Cameron A. Elliott, Mark MacKenzie and Cian J. O’Kelly
Mannitol is commonly used to treat elevated intracranial pressure (ICP). The authors analyzed mannitol dosing errors at peripheral hospitals prior to or during transport to tertiary care facilities for intracranial emergencies. They also investigated the appropriateness of mannitol use based on the 2007 Brain Trauma Foundation guidelines for severe traumatic brain injury.
The authors conducted a retrospective review of the Shock Trauma Air Rescue Society (STARS) electronic patient database of helicopter medical evacuations in Alberta, Canada, between 2004 and 2012, limited to patients receiving mannitol before transfer. They extracted data on mannitol administration and patient characteristics, including diagnosis, mechanism, Glasgow Coma Scale score, weight, age, and pupil status.
A total of 120 patients with an intracranial emergency received a mannitol infusion initiated at a peripheral hospital (median Glasgow Coma Scale score 6; range 3–13). Overall, there was a 22% dosing error rate, which comprised an underdosing rate (< 0.25 g/kg) of 8.3% (10 of 120 patients), an overdosing rate (> 1.5 g/kg) of 7.5% (9 of 120), and a nonbolus administration rate (> 1 hour) of 6.7% (8 of 120). Overall, 72% of patients had a clear indication to receive mannitol as defined by meeting at least one of the following criteria based on Brain Trauma Foundation guidelines: neurological deterioration (11%), severe traumatic brain injury (69%), or pupillary abnormality (25%).
Mannitol administration at peripheral hospitals is prone to dosing error. Strategies such as a pretransport checklist may mitigate this risk.
Cameron A. Elliott, Richard Fox, Robert Ashforth, Sita Gourishankar and Andrew Nataraj
This study was undertaken to evaluate the impact of postoperative MRI artifact on the assessment of ongoing spinal cord or nerve root compression after anterior cervical discectomy and fusion (ACDF) using a trabecular tantalum cage or bone autograft or allograft.
The authors conducted a retrospective review of postoperative MRI studies of patients treated surgically for cervical disc degenerative disease or cervical instability secondary to trauma. Standard ACDF with either a trabecular tantalum cage or interbody bone graft had been performed. Postoperative MR images were shown twice in random order to each of 3 assessors (2 spine surgeons, 1 neuroradiologist) to determine whether the presence of a tantalum interbody cage and/or anterior cervical fixation plate or screws imparted MRI artifact significant enough to prevent reliable postoperative assessment of ongoing spinal cord or nerve root compression.
A total of 63 patients were identified. One group of 29 patients received a tantalum interbody cage, with 13 patients (45%) undergoing anterior plate fixation. A second group of 34 patients received bone auto- or allograft, with 23 (68%) undergoing anterior plate fixation. The paramagnetic implant construct artifact had minimal impact on visualization of postoperative surgical level spinal cord compression. In the cage group, 98% (171/174) of the cases were rated as assessable versus 99% in the bone graft group (201/204), with high intraobserver reliability. In contrast, for the assessment of ongoing surgical level nerve root compression, the presence of a tantalum cage significantly decreased visualization of nerve roots to 70% (121/174) in comparison with 85% (173/204) in the bone graft group (p < 0.001). When sequences using turbo spin echo (TSE), a T2-weighted axial sequence, were acquired, nerve roots were rated as assessable in 88% (69/78) of cases; when only axial T2-weighted sequences were available, the nerve roots were rated as assessable in 54% (52/96) of cases (p < 0.01). The presence of anterior plate fixation had minimal impact on visualization of the spinal cord (99% [213/216] for plated cases vs 98% [159/162] for nonplated cases; p = 1.0) or nerve roots (79% [170/216] for plated cases vs 77% [124/162] for nonplated cases; p = 0.62).
Interbody fusion with tantalum cage following anterior cervical discectomy imparts significant paramagnetic artifact, which significantly decreases visualization and assessment of ongoing surgical level nerve root, but not spinal cord, compression. Anterior plate constructs do not affect visualization of these structures. TSE T2-weighted sequences significantly improve nerve root visualization and should be performed as part of a standard postoperative protocol when imaging the cervical spine following interbody implantation of materials with potential for paramagnetic artifact.
Cameron A. Elliott, Andrew Broad, Karl Narvacan, Trevor A. Steve, Thomas Snyder, Jordan Urlacher, B. Matt Wheatley and D. Barry Sinclair
The aim of this study was to investigate long-term seizure outcome, rate of reoperation, and postoperative neuropsychological performance following selective amygdalohippocampectomy (SelAH) or anterior temporal lobectomy (ATL) in pediatric patients with medically refractory temporal lobe epilepsy (TLE).
The authors performed a retrospective review of cases of medically refractory pediatric TLE treated initially with either SelAH or ATL. Standardized pre- and postoperative evaluation included seizure charting, surface and long-term video-electroencephalography, 1.5-T MRI, and neuropsychological testing.
A total of 79 patients treated initially with SelAH (n = 18) or ATL (n = 61) were included in this study, with a mean follow-up of 5.3 ± 4 years (range 1–16 years). The patients’ average age at initial surgery was 10.6 ± 5 years, with an average surgical delay of 5.7 ± 4 years between seizure onset and surgery. Seizure freedom (Engel I) following the initial operation was significantly more likely following ATL (47/61, 77%) than SelAH (8/18, 44%; p = 0.017, Fisher’s exact test). There was no statistically significant difference in the proportion of patients with postoperative neuropsychological deficits following SelAH (8/18, 44%) or ATL (21/61, 34%). However, reoperation was significantly more likely following SelAH (8/18, 44%) than after ATL (7/61, 11%; p = 0.004) and was more likely to result in Engel I outcome for ATL after failed SelAH (7/8, 88%) than for posterior extension after failed ATL (1/7, 14%; p = 0.01). Reoperation was well tolerated without significant neuropsychological deterioration. Ultimately, including 15 reoperations, 58 of 79 (73%) patients were free from disabling seizures at the most recent follow-up.
SelAH among pediatric patients with medically refractory unilateral TLE yields significantly worse rates of seizure control compared with ATL. Reoperation is significantly more likely following SelAH, is not associated with incremental neuropsychological deterioration, and frequently results in freedom from disabling seizures. These results are significant in that they argue against using SelAH for pediatric TLE surgery.
Cameron A. Elliott, Hayden Danyluk, Keith E. Aronyk, Karolyn Au, B. Matt Wheatley, Donald W. Gross, Tejas Sankar and Christian Beaulieu
Diffusion tensor imaging (DTI) tractography is commonly used in neurosurgical practice but is largely limited to the preoperative setting. This is due primarily to image degradation caused by susceptibility artifact when conventional single-shot (SS) echo-planar imaging (EPI) DTI (SS-DTI) is acquired for open cranial, surgical position intraoperative DTI (iDTI). Readout-segmented (RS) EPI DTI (RS-DTI) has been reported to reduce such artifact but has not yet been evaluated in the intraoperative MRI (iMRI) environment. The authors evaluated the performance of RS versus SS EPI for DTI of the human brain in the iMRI setting.
Pre- and intraoperative 3-T 3D T1-weighted and 2D multislice RS-iDTI (called RESOLVE [readout segmentation of long variable echo-trains] on the Siemens platform) and SS-iDTI images were acquired in 22 adult patients undergoing intraaxial iMRI resections for suspected low-grade glioma (14; 64%), high-grade glioma (7; 32%), or focal cortical dysplasia. Regional susceptibility artifact, anatomical deviation relative to T1-weighted imaging, and tractographic output for surgically relevant tracts were compared between iDTI sequences as well as the intraoperative tract shifts from preoperative DTI.
RS-iDTI resulted in qualitatively less regional susceptibility artifact (resection cavity, orbitofrontal and anterior temporal cortices) and mean anatomical deviation in regions most prone to susceptibility artifact (RS-iDTI 2.7 ± 0.2 vs SS-iDTI 7.5 ± 0.4 mm) compared to SS-iDTI. Although tract reconstruction success did not significantly differ by DTI method, susceptibility artifact–related tractography failure (of at least 1 surgically relevant tract) occurred for SS-iDTI in 8/22 (36%) patients, and in 5 of these 8 patients RS-iDTI permitted successful reconstruction. Among cases with successful tractography for both sequences, maximal intersequence differences were substantial (mean 9.5 ± 5.7 mm, range −27.1 to 18.7 mm).
RS EPI enables higher quality and more accurate DTI for surgically relevant tractography of major white matter tracts in intraoperative, open cranium neurosurgical applications at 3 T.
Chih-Chang Chang, Ching-Lan Wu, Jau-Ching Wu, Hsuan-Kan Chang, Li-Yu Fay, Tsung-Hsi Tu, Wen-Cheng Huang and Henrich Cheng