The Effect of Locally Administered Fibrinolytic Drugs Following Aneurysmal Subarachnoid Hemorrhage : A Meta-Analysis with Eight Randomized Controlled Studies

Objective@#: Rapid dissolution of blood clots reduces vasospasm and hydrocephalus after subarachnoid hemorrhage (SAH), and locally administered fibrinolytic drugs (LAFDs) could facilitate the dissolution. However, the efficacy of LAFDs remains controversial. The aim of this meta-analysis was to determine the efficacy of LAFDs for vasospasm and hydrocephalus and in clinical outcomes. @*Methods@#: From PubMed, EMBASE, and Cochrane database, data were extracted by two authors. Meta-analysis was performed using a random effect model. Inclusion criteria were patients who had LAFDs with urokinase-type or recombinant tissue-plasminogen activator after SAH in comparison with medically untreated patients with fibrinolytic drugs. We only included randomized controlled trials (RCTs) in this analysis. The outcomes of interest were vasospasm, hydrocephalus, mortality, and 90-day unfavorable functional outcome. @*Results@#: Data from eight RCTs with 550 patients were included. Pooled-analysis revealed that the LAFDs were significantly associated with lower rates of vasospasm (LAFDs group vs. control group, 26.5% vs. 39.2%; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32–0.73); hydrocephalus (LAFDs group vs. control group, 26.0% vs. 31.6%; OR, 0.54; 95% CI, 0.32–0.91); and mortality (LAFDs group vs. control group, 10.5% vs. 15.7%; OR, 0.58; 95% CI, 0.34–0.99). The proportion of 90-day unfavorable outcomes was lower in the LAFDs group (LAFDs group vs. control group, 32.7% vs. 43.5%; OR, 0.55; 95% CI, 0.37–0.80). @*Conclusion@#: This meta-analysis with eight RCTs indicated that LAFDs were significantly associated with lower rates of vasospasm and hydrocephalus after SAH. Thus, LAFDs could consequently reduce mortality and improve clinical outcome after SAH.

Comparison of Postoperative Complications between Simultaneous and Staged Surgery in Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy / 대한신경손상학회지

Objective@#Cranioplasty (CP) and ventriculoperitoneal shunt (VPS) are required procedures following decompressive craniectomy (DC) for craniofacial protection and to prevent hydrocephalus. This study assessed the safety and efficacy of simultaneous operation with CP and VPS after DC, and determined the preoperative risk factors for postoperative complications. @*Methods@#Between January 2009 and December 2019, 81 patients underwent CP and VPS in simultaneous or staged operations following DC. Cumulative medical records and radiologic data were analyzed using univariate analysis to identify factors predisposing patients to complications after CP and VPS. @*Results@#CP and VPS were performed as simultaneous or staged operations in 18 (22.2%) and 63 (77.8%) patients, respectively. The overall postoperative complication rate was 16.0% (13/81). Patients who underwent simultaneous CP and VPS were significantly more likely to experience complications when compared with patients who underwent staged operations (33.3% vs. 9.6%, p<0.01). Univariate analysis revealed that simultaneous CP and VPS surgery was the only significant predictor of postoperative complications (p=0.031). @*Conclusion@#This study provided detailed data on surgical timing and complications for CP and VPS after DC. We showed that simultaneous procedures were a significant risk factor for postoperative complications.

Relationship between Increased Intracranial Pressure and Mastoid Effusion

Objective@#: This study aimed to assess the relationship between increased intracranial pressure (ICP) and mastoid effusions (ME). @*Methods@#: Between January 2015 and October 2018, patients who underwent intracranial surgery and had ICP monitoring catheters placed were enrolled. ICP was recorded hourly for at least 3 days. ME was determined by the emergence of opacification in mastoid air cells on follow-up brain imaging. C-reactive protein (CRP) levels, presence of endotracheal tube (ETT) and nasogastric tube (NGT), duration of intensive care unit (ICU) stay, duration of mechanical ventilator application, diagnosis, surgical modalities, and presence of sinusitis were recorded. Each factor’s effect on the occurrence of ME was analyzed by binary logistic regression analyses. To analyze the independent effects of ICP as a predictor of ME a multivariable logistic regression analysis was performed. @*Results@#: Total of 61 (53%) out of 115 patients had ME. Among the patients who had unilateral brain lesions, 94% of subject (43/50) revealed the ipsilateral development of ME. ME developed at a mean of 11.1±6.2 days. The variables including mean ICP, peak ICP, age, trauma, CRP, ICU stays, application of mechanical ventilators and presence of ETT and NGT showed statistically significant difference between ME groups and non-ME groups in univariate analysis. Sex and the occurrence of sinusitis did not differ between two groups. Adding the ICP variables significantly improved the prediction of ME in multivariable logistic regression analysis. @*Conclusion@#: While multiple factors affect ME, this study demonstrates that ICP and ME are probably related. Further studies are needed to determine the mechanistic relationship between ICP and middle ear pressure.

Arachnoid Plasty to Prevent and Reduce Chronic Subdural Hematoma after Clipping Surgery for Unruptured Intracranial Aneurysm : A Meta-Analysis

Objective@#: Recent studies have reported that arachnoid plasty (ARP) using gelatin sponges with fibrin glue reduced the occurrence of chronic subdural hematoma (CSDH) following clipping surgery for unruptured intracranial aneurysm (UIA). This metaanalysis was conducted to collate further evidence for the efficacy of ARP in preventing postoperative CSDH. @*Methods@#: Data of patients who underwent clipping surgery were extracted from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials by two independent reviewers. A random effects model was used to investigate the efficacy of ARP by using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for male sex was additionally preformed. @*Results@#: Data from six studies with 1715 patients were consecutively included. Meta-analysis revealed that ARP was significantly associated with lower rates of CSDH development after surgical clipping for UIA (ARP group vs. control group : 3.2% vs. 7.2%; OR, 0.40; 95% CI, 0.18–0.93; I2 =44.3%; p=0.110). Meta-regression analysis did not highlight any modifying effect of the male sex on postoperative CSDH development (p=0.951). @*Conclusion@#: This meta-analysis indicated that ARP reduced the incidence rates of CSDH following clipping surgery for UIA. If feasible, ARP would be implemented as an additional surgical technique to prevent postoperative CSDH development during surgical clipping of UIA.

Comparison of Postoperative SurgicalSite Infection and Symptomatic Intracranial Hemorrhage between Staged and Simultaneous Cranioplasty with Ventriculoperitoneal Shunt Placement: A Meta-Analysis / 대한신경손상학회지

Objective@#Consensus about the sequence of cranioplasty and ventriculoperitoneal shunt placement to reduce postoperative complications has not been established. This meta-analysis investigated and collated further evidence to determine whether staged cranioplasty with ventriculoperitoneal shunt placement would significantly reduce the risk of postoperative surgical-site infection (SSI) and symptomatic intracranial hemorrhage. @*Methods@#Two independent reviewers identified articles and extracted the data of patients who underwent cranioplasty and ventriculoperitoneal shunt placement from PubMed, Embase, and Cochrane Central Register of Controlled Trials. A random effects model was used to compare the complication rates using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for traumatic brain injury (TBI) was additionally performed. @*Results@#Data from 7 studies with 391 patients were consecutively included. The metaanalysis revealed that staged surgery was significantly associated with lower rates of SSI after decompressive craniectomy (staged group vs. simultaneous group: 6.2% vs. 23.7%, OR:2.72, 95% CI: 1.46–5.06, I 2 =2.4%, p=0.407). Pooled analysis did not indicate a statistically significant difference between the 2 groups for symptomatic intracranial hemorrhage (staged group vs. simultaneous group: 10.4% vs. 23.0%, OR: 1.66, 95% CI: 0.74–3.73, I2 =0.0%, p=0.407). The meta-regression analysis did not indicate any modifying effect of TBI on postoperative SSI development (p=0.987). @*Conclusion@#This meta-analysis indicated that staged surgery is significantly associated with a lower rate of postoperative SSI as compared with simultaneous surgery, but there is no difference in symptomatic intracranial hemorrhage. Additionally, there is no modifying effect of TBI on SSI.

Comparison of the Outcomes and Recurrence with Three Surgical Techniques for Chronic Subdural Hematoma: Single, Double Burr Hole, and Double Burr Hole Drainage with Irrigation / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (CSDH), a disease commonly encountered by neurosurgeons, is treated by burr hole drainage (BHD). However, the optimal surgical technique among the three types of BHD has not been determined. METHODS: We conducted a retrospective study on BHD performed on 93 patients who were diagnosed with CSDH. The subjects were divided into three groups based on the surgical technique performed: single BHD without irrigation (Group A, n=31), double BHD without irrigation (Group B, n=32), and double BHD with irrigation (Group C, n=30). The clinical factors, radiological factors and recurrences were compared between the three groups. Moreover, independent factors affecting the recurrence were analyzed. RESULTS: The change in hematoma thickness was 29.77+/-7.94%, 49.73+/-12.87%, and 75.29+/-4.32% for Group A, B, and C, respectively, while the change in midline shift was 40.81+/-15.47%, 51.78+/-10.94%, and 56.16+/-16.16%, respectively. Thus, Group C showed the most effective for resolution of hematoma and midline shift (p<0.05). Group A, B, and C had 12 cases (38.7%), 8 cases (25.0%), and 3 cases (10.0%) of recurrences, respectively. Group C had a statistically significantly fewer recurrence rate than Group A (p<0.05). Double burr hole, irrigation, and coagulopathy were each identified as independent factors that reduce recurrence (p<0.05). CONCLUSION: Among the three techniques, the double BHD with saline irrigation resulted in the fewest recurrences. It is probably the most effective technique for preventing the recurrence of CSDH.

Acute Contralateral Radiculopathy after Unilateral Transforaminal Lumbar Interbody Fusion

OBJECTIVE: Cases of contralateral radiculopathy after a transforaminal lumbar interbody fusion with a single cage (unilateral TLIF) had been reported, but the phenomenon has not been explained satisfactorily. The purpose of this study was to determine its incidence, causes, and risk factors. METHODS: We did retrospective study with 546 patients who underwent a unilateral TLIF, and used CT and MRI to study the causes of contralateral radicular symptoms that appeared within a week postoperatively. Clinical and radiological results were compared by dividing the patients into the symptomatic group and asymptomatic group. RESULTS: Contralateral symptoms occurred in 32 (5.9%) of the patients underwent unilateral TLIF. The most common cause of contralateral symptoms was a contralateral foraminal stenosis in 22 (68.8%), screw malposition in 4 (12.5%), newly developed herniated nucleus pulposus in 3 (9.3%), hematoma in 1 (3.1%), and unknown origin in 2 patients (6.3%). 16 (50.0%) of the 32 patients received revision surgery. There was no difference in visual analogue scale and Oswestry disability index between the two groups at discharge. Both preoperative and postoperative contralateral foraminal areas were significantly smaller, and postoperative segmental angle was significantly greater in the symptomatic group comparing to those of the asymptomatic group (p<0.05). CONCLUSION: The incidence rate is not likely to be small (5.9%). If unilateral TLIF is performed for cases when preoperative contralateral foraminal stenosis already exists or when a large restoration of segmental lordosis is required, the probability of developing contralateral radiculopathy is increased and caution from the surgeon is needed.

An Intramuscular Hemangioma at the Cervical Muscle: A Case Report

Intramuscular hemangioma (IMH) primarily develops in the skeletal muscles of the limbs or trunk. The occurrence of IMH in the neck muscle is very rare. In the present report, we describe a case of IMH in the posterior neck muscle. A 58-year-old woman presented with a mass on the right posterior neck area, which had developed 2 years previously. The tumor was round in shape, had a size of 3.5x3.0 cm, and was fixed to the surrounding soft tissue. The patient complained of mild dull pain and tenderness at the mass without reddish discoloration. The mass showed a diurnal variation in size - the mass grew in size in the morning and became smaller in the afternoon. Preoperative study confirmed the vascular nature of the tumor. During peritumoral dissection, the mass shrank rapidly following profuse bleeding and arterial cauterization, and hence, it was difficult to distinguish the mass from the surrounding tissues. A total resection was possible with careful dissection of its fibrotic boundary. Based on the histological findings, a definitive diagnosis of cavernous type IMH was made. An initial suspicion of IMH, according to the clinical findings, would be helpful for decision making of further evaluations and surgical plan.