Browse

You are looking at 61 - 70 of 38,690 items for

  • Refine by Access: all x
Clear All
Restricted access

Samantha E. Hoffman, Saksham Gupta, Matthew O’Connor, Casey A. Jarvis, Maryann Zhao, Blake M. Hauser, Joshua D. Bernstock, Shayna Murphy, Siobhan M. Raftery, Karen Lane, E. Antonio Chiocca, and Omar Arnaout

OBJECTIVE

The authors created a postoperative postanesthesia care unit (PACU) pathway to bypass routine intensive care unit (ICU) admissions of patients undergoing routine craniotomies, to improve ICU resource utilization and reduce overall hospital costs and lengths of stay while maintaining quality of care and patient satisfaction. In the present study, the authors evaluated this novel PACU-to-floor clinical pathway for a subset of patients undergoing craniotomy with a case time under 5 hours and blood loss under 500 ml.

METHODS

A single-institution retrospective cohort study was performed to compare 202 patients enrolled in the PACU-to-floor pathway and 193 historical controls who would have met pathway inclusion criteria. The pathway cohort consisted of all adult supratentorial brain tumor cases from the second half of January 2021 to the end of January 2022 that met the study inclusion criteria. Control cases were selected from the beginning of January 2020 to halfway through January 2021. The authors also discuss common themes of similar previously published pathways and the logistical and clinical barriers overcome for successful PACU pathway implementation.

RESULTS

Pathway enrollees had a median age of 61 years (IQR 49–69 years) and 53% were female. Age, sex, pathology, and American Society of Anesthesiologists physical status distributions were similar between pathway and control patients (p > 0.05). Most of the pathway cases (96%) were performed on weekdays, and 31% had start times before noon. Nineteen percent of pathway patients had 30-day readmissions, most frequently for headache (16%) and syncope (10%), whereas 18% of control patients had 30-day readmissions (p = 0.897). The average time to MRI was 6 hours faster for pathway patients (p < 0.001) and the time to inpatient physical therapy and/or occupational therapy evaluation was 4.1 hours faster (p = 0.046). The average total length of stay was 0.7 days shorter for pathway patients (p = 0.02). A home discharge occurred in 86% of pathway cases compared to 81% of controls (p = 0.225). The average total hospitalization charges were $13,448 lower for pathway patients, representing a 7.4% decrease (p = 0.0012, adjusted model). Seven pathway cases were escalated to the ICU postoperatively because of attending physician preference (2 cases), agitation (1 case), and new postoperative neurological deficits (4 cases), resulting in a 96.5% rate of successful discharge from the pathway. In bypassing the ICU, critical care resource utilization was improved by releasing 0.95 ICU days per patient, or 185 ICU days across the cohort.

CONCLUSIONS

The featured PACU-to-floor pathway reduces the stay of postoperative craniotomy patients and does not increase the risk of early hospital readmission.

Restricted access

Nirali Patel, Kathleen Felton, Surajit Bhattacharya, Maria Isabel Almira-Suarez, Augustine Eze, Joyce Turner, Robert Keating, Chima Oluigbo, Reuven J. Schore, Lindsay Kilburn, Roger J. Packer, John S. Myseros, and Miriam Bornhorst

OBJECTIVE

Li-Fraumeni syndrome (LFS) is a cancer predisposition syndrome caused by germline mutations in the TP53 gene. CNS tumors are the fourth most common tumor type in LFS, and recent screening guidelines demonstrate that early tumor detection is associated with improved long-term survival. However, there is a paucity of data regarding surgical intervention when lesions are identified in asymptomatic patients on surveillance imaging. The authors investigated this through their cohort and literature review.

METHODS

The cohort consisted of children seen in the Pediatric Cancer Genetics Program at Children’s National Hospital between August 2012 and August 2021. The authors also include a PubMed (MEDLINE) literature search of articles from 2006 to 2021 related to surveillance and CNS tumors in patients with LFS. Studies in which CNS tumors were not identified or detailed patient information was not provided were excluded. Patients from the selected articles and the authors’ cohort were added for further analysis.

RESULTS

Between August 2012 and August 2021, 10 children with LFS and CNS tumors were assessed at Children’s National Hospital: 4 who were known carriers of the TP53 mutation had CNS lesions found on surveillance imaging, whereas 6 presented with symptomatic CNS lesions and were either known or subsequently found to have germline TP53 mutations. The literature search identified 148 articles, 7 of which were included in this review. Patients from the literature and the present cohort were added for a total of 56 CNS lesions. A majority of the low-grade CNS lesions (22/24, 92%) were found on surveillance protocols in asymptomatic patients, whereas the majority of the high-grade lesions (22/26, 85%) presented in symptomatic patients who were not undergoing routine surveillance or as the initial diagnosis of LFS. The authors noted a significant survival advantage in pediatric patients with low-grade lesions, with an overall survival of 100% at 30 months. Minor limitations of the study include patient sample size and limitations in the patient cohort due to this being a retrospective rather than a prospective study.

CONCLUSIONS

Data presented in this study support surveillance protocols in LFS and demonstrate the importance of dedicated CNS imaging and early surgical intervention when lesions are identified.

Systematic review registration no.: CRD42022372610 (www.crd.york.ac.uk/prospero)

Restricted access

Samantha M. Bouchal, Ryan M. Naylor, and David J. Daniels

OBJECTIVE

Paroxysmal sympathetic hyperactivity (PSH) is a complication of severe traumatic or hypoxic brain injury characterized by transient episodes of tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis, and/or dystonic posturing. Posttraumatic "sympathetic storms" are associated with poor outcomes. PSH rarely occurs after brain tumor resection in pediatric patients; only 4 cases have been published since 1929. Thus, the authors sought to report their experience with postcraniotomy PSH in pediatric brain tumor patients.

METHODS

A retrospective study of patients younger than 18 years of age who underwent craniotomy for brain tumor resection at a single center by a single surgeon over a 7-year period was performed. A clinical diagnosis of postoperative PSH was recorded. Recorded outcomes included the interval between surgery and initiation of cytotoxic therapy, need for long-term CSF diversion, length of hospital stay, and survival.

RESULTS

Of the 150 patients who were included for analysis, 4 patients were diagnosed with postoperative PSH for an overall occurrence of 2.7%. PSH patients were younger than non-PSH patients (1.8 ± 0.4 years vs 9.2 ± 5.3 years, p = 0.010) and tended to have intraventricular tumors close to the thalamus, basal ganglia, and/or brainstem. PSH patients experienced longer hospital admissions (44.3 ± 23.4 days vs 6.8 ± 9.4 days, p = 0.001), a shorter interval between surgery and initiation of cytotoxic cancer-directed therapy (14.3 ± 8.0 days vs 90.7 days ± 232.9 days, p = 0.011), and increased need for long-term CSF diversion compared with non-PSH patients (75% vs 25%, p = 0.005). At the last follow-up, 50% of PSH patients had died compared with 13% of non-PSH patients (p = 0.094).

CONCLUSIONS

PSH is a rare postoperative complication that may affect young children with periventricular tumors and is associated with poorer clinical outcomes. Increasing awareness of this condition is vital to improving patient outcomes.

Open access

Guido Mazzaglia, Giulio Bonomo, Emanuele Rubiu, Paolo Murabito, Alessia Amato, Paolo Ferroli, and Marco Gemma

BACKGROUND

Takotsubo syndrome (TS) represents a form of nonischemic cardiomyopathy characterized by sudden and temporary weakening of the myocardium. Many data suggest a primary role for sympathetic overstimulation in its pathogenesis. Nevertheless, these correlates are less easily identified during anesthesia.

OBSERVATIONS

A 50-year-old female patient with a 4-year history of drug-resistant left trigeminal neuralgia. She was scheduled for surgical microvascular decompression. In the operating room, after induction of general anesthesia and oral intubation, the electrocardiogram revealed a significant ST segment elevation along with a sudden decrease in systolic blood pressure and heart rate. Administration of atropine caused a conversion into ventricular tachycardia. The advanced cardiac life support protocols were applied with prompt defibrillation and rapid recovery at sinus rhythm. A transthoracic echocardiogram revealed apical akinesia with ballooning of the left ventricle with a reduction of systolic function. An emergency coronary arteriography was performed, showing normal epicardial coronary vessels. After 4 days, echocardiography revealed normalization of the left ventricular function with improvement of the ejection fraction.

LESSONS

In patients affected by trigeminal neuralgia, chronic pain can lead to a state of adrenergic hyperactivation, which can promote TS during the induction of general anesthesia, probably through the trigeminocardiac reflex.

Open access

Rohin Singh and Robert J. Spinner

BACKGROUND

Delayed facial palsy (DFP) after vestibular schwannoma resection is a well-documented, yet poorly understood condition. The exact pathophysiological mechanisms of DFP are unknown, although diminished intraoperative nerve response has been shown to be a prognostic factor. To date, no such condition has been described in regard to peripheral nerve schwannomas.

OBSERVATIONS

Here the authors present the first reported cases of delayed motor weakness (DMW) after peripheral schwannoma resection of the ulnar nerve at the elbow and peroneal nerve in the popliteal fossa. Both patients presented with a mass lesion and radiating paresthesias and had normal motor function preoperatively. Immediately after surgical resection, the patients had full strength. Within 24 hours, both patients exhibited marked weakness that gradually resolved over the course of several weeks.

LESSONS

DMW after peripheral schwannoma resection is a rare condition likely akin to delayed facial nerve palsy after VS resection. The mechanism of this phenomenon remains unknown, although symptoms appear to self-resolve with time. A better understanding of the processes driving this condition may allow for therapies that can expedite and improve long-term outcomes.

Open access

Alexander Keister, Joshua Vignolles-Jeong, Daniel Kreatsoulas, Kyle VanKoevering, Stephanus Viljoen, Daniel Prevedello, and Andrew J. Grossbach

BACKGROUND

Operative management of craniovertebral junction (CVJ) osteomyelitis has traditionally been extracranial and focused on debriding the infection. In select patients, the endoscopic endonasal approach (EEA) with a focus on additional resection versus debridement may be preferred. The goal of this study is to present the authors’ experience with the EEA with gross or subtotal resection for the treatment of osteomyelitis at the CVJ and describe their technique in the context of the literature.

OBSERVATIONS

Two patients of the authors’ and 6 detailed case reports in the literature were identified with a mean age of 58.9 years. Most patients (n = 5; 62.5%) underwent skull base surgery and debridement (n = 5; 62.5%). Although more common, debridement was inferior to resection in terms of neurological improvement (66.7% vs. 100.0%) postoperatively. The majority (n = 7; 87.5%) of patients underwent occipitocervical fusion.

LESSONS

Osteomyelitis is an exceedingly rare lesion of the CVJ. Despite the region’s delicate biomechanical stability, resection of infected bone may be superior to debridement alone in terms of clinical outcome. Given how well established the safety of the EEA is to this region, further study of outcomes with resection is warranted.

Open access

Mahdi Arjipour, Mohammad Gharib, and Mohamadmehdi Eftekharian

BACKGROUND

Colloid cysts are an unusual differential diagnosis for lesions in the lateral ventricles. Microsurgery is usually recommended for the treatment of giant colloid cysts. This case is the largest reported colloid cyst in this unusual location treated with an endoscope.

OBSERVATIONS

A 39-year-old woman with a history of pulsing headaches presented with nausea, vomiting, vision blurring, and paresthesia of the left leg. On the brain computed tomography, a huge, well-defined homogeneous hyperdense intraventricular lesion with hydrocephalus was observed. Magnetic resonance imaging showed a spherical lesion over the third ventricle inside the lateral ventricles, obstructing the Sylvius aqueduct. There was no enhancement and no diffusion restriction on diffusion-weighted images. Endoscopic third ventriculostomy was undertaken for hydrocephalus treatment. Then the lesion was resected grossly. The cyst wall was resected as much as it was safe. There was no clot or bloody product inside the lesion.

LESSONS

Colloid cyst is rarely encountered in the velum interpositum and lateral ventricles, but the authors’ giant colloid cyst case along with similar cases led to considering it out of the third ventricle. According to their experience, endoscopic removal is a safe and efficient method for colloid cyst surgery, even in giant cases.

Open access

Valérie N. E. Schuermans, Ank van de Goor, Martinus P. G. Broen, and Toon F. M. Boselie

BACKGROUND

A rare meningioma subtype is a clear cell (CC) meningioma, which can be associated with a SMARCE1 gene mutation. Manifestation of a CC meningioma in the cervical spine is unusual. In the current case, both mother and daughter present with a CC meningioma at an identical cervical location.

OBSERVATIONS

A 67-year-old patient with an intradural extramedullary mass at the level of C5 presented with progressive myelopathy. The mass was resected through a ventral approach by a two-level corpectomy with an expandable cage and instrumentation. The daughter of this patient appeared to have had an intradural extramedullary mass at C5 at the age of 20, which was resected through a posterior approach. Pathological investigation of both tumors revealed CC meningioma. Genetic testing of the daughter revealed a SMARCE1 mutation.

LESSONS

It is of major importance to consider a SMARCE1 mutation in elderly presenting with a CC meningioma, which is still uncommon in current practice. This could lead to timely diagnostics in the succeeding generation. Complete resection of a CC meningioma is important because of the high recurrence rate. Routine follow-up should therefore be performed in the postoperative period. An anterior approach should be considered for a ventral cervical CC meningioma.

Open access

Morito Takano, Tomohiro Hikata, Soraya Nishimura, Masayuki Ishikawa, and Michihiro Kamata

BACKGROUND

Spinal extradural arachnoid cysts are thought to be pouches that communicate with the intraspinal subarachnoid space through a dural defect. The treatment for these cysts is resection of the cyst wall followed by obliteration of the communicating defect, which is often elusive.

OBSERVATIONS

The authors report the case of a 22-year-old man with an extradural arachnoid cyst with claudication and progressive motor weakness. Regular magnetic resonance imaging (MRI) and computed tomography did not reveal the location of the defect in the cyst. However, three-dimensional (3D) phase-contrast MRI clearly indicated the location of the defect and the flow of cerebrospinal fluid into the cyst. These findings allowed the authors to perform the least invasive surgery; the patient recovered motor function and could walk more smoothly.

LESSONS

3D phase-contrast MRI can reveal a subtle dural defect in patients with spinal extradural arachnoid cysts.

Open access

Stephen P. Miranda, Jessica Nguyen, Ben J. Gu, Zarina S. Ali, and Eric L. Zager

Acellularized nerve allografts (ANAs) have been developed as substitutes for nerve autograft to promote nerve regeneration after surgical repair. In this video, the authors demonstrate operative techniques for using ANAs to repair potentially functional nerve fascicles during tumor resection. A 67-year-old female with schwannomatosis requested resection of a painful enlarging mass of the left ulnar nerve proximal to the elbow. During surgery, neuromonitoring suggested that fascicles entering the tumor could be functional. Therefore, nerve allograft was used to repair the transected fascicles. The patient recovered with full strength and sensation in the ulnar distribution, with resolution of her preoperative symptoms.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22101