Fungal sinusitis with intracranial extension in immuno-competent patients: surgical planning according to relation to eloquent neurovascular structures

To evaluate the results of combined neurosurgical and ENT surgical management for patients with fungal sinusitis with intracranial extension. We managed 10 cases with fungal sinusitis with intracranial extension. This included 7 females and 3 males. Four patients presented with unilateral proptosis, 2 with deterioration of level of consciousness due to meningitis, 2 with chronic headache, one with epilepsy and one patient presented with trigeminal pain. All cases had long history of chronic headache and nasal obstruction. CT was done in all cases, MR in 8 patients, CT angiography and conventional cerebral angiography in one patient. Surgical intervention was decided according to the relation of the fungal granuloma to eloquent intracranial structures. Endonasal approach alone was used when the granuloma was not related to the optic nerve, internal carotid artery or cavernous sinus [n=3]. Combined subfrontal and endonasal approach was used when the granuloma was closely related to one or more of these structures [n=5]. Transcranial approach alone was done for 2 patients with isolated sphenoid fungal sinusitis that was associated with a mycotic internal carotid artery aneurysm in one patient and with a temporal lobe abscess in the other. In addition, antifungal treatment was used for 8-12 weeks. Patients were followed up clinically and radiologically for 6-36 month period. No morbidity related to the operative procedures was recorded in the study group. One patient died two month post-operatively due to fungal meningitis. In survivors [n=9]: headache and nasal obstruction improved, proptosis was corrected, epilepsy and trigeminal pain were controlled by medication. Follow-up CT showed eradication of the fungal granuloma in all survivors. Histopathological results showed mucormycosis [n=2], aspirgillosis [n=4], and no fungus [4 patients. Team work by ENT and neurosurgical staff and early diagnosis are mandatory in the management of fungal sinusitis with intracranial extension in immune-competent patients. Surgical planning according to the relation of fungal granuloma to eloquent neurovascular structures is the cornerstone for save removal of granuloma

Fate of kyphosis in dorsolumbar fractures after pedicle-screw fixation

Using pedicle-screw fixation for the management of spinal fractures in the dorsolumbar junction is widely used. Despite the proper insertion of the pedicle screws, progressive kyphotic deformity may develop post-operatively. Study of different factors related to pedicle-screw fixation in cases with dorsolumbar spinal fractures trying to find out the underlying causes of progressive kyphotic deformity after fixation. This retrospective study includes 52 patients with traumatic fractures of the dorsolumbar junction. All cases were managed by pedicle screw fixation and decompressive laminectomy. Two-level fixation [one above and one below the fractured vertebra] was done in 41 patients, 3 level-fixation in 8 patients, and 4-level fixation in 3 patients. Mean follow up period was 28 months [range from 12-39 months]. Fifteen cases developed post-operative progressive kyphotic deformity. Four of these 15 patients had malposition of pedicle screws and were excluded from the study. The other 11 patients [group A] had two-level fixation and had proper position of the screws as documented by CT scan. Patients in group A were compared to the group of patients who were also operated by two-level fixation but they did not develop postoperative progressive kyphosis [group B, n = 26]. Comparison included number of spinal columns fractured, disruption of facet joints, percentage reduction in the height of the anterior border of vertebral body by the fracture, presence of vertebral body fracture in the coronal plan dividing the body into anterior and posterior segments, presence of anterior dislocation or translation, degree of canal compromise, and presence of associated fracture in the vertebral body adjacent to the injured vertebra. The remaining 11 patients [group C] had 3 or 4 level fixation and did not develop this progressive post-operative kyphosis. Our results showed that the incidence of the following findings were significantly higher in group A than in group B: reduction in the height of the anterior border of vertebral body of 50% or more [82% and -15% respectively], body fracture in the coronal plan [73% and 19% respectively], associated adjacent vertebral body fractures [73% and 27%]. No significant difference was observed between the two groups in the other aspects of comparison. The results of this study indicate that the presence of: more than 50% reduction in the anterior body height, body fracture in the coronal plan, and/or associated adjacent body fracture would indicate a higher degree of spinal instability in patients with fractures of the dorsolumbar junction. It also infers that 2-level fixation is not enough to avoid post-operative progressive kyphosis in such patients

Early experience with surgical management of cerebral aneurysms: report of 32 cases

To review the results of surgical intervention in 32 patients with cerebral aneurysms aiming to find out the pitfalls and lessons one can learn from this early experience with aneurysm surgery. The clinical, radiological and operative data of 32 patients operated for cerebral aneurysms were correlated with 3-month clinical outcome. Clinical data included: age, gender and clinical grading according to the World Federation of Neurological surgeons classification. Radiological data included site, size, neck size of the aneurysm, and the presence of associated vasospasm, intracerebral hemorrhage, and/or hydrocephalus. Operative data included brain swelling, intraoperative aneurysm rupture, temporary clipping of parent vessels, and difficult clipping. Outcome was assessed according the Glasgow outcome score [GOS]. Out of 32 patients, 25 [78.1%] had favorable outcome [GOS 3 and 4], and 7 [21.9%] had unfavorable outcome [GOS 0, 1 and 2]. All early-operated grade 4- and 5-patients died [n=4]. On the other hand, unfavorable outcome was observed in 22% of grade 3-patients and in 5% only of grade 1- and 2-patients. Meanwhile, the following factors were associated with unfavorable outcome: brain edema [40%], vasospasm [33.3%], temporary clipping [55.5%], intraoperative rupture of aneurysm [57%]. These factors were frequently observed in early-operated grade 3-, 4- and 5-patients. In grade 3-, 4- and 5-patients, unfavorable outcomes associated with early- and late-surgery were 83% and 14%, respectively. When early-operated grade 3-, 4- and 5-patients were eliminated from the analysis, the incidence of unfavorable outcome decreased to less than 8%.In order to minimize the postoperative morbidity and mortality in newly-developed neurovascular centers, it would be recommended to avoid early surgical intervention for patients in grade 3, 4 and 5