Publications by authors named "Mario Ganau"

97 Publications

Posterior fossa dural arteriovenous fistula presenting as 'head-turning syncope': a case report.

Acta Neurol Belg 2021 May 14. Epub 2021 May 14.

Department of Neurosurgery, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK.

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http://dx.doi.org/10.1007/s13760-021-01701-6DOI Listing
May 2021

Clinical Significance of Isolated Third Cranial Nerve Palsy in Traumatic Brain Injury: A Detailed Description of Four Different Mechanisms of Injury through the Analysis of Our Case Series and Review of the Literature.

Emerg Med Int 2021 23;2021:5550371. Epub 2021 Apr 23.

Department of Neurosurgery, The Royal London Hospital, London E1 1FR, UK.

Third cranial nerve palsy (3cnP) following traumatic brain injury (TBI) is a worrying neurological sign and is often associated with an expanding mass lesion, such as extradural or acute subdural haematomas. Isolated 3cnP can be found in the absence of posttraumatic space-occupying mass lesion, yet it is often considered as a devastating prognostic factor in the context of diffuse axonal injury (DAI). Through the analysis of five exemplificative cases and a thorough review of the literature, we identified four possible mechanisms leading to 3cnP: (1) a partial rootlet avulsion at the site of exit from the midbrain, representing a direct shearing injury to the nerve; (2) a direct traction injury due to the nerve stretching against the posterior petroclinoid ligament at the base of the oculomotor triangle secondary to the downward displacement of the brainstem at the time of impact; (3) a direct vascular compression as a result of internal carotid artery (ICA) dissection or pseudoaneurysm; (4) an indirect injury caused by impaired blood supply to the third nerve in addition to the detrimental biochemical effects of the underlying brain injury itself. Understanding the exact mechanism underlying the onset of 3cnP is key to provide an informed clinical decision-making to the patients and ensure their best chances of recovery. Our experience corroborates data from the literature showing that, even in Grade III DAI, prompt recognition of isolated 3cnP can guide adequate treatment. Nonetheless, even when an overall good neurological outcome is achieved, recovery of isolated 3cnP is dismal, and only rarely the visual deficit completely resolves.
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http://dx.doi.org/10.1155/2021/5550371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087465PMC
April 2021

Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: a systematic review of the literature.

Neurochirurgie 2021 Apr 23. Epub 2021 Apr 23.

Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France.

Introduction: recent years have been characterized by a great technological and clinical development in spine surgery. In particular, enhanced recovery after surgery (ERAS) programs, started to gain interest also in this surgical field. Here we tried to analyse the current state of art of ERAS technique in spine surgery.

Material And Method: A systematic review of the literature has been performed in order to find all the possible inclusions. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, Medline databases was conducted to identify all full-text articles in the English-language literature describing the use of ERAS programs or techniques for spine surgery in adult patients.

Results: out of the 827 studies found, only 21 met the inclusion criteria has been retained to be included in the present study. The most frequently benefits of ERAS protocols were shorter hospitalisations (n = 15), and decreased complication rates (n = 8) lower postoperative pain scores (n = 4). These benefits were seen in the 3 main categories considered: lumbar spine surgeries, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine Conclusion: There are an arising amount of data showing that the use of ERAS programs could be helpful in reducing the days of hospitalizations and the number of complications for certain spinal procedures and in a highly selected group of patients. Despite the large interest on the topic; there is an important lack of high level of scientific evidences. Because of that, there is the need to encourage the design and creation of new randomized clinical trials that will validate the present findings.
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http://dx.doi.org/10.1016/j.neuchi.2021.04.007DOI Listing
April 2021

Natural History, Neuroradiological Workup, and Management Options of Chronic Atlantoaxial Rotatory Fixation Caused by Drug-Induced Cervical Dystonia.

Case Rep Orthop 2021 3;2021:6683268. Epub 2021 Mar 3.

Department of Orthopaedic Surgery, The University of Tokyo, 113-8655, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan.

Atlantoaxial rotatory fixation (AARF) resulting from drug-induced cervical dystonia (DICD) represents an extremely rare complication of antipsychotic treatment, requiring a comprehensive assessment of pharmacologic therapy and timely radiologic workup. We report a chronic case of Fielding type I, Pang type I AARF secondary to schizophrenia treatment in a 16-year-old girl, along with a review of the literature on the management challenges posed in this condition. In this scenario, torticollis may just represent the tip of the iceberg, and only an effective multidisciplinary approach increases the chances of satisfactory correction with closed reduction, hence avoiding the burden of more invasive treatment options.
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http://dx.doi.org/10.1155/2021/6683268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946456PMC
March 2021

COVID-legal study: neurosurgeon experience in Britain during the first phase of the COVID-19 pandemic - medico-legal considerations.

Br J Neurosurg 2021 Mar 24:1-4. Epub 2021 Mar 24.

Department of Neurosurgery, John Radcliffe Hospital, Nuffield Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

The COVID-19 pandemic has resulted in a significant number of changes to elective and emergency neurosurgical practice. This paper reports the results of an online survey of Society of British Neurological Surgeons (SBNS) members undertaken between 10th and 24th of June 2020 regarding changes in consent practice in response to COVID-19, as well as the physical challenges experienced while operating under higher levels of personal protective equipment (PPE). Despite the real and substantial risks associated with COVID-19, 23% of surgeons reported they were not made any changes to their usual consent process, and 54% of surgeons indicated that they made reference to COVID-19-associated risks in their written consent documentation. 93% of neurosurgeons reported physical difficulties operating using PPE; 62% reported visors/goggles fogging up, 55% experienced 'overheating', 62% reported fatigue, and 82% of surgeons reported difficulty communicating with the theatre staff. This survey highlights discrepancies in the consent practice between neurosurgeons which needs to be addressed at both local and national levels. The PPE being used in neurosurgical operations is not designed for use with specialist equipment (82% of respondents reported having to remove PPE to use the microscope) and the reported physical difficulties using PPE intraoperatively could significantly impact on both neurosurgeon performance and patient outcomes. This requires urgent attention by NHS procurement and management and should be urgently escalated to trust occupational health authorities as a workplace safety concern.
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http://dx.doi.org/10.1080/02688697.2021.1902475DOI Listing
March 2021

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.

World Neurosurg 2021 Mar 20. Epub 2021 Mar 20.

Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France.

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.
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http://dx.doi.org/10.1016/j.wneu.2021.03.069DOI Listing
March 2021

Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: Exploring the Potentialities of a Modified Lateral Retrocanthal Approach.

World Neurosurg 2021 Feb 27. Epub 2021 Feb 27.

Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France.

Background: Among the new perspectives to revolutionize skull base surgery, there are the transorbital neuroendoscopic (TONES) approaches to reach the anterior and middle cranial fossa (ACF and MCF). We conceived to explore the potentialities of a modified superiorly and medially extended lateral retrocanthal (LRC) approach.

Methods: Six head specimens were dissected. Applying the established conic model and the key surgical landmark of sphenofrontal suture, we tested the feasibility of a modified LRC to reach ACF and MCF; computed tomography (CT) scans were performed before and after dissection to obtain a morphometric analysis of the surgical corridors using a polygonal surfaces model.

Results: Through our anatomical study, we were able to identify and explore 3 different surgical corridors to reach the ACF and MCF: the superomedial, the superolateral, and the inferolateral. The superomedial corridor appeared most suitable to reach the medial part of the ACF and the optic-carotid region, whereas through the superolateral and inferolateral corridors it was possible to reach and explore the lateral part of ACF and MCF. The mean volumes of the 3 surgical corridors calculated on post-dissection CT scans were: 12.72 ± 1.99, 5.69 ± 0.34, and 6.24 ± 0.47 cm, respectively.

Conclusions: The development of TONES approaches has not replaced the traditional open or endoscopic approach; nonetheless, identification of surgical corridors and the possibility to combine them represent a major breakthrough. Clinical studies are necessary to demonstrate their validity and test the effectiveness, safety, and reproducibility of TONES approaches in managing lesions harboring in the ACF and MCF.
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http://dx.doi.org/10.1016/j.wneu.2021.02.095DOI Listing
February 2021

Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy.

Int J Mol Sci 2021 Jan 23;22(3). Epub 2021 Jan 23.

Neuroscience and Ophthalmology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.

The brain tissue partial oxygen pressure (PbtO) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO and NIRS neuromonitoring is given.
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http://dx.doi.org/10.3390/ijms22031122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865258PMC
January 2021

Inter-Rater Reliability of the Modified Japanese Orthopaedic Association Score in Degenerative Cervical Myelopathy: A Cross-Sectional Study.

Spine (Phila Pa 1976) 2021 Jan 22. Epub 2021 Jan 22.

Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada Department of Neurological Surgery, University of California - Davis, Sacramento, California, USA Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland University of Nebraska Medical Center, Omaha, Nebraska, USA Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Study Design: Prospective cross-sectional blinded-assessor cohort study.

Objective: To determine the inter-rater reliability of the modified Japanese Orthopaedic Association (mJOA) in a large cohort of degenerative cervical myelopathy (DCM) patients.

Summary Of Background Data: The mJOA score is widely accepted as the primary outcome measure in DCM; it has been utilized in clinical practice guidelines and directly influences treatment recommendations, but its reliability has not been established.

Methods: A refined version of the mJOA was administered to DCM patients by 2 or more blinded clinicians. Inter-rater reliability was measured using intra-class correlation (ICC), agreement, and mean difference for mJOA total score and subscores. Data were also analyzed with ANOVA for differences by mJOA severity (mild: 15-17, moderate: 12-14, severe: < 12), assessor, assessment order, previous surgery, age, and sex.

Results: 154 DCM patients underwent 322 mJOA assessments (183 paired assessments). ICC was 0.88 for total mJOA, 0.79 for upper extremity (UE) motor, 0.84 for lower extremity (LE) motor, 0.63 for UE sensation, and 0.78 for urinary function subscores. Paired assessments were identical across all 4 subscores in 25%. The mean difference in mJOA was 0.93 points between assessors, and this differed by severity (mild: 0.68, moderate: 1.24, severe: 0.87, p = 0.001). Differences of >  = 2 points occurred in 19%. Disagreement between mild and moderate severity occurred in 12% of patients. Other variables did not demonstrate significant relationships with mJOA scores.

Conclusion: The inter-rater reliability of total mJOA and its subscores is good, except for UE sensory function (moderate). However, the vast majority of assessments differed between observers, indicating that this measure should be interpreted carefully, particularly when near the threshold between severity categories, or when a patient is reassessed for deterioration. Further efforts to educate clinicians on administration and refine UE sensory subscore may enhance the reliability of this tool.Level of Evidence: 1.
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http://dx.doi.org/10.1097/BRS.0000000000003956DOI Listing
January 2021

Pitfalls regarding the neurosurgical management of traumatic supra and infratentorial extradural haematomas.

Neurosurg Rev 2021 Jan 3. Epub 2021 Jan 3.

Department of Neurosciences, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.

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http://dx.doi.org/10.1007/s10143-020-01467-0DOI Listing
January 2021

Prognostic Value of Age and Early Magnetic Resonance Imaging in Patients with Cervical Subaxial Spinal Cord Injuries.

Neurol India 2020 Nov-Dec;68(6):1345-1350

Department of Neurosurgery, Centro de Investigaciones Biomedicas (CIB), University of Cartagena, Cartagena, Colombia.

Background And Objective: The predictive role of a patient's age in spinal cord injury (SCI) is still unclear given the coexistence of potential confounding factors, whether clinical or radiological. Thus, it is the aim of this work to assess the prognostic role of a patient's age against initial radiological features in a traumatic cervical SCI population.

Methods: Clinical and radiological data from patients with acute traumatic cervical SCI and a first MRI performed within 48 h of trauma were retrospectively reviewed. Patients were dichotomized according to the length intramedullary lesion, and associations between age and other clinical or radiological prognostic variables were analyzed. The receiver-operating characteristic (ROC) curve was used to test the discriminative capacity of the patient age to predict neurological and functional outcomes. Poor functional outcome was defined as a Walking Index Spinal Cord Injury score <1 and poor neurological outcome as the lack of neurological improvement between admission and follow up.

Results: 134 patients fulfilled the inclusion criteria and were analyzed. The mean age was 43 years, with a male/female ratio of 4:1. polytrauma and soft tissue injuries were inversely proportional to patient age (P < 0.001). A critical value of 55-year-old was established as a threshold for determining poor functional and neurological outcomes. Across the group of patients with minor intramedullary lesions, older age was correlated with poor functional and neurological outcomes (P < 0.001 and P = 0.04, respectively).

Conclusions: Patient age is an important prognostic factor in patients with traumatic cervical SCI. Fifty-five years is the critical cutoff associated with poor prognostic outcome.
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http://dx.doi.org/10.4103/0028-3886.304104DOI Listing
December 2020

Management Challenges of Metastatic Spinal Cord Compression in Pregnancy.

Case Rep Surg 2020 1;2020:8891021. Epub 2020 Nov 1.

Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.

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.
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http://dx.doi.org/10.1155/2020/8891021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652620PMC
November 2020

Mechanical thrombectomy in a pediatric patient with sedation aided by contralateral intra-arterial propofol injection: feasibility in an extreme condition.

Childs Nerv Syst 2021 May 27;37(5):1785-1789. Epub 2020 Aug 27.

Institute of Anesthesia and Intensive Care, University of Padova, Padova, Italy.

Pediatric patients undergoing mechanical thrombectomy may be challenging for the anesthesiologists as regards the best anesthetic choice, especially if concomitant to severe comorbidities such as heart failure. A 16-year-old patient affected by arrhythmogenic right ventricle dysplasia/cardiomyopathy underwent mechanical thrombectomy. He was not eligible for deep sedation or general anesthesia since he has been suffering from severe heart failure. The patient stillness was obtained by intra-arterial injection of propofol from the contralateral internal carotid artery. The procedure has been well tolerated, without cardiorespiratory impairment. The case stresses the growing importance to tailor a proper anesthesiologic plan during mechanical thrombectomy, especially in extreme conditions.
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http://dx.doi.org/10.1007/s00381-020-04872-4DOI Listing
May 2021

The continuous quest for a more tailored approach to anesthetic management of patients undergoing endovascular therapy for acute stroke.

J Neurointerv Surg 2021 Mar 17;13(3):e2. Epub 2020 Aug 17.

Anaesthesia & NeuroIntensive Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

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http://dx.doi.org/10.1136/neurintsurg-2020-016512DOI Listing
March 2021

Primary Endoscopic Management of Apoplexy in a Giant Pituitary Adenoma.

World Neurosurg 2020 10 20;142:312-313. Epub 2020 Jul 20.

Department of Neurosurgery, University of Strasbourg, Strasbourg, France.

Background: Sellar lesions with large suprasellar extension represent a neurosurgical challenge because of their nature and anatomic complexity. The goal of the extended transphenoidal-transtuberculum approach is enlarging the transsphenoidal route superiorly and laterally allowing for a surgical adequate exposure and offering a remarkable versatility in many sellar pathologies.

Case Description: We present the case of a 65-year-old man who suddenly developed blindness, right hemiparesis, and decreased alertness. The initial head computed tomography scan revealed a pituitary apoplexy of a giant adenoma associated with hydrocephalus resulting from obstruction of the foramen of Monro. The video shows a complete lesion removal through the sole endoscopic approach, with opening of the dural layer of sphenoidal plane and successful decompression of the third ventricle. Visual and functional improvement occurred in the immediate postoperative course. No lumbar drain has been used.

Conclusions: This case demonstrates how the endoscopic approach can be attempted as a first and possibly stand-alone option for the surgical management of large sellar-suprasellar lesions. The endoscopic route is not associated with high rates of major complications and is safe when performed by experienced surgeons. In fact, it guarantees an enhanced control of the vascular feeders reaching the tumor from the anterior and middle fossa and results in a satisfactory manipulation of lesions invaginating into the floor of the third ventricle. A careful preoperative assessment of Knosp grade, tumor volume, hemorrhagic components, suprasellar extension, and sphenoid sinus invasion should always guide the management plan and suggest a staged or a combined (with transventricular or pterional approach) removal in particularly challenging cases.
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http://dx.doi.org/10.1016/j.wneu.2020.07.059DOI Listing
October 2020

Postoperative Distal Coronal Decompensation After Fusion to L3 for Adolescent Idiopathic Scoliosis Is Affected by Sagittal Pelvic Parameters.

Spine (Phila Pa 1976) 2020 Nov;45(21):E1416-E1420

Division of Orthopaedics, Hospital for Sick Children, Toronto, Ontario, Canada.

Study Design: Retrospective study.

Objective: To identify on early postoperative radiographs the risk factors for late distal decompensation in adolescent idiopathic scoliosis (AIS) patients undergoing posterior fusion surgery to L3.

Summary Of Background Data: Sparing distal fusion levels in AIS surgery is considered beneficial for postoperative mobility and outcomes; nonetheless, late distal decompensation is of concern. L3 is often advocated as lower instrumented vertebra in posterior fusion, but progressive angulation of the L3/4 disc is commonly observed.

Methods: A retrospective analysis was conducted on 78 AIS patients who underwent posterior fusion to L3 from 2007 to 2014. Patients' demographic data, early and 2-year postoperative standing radiographs by biplanar imaging system were investigated. Late decompensation was defined as progressive increase of L3-4 disc wedging angle at 2-year follow-up. Coronal, sagittal, and rotational radiographic parameters were compared between those with and without decompensation. SRS-30 scores were reviewed.

Results: Mean age was 14.5-year, and fusion levels averaged 12.0 (range: 6-15); 43 out of 78 patients (55%) experienced progressive L3-4 disc wedging, with 6 showing wedging >5°. L3 translation from the central sacral vertical line (13.9 vs. 11.1 mm, P = 0.13) and increased pelvic tilt (13.3° vs. 8.6°, P = 0.06) on the early postoperative radiograph were associated with increased L3-4 disc wedging. Multivariate analysis revealed that larger pelvic tilt was a significant risk factor for decompensation (odds ratio = 1.1 per 1°, 95% confidence interval: 1.0-1.1, P = 0.04). SRS-30 scores did not differ significantly between the two groups (4.0 vs. 4.1, P = 0.44).

Conclusions: Pelvic retroversion and increased translation of L3 from the central sacral line on the early postoperative radiograph were associated with late L3-4 disc wedging in AIS fusions to L3. Careful surgical planning and correction of sagittal alignment are imperative to ensure the long-term outcomes.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003616DOI Listing
November 2020

In Response.

Anesth Analg 2020 10;131(4):e193-e195

Department of Anesthesia, McGill University, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1213/ANE.0000000000005121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365582PMC
October 2020

Technologies to Optimize the Care of Severe COVID-19 Patients for Health Care Providers Challenged by Limited Resources.

Anesth Analg 2020 08;131(2):351-364

Department of Anesthesia, McGill University, Montreal, Canada.

Health care systems are belligerently responding to the new coronavirus disease 2019 (COVID-19). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a specific condition, whose distinctive features are severe hypoxemia associated with (>50% of cases) normal respiratory system compliance. When a patient requires intubation and invasive ventilation, the outcome is poor, and the length of stay in the intensive care unit (ICU) is usually 2 or 3 weeks. In this article, the authors review several technological devices, which could support health care providers at the bedside to optimize the care for COVID-19 patients who are sedated, paralyzed, and ventilated. Particular attention is provided to the use of videolaryngoscopes (VL) because these can assist anesthetists to perform a successful intubation outside the ICU while protecting health care providers from this viral infection. Authors will also review processed electroencephalographic (EEG) monitors which are used to better titrate sedation and the train-of-four monitors which are utilized to better administer neuromuscular blocking agents in the view of sparing limited pharmacological resources. COVID-19 can rapidly exhaust human and technological resources too within the ICU. This review features a series of technological advancements that can significantly improve the care of patients requiring isolation. The working conditions in isolation could cause gaps or barriers in communication, fatigue, and poor documentation of provided care. The available technology has several advantages including (a) facilitating appropriate paperless documentation and communication between all health care givers working in isolation rooms or large isolation areas; (b) testing patients and staff at the bedside using smart point-of-care diagnostics (SPOCD) to confirm COVID-19 infection; (c) allowing diagnostics and treatment at the bedside through point-of-care ultrasound (POCUS) and thromboelastography (TEG); (d) adapting the use of anesthetic machines and the use of volatile anesthetics. Implementing technologies for safeguarding health care providers as well as monitoring the limited pharmacological resources are paramount. Only by leveraging new technologies, it will be possible to sustain and support health care systems during the expected long course of this pandemic.
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http://dx.doi.org/10.1213/ANE.0000000000004985DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7258840PMC
August 2020

Primary Brain Rhabdomyosarcoma Causing Extracranial Metastases: Case Report with Narrative Review of Atypical Presentations and Their Diagnostic Challenges.

World Neurosurg 2020 06 27;138:363-368. Epub 2020 Mar 27.

Neurosurgery Department, Strasbourg University Hospital, Strasbourg, France.

Background: Rhabdomyosarcoma is a rare malignant tumor originating from striated muscle cells. It accounts for only 3% of all soft tissue sarcomas in adults, and its metastases can also reach the central nervous system. Only sporadic cases of primary brain rhabdomyosarcoma (PBRMS) have been reported so far.

Case Description: We discuss the atypical presentation and diagnostic challenge of PBRMS in a 65-year-old man. He presented with a 3-day history of progressive right hemiparesis caused by an unspecific left frontoparietal heterogeneously enhancing lesion. Total body computed tomography and positron emission tomography scans performed at baseline did not reveal other secondarisms. The patient underwent radical excision of the lesion, which allowed to establish the diagnosis, with immunohistochemical staining positive for desmin and myogenin. Stereotactic radiotherapy guaranteed local disease control; nonetheless, the patient also required adjuvant chemotherapy when he developed large right lung metastases 6 months postoperatively.

Conclusions: PBRMS can be hardly distinguished from other malignant brain tumors during preoperative radiologic workup; only histology can raise the suspicion of primary or metastatic rhabdomyosarcoma, depending on the presence of other distant lesions. Our review of the literature demonstrates that prognosis is poor: 44% of patients die within 1 year from diagnosis. Overall, survival seems to correlate with radical resection, tolerance of stereotactic or if necessary full neuraxis radiotherapy, and adjuvant chemotherapy. Given the high relapse rate, close monitoring and restaging are imperative.
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http://dx.doi.org/10.1016/j.wneu.2020.03.110DOI Listing
June 2020

Letter to the Editor. Academic rank achievement by gender.

J Neurosurg 2020 Mar 27:1-3. Epub 2020 Mar 27.

7Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden.

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http://dx.doi.org/10.3171/2020.1.JNS2052DOI Listing
March 2020

Endovascular versus surgical treatment for improvement of oculomotor nerve palsy caused by unruptured posterior communicating artery aneurysms.

J Neurointerv Surg 2020 Oct 5;12(10):964-967. Epub 2020 Mar 5.

Neurosurgery, University Hospitals Strasbourg, Strasbourg, Alsace, France.

Background: There is no consensus regarding the best treatment option for unruptured aneurysms of the posterior communicating artery (PCom) presenting with oculomotor nerve palsy (ONP). We aimed to assess predictors of ONP recovery in a multicenter series of consecutive patients.

Materials And Methods: A retrospective review of prospective databases in three tertiary neurosurgical centers was carried out, selecting patients with ONP caused by unruptured PCom aneurysms, treated by surgical clipping or embolization, between January 2006 and December 2013. Patient files and imaging studies were used to extract ophthalmological assessments, treatment outcomes, and follow-up data. Predictors of ONP recovery during follow-up were explored using univariate and multivariate analyses.

Results: We identified 55 patients with a median ONP duration before treatment of 11 days (IQR 4.5-18); the deficit was complete in 27 (49.1%) and incomplete in 28 (50.9%) cases. Median aneurysm size was 7 mm (IQR 5-9). Twenty-four (43.6%) patients underwent surgical clipping and 31 (56.4%) embolization as the primary treatment. Overall, ONP improved in 40 (72.7%) patients and persisted/recurred in 15 (27.3 %). Surgery, interval to complete treatment <4 weeks, aneurysm recurrence during follow-up, and retreatment during follow-up were significantly correlated with ONP outcome in the univariate analysis. In the multivariate analysis, independent predictors of ONP improvement were interval to complete treatment <4 weeks (OR 5.15, 95% CI 1.37 to 23.71, p=0.015) and aneurysm recurrence during follow-up (OR 0.1, 95% CI 0.02 to 0.47, p=0.003).

Conclusion: There was no significant difference in ONP recovery between surgical clipping and embolization. The best predictor for ONP recovery was timely, complete, and durable aneurysm exclusion.
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http://dx.doi.org/10.1136/neurintsurg-2020-015802DOI Listing
October 2020

Improving Gender Equality in the Surgical Workplace.

JAMA Surg 2020 05;155(5):448-449

Department of Neurological Surgery, Oxford University Teaching Hospitals NHS Foundation Trust, Oxford, England.

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http://dx.doi.org/10.1001/jamasurg.2019.6026DOI Listing
May 2020

Surgical preference regarding different materials for custom-made allograft cranioplasty in patients with calvarial defects: Results from an internal audit covering the last 20 years.

J Clin Neurosci 2020 Apr 4;74:98-103. Epub 2020 Feb 4.

Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France.

Background: Secondary cranioplasty (CP) plays a key role in restoring cranial vault anatomy and normal brain function following decompressive craniectomy (DC). The scientific literature provides only fragmentary information regarding the best timing and material for CP, making a direct comparison of different materials difficult.

Object: To identify and report according to STROBE guidelines local trends in choice of materials for CP, complications rate and surgical outcomes.

Methods: We conducted an audit on secondary CP covering the last 20 years of surgical practice at our Institution. Custom-made CP used over the years were made of: porous hydroxyapatite (PHA), polymetylmethacrylate (PMMA), polyetheretherketone (PEEK), acrylic and titanium. The primary endpoint of this study was the incidence of postoperative complications, such as: implant infection, fracture and dislocation. Secondary endpoints were the followings: patients satisfaction with cosmetic result, rate of implant integration, and long-term neurological outcome.

Results: A total of 218 patients were included, given the predominance of PHA (Group A) or PMMA (Group B) CP, a direct comparison was made only between those two groups. Overall reoperation rate was 6.5% versus 28%; implants' osseointegration rate was of 69% versus 24%; satisfaction rate was 66% versus 44%, in Group A and B respectively.

Conclusions: This single-centre study provides Level 3 evidence that PHA yields better outcomes than PMMA CP. Designing a management algorithm for planning and executing CP is difficult for clinical and organizational reasons; till a widespread consensus is reached, neurosurgeons with subspecialty interest in neurotrauma should favor pragmatism and patient safety over costs.
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http://dx.doi.org/10.1016/j.jocn.2020.01.087DOI Listing
April 2020

Comparison of the Asleep-Awake-Asleep Technique and Monitored Anesthesia Care During Awake Craniotomy: A Systematic Review and Meta-analysis.

J Neurosurg Anesthesiol 2020 Jan 16. Epub 2020 Jan 16.

Neuroanaesthesia and Neurosciences Intensive Care Unit.

Awake craniotomy (AC) is the preferred surgical option for intractable epilepsy and resection of tumors adjacent to or within eloquent cortical areas. Monitored anesthesia care (MAC) or an asleep-awake-asleep (SAS) technique is most widely used during AC. We used a random-effects modeled meta-analysis to synthesize the most recent evidence to determine whether MAC or SAS is safer and more effective for AC. We included randomized controlled trials and observational studies that explored the incidence of AC failure, duration of surgery, and hospital length of stay in adult patients undergoing AC. Eighteen studies were included in the final analysis. MAC was associated with a lower risk of AC failure when compared with SAS (global pooled proportion MAC vs. SAS 1% vs. 4%; odds ratio [ORs]: 0.28; 95% confidence interval [CI]: 0.11-0.71; P=0.007) and shorter surgical procedure time (global pooled mean MAC vs. SAS 224.44 vs. 327.94 min; mean difference, -48.76 min; 95% CI: -61.55 to -35.97; P<0.00001). SAS was associated with fewer intraoperative seizures (global pooled proportion MAC vs. SAS 10% vs. 4%; OR: 2.38; 95% CI: 1.05-5.39; P=0.04). There were no differences in intraoperative nausea and vomiting between the techniques (global pooled proportion MAC vs. SAS: 4% vs. 8%; OR: 0.86; 95% CI: 0.30-2.45; P=0.78). Length of stay was shorter in the MAC group (MAC vs. SAS 3.96 vs. 6.75 days; mean difference, -1.30; 95% CI: -2.69 to 0.10; P=0.07). In summary, MAC was associated with lower AC failure rates and shorter procedure time compared with SAS, whereas SAS was associated with a lower incidence of intraoperative seizures. However, there was a high risk of bias and other limitations in the studies included in this review, so the superiority of 1 technique over the other needs to be confirmed in larger randomized studies.
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http://dx.doi.org/10.1097/ANA.0000000000000675DOI Listing
January 2020

Neuroradiological findings in three cases of pontocerebellar hypoplasia type 9 due to mutation: typical MRI appearances and pearls for differential diagnosis.

Quant Imaging Med Surg 2019 Dec;9(12):1966-1972

Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.

Pontocerebellar hypoplasia type 9 (PCH9) is a rare autosomal recessive neurodegenerative disorder with prenatal onset caused by mutations in adenosine monophosphate deaminase 2 (). PCH9 patients demonstrate severe neurodevelopmental delay with early onset and typical magnetic resonance imaging (MRI) findings consisting in: pontine hypoplasia or atrophy with dragonfly cerebellar atrophy appearance on coronal images, reduction in size of the pons and middle cerebellar peduncles, abnormal midbrain describing a figure of "8" on axial images, diffuse loss of cerebral white matter with striking periventricular leukomalacia (PVL), and absence or extreme thinning of the corpus callosum. A review of the literature on PCH9 shows that the MRI phenotype observed in the series herein presented is similar to the eleven cases of PCH9 previously reported. Finally, the main radiological elements which differentiate this diagnosis from other PCH subtypes are described.
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http://dx.doi.org/10.21037/qims.2019.08.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942969PMC
December 2019