Clinical Outcome of Patients Over 90 Years of Age Treated for Chronic Subdural Hematoma.

OBJECTIVE: Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years. METHODS: This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1-6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated. RESULTS: Their mean age was 92.8 years and the median was 92.4 years (range, 90-100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups. CONCLUSION: In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

Clinical and radiological risk factors of autograft cranioplasty resorption after decompressive craniectomy for traumatic brain injury.

OBJECTIVE: The repositioning of an autologous bone flap after decompressive craniectomy (DC) for traumatic intracranial hypertension remains the first-line treatment for cranial reconstruction. Aseptic autologous bone flap resorption (BFR) is the most frequent complication. The identification of possible predictive parameters for BFR would help to improve the management of these patients. PATIENTS AND METHODS: Three hundred and nine patients undergoing autologous bone flap repositioning after previous DC for TBI between September 2003 and September 2017 were included in the study. RESULTS: BFR was identified in 76 (24,59 %) of the 309 patients undergoing autologous CP. Age of ≤ 45 years and CP bone fragmentation were seen to be significant independent risk factors for BFR (p =  0.001 and p =  0.018, respectively) using multivariate logistic regression analysis. Of the radiologic predictors, CP size and the gap between CP and the skull defect were independently associated with BFR (p =  0.034 and p =  0.0003, respectively). The Youden index and ROC curve analysis were used to estimate the cut-off values for the continuous parameters and determine the sensitivity and specificity of the radiologic risk factors. The cut-off value for these two factors was found to be 114,98 cm2 and ≥ 578,5 mm2, respectively. The area under the ROC curve was 0.627 for bone flap size and 0.758 for the DC-CP gap. The DC-CP gap had greater sensitivity and specificity as a predictor of BFR, compared to bone flap size (p = 0.079 and p = ≤ 0.001, respectively). CONCLUSIONS: In this large cohort of patients with autologous cranioplasty, younger age, fragmented autologous bone flap and a wide gap between CP and cranial defect were predictive of bone flap resorption.

Stereoelectroencephalography: retrospective analysis of 742 procedures in a single centre.

This retrospective description of a surgical series is aimed at reporting on indications, methodology, results on seizures, outcome predictors and complications from a 20-year stereoelectroencephalography (SEEG) activity performed at a single epilepsy surgery centre. Prospectively collected data from a consecutive series of 742 SEEG procedures carried out on 713 patients were reviewed and described. Long-term seizure outcome of SEEG-guided resections was defined as a binomial variable: absence (ILAE classes 1-2) or recurrence (ILAE classes 3-6) of disabling seizures. Predictors of seizure outcome were analysed by preliminary uni/bivariate analyses followed by multivariate logistic regression. Furthermore, results on seizures of these subjects were compared with those obtained in 1128 patients operated on after only non-invasive evaluation. Survival analyses were also carried out, limited to patients with a minimum follow-up of 10 years. Resective surgery has been indicated for 570 patients (79.9%). Two-hundred and seventy-nine of 470 patients operated on (59.4%) were free of disabling seizures at least 2 years after resective surgery. Negative magnetic resonance and post-surgical lesion remnant were significant risk factors for seizure recurrence, while type II focal cortical dysplasia, balloon cells, glioneuronal tumours, hippocampal sclerosis, older age at epilepsy onset and periventricular nodular heterotopy were significantly associated with seizure freedom. Twenty-five of 153 patients who underwent radio-frequency thermal coagulation (16.3%) were optimal responders. Thirteen of 742 (1.8%) procedures were complicated by unexpected events, including three (0.4%) major complications and one fatality (0.1%). In conclusion, SEEG is a safe and efficient methodology for invasive definition of the epileptogenic zone in the most challenging patients. Despite the progressive increase of MRI-negative cases, the proportion of seizure-free patients did not decrease throughout the years.