Neurosurgery
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Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery. ⋯ Our study found a significant reduction in SSI rates after introduction of topical vancomycin. Thus, this simple intervention should be considered in all open craniotomy patients as both infection prophylaxis and a potential cost saving intervention.
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Cerebral bypass has been an important tool in the treatment of complex intracranial aneurysms. The recent advent of flow-diverting stents (FDS) has expanded the capacity for endovascular arterial reconstruction. ⋯ After the introduction of FDS, cerebral bypass was performed in a lower proportion of patients with aneurysms. Patients selected for bypass in the flow-diverter era had worse preoperative modified Rankin Scale scores indicating a greater complexity of the patients. Cerebral bypass in well-selected patients and revascularization remains an important technique in vascular neurosurgery. It is also useful as a rescue technique after failed FDS treatment of aneurysms.
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Cases of post carotid endarterectomy (CEA) Horner's syndrome have been reported, with symptoms attributed to manipulation of the sympathetic plexus situated along the carotid artery; however, these patients presented with the typical constricted pupil. We report the first 3 cases to our knowledge of mydriasis following CEA. ⋯ We suggest that these cases are secondary to an ischemic phenomenon, specifically to parasympathetic structures such as the ciliary ganglion and/or oculomotor nerve, resulting in autonomic dysfunction manifested by pupillary dilation. A similar finding of mydriasis occurring subsequent to other carotid pathology has been reported, with ischemia to parasympathetic structures also proposed as the underlying etiology. Although pupillary dilation often represents a worrisome neurosurgical sign indicating herniation, it should be recognized that after CEA this finding may be a transient, benign occurrence.
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Biophysical modeling of glioma is gaining more interest for clinical practice. The most popular model describes aggressivity of tumor cells by two parameters: net proliferation rate (ρ) and propensity to migrate (D). The ratio ρ/D, which can be estimated from a single preoperative magnetic resonance imaging (MRI), characterizes tumor invasiveness profile (high ρ/D: nodular; low ρ/D: diffuse). A recent study reported, from a large series of glioblastoma multiforme (GBM) patients, that gross total resection (GTR) would improve survival only in patients with nodular tumors. ⋯ Whatever the degree of tumor invasiveness, as estimated from MRI-driven biophysical modeling, GTR improves survival of GBM patients, compared to PR or BST. This conflicting result should motivate further studies.
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Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern. ⋯ The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.