Peripheral white blood cell count as a screening tool for ventriculostomy-related infections.

One of the most common complications following external ventricular drain (EVD) placement is infection. Routine cultures of cerebrospinal fluid (CSF) are often used to screen for infection, however several days may pass before infection is discovered. In this study, we compared the predictive value of daily recorded vital sign parameters and peripheral white blood count (WBC) in identifying ventriculostomy-related infections. Patients with EVDs who had CSF cultures for microorganisms performed between January 2011 and July 2017 were assigned to either an infected and/or uninfected study group. Clinical parameters were then compared using t-test, chi squared and multiple logistic regression analyses. Patients of any age and gender were included. One hundred seventy uninfected and 10 infected subjects were included in the study. Nine of the 10 infected patients had an elevated WBC (>10.4 × 103/µL), with a significantly greater WBC (15.9 × 103/µL) than the uninfected group (10.4 × 103/µL) (p-value ≤ 0.0001). Using logistic regression, we found no association between patient vital signs and CSF infection except for WBC (p = .003). As a diagnostic marker for CSF infection, the sensitivity and specificity of WBC elevation greater than 15 × 103/µL was 70% (7/10) and 90.2% (147/163), respectively. This study serves as a 'proof of concept' that WBC could be useful as potential screening tool for early detection of CSF infection post-EVD placement. Future investigation using a large, multicenter prospective study is needed to further assess the applicability of this parameter.

Occipital Artery Harvesting and Anastomosis to P3 Segment of Posterior Inferior Cerebellar Artery: Operative Video.

Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) have a greater incidence of fusiform morphology, intraluminal thrombi, and wall calcifications. At times, a complex treatment strategy with vessel occlusion and revascularization using a bypass graft is necessary for successful obliteration of these aneurysms. The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa because of its proximity to the target recipient vessels. However, dissection of an OA can be challenging, given its anatomically tortuous path and the presence of thick surrounding muscles. This video captures the dissection of the OA using an unconventional, "inside-out" harvesting technique and the end-to-side anastomosis of the OA to the PICA at the p3 segment. This was performed in a 58-year-old man who presented with a subarachnoid hemorrhage (Hunt and Hess grade IV) from a ruptured fusiform aneurysm located at the origin of the right PICA. Major steps in Video 1 during this case include 1) dissection and harvesting of the OA using the "inside out" technique, 2) placement of 2 temporary clips occluding the PICA and isolating the P3 segment, 3) end-to-side OA-P3 anastomosis, and 4) removal of the temporary clips and confirmation of the PICA's patency using intraoperative indocyanine green. Due to the potential for infarction of the brainstem, the patient was started on dual antiplatelet therapy postoperatively. The patient tolerated the procedure well and suffered no major complications related to the operation or from being placed on dual antiplatelet therapy. He did experience some mild, posterior neck pain and rigidity at the time of his 3-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. Complex fusiform aneurysms at the origin of PICA can be successfully treated via an OA-PICA bypass.

Outcomes in different age groups with primary Ewing sarcoma of the spine: a systematic review of the literature.

OBJECTIVEEwing sarcoma (ES) is among the most prevalent of bone sarcomas in young people. Less often, it presents as a primary lesion of the spine (5%-15% of patients with ES).METHODSA systematic literature search was performed, querying several scientific databases per PRISMA guidelines. Inclusion criteria specified all studies of patients with surgically treated ES located in the spine. Patient age was categorized into three groups: 0-13 years (age group 1), 14-20 years (age group 2), and > 21 (age group 3).RESULTSEighteen studies were included, yielding 28 patients with ES of the spine. Sixty-seven percent of patients experienced a favorable outcome, with laminectomies representing the most common (46%) of surgical interventions. One-, 2-, and 5-year survival rates were 82% (n = 23), 75% (n = 21), and 57% (n = 16), respectively. Patients in age group 2 experienced the greatest mortality rate (75%) compared to age group 1 (9%) and age group 3 (22%). The calculated relative risk score indicated patients in age group 2 were 7.5 times more likely to die than other age groups combined (p = 0.02).CONCLUSIONSPrimary ES of the spine is a rare, debilitating disease in which the role of surgery and its impact on one's quality of life and independence status has not been well described. This study found the majority of patients experienced a favorable outcome with respect to independence status following surgery and adjunctive treatment. An increased risk of recurrence and death was also present among the adolescent age group (14-20 years).

Insular cavernous malformation resection through a minipterional, transsylvian approach.

Cavernous malformations of the brain are low-flow vascular lesions that have a propensity to hemorrhage. Extensive surgical approaches are often required for operative cure of deep-seated lesions. A 23-year-old female presented with a cavernous malformation of the left posterior insula with surrounding hematoma measuring up to 3 cm. A minimally invasive (mini-)pterional craniotomy with a transsylvian approach was selected. Endoscopic assistance was utilized to confirm complete resection of the lesion. The minipterional craniotomy is a minimally invasive approach that provides optimal exposure for sylvian fissure dissection and resection of many temporal and insular lesions. The video can be found here: https://youtu.be/9z6_EhU6lxs.

Survival as a Function of Nonsteroidal Anti-inflammatory Drug Use in Patients with Glioblastoma.

Background Findings of both case control and in vitro investigations suggest that non-steroidal anti-inflammatory drugs (NSAIDs) may play a beneficial role in the occurrence, growth, and subsistence of glioblastoma multiforme (GBM) brain tumor in humans. Objective In the present retrospective cohort study, we assessed the impact of NSAID use on survival in patients diagnosed with and treated for GBM brain tumors. Methods The impact of NSAID use and six other potential prognostic indicators of survival were assessed in 71 patients treated for GBM brain tumors from February 2011 to June 2016. Survival analysis and cross-tabulation analyses were performed to examine the potential relationship between NSAID use and occurrence of intracranial hemorrhage over the course of treatment for GBM. Results Kaplan-Meier analysis revealed no significant difference in survival between patients with and without NSAID use (p = 0.75; 95% CI: 10.12, 18.13). Multiple Cox regression analysis identified only treatment with chemotherapy as imposing any statistically significant effect on survival (Hazard Ratio (HR) = 3.31; p < 0.001; 95% CI: 1.80, 6.07). Cross-tabulation revealed no significant effect of NSAID use on occurrence of hemorrhage during treatment, X2 (2, N = 71) = 0.65, p2-Sided = 0.42, (Fisher's Exact Test: p2-sided = 0.56, p1-sided = 0.31). Conclusion These results suggest that history of NSAID use is not a determinant of survival in GBM patients. More rigorous, prospective investigations of the effect of NSAID use on tumor progression are necessary before the utility of this family of drugs in the treatment of GBM can be adequately appraised.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine.

BACKGROUND: Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment. METHODS: A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision. RESULTS: In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001). CONCLUSIONS: CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Aneurysms of the Proximal Segment of the Anterior Cerebral Artery: A New Classification System with Corresponding Therapeutic Options.

OBJECTIVE: This study aims to establish a new classification system for proximal anterior cerebral artery (A1) aneurysms and to offer treatment strategies, based on the lessons learned by studying the case reports of 41 patients with A1 aneurysms. METHODS: A total of 2332 consecutive patients with intracranial aneurysms were treated at a single medical center between June 2005 and May 2015. Forty-one patients with 42 A1 aneurysms were treated by surgical clipping or endovascular coiling. Clinical data, radiographic results, treatments, and patient outcomes were later collected and analyzed. RESULTS: Of 2332 intracranial aneurysm patients, 1.76% (n = 41) had a total of 42 A1 aneurysms. Twenty-six of these (62%) were proximal A1 segment aneurysms, 9 (21%) were distal A1 segment aneurysms, and 7 (17%) were fusiform A1 aneurysms. A1 aneurysms can be classified into 3 main types. Types IA and IB originate from the posterior wall of the proximal A1 segment. Type IA projects posterior-inferiorly, whereas type IB projects posterior-superiorly. Type IIA originates from the distal trunk of the A1 artery. Type IIB originates from an angle of an abnormal cortical branch or a ring of an A1 arterial fenestration. Type III consists of fusiform or dissecting aneurysms located anywhere along the A1 segment. After studying the range of treatments and outcomes, when treating these complex morphologies, we recommend clipping type I and II A1 aneurysms and embolizing type III A1 aneurysms. CONCLUSIONS: A1 artery aneurysms are a rare type of aneurysm with unique characteristics. The classification system proposed here accurately summarizes these characteristics to better guide treatment strategies.