Role of Craniectomy Versus Craniotomy via the Retrosigmoid Approach in Decreasing the Incidence of Postoperative Headache

Background: Postoperative headache is a major complaint after RS surgery. PH affected the patient’s quality of life. The role of craniotomy in the prevention of such headaches. We aimed to evaluate the role of craniectomy versus craniotomy via the retrosigmoid approach in reducing the incidence of postoperative headaches. Materials and methods: Patients who underwent surgery between January 2012 and December 2018 were retrospectively assessed and were classified into the craniectomy and craniotomy groups. Clinical data, such as those on age, sex, type of surgery, surgical repair technique, development of infection, postoperative cerebrospinal fluid leak, postoperative meningitis, size of the bone flap, and wound infection, were collected. The severity of headache in all patients was clinically assessed using the Catalano grading system. Results: Overall, 95 patients underwent microsurgery via the retrosigmoid approach. Of these, 48 were men and 47 were women. In total, 34 patients underwent craniectomy, and 61 patients underwent craniotomy. On discharge, postoperative headache was observed in 47% (16/34) and 21% (13/61) of patients who underwent craniectomy and craniotomy, respectively ( P =.01). The incidence of headache decreased at follow-up. At 12 months after surgery, 15% of patients in the craniectomy group (5/34) and 2% of patients in the craniotomy group (2/61) experienced headache ( P =.01). Of the 61 patients in the craniotomy group, 2 (2%) had less severe headache at 12 months of follow-up. Conclusion: The severity of headache after surgery and upon discharge significantly decreased in patients who underwent craniotomy than in those who underwent craniectomy.

Evaluation of Intraventricular/Intrathecal Antimicrobial Therapy in the Treatment of Nosocomial Meningitis Caused by Multidrug-Resistant Gram-Negative Bacteria after Central Nervous System Surgery

Introduction. Postoperative meningitis (POM) is an infection with high mortality and morbidity following central nervous system surgery due to trauma or tumor. Intrathecal/intraventricular (IT/IVT) antibiotic administrations have been considered as the last treatment options for multidrug-resistance (MDR) Gram-negative bacteria that do not respond to intravenous (IV) regimens. IT/IVT can bypass the blood-brain barrier, obtain a more effective antibiotic concentration in CSF, and reduce systemic side effects. We aimed to determine the characteristics of postoperative patients who were diagnosed with MDR POM during follow-up in our intensive care unit (ICU). Material and Methods. In this study, POM patients who were followed up in ICU after the central nervous system intervention between January 2016 and December 2019 and whose MDR Gram-negative bacteria were isolated from CSF were evaluated. As soon as the patients were diagnosed with POM, a catheter was inserted and treatment was started. Results. Microbiological eradication was achieved in 3 ± 0.8 days with 30 mg/day amikacin treatment in POM due to K. pneumoniae and 3.7 ± 1.95 days with colistin sodium 10 mg/day treatment in POM due to A. baumannii via IT/IVT catheter. IT/IVT treatment was utilized for a median of 10 days and continued until the defined cure criteria were achieved. While cure was achieved in 6 of 14 POM cases, 8 of them were exitus. Discussion and Conclusion. To avoid the severe consequences of postoperative meningitis, acting fast and adding IT/IVT methods to parenteral administration routes by considering the distribution of MDR microorganisms within the hospital while planning effective treatment will increase the clinical success.

Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review

Objective This study was aimed to study the current use of intraoperative indocyanine green (ICG) angiography during skull base reconstruction and understand its efficacy in predicting postoperative magnetic resonance imaging (MRI) enhancement and flap. Study Design The Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar databases were searched from the date of inception until August 2020 for studies of ICG flap perfusion assessment during skull base reconstruction. The primary outcome of interest was the development of cerebrospinal fluid (CSF) leak after skull base reconstruction. Secondary outcomes of interest included postoperative meningitis, flap MRI enhancement, flap necrosis, flap perfusion measurements, and total complications. Results Search results yielded 189 studies, from which seven studies with a total of 104 patients were included in the final analysis. There were 44 nasoseptal flaps (NSF), two lateral nasal wall flaps (LNWF), 14 pericranial flaps (PCF), and 44 microvascular free flaps. The rates of CSF leak and postoperative MRI enhancement were 11 and 94%, respectively. There was one case of postoperative meningitis. Pooled analysis of the available data showed that intraoperative ICG flap perfusion was associated with flap enhancement on postoperative MRI (p = 0.008) and CSF leak (p = 0.315) by Fisher's exact test. Conclusion The available literature suggests intraoperative ICG enhancement is associated with postoperative MRI enhancement. Given the small sample sizes in the literature and the rarity of complications associated with skull base reconstruction, intraoperative ICG enhancement has not been predictive of flap necrosis or postoperative complications such as CSF leak or meningitis. Level of Evidence This study presents level 3 evidence as a systematic review of case studies, case reports, and retrospective and prospective trials with no blinding, controls, and inconsistently applied reference standards.

Decompressive Craniectomy in Traumatic Brain Injuries. Indications and Limits

Background: Decompressive craniectomy is a surgical technique proposed in the treatment of intracranial hypertension refractory to medical treatment and engaging the vital prognosis of patients. Materials and methods: We conducted a retrospective study about 41 cases of decompressive flap in the neurosurgery department of CHU ibn Rochd of Casablanca between 2015 and 2018. Aim: This study aims to discuss the management of intractable ICH in adults, focusing on the role of DC in patients with traumatic brain and identify the different indications, contraindications and complications. Results: The results show a clear male predominance with an average age of 40 years. The initial GCS >7 was in 63%, and <7 in 36% of cases, anisocoria was present in 65%. The most frequent indication for craniectomy is a neurological worsening. The type of craniectomy performed in the majority of cases is a hemi craniectomy in 92% of cases. Concerning the prognosis, we observed 32% of deaths and 68% of survivors of which 39% of patients without sequelae GOS 5 and 32% with a moderate disability GOS 4. The moderate disability GOS 3 was found in 21% and one case in vegetative state GOS 2. Regarding immediate complications after craniectomy: 33% of patients presented convulsions, 12% a new homolateral hematoma, 49% a nosocomial pneumopathy and 10% a postoperative meningitis. Conclusion: Decisions to recommend DC must always be made not only in the context of its clinical indications but also after consideration of an individual patient's preferences and quality of life expectations.

Phenotype, molecular characterisation and risk factors for postoperative meningitis caused by ESBL-producing-Enterobacteriaceae: a six years multi-Centre comparative cohort study

Background To determine the phenotype, molecular characterisation and risk factors of postoperative meningitis induced by Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (EPE) in China. Methods We performed a multi-centre comparative cohort study of postoperative meningitis patients infected with Enterobacteriaceae in 4 neurosurgical centres in China from January 2014 to December 2019. Phenotype and molecular characteristics of the isolates were reviewed and tested, and independent risk factors of the EPE meningitis were evaluated by binary logistic regression. Results In total, 220 Enterobacteriaceae include 78 EPE were available in this study. 85.6% (67/78) ESBL-related genes were tested, and blaSHV (14.9%) and blaSHV + blaTEM + blaCTX-M-9 (20.9%) were found to be the most frequent mono and combined ESBL-related genes harboured by Enterobacteriaceae. On binary logistic analysis, craniotomy (OR. 2.583, 95% C.I. 1.274–5.235, P = 0.008) and malignancy (OR. 2.406, 95% C.I. 1.299–4.456, P = 0.005) were the associated independent risk factors to meningitis induced by EPE. Conclusions To the best of our knowledge, this is the largest series focusing on risk factors of EPE meningitis which has been conducted in China. Craniotomy and malignancy were independent risk factors for EPE meningitis. The risk factors identified may be further utilized in clinical practice and research to avoid and reduce the mortality in future.

FORM24 electrode array and perioperative cerebrospinal fluid leakage in cochlear implant recipients with cochleovestibular malformations

ABSTRACT BACKGROUND: Cochlear implant (CI) recipients with a cochleovestibular malformation (CVM) are at a higher risk of experiencing an intra-operative cerebrospinal fluid (CSF) gusher and, therefore are at greater risk of developing postoperative meningitis than are CI recipients with normal cochlear anatomy. To control CSF gushers, the FORM electrode array was developed. OBJECTIVES: To assess the ability of the FORM24 electrode array in managing intraoperative CSF gushers and preventing postoperative CSF leakage in a population of CI recipients. DESIGN: Retrospective. SETTING: Tertiary health care center. PATIENTS AND METHODS: All CIs in which a FORM24 was used between January 2014 and March 2018 were reviewed for demographic and safety results. MAIN OUTCOME MEASURES: Safety results were assessed as the intraoperative or postoperative presence of an episode of CSF leakage or meningitis. SAMPLE SIZE: 177 CI recipients. RESULTS: Thirty-six (20.3%) had a CVM and 141 had normal anatomy (79.7%). Of the 36 participants with a CVM, 20 (55.6%) experienced an intraoperative CSF gusher, all of which were resolved. No cases of postoperative leakage or meningitis were recorded after a mean follow-up time of 36 months. CONCLUSION: The FORM24 array is able to help surgeons stop intraoperative CSF gushers and prevent postoperative CSF leakage and meningitis in CI recipients with a CVM. LIMITATIONS: Further studies are needed. CONFLICT OF INTEREST: None.

Is a Single-Dose, Single-Agent Perioperative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 10-Year Review of 422 Cases

Objectives Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the safety of a single-agent, single-dose protocol. Design, Setting, and Participants A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies. Main Outcome Measures Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery. Results Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33). Conclusion For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.

Dynamic curve analysis of indicators related to lumbar cistern drainage for postoperative meningitis

Background Lumbar cisterna drainage (LCD) is widely used in neurosurgery as an effective treatment for postoperative meningitis, vasospasm of subarachnoid hemorrhage and ventricular system hemorrhage, and for reducing intracranial pressure in patients with severe craniocerebral trauma. The purpose of this work was two-fold: to analyze the dynamic curve of cerebrospinal fluid (CSF) related indices in cases of postoperative meningitis after selective craniotomy and to provide reference data for the clinical treatment with LCD. Methods We conducted a retrospective study of LCD placement in patients who underwent either supratentorial craniotomy (n=23) or subtentorial craniotomy (m=28). Primary outcomes measured included pre-intervention and post-intervention dynamic changes of body temperature, and CSF biochemical parameters (white blood cell (WBC) count, polykaryocyte percentage, protein, glucose and chloride) over the course of 13 days of catheter placement. We also assessed the bivariate correlation between WBC count changes, polykaryocyte percentage, body temperature and daily CSF drainage volume. Finally, we analyzed the effect of average daily drainage volume, antibiotic choice, and surgical site on the WBC count change curves. Results After LCD, a trend of increased WBC count was observed on the first day of drainage, followed by an overall decrease in WBC count. There was a statistically significant ( P<0.05 ) difference between the WBC count before drainage and the WBC count on the fourth day of drainage. Polykaryocyte percentage decreased initially and then increased progressively each day after drainage. There was a negative correlation between the change curve of the WBC count and the curve of daily drainage volume (r = -0.56). When the daily drainage volume was 250-300 ml/d, the change curve pattern of the WBC count was consistent with the overall trend of the WBC count, and there was no significant difference in the curve of the WBC count between different surgical sites ( P > 0.05 ). Conclusions LCD is an effective method for the treatment of postoperative meningitis. The WBC count can decrease significantly by the fourth day after drainage, and placement of the LCD for six to seven days is ideal. An average drainage volume of 250-300 ml/d is safe and effective.