Lucas Troude

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.

How I do it: the combined petrosectomy

BackgroundPetroclival and ventral brain stem tumors require a complex approach.MethodThe combined petrosectomy is an epidural transtentorial-transpetrosal otoneurosurgical approach to achieve a retrolabyrinthine presigmoidal approach and an anterior petrosectomy in one single procedure. The different steps of this approach are described and illustrated by figures and a video. The indications and limitations of the technique are presented.ConclusionThe combined petrosectomy offers multiple corridors to the petroclival region and ventral brainstem while preserving the intrapetrous neurotological structures. Meticulous stepwise bony resection optimizing the dural opening and preservation of veins contributes to reducing the risk inherent to this technique.

The epidural approach to the Meckel’s cave: a how I do it

BackgroundMeckel’s cave (MC) is a meningeal cleft lying in the middle fossa laterally to the cavernous sinus. Tumours that develop inside the MC may require a surgical resection. The authors describe the surgical technique of the intracranial epidural approach to the MC.MethodsBased upon anatomical dissection showing the relevant surgical anatomy, and illustrated by the video of an operated case, the authors detail the surgical procedure. The key point is to shave the floor of the middle fossa and skeletonize the superior orbital fissure, rotundum and ovale foramen in order to delineate the plane of dural elevation and expose the lateral wall of the MC. The rules of exposure and resection of the tumour are then shown. Variations and limitations of the approach are discussed.ConclusionConducted in a stepwise manner and following relevant landmarks, the epidural anterolateral approach offers a safe and reliable exposure to the diseases that develop within the MC.

The Surgeon in Action: Representations of Neurosurgery in Movies from the Frères Lumière to Today

In this review, we examine the portrayal of neurosurgery and neurosurgeons in 61 movies produced from the beginnings of cinema from the Lumière brothers (1895) to 2017, across 4 continents and covering 10 cinematic genres. We find that these movies tend to shape most beliefs and stereotypes about neurosurgery. However, we notice that there is a trend to describe neurosurgery and neurosurgical disorders with more accuracy as we progress in time. Although it is not for the medical profession to dictate or censor fictional content, a keen eye on these depictions will help us to understand, and perhaps combat, some of the stereotypes and myths that continue to surround neurosurgery in the twenty-first century.

Stereoscopic Surgical Video of Combined Petrosectomy With Virtual Reality Headset: 3-Dimensional Operative Video

The use of 3-dimensional (3D) videos allows students to visualize surgical procedures from the perspective of the surgeon without missing the essential parts.1 This 3D commented video demonstrates the operative technique and surgical nuances of the combined petrosectomy, visualize using virtual reality headsets. Historically, traditional intradural cisternal routes using suboccipital and pterional approaches have been proposed to remove petroclival tumors.2-5 It allows rapid identification of neurovascular structures and a short exposure time. However, access to the petroclival region is far, not direct, and requires intradural cerebral retraction.6 In order to improve the access for tumoral dissection, lateral transpetrosal approaches have been proposed.7-12 The extradural route shortened the distance to the petroclival region, allows to better preserve the veins, to decrease the cerebral retraction, to interrupt early the tumor vascular supply, and a larger extent of resection.6 Transpetrosal approaches includes middle fossa approach8,10 (removing the petrous apex), posterior petrosal approach9,13,14 (removing of presigmoid retrolabyrinthine bone), and translabyrinthine petrosectomy.12 A combined petrosectomy may be used to approach larger tumor extending across the clival midline, upward to the tentorium or downward to the lower cranial nerves.6,10,15,16 Alternatively, according to Nanda, a retro-sigmoid approach may need to be performed to avoid critical draining veins injury.10,17 Good resection and outcomes are obtained when experienced surgeons use familiar approaches and microsurgical techniques.10.

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.

Le granulome réparateur à cellules géantes : un diagnostic différentiel exceptionnel pour une lésion lytique de l’os temporal

Introduction Le granulome reparateur a cellules geantes est une lesion osteolytique benigne rare. Classiquement, elle atteint la mandibule, rarement la base du crâne. Patient et methodes Un patient de 25 ans fut admis dans notre institution en aout 2002 pour une tumefaction indolore preauriculaire gauche, progressivement croissante depuis quelques mois. Le scanner montrait une lesion osteolytique extradurale de l’os temporal avec extension infratemporale. Une exerese partielle fut realisee par voie frontotemporale. A 36 mois postoperatoire, la lesion progresse, c’est pourquoi une voie preauriculaire infratemporale complementaire fut realisee. Apres 10 ans de suivi, un petit residu tumoral est stable, le patient demeure asymptomatique. Discussion Les granulomes reparateurs a cellule geantes de l’os temporal sont exceptionnels. Il n’existe aucune semiologie radiologique pathognomonique. Le diagnostic est obtenu par l’analyse anatomopathologique de la piece operatoire. Une progression tumorale necessite un traitement chirurgical.

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.