation(s)
- Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Madeline E Greil
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA, 98104, USA
| | - Siri Sahib S Khalsa
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA, 98104, USA.
| |
Collapse
|
5
|
Eaton JC, Greil ME, Nistal D, Caldwell DJ, Robinson E, Aljuboori Z, Temkin N, Bonow RH, Chesnut RM. Complications associated with early cranioplasty for patients with traumatic brain injury: a 25-year single-center analysis. J Neurosurg 2022; 137:1-6. [PMID: 35061995 DOI: 10.3171/2021.11.jns211557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors' high-volume level 1 trauma center over a 25-year time period. METHODS A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91-180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed. RESULTS Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined. CONCLUSIONS In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Nancy Temkin
- 1Department of Neurological Surgery
- 3Department of Biostatistics
| | - Robert H Bonow
- 1Department of Neurological Surgery
- 4Harborview Injury Prevention Research Center, and
| | - Randall M Chesnut
- 1Department of Neurological Surgery
- 5School of Global Health, University of Washington, Seattle, Washington
| |
Collapse
|
6
|
McAvoy M, Lee G, Boop S, Greil ME, Durler KA, Young CC, Craft L, Chesnut RM, Wahlster S. Fixed, Dilated, and Conversing—Unreactive Pupil With Preserved Consciousness Indicating Acutely Rising Intracranial Pressure due to Traumatic Intraparenchymal Contusions: Case Report and Review of the Literature. Neurohospitalist 2021; 12:355-360. [PMID: 35419147 PMCID: PMC8995591 DOI: 10.1177/19418744211056613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with fixed and dilated pupils (FDPs) due to rising intracranial pressure (ICP) typically experience a deterioration in consciousness. We describe an exceptional case of a patient with bifrontal contusions who developed worsening edema and a unilaterally FDP while maintaining consciousness and the ability to communicate. A 58-year-old man with history of hypertension and diabetes mellitus type II presented after being assaulted, with bifrontal contusions and right frontal intraparenchymal hemorrhage. On hospital day 8, his right pupil became fixed (NPi 0) and dilated (4.8 mm). The patient was drowsy, arousable to tactile stimuli, answering questions, oriented to place and time, following commands on his right side, maintaining Glasgow Coma Scale of 14 (E4, V5, M6). He described complete loss of vision and could not identify objects or count fingers. His gaze was dysconjugate with impaired vertical excursion and inability to fully abduct to the right side. Corneal reflexes were intact bilaterally. Hypertonic saline and mannitol produced no improvement in his pupillary exam. Head computed tomography showed worsening midline shift and interval increase in subfalcine herniation related to increased peri-hematoma edema. We performed an emergent right-sided decompressive hemicraniectomy with durotomy and duraplasty. His pupil became reactive 5 hours after surgery. While FDP without deterioration of consciousness has been described due to traumatic subdural and epidural hematomas, we report this unusual constellation as a sign of rising ICP and impeding herniation due to intraparenchymal contusions, highlighting that any pupillary change warrants prompt work-up and intervention.
Collapse
Affiliation(s)
- Malia McAvoy
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Gina Lee
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Scott Boop
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Madeline E. Greil
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Kayla A. Durler
- Department of Nursing, Harborview Medical Center, Seattle, WA, USA
| | | | - Lindy Craft
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Orthopedic Surgery, University of Washington, Seattle, WA, USA
- School of Global Health, University of Washington, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
| |
Collapse
|
7
|
Pan J, Barros G, Greil ME, Meyer RM, Ene CI, Chesnut RM. Pseudoaneurysm of the Superficial Temporal Artery After Intracranial Pressure Monitoring Device Placement: Case Report of a Rare Complication. Oper Neurosurg (Hagerstown) 2021; 19:288-291. [PMID: 32503046 DOI: 10.1093/ons/opaa151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/26/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Pseudoaneurysms involving the superficial temporal artery (STA), either iatrogenic or caused by direct trauma, are rare. The STA is prone to injury due to its long course throughout the scalp. Injuries can cause cosmetic defects and/or skin breakdown leading to further complications. CLINICAL PRESENTATION We report a case of delayed iatrogenic pseudoaneurysm of the STA after placement of an intracranial pressure monitor in the setting of acute traumatic brain injury. The patient had a delayed development of a pulsatile mass over his right frontal region, with computed tomography angiography concerning for a pseudoaneurysm of the STA. This was managed with surgical resection with complete resolution of symptoms at follow-up. CONCLUSION We review the literature regarding the etiology, pathogenesis, and management of these lesions. While iatrogenic injuries to the STA have been previously reported, this is a curious case related to placement of an intracranial pressure monitor. We recommend direct surgical resection of the pseudoaneurysm for cosmetic effect and prevention of further wound breakdown.
Collapse
Affiliation(s)
- James Pan
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Guilherme Barros
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Madeline E Greil
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - R Michael Meyer
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Chibawanye I Ene
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| |
Collapse
|
8
|
Gibson AW, Feroze AH, Greil ME, McGrath ME, Sivakanthan S, White-Dzuro GA, Williams JR, Young CC, Hofstetter CP. Cellular allograft for multilevel stand-alone anterior cervical discectomy and fusion. Neurosurg Focus 2021; 50:E7. [PMID: 34062509 DOI: 10.3171/2021.3.focus2150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is the most common treatment for degenerative disease of the cervical spine. Given the high rate of pseudarthrosis in multilevel stand-alone ACDF, there is a need to explore the utility of novel grafting materials. In this study, the authors present a single-institution retrospective study of patients with multilevel degenerative spine disease who underwent multilevel stand-alone ACDF surgery with or without cellular allograft supplementation. METHODS In a prospectively collected database, 28 patients who underwent multilevel ACDF supplemented with cellular allograft (ViviGen) and 25 patients who underwent multilevel ACDF with decellularized allograft between 2014 and 2020 were identified. The primary outcome was radiographic fusion determined by a 1-year follow-up CT scan. Secondary outcomes included change in Neck Disability Index (NDI) scores and change in visual analog scale scores for neck and arm pain. RESULTS The study included 53 patients with a mean age of 53 ± 0.7 years who underwent multilevel stand-alone ACDF encompassing 2.6 ± 0.7 levels on average. Patient demographics were similar between the two cohorts. In the cellular allograft cohort, 2 patients experienced postoperative dysphagia that resolved by the 3-month follow-up. One patient developed cervical radiculopathy due to graft subsidence and required a posterior foraminotomy. At the 1-year CT, successful fusion was achieved in 92.9% (26/28) of patients who underwent ACDF supplemented with cellular allograft, compared with 84.0% (21/25) of patients who underwent ACDF without cellular allograft. The cellular allograft cohort experienced a significantly greater improvement in the mean postoperative NDI score (p < 0.05) compared with the other cohort. CONCLUSIONS Cellular allograft is a low-morbidity bone allograft option for ACDF. In this study, the authors determined favorable arthrodesis rates and functional outcomes in a complex patient cohort following multilevel stand-alone ACDF supplemented with cellular allograft.
Collapse
Affiliation(s)
| | - Abdullah H Feroze
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Madeline E Greil
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Margaret E McGrath
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Sananthan Sivakanthan
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - John R Williams
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Christopher C Young
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | |
Collapse
|
9
|
Williams JR, Meyer MR, Ricard JA, Sen R, Young CC, Feroze AH, Greil ME, Barros G, Durfy S, Hanak B, Morton RP, Temkin NR, Barber JK, Mac Donald CL, Chesnut RM. Re-examining decompressive craniectomy medial margin distance from midline as a metric for calculating the risk of post-traumatic hydrocephalus. J Clin Neurosci 2021; 87:125-131. [PMID: 33863519 DOI: 10.1016/j.jocn.2021.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
Decompressive craniectomy (DC) is a life-saving procedure in severe traumatic brain injury, but is associated with higher rates of post-traumatic hydrocephalus (PTH). The relationship between the medial craniectomy margin's proximity to midline and frequency of developing PTH is controversial. The primary study objective was to determine whether average medial craniectomy margin distance from midline was closer to midline in patients who developed PTH after DC for severe TBI compared to patients that did not. The secondary objective was to determine if a threshold distance from midline could be identified, at which the risk of developing PTH increased if the DC was performed closer to midline than this threshold. A retrospective review was performed of 380 patients undergoing DC at a single institution between March 2004 and November 2014. Clinical, operative and demographic variables were collected, including age, sex, DC parameters and occurrence of PTH. Statistical analysis compared mean axial craniectomy margin distance from midline in patients with versus without PTH. Distances from midline were tested as potential thresholds. No significant difference was identified in mean axial craniectomy margin distance from midline in patients developing PTH compared with patients with no PTH (n = 24, 12.8 mm versus n = 356, 16.6 mm respectively, p = 0.086). No significant cutoff distance from midline was identified (n = 212, p = 0.201). This study, the largest to date, was unable to identify a threshold with sufficient discrimination to support clinical recommendations in terms of DC margins with regard to midline, including thresholds reportedly significant in previously published research.
Collapse
Affiliation(s)
- John R Williams
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA.
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Jocelyn A Ricard
- University of Minnesota, 3 Morrill Hall, 100 Church St. S.E, Minneapolis, MN 55455, USA
| | - Rajeev Sen
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Abdullah H Feroze
- Department of Neurosurgery, Loma Linda University Health, 11234 Anderson St., Suite 2562B, Loma Linda, CA 92354, USA
| | - Madeline E Greil
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Guilherme Barros
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Sharon Durfy
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Brian Hanak
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Ryan P Morton
- Department of Neurosurgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Christine L Mac Donald
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| |
Collapse
|
10
|
Girgis F, Greil ME, Fastenau PS, Sweet J, Lüders H, Miller JP. Resection of Temporal Neocortex During Multiple Hippocampal Transections for Mesial Temporal Lobe Epilepsy Does not Affect Seizure or Memory Outcome. Oper Neurosurg (Hagerstown) 2017; 13:711-717. [DOI: 10.1093/ons/opx031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 01/31/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Multiple hippocampal transection (MHT) is a surgical treatment for mesial temporal lobe epilepsy associated with improved postoperative neuropsychological outcomes compared with lobectomy.
OBJECTIVE
To determine whether resection of the amygdala and anterior temporal neocortex during MHT affects postoperative seizure/memory outcome.
METHODS
Seventeen patients with normal magnetic resonance imaging and stereo-electroencephalogram-proven drug-resistant dominant mesial temporal lobe epilepsy were treated with MHT. Nine patients underwent MHT alone (MHT–) and 8 patients underwent MHT plus removal of the amygdala and anterior 4.5 cm of temporal neocortex lateral to the fusiform gyrus (MHT+). Verbal and visual-spatial memory were assessed in all patients preoperatively and in 14 patients postoperatively using the Wechsler Memory Scale. Postoperative seizure control was assessed at 12 months for all patients.
RESULTS
Overall, 11 of 17 patients (64.7%) were Engel class 1 at 1 year (6/9 MHT–, 5/8 MHT+, P = .38), and 10 of 14 patients (71.4%) had no significant postoperative decline in either verbal or visual memory (6/8 MHT–, 4/6 MHT+, P = .42). Verbal memory declined in 2 of 8 MHT– and 1 of 6 MHT+ patients, and visual memory declined in 1 of 8 MHT– and 2 of 6 MHT+ patients. Two patients had improved visual memory postoperatively, both in the MHT+ group.
CONCLUSION
MHT on the dominant side is associated with high rates of seizure freedom and favorable memory preservation outcomes regardless of the extent of neocortical resection. Preservation of the temporal neocortex and amygdala during MHT does not appear to decrease the risk of postoperative memory decline, nor does it alter seizure outcome.
Collapse
Affiliation(s)
- Fady Girgis
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Madeline E Greil
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Philip S Fastenau
- Department of Neurology, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jennifer Sweet
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Hans Lüders
- Department of Neurology, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|