Anthony Melot

Risk factors for surgical site infections after neurosurgery: A focus on the postoperative period

BACKGROUND Surgical site infection (SSI) after neurosurgery has potentially devastating consequences. METHODS A prospective cohort study was conducted over a period of 24 months in a university center. All adult patients undergoing neurosurgical procedures, with exception of open skull fractures, were included. Multivariate logistic regression analysis was used to identify independent risk factors. RESULTS We included 949 patients. Among them, 43 were diagnosed with SSI (4.5%). A significant reduction in postneurosurgical SSI from 5.8% in 2009 to 3.0% in 2010 (P = .04) was observed. During that period, an active surveillance with regular feedback was established. The most common microorganisms isolated from SSI were Staphylococcus aureus (23%), Enterobacteriaceae (21%), and Propionibacterium acnes (12%). We identified the following independent risk factors for SSI postcranial surgery: intensive care unit (ICU) length of stay ≥7 days (odds ratio [OR] = 6.1; 95% confidence interval [CI], 1.7-21.7), duration of drainage ≥3 days (OR = 3.3; 95% CI, 1.1-11), and cerebrospinal fluid leakage (OR = 5.6; 95% CI, 1.1-30). For SSIs postspinal surgery, we identified the following: ICU length of stay ≥7 days (OR = 7.2; 95% CI, 1.6-32.1), coinfection (OR = 9.9; 95% CI, 2.2-43.4), and duration of drainage ≥3 days (OR = 5.7; 95% CI, 1.5-22). CONCLUSION Active surveillance with regular feedback proved effective in reducing SSI rates. The postoperative period is associated with overlooked risk factors for neurosurgical SSI. Infection control measures targeting this period are therefore promising.

Arteriovenous malformation of the filum terminale: an exceptional case

Arteriovenous malformations (AVMs) of the spine display a variety of different locations, angioarchitectures, and clinical presentations. The authors describe an exceptional case of a filum terminale AVM that is not described in any classification and discuss the origin and management of this malformation. A 59-year-old woman was admitted in June 2012 for cauda equina syndrome. Magnetic resonance imaging and spinal angiography revealed an AVM of the filum terminale, located below the conus medullaris, fed by the anterior spinal artery. After an unsuccessful attempt to reach the nidus with a microcatheter, the AVM was resected. At 20 months after surgery, the patient was fully independent and radiological images confirmed the exclusion of the malformation. AVMs that originate from the filum terminale are exceptional. According to updated classifications, AVMs of the filum terminale should be categorized as a separate entity.

Tumors of the Skull Base

The big chapter about tumors of the skull base demonstrates the different aspects and neurosurgical techniques by renowned and very experienced skull base surgeons in a compact form. Due to the consecutive illustration with corresponding intraoperative photographic images, every single step of even complex surgical procedures can be reproduced and understood underlining the didactic value of the book. By means of the different tumor entities, the different surgical approaches including their advantages and disadvantages are demonstrated. The surgical and further strategies are explained from a practical point of view by using selected clinical cases as examples.

Intraventricular schwannoma: Case report and review of literature

We report here a case of intraventricular schwannoma. This location is rare. Our patient was a 68-year-old female with a large intraventricular lesion of the body of the lateral ventricle on the right side. Brain magnetic resonance imaging (MRI) revealed this lesion. After a right parietotemporal craniotomy, microsurgical excision using neuronavigation was performed to completely remove the tumor. Histological and immunohistochemical examination confirmed the diagnosis of intraventricular schwannoma devoid of atypical features. Postoperative MRI showed macroscopically complete tumor removal with no recurrence after 12 months of follow-up. A review of the literature identified 32 such cases published to date.

Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation

Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.

Hydrocephalies and Vestibular Schwannoma of Great Size: Therapeutic Strategies: About a Series of 32 Cases

Introduction: The association hydrocephalus and vestibular schwannoma (VS) has been known for a long time. However, there is no therapeutic consensus, especially the place of drainage of cerebrospinal fluid (CSF). We report the result of our experience on the management of this pathology from a group of patients with a high volume VS (Koos IV) and operated consecutively. After reflections based on current literature data, we propose a therapeutic decisional algorithm. Materials and Methods: This is an analytical, retrospective study of 171 patients operated on KOOS IV vestibular schwannoma from January 2003 to December 2016 at the Marseille University Hospital Center. Of these, 32 patients with hydrocephalus and stage IV vestibular schwannoma were included. Radio-diagnostic criteria for hydrocephalus were based on Evans’ index, cortical furrow status, and the presence of trans-ependymal resorption. Our sample was divided into 2 groups. The first consisted of patients first operated on their hydrocephalus and secondarily treated with schwannoma surgery (group I); patients who underwent surgical resection of their first-line tumor were group II. Epidemiological, clinical, radiological, therapeutic and monitoring data were analyzed. The comparison of the quantitative variables was made by Fisher’s test. Results: During our study period (13 years), 171 cases of stage IV SV had been operated. The association between hydrocephalus and SV stage IV of Koos accounted for 18.7%. The average age of our patients was 53 years with a sex ratio of 0.7. The clinical picture was primarily composed of otological signs (90.6%), headache (56.3%) and cerebellar involvement (43.8%). The average diameter of VS inponto-cerebellar angle (PCA) was 31.5 mm. The treatment consisted of placing a first shunt of the CSF in 34.4% (group I). The ventriculoperitoneal shunt (VPS) was performed in 90.9% of cases. The first surgical removal of the tumor (group II) involved 65.6% of the patients. The postoperative tumor residue averaged 0.76 cc. The Evans index was evaluated on average at 0.33 in each of the 2 groups postoperatively. The average follow-up time for patients was 51 months. Eight cases of complications were recorded during the study. Secondly, in group II, VPS was performed in 9.5% (2 cases). Conclusion: Hydrocephalus is a condition commonly associated with stage IV vestibular schwannoma. The first optimal surgical excision of the tumor seems to be the treatment of choice for this pathological association. The success of the surgery is very often related to the management of hydrocephalus pre, per and post operative.

Aneurisma intracraneal traumático secundario a un trauma balístico. Caso clínico y revisión de la literatura

Traumatic intracranial aneurysms (AICT) are rare and are associated with high morbidity and mortality. AICT are the result of head injuries caused by accidents, explosions, and gunfire. The case is reported here of a 28 year old man who was admitted to our hospital after suffering a penetrating head injury caused by a bullet. Radiographic studies showed interhemispheric subarachnoid haemorrhage and a likely AICT image that initially went unnoticed. One week later he underwent a cerebral angiography which showed a bilateral vasospasm of the terminal portion of the internal carotid and the appearance of a 2mm fusiform AICT at the orbit-frontal branch of the anterior cerebral artery. This was surgically treated after an aneurismal growth of 3.4mm and failure of the endovascular treatment. The patient showed a favourable outcome after surgery.

Ruptured posterior ethmoidal artery aneurysm and Moyamoya disease in an adult patient. Case report

The association between Moyamoya disease and intracranial aneurysms is well described. In our case, we describe a unique aneurismal location and its management. We report the case of a 74-year-old woman affected by a Moyamoya disease who displayed a frontal lobe hematoma. The origin of the bleeding came from the rupture of a posterior ethmoidal artery aneurysm that was treated surgically with favourable outcome. This case of a ruptured posterior ethmoidal artery aneurysm in a Moyamoya patient illustrates the polymorphism of the vascular complications encountered in this disease. It stresses the need to obtain information from an angiographic investigation in order to select the best therapeutic option and to reduce procedural complications.