Nicotine Replacement Therapy for Smokers with Acute Aneurysmal Subarachnoid Hemorrhage: An International Survey.

INTRODUCTION: Smoking prevalence is twice as high among patients admitted to hospital because of the acute condition of aneurysmal subarachnoid hemorrhage (aSAH) as in the general population. Smoking cessation may improve the prognosis of aSAH, but nicotine replacement therapy (NRT) administered at the time of aSAH remains controversial because of potential adverse effects such as cerebral vasospasm. We investigated the international practice of NRT use for aSAH among neurosurgeons. METHODS: The online SurveyMonkey software was used to administer a 15-question, 5-min online questionnaire. An invitation link was sent to those 1425 of 1988 members of the European Association of Neurosurgical Societies (EANS) who agreed to participate in surveys to assess treatment strategies for withdrawal of tobacco smoking during aSAH. Factors contributing to physicians' posture towards NRT were assessed. RESULTS: A total of 158 physicians from 50 nations participated in the survey (response rate 11.1%); 68.4% (108) were affiliated with university hospitals and 67.7% (107) practiced at high-volume neurovascular centers with at least 30 treated aSAH cases per year. Overall, 55.7% (88) of physicians offered NRT to smokers with aSAH, 22.1% (35) offered non-NRT support including non-nicotine medication and counselling, while the remaining 22.1% (35) did not actively support smoking cessation. When smoking was not possible, 42.4% (67) of physicians expected better clinical outcomes when prescribing NRT instead of nicotine deprivation, 36.1% (57) were uncertain, 13.9% (22) assumed unaffected outcomes, and 7.6% (12) assumed worse outcomes. Only 22.8% (36) physicians had access to a local smoking cessation team in their practice, of whom half expected better outcomes with NRT as compared to deprivation. CONCLUSIONS: A small majority of the surveyed physicians of the EANS offered NRT to support smoking cessation in hospitalized patients with aSAH. However, less than half believed that NRT could positively impact clinical outcome as compared to deprivation. This survey demonstrated the lack of consensus regarding use of NRT for hospitalized smokers with aSAH.

Treatment of type II odontoid fracture in the elderly.

Odontoid fractures constitute the commonest cervical spinal fracture in the elderly. There are varied management approaches with paucity of robust evidence to guide decision-making. We review the case of a 92-years-old man with traumatic Grauer type II B odontoid fracture treated with anterior cannulated screw fixation. Postoperatively, he was noted to have dysphagia due to a zenker's diverticulum. Further history revealed repair of a zenker's diverticulum ~40 years prior. Cervical spine images and video fluoroscopy demonstrated a recurrent zenker's diverticulum. After re-excision of the recurrent zenker's diverticulum his dysphagia resolved. This unique case describes dysphagia due to recurrent zenker's diverticulum presenting after anterior cannulated screw fixation for type II B odontoid fracture. The dysphagia was diagnosed and treated in close collaboration with speech and language therapists and otorhinolaryngologist. This underscores the importance of holistic approach to the elderly patient with odontoid fractures.

Fulminant necrotizing fasciitis to the hand in a patient on high-dose steroids: A case report of successful limb salvage.

Glucocorticoids are commonly used in the management of patients with brain Tumour for reducing peritumoral and vasogenic edema. However, they may lead to development of limb and life-threatening conditions such as necrotizing fasciitis (NF). NF is a rare but potentially lethal condition. Early detection and aggressive treatment may lead to decreased mortality and limb salvage. The diagnosis is predominately clinical but may be supported by laboratory and radiological investigations. Chronic steroid use not only predisposes to the development of NF but also may mask early features delaying presentation and diagnosis. Clinicians should have a high index of suspicion especially in patients on chronic steroid therapy as this may aid in early detection and treatment. We present a case report of a successful limb salvage that exemplifies these points.

Papillary meningioma: a rare cause of massive supratentorial intracerebral hemorrhage.

Papillary meningioma (PM) represents a very rare histological subtype, which may present with massive intracerebral hemorrhage. Gross total tumor resection results in a lower recurrence rate and mortality. A 69-year-old man had been experiencing headache for 6 months. After exacerbating right frontal headache, he was brought to the emergency room. His Glasgow Coma Scale (GCS) was 11/15 and he had a left-sided hemiparesis. A computed tomography brain scan revealed a massive right frontal intracerebral hematoma with transtentorial herniation. During right frontal craniotomy and blood clot evacuation, a fleshy, pigmented tissue was encountered. Histopathological findings were consistent with PM World Health Organization Grade III. Complete tumor resection, Simpson II was achieved with a second operation. The hemiparesis and GCS normalized subsequently. The diagnosis of PM relies largely on histopathology and is not commonly encountered preoperatively in emergency cases. Staged surgery in this case resulted in a good outcome.

Metastatic epidural spinal cord compression.

Up-to-date management for metastatic epidural spinal cord compression is based on appropriate scoring systems. In this case, separation surgery and stereotactic radiosurgery achieved an optimized outcome. A 75-year-old man had thoracic band-like pain, left lower limb weakness and difficulty ambulating for 6 weeks. Spinal images showed a T4 metastatic epidural spinal cord compression with a pathological fracture of T4 and T10 and L3 lytic lesions. There was no other neoplastic lesion. The metastasized T4 was decompressed by a posterolateral right costotransversectomy, vertebrectomy and insertion of an expandable titanium cage. The spinal sagittal alignment was restored with T1-T7 pedicle screw fixation. Post-operatively the pain and motor power improved significantly so that the patient was discharged home. Separation surgery and adjuvant stereotactic radiosurgery of the spine successfully improved tumor burden, pain control and overall prognosis.

Spinal arachnoid web-a review article.

The spinal arachnoid web is an abnormal formation of an arachnoid membrane in the subarachnoid space. It is a rare entity with some degree of uncertainty surrounding its etiology. It can result in a displacement of the spinal cord causing pain and neurological symptoms as well as blockage of cerebrospinal fluid (CSF) flow and subsequent syringomyelia. The syrinx resulting from the altered CSF flow dynamics has been described to assume variable positions relative to the web itself. The "scalpel sign" is regarded as a pathognomonic feature of a spinal arachnoid web. The arachnoid web, however, is relatively thin and may be elusive of routine radiological investigations. As such, a myriad of preoperative and intraoperative investigations have been postulated to improve the sensitivity of detecting this abnormality. Management of spinal arachnoid webs ranges from conservative management to surgical excision where in the latter, the extent of excision remains the subject of debate. The authors herein present a review of the available information on this rare topic.

Delayed central nervous system manifestation of Chikungunya virus with magnetic resonance T2 weighted imaging high signal changes-a case report.

CHIKV is a relatively new virus and we are still learning about the illness. Very little is known about CNS its involvement and even less about its delayed or long-term manifestations if any. It therefore behoves us to consider delayed CNS involvement when assessing patients with CHIKV infections that may not have had an acute neurological manifestation at the time of diagnosis coupled with new onset neurological manifestations and MRI abnormalities. It seems likely that patients with CHIKV may experience delayed CNS manifestation of the viral infection. This report highlights the importance of a travel history when assessing patients with a neurological complaint. The pathway to best manage such cases is with repeated imaging to assess if the signal changes either progress, resolve or more importantly if there is any MRI correlation should changes in neurology develop during the surveillance period.

Clinical outcomes of VNS therapy with AspireSR® (including cardiac-based seizure detection) at a large complex epilepsy and surgery centre.

PURPOSE: To compare the efficacy of AspireSR® to preceding VNS battery models for battery replacements, and to determine the efficacy of the AspireSR® for new implants. METHODS: Data were collected retrospectively from patients with epilepsy who had VNS AspireSR® implanted over a three-year period between June 2014 and June 2017 by a single surgeon. Cases were divided into two cohorts, those in whom the VNS was a new insertion, and those in whom the VNS battery was changed from a previous model to AspireSR®. Within each group, the seizure burden was compared between the periods before and after insertion of AspireSR®. RESULTS: Fifty-one patients with a newly inserted AspireSR® VNS model had a significant reduction in seizure frequency (p < 0.001), with 59% (n = 30) reporting ≥50% reduction. Of the 62 patients who had an existing VNS, 53% (n = 33) reported ≥50% reduction in seizure burden when the original VNS was inserted. After the battery was changed to the AspireSR®, 71% (n = 44) reported a further reduction of ≥50% in their seizure burden. The size of this reduction was at least as large as that resulting from the insertion of their existing VNS in 98% (61/62) of patients. CONCLUSION: The results suggest that approximately 70% of patients with existing VNS insertions could have significant additional benefit from cardiac based seizure detection and closed loop stimulation from the AspireSR® device. For new insertions, the AspireSR® device has efficacy in 59% of patients. The 'rule of thirds' used in counseling patients may need to be modified accordingly.