George Fotakopoulos

Outcomes in meningitis/ventriculitis treated with intravenous or intraventricular plus intravenous colistin

BackgroundThe aim of this work is to evaluate the outcome of patients treated with intrathecal colistin for meningitis/ventriculitis.MethodsThis retrospective case series study included patients presenting with nosocomial meningitis/ventriculitis following neurosurgical interventions and having intravenous (IVC group) or intravenous and intrathecal/intraventricular colistin (ITC group) treatment between 2006 and 2014.ResultsThirty-four patients presented nosocomial meningitis/ventriculitis; 11 (32.5xa0%) were included in the IVC group and 23 (67.6xa0%) in the ITC group. The most frequent isolated bacteria were Acinetobacter baumannii. The mean dose was 170,000 (±400) IU and the duration of intraventricular treatment was 16.0 (±8.3) days. The duration of intravenous treatment was 16.0 (±8.3) days in the ITC group and 15.3u2009±u20097.6xa0days in IVC group. Hospital mortality was significantly lower in the ITC group compared with the IVC group (13 vs. 72.7xa0%, pu2009=u20090.001).ConclusionsThe combination of intravenous plus intraventricular (IV-IVT) colistin therapy may improve outcomes in patients attending with meningitis/ventriculitis due to multi-drug resistance infections.

DNA content is associated with malignancy of intracranial neoplasms.

OBJECTIVEnFlow cytometry has been applied to analyze the DNA-content distribution of tumors, in order to relate this to clinical and biological parameters of tumor behavior. Herewith, we investigated the value of cell cycle analysis in the characterization of intracranial lesions and its possible prognostic role.nnnMETHODSnDNA analysis was performed in tumor samples that were taken during surgery over a five year period. Diagnosed tumors were graded according to the World Health Organization 2007 classification scheme.nnnRESULTSnFifty-six patients were included in the study. There was a significant difference in G0/G1 phase and S-phase between low-grade and high-grade gliomas. There were 12 (57%) diploid and 9 (43%) aneuploid tumors. All aneuploid tumors were glioblastomas. Patients with G0/G1 value ≤ 69% and S phase value greater than 6% were associated with worse survival. As regards meningiomas, there was a significant difference in G0/G1 phase, S phase and mitoses fraction between benign and both atypical and anaplastic meningiomas. Aneuploidy was observed in the anaplastic tumors and in 2/4 atypical meningiomas.nnnCONCLUSIONnThe results of the present study, showed that cell cycle analysis could differentiate low from high grade gliomas and benign from atypical/anaplastic meningiomas. Furthermore, a prognostic significance was found in glioma patients. The role of cell cycle analysis in brain tumors thus warrants further investigation.

Posttraumatic Hydrocephalus after Decompressive Craniectomy in 126 Patients with Severe Traumatic Brain Injury.

OBJECTIVEnSevere traumatic brain injuries (TBIs) occur frequently. In some of these patients decompressive craniectomy (DC) must be performed. Posttraumatic hydrocephalus (PTH) can develop after TBI further damaging the brain. DC is considered to be one of the causes of PTH. This study defines the incidence of PTH in TBI patients who underwent DC and tries to determine associated factors.nnnMATERIALS AND METHODSnWe conducted a retrospective study (2009-2013) that included 126 patients with severe TBI and DC. The collected data were demographics, the craniectomy size, the presence or absence of hydrocephalus, the need for changing the opening pressure of the valve of the cerebrospinal fluid (CSF) shunt or replacing all or parts of the CSF shunt, and the interval between cranioplasty and shunt placement. We excluded patients with additional intraventricular hemorrhage and those with bilateral or bifrontal DC.nnnRESULTSnTen of the 126 patients (7.9%) developed PTH and were treated with a CSF shunt. There was no statistical correlation between development of PTH and age or sex, but a statistically significant correlation between development of PTH and the size of DC.nnnCONCLUSIONnOur study suggests that PTH development is multifactorial and shows that PTH is not that rare. We showed a correlation between craniectomy size and the incidence of PTH.

Admission glucose and coagulopathy occurrence in patients with traumatic brain injury.

Abstract Introduction: Coagulopathy after traumatic brain injury (TBI) is a frequent event and is associated with patients’ prognosis. TBI is also associated with a stress response that includes hyperglycemia. This study investigated if coagulopathy occurrence is associated with admission blood glucose levels in patients with TBI. Methods: This study retrospectively evaluated patients with TBI who were admitted to a neurosurgical department over a 4-year period. Coagulopathy was defined as an aPTT >40 seconds and/or INR >1.2 and/or a platelet count <120*109 per litre. Results: One-hundred and forty-nine patients were included in the study. Thirty-four patients developed coagulopathy. Patients with coagulopathy had significantly lower haemoglobin levels, increased INR and increased aPTT. Patients with severe TBI had more frequent coagulopathy. Patients with severe TBI had significant higher serum glucose levels compared to patients with mild TBI. Using ROC curves it was found that a serum glucose of 151u2009mgu2009dl−1 was the threshold for the discrimination of patients that developed coagulopathy. Logistic regression analysis revealed that serum glucose greater than 151u2009mgu2009dl−1 and haemoglobin levels lower than 12.4u2009mgu2009dL−1 were significantly associated with coagulopathy occurrence. Conclusion: Coagulopathy frequently occur after TBI. Patients with lower GCS score and lower haemoglobin levels and increased blood glucose levels at admission are at greater risk.

Chronic subdural haematomas: a comparative study of an enlarged single burr hole versus double burr hole drainage

Various surgical treatments have been proposed for the treatment of chronic subdural haematoma (CSDH). Herewith, we set out to compare the efficacy of an enlarged single burr hole versus double burr hole drainage for the treatment of CSDH. We studied patients with symptomatic CSDH proven by CT scan that were treated in our institute between January 2002 and January 2009. All patients were treated by an enlarged single or double burr hole drainage. A subdural drain was placed in all cases. A total of 245 patients were included in the study. Double hole drainage was performed in 156 (63.7xa0%) patients (group A) and an enlarged single burr hole drainage in 89 (36.3xa0%) patients (group B). There were nine recurrences in group A and five in group B; however, the difference was not statistically significant. There was no significant relationship between recurrence rate and age, gender, bilateral haematoma and antiplatelet or anticoagulant therapy. There was a trend towards higher risk of recurrence for patients with residual clots on postoperative CT scan. The mean hospitalization time was 6.2xa0days, and there was no significant difference between the two groups. No significant difference was found between patients outcome, as assessed by Glasgow outcome scale score, and treatment method. Enlarged single burr hole and double burr hole drainage had the same efficacy in the treatment of CSDH.

Spinal ependymomas: Prognostic factors and treatment results

OBJECTIVEnWe retrospectively analyzed patients with spinal ependymomas who were treated in our institute. We correlated outcome and recurrence with clinical and pathological features.nnnMATERIALS AND METHODSnBetween January 2000 and January 2010, we treated 14 patients with spinal ependymoma (10 males, 4 females; mean age: 48.3 ± 18 years, range: 18-79 years). All patients were operated and received standard postoperative care. The outcome was estimated based on Frankel scale.nnnRESULTSnThe most common presenting symptom was pain. All tumors were operated through a posterior approach and gross total resection was performed in 13/14 cases. Histopathological examination revealed the presence of one anaplastic ependymoma, nine grade II ependymomas, and four myxopapillary ependymomas. The mean Ki-67 index was 1.5%. All the patients were followed up postoperatively for an average of 5.1 years. One patient was reoperated because of recurrent disease and another received radiotherapy due to dissemination of disease. No association was found between extent of resection, tumor location, Ki-67 index, and recurrence of disease. There was a trend toward a higher risk of recurrence in myxopapillary ependymomas. Eight patients improved postoperatively. Interestingly, during the follow-up period, four patients developed a secondary neoplasia.nnnCONCLUSIONnEarly intervention and gross total resection of spinal ependymomas are associated with a favorable outcome. Further studies are needed to clarify the incidence of the development of a second cancer in these patients.

Indirect Traumatic Optic Neuropathy Following Head Injury: Report of Five Patients and Review of the Literature

BACKGROUNDnIndirect traumatic optic neuropathy (ITON) is a rare occurrence in patients with head injuries, mostly affecting young people. Loss of vision is a feared consequence. Its natural history and optimal care remain undetermined. Randomized controlled studies are missing. Treatment alternatives include mere observation, corticosteroid administration, or surgical decompression of the optic canal. Among these options, an individual approach is considered.nnnCASE REPORTSnWe report five patients with head injury and ITON: a 63-year-old woman was left permanently blind after a fall; a 33-year-old man lost his vision of the left eye immediately after a car accident; and three young men (aged 26, 21, and 22 years) who were intubated after a road accident noted loss of vision from one eye after they became conscious. The 26-year-old patient in the last group regained his sight 1 month later, whereas the other two never had it returned. All of our patients were treated conservatively: Methylprednisolone was administrated.nnnCONCLUSIONnPatients with ITON are managed on an individual basis. Informed consent must be obtained for mere observation or administration of corticosteroids and/or optic canal decompression. The natural history of this disorder is unknown. Only randomized controlled studies can fix standard guidelines of care. Preventive measures to decrease the incidence of head injured patients are mandatory.

Clipping Versus Coiling in Anterior Circulation Ruptured Intracranial Aneurysms: A Meta-Analysis

OBJECTIVEnTo evaluate open surgical versus endovascular repair of anterior circulation ruptured intracranial aneurysms based on operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.nnnMETHODSnThis meta-analysis included articles published since December 6, 2016, that compared outcomes of the 2 methods. Extracted data were organized in a standard table format, including first author, country, covered study period, publication year, number of patients and patients at follow-up, operative mortality rate (with 30 days from treatment), permanent neurologic deficit (appearing after surgery), late mortality (after 1 month), and reintervention (surgery or coiling) for both groups of patients. Follow-up was at least 1 year.nnnRESULTSnThere were 8 articles that matched our study criteria. The study population was 628 patients; 374 were treated with surgical clipping, and 254 were treated with endovascular coiling. Pooled results showed no statistically significant difference between the 2 groups in terms of operative mortality, permanent neurologic deficit, late mortality, and need for reintervention.nnnCONCLUSIONSnSelection of the appropriate procedure must be made on the basis of the special characteristics of each case.

The value of transcranial motor-evoked potentials and free-running electromyography in surgery for cervical disc herniation

The present study prospectively investigated the value of free-running electromyography (EMG) and transcranial motor-evoked potentials (TcMEP) during anterior cervical microdiscectomy and fusion for cervical disc herniation with radiculopathy. Thirty-eight patients were eligible for inclusion in the study. Pain was assessed using the visual analogue scale (VAS) score. Quality of life results were scored according to Odoms criteria in the postoperative period. Patients with at least a 41% increase in TcMEP amplitude had an excellent postoperative outcome. When the increase of TcMEP amplitude was ⩽ 11% the patients outcome was fair. The VAS score decreased from a preoperative mean value of 6.39 ± 2.16 to a 3-month postoperative value of 2.39 ± 1.17. At 12-month follow-up the mean VAS score was 1.65 ± 0.90. TcMEP and free-running EMG are effective for monitoring the spinal cord during surgery and may hold an additional prognostic role.

The value of computed tomography perfusion & transcranial Doppler in early diagnosis of cerebral vasospasm in aneurysmal & traumatic subarachnoid hemorrhage

Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage may be challenging both on clinical and radiographic grounds. In this respect we conducted a pilot study in order to assess the feasibility of the technique in the everyday setting of a tertiary hospital and to evaluate the diagnostic performance of different diagnostic computed tomography perfusion aspects in diagnosing the clinical outcome of patients with subarachnoid hemorrhage. Receiver-operating characteristic analysis showed that a cerebral blood flow value of <24.5 presented 67% sensitivity and 100% specificity to diagnose adverse ischemic events at 1 month (p = 0.041). These case series data provide evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that may detect the degree of cerebral ischemia in a very early stage.