A Case of Pott's Puffy Tumor in a Patient With Eosinophilic Chronic Rhinosinusitis.

Eosinophilic chronic rhinosinusitis (ECRS) is a refractory type 2 inflammation-based airway allergic disease that is prone to complications such as bronchial asthma. Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone accompanied by a subperiosteal abscess. A 56-year-old female with a history of cranial surgery and bronchial asthma presented to an otolaryngology clinic with nasal obstruction and loss of smell, later developing swelling and redness on her forehead. She was diagnosed and treated for ECRS and was thought to have developed PPT during her course. Nasal endoscopy reveals bilateral polyp formation originating from the middle meatus. Paranasal computed tomography (CT) indicates substantial swelling extending from the opening of the frontal sinus to the adjacent subcutaneous tissue, accompanied by a defect in the frontal bone and osteolysis at the base of the frontal skull. Her management included conservative antibiotic therapy adjusted due to a drug eruption and, subsequently, endoscopic sinus surgery (ESS). The case was complicated by the patient's medical history and the absence of detailed surgical records, which limited the use of enhanced imaging techniques. This underscores the complexity of diagnosing and managing PPT in adults, particularly those with prior surgeries, emphasizing the need for a tailored diagnostic and therapeutic approach that integrates detailed patient history with current clinical indicators to effectively guide treatment. This case contributes to the limited literature on adult PPT and underscores the critical need for careful patient monitoring and detailed surgical history.

Enhanced Recovery after Cranial Surgery in Elderly: A Review.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS: Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS: Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS: This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

The Lenticular.

OBJECTIVE: The lenticular was an instrument introduced by Galen to facilitate cutting the bone of the cranium. Illustrations of the instrument first appeared in the 16th century during the Renaissance. These illustrations have been widely used, but the instrument's shape seems ill-adapted to its function. Archaeological research in Rimini, Italy, unearthed a similar instrument with a shape that seems more suitable for the function of cutting cranial bone. The object of this study was to evaluate the efficacy of these two instruments for cutting the bone of the cranium. METHODS: Replicas of the two instruments were obtained. Trepanation was performed in the left parietal region of a sheep's head. In addition, the application of the instruments in the literature was analyzed. RESULTS: The Roman lenticular cut the cranium with ease. The Renaissance instrument failed to cut the bone and only separated the dura mater from the bone. The lenticular had been used to cut bone up to the 13th century. In contrast, the Renaissance instrument was not used to cut bone but to smooth roughened bony surfaces and to remove spicules of bone that were in contact with the dura. CONCLUSIONS: Analysis of illustrations in medical publications should be undertaken with the same rigor as applied to analysis of text.

Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal.

PURPOSE: Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity. METHODS: The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool. RESULTS: A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis. CONCLUSION: The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.

Role of decompressive craniectomy in the management of acute ischemic stroke (Review).

The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.

Enhanced recovery in cranial surgery (ERACraS) - A single-centre quality improvement study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a well-established, protocol-driven, evidence-based approach to peri-operative care. ERAS protocols have been used to improve patient morbidity and mortality outcomes in various surgical specialties. More recently, it has been introduced to neurosurgery. Our aim was to establish an Enhanced Recovery After Cranial Surgery (ERACraS) protocol for patients as part of a quality improvement project (QIP) with the intention of reducing hospital length of stay (HLOS). METHODS: This QIP was carried out in the Department of Neurosciences (DCN), Edinburgh, over two four-month periods. A total of 40 patients over 18 years of age undergoing elective craniotomy surgery under a sole neurosurgeon were invited to take part in this QIP. Subsequently, data was retrospectively collected through our institution's online documentation system. RESULTS: 19 patients received conventional perioperative care (pre-ERACraS group) during December 2021-March 2022, and 21 received care according to the novel ERACraS (ERACraS group) during June-September 2022. Regarding supra-tentorial surgery, there was a reduction of 73% in HLOS in the ERACraS group. No change was observed in infra-tentorial surgery. Overall, the ERACraS protocol reduced HLOS by 50% in cranial surgery. CONCLUSION: The QIP data from ERACraS in our unit has shown that implementing ERAS protocols is feasible. A reduction in HLOS has implications for patient morbidity, mortality, and quality of care. We endeavour to collect long-term data by collaborating with neurosurgical units across the UK and Ireland to validate its feasibility and sustainability as part of a major QIP in neurosurgical practice. This can be potentially adopted by neurosurgical centres across the globe in a safe and sustained manner.

Effects of Dexmedetomidine on Cognitive Function, Oxidative Stress and Brain Protection in Patients Undergoing Craniocerebral Surgery

Background: The protective mechanism of dexmedetomidine on the brains of patients undergoing craniocerebral surgery remains unclear. The aim of this study was to examine the impact of dexmedetomidine on cognitive function, oxidative stress, and brain protection in such patients. Methods: Fifty-four patients who underwent craniocerebral surgery at our hospital from January 2020 to June 2023 were retrospectively selected as study subjects. They were divided into two groups: the control group (n = 27) and the study group (n = 27), based on different auxiliary anesthesia protocols. Patients in the study group received dexmedetomidine before anesthesia induction, using a midline intravenous pump to assist anesthesia, while the control group received an equivalent amount of normal saline. The remaining anesthesia induction and maintenance protocols were consistent for both groups. Cognitive function was assessed using the Mini Mental State Examination (MMSE) before and 1 day after surgery for both groups. Oxidative stress indicators, including malondialdehyde (MDA), glutathione peroxidase (GSH-Px), and superoxide dismutase (SOD) levels in the serum of both groups, were measured using enzyme-linked immunosorbent assay (ELISA). Additionally, changes in postoperative brain injury indicators, namely neuron-specific enolase (NSE) and central nervous system-specific protein (S100β), were detected and compared in the serum of both groups. Concurrently, postoperative adverse reactions were recorded for both groups. Results: The MMSE scale scores of both groups of patients 24 hours after surgery were significantly lower than those before surgery. However, the MMSE scale scores of the study group patients were notably higher than those in the control group, with a statistically significant difference (p < 0.05). One hour after surgery, the serum levels of MDA, GSH-Px, and SOD in both groups of patients were significantly elevated compared to pre-surgery levels. ... (AU)

Theory-based implementation of an enhanced recovery protocol for cranial surgery.

OBJECTIVE: There is growing evidence for the use of enhanced recovery protocols (ERPs) in cranial surgery. As they become widespread, successful implementation of these complex interventions will become a challenge for neurosurgical teams owing to the need for multidisciplinary engagement. Here, the authors describe the novel use of an implementation framework (normalization process theory [NPT]) to promote the incorporation of a cranial surgery ERP into routine neuro-oncology practice. METHODS: A baseline audit was conducted to determine the degree of implementation of the ERP into practice. The Normalization MeAsure Development (NoMAD) questionnaire was circulated among 6 groups of stakeholders (neurosurgeons, anesthetists, intensivists, recovery nurses, preoperative assessment nurses, and neurosurgery ward staff) to examine barriers to implementation. Based on these findings, a theory-guided implementation intervention was delivered. A repeat audit and NoMAD questionnaire were conducted to assess the impact of the intervention on the uptake of the ERP. RESULTS: The baseline audit (n = 24) demonstrated limited delivery of the ERP elements. The NoMAD questionnaire (n = 32) identified 4 subconstructs of the NPT as barriers to implementation: communal specification, contextual integration, skill set workability, and relational integration. These guided an implementation intervention that included the following: 1) teamwork-focused training; 2) ERP promotion; and 3) procedure simplification. The reaudit (n = 21) demonstrated significant increases in the delivery of 5 protocol elements: scalp block (12.5% of patients before intervention vs 76.2% of patients after intervention, p < 0.00001), recommended analgesia (25.0% vs 100.0%, p < 0.00001) and antiemetics (12.5% vs 100.0%, p < 0.00001), trial without catheter (13.6% vs 88.9%, p < 0.00001), and mobilization on the 1st postoperative day (45.5% vs 94.4%, p < 0.00001). There was a significant reduction in the mean hospital length of stay from 6.3 ± 3.4 to 4.2 ± 1.7 days (p = 0.022). Two months after implementation, a repeat NoMAD survey demonstrated significant improvement in communal specification. CONCLUSIONS: Here, the authors have demonstrated the successful implementation of a cranial surgery ERP by using a systematic theory-based approach.

Anticoagulation Options for Cranial Procedures: A Comparative Review of Aspirin, Plavix, and Aggrastat.

Anticoagulation therapy is critical to avoiding thrombotic events in patients following cranial surgery. Although Aspirin, Plavix, and Aggrastat are used as anticoagulants for this purpose, there is no consensus on which agent is the most effective and safe. In this comparative study, we analyze the current evidence on the efficacy and safety of these three anticoagulants in the context of cranial surgeries. This review focuses on the advantages and disadvantages of each anticoagulant, such as its pharmacokinetics, indications, contraindications, and possible consequences. The outcomes of this study will help physicians choose the best anticoagulant for their patients based on individual patient characteristics and the kind of cranial procedure. Aggrastat's potential to be included as a recommended anticoagulant for cranial procedures warrants further study.

Preoperative frailty and 30-day mortality after resection of brain metastases: a multicenter surgical registry analysis of 11,038 patients.

OBJECTIVE: Surgery plays a key role in the management of brain metastases. Stratifying surgical risk and individualizing treatment will help optimize outcomes because there is clinical equipoise between radiation and resection as treatment options for many patients. Here, the authors used a multicenter database to assess the prognostic utility of baseline frailty, calculated with the Risk Analysis Index (RAI), for prediction of mortality within 30 days after surgery for brain metastasis. METHODS: The authors pooled patients who had been surgically treated for brain metastasis from the American College of Surgeons National Surgical Quality Improvement Program database (2012-2020). The authors studied the relationship between preoperative calculated RAI score and 30-day mortality after surgery for brain metastasis by using linear-by-linear proportional trend tests and binary logistic regression. The authors calculated C-statistics (with 95% CIs) in receiver operating characteristic (ROC) curve analysis to assess discriminative accuracy. RESULTS: The authors identified 11,038 patients who underwent brain metastasis resection with a median (interquartile range) age of 62 (54-69) years. The authors categorized patients into four groups on the basis of RAI: robust (RAI 0-20), 8.1% of patients; normal (RAI 21-30), 9.2%; frail (RAI 31-40), 75%; and severely frail (RAI ≥ 41), 8.1%. The authors found a positive correlation between 30-day mortality and frailty. RAI demonstrated superior predictive discrimination for 30-day mortality as compared with the 5-factor modified frailty index (mFI-5) on ROC analysis (C-statistic 0.65, 95% CI 0.65-0.66). CONCLUSIONS: The RAI frailty score accurately estimates 30-day mortality after brain metastasis resection and can be calculated online with an open-access software tool: https://nsgyfrailtyoutcomeslab.shinyapps.io/BrainMetsResection/. Accordingly, RAI can be utilized to measure surgical risk, guide treatment options, and optimize outcomes for patients with brain metastases. RAI has superior discrimination for predicting 30-day mortality compared with mFI-5.

The role of extended coagulation screening in adult cranial neurosurgery.

Introduction: Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question: We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods: A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results: The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p â€‹= â€‹.546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p â€‹= â€‹.023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p â€‹= â€‹.034). Differences in mean intraoperative blood loss were not significant with 528 â€‹ml in the study cohort and 486 â€‹ml in the control cohort (p â€‹= â€‹.376). Conclusion: Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.

Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis.

BACKGROUND AND OBJECTIVE: Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy. METHODS: Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care. RESULT: Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group. CONCLUSION: ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.

Analysis of the Robotic-Based In Situ Bioprinting Workflow for the Regeneration of Damaged Tissues through a Case Study.

This study aims to critically analyse the workflow of the in situ bioprinting procedure, presenting a simulated neurosurgical case study, based on a real traumatic event, for collecting quantitative data in support of this innovative approach. After a traumatic event involving the head, bone fragments may have to be removed and a replacement implant placed through a highly demanding surgical procedure in terms of surgeon dexterity. A promising alternative to the current surgical technique is the use of a robotic arm to deposit the biomaterials directly onto the damaged site of the patient following a planned curved surface, which can be designed pre-operatively. Here we achieved an accurate planning-patient registration through pre-operative fiducial markers positioned around the surgical area, reconstructed starting from computed tomography images. Exploiting the availability of multiple degrees of freedom for the regeneration of complex and also overhanging parts typical of anatomical defects, in this work the robotic platform IMAGObot was used to regenerate a cranial defect on a patient-specific phantom. The in situ bioprinting process was then successfully performed showing the great potential of this innovative technology in the field of cranial surgery. In particular, the accuracy of the deposition process was quantified, as well as the duration of the whole procedure was compared to a standard surgical practice. Further investigations include a biological characterisation over time of the printed construct as well as an in vitro and in vivo analysis of the proposed approach, to better analyse the biomaterial performances in terms of osteo-integration with the native tissue.

Do overlapping neurosurgical procedures affect patient outcomes? A systematic review and meta-analysis.

Overlapping surgery (OS) is a common practice in neurosurgery that has recently come under scrutiny. This study includes a systematic review and meta-analysis on articles evaluating the effects of OS on patient outcomes. PubMed and Scopus were searched for studies that analyzed outcome differences between overlapping and non-overlapping neurosurgical procedures. Study characteristics were extracted, and random-effects meta-analyses were performed to analyze the primary outcome (mortality) and secondary outcomes (complications, 30-day readmissions, 30-day operating room returns, home discharge, blood loss, and length of stay). Mantel-Haenszel tests were completed for binary outcomes, whereas the inverse variance tests were conducted for continuous outcomes. Heterogeneity was measured using the I2 and X2 tests. The Egger's test was conducted to evaluate publication bias. Eight of 61 non-duplicate studies were included. Overall, 21,249 patients underwent non-OS (10,504 female) and 15,863 patients underwent OS (8393 female). OS was associated with decreased mortality (p = 0.002), 30-day returns to OR (p < 0.001), and blood loss (p < 0.001) along with increased home discharges (p < 0.001). High heterogeneity was observed for home discharge (p = 0.002) and length of stay (p < 0.001). No publication bias was observed. OS was not associated with worse patient outcomes compared to non-OS. However, considering multiple sources of limitation in the methodology of the included studies (such as limited number of studies, reports originating from mostly high-volume academic centers, discrepancy in the definition of "critical portion(s)" of the surgery across studies, and selection bias), extra caution is advised in interpretation of our results and further focused studies are warranted.

Effects of serum fibrinogen correction on outcome of traumatic cranial surgery: A randomized, single-blind, placebo-controlled clinical trial.

BACKGROUND: Traumatic brain injury (TBI) is strongly associated with coagulopathy that occurs in 25-35% of patients. This complication is linked to higher mortality and morbidity. Recent lines of evidance have supported administration of fibrinogen concentrate (FC) in patients with severe TBI, while its efficacy remains controversial. In this study we aim to evaluate the effectiveness of serum fibrinogen level correction from 1.5 and 2.0 g/l to more than 2.0 g/l in patients with severe TBI undergoing traumatic cranial surgery. METHOD: This randomized, single-blind, placebo-controlled clinical trial included trauma patients who had abbreviated injury scale (AIS) more than 3 in head and below 3 in other organs. FC was administered intravenously to patients with severe TBI undergoing TBI to correct the fibrinogen level above 2 g/l. Patients were randomly assigned to FC and control groups. The amount of intra-operative blood loss, packed cell (PC) transfusion, formation of new intracranial hemorrhage, and hemovac drainage were compared between the two study groups. RESULTS: Forty-seven of 65 participants received the study intervention within 40-112 min of admission. Intra-operative PC transfusion was higher in FC group (80%) compared to control group (55.5%) while the differance was not statistically significant (p > 0.05). Intra-operative blood loss was significantly higher in control group than FC group (P = 0.036). Chance of re-operation and new intracranial hematoma were not significantly different between two study groups. CONCLUSION: Early delivery of FC, decreases intraoperative bleeding. Although based on our findings it has no other effect on other parameters, further multicenter studies are recommended to investigate the role of early FC administration in management of post traumatic coagulopathy.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Far Lateral Approach.

Introduction Skull base neuroanatomy is classically taught using surgical atlases. Although these texts are critical and rich resources for learning three-dimensional (3D) relationships between key structures, we believe they could be optimized and complemented with step-by-step anatomical dissections to fully meet the learning needs of trainees. Methods Six sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A far lateral craniotomy was performed by each of three neurosurgery resident/fellow at varying stages of training. The study objective was the completion and photodocumentation of the craniotomy to accompany a stepwise description of the exposure to provide a comprehensive, intelligible, and anatomically oriented resource for trainees at any level. Illustrative case examples were prepared to supplement approach dissections. Results The far lateral approach provides a wide and versatile corridor for posterior fossa operation, with access spanning the entire cerebellopontine angle (CPA), foramen magnum, and upper cervical region. Key Steps Include The study includes the following steps: positioning and skin incision, myocutaneous flap, placement of burr holes and sigmoid trough, fashioning of the craniotomy bone flap, bilateral C1 laminectomy, occipital condyle/jugular tubercle drilling, and dural opening. Conclusion Although more cumbersome than the retrosigmoid approach, a far lateral craniotomy offers unparalleled access to lesions centered lower or more medially in the CPA, as well as those with significant extension into the clival or foramen magnum regions. Dissection-based neuroanatomic guides to operative approaches provide a unique and rich resource for trainees to comprehend, prepare for, practice, and perform complex cranial operations, such as the far lateral craniotomy.

Incisional CSF leakage after intradural cranial surgery in children: incidence, risk factors, and complications.

OBJECTIVE: The risk of cerebrospinal fluid (CSF) leakage after cranial surgery and its associated complications in children are unclear because of variable definitions and the lack of multicenter studies. In this study, the authors aimed to establish the incidence of CSF leakage after intradural cranial surgery in the pediatric population. In addition, they evaluated potential risk factors and complications related to CSF leakage in the pediatric population. METHODS: The authors performed an international multicenter retrospective cohort study in three tertiary neurosurgical referral centers. Included were all patients aged 18 years or younger who had undergone cranial surgery to reach the subdural space during the period between 2015 and 2021. Patients who died or were lost to follow-up within 6 weeks after surgery were excluded. The primary outcome measure was the incidence of CSF leakage, defined as leakage through the skin, within 6 weeks after surgery. Univariable and multivariable logistic regression analyses were performed to identify risk factors for and complications related to CSF leakage. RESULTS: In total, 759 procedures were identified, performed in 687 individual patients. The incidence of CSF leakage was 7.5% (95% CI 5.7%-9.6%). In the multivariate model, independent risk factors for CSF leakage were hydrocephalus (OR 4.5, 95% CI 2.2-8.9) and craniectomy (OR 7.6, 95% CI 3.0-19.5). Patients with CSF leakage had higher odds of pseudomeningocele (5.7, 95% CI 3.0-10.8), meningitis (21.1, 95% CI 9.5-46.8), and surgical site infection (7.4, 95% CI 2.6-20.8) than patients without leakage. CONCLUSIONS: CSF leakage risk in children after cranial surgery, which is comparable to the risk reported in adults, is an event of major concern and has a serious clinical impact.

Effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery: A meta-analysis.

We performed a meta-analysis to evaluate the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery. A systematic literature search up to July 2022 was performed and 24 137 subjects with neurosurgery at the baseline of the studies; 10 496 of them were using the powdered vancomycin, and 13 641 were not using the powdered vancomycin as a control. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of powdered vancomycin on stopping surgical site wound infections in neurosurgery using dichotomous methods with a random or fixed-effect model. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery (OR, 0.53; 95% CI, 0.41-0.70, P < .001), deep surgical site wound infections after spinal surgery (OR, 0.45; 95% CI, 0.35-0.57, P < .001), superficial surgical site wound infections after spinal surgery (OR, 0.60; 95% CI, 0.43-0.83, P = .002), and surgical site wound infections after cranial surgery (OR, 0.37; 95% CI, 0.22-0.61, P < .001) compared to control in subjects with neurosurgery. The powdered vancomycin had significantly lower surgical site wound infections after spinal surgery, deep surgical site wound infections after spinal surgery, superficial surgical site wound infections after spinal surgery, and surgical site wound infections after cranial surgery compared to control in subjects with neurosurgery. The analysis of outcomes should be done with caution even though the low number of studies with low sample size, 3 out of the 42 studies, in the meta-analysis, and a low number of studies in certain comparisons.

Combined sclerotherapy followed by surgical resection of a large extracranial venous malformation in a 14-month-old child: preoperative workup and technical note.

INTRODUCTION: Venous malformations affect around 2 per 10,000 newborn and are the most common type of congenital vascular malformation. They are always present at birth and are often misdiagnosed with hemangiomas. Accurate diagnosis and adequate targeted therapy through a multidisciplinary approach is advocated for a successful treatment, considering a combination of modalities in complex cases. We present here the workup and treatment of a venous malformation in a 14 month old child by combining a preoperative sclerotherapy with sodium tetradecyl sulfate (STS) followed by complete surgical excision respecting the calvarium. CASE PRESENTATION: A large right extracranial fronto-parietal venous malformation and scalloping of the underlying calvarium, attached to the pericranium, surgically excised after preoperative sclerotherapy with STS in a 14-month-old child. RESULTS: The patient had an uneventful postoperative course with complete resection of the lesion, satisfying cosmetic appearance and no complications. Histopathological examination confirmed a venous malformation. CONCLUSION: We demonstrated the workup and the rationale of the combined sclerotherapy followed by surgical resection of a large growing extracranial venous malformation. Preoperative direct contrast injection and sclerotherapy allowed to rule out significative extracranial to intracranial venous inflow and reduce blood loss for the surgical procedure, respectively. Complete removal of the malformation minimized the impact on future growth of the calvarium.

Point-of-Care Virtual Surgical Planning and 3D Printing in Oral and Cranio-Maxillofacial Surgery: A Narrative Review.

This paper provides an overview on the use of virtual surgical planning (VSP) and point-of-care 3D printing (POC 3DP) in oral and cranio-maxillofacial (CMF) surgery based on a literature review. The authors searched PubMed, Web of Science, and Embase to find papers published between January 2015 and February 2022 in English, which describe human applications of POC 3DP in CMF surgery, resulting in 63 articles being included. The main review findings were as follows: most used clinical applications were anatomical models and cutting guides; production took place in-house or as "in-house-outsourced" workflows; the surgeon alone was involved in POC 3DP in 36 papers; the use of free versus paid planning software was balanced (50.72% vs. 49.27%); average planning time was 4.44 h; overall operating time decreased and outcomes were favorable, though evidence-based studies were limited; and finally, the heterogenous cost reports made a comprehensive financial analysis difficult. Overall, the development of in-house 3D printed devices supports CMF surgery, and encouraging results indicate that the technology has matured considerably.