Clinical Characteristics of Hydrocephalus Following the Treatment of Pyogenic Ventriculitis Caused by Multi/Extensive Drug-Resistant Gram-Negative Bacilli, Acinetobacter Baumannii, and Klebsiella Pneumoniae.

Objective: Hydrocephalus is common after ventriculitis. This study explores hydrocephalus's clinical characteristics following pyogenic ventriculitis due to multidrug-resistant and extensively drug-resistant Acinetobacter baumannii and Klebsiella pneumoniae. Patients and Methods: We retrospectively reviewed patients with post-neurosurgical pyogenic ventriculitis due to multidrug-resistant and extensively drug-resistant A. baumannii and K. pneumoniae in our department between January 2014 and June 2020. Once diagnosed, patients received intraventricular lavage followed by daily intraventricular administration of Colistin (polymyxin-E). The patient's clinical/radiographic findings were analyzed and evaluated 6 months after discharge. Results: In total, 48 cases were included in this study, and 25% were female. The median age was 45 (SD ± 15) years old. Median intraventricular Colistin administration to acquire sterile cerebrospinal fluid (CSF) was 20 days. Forty-one patients developed hydrocephalus; among them, 18 (43%) had multiloculated hydrocephalus (MLH), 23 (56%) had uni/non-loculated hydrocephalus (ULH/NLH), and 7 (17%) did not develop hydrocephalus. The patients with MLH had (15 days) delayed initiation of intraventricular irrigation (p < 0.022). They had (32 days) longer intraventricular Colistin (p < 0.003) and showed worse outcomes in terms of Glasgow outcome score (GOS) at 6 months follow-up than those without hydrocephalus. The mean score of the MLH group was 1.67 (SD1.23), and ULH/NLH was 2.61 (SD1.4) at p < 0.008. Conclusion: Multiloculated hydrocephalus is common in patients receiving delayed intraventricular administration of Colistin and required a longer duration on intraventricular Colistin to treat the pyogenic ventriculitis caused by multidrug/extensive drug-resistant A. baumannii and K. pneumoniae. It is associated with worse clinical outcomes.

Low Serum Magnesium Levels Are Associated With Hemorrhagic Transformation After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke.

Objective: In patients with acute ischemic stroke (AIS), hemorrhagic transformation (HT) is a major complication after mechanical thrombectomy (MT). This study aimed to investigate the relationship between serum magnesium levels and HT after MT. Methods: We collected 199 cases of consecutive AIS that received MT due to acute anterior circulation occlusions in our institution between January 2017 and January 2020. Baseline serum magnesium was obtained from all patients on admission before MT. The patients were divided into two groups based on the occurrence of HT. Univariate and multivariate analyses were performed to investigate whether magnesium was an independent predictor of HT. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were determined. Results: Of the 199 enrolled patients, 40 (20.1%) presented with HT, and 12 (6%) developed symptomatic intracranial hemorrhage (sICH). Patients with HT had lower serum magnesium levels compared to those without HT (0.76 [0.69-0.80] vs. 0.84 [0.80-0.90], p < 0.001). The multivariate logistic analysis showed that the serum magnesium level (odds ratio, [OR]: 0.000, 95% confidence interval [CI]: 0.000-0.001, p < 0.001) was significantly associated with the occurrence of HT. The ROC curve analysis revealed that the serum magnesium level could predict HT with an AUC of.820 (95% CI: 0.750-0.891 p < 0.001). Serum magnesium ≤ 0.80 mmol/L could predict HT with a sensitivity of 79.2% and a specificity of 70.0%. Of interest, the serum magnesium level was not associated with HT when the baseline of serum magnesium was higher than the cut-off value (0.80 mmol/L) in the subgroup analysis. Conclusions: Lower baseline serum magnesium levels (<0.80 mmol/L) on admission are associated with increased risk of HT in AIS patients receiving MT.

Increased Systemic Immune-Inflammation Index Is Associated With Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage Patients.

Background: Systemic immune-inflammation index (SII) is a novel biomarker that reflects the state of a patient's inflammatory and immune status. This study aimed to determine the clinical significance of SII as a predictor of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods: Retrospective data were collected from aneurysmal SAH patients who had been admitted to our hospital between January 2015 and October 2019. Both univariate and multivariate analyses were performed to investigate whether SII was an independent predictor of DCI. In addition, the receiver operating characteristic (ROC) curve and area under the curve (AUC) were also evaluated. Results: There were 333 patients with aneurysmal SAH included in this study. Multivariate logistic analysis revealed that a modified Fisher grade 3 and 4 score [odds ratio (OR) = 7.851, 95% confidence interval (CI): 2.312-26.661, P = 0.001] and elevated SII (OR = 1.001, 95% CI: 1.001-1.002, P < 0.001) were independent risk factors for DCI. ROC curves showed that SII could predict DCI with an AUC of 0.860 (95% CI: 0.818-0.896, P < 0.001). The optimal cut-off value for SII to predict DCI was 1,424, and an SII ≥ 1,424 could predict DCI with a sensitivity of 93.1% and a specificity of 68.1%. Patients with higher SII value on admission tended to have higher incidence of acute hydrocephalus and DCI, greater modified Fisher and Hunt-Hess scales, and poorer outcomes. Conclusions: SII is an independent predictor of DCI in patients with aneurysmal SAH. The SII system can be implemented in a routine clinical setting to help clinicians diagnose patients with high risk of DCI.

Impact of homocysteine levels on clinical outcome in patients with acute ischemic stroke receiving intravenous thrombolysis therapy.

BACKGROUND: The purpose of this study was to retrospectively assess the potential correlation between clinical outcomes and homocysteine (Hcy) levels in acute ischemic stroke (AIS) patients after recombinant tissue plasminogen activator (rtPA) treatment. METHODS: AIS patients treated by rtPA were enrolled between September 2018 and March 2019 in the Stroke Center (Department of Neurology and Neurosurgery), Shanghai Tenth People's Hospital, Tongji University School of Medicine. Demographics, baseline and clinical characteristics, and modified Rankin Scale (mRS) score after three months from the onset were retrospectively analyzed. Then we compared data about demographics, baseline and clinical characteristics between patients with favorable (mRS score 0-2) and unfavorable (mRS score 3-6) outcomes. RESULTS: Among 141 patients, 36 patients had poor outcome, for an incidence of 25.53%. Univariate analysis showed that higher Hcy levels (OR = 1.07, 95% CI [1.02-1.12]), older age (OR = 1.06, 95% CI [1.02-1.10]), longer door to needle time (DNT) (OR = 1.03, 95% CI [1.01-1.05]), higher D-Dimer levels (OR = 1.33, 95% CI [1.03-1.71]), and higher National Institutes of Health Stroke Scale (NIHSS) score before treatment (OR = 1.21, 95% CI [1.08-1.35]) were each associated with poor outcome. Also, without internal carotid artery plaque (OR = 0.30, 95% CI [0.10-0.92]) showed a protective effect on patients' clinical outcome. Patients with higher levels of Hcy decline also showed an increased risk of poor outcome for AIS patients obtaining rtPA treatment (Non-adjusted: OR = 1.07, 95% CI [1.02-1.12]; Adjust model I adjusts for demographics (age, male): OR = 1.06, 95% CI [1.02-1.11]; Adjust model II adjusts for hospital care factors (onset to treatment, DNT): OR = 1.08, 95% CI [1.03-1.13]; Adjust model III adjusts for health and stroke factors (INR, D-Dimer, HGB, NIHSS score before treatment, smoking, drinking, hypertension, diabetes, coronary disease, hyperlipidemia, previous stroke, atrial fibrillation, hemorrhagic transformation, internal carotid artery plaque): OR = 1.06, 95% CI [1.02-1.11]). The results are very stable in all three models constructed. CONCLUSION: The results of this study indicate that increased Hcy level independently predicts unfavorable outcome in AIS patients accepting thrombolytic therapy. However, the contribution of Hcy to the outcome, although significant, is relatively small and perhaps not clinically significant when all the other confounders are considered.

A retrospective study on outcomes following posterior fossa decompression with dural splitting surgery in patients with Chiari type I malformation.

BACKGROUND: Chiari type I malformation (CM I) is a congenital defect of the skull base and brain. Posterior fossa decompression alone or with duraplasty and partial resection of cerebellar tonsils is a standard approach. The effectiveness of other approaches such as the dural splitting technique is still under the study. OBJECTIVE: To study and compare the outcome following a dural splitting surgery with the duraplasty group. METHOD: 184 patients that received dural splitting surgery and 39 patients that received duraplasty surgery were identified. The outcome of the individual procedure in terms of symptoms, pre- and postoperative presence of syrinx, operation time, hospital admission period, and Chicago Chiari Outcome Scale (CCOS) were analyzed and compared. RESULTS: The observed values in terms of symptomatic relief between the two groups were similar Pearson's chi-square test was 0.677 with p=0.411. Independent samples Mann-Whitney U test to analyze CCOS score showed p = 0.249 at Z = 1.152. The average postoperative period in days was less in PFDDS group 9.25 days, the average admission period in days for the group was less in PFDDS group 14.23 days with p < 0.0005. Fisher's exact test showed the Syrinx disappearance rate was better in the PFDDS group. The average duration for surgery was less on the PFDDS group. CONCLUSION: Our study showed that more optimal results were obtained in terms of syrinx resolution as well as shorter operation time and postoperative stay among the PFDDS group. Both procedures are equally effective in terms of CCOS score.

Perforating Brain Injury By a Rusty Steel Bar.

A perforating head injury is a type of an injury wherein the projectile passes entirely through the cranium leaving both entrance and exit wounds. It is considered less prevalent than other kinds of head trauma such as closed or penetrating head injuries carry a worse prognosis among other varieties of head injuries. Having unique mechanism and pathophysiology it is considered a significant challenge for the practicing neurosurgeon mandating high precaution and novel approach to minimize further damage. Here, we presented a case of a 5-year-old boy who suffered from perforating brain injury by a fallen rusty steel bar.

The Most-Cited Works in Severe Traumatic Brain Injury: A Bibliometric Analysis of the 100 Most-Cited Articles.

BACKGROUND: There is an abundance of works published on severe traumatic brain injury (sTBI). Bibliometric analyses aim to provide a macroscopic view of research activities regarding sTBI and are helpful in determining the most impactful studies within this field. METHODS: We performed a generalized search using the database of Web of Science, organized the references by the number of citations, and reviewed full length-articles for the top-100 most-cited articles on sTBI. The articles were classified according to focus. RESULTS: The top-100 articles were cited on average 326.4 times per paper. The Journal of Neurosurgery published the greatest number of top-100 cited articles (9 of 100). Authors from the United States published the majority (67%) of the most-cited articles. The most popular categories were "reviews and guidelines" and "etiology and epidemiology." CONCLUSIONS: The present study provides a cross-sectional summary of the 100 most-cited articles on sTBI, highlighting areas of research needing further investigation and development.

Bibliometric Analysis of Journals in the Field of Endoscopic Endonasal Surgery for Pituitary Adenomas.

Endoscopic endonasal surgery for pituitary adenomas is being performed more frequently worldwide in the recent years. This first bibliometric analysis was conducted aiming to have a microscopic view of research activities about endoscopic endonasal surgery for pituitary adenomas. The original articles about endoscopic endonasal surgery for pituitary adenomas were extracted from the Web of Science (WoS) and analyzed concerning their distributions. We also explored the potential correlations between publications of different countries and their gross domestic product (GDP) via Pearson correlation test. The total number of original articles retrieved from WoS was 307 from 1997 to 2017. The number of original articles published in the last decade has increased by 530.95% compared with that published in the former decade. The United States has published 124 articles (40.391%), followed by Italy with 40 (13.029%) and Japan with 27 articles (8.795%). The journal that published the highest number of original articles was Journal of Neurosurgery with 31 (10.098%), followed by Neurosurgery (n = 23, 7.492%), World Neurosurgery (n = 23, 7.492%), and Neurosurgical Focus (n = 15, 4.886%). There was a strong correlation between publication numbers and GDP of different countries (r = 0.889, P < 0.001). There is a skyrocket trend of endoscopic endonasal surgery for pituitary adenomas during the last 2 decades, and countries with high GDP tend to make more contributions to this field.

Outcome Following the Treatment of Ventriculitis Caused by Multi/Extensive Drug Resistance Gram Negative Bacilli; Acinetobacter baumannii and Klebsiella pneumonia.

Introduction: CNS ventriculitis is a serious complication following an intracranial insult that demands immediate treatment with broad-spectrum antibiotics in a critical care setting. Infections due to multi/extensive drug resistance (MDR/XDR) microorganisms are very challenging, which may demand an additional approach to the ongoing practice; intravenous and intraventricular administration of antibiotics. Aim: To study the efficacy and safety of thorough ventricular irrigation followed by daily intraventricular antibiotic administration in patients with MDR/XDR ventriculitis. Materials and Methods: A retrospective analysis was done on 19 inpatients with ventriculitis caused by Acinetobacter baumannii (AB) or Klebsiella pneumonia (KP), at Shanghai Tenth People's Hospital from January 2016 to October 2017. We reviewed our experience; the role of thorough ventricular irrigation with Colistin mixed normal saline, followed by intraventricular Colistin therapy. Treatment outcomes were evaluated based on the clinical symptoms, Cerebro-Spinal Fluid (CSF) culture, laboratory findings and complications. Results: A total of 19 patients were included (15 males and 4 females), with a mean age in years of 51, which ranged from 18-67. Fourteen patients had Acinetobacter baumannii (AB) and 5 had Klebsiella pneumoniae (KP). The average CSF sterilization period following ventricular irrigation and intraventricular Colistin was 6 days. Sixteen patients (84%) were cured, and 3 patients (15%) died during the course of the treatment. Conclusion: In addition to Intraventricular Colistin, thorough ventricular irrigation could increase the cure rate up to 84% in patients suffering from MDR/XDR CNS ventriculitis.

Delayed Catheter-Related Intracranial Hemorrhage After a Ventriculoperitoneal or Ventriculoatrial Shunt in Hydrocephalus.

OBJECTIVE: Delayed catheter-related intracranial hemorrhage is not rare after a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt for the treatment of hydrocephalus. Immediate postoperative catheter-related intracranial hemorrhage is possibly due to the procedure itself; however, delayed intracranial hemorrhage may have other underlying mechanisms. This study aimed to investigate the clinical characteristics and reveal the risk factors of delayed catheter-related intracranial hemorrhage after a VP or VA shunt. METHODS: We did a retrospective study to review patients with hydrocephalus and underwent VP or VA shunt in our department from September 2011 to December 2015. We reviewed the clinical characteristics of the patients with delayed catheter-related intracranial hemorrhage, and its risk factors were analyzed with SPSS 16.0. RESULTS: Of the 218 patients enrolled in the study (145 male, 73 female), 17 (7.8%) patients experienced delayed catheter-related intracranial hemorrhage, including 11 of 151 (7.3%) patients with a VP shunt and 6 of 67 (9.0%) patients with a VA shunt. Additionally, 4 of the 16 patients with postoperative low-molecular-weight heparin (LMWH) therapy and 13 of the 202 patients without LMWH experienced bleeding, showing a significant difference (25% vs. 6.4%, P = 0.026). The relative risk was 4.8 (95% confidence interval: 1.4-17.1). CONCLUSION: Delayed catheter-related intracranial hemorrhage is not rare after a VP or VA shunt. However, most patients can be cured after appropriate treatment. Postoperative anticoagulation therapy with enoxaparin may be associated with an increased risk of bleeding.

Negative-Pressure Hydrocephalus: A Case Report on Successful Treatment Under Intracranial Pressure Monitoring with Bilateral Ventriculoperitoneal Shunts.

BACKGROUND: Negative-pressure hydrocephalus (NegPH), a very rare condition of unknown etiology and optimal treatment, usually presents postneurosurgery with clinical and imaging features of hydrocephalus, but with negative cerebrospinal fluid pressure. CASE DESCRIPTION: We describe a NegPH case of -3 mm Hg intracranial pressure that was successfully treated to achieve 5 mm Hg under continuous intracranial pressure monitoring with horizontal positioning, head down and legs elevated to 10°-15°, neck wrapping for controlled venous drainage, chest and abdomen bandages, infusion of 5% dextrose fluid to lower plasma osmolarity (Na+, 130-135 mmol/L), daily cerebrospinal fluid drainage >200 mL, and arterial blood gas partial pressure of carbon dioxide >40 mm Hg.