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Salvatore Chibbaro, Marco Marsella, Antonio Romano, Salvatore Ippolito and Eugenio Benericetti

Object

Transtentorial brain herniation is a major cause of morbidity and death following severe closed head injury. The purpose of this study was to evaluate the efficacy of selective uncoparahippocampectomy and tentorial splitting as an adjuvant method of treating otherwise uncontrollable elevated intracranial pressure (ICP) while attempting to prevent or minimize the devastating consequences caused by transtentorial herniation.

Methods

The authors retrospectively reviewed data from a series of 80 consecutive cases of severe closed head injury (Glasgow Coma Scale [GCS] score <8) treated in their neurosurgical unit. All patients had elevated ICP and downward tentorial herniation, as documented with ICP monitoring, and clinical examination and computed tomography, respectively. Given the evidence of acute and ongoing neurological deterioration, all patients were treated with selective uncoparahippocampectomy and tentorial edge incision followed by wide decompressive craniectomy and duraplasty.

Results

All injuries were caused by blunt trauma with signs of acute and/or progressive increased ICP causing downward transtentorial herniation. Fifty-eight patients were male and 22 were female with a mean age of 35 years and a mean preoperative GCS score of 5. Based on the current American Association of Neurological Surgeons guidelines for head trauma, an intraparenchymal ICP device (Camino, Integra) was placed in all patients who had a GCS score <8, and ICP was consistently >20 cm H2O. Whenever possible, risks and benefits were explained to family members, and then surgery was performed within 3–16 hours (median 6 hours). At a mean follow-up of 30 months, the outcome was favorable (Glasgow Outcome Scale [GOS] score of 4 or 5) in 60 patients (75%) and unfavorable (GOS score of 3) in 8 (10%), whereas the remaining 12 patients (15%) died at some point during the postoperative course. There was no survivor patient in a vegetative state. A younger age had a significant effect on positive outcome (p < 0.0005), as did an earlier operation (p < 0.04). The preoperative neurological status as assessed using the GCS as well as pupillary reactivity had no significant effect on outcome (p = 0.054 and p > 0.05, respectively).

Conclusions

A selective uncoparahippocampectomy with a tentorial edge incision and a wide decompressive craniectomy with duraplasty can be an effective adjuvant form of aggressive treatment to improve outcome in patients with severe closed head injury, especially in those who are younger if they are treated promptly.

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Reza Ghadirpour, Davide Nasi, Corrado Iaccarino, Antonio Romano, Luisa Motti, Rossella Sabadini, Franco Valzania and Franco Servadei

OBJECTIVE

The purpose of this study was to evaluate the technical feasibility, accuracy, and relevance on surgical outcome of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during resection of intradural extramedullary (IDEM) spinal tumors.

METHODS

Clinical and intraoperative neurophysiological monitoring (IONM) data obtained in 108 consecutive patients who underwent surgery for IDEM tumors at the Institute for Scientific and Care Research “ASMN” of Reggio Emilia, Italy, were prospectively entered into a database and retrospectively analyzed. The IONM included SSEPs, MEPs, and—whenever possible—D-waves. All patients were evaluated using the modified McCormick Scale at admission and at 3, 6, and 12 months of follow-up .

RESULTS

A total of 108 patients were included in this study. A monitorable D-wave was achieved in 71 of the 77 patients harboring cervical and thoracic IDEM tumors (92.2%). Recording of D-waves in IDEM tumors was significantly associated only with a preoperative deeply compromised neurological status evaluated using the modified McCormick Scale (p = 0.04). Overall, significant IONM changes were registered in 14 (12.96%) of 108 patients and 9 of these patients (8.33%) had permanent loss of at least one of the 3 evoked potentials. In 7 patients (6.48%), the presence of an s18278 caudal D-wave was predictive of a favorable long-term motor outcome even when the MEPs and/or SSEPs were lost during IDEM tumor resection. However, in 2 cases (1.85%) the D-wave permanently decreased by approximately 50%, and surgery was definitively abandoned to prevent permanent paraplegia. Cumulatively, SSEP, MEP, and D-wave monitoring significantly predicted postoperative deficits (p = 0.0001; AUC = 0.905), with a sensitivity of 85.7% and a specificity of 97%. Comparing the area under the receiver operating characteristic curves of these tests, D-waves appeared to have a significantly greater predictive value than MEPs and especially SSEPs alone (0.992 vs 0.798 vs 0.653; p = 0.023 and p < 0.001, respectively). On multiple logistic regression, the independent risk factors associated with significant IONM changes in the entire population were age older than 65 years and an anterolateral location of the tumor (p < 0.0001).

CONCLUSIONS

D-wave monitoring was feasible in all patients without severe preoperative motor deficits. D-waves demonstrated a statistically significant higher ability to predict postoperative deficits compared with SSEPs and MEPs alone and allowed us to proceed with IDEM tumor resection, even in cases of SSEP and/or MEP loss. Patients older than 65 years and with anterolateral IDEM tumors can benefit most from the use of IONM.