Neurosurgery

Object The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies. Methods The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications. Results Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 ± 20.2 years and a mean follow-up period of 182.4 ± 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 ± 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epis...

Introduction. The number of patients with face trauma is increasing rapidly because of spreading of aggressions and other forms of violence in urban setting. The objective of our work is to describe the epidemiological considerations and the management of the isolated trauma of the face in Conakry. Methodology. This was a prospective, descriptive, 12-month study that covered all patients admitted to the Ignace Deen National Hospital for facial trauma during this period. We were interested in sociodemographic data, aetiologies, clinical findings, type of lesions and management procedures. Results. Among 2824 patients received during our study period, 139 had isolated facial trauma (of 4.92%). The age group 21-30 years was the most affected (n = 62 -44.6%) and the mean age was 28.6 years ± 4.5 years (extremes: 1 – 63). Men accounted for 78.4% of cases. Brawls and aggressions were the most frequent etiologies (n = 66, 47.5%) and facial tumefaction was the overwhelming reason for consul...

Background: Posttraumatic nerve repair and prevention of muscle atrophy represent a major challenge in restorative medicine. Considerable interest exists in the potential therapeutic value of laser phototherapy for restoring or temporary preventing denervated muscle atrophy as well as enhancing regeneration of severely injured peripheral nerve. Methods: I-Muscle and Peripheral Nerve Experimental Studies: low power laser irradiation (laser phototherapy) was applied for treatment of rat denervated muscle in order to estimate the biochemical transformation at cellular and tissue levels, as well as in a rat sciatic nerve model after crush injury, direct anastomosis and neurotube reconstruction. II-Intraoperative Clinical Study: following microsurgical release and neurolysis the nerve was subjected to direct laser irradiation using fiber optics. III-Clinical double-blind, placebo-controlled randomized study: based on the outcome of the animal trials, a clinical trial, which measured the effectiveness of 780-nm laser phototherapy on patients suffering from incomplete peripheral nerve injuries for 6 months up to several years, was designed. Results: Experimental model of denervated muscle: the animal study suggested that function of denervated muscles was partially preserved by temporary prevention of denervation-induced biochemical changes. The function of denervated muscles was restored, not completely but to a very substantial degree, by laser treatment, initiated at the earliest possible stage post-injury. Experimental peripheral nerve injury: laser phototherapy had an immediate protective effect, maintained functional activity of the injured nerve, decreased scar tissue formation at the injury site, decreased degeneration in corresponding motor neurons of the spinal cord and significantly increased axonal growth and myelinization. Intraoperative clinical study: direct laser irradiation was shown to improve functional activity of the surgically treated nerve. Clinical, double-blind, placebo-controlled randomized pilot study: in patients with incomplete long-term peripheral nerve injury, it was demonstrated that 780-nm laser irradiation progressively improved peripheral nerve function, which lead to significant functional recovery. Conclusions: Laser phototherapy temporarily preserves the function of a denervated muscle and accelerates and enhances axonal growth and regeneration after peripheral nerve injury or reconstructive procedures. Animal and clinical studies have both demonstrated the promoting action of phototherapy on peripheral nerve regeneration, which makes it possible to suggest that the time for broader clinical trials has come.

QUESTION: Do steroids improve neurological symptoms and/or quality of life in patients with metastatic brain tumors compared to supportive care only or other treatment options? If steroids are given, what dose should be used? TARGET POPULATION: These recommendations apply to adults diagnosed with brain metastases. Insufficient evidence exists to make a treatment recommendation for this clinical scenario. Brain metastases patients with mild symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of 4 to 8 mg/d of dexamethasone be considered. Brain metastases patients with moderate to severe symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms consistent with increased intracranial pressure, it is recommended that higher doses such as 16 mg/d or more be considered. Level 3: If corticosteroids are given, dexamethasone is the best drug choice given the available evidence. Level 3: Corticosteroids, if given, should be tapered as rapidly as possible but no faster than clinically tolerated, based upon an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy. Given the very limited number of studies (2) which met the eligibility criteria for the systematic review, these are the only recommendations that can be offered based on this methodology. The full guideline can be found at .

BACKGROUND Stereotactic radiosurgery (SRS) is increasingly used for management of perioptic meningiomas. OBJECTIVE To study the safety and effectiveness of SRS for perioptic meningiomas. METHODS From 12 institutions participating in the International Radiosurgery Research Foundation (IRRF), we retrospectively assessed treatment parameters and outcomes following SRS for meningiomas located within 3 mm of the optic apparatus. RESULTS A total of 438 patients (median age 51 yr) underwent SRS for histologically confirmed (29%) or radiologically suspected (71%) perioptic meningiomas. Median treatment volume was 8.01 cm3. Median prescription dose was 12 Gy, and median dose to the optic apparatus was 8.50 Gy. A total of 405 patients (93%) underwent single-fraction SRS and 33 patients (7%) underwent hypofractionated SRS. During median imaging follow-up of 55.6 mo (range: 3.15-239 mo), 33 (8%) patients experienced tumor progression. Actuarial 5-yr and 10-yr progression-free survival was 96% a...

Cancer is the second leading cause of death and continues to grow globally, exerting tremendous physical, emotional and financial strain on individuals and their families. Glioblastoma is the most frequent malignant tumor of the Central nervous system with the worst prognosis. The current conventional treatment of surgery chemo and radiation does not provide complete remission. Dendritic cells (DCs) are the most powerful antigen presenting cells and DC-based vaccination has the potential to target and eliminate GBM cells and enhance the responses of these cells to the existing therapies with minimal damage to the healthy tissues around them. It can enhance recognition of GBM cells by the patients' immune system and activate vast, potent, and longlasting immune reactions to eliminate them. Dendritic cell immunotherapy aims at inducing an antitumoral immune response seeking to exploit this pivotal role of DC therapeutically. Keeping this in mind, a retrospective study was conducted to evaluate the safety and efficacy of dendritic cell immunotherapy in GBM patients who had recurrence or residual disease post conventional therapy. The outcome of the study has been encouraging proving beneficial for patients with minimum residual tumor burden.

Introduction: There is still controversy about the effect of early hypothermia on the outcome of spinal cord injury (SCI). The aim of this review article is to investigate the effect of local or general hypothermia on improving the locomotion after traumatic SCI. Methods: Electronic databases (Medline and Embase) were searched from inception until May 7, 2018. Two independent reviewers screened and summarized the relevant experimental studies on hypothermia efficacy in traumatic SCI. The data were analyzed and the findings were presented as pooled standardized mean difference (SMD) and 95% confidence interval (95% CI). Results: 20 papers containing 30 separate experiments were included in meta-analysis. The onset of hypothermia varied between 0 and 240 minutes after SCI. Administration of hypothermia has a positive effect on locomotion following SCI (SMD=0.56 95% CI: 0.18-0.95, p=0.004). Subgroup analysis showed that general hypothermia improves locomotion recovery (SMD =0.89, 95% C...

Intracerebral cavernomas represent 5-10% of all vascular malformations of the central nervous system. Their location in the third ventricle is very rare. Only about a hundred cases have been reported in the literature so far. We present for the first time a case of third ventricular cavernoma encountered in a 39-yearold patient admitted in our department, while detailing the various difficulties encountered in the management of this rare entity. Keywords: cavernoma – third ventricle – transcallosal approach I. Introduction Intracerebral cavernomas represent 5-10% of all vascular malformations of the central nervous system. Their intraventricular location is rare; estimated at 2.5 to 10.8%, even more rare in the third and fourth ventricles. Nearly 100 cases have been reported in the literature. The median age is 43.5 years, with a female predominance. Surgery is indicated whenever the lesion is accessible. This is a case of third ventricle cavernoma which has been operated in our ins...

O tromboembolismo pulmonar (TEP) é uma importante causa de morbimortalidade nos pacientes submetidos a procedimentos neurocirúrgicos 1,2 . Nos casos de TEP em pacientes que se encontram em pós-operatório recente de neurocirurgia, há contra-indicação à terapêutica trombolítica, sendo realizada apenas em casos selecionados 2 . O objetivo deste estudo foi apresentar um caso de paciente que apresentou TEP maciço no sétimo dia de pós-operatório de clipagem de aneurisma cerebral, em que foi realizada trombólise intra-arterial, com boa evolução clínica. Paciente do sexo masculino, 36 anos, com diagnóstico de aneurisma de artéria comunicante anterior, sendo indicado tratamento cirúrgico. Apresentava como antecedente acidente vascular encefálico isquêmico na região occipital. Foi admitido na unidade de terapia intensiva (UTI) no pós-operatório imediato de clipagem de aneurisma de artéria comunicante anterior, sem intercorrências, recebendo alta da UTI no segundo dia de pós-operatório. No sétimo dia após a cirurgia, apresentou quadro de dor precordial em queimação, acompanhada de taquicardia, sudorese fria e instabilidade hemodinâmica, sendo transferido para UTI, necessitando de administração de fármacos

Neurosurgery for psychiatric disorders, notably for obsessive-compulsive disorder (OCD), was initiated in Venezuela in the decade of 1970, and consisted since that time in the classic stereotactic anterior cingulotomy. In order to know further about the physiopathology of this disorder, we performed intracerebral microdialysis in 2 patients who were operated on. The aim was to measure changes in extracellular neurotransmitters within the basal ganglia. The microdialysis probes were stereotactically placed in the right caudate nucleus and in the dorsomedial nucleus of the right thalamus. The microdialysis was done before the left cingulotomy, during the pause and after the right cingulotomy. Glutamate and gamma-aminobutyric acid (GABA) changes were similar in the caudate nucleus of both patients, whereas in the dorsomedial nucleus the changes were opposite among the 2 patients. Although this study does not bring enough data to explain such differences yet, the existence of dynamic changes in the neurochemistry of the basal ganglia during cingulotomy shows that intracerebral microdialysis can help in the understanding of the pathophysiology of OCD and eventually in the design of new surgeries with better results.

Object The aim of this study was to evaluate the impact of a newly appointed neurointensivist on outcomes in head-injured patients in the neurological/neurosurgical intensive care unit (NICU). Methods The mortality rate, length of stay (LOS), and discharge disposition of all patients with head trauma who had been admitted to a 10-bed tertiary care university hospital NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University HealthSystem Consortium (UHC) database. Samples of medical records were reviewed for Glasgow Coma Scale (GCS) score documentation. The authors analyzed data pertaining to 328 patients before and 264 after the neurointensivist's appointment. The unadjusted mean in-hospital mortality rate increased 1.1% in the after period, but this increase was significantly lower compared with the UHC-based expected increase of 8.1% in the...

Recent advances in pathophysiological and genetic mechanisms of some neuromuscular diseases and a rapid progress in new pharmacological technologies led to an accelerated development of innovative treatments, generating an unexpected therapeutic revolution. In part 1, we report already commercially available drugs, just approved drugs and new therapeutic promises in the treatment of peripheral neuropathies. Hereditary transthyretin amyloidosis (hATTR) is a devastating disease due to amyloid accumulation in peripheral nerves, heart and autonomic system. The first specific drug approved for hATTR was tafamidis, a TTR tetramer stabilizer. In 2018, the positive results of two phase 3 trials have been reported leading to start of regulatory approval route for inotersen, an antisense oligonucleotide and patisiran, the first-ever RNA interference (RNAi) therapeutic. System biology targeting approach has indicated baclofen, naltrexone and sorbitol in combination (PXT3003) as candidate drugs for Charcot-Marie-Tooth disease type 1A. This hypothesis was confirmed in experimental models and in phase 2 and 3 clinical trials. Givosiran, another RNAi therapeutic, targeting 5-aminolevulinic acid synthase, has been positively tested in acute intermittent porphyria in phase 1/2 and ongoing phase 3 trials. Although allogenic hematopoietic stem cell transplantation resulted recently a long-term therapy in mitochondrial neurogastrointestinal encephalomyopathy (MNGIE), a new strategy is liver transplantation which is able to revert the severe biochemical and clinical imbalance of the disease. Recently, a gene therapy has been tested in a MNGIE murine model, indicating that it may become a new therapeutic option.

Introduction Late-Onset Pompe Disease (LOPD) is characterized by progressive limb-girdle muscle weakness and respiratory dysfunction. Diaphragm is the most impaired muscle in LOPD and its dysfunction cause major respiratory symptoms. The aim of this study was to evaluate the correlation between diaphragm thickness and mobility assessed by ultrasonography and respiratory function and muscle strength tests in patients with LOPD. Methods 17 patients with LOPD (9 female, 47 ± 15 years) and 17 age and gender-matched healthy controls underwent spirometry, muscle strength testing, and ultrasound evaluation of diaphragm excursion and thickness. The following parameters were significantly reduced in LOPD patients versus controls (all p < 0.001): forced vital capacity (FVC) in seated and supine position, maximum inspiratory and expiratory pressure (MIP and MEP), diaphragm excursion, thickness at functional residual capacity (FRC) and total lung capacity (TLC), and thickness fraction (TF). Ultrasound studies of diaphragm thickness at FRC correlated with MIP (r = 0.74; p < 0.0001) and seated FVC(r = 0.73; p < 0.05). Diaphragm thickness at TLC correlated with MIP (r = 0.85; p < 0.0001) and FVC in both seated (r = 0.77; p < 0.0001) and supine position (r = 0.68; p < 0.05). TF correlated significantly with MIP (r = 0.80; p < 0.001), FVC in both seated (r = 0.66; p < 0,005) and supine position (r = 0.61; p < 0.05). Interestingly diaphragm thickness at FRC correlated with disease duration (years) in LOPD patients (r = -0.53; p < 0,05). Ultrasound diaphragm mobility correlated with diaphragm thickness at TLC(r = 0.87; p < 0.0001), FRC (r = 0.84; p < 0.005) and TF (r = 0.73; p < 0.05). Moreover diaphragm mobility correlated with FVC in seated(r = 0.79; p < 0.005) and supine position(r = 0.74; p < 0.05) and MIP (r = 0.81; p < 0.005). Conclusion Diaphragm ultrasonography is a simple and reproducible technique for manage respiratory dysfunction in LOPD patients.

✓ The authors review 29 cases of surgically-proven isodense subdural hematomas examined by non-contrast and contrast-enhanced computerized tomography scans. Three types of isodense collections were noted: homogeneous isodense collections, mixed-density collections, and gravitational layering within subdural collections. Contrast enhancement within the cerebral cortex, cortical vessels, and subdural membranes led to the correct diagnosis in each case. Contrast-enhanced scans are essential for the evaluation of isodense subdural hematomas.

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

Purpose The management of cervical facet dislocation injuries remains controversial. The main purpose of this investigation was to identify whether a surgeon’s geographic location or years in practice influences their preferred management of traumatic cervical facet dislocation injuries. Methods A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. The survey included clinical case scenarios of cervical facet dislocation injuries and asked responders to select preferences among various diagnostic and management options. Results A total of 189 complete responses were received. Over 50% of responding surgeons in each region elected to initiate management of cervical facet dislocation injuries with an MRI, with 6 case exceptions. Overall, there was considerable agreement between American and European responders regarding management of these injuries, with only 3 cases exhibiting a significant difference. Additionally, results...

To identify the effects of computer assisted training schemes provided to patients who have undergone surgical intervention for lumbar disc herniation on their level of knowledge, level of anxiety, problems experienced after discharge, and level of functional incapacity. The study was performed as a randomized controlled invasive study with a pre-test-post-test design. The study was conducted with 62 patients, 31 of which were included in the intervention group and 31 in the control group. Training and counselling were provided to the patients included in the intervention group via a training web-site, while a training guidebook with the same content as the website for patients was given to the patients included in the control group. The patients who have undergone a surgical intervention for lumbar disc herniation, those who were provided computer assisted training were better informed, had better functional capacity, and experienced less anxiety after discharge than those who were only informed through the training guidebook. Computer-assisted training was efficient educational tool for patients undergoing lumbar disc hernia surgery.

In antiquity, some substances were considered to be susceptible to heal any human disease. They were defined as panacea (universal remedy). Many of them were associated with mythological creatures, heroes, or gods. We find similar accounts for the πάνακες Χειρώνιον, the πάνακες Ἡράκλειον, and the πάνακες Ἀσκληπίειον. Examining a few prominent case studies, this paper intends to highlight the connections between pharmacotherapeutics and mythology. This would lead to a re-evaluation of ancient panaceas and their mythological background.

A 4-year-old girl presented with fever, coughing, and vomiting; followed by unconsciousness. Magnetic resonance imaging showed hyperintense changes in the thalami bilaterally, brain stem, cerebellum, and subcortical cortex. Novel influenza A (H1N1) virus was identified by polymerase chain reaction in patient's nasopharyngeal swab specimen. We reported a rare case of clinically severe, novel influenza A-associated encephalitis. Novel influenza A should be considered in the differential diagnosis in patients with seizures and mental status changes, especially during an influenza outbreak.

SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...

Introduction: Various surgical technique is used for evacuation of chronic subdural hematoma. Burr hole drainage is a most preferred. However, there exist a controversy regarding single versus double burr hole among neurosurgeon. This study aims to compare the single versus double burr hole drainage for chronic subdural hematoma in terms of mortality, wound infection andrecurrence. Methods: A retrospective observational study was performed over the period of 3 years. Data were collected in terms age, gender, type of surgery, mortality, wound infection and recurrence. These data were analysed to compare between the single versus double burr hole groups.  Results: A total of 53 patients with chronic subdural hematoma underwent burr hole drainage were enrolled. Mean age of patients was 61.87 ± 17.35 years with male to female ratio 4.88:1. In this study, single burr hole was performed in 35 patients (66%) versus double burr hole in 18 patients (34%). Superficial surgical site infection ...

Neurological manifestations in patients with COVID-19 are more frequently being reported. Cerebrovascular events have been reported in around 3% of patients. In this review we summarize the published literature on cerebrovascular events in patients with COVID-19 as available on the PubMed database. So far, 3 studies have reported cerebrovascular events. Cerebrovascular events were identified on screening patients with decreased consciousness or in the presence of focal neurological deficits. These events were common in elderly, critically ill patients and in patients with prior cardio-cerebrovascular comorbidities. The diagnosis of cerebrovascular events was confirmed with computed tomography of the brain in most studies reporting neurological events. Multiple pathological mechanisms have been postulated regarding the process of neurological and vascular injury among which cytokine storm is shown to correlate with mortality. Patients with severe illness are found to have a higher cardio-cerebrovascular comorbidity. With an increasing number of cases and future prospective studies, the exact mechanism by which these cerebrovascular events occur and attribute to the poor outcome will be better understood. Studies reporting neurological involvement have reported clinical features of headache, dizziness, impaired vision, decreased consciousness, agitation, presence of ataxia, and seizure in patients with . However, the symptoms

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

In a special conversation hosted by Dr. Sumer Sethi, founder of DAMS, we had the privilege of speaking with Dr. Sidharth Mishraone of the most loved and respected educators in the field of Community Medicine in India. Known for his engaging teaching style and deep understanding of postgraduate training needs, Dr. Mishra has transformed the way Community Medicine is taught to residents across the country through the DAMS Resident Course.

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45•6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84•5 (95% CI 84•1-84•9), which varied between HIC (88•5 [89•0-88•0]), MIC (81•8 [82•5-81•1]), and LIC (66•8 [64•9-68•7]) settings. In the third phase, 1217 (74•6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51•4%) were from HIC, 538 (44•2%) from MIC, and 54 (4•4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3•6% (95% CI 3•0-4•1; p<0•0001) increase in SVR. This was consistent in HIC (4•8% [4•1-5•5]; p<0•0001), MIC (2•8 [2•0-3•7]; p<0•0001), and LIC (3•8 [1•3-6•7%]; p<0•0001) settings. Interpretation The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

OBJECTIVE While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors. METHODS Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed. RESULTS One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18–58 years). Thirty-four pa...

The impact of targeted therapies in glioma has been modest. All the therapies that have demonstrated a significant survival benefit for gliomas in Phase III trials, including radiation, chemotherapy (temozolomide and PCV [procarbazine, lomustine, vincristine]), and tumor-treating fields, are based on nonspecific targeting of proliferating cells. Recent advances in the molecular understanding of gliomas suggest some potential reasons for the failure of more targeted therapies in gliomas. Specifically, the histologic-based glioma classification is composed of multiple different molecular subtypes with distinct biology, natural history, and prognosis. As a result of these insights, the diagnosis and classification of gliomas have recently been updated by the World Health Organization. However, these changes and other novel observations regarding glioma biomarkers and subtypes highlight several clinical challenges. First, the field is faced with the difficulty of reinterpreting the results of prior studies and retrospective data using the new classifications to clarify prognostic assessments and treatment recommendations for patients. Second, the new classifications and insights require rethinking the design and stratification of future clinical trials. Last, these observations provide the essential framework for the development and testing of new specific targeted therapies for particular glioma subtypes. This review aims to summarize the current literature regarding glioma subclassifications and their clinical relevance in this evolving field.

Background: The insertion of an external ventricular drain (EVD) is a fundamental neurosurgical procedure predominantly performed by junior neurosurgical trainees. It is vital for managing conditions like hydrocephalus, intracranial hypertension, traumatic brain injury, and others. The procedure's success heavily relies on the precise identification of anatomical landmarks and the trainee's experience. Objective: This study aims to assess the precision and safety of EVD placement in patients treated by first-year (R1) and second-year (R2) neurosurgical residents, evaluating the impact of the residents' experience levels on the outcomes of the procedure. Methods: Conducted at the Neurosurgery Department of Jinnah Post Graduate Medical Center, Karachi, from February to July 2022, this prospective cohort study involved individuals aged 18 years or older undergoing EVD placement for hydrocephalus. Exclusion criteria included patients with more than 5mm midline shift on initial scans or those without a post-EVD placement scan. Procedures were performed under senior resident supervision, with postoperative CT scans assessing catheter tip placement and potential complications. Statistical analyses utilized IBM SPSS Statistics for Windows, Version 25.0, with Student's t-test, Chi-square, and Fisher exact tests applied as appropriate. Results: The study comprised 152 patients (mean age: 39.4 ± 10.7 years; 52.6% male). The initial GCS scores varied, with 44.7% scoring above 8. Most EVD placements (60.5%) were by residents in their fourth or fifth year. The average procedure duration was 43 ± 8.7 minutes, with an average of 1.44 ± 0.12 passes. Optimal placement (Kakarla Grade 1) was achieved in 59.2% of cases, with significant differences in placement accuracy between R1 and R2 residents (p<0.05). The study highlights the significant role of experience and training in the successful placement of EVDs. The higher accuracy rates in more experienced residents underscore the need for enhanced training programs for junior neurosurgical trainees, focusing on anatomical landmark identification and procedural practice.

Multiplerisk factors are identified for lower back pain have been recalled in studies which include body mass index (BMI), age, diabetes, gender, smoking, and weight 2 lifting. Low back pain is one of the prominent issues faced by health care throughout the world, as the population ages with time it is observed that suffering from low 3 back pain is also at rise. Although during examination, the patient has back tenderness associated with spasm, numbness of the leg, and limited straight leg raising movement cross leg test, femoral stretch test these examination findings are supported by imaging that commonly includes Flexion and extension x-ray of

Objective: To explore the result and frequency of different problems that occur in the early post-operative period and the incidence of these complications in our community. It will give insight and drive further development in the care of myelomeningoceles as well as the unique problems that emerge in these patients post-operatively. At the Jinnah Postgraduate Medical Center in Karachi, the Department of Neurosurgery, this prospective, observational study was carried out over 12 months. Patients of both genders from 1 month to 2 years of age, diagnosed with myelomeningocele, and admitted to the ward for surgical repair were included in the study. Results: Out of 94, there were 58.5% female patients, with the highest percentage of age group i.e. 48.9% in > 3 months to 9 months. Medium size of MMC (71.3%) at the lumbar side location (46.8%) was observed in the highest frequency among the study sample. The overall postoperative complication rate was 19.1%, with CSF leak being the most common (9.6%) followed by wound infection (5.3%). There was no association of the complications with the age, size, and location of MMC. Myelomeningocele treatment may be delayed as a result of distant homebirths. Neurosurgeons who are trying to give prompt access to medical care for individuals born with MMC face various hurdles, including the family's desire to seek medical attention, their capacity to do so, and the availability of proper medical treatment.

Objective: Diagnosis of supratentorial space occupying lesion is a frequent dilemma in neurosurgical practice. MR spectroscopy that is an advanced MR imaging sequence can prove to be decisive in such cases. The objective of the study is to determine diagnostic accuracy of MRS in differentiating supra-tentorial brain space occupying lesions taking histopathology as gold standard The cross sectional study was conducted at Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi from August 2018 to July 2019. A calculated sample size of 156 patients aged between 18-50 years after informed consent. All patients underwent MR Spectroscopy pre-operatively. Surgery was performed and histopathological findings were compared with spectroscopic findings. The average age of the patients was 32.41 ± 10.02 years. There were 84 (53.84%) males and 72 (46.15%) females. The sensitivity of MRS was 90.69% with a specificity of 97.34%. MR Spectroscopy is an accurate diagnostic tool for establishing pre-operative differentiation between neoplastic and inflammatory lesion. It should be performed in all cases where contrast MRI is inconclusive in establishing the diagnosis.

Objective: To determine the outcome of Transpedicular Fixation via Posterior Approach for Dorsal and Lumbar Spine Tuberculosis. Material/Methods: This study was cross-sectional and conducted from 01/02/2015 to 30/7/2020 in the department of neurosurgery. A total of 36 patients with dorsal and lumbar spine tuberculosis were operated on for transpedicular fixation. Assessment scores were used pre-operative and post-operative and patients were kept on follow-up till six months after the surgical procedure. Variables like age, gender, spinal level, preoperative, and follow-up clinical status were calculated. Results: There were 19 (53%) male and 17 (47%) female patients with a mean age of 27 ± 8. Thoracolumbar was the commonest segment involved in 17 (47%) patients, followed by lower thoracic in 8 (22%) and lumbar in 7 (19%). There were 7 (19%) patients on the preoperative American Spinal Injury Association (ASIA) impairment scale in grade B, 12 (33%) in grade C, 15 (42%) in grade D, and 2 (5%) in grade E. The follow-up assessment at 6 months showed that ASIA grade B was seen in 3 (8%), grade C in 4 (11%), grade D in 16 (44%), and Grade E in 13 (36%) patients. Preoperative and follow-up scores on the ASIA impairment scale, COBS ANGLE, and ESR showed a significant difference (p-value < 0.05). We concluded that transpedicular fixation can restore the stability of the spine in thoracic and lumbar tuberculosis. The procedure is important for the improvement of clinical symptoms, correction of kyphosis, and stabilization of the spinal column.

Objective: Skull fractures are common in the pediatric age group. The surgical management of pediatric patients with skull fractures differs among institutions and surgeons. Our object of this study was to assess the pattern of skull fractures and outcome in the pediatric population. This study was conducted in the department of neurosurgery of a tertiary care hospital from June 2018 to April 2020. We included 152 children between ages 5 to 11 years who were brought with head trauma and diagnosed to have a skull fracture on computerized tomography (CT) Scan brain. The mean age of patients was 6.91 ± 1.84 years. Out of those, 59.8% were male and 40.1% were female. The most common type of fracture at presentation was depressed fracture in 42% patients, followed by linear (35%) and compound fractures (23%). Parietal fractures were the commonest (63.1%) in our study. Associated intracranial hematomas were seen in 37.5% patients, epidural hematoma being the most common. Surgically treated patients were 36%. Good recovery was seen in 73% patients while mortality was 10.5%. Isolated skull fractures are overall benign conditions. Linear parietal skull fractures have good outcomes amongst all fracture types.

Background: Head trauma is the most common case encountered in neurosurgery, and it is on the rise daily; head trauma sometimes requires the removal of skull bone which leads to another set of complications and associated issues related to cranioplasty. The study's objective was to share the single-center tertiary care hospital experience of cranioplasty, including outcomes, management, and associated complications. Methodology: Patients who underwent reconstructive cranioplasty at the study site from 2015-2020 were examined in this retrospective descriptive study conducted at the department of neurosurgery, Jinnah postgraduate medical center, Karachi. Patients aged 18 to 60 years were considered for cranioplasty procedures, preceded by the decompressive post-craniotomy for brain trauma, skull fracture, intractable intracranial hypertension, brain tumor, and infected post-craniotomy bone flaps were included in the study. Results: A total of 68 patients who presented to the study center with cranial defects were included in this study. The frequent cause of cranioplasty was the traumatic injury to the brain in 38(55.88%), followed by brain tumors in 321(0.4%) and cerebrovascular injury in 9(13.23%) cases. In our study, no patient required more than one cranial procedure. The anatomical regional wise division of defects was temporal 29(42.64%), frontal 15(22%), and parietal 24(35.39%). Conclusion: Indications for cranioplasty, type of bone graft, associated comorbidities, and complications have been addressed that are potentially preventable.

Objective: A prospective descriptive study was aimed to evaluate frequency of hydrocephalus in preoperative brain tumor to determine the need of permanent ventriculoperitoneal shunt (VP) shunt. We operated 156 cases of brain tumor concomitant with hydrocephalus (preoperative and post-surgery development). The tumor character, type & volume of tumor, histopathology and location of tumor were documented and therefore, the need of postoperative radiotherapy and chemotherapy were recorded on a structured proforma. We divided hydrocephalus into pre and postoperative in this study. Results: 41.6% were adults and 58.33% were pediatric patients, who had hydrocephalus due to brain tumor. Supratentorial tumor location was found in 41% patients and Infratentorial was found in 59% patients. The patients who had preoperative hydrocephalus were 21.7% among adults, and 35.25% in pediatric patients. The most common type of brain tumor with hydrocephalus in 15.3% adults was Cerebellopontine (CP) Angle Tumor. Most common type of brain tumor with hydrocephalus in 15.3% pediatric patients was Medulloblastoma. We administered Mannitol in 42.9% patients, while corticosteroid was received by all patients. The VP shunt was done in most of the patients (87%). Majority of the patients (86.5%) were found with a Karnofsky score of > 70. The common brain tumor associated with hydrocephalus in children were Craniopharyngioma and in CP angle tumor in adults. 2.6% cases required the VP shunt dependency. Considering the cause of hydrocephalus in brain tumors, perioperative decision-making plays a pivotal role in the management of tumor-associated hydrocephalus.

Objective: To determine the impact of helmet wearing on traumatic brain injury. Methods: We analyzed 400 cases of traumatic brain injury (TBI) in motorbike riders with and without helmet, from July 2017 to December 2020 presenting to the neurosurgery department at Jinnah Postgraduate Medical Center (JPMC), Karachi, Pakistan. The medical records were analyzed for CT scan findings, length of hospital stay, complications (mortality and disability), Glasgow Coma Scale (GCS) and Glasgow outcome score (GOS) at time of discharge. Results: A total of 400 patients with head injury due to motorbike accidents were included and all were male patients. They were equally divided into two groups, 200 in Group-A (with helmet) and 200 in Group-B (without helmet). Majority of the unhelmeted patients i.e. 102 (51%), needed admission in the Intensive Care Unit (ICU) compared to 70 (35%) in helmeted. When comparing non-helmeted patients to helmeted patients, the total median length of hospital stay was greater among non-helmeted patients (10 vs 05 days). Mortality was higher among nonhelmeted patients seen in 50 (25%) as compared to 14 (7%) in helmeted patients. Overall, the good outcome was observed in 119 (59.5%) patients in Group-A as compared to70 (35%) patients in Group-B while 81 (40.5%) showed bad outcome in Group-A and 130 (64%) in Group-B. The failure to wear a helmet was found to be strongly linked with abnormal neuroimaging more complications, poor outcome and lower GCS on discharge as compared to patients using helmet. Conclusion: Lack of helmet use is linked to abnormal brain imaging, more complications, and a longer stay in the hospital after a head injury.

Prolapse of intervertebral disc is a common pathology seen in the neurosurgery field but intradural lumbar disc herniation is a rare entity encountered only during the surgical treatment of prolapse. We present a 30year-old male who reported lower back pain radiating to the right lower limb for the last 2.5 years. The pain started after a brief history of weight lifting. There were no associated motor or sensory deficits. The magnetic resonance imaging of the lumbosacral spine showed prolapse of intervertebral disc at the level of lumbar L4-L5. The patient underwent laminectomy and intradural discectomy of L4-L5. Patient had a smooth post-operative recovery with no neurological deficits. A thorough radiological examination can aid in the pre-operative diagnosis of an intradural lumbar disc herniation.

This study was conducted to assess the outcome in patients with hydrocephalus who underwent ventriculoperitoneal (VP) shunt surgery. This retrospective study was conducted at the neurosurgery department of a tertiary care hospital. The time frame was three years and five months from January 2017 to May 2020 with a follow-up of six months. This study included 1030 patients, out of whom 64.2% were male and 35.8% were female. While the majority of the patients were more than 11 years of age (466), age did not have any significant impact on the outcome of the ventriculoperitoneal shunt surgery. The most common cause of hydrocephalus was congenital (47.6%). A good outcome was seen in 63.4%, mortality was 10.6%, and complications were identified for 25.8%. The underlying pathology had a significant impact on the outcome in our study (p-value < 0.05) where the congenital cause of hydrocephalus showed a better outcome than any other cause. Ventriculoperitoneal shunt is a good way to manage hydrocephalus, but there is always a high risk of complications.

Objective:  To explore the result and frequency of different problems that occur in the early post-operative period and the incidence of these complications in our community. It will give insight and drive further development in the care of myelomeningoceles as well as the unique problems that emerge in these patients post-operatively. Materials and Methods:  At the Jinnah Postgraduate Medical Center in Karachi, the Department of Neurosurgery, this prospective, observational study was carried out over 12 months. Patients of both genders from 1 month to 2 years of age, diagnosed with myelomeningocele, and admitted to the ward for surgical repair were included in the study. Results:  Out of 94, there were 58.5% female patients, with the highest percentage of age group i.e. 48.9% in &gt; 3 months to 9 months. Medium size of MMC (71.3%) at the lumbar side location (46.8%) was observed in the highest frequency among the study sample. The overall postoperative complication rate was 19.1%,...

Objective:  To evaluate the role of the degree of midline shift on CT scans in predicting clinical outcomes in traumatic brain injury (TBI). Materials and Methods:  A prospective observational study was conducted at the Department of Neurosurgery of a tertiary care hospital. We included 148 patients. After fulfilling the inclusion criteria, the patient’s baseline data, including the patient&#39;s age, gender, and CT scan findings with the degree of midline shift, was noted. The patients were monitored for three months to evaluate the outcome. The collected data was analyzed using SPSS version 22.0. Results:  Our study showed that 105 (70.9%) patients showed satisfactory outcomes while 43 (29.1%) showed unsatisfactory outcomes. Patients with no midline shift were 70, out of which 55 (78.6%) showed satisfactory outcomes. Similarly, patients with 1-2 mm midline shifts showed satisfactory outcomes in 39 (69.6%) while 3-5 mm midline shifts showed 11 (50%) satisfactory outcomes. In our st...