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Michael D. Cusimano and Nadine Parker

Injuries to children caused by falling televisions have become more frequent during the last decade. These injuries can be severe and even fatal and are likely to become even more common in the future as TVs increase in size and become more affordable.

To formulate guidelines for the prevention of these injuries, the authors systematically reviewed the literature on injuries related to toppling televisions. The authors searched MEDLINE, PubMed, Embase, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, and Google Scholar according to the Cochrane guidelines for all studies involving children 0–18 years of age who were injured by toppled TVs. Factors contributing to injury were categorized using Haddon’s Matrix, and the public health approach was used as a framework for developing strategies to prevent these injuries.

The vast majority (84%) of the injuries occurred in homes and more than three-fourths were unwitnessed by adult caregivers. The TVs were most commonly large and elevated off the ground. Dressers and other furniture not designed to support TVs were commonly involved in the TV-toppling incident. The case fatality rate varies widely, but almost all deaths reported (96%) were due to brain injuries. Toddlers between the ages of 1 and 3 years most frequently suffer injuries to the head and neck, and they are most likely to suffer severe injuries. Many of these injuries require brain imaging and neurosurgical intervention. Prevention of these injuries will require changes in TV design and legislation as well as increases in public education and awareness. Television-toppling injuries can be easily prevented; however, the rates of injury do not reflect a sufficient level of awareness, nor do they reflect an acceptable effort from an injury prevention perspective.

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Michael D. Cusimano and Laligam N. Sekhar

✓ Because of its potentially serious sequelae, cerebrospinal fluid (CSF) leakage following surgery for lesions of the cranial base is given immediate attention by neurosurgeons. Despite a multitude of approaches used to prevent its occurrence, CSF leakage complicates up to 30% of difficult skull-base tumor operations.

The authors describe the cases of 11 patients who developed a syndrome, not previously described in the literature, termed “pseudo-CSF rhinorrhea.” This syndrome occurs after surgery of the cranial base, usually involving dissection or removal of the petrous or cavernous carotid artery, the greater superficial petrosal nerve, and the pericarotid sympathetic plexus. It is characterized by nasal stuffiness and nasal hypersecretion and is sometimes accompanied by facial flushing. The symptoms are characteristically exacerbated by exertion or by elevated ambient room temperatures. Lacrimation is typically absent ipsilateral to the pseudo-CSF rhinorrhea. It is believed that pseudo-CSF rhinorrhea developed in these patients because of a relative imbalance of the regulatory autonomic supply of the nasal mucosa.

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Michael D. Cusimano and Ronald S. Fenton

A number of milestones have marked the development of transsphenoidal pituitary tumor resection this century. The introduction of headlamp illumination, followed by the use of the operating microscope and fluoroscopy have allowed neurosurgeons to perform this surgery in a safe and highly effective manner.

With the aid of a case report, we describe the incorporation of endoscopic techniques in pituitary tumor resection. The technique described is minimally invasive, avoiding septal dissection and allowing unsurpassed, unobstructed, and panoramic visualization of the region of interest to the surgeon and operative team.

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Melfort R. Boulton and Michael D. Cusimano

Foramen magnum meningiomas represent a common histological tumor in a rare and eloquent location. The authors review the clinical presentation, relevant anatomical details of the foramen magnum region, neuroimaging features, the posterior and posterolateral surgical approaches for resection, and outcomes. Based the experiences of the senior author (M.D.C.) and a review of the literature, they introduce the concept of a “surgical corridor,” discuss the classification of these tumors, and the nuances of care for patients with these challenging lesions.

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Gregory W. J. Hawryluk and Michael D. Cusimano

✓ Recombinant activated factor VII (rFVIIa) is a relatively new pharmaceutical agent developed for use in patients with hemophilia in whom inhibitors to clotting factors VIII or IX have developed. Use of this drug has become common in recent years because of its efficacy and safety in patients with coagulation disorders as well as in patients who are at high risk for thromboembolism, even when other means of establishing hemostasis have failed. The use of rFVIIa in neurosurgery has lagged behind its use in other fields, although there is a growing body of literature on such uses. In this article the authors review the history and science of rFVIIa as well as dosing and safety information. Various uses pertinent to the neurosurgeon are reviewed, including the treatment of patients with coagulation disorders, those suffering trauma, and those with perioperative hemorrhage, intracerebral hemorrhage, or subarachnoid hemorrhage. Based on their review of the uses of rFVIIa, the authors conclude that rFVIIa is a safe and effective agent with the potential to revolutionize the treatment of neurosurgical patients with hemorrhage. Cost is a major impediment to the widespread use of rFVIIa, and there is some evidence that its use in the neurosurgical population may be subject to higher risk than in other populations studied thus far. Although further study is needed to better delineate the safety and efficacy of the drug in many nonlicensed uses, it is clear that rFVIIa is an agent with tremendous promise.

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Hussein Alahmadi, Shobhan Vachhrajani and Michael D. Cusimano

Object

Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm.

Methods

The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome.

Results

Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233–1.755, p < 0.001 and OR 0.949, CI 0.912–0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation.

Conclusions

Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.

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Michael D. Cusimano, Iryna Pshonyak, Michael Y. Lee and Gabriela Ilie

OBJECT

Thirty-day readmission has been cited as an important indicator of the quality of care in several fields of medicine. The aim of this systematic review was to examine rate of readmission and factors relevant to readmission after neurosurgery of the spine.

METHODS

The authors carried out a systematic review using several databases, searches of cited reference lists, and a manual search of the JNS Publishing Group journals (Journal of Neurosurgery; Journal of Neurosurgery: Spine; Journal of Neurosurgery: Pediatrics; and Neurosurgical Focus), Neurosurgery, Acta Neurochirurgica, and Canadian Journal of Neurological Sciences. A quality review was performed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

A systematic review of 1136 records published between 1947 and 2014 revealed 31 potentially eligible studies, and 5 studies met inclusion criteria for content and quality. Readmission rates varied from 2.54% to 14.7%. Sequelae that could be traced back to complications that arose during neurosurgery of the spine were a prime reason for readmission after discharge. Increasing age, poor physical status, and comorbid illnesses were also important risk factors for 30-day readmission.

CONCLUSIONS

Readmission rates have predictable factors that can be addressed. Strategies to reduce readmission that relate to patient-centered factors, complication avoidance during neurosurgery, standardization with system-wide protocols, and moving toward a culture of nonpunitive system-wide error and “near miss” investigations and quality improvement are discussed.

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Michael D. Cusimano, Iryna Pshonyak, Michael Y. Lee and Gabriela Ilie

OBJECTIVE

The 30-day readmission rate has emerged as an important marker of the quality of in-hospital care in several fields of medicine. This review aims to summarize available research reporting readmission rates after cranial procedures and to establish an association with demographic, clinical, and system-related factors and clinical outcomes.

METHODS

The authors conducted a systematic review of several databases; a manual search of the Journal of Neurosurgery, Neurosurgery, Acta Neurochirurgica, Canadian Journal of Neurological Sciences; and the cited references of the selected articles. Quality review was performed using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

A total of 1344 articles published between 1947 and 2015 were identified; 25 were considered potentially eligible, of which 12 met inclusion criteria. The 30-day readmission rates varied from 6.9% to 23.89%. Complications arising during or after neurosurgical procedures were a prime reason for readmission. Race, comorbidities, and longer hospital stay put patients at risk for readmission.

CONCLUSIONS

Although readmission may be an important indicator for good care for the subset of acutely declining patients, neurosurgery should aim to reduce 30-day readmission rates with improved quality of care through systemic changes in the care of neurosurgical patients that promote preventive measures.

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Abdurrahim A. Elashaal, Michael Corrin and Michael D. Cusimano

Good abdominal wall closure is one of the basic surgical skills and is a common feature of almost all modernday CSF shunt operations. The fact that some patients require multiple abdominal operations highlights the need for a simple and effective technique for peritoneal catheter insertion through the abdominal wall and abdominal wall closure. Although technically simple, abdominal wall closure becomes more complex when combined with the requirement to maintain CSF shunt function in cases in which the shunt catheter passes through the abdominal wall into the peritoneal cavity. In this report, the authors describe a simple technique for passing the peritoneal catheter of a ventriculoperitoneal shunt through the abdominal wall on a pathway separate from the fascial opening. This technique minimizes the risk of abdominal wall–related complications and is especially important in high-risk patients such as those with obesity and/or diabetes and in children.