Early surgery versus conservative management of asymptomatic severe aortic stenosis: A meta-analysis.

OBJECTIVE: Although current guidelines generally recommend watchful waiting strategy for patients with asymptomatic severe aortic stenosis until symptoms develop, early surgery for asymptomatic aortic stenosis remains controversial. This study aimed to compare the outcomes of early surgery versus conservative strategy for patients with asymptomatic severe aortic stenosis. METHODS: MEDLINE and EMBASE were searched through February 2020 to identify clinical trials that investigated early surgery and conservative strategy for patients with asymptomatic severe aortic stenosis. From each study, we extracted the hazard ratio of all-cause mortality and cardiovascular mortality. Subgroup analyses were conducted by dividing into severe aortic stenosis (peak aortic jet velocity ≥4.0 m/s, mean aortic pressure gradient ≥40 mm Hg, or aortic valve area ≤1.0 cm2) and very severe aortic stenosis (peak aortic jet velocity ≥4.5 m/s, mean pressure gradient ≥50 mm Hg, or aortic valve area ≤0.75 cm2) groups. RESULTS: One randomized controlled trial and 7 observational studies were identified. Pooled analyses demonstrated that all-cause mortality and cardiovascular mortality for early surgery were significantly lower compared with conservative strategy (hazard ratio, 0.49; 95% confidence interval, 0.36-0.68; P < .0001, hazard ratio, 0.42; 95% confidence interval, 0.22-0.82; P = .01, respectively). Subgroup analyses showed significant reduction for early surgery in all-cause mortality (severe aortic stenosis: hazard ratio, 0.52; 95% confidence interval, 0.35-0.78; P = .001, very severe aortic stenosis: hazard ratio, 0.38; 95% confidence interval, 0.17-0.85; P = .02). CONCLUSIONS: We demonstrated that early surgery was associated with significant reduction in all-cause and cardiovascular mortality in patients with severe aortic stenosis. Further randomized trials are warranted to confirm our findings.

Surgical treatment of segmental spinal dysgenesis: a report of 19 cases.

STUDY DESIGN: Retrospective review. OBJECTIVE: To describe clinical presentation, surgical management, long-term results, and complications in patients with segmental spinal dysgenesis (SSD). In addition, we sought to emphasize early surgery for this complex congenital abnormality. SSD is a rare congenital malformation characterized by focal stenosis, spinal subluxation, kyphosis, and absence of the nerve roots. Neurologic function ranges from normal to complete paraplegia. Progression of the deformity and neurologic deterioration is the rule. METHODS: An independent spinal surgeon reviewed the complete records of 19 patients with SSD, between 1998 and 2015 at a single institution. Mean follow-up was 10 years and 6 months (2-14 years). RESULTS: We evaluated 11 males and 8 females, with a mean age of 2 years and 9 months (5 months-15 years). The dysgenetic segment involved an average of 2.9 vertebrae (1-5); the upper thoracic region was most commonly involved in ten cases. Fifteen patients had severe spinal stenosis. 14 patients presented neurological deficits and 15 patients had associated organ and musculoskeletal anomalies.Twenty-seven surgeries were performed, a mean of 1.76 procedures (1-5) to obtain solid fusion. Neurologic function improved in four, deteriorated in three, and remained unchanged in 12 patients Seven complications were recorded. CONCLUSION: We strongly recommend decompression and fusion as soon as possible to preserve or prevent neurologic deterioration. Although challenging, it was possible to achieve a solid instrumented fusion in all cases; however, a high rate of patients may deteriorate or not recover neurological status after surgery. LEVEL OF EVIDENCE: Level IV evidence.

Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre. Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome. Results 343 patients who were submitted to surgical clipping in the first 72 hours postictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Goodgrade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improvedGOS at discharge and at 6months. Poor-grade patients according to theWFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge. Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

Time of Surgery in the Outcome of Cervical Spinal Cord Injury: the University of Puerto Rico Experience.

OBJECTIVE: The purpose of this study was to determine the effect of the timing of surgery on the neurological function of patients with a cervical spinal cord injury. METHODS: Retrospectively, an analysis was done of patients who underwent decompression and/or spinal cord stabilization surgeries from 2010 through 2014 for cervical trauma. All patients were older than 18 years of age, had had surgery at our facility, and had made at least 1 follow-up visit. American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores were compared for patients who underwent early surgeries (less than 72 hours after trauma) and for those who underwent late surgeries (more than 72 hours after trauma). RESULTS: There were a total of 107 patients. Sixty-two patients had spinal cord injuries. The average age was 38.6 years, and 84% of the participants were male. The most common mechanism of trauma was motor vehicle accident. Twenty-nine percent of the patients developed neurogenic shock and 27% experienced respiratory failure during the first week after admission. Seventeen patients died during the study period. A multivariate analysis of AIS score improvement revealed that the only significant factor was incomplete neurological injury. There was no significant difference in the percentage of patients that improved with early surgery compared to that of those that improved after late surgery. CONCLUSION: Traumatic cervical spinal cord injury is associated with high mortality and morbidity. Early surgery was not associated with an improved neurological outcome at long-term follow-up. The benefit of early surgery was seen only in terms of decreasing each patient's length of hospital stay.

Early surgery for ruptured cerebral aneurysms: technical note

We describe a collection of techniques to be considered in the early clipping of ruptured cerebral aneurysms located in the anterior circulation when dealing with the swollen red and scaring brain many times found after craniotomy.

Descrevemos uma coleção de técnicas a serem consideradas na clipagem precoce dos aneurismas cerebrais rotos localizados na circulação anterior quando lidando com o cérebro vermelho inchado e assustador encontrado muitas vezes após a craniotomia.