Venkatesh S. Madhugiri

Spinal aneurysms: clinicoradiological features and management paradigms

OBJECT Spinal aneurysms (SAs) are rare lesions. The clinicoradiological features and the exact degree of their association with comorbid conditions such as arteriovenous malformations (AVMs) and coarctation of the aorta have not been definitively described. The ideal management paradigm has not been established. The authors reviewed literature to determine the clinical patterns of presentation, management, and outcome of spinal aneurysms. METHODS A systematic review of literature was performed using 23 separate strings. A total of 10,190 papers were screened to identify 87 papers that met the inclusion criteria. A total of 123 SAs could be included for analysis. RESULTS The mean age of patients at presentation was 38 years; 10% of patients were aged less than 10 years and nearly 50% were greater than 38 years. Spinal aneurysms can be divided into 2 groups: those associated with AVMs (SA-AVMs, or Type 1 SAs) and those with isolated aneurysms (iSAs, or Type 2 SAs). Patients with Type 2 SAs were older and more likely to present with bleeding than those with Type 1 SAs. The acute syndromes can be divided into 3 groups of patients: those with spinal syndrome, those with cranial/craniospinal syndrome, and those with nonspecific presentation. Overall, 32.6% presented with angiography-negative cranial subarachnoid hemorrhage (SAH). Presentation with evidence of cord dysfunction (myelopathy/weakness/sensory loss/bladder involvement) correlated with poor outcome, as did presentation with hemorrhage and association with other comorbid conditions. Surgery and endovascular therapy both led to comparable rates of complete aneurysm obliteration for Type 2 SAs, whereas for the AVM-associated Type 1 SAs, surgery led to better rates of lesion obliteration. The authors propose a classification scheme for spinal aneurysms based on whether the lesion is solitary or is associated with a coexistent spinal AVM; this would also imply that the ideal therapy for the aneurysm would differ based on this association. CONCLUSIONS The clinical and radiological patterns that influence outcome are distinct for Type 1 and Type 2 SAs. The ideal treatment for Type 1 SAs appears to be excision, whereas surgery and endovascular therapy were equally effective for Type 2 SAs.

The Pterional and Suprabrow Approaches for Aneurysm Surgery: A Systematic Review of Intraoperative Rupture Rates in 9488 Aneurysms

OBJECTIVE To assess the safety of the suprabrow approach (SBCA) for aneurysm surgery by comparing intraoperative rupture rates with those for the standard pterional approach. METHODS A systematic review of all literature published in or after 1997 was performed using specified search words. All articles described aneurysm surgery by one of two approaches--pterional or suprabrow--and mentioned the rate of intraoperative rupture. A total of 41 articles were found fit for inclusion for the final analysis. Articles that focused on giant, bilateral, posterior fossa, or previously coiled aneurysms were not included. The χ(2) test was used to compare the two cohorts and various subgroup analyses were carried out. A P value of <0.05 was considered significant. RESULTS The search of literature yielded 9488 aneurysm reports (41 articles), 7535 operated by the pterional approach and 1953 aneurysms by the SBCA. The overall intraoperative rupture (IOR) rate for the entire group was 9.20%. In the pterional craniotomy approach (PtCA) group, the rate of IOR was 10.09% and in the SBCA group, IOR occurred in 5.78%. The IOR rate in the PtCA group was almost double that in the SBCA group and the odds ratio (OR) for this difference was 1.8 (95% confidence interval [CI] 1.49-2.26; P< 0.001). A total of 3039 ruptured aneurysms were analyzed--2848 aneurysms in the PtCA group and 191 in the SBCA group. The rate of IOR was 14.15% for the overall group, 13.8% in the PtCA group, and 19.37% in the SBCA group. The difference in IOR between the PtCA group and the SBCA group for ruptured aneurysms was found to be significant (OR 1.5, 95% CI 1.003-2.119; P< 0.05). The number of unruptured aneurysms in the PtCA group was 862 (39.4%) and in the SBCA group, it was 232 (49.1%). The difference in the number of unruptured aneurysms between the groups was significant (P< 0.001). The rate of IOR was significantly less with the SBCA than with the pterional approach. CONCLUSIONS The rate of intraoperative rupture is significantly higher when ruptured aneurysms are operated with the SBCA (in comparison to the pterional approach). However, the SBCA may be safer for unruptured and middle cerebral artery aneurysms with a lower rate of IOR.

Unruptured intracranial aneurysms: Comparison of perioperative complications, discharge disposition, outcome, and effect of calcification, between clipping and coiling: A single institution experience

OBJECTIVE The aim of the study was to compare the perioperative complications, obliteration rates, discharge dispositions, clinic-radiological outcomes, and the role of calcification between the microsurgical and endovascular treatment of unruptured intracranial aneurysms. MATERIALS AND METHODS Retrospective data of the patients treated with microsurgical clipping and those treated by endovascular coiling from January 2007 to August 2012 was collected from the database. RESULTS Intraoperative rupture was not different in both the treatment groups (4.05% vs. 1.5% clip vs. coil). A total of 9.4% of the patients in the clipping group and 4.5% of the patients in the coiling group suffered postoperative stroke. At last follow up, 89% of the patients in the clipping group and 93% of the patients in the coiling group had favorable outcomes. The mean length of stay was more in clipping group (6.1 vs. 2.7, clip vs. coil, P < 0.05). Patients discharged to home without assistance/rehabilitation services were more in coiling ( P = 0.001). A total of 28.4% (23/81) of the coiled aneurysms were found to have residue neck on postoperative angiograms as compared with 12.6% (10/79) of the clipped aneurysms ( P = 0.01). Calcification within the aneurysm was strongly correlated to the size, perioperative complications, and the outcome ( P < 0.05). However, on excluding the calcified cases the size and outcome do not show a significant correlation. CONCLUSION With appropriate patient selection, the majority of the UIAs can be managed by either of the treatment modalities with very low mortality and morbidity. Both the treatment modalities should be employed synergistically.

An analysis of the citation climate in neurosurgical literature and description of an interfield citation metric.

BACKGROUND The citation climate in neurosurgical literature is largely undefined. OBJECTIVE To study the patterns of citation of articles in neurosurgery as a scientific field and to evaluate the performance of neurosurgery journals vis-à-vis journals in other fields. METHODS References cited in articles published in neurosurgery journals during a specified time period were analyzed to determine the age of articles cited in neurosurgical literature. In the next analysis, articles published in neurosurgical journals were followed up for 13 years after publication. The postpublication citation patterns were analyzed to determine the time taken to reach the maximally cited state and the time when articles stopped being cited. The final part of the study dealt with the evolution of a new interfield citation metric, which was then compared with other standardized citation indexes. RESULTS The mean ± SD age of articles cited in neurosurgical literature was 11.6 ± 11.7 years (median, 8 years). Citations received by articles gradually increased to a peak (at 6.25 years after publication in neurosurgery) and then reached a steady state; articles were still cited well into the late postpublication period. Neurosurgical articles published in nonneurosurgical high-impact journals were cited more highly than those in neurosurgical journals, although they took approximately the same time to reach the maximally cited state (7.2 years). The most cited pure neurosurgery journal was Neurosurgery. CONCLUSION The citation climate for neurosurgery was adequately described. The interfield citation metric was able to ensure cross-field comparability of journal performance. ABBREVIATIONS G1, group 1G2, group 2G3, group 3G4, group 4IFCM, interfield citation metric.

Morphological Differences between Ruptured and Unruptured Basilar Bifurcation Aneurysms.

Background Aspect ratio (AP), daughter artery ratio (DA), and lateral angle ratio (LA) have been reported in middle cerebral artery bifurcation aneurysms to correlate with rupture status. Objective To study the differences in AP, DA, LA, and aneurysm orientation between ruptured and unruptured basilar bifurcation aneurysms. Methods Three-dimensional (3D) angiograms of patients with basilar bifurcation aneurysms were analyzed for AP, DA, and LA. Aneurysm projection was classified as type A if the long axis of aneurysm was along basilar artery and type-B if otherwise. Results Thirty-one ruptured and 17 unruptured aneurysms were analyzed. The APs were significantly different (p = 0.008), 2.63 ± 1.1 for ruptured aneurysms and 1.7 ± 0.55 for unruptured aneurysms. AP ≥ 1.9 correlated with rupture status with 68% sensitivity and 70% specificity. Type-A configuration was significantly associated with ruptured aneurysms with an odds ratio (OR) of 5.9. LAs were 0.9 ± 0.4 and 1.4 ± 0.8 for ruptured and unruptured aneurysms, respectively, and the difference tended to be significant (p = 0.56). DAs were 1.25 ± 0.22 and 1.21 ± 0.19 for ruptured and unruptured aneurysms without any statistical difference. Conclusion AP > 1.9, type-A configuration, and lower LA is associated with ruptured basilar bifurcation aneurysms. DA did not differ between ruptured and unruptured aneurysms.

Louisiana motorcycle fatalities in the wake of governmentally implemented change: A retrospective analysis of the motorcycle morbidity and mortality before, during, and after the repeal of a statewide helmet mandate

BACKGROUND On August 15, 2004, Louisiana’s universal motorcycle helmet mandate was reinstated. Previous studies have shown that mortality and morbidity of motorcycle riders who crashed had increased during the 5 years the mandate was repealed. The objective of this study was to discern whether the reinstatement of the universal helmet mandate has resulted in a subsequent decrease in motorcycle-related mortality and morbidity in the state of Louisiana. METHODS A retrospective analysis was performed observing the regularity of helmet use and the associated morbidity and mortality of motorcycle traffic accidents from the time before, during, and after the universal motorcycle helmet mandate was repealed in the state of Louisiana. Fatality statistics were obtained through the National Highway Safety Traffic Association. Injury, helmet use, and collision data were obtained from the Louisiana Highway Safety Commission. Motorcycle registration data were obtained from the Federal Highway Administration. RESULTS Motorcycle crash-related fatalities increased significantly when the statewide helmet mandate was repealed, and interestingly, after reinstatement, these fatality rates never returned to their previous lows. Motorcycle fatalities have increased out of proportion to the increase in motorbike registrations, even when yearly fatalities are normalized to fatalities per 10,000 registered bikes. An all-time high in fatalities was seen in 2006, a year subsequent to the mandate’s reinstatement. Fatalities per collision were elevated significantly after the mandate’s repeal but did not return to prerepeal lows after the mandate’s reinstatement. CONCLUSION Although helmet use after reinstatement has reached all-time highs, fatality rates have remained elevated since the original mandate repeal in 1999. Other achievable changes in state policy and law enforcement should be explored to quell this heightened risk to motorcycle enthusiasts in Louisiana, and states considering changing their own motorcycle helmet legislation should observe keenly the aftermath of both a mandate repeal and reinstatement. LEVEL OF EVIDENCE Epidemiological study, level IV.

Tuberculoma of the Cavernous Sinus and Meckel's Cave in a Child.

Tuberculous infection of the cavernous sinus and Meckels cave is extremely rare. In this report, we describe a patient with tuberculoma of the cavernous sinus and Meckels cave, extending to the petrous apex. The patient underwent microsurgical excision of the lesion and antitubercular chemotherapy resulting in a good outcome. We describe the diagnostic difficulties and review the relevant literature.

Acute pyogenic necrotizing encephalomyelitis: a fulminant and fatal infection

In this report the authors describe a rare case of a fulminant, pyogenic, necrotizing infection of the spinal cord and brain. Necrotizing lesions of the brain and spinal cord are usually infectious in origin and are associated with high rates of morbidity and death. Although the pathogens responsible have been identified in a few instances, the causal factors remain unknown in many cases. An 11-year-old girl developed acute, rapidly progressive paraplegia with bladder involvement and sensory loss below T-10. She had been treated recently for a Staphylococcus aureus infection of the knee joint precipitated by a penetrating injury with organic matter in the aftermath of a cyclone. Although appropriate antibiotic therapy was instituted, the spinal cord infection progressed to involve the entire spinal cord, brainstem, and brain. This fulminant course was marked by a rapid deterioration in the patients clinical condition, ultimately leading to her death. Magnetic resonance imaging demonstrated a previously undescribed pattern of longitudinal enhancement along the spinal cord, as well as the white matter tracts in the brainstem and brain. The possible route of spread of infection along the neuraxis is postulated to be the potential space along the white matter tracts. Treatment is not standardized due to the rarity of the condition.

Incidence of Potential Drug-Drug Interactions in a Limited and Stereotyped Prescription Setting - Comparison of Two Free Online Pharmacopoeias

Background: Drug-drug interactions (DDIs) are very common adverse events in health care delivery settings. The use of electronic pharmacopeias can potentially reduce the incidence of DDIs, but they are often thought to be cumbersome to use. This study is aimed at studying the incidence of potential DDIs in a surgical department, where a limited number of drugs are used in stereotyped combinations. We also compared two popular drug compendia in detecting potential DDIs. Methods: The prescriptions of selected patients were entered into Epocrates® and Medscape® for Android smartphones. Potential DDIs were generated and their categories were noted. The warnings generated by Epocrates® were compared with those generated by Medscape® and an agreement index was calculated. Results: Three hundred and thirty-one patients were included for analysis who had received a total of 2,878 drug orders. The incidence of potential DDIs was very high - 89% of all prescriptions. Phenytoin was the drug most commonly implicated, followed by furosemide. Of the DDIs detected, 0.14% were potentially serious and the drug combinations were contraindicated. There was a significant discrepancy between the categories of potential DDIs detected by Epocrates® and Medscape®. No clinically significant DDI was detected in any patient in this cohort. Conclusions: Despite routinely using only a limited number of drugs in stereotyped combinations, prescriptions in surgical departments may not be immune from a significant incidence of DDIs. The use of free apps could reduce the incidence of DDIs, enhance patient safety, and also aid in educating trainees.

Endovascular therapy for acute stroke: Quo vadis?

Endovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.