Publications by authors named "Kostas N Fountas"

119 Publications

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience.

Int J Neurosci 2020 Aug 4:1-13. Epub 2020 Aug 4.

Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.

Background: It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping.

Material And Methods: In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors.

Results: Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15 and the 60 post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival.

Conclusions: Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.
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http://dx.doi.org/10.1080/00207454.2020.1801676DOI Listing
August 2020

Dissecting the default mode network: direct structural evidence on the morphology and axonal connectivity of the fifth component of the cingulum bundle.

J Neurosurg 2020 Apr 24:1-12. Epub 2020 Apr 24.

1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens.

Objective: Although a growing body of data support the functional connectivity between the precuneus and the medial temporal lobe during states of resting consciousness as well as during a diverse array of higher-order functions, direct structural evidence on this subcortical circuitry is scarce. Here, the authors investigate the very existence, anatomical consistency, morphology, and spatial relationships of the cingulum bundle V (CB-V), a fiber tract that has been reported to reside close to the inferior arm of the cingulum (CingI).

Methods: Fifteen normal, formalin-fixed cerebral hemispheres from adults were treated with Klingler's method and subsequently investigated through the fiber microdissection technique in a medial to lateral direction.

Results: A distinct group of fibers is invariably identified in the subcortical territory of the posteromedial cortex, connecting the precuneus and the medial temporal lobe. This tract follows the trajectory of the parietooccipital sulcus in a close spatial relationship with the CingI and the sledge runner fasciculus. It extends inferiorly to the parahippocampal place area and retrosplenial complex area, followed by a lateral curve to terminate toward the fusiform face area (Brodmann area [BA] 37) and lateral piriform area (BA35). Taking into account the aforementioned subcortical architecture, the CB-V allegedly participates as a major subcortical stream within the default mode network, possibly subserving the transfer of multimodal cues relevant to visuospatial, facial, and mnemonic information to the precuneal hub. Although robust clinical evidence on the functional role of this stream is lacking, the modern neurosurgeon should be aware of this tract when manipulating cerebral areas en route to lesions residing in or around the ventricular trigone.

Conclusions: Through the fiber microdissection technique, the authors were able to provide original, direct structural evidence on the existence, morphology, axonal connectivity, and correlative anatomy of what proved to be a discrete white matter pathway, previously described as the CB-V, connecting the precuneus and medial temporal lobe.
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http://dx.doi.org/10.3171/2020.2.JNS193177DOI Listing
April 2020

Fluorescent Guided Surgery in the Surgical Management of Glioma: The Dawn of a New Era.

Authors:
Kostas N Fountas

Brain Sci 2020 Apr 16;10(4). Epub 2020 Apr 16.

Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Biopolis, 41110 Larisa, Greece.

A growing body of evidence supports the importance of marginal or even supramarginal resection in cases of high- but also of low-grade gliomas [...].
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http://dx.doi.org/10.3390/brainsci10040237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226232PMC
April 2020

Neuroimaging methods in Epilepsy of Temporal Origin.

Curr Med Imaging Rev 2019 ;15(1):39-51

Department of Medical Physics, School of Medicine, University of Thessaly, Larisa, Greece.

Background: Temporal Lobe Epilepsy (TLE) comprises the most common form of symptomatic refractory focal epilepsy in adults. Accurate lateralization and localization of the epileptogenic focus are a significant prerequisite for determining surgical candidacy once the patient has been deemed medically intractable. Structural MR imaging, clinical, electrophysiological, and neurophysiological data have an established role in the localization of the epileptogenic foci. Nevertheless, hippocampal sclerosis cannot be detected on MR images in more than 30% of patients with TLE, and the presurgical assessment remains controversial.

Discussion: In the last years, advanced MR imaging techniques, such as 1H-MRS, DWI, DTI, DSCI, and fMRI, may provide valuable additional information regarding the physiological and metabolic characterization of brain tissue. MR imaging has shifted towards functional and molecular imaging, thus, promising to improve the accuracy regarding the lateralization and the localization of the epileptogenic focus. Additionally, nuclear medicine studies, such as SPECT and PET imaging modalities, have become an asset for the decoding of brain function and activity, and can be diagnostically helpful as well, since they provide valuable data regarding the altered metabolic activity of the seizure foci.

Conclusion: Overall, advanced MRI, SPECT, and PET imaging techniques are increasingly becoming an essential part of TLE diagnostics, when the epileptogenic area is not identified on structural MRI or when structural MRI, clinical, and electrophysiological findings are not in concordance.
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http://dx.doi.org/10.2174/1573405613666170622114920DOI Listing
July 2020

Arteriovenous Malformations: Congenital or Acquired Lesions?

World Neurosurg 2020 Feb 9;134:e799-e807. Epub 2019 Nov 9.

Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.

Objective: Arteriovenous malformations (AVMs) were believed to be congenital. However, an increasing number of de novo AVM cases have questioned this doctrine.

Methods: A consensus meeting of international experts attempted to establish a consensus on the nature of these relatively rare but challenging vascular lesions. In addition, an extensive search of the subject was performed using the PubMed medical database.

Results: All participants agreed that genetic factors may play a role in the pathogenesis of AVMs. All but 1 participant believed that an underlying genetic predisposition may be detected later on in a patient's life, whereas genetic variations may contribute to sporadic AVM formation. The presence of genetic variations alone may not be enough for an AVM formation. A second hit is probably required. This consensus opinion is also supported by our literature search.

Conclusions: We discuss the literature on the genetics of AVMs and compare it with the consensus meeting outcomes. The congenital or noncongenital character of intracranial AVMs has an impact on the understanding their biological behavior, as well as their efficient short-term and long-term management.
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http://dx.doi.org/10.1016/j.wneu.2019.11.001DOI Listing
February 2020

Complications Associated with Surgery for Thoracic Disc Herniation: A Systematic Review and Network Meta-Analysis.

World Neurosurg 2019 Dec 5;132:334-342. Epub 2019 Sep 5.

Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece; Medical School, University of Thessaly, Thessaly, Greece.

Background: A systematic review and network meta-analysis (Prospero ID CRD42018106936) were performed.

Objective: The selection of the appropriate surgical approach for the management of thoracic disc herniation (TDH) is often challenging because of the frequency and variability of the associated complications. We evaluated the safety of the surgical approaches for TDH by estimating the mortality (Q1) and morbidity (Q2), and frequency of the most common complications (Q3).

Methods: We searched the medical literature for randomized controlled trials and observational studies reporting on the management of TDH. Postoperative complications were the outcome of interest. The absolute and relative risk estimates, along with the rank probability scores, were estimated for each approach, through a network meta-analysis. The results were read in the light of the quality of the available evidence.

Results: Fifteen studies with a total of 1036 patients fulfilled our eligibility criteria. Three deaths were reported. The overall morbidity was as high as 29%, largely attributed to medical (21%; 95% confidence interval [CI], 10%-38%), surgical site (11%; 95% CI, 5%-22%), cerebrospinal fluid-related (8%; 95% CI, 3%-8%), and neurologic complications (5%; 95% CI, 1%-24%). The anterior and lateral approaches were associated with a higher risk for medical and surgical complications compared with the posterolateral approach.

Conclusions: Surgery for TDH is associated with minimal mortality but significant morbidity, with large variations among the available approaches. An understanding of the perioperative complications rates is important to develop complication avoidance strategies and to aid accurate patient-to-doctor communication.
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http://dx.doi.org/10.1016/j.wneu.2019.08.202DOI Listing
December 2019

Complications after Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and Meta-Analysis.

Stereotact Funct Neurosurg 2019 9;97(2):69-82. Epub 2019 Jul 9.

Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.

Background: The efficacy of surgery in the management of patients with longstanding temporal lobe epilepsy has been established. Anterior temporal lobectomy (ATL) is the most frequently implemented procedure. However, there is an obvious need to assess its perioperative safety.

Objective: We conducted a meta-analysis to estimate the postoperative mortality (Q1) and morbidity (Q2) associated with ATL for medically intractable epilepsy. In addition, we tried to identify the most frequent complications after ATL and assess their relative frequency (Q3) in children and adults.

Methods: Fixed- and random-effects model meta-analysis was conducted to assess the proportion estimate for each outcome individually.

Results: The postoperative mortality and cumulative morbidity were estimated to be as high as 0.01 (95% CI: 0.01, 0.02) and 0.17 (95% CI: 0.12, 0.24), respectively. Psychiatric disorders were the most common postoperative complications after ATL, with an estimated frequency as high as 0.07 (95% CI: 0.04, 0.10), followed by visual field defects (0.06; 0.03, 0.11), and cognitive disorders (0.05; 0.02, 0.10). Less frequent complications included hemiparesis and language disorders (0.03; 0.01, 0.06), infections (0.03; 0.02, 0.04), hemorrhage (0.02; 0.01, 0.05), cranial nerve deficits (0.03; 0.02, 0.05), extra-axial fluid collections (0.02; 0.01, 0.03), and medical complications (0.02; 0.01, 0.03).

Conclusions: Even though the mortality after ATL is minimal, the overall morbidity cannot be ignored. Psychiatric disturbances, visual field defects, and cognitive disorders are the most common postoperative complications, and should be considered during the preoperative planning and consultation.
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http://dx.doi.org/10.1159/000500136DOI Listing
February 2020

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

Acta Neurochir (Wien) 2019 07 28;161(7):1261-1274. Epub 2019 May 28.

Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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http://dx.doi.org/10.1007/s00701-019-03936-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581926PMC
July 2019

Bilateral Tapia's syndrome secondary to cervical spine injury: a case report and literature review.

Br J Neurosurg 2019 May 17:1-5. Epub 2019 May 17.

a Department of Neurosurgery , University Hospital of Larissa , Larissa , Greece.

A 24-year-old man presented with bilateral Tapia's syndrome (TS) after a traumatic cervical spine injury, manifested by apraxia of the hypoglossal and recurrent laryngeal nerves. The initial presentation was a profound inability to maintain upper respiratory airway patency due to bilateral vocal cord paralysis, accompanied by impairment of swallowing and loss of speech. The diagnosis was based on clinical grounds and verified by endoscopic laryngoscopy. A C7 corpectomy was performed for stabilizing the cervical spine, while conservative treatment with steroids was reserved for the TS. Over the following six months, there was complete resolution of the symptoms.
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http://dx.doi.org/10.1080/02688697.2019.1617408DOI Listing
May 2019

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature.

World Neurosurg 2019 Jun 14;126:581-587. Epub 2019 Mar 14.

Department of Diagnostic Radiology, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece.

Background: Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst.

Case Description: A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed.

Conclusions: Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.
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http://dx.doi.org/10.1016/j.wneu.2019.02.222DOI Listing
June 2019

Hemorrhagic transformation of posterior fossa ischemia after antithrombotic therapy for a blunt vertebral artery injury: a case report.

AME Case Rep 2018 11;2:30. Epub 2018 Jun 11.

Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece.

We describe a rare case of a 69-year-old male who developed a hemorrhagic transformation of a posterior fossa ischemia after the initiation of antithrombotic therapy for the management of blunt vertebral artery injury (BVAI). To the best of our knowledge, this is the first reported case in the literature so far. Thus, we present our diagnostic approach, its associated treatment challenges, and its overall outcome.
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http://dx.doi.org/10.21037/acr.2018.06.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6155717PMC
June 2018

The Role of Intraventricular Antibiotics in the Treatment of Nosocomial Ventriculitis/Meningitis from Gram-Negative Pathogens: A Systematic Review and Meta-Analysis.

World Neurosurg 2018 Dec 29;120:e637-e650. Epub 2018 Aug 29.

Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece.

Background: The emergence of multidrug-resistant pathogens has resulted in difficult-to-treat ventriculitis/meningitis (VM). We used a meta-analysis to study the role of intraventricular (IVT) antibiotic administration as an adjunct (IVT plus intravenous [IV]) to the classic intravenous antimicrobial therapy (IV-only) in the management of VM in terms of infection control, functional outcome, microbial eradication, complications, cost-benefit analysis, infectious mortality, and overall mortality.

Methods: The electronic search focused on adult neurosurgical cases complicated by gram-negative VM and was limited to studies comparing IVT plus IV and IV-only. The quality of the overall body of evidence was assessed according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). The pooled estimates for each question were summarized as odds ratios (ORs) and visualized using forest plots. Every outcome was stratified according to carbapenem resistance.

Results: Eleven studies with 348 patients fulfilled the eligibility criteria. No evidence was found for infection control, functional outcome, or complications. For the remaining items evaluated, the overall quality of the best available evidence was low. IVT plus IV treatment was statistically superior to IV-only therapy in eradication (OR, 10.06; 95% confidence interval [CI], 2.62-38.65), infectious mortality (OR, 0.1; 95% CI, 0.03-0.36), and overall mortality (OR, 0.22; 95% CI, 0.08-0.60) in the management of carbapenem-resistant pathogens only.

Conclusions: Combined IVT plus IV treatment did not prove superior to standard IV-only treatment in the management of VM. Nevertheless, weak evidence showed that IVT treatment might serve as an adjunct in the management of carbapenem-resistant pathogens.
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http://dx.doi.org/10.1016/j.wneu.2018.08.138DOI Listing
December 2018

Letter to the editor regarding "Dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis".

Acta Neurochir (Wien) 2018 11 28;160(11):2145-2147. Epub 2018 Aug 28.

Department of Neurosurgery, Medical School of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1007/s00701-018-3661-2DOI Listing
November 2018

Surgical and functional outcome of olfactory groove meningiomas: Lessons from the past experience and strategy development.

Clin Neurol Neurosurg 2018 08 18;171:46-52. Epub 2018 May 18.

Department of Neurosurgery, Sanador Medical Center Hospital, Bucharest, Romania.

Object: Olfactory groove meningiomas (OGMs) constitute a unique subset of intracranial meningiomas, since they usually remain clinically silent for a long period of time, and they may be of large size upon their diagnosis. Their surgical management remains quite challenging. The surgical and the neuropsychological outcome of patients with OGM are presented in our current study, in order to establish a basis for developing efficacious surgical strategies for the management of this clinico-pathological entity.

Methods: A retrospective study covering a 17-year period examined a total of 78 patients (31 males and 47 females) diagnosed with OGM, and surgically managed in the two participating institutions (Greece and Romania). The patients' charts as well as their imaging studies (head CT, brain MRI/HMRS, brain MRA/MRV, cerebral DSA), and their operative reports were carefully reviewed. All participants underwent pre- and post-operative neurocognitive evaluation with the Mini Mental Status Examination (MMSE), and the Frontal Assessment Battery (FAB). Microsurgical resection was performed by employing a bilateral subfrontal, a unilateral subfrontal, or a pterional approach. The Simpson scale was utilized for assessing the extent of resection. The histological type of the resected meningioma was identified. The follow up period ranged from 2 to 15 years (mean: 5.6).

Results: Non-specific headache was the most common presenting symptom, followed by personality changes in our series. Grade 1 Simpson resection was accomplished in 19.2%, grade 2 in 46.2%, grade 3 in 17.9%, and grade 4 in 16.7%. The most common postoperative complication was anosmia (89.7%), followed by CSF leakage (21.8%). The observed 5-year recurrence rate was 11.8%. Analysis of our data demonstrated that patients with larger tumors presented with poorer neurocognitive status, and had also lower, compared with patients with smaller meningioma, postoperative neurocognitive outcome. Meningioma's histological type had no correlation with complication occurrence or tumor recurrence. Surgical resection significantly improved the preoperative MMSE scores of our patients, while the observed postoperative improvement of the FAB scores was not statistically significant. The bilateral subfrontal approach demonstrated higher complication rate than the other two approaches, in our series. Interestingly, bifrontal approach was associated with higher tumor recurrence rate. Tumor size, patient's age, and ethmoid bone infiltration seem to be predisposing factors for complication occurrence and tumor recurrence.

Conclusion: Individualized surgical strategy is necessary for mitigating the postoperative complication rate, and the possibility of recurrence in the management of OGMs. The exact role of less invasive, endoscopic approaches in the management of these patients remains to be defined.
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http://dx.doi.org/10.1016/j.clineuro.2018.05.016DOI Listing
August 2018

Correlation of Clinical and Radiological Outcome After Anterior Cervical Discectomy and Fusion With a Polyetheretherketone Cage.

J Clin Med Res 2018 Mar 26;10(3):268-276. Epub 2018 Jan 26.

Department of Neurosurgery, School of Medicine, University of Thessaly, Larissa, Greece.

Background: Anterior cervical discectomy and fusion (ACDF) with a polyetheretherketone (PEEK) cage is considered as the gold standard for patients with cervical disc disease. However, there are limited data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. The purpose of this study was to investigate the impact of altered cervical sagittal alignment (cervical lordosis) and sagittal range of motion (ROM) on patients' self-reported pain and functional disability, after ACDF with a PEEK cage.

Methods: We prospectively studied 74 patients, who underwent single-, or consecutive two-level ACDF with a PEEK interbody cage. The clinical outcomes were assessed by using the pain numeric rating scale (NRS) and the neck disability index (NDI). Radiological outcomes included cervical lordosis and C2-C7 sagittal ROM. The outcome measures were collected preoperatively, at the day of patients' hospital discharge, and also at 6 and 12 months postoperatively.

Results: There was a statistically significant reduction of the NRS and NDI scores postoperatively at each time point (P < 0.005). Cervical lordosis and also ROM significantly reduced until the last follow-up (P < 0.005). There was significant positive correlation between NRS and NDI preoperatively, as well as at 6 and 12 months postoperatively (P < 0.005). In regard to the ROM and the NDI scores, there was no correlation preoperatively (P = 0.199) or postoperatively (6 months, P = 0.322; 12 months, P = 0.476). Additionally, there was no preoperative (P = 0.134) or postoperative (6 months, P = 0.772; 12 months, P = 0.335) correlation between the NDI scores and cervical lordosis.

Conclusions: In our study, reduction of cervical lordosis and sagittal ROM did not appear to significantly influence on patients' self-reported disability. Such findings further highlight the greater role of pain level over the mechanical limitations of ACDF with a PEEK cage on patients' own perceived recovery.
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http://dx.doi.org/10.14740/jocmr3326wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798276PMC
March 2018

Multimodality treatment of intradural extramedullary Ewing's sarcomas. A systematic review.

Clin Neurol Neurosurg 2018 01 7;164:169-181. Epub 2017 Dec 7.

Department of Neurosurgery, University Hospital of Larissa, Greece.

Ewing's sarcoma (ES) is an aggressive bone and soft tissue sarcoma that usually affects adolescents and young adults. ES occasionally presents as an intradural-extramedullary lesion of the spine. Our aim was to study the role of the multimodality treatment on the survival (overall survival, recurrence-free survival, and metastasis-free survival) of patients with intradural-extramedullary Ewing's sarcoma. Pubmed, EMBASE, Scopus, Web of Science, Cochrane Reviews were searched up to January 2017, using as mesh terms "intradural extramedullary", "Ewing's sarcoma", AND "treatment". The multidisciplinary treatment was recorded in binary variables under the headings of "surgery", "chemotherapy" and "radiotherapy". We also recorded three time-to-event variables, including death, recurrence, and metastasis. We performed survival analysis for all potential combinations. Twenty articles with twenty-three patients were eligible for the current review. The survival curves of GTR did not differ from the equivalent of STR regarding survival (p=0.098), recurrence-free survival (p=0.318), and metastasis-free survival (p=0.089). Patients who received chemotherapy enjoyed longer survival regarding overall survival (p<0.05), recurrence-free survival (p<0.05), and metastasis-free survival (p<0.05), when compared to those who did not receive chemotherapy. Their overall survival of patients who had radiotherapy was marginally superior to those who did not receive (p=0.0653). However, their recurrence-free survival (p<0.05), and metastasis-free survival (p<0.05) were significantly improved in comparison to the latter. In conclusion, the multimodality treatment is mandatory for the management of patients with intradural extramedullary Ewing's sarcomas, with surgery assisting in the diagnosis and decompression the neural elements. However, it is chemotherapy that improves survival, recurrence-free survival, and metastasis-free survival. Radiotherapy is reserved as an adjuvant therapy in the local control, especially in cases with subtotal tumour resection.
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http://dx.doi.org/10.1016/j.clineuro.2017.11.014DOI Listing
January 2018

Collagen type-I A2 gene polymorphisms and susceptibility to intracranial aneurysms: a meta-analysis of genetic association studies.

Int J Neurosci 2018 Jul 13;128(7):640-653. Epub 2017 Dec 13.

a Department of Neurosurgery , University Hospital of Larissa , Larissa , Greece.

Background: The development, evolution and rupture of intracranial aneurysms are in part related to genetic factors. The role of collagen type-I a2 genetic polymorphisms has not been clarified yet.

Material And Methods: A meta-analysis was realized by means of a genotype model-fitting process (allele contrast, recessive, dominant, additive and co-dominant), and a model-free approach using the generalized odds ratio. The latter was assessed in association to the degree of dominance (h-index).

Results: No statistically significant association was documented between EX28 G>C collagen type-I a2 variant and intracranial aneurysms (generalized odds ratio = 1.23, 95% confidence interval = 0.57, 2.63). Significant associations between INT46 T>G collagen type I a2 variant and intracranial aneurysms were documented in three models, the dominant [0.52 (0.38, 069)], the co-dominant [0.50 (0.32, 0.78)] and the allele contrast models [0.63 (0.49, 0.82)]. The generalized odds ratio was estimated to be as high as 1.94 (1.23, 3.06). The degree of dominance (h-index = -1.54) indicated that the TG genotype was characterized by lower risk of developing intracranial aneurysms compared to the TT genotype.

Conclusions: The available literature data demonstrated that there is no association of collagen type-(2a) and intracranial aneurysms, through EX28 G>C (rs42524) polymorphism according to the model-fitting process and the model-free approach. Regarding the INT46 T>G (rs2621215) polymorphisms, the latter models indicated that there could be a protective effect of the G-allele against the development of intracranial aneurysms. However, the majority of studies are from East Asia, therefore the results are applicable primarily to that patient population.
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http://dx.doi.org/10.1080/00207454.2017.1408616DOI Listing
July 2018

Anterior cervical spine surgery-associated complications in a retrospective case-control study.

J Spine Surg 2017 Sep;3(3):444-459

Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece.

Anterior cervical spine procedures have been associated with satisfactory outcomes. However, the occurrence of troublesome complications, although uncommon, needs to be taken into consideration. The purpose of our study was to assess the actual incidence of anterior cervical spine procedure-associated complications and identify any predisposing factors. A total of 114 patients undergoing anterior cervical procedures over a 6-year period were included in our retrospective, case-control study. The diagnosis was cervical radiculopathy, and/or myelopathy due to degenerative disc disease, cervical spondylosis, or traumatic cervical spine injury. All our participants underwent surgical treatment, and complications were recorded. The most commonly performed procedure (79%) was anterior cervical discectomy and fusion (ACDF). Fourteen patients (12.3%) underwent anterior cervical corpectomy and interbody fusion, seven (6.1%) ACDF with plating, two (1.7%) odontoid screw fixation, and one anterior removal of osteophytes for severe Forestier's disease. Mean follow-up time was 42.5 months (range, 6-78 months). The overall complication rate was 13.2%. Specifically, we encountered adjacent intervertebral disc degeneration in 2.7% of our cases, dysphagia in 1.7%, postoperative soft tissue swelling and hematoma in 1.7%, and dural penetration in 1.7%. Additionally, esophageal perforation was observed in 0.9%, aggravation of preexisting myelopathy in 0.9%, symptomatic recurrent laryngeal nerve palsy in 0.9%, mechanical failure in 0.9%, and superficial wound infection in 0.9%. In the vast majority anterior cervical spine surgery-associated complications are minor, requiring no further intervention. Awareness, early recognition, and appropriate management, are of paramount importance for improving the patients' overall functional outcome.
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http://dx.doi.org/10.21037/jss.2017.08.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637201PMC
September 2017

The diagnostic accuracy of magnetic resonance angiography for blunt vertebral artery injury detection in trauma patients: A systematic review and meta-analysis.

Clin Neurol Neurosurg 2017 Sep 21;160:152-163. Epub 2017 Jul 21.

Department of Radiology, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece.

The role of magnetic resonance angiography (MRA) in the evaluation of patients with blunt vertebral artery has not been fully established. Our aim is to define the diagnostic accuracy of MRA in comparison to digital subtraction angiography (DSA) for the detection of blunt vertebral artery injury in trauma patients. A computer-assisted literature search of the PubMed, Scopus, Highwire, Web of Science, and LILACS was conducted, in order to identify studies reporting on the sensitivity and specificity of MRA in comparison to DSA for the detection of blunt vertebral artery injury in trauma patients. The Database search retrieved 91 studies. Five studies fulfilled our eligibility criteria. Two authors assessed the risk of bias and applicability concerns using QUADAS-2. Two-by-two contingency tables were constructed on a per-vessel level. Heterogeneity was tested by the statistical significance of Cochran's Q, and was quantified by the Higgins's I metric. The pooled estimates of sensitivity and specificity for blunt vertebral artery injury detection with MRA in comparison to DSA were calculated based on the bivariate model. The meta-analysis was supplemented by subgroup and sensitivity analysis, as well as analysis for publication bias. There was significant clinical heterogeneity in the targeted population, inclusion criteria, and MRA related parameters. The reporting bias and applicability concerns were moderate and low, respectively. In the overall analysis, the sensitivity ranged from 25% to 85%, while the specificity varied from 65% to 99%, across studies. According to the bivariate model, the pooled sensitivity and specificity of MRA in the evaluation of patients with blunt vertebral artery was as high as 55% (95% CI 32.1%-76.7%), and 91% (95% CI 66.3%-98.2%), respectively. Subgroup analysis in terms of MRA sequence sensitivity of phase, the contrasted MRA (75% [95% CI 43%-92%]) seemed to be superior to the TOF MRA (46% [95%CI 20%-74%]). The addition of contrast enhancement did not seem to improve the diagnostic yield of MRA. The Egger's test did not identify any significant publication bias (p=0.2). An important limitation of the current meta-analysis is the small number of eligible studies, as well as the lack of studies on newer, high-field MR scanners. We concluded that MRA has a moderate diagnostic accuracy in the diagnosis of blunt vertebral artery injuries. Further studies on high-field magnetic resonance scanners are recommended.
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http://dx.doi.org/10.1016/j.clineuro.2017.07.005DOI Listing
September 2017

The Role of Gait Analysis in the Evaluation of Patients with Cervical Myelopathy: A Literature Review Study.

World Neurosurg 2017 May 9;101:275-282. Epub 2017 Feb 9.

Department of Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece.

Background: Gait analysis represents one of the newest methodologies used in the clinical evaluation of patients with cervical myelopathy (CM).

Objective: To describe the role of gait analysis in the clinical evaluation of patients with CM, as well as its potential role in the evaluation of the functional outcome of any surgical intervention.

Methods: A literature review was performed in the PubMed, OVID, and Google Scholar medical databases, from January 1995 to August 2016, using the terms "analysis," "anterior," "cervical myelopathy," "gait," "posterior," and "surgery." Clinical series comparing the gait patterns of patients with CM with healthy controls, as well as series evaluating gait and walk changes before and after surgical decompression, were reviewed. Case studies were excluded.

Results: Nine prospective and 3 retrospective studies were found. Most of the retrieved studies showed the presence of characteristic, abnormal gait patterns among patients with CM, consisting of decreased gait speed, cadence, step length, stride length, and single-limb support time. In addition, patients with CM routinely present increased step and stride time, double-limb support time, and step width, and they have altered knee and ankle joint range of motion, compared with healthy controls. Moreover, gait and walk analysis may provide accurate functional assessment of the functional outcome of patients with CM undergoing surgical decompression.

Conclusions: Gait analysis may well be a valuable and objective tool along with other parameters in the evaluation of functionality in patients with CM, as well as in the assessment of the outcome of any surgical intervention in these patients.
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http://dx.doi.org/10.1016/j.wneu.2017.01.122DOI Listing
May 2017

The role of diffusion tensor imaging and fractional anisotropy in the evaluation of patients with idiopathic normal pressure hydrocephalus: a literature review.

Neurosurg Focus 2016 Sep;41(3):E12

Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;

OBJECTIVE Diffusion tensor imaging (DTI) for the assessment of fractional anisotropy (FA) and involving measurements of mean diffusivity (MD) and apparent diffusion coefficient (ADC) represents a novel, MRI-based, noninvasive technique that may delineate microstructural changes in cerebral white matter (WM). For example, DTI may be used for the diagnosis and differentiation of idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases with similar imaging findings and clinical symptoms and signs. The goal of the current study was to identify and analyze recently published series on the use of DTI as a diagnostic tool. Moreover, the authors also explored the utility of DTI in identifying patients with iNPH who could be managed by surgical intervention. METHODS The authors performed a literature search of the PubMed database by using any possible combinations of the following terms: "Alzheimer's disease," "brain," "cerebrospinal fluid," "CSF," "diffusion tensor imaging," "DTI," "hydrocephalus," "idiopathic," "magnetic resonance imaging," "normal pressure," "Parkinson's disease," and "shunting." Moreover, all reference lists from the retrieved articles were reviewed to identify any additional pertinent articles. RESULTS The literature search retrieved 19 studies in which DTI was used for the identification and differentiation of iNPH from other neurodegenerative diseases. The DTI protocols involved different approaches, such as region of interest (ROI) methods, tract-based spatial statistics, voxel-based analysis, and delta-ADC analysis. The most studied anatomical regions were the periventricular WM areas, such as the internal capsule (IC), the corticospinal tract (CST), and the corpus callosum (CC). Patients with iNPH had significantly higher MD in the periventricular WM areas of the CST and the CC than had healthy controls. In addition, FA and ADCs were significantly higher in the CST of iNPH patients than in any other patients with other neurodegenerative diseases. Gait abnormalities of iNPH patients were statistically significantly and negatively correlated with FA in the CST and the minor forceps. Fractional anisotropy had a sensitivity of 94% and a specificity of 80% for diagnosing iNPH. Furthermore, FA and MD values in the CST, the IC, the anterior thalamic region, the fornix, and the hippocampus regions could help differentiate iNPH from Alzheimer or Parkinson disease. Interestingly, CSF drainage or ventriculoperitoneal shunting significantly modified FA and ADCs in iNPH patients whose condition clinically responded to these maneuvers. CONCLUSIONS Measurements of FA and MD significantly contribute to the detection of axonal loss and gliosis in the periventricular WM areas in patients with iNPH. Diffusion tensor imaging may also represent a valuable noninvasive method for differentiating iNPH from other neurodegenerative diseases. Moreover, DTI can detect dynamic changes in the WM tracts after lumbar drainage or shunting procedures and could help identify iNPH patients who may benefit from surgical intervention.
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http://dx.doi.org/10.3171/2016.6.FOCUS16192DOI Listing
September 2016

Anterior Cervical Discectomy and Fusion: Practice Patterns Among Greek Spinal Surgeons.

J Clin Med Res 2016 Jul 29;8(7):506-12. Epub 2016 May 29.

Department of Neurosurgery, School of Medicine, University of Thessaly, Larissa, Greece.

Background: A web-based survey was conducted among Greek spinal surgeons to outline the current practice trends in regard to the surgical management of patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathology. Various practice patterns exist in the surgical management of patients undergoing anterior cervical discectomy for degenerative pathology. No consensus exists regarding the type of the employed graft, the necessity of implanting a plate, the prescription of an external orthotic device, and the length of the leave of absence in these patients.

Methods: A specially designed questionnaire was used for evaluating the criteria for surgical intervention, the frequency of fusion employment, the type of the graft, the frequency of plate implantation, the employment of an external spinal orthosis (ESO), the length of the leave of absence, and the prescription of postoperative physical therapy. Physicians' demographic factors were assessed including residency and spinal fellowship training, as well as type and length in practice.

Results: Eighty responses were received. Neurosurgeons represented 70%, and orthopedic surgeons represented 30%. The majority of the participants (91.3%) considered fusion necessary. Allograft was the preferred type of graft. Neurosurgeons used a plate in 42.9% of cases, whereas orthopedic surgeons in 100%. An ESO was recommended for 87.5% of patients without plates, and in 83.3% of patients with plates. The average duration of ESO usage was 4 weeks. Physical therapy was routinely prescribed postoperatively by 75% of the neurosurgeons, and by 83.3% of the orthopedic surgeons. The majority of the participants recommended 4 weeks leave of absence.

Conclusions: The vast majority of participants considered ACDF a better treatment option than an ACD, and preferred an allograft. The majority of them employed a plate, prescribed an ESO postoperatively, and recommended physical therapy to their patients.
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http://dx.doi.org/10.14740/jocmr2572wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4894019PMC
July 2016

According to which factors in severe traumatic brain injury craniectomy could be beneficial.

Surg Neurol Int 2016 17;7:19. Epub 2016 Feb 17.

Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece; Center for Research and Technology of Thessaly, 38500 Larissa, Greece.

Background: To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI).

Methods: Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan.

Results: The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant.

Conclusion: Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.
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http://dx.doi.org/10.4103/2152-7806.176671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774169PMC
March 2016

Traumatic brain injury and gene knockout animal models: an up-to-date review.

J Neurosurg Sci 2017 Dec 20;61(6):652-664. Epub 2016 Jan 20.

Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, Larissa, Greece.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Identification of endogenous neuroprotective mechanisms after TBI and the development of therapeutic targets to improve TBI outcomes are areas of intense scientific research. In this review, we summarize genetically modified TBI mouse models and highlight the recent scientific findings from using such models, including mediators of inflammation, programmed cell death and metabolism, modulators of vascular tone and membrane channel proteins. A deeper understanding of the complex biochemical processes and genetic pathways in TBI could offer personalized genomic-based therapies for and improve clinical outcomes in TBI patients.
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http://dx.doi.org/10.23736/S0390-5616.16.03589-XDOI Listing
December 2017

An evidence-based approach towards the cranio-cervical junction injury classifications.

Eur Spine J 2015 May 22;24(5):931-9. Epub 2015 Mar 22.

Department of Neurosurgery, University Hospital of Larissa, Biopolis, 41110, Larissa, Greece,

Purpose: The cranio-cervical junction (CCJ) is an anatomically, functionally and biomechanically complex region. It is commonly involved in trauma of varying severity that can be managed with a multitude of treatment options and carry diverse prognosis. Our objective is to evaluate the quality of currently used CCJ injury classifications in an evidence-based approach.

Methods: We performed two consecutive literature reviews. In the first, we tried to find which classifications are currently used in CCJ injuries. In the second, we scrutinized the gathered classifications in terms of validity, reliability, severity grading, treatment guidance and prognosis assessment.

Results: Twenty classifications are currently used to describe the CCJ injuries and 72 individual injury patterns have been recognized. Almost a third of them can grade severity, guide treatment and assess prognosis. Only two classifications have been tested for validity and reliability.

Conclusions: CCJ injuries are poorly described by the current classifications according to evidence-based criteria. There is an obvious need for a simple and reliable classification tool to guide patient management in the evidence-based medicine era.
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http://dx.doi.org/10.1007/s00586-015-3877-2DOI Listing
May 2015

Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference.

Acta Neurochir (Wien) 2014 Aug 22;156(8):1615-22. Epub 2014 May 22.

Department of Physiopathology and Transplant, Milan University, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.

Background: Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.

Methods: A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.
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http://dx.doi.org/10.1007/s00701-014-2127-4DOI Listing
August 2014

Temporal lobe resective surgery for medically intractable epilepsy: a review of complications and side effects.

Epilepsy Res Treat 2013 31;2013:752195. Epub 2013 Oct 31.

Departments of Neurosurgery, University Hospital of Larisa, Faculty of Medicine, University of Thessaly, Biopolis, Larissa 41110, Greece.

Object. It is widely accepted that temporal resective surgery represents an efficacious treatment option for patients with epilepsy of temporal origin. The meticulous knowledge of the potential complications, associated with temporal resective procedures, is of paramount importance. In our current study, we attempt to review the pertinent literature for summating the complications of temporal resective procedures for epilepsy. Method. A PubMed search was performed with the following terms: "behavioral," "cognitive," "complication," "deficit," "disorder," "epilepsy," "hemianopia," "hemianopsia," "hemorrhage," "lobectomy," "medial," "memory," "mesial," "neurobehavioral," "neurocognitive," "neuropsychological," "psychological," "psychiatric," "quadranopia," "quadranopsia," "resective," "side effect," "surgery," "temporal," "temporal lobe," and "visual field." Results. There were six pediatric, three mixed-population, and eleven adult surgical series examining the incidence rates of procedure-related complications. The reported mortality rates varied between 0% and 3.5%, although the vast majority of the published series reported no mortality. The cumulative morbidity rates ranged between 3.2% and 88%. Conclusions. Temporal resective surgery for epilepsy is a safe treatment modality. The reported morbidity rates demonstrate a wide variation. Accurate detection and frank reporting of any surgical, neurological, cognitive, and/or psychological complications are of paramount importance for maximizing the safety and improving the patients' overall outcome.
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http://dx.doi.org/10.1155/2013/752195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3833403PMC
November 2013

Bundle of measures for external cerebral ventricular drainage-associated ventriculitis.

Crit Care Med 2014 Jan;42(1):66-73

1Department of Critical Care Medicine, University Hospital of Larissa, Larissa, Greece. 2Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece.

Objective: To assess the prevalence and outcome of external cerebral ventricular drainage-associated ventriculitis in neurocritical patients before and after the implementation of a bundle of external cerebral ventricular drainage-associated ventriculitis control measures.

Design: Clinical prospective case series.

Setting: University Hospital of Larissa, Greece.

Patients: Consecutive patients were recruited from the ICU of the hospital. Patient inclusion criteria included presence of external ventricular drainage and ICU stay more than 48 hours.

Intervention: The bundle of external cerebral ventricular drainage-associated ventriculitis control measures included 1) reeducation of ICU personnel on issues of infection control related to external cerebral ventricular drainage, 2) meticulous intraventricular catheter handling, 3) cerebrospinal fluid sampling only when clinically necessary, and 4) routine replacement of the drainage catheter on the seventh drainage day if the catheter was still necessary. The bundle was applied after an initial period (preintervention) where standard policy for external cerebral ventricular drainage-associated ventriculitis was established.

Measurements: External cerebral ventricular drainage-associated ventriculitis prevalence, external cerebral ventricular drainage-associated ventriculitis events per 1,000 drainage days (drain-associated infection rate), length of ICU stay, Glasgow Outcome Scale at 6 months, and risk factors for external cerebral ventricular drainage-associated ventriculitis.

Main Results: Eighty-two patients entered the study in the preintervention period and 57 patients during the intervention period. During the preintervention and intervention period, external cerebral ventricular drainage-associated ventriculitis prevalence was 28% and 10.5% (p = 0.02) and drain-associated infection rate was 18 and 7.1, respectively (p = 0.0001); mean (95% CI) length of ICU stay in patients who presented external cerebral ventricular drainage-associated ventriculitis was 44.4 days (36.4-52.4 d), whereas mean (95% CI) length of ICU stay in patients who did not was 20 days (16.9-23.2 d) (p < 0.001). Furthermore, the length of ICU stay was associated with length of drainage (p = 0.0001). Therefore, the presence of external cerebral ventricular drainage-associated ventriculitis and the length of drainage were the only variables associated with a prolonged ICU stay. Unfavorable outcome in Glasgow Outcome Scale at 6 months was not associated with the presence of external cerebral ventricular drainage-associated ventriculitis (p = 0.5). No significant differences were found when Glasgow Outcome Scale was analyzed according to the two study periods.

Conclusions: The implementation of a bundle of measures for external cerebral ventricular drainage-associated ventriculitis control was associated with significantly decreased postintervention prevalence of the infection.
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http://dx.doi.org/10.1097/CCM.0b013e31829a70a5DOI Listing
January 2014