Impact of Postoperative Infarcts in Determining Outcome after Clipping of Anterior Communicating Artery Aneurysms.

BACKGROUND: Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome. MATERIAL AND METHODS: This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated. RESULTS: 29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery. CONCLUSION: Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts.

Factors predicting long-term outcome after short-segment posterior fixation for traumatic thoracolumbar fractures.

BACKGROUND: The "gold standard" for instrumentation of unstable thoracolumbar fracture-dislocations is pedicle screw and rod fixation. Although traditional treatment supports long-segment posterior fixation (LSPF), more recent studies show short-segment posterior fixation (SSPF) may be effective, but incur higher failure rates. Here, we evaluated the effectiveness of SSPF in the management of unstable thoracolumbar injuries and analyzed the factors impacting long-term outcomes. METHODS: In this retrospective analysis of 91 patients with thoracolumbar fractures managed with SSPF alone, we assessed the clinical and radiological parameters at preoperative, postoperative, and follow-up intervals along with reasons for failures of SSPF. RESULTS: We analyzed 91 patients (mean age: 33.5 years; Male: Female = 50:41) with thoracolumbar fractures treated with SSPF over a median follow-up period of 30 months. SSPF failures were observed in 26 of 91 (28.6%) patients; the median time to implant failure was 17 months. On univariate analysis, statistically significant factors contributing to failure of SSPF included the presence of a burst fracture, a preoperative LSC (load-sharing classification) score >6, and translation/dislocation. With multinomial regression analysis, the only factor predictive for SSPF failure was the patients' postoperative ambulatory status. CONCLUSION: Patients with thoracolumbar facture dislocations, subjected to axial spinal loading postoperatively, should not be considered for SSPF alone. The following factors also contributed to SSPF failures: a burst fracture, a preoperative LSC score of >6, and/or presence of transverse dislocation.