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© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49). Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. Funding: National Institute for Health Research Global Health Research Group.

The H3K27M-mutant spinal cord gliomas are very aggressive with a dismal prognosis, very few cases have been reported in the thoracic spinal cord and conus medullaris, and it is extremely rare with morphological features of pilocytic astrocytoma.A 20-year-old man presented with thoracolumbar pain, progressive paraparesis, and urinary incontinence. Magnetic resonance imaging revealed an intramedullary solid-cystic lesion from D9 to conus medullaris. Subtotal resection was performed, restricted by the indistinct margins and the decline of the motor evoked potential during the surgery. Pathologic findings revealed a pilocytic astrocytoma with anaplastic features. However, a further assessment determined a diffuse midline glioma H3K27M-mutant, and adjuvant chemoradiotherapy was administered. After seven months of progression-free survival, the paraparesis worsened; at twelve months of follow-up, the patient developed paraplegia, and at 24 months the patient remains alive without any neurologic functions distal to the tumor and he is still under adjuvant treatment.The H3K27M-mutant spinal cord glioma is a very infrequent tumor with a wide variety of histological presentations even as indolent as pilocytic astrocytoma, which should be considered in spinal cord tumors, especially if there are clinical, histological, or radiological data that suggest aggressiveness. On the other hand, the fast progression led to the loss of complete neurological function distal to the tumor, in spinal tumors could explain a not so poor prognosis as it is in functionally and vital structures.

OBJECTIVEA considerable percentage of preterm infants with posthemorrhagic hydrocephalus initially managed with an Ommaya reservoir require a permanent CSF shunt. The objective of the study was to analyze possible risk factors associated with the need for converting an Ommaya reservoir to a permanent shunt.METHODSThe authors retrospectively reviewed the clinical records of premature infants weighing 1500 g or less with posthemorrhagic hydrocephalus (Papile grades III and IV) managed with an Ommaya reservoir at their institution between 2002 and 2017.RESULTSForty-six patients received an Ommaya reservoir. Five patients (10.9%) were excluded due to intraventricular infection during management with an Ommaya reservoir. Average gestational age and weight for the remaining 41 patients was 27 ± 1.8 weeks and 987 ± 209 grams, respectively. Thirty patients required a permanent shunt and 11 patients did not require a permanent shunt. The conversion rate from an Ommaya reservoir to a permanent shunt was 76.1%. Symptomatic persistent ductus arteriosus (PDA) was more frequent in the nonpermanent shunt group than in the shunt group (88.9% vs 50%, p = 0.04). The need for extraction of more than 10 ml/kg per day of CSF through the Ommaya reservoir was lower in the nonpermanent shunt group than in the shunt group (9.1% vs 51.7%, p = 0.015). CSF lactate was lower in the nonpermanent group than in the shunt group (mean 2.48 mg/dl vs 3.19 mg/dl; p = 0.004). A cutoff value of ≥ 2.8 mg/dl CSF lactate predicted the need for a permanent shunt with sensitivity and specificity of 82.4% and 80%, respectively. There were no significant differences in gestational age, sex, weight, Papile grade, ventricular index, or other biochemical markers. After the multivariate analysis, only CSF lactate ≥ 2.8 mg/dl was associated with a higher conversion rate to a permanent shunt.CONCLUSIONSThis study showed that a high level of CSF lactate, absence of symptomatic PDA, and a higher CSF extraction requirement were associated with a higher likelihood of implanting a permanent CSF shunt. The authors believe these findings should be considered in future studies.

Objective The aim of this study was to evaluate the rate of complications and the extent of resection (EOR) of nonfunctioning pituitary adenomas by endoscopic endonasal approach (EEA) in a 15-year learning curve. Methods A total of 100 patients operated by the same surgical team were divided chronologically into two, three, and four groups, comparing differences in EOR measured by a semiautomatic software (Smartbrush, Brainlab), rate of immediate postoperative complications, and the visual and hormonal status at 6 months. Results There were no significant differences over the years in rates of postoperative complications and in visual status at 6 months. A significant linear correlation between the EOR and the number of surgeries (rho = 0.259, p = 0.007) was found. The analysis was performed in three groups because of the remarkable differences among them; the EOR were: 87.2% (early group), 93.03% (intermediate group), and 95.1% (late group) (p = 0.019). Gross total resection was achieved in 30.3, 51.5, and 64%, respectively (p = 0.017); also, the rate of reoperation and the worsening of at least one new hormonal axis were worse in the early group. Consequently, the early group had a higher risk of incomplete resection compared with the late group (odds ratio: 4.2; 95% confidence interval: 1.5–11.7). The three groups were not different in demographic and volume tumor variables preoperatively. Conclusions The first 33 interventions were associated with a lower EOR, a high volume of residual tumor, a high reoperation rate, and a higher rate of hormonal dysfunction. We did not find differences in terms of postoperative complications and the visual status at 6-month follow-up.

Resumen Objetivo El pronostico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectomia descompresiva. ?Que resultados a corto y medio plazo se obtienen? ?Estan las familias satisfechas con la cirugia una vez el enfermo se encuentra en su domicilio? En el presente trabajo analizamos nuestra experiencia en esta materia en los ultimos 13 anos. Material y metodos Incluimos en nuestra revision a 21 pacientes intervenidos entre 2004 y 2017 siguiendo la via clinica de nuestro centro para el ictus. Se entrevisto a los familiares via telefonica. Se midio el resultado funcional al alta, 3 meses, un ano y actual con la escala modificada de Rankin (mRS). Resultados La edad demostro estar directamente relacionada con la mRS (r = 0,56; p = 0,035) y en el 37,5% se obtuvo un buen resultado (mRS ≤ 3). El 78,9% de los familiares entrevistados repetirian la decision quirurgica tomada. Conclusiones Aportamos un grupo de 21 pacientes intervenidos mediante craniectomia descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los

Background We review 2 previously published cases of epidural lipomatosis associated with syringomyelia. We also present the case of a 42-year-old woman with a medullary syrinx from C1 to T3, initially only with upper limb paresthesias that presented after 10 years of follow-up for left hemiparesis and paresthesias in the tongue. Chiari malformation and cerebral or spinal space-occupying lesions were ruled out, as were other causes of syrinx except the presence of epidural lipomatosis extending from T1 to T12. Case Description Right laminotomies were performed from T1 to T12, removing excessive epidural fat tissue. After surgery the symptoms remained stable. At discharge the patient progressively recovered from the hemiparesis, and in follow-up magnetic resonance imaging the resolution of the syrinx was confirmed. Conclusions This is the third case of a patient with a spinal syrinx and no other related causes except from spinal lipomatosis, although with only 3 cases it is not possible to completely state that lipomatosis caused the syrinx. Our case supports the trend established by the 2 previous cases. For treatment, initially patients should be managed conservatively, trying to correct the underlying etiologies of spinal lipomatosis. In case of failed conservative treatment, removal of adipose epidural excess in the most appropriate way is preferred.

Resumen Objetivos La cirugia de columna lumbar produce una lesion muscular durante su abordaje que podria empeorar los resultados funcionales postoperatorios a largo plazo. Este estudio pretende analizar la atrofia paraespinal postoperatoria asociada a dos tipos de intervenciones. Material y metodos Se recogieron historias clinicas y resonancias magneticas lumbares pre- y postoperatorias de un grupo de 41 pacientes, 20 se sometieron a laminectomia con fijacion lumbar por estenosis de canal (Grupo fijacion) y otro grupo de 21 se sometieron a una hemilaminectomia sin fijacion por enfermedad discal (Grupo no fijacion). En los que se analizo la atrofia muscular de manera cuantitativa. Resultados Se hallo una correlacion negativa entre la edad y la musculatura preoperatoria, siendo mayor en el grupo laminectomia con fijacion (rho = −0,64 p = 0,002). Observamos tambien una correlacion positiva entre la musculatura preoperatoria y la atrofia postoperatoria (rho = 0,32 p = 0,041). En el modelo de regresion lineal multivariado ajustado por la edad, sexo y tipo de intervencion, observamos que la prediccion de la atrofia postoperatoria fue del 31% (R2 = 0,31); a la laminectomia con fijacion se le atribuye una atrofia del 5,3% (IC95 1,4-9,5%, p = 0,017); a la musculatura preoperatoria > 70% se le atribuye una atrofia del 13,8% (IC95 5,5-22%, p = 0,002). La edad no se correlaciono con la atrofia postoperatoria. Conclusiones La atrofia muscular paraespinal que se produce despues de la cirugia lumbar es mayor si se realiza un abordaje mas amplio como la laminectomia completa con facetectomia bilateral y fijacion transpedicular. Una mayor musculatura previa independientemente de la edad, el sexo y el tipo de cirugia tambien predice una mayor atrofia postoperatoria.

© 2020 Palpan Flores, Vivancos Sanchez, Roda, Cerdán, Barrios, Utrilla, Royo and Gandía González., [Objective]: We evaluate the performance of three MRI methods to determine non-invasively tumor size, as overall survival (OS) and Progression Free Survival (PFS) predictors, in a cohort of wild type, IDH negative, glioblastoma patients. Investigated protocols included bidimensional (2D) diameter measurements, and three-dimensional (3D) estimations by the ellipsoid or semi-automatic segmentation methods. [Methods]: We investigated OS in a cohort of 44 patients diagnosed with wild type IDH glioblastoma (58.2 ± 11.4 years, 1.9/1 male/female) treated with neurosurgical resection followed by adjuvant chemo and radiotherapy. Pre-operative MRI images were evaluated to determine tumor mass area and volume, gadolinium enhancement volume, necrosis volume, and FLAIR-T2 hyper-intensity area and volume. We implemented then multivariate Cox statistical analysis to select optimal predictors for OS and PFS. [Results]: Median OS was 16 months (1–42 months), ranging from 9 ± 2.4 months in patients over 65 years, to 18 ± 1.6 months in younger ones. Patients with tumors carrying O6-methylguanin-DNA-methyltransferase (MGMT) methylation survived 30 ± 5.2 vs. 13 ± 2.5 months in non-methylated. Our study evidenced high and positive correlations among the results of the three methods to determine tumor size. FLAIR-T2 hyper-intensity areas (2D) and volumes (3D) were also similar as determined by the three methods. Cox proportional hazards analysis with the 2D and 3D methods indicated that OS was associated to age ≥ 65 years (HR 2.70, 2.94, and 3.16), MGMT methylation (HR 2.98, 3.07, and 2.90), and FLAIR-T2 ≥ 2,000 mm2 or ≥60 cm3 (HR 4.16, 3.93, and 3.72), respectively. Other variables including necrosis, tumor mass, necrosis/tumor ratio, and FLAIR/tumor ratio were not significantly correlated with OS. [Conclusion]: Our results reveal a high correlation among measurements of tumor size performed with the three methods. Pre-operative FLAIR-T2 hyperintensity area and volumes provided, independently of the measurement method, the optimal neuroimaging features predicting OS in primary glioblastoma patients, followed by age ≥ 65 years and MGMT methylation., This work was supported in part by grants PI 2017/00361 from Instituto de Salud Carlos III to JR, MG, and AP and by grant B2017/BMD3688 from the Community of Madrid to JR, MG, and SC.

Resumen Objetivo Los quistes intraneurales son lesiones benignas de contenido mucinoso que se ubican dentro del epineuro de algunos nervios perifericos, de etiopatogenia controvertida. La mayoria se localizan a nivel de los miembros inferiores. Cuando aparece en los miembros superiores, el nervio mas frecuentemente afectado es el cubital. De extraordinaria infrecuencia es el sindrome de atrapamiento del nervio supraescapular debido a la formacion de un quiste intraneural del mismo. Con este articulo, aportamos un nuevo caso y realizamos una revision de la literatura de los quistes intraneurales localizados en el nervio supraescapular. Metodos Presentamos el caso de una paciente de 49 anos con dolor en region lateral del hombro de varios meses de evolucion. Se realizo RM plexo braquial donde se objetivo una tumoracion de aproximadamente 2 × 1,5 cm, de aspecto quistico, en relacion al tronco superior del plexo braquial derecho. Resultados Fue intervenida bajo control neurofisiologico, mediante un abordaje supra-infraclavicular. La tumoracion quistica afectaba a la extension del nervio supraescapular. Tras localizar una zona en la superficie libre de fasciculo nervioso se procedio a la diseccion, vaciamiento del quiste con contenido gelatinoso xantocromico y reseccion parcial de la capsula. El examen anatomopatologico confirmo el diagnostico de quiste intraneural (ganglion). Conclusion El nervio supraescapular es un nervio mixto que procede del tronco superior. Proporciona las ramas motoras al musculo supraespinoso e infraespinoso, y puede derivar, resultado de la compresion, en una atrofia de los mismos. Es importante conocer esta entidad que, aun de extraordinaria infrecuencia, es uno de los diagnosticos diferenciales que deben ser tenidos en cuenta al estudiar un paciente con dolor irradiado al hombro, y su tratamiento correcto redunda muchas veces en la remision completa de la sintomatologia.

Background The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. Methods In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). Results Patient age was shown to be directly related to the mRS (r = 0.56; p = 0.035) and 37.5% achieved a good outcome (mRS≤3). 78.9% of the interviewed relatives would repeat the surgical decision. Conclusion We present a 21 patients group where the best outcome was achieved in patients ≤60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients.