The role of decompressive craniectomy following microsurgical repair of a ruptured aneurysm: Analysis of a South Australian cerebrovascular registry.

OBJECTIVE: Decompressive craniectomy (DC) remains a controversial intervention for intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS: We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. Outcomes of interest were inpatient mortality, unfavourable outcome, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS). RESULTS: A total of 246 patients with aSAH underwent clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 underwent DC and were included in the final analysis. Unsurprisingly, DC patients had a greater chance of unfavourable outcome (p < 0.001) and higher median mRS (p < 0.001) at final follow-up. Despite this, almost two-thirds (64.1 %) of DC patients had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome. CONCLUSIONS: Our data suggest that DC can be performed with acceptable rates of morbidity and mortality. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.

Quality of Literature Searches Published in Leading Neurosurgical Journals: A Review of Reviews.

BACKGROUND: There is mounting evidence that the search strategies upon which systematic reviews (SRs) are based frequently contain errors are incompletely reported or insensitive. OBJECTIVE: To appraise the quality of search strategies in the 10 leading specialty neurosurgical journals and identify factors associated with superior searches. METHODS: This research-on-research study systematically surveyed SRs published in the 10 leading neurosurgical journals between 01/10/2017 and 31/10/2019. All SRs were eligible for assessment using a predefined coding manual that was adapted from the preferred reporting items for systematic reviews and meta-analyses (PRISMA), a measurement tool to assess systematic reviews (AMSTAR), and Cochrane Collaboration guidelines. The PubMed interface was used to search the MEDLINE database, which was supplemented by individual journal searches. Descriptive statistics were utilized to identify factors associated with improved search strategies. RESULTS: A total of 633 articles were included and contained a median of 19.00 (2.00-1654.00) studies. Less than half (45.97%) of included search strategies were considered to be reproducible. Aggregated reporting score was positively associated with in-text reference to reporting guideline adherence (τb = 0.156, P < .01). The number of articles retrieved by a search (τb = 0.11, P < .01) was also associated with the reporting of a reproducible search strategy. CONCLUSION: This study demonstrates that the search strategies used in neurosurgical SRs require improvement. In addition to increasing awareness of reporting standards, we propose that this be achieved by the incorporation of PRISMA and other guidelines into article submission and peer-review processes. This may lead to the conduct of more informative SRs, which may result in improved clinician decision-making and patient outcomes.

Effect of the Presence and Type of Plate Augmentation on Postoperative Dysphagia Among Adult Patients Undergoing Elective Anterior Cervical Discectomy and Fusion for Spondylosis: A Randomized Trial.

OBJECTIVE: To determine the effect of anterior plating on postoperative dysphagia (POD) among adult patients undergoing elective anterior cervical discectomy and fusion (ACDF) for cervical spondylosis and determine the potential role of demographic and clinical characteristics in the development of POD. METHODS: Consecutive adults undergoing an elective, single-level, ACDF were randomly assigned to receive a stand-alone CoRoent Cage or a CoRoent Cage with a Helix, or HelixMini plate. Patients with a history of cervical spine surgery were excluded. M. D. Anderson Dysphagia Inventory and Bazaz questionnaires were completed at regular intervals for 12 months postoperatively. RESULTS: Twenty-five patients were recruited over a 2-year period, with 8 allocated to receive a stand-alone cage, 5 to receive a cage and Helix Mini plate, and 12 to receive a cage and Helix plate. The POD rate was 68% at 48 hours, before falling to 16% at 6 and 12 months. A longer retraction time was observed in the Helix plate group compared to the stand-alone cage group (7.88; 95% confidence interval, 0.12-15.63; p = 0.046), although there was no difference in the incidence or severity of dysphagia between cohorts at any timepoint. With the exception of body mass index, there was no difference in patients with and without dysphagia, and each of the interventions was equally efficacious with respect to clinical and radiological endpoints. CONCLUSION: Dysphagia is a common consequence of ACDF and, while the placement of a large plate results in longer retraction time, it was not associated with higher rates of dysphagia. Further research is required to identify both patient-specific and surgical contributors to this complication.

Accuracy of K-Wireless Insertion of Percutaneous Pedicle Screws Using Computer-Assisted Spinal Navigation: A Systematic Review and Single-Center Experience.

OBJECTIVE: This study sought to 1) describe the use K-wireless pedicle screw insertion among adults (age ≥18 years) undergoing a minimally invasive fusion and 2) perform a systematic review (SR) of all studies that describe a navigated, K-wireless technique with 3-dimensional fluoroscopy. METHODS: Patients undergoing a minimally invasive fusion requiring pedicle screw fixation for any indication were prospectively enrolled in the observational component of this study. An assessment of pedicle breach was performed independently and in duplicate based on a modification of the Belmont grading scale. Articles for the SR were identified from a structured search of Medline from inception to May 8, 2019, without restriction of language. RESULTS: A total of 82 pedicle screws were placed in 20 patients who underwent surgery between January and June 2014. There was no significant difference in mean operative time between the cases included in this study and a matched cohort of 20 patients undergoing surgery with 2-dimensional fluoroscopy and K-wire-assisted pedicle screw placement (95 ± 13 vs. 87 ± 20 minutes, respectively; P > 0.05). There were 2 major pedicle breaches (Belmont grade 3) in a single patient, yielding a major breach rate of 2.44%. A total of 6 papers that described the placement of 700 pedicle screws in 160 patients between May 2011 and March 2017 were included in the SR. The overall breach rate was 7.00% (n = 37). CONCLUSIONS: Percutaneous pedicle screws can be placed accurately and safely using 3-dimensional navigation without the use of K-wires and may confer benefits to patients and clinicians by reducing K-wire-associated complications and radiation exposure.

Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review.

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, -0.2; 95% confidence interval, -5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Reporting Quality of Systematic Review Abstracts Published in Leading Neurosurgical Journals: A Research on Research Study.

BACKGROUND: Systematic review (SR) abstracts are frequently relied upon to guide clinical decision-making. However, there is mounting evidence that the quality of abstract reporting in the medical literature is suboptimal. OBJECTIVE: To appraise SR abstract reporting quality in neurosurgical journals and identify factors associated with improved reporting. METHODS: This study systematically surveyed SR abstracts published in 8 leading neurosurgical journals between 8 April 2007 and 21 August 2017. Abstracts were identified through a search of the MEDLINE database and their reporting quality was determined in duplicate using a tool derived from the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Abstracts (PRISMA-A) statement. All SR abstracts that provided comparison between treatment strategies were eligible for inclusion. Descriptive statistics were utilized to identify factors associated with improved reporting. RESULTS: A total of 257 abstracts were included in the analysis, with a mean of 22.8 (±25.3) included studies. The overall quality of reporting in included abstracts was suboptimal, with a mean score of 53.05% (±11.18). Reporting scores were higher among abstracts published after the release of the PRISMA-A guidelines (M = 56.52; 21.74-73.91) compared with those published beforehand (M = 47.83; 8.70-69.57; U = 4346.00, z = -4.61, P < .001). Similarly, both word count (r = 0.338, P < .001) and journal impact factor (r = 0.199, P = .001) were associated with an improved reporting score. CONCLUSION: This study demonstrates that the overall reporting quality of abstracts in leading neurosurgical journals requires improvement. Strengths include the large number abstracts assessed, and its weaknesses include the fact that only neurosurgery-specific journals were surveyed. We recommend that attention be turned toward strengthening abstract submission and peer-review processes.

Significance of Anti-Myosin Antibody Formation in Patients With Myocardial Infarction: A Prospective Observational Study.

BACKGROUND: Anti-myosin antibodies (AMAs) are often formed in response to myocardial infarction (MI) and have been implicated in maladaptive cardiac remodelling. We aimed to: (1) compare AMA formation in patients with Non-ST-Elevation MI (NSTEMI) and ST-Elevation MI (STEMI); (2) evaluate factors predicting autoantibody formation; and, (3) explore their functional significance. METHODS: Immunoglobulin M (IgM) and Immunoglobulin G (IgG) AMA titres were determined in serum samples collected at admission, 3 and 6 months post MI. The relationship between demographic and clinical data, and antibody formation, was investigated to determine factors predicting antibody formation and functional significance. RESULTS: Forty-three (43) patients were consecutively recruited; 74.4% were positive for IgM at admission, compared with 23.3% for IgG. Mean IgG levels increased by 1.24% (±0.28) at 3 months, and 13.55% (±0.13) at 6 months post MI. Mean antibody levels were significantly higher in the NSTEMI cohort at both follow-up time points for IgG (p<0.001, p<0.0001), but not IgM (p=0.910, p=0.066). A moderately positive correlation between infarct size and increase in mean IgM concentration was observed at 3 months (r(98)=0.455; p=0.015). Anti-myosin antibody formation was not associated with an unfavourable outcome at follow-up. CONCLUSIONS: Anti-myosin antibodies are formed in a significant proportion of patients following MI, particularly among those with NSTEMI. While IgM levels fall after infarction, IgG levels increase and persist beyond 6 months of follow-up. This raises the possibility that they may contribute to long-term myocardial damage and dysfunction. Future research should focus on the specific epitopes that are targeted by these antibodies, and their functional significance. This may result in the emergence of novel therapies to attenuate cardiac dysfunction in MI patients.

Acute compartment syndrome: A rare but important complication of transradial cardiac catheterization.

The transradial approach has become the gold-standard for coronary angiography. It is better tolerated by patients, associated with less bleeding, earlier post-procedure mobilization, and reduced mortality in patients with myocardial infarction. Given the hand's dual arterial supply and extensive collateral circulation, the risk of serious functional injury after radial catheterization is essentially reduced to zero. However, even a small amount of bleeding in the volar compartment can lead to compartment syndrome (CS) and permanent neurovascular injury. The purpose of this paper is to describe our experience with an unusual case of late-onset acute CS following transradial coronary angiography, and to summarize the available literature on this topic. .

Anti-troponin antibodies following myocardial infarction.

Recent improvements in medical and surgical coronary revascularization techniques have significantly improved outcomes for patients with acute myocardial infarction (MI). However, large infarctions are often followed by a poorly understood process of pathological ventricular remodelling, which fails to return the heart to its premorbid state. Although it remains incompletely understood, there is increasing interest in the role of the immune system in this process. One hypothesis is that released cardiac proteins become the focus of an immune response that results in the formation of functionally significant autoantibodies. This review summarizes the current literature, both human and animal, relating to the formation and clinical relevance of anti-troponin antibodies (ATAs) in patients with MI.

The role of anti-myosin antibodies in perpetuating cardiac damage following myocardial infarction.

Recent improvements in the medical and surgical management of myocardial infarction mean that many patients are now surviving with greater impairment of cardiac function. Despite appropriate management, some of these patients subsequently develop pathological ventricular remodelling, which compounds their contractile dysfunction and can lead to congestive cardiac failure (CCF). The pathophysiological mechanism underpinning this process remains incompletely understood. One hypothesis suggests that a post-infarction autoimmune response, directed against constituents of cardiac myocytes, including cardiac myosin, may make an important contribution. Our review summarises the current literature related to the formation and clinical relevance of anti-myosin antibodies (AMAs) in patients with myocardial infarction. This discussion is supplemented with reference to a number of important animal studies, which provide evidence of the potential mechanisms underlying AMA formation and autoantibody mediated cardiac dysfunction.