Factors influencing the recurrence rate of operated chronic subdural hematomas

In this study we are trying to establish a correlation between the surgical technique used for the treatment of chronic subdural hematomas and the risk of recurrence. Between 01.06.2008 and 31.05.2014, 123 patients with 138 chronic subdural hematomas (CSDH) were operated on and followed-up in our department. Among them, 16 hematomas (11,6%) recurred. Factors related to the patients (gender, age, location of the hematoma) are analyzed as possible predictors of recurrence. Several surgical techniques were used in the treatment of chronic subdural hematomas. Each of them is analyzed to find possibly connections with the recurrence risk of the size of the approach, the reposition of the bone flap, the suture of the dura and other aspects. There are obvious, statistically significant correlations between the risk of recurrence and some elements of the surgical technique employed

Giant hyperostosis after sphenoid ridge en plaque meningioma removal

Meningioma is in most cases a benign tumor of the central nervous system with two growth patterns: en masse and en plaque. Hyperostosis is associated in 13 – 49 % of the cases with en plaque meningioma. We describe the case of a 47 years old woman with meningotelial sphenoid ridge meningioma which was totally removed. At the first admission she presented with no neurological deficits, seizures and a mild right exophthalmos. This had an indolent growth. After 10 years, the patient was readmitted for headache, blurred vision and right exophthalmos. Skull X-rays and brain MRI revealed an important thickening of the right superior orbit wall and sphenoid ridge. She underwent a new surgery. There was no intradural tumor found. Instead, bones of the superior and lateral right orbit walls were very hiperostotic. A hole of 3/2 cm in the right superior orbital wall was drilled and the orbital cavity was decompressed. In the postoperative period, the symptoms were remitted and the exophthalmos reduced. We discuss the causes and management of hyperostosis associated with meningiomas

Topical vancomycine and bacterial culture from intervertebral herniated disc prevent postoperative osteodiscitis

Osteodiscitis represents a serious complication of lumbar disc herniation operations. The treatment of osteodiscitis is controversial and expensive to society. It extends over a period of several months from diagnosis. Reducing postoperative osteodiscitis by using simple measures may limit patient's suffering and reduce costs. The purpose of this study is to evaluate the early diagnosis of bacterial infections of the intervertebral disc by isolating germs located in the herniated disc fragment and topical Vancomycine powder application, along with the conventional anti-infective therapy. Medical files of patients who were operated on for lumbar disc herniations during 01.01.2013 - 30.06.2014 were reviewed. The diagnosis of lumbar disc herniation was established based on the clinical evaluation, confirmed by MRI results. The surgical intervention was performed by mini-open approach: fenestration and foraminotomy completed with removal of the herniated disc fragment and disc remnants from the intervertebral space. A group of 162 patients (group A) received conventional therapy for prevention of post-operative infections with 2 doses of cephalosporin. In the second group of 137 patients (group B), after the removal of the herniated disc fragments, 1g of Vancomycine powder was topically applied and the disc fragments were bacteriologically analyzed. They received the conventional treatment of preventing post-operative infections with cephalosprin - 2 doses. The two groups of patients were similar in terms of demographic characteristics: age, sex, operative level. Out of the 162 patients of group A, one patient developed postoperative osteodiscitis and was treated for 3 months with antibiotics. Regarding patients in group B, in four cases Staphylococcus was isolated from the disc fragments. Postoperative treatment for these patients with prolonged antibiotic therapy over the standard period avoided the developement of the clinical picture of osteodiscitis. Postoperative osteodiscitis requires prolonged antibiotherapy. By using simple measures, like topical Vancomycine powder application and early isolation of germs from the herniated intervertebral disc, followed by the immediate establishment of appropriate antibiotic treatment, this serious complication is avoided

Microcystic meningioma mimicking an arachnoid cyst

Microcystic meningioma is a particular morphopathological form of benign meningiomas, with different imaging characteristics compared to other forms of meningiomas. It is presented the case of an 80 year old woman with repeated head injuries, initially operated for a right fronto-temporo-parietal pericerebral fluid collection. After four years, the patient returned with headache, confusional status, somnolence, symptoms wich appeared after a new head injury. Cerebral CT scan revealed a hypodense lesion in the right sylvian fissure of 5.7/3.5 cm, without perilesional edema, which was interpreted as an arachnoid cyst. Intraoperative, a soft, gelatin-fibrous tumor mass was identified, partially adherent to the dura mater and the underlying cortex, which was completely resected. The morphopathological diagnosis was microcystic meningioma. It is discussed the imaging aspect of the presented case compared to the literature data regarding the microcystic meningiomas and the relationship between head traumas and the occurrence of meningiomas

PERIOPERATIVE ANTICOAGULANT TREATMENT IN BRAIN SURGERY

In clinical practice, neurosurgeons are often faced with problems raised by the anticoagulant therapy of patients with cerebral pathologies. They are routinely asked to decide between the risk of postoperative ICH and the benefit of therapeutic AC in high-risk situations and without strong guidelines. There are many controversial situations in which the neurosurgeon can be put in a dilemma regarding the best therapeutic attitude towards anticoagulation.   The first question related to the anticoagulant treatment that the neurosurgeon asks before a brain intervention is: how long before the operation should the chronic anticoagulant therapy be stopped, under safe conditions? Another problem that neurosurgeons often face is that of postoperative anticoagulant treatment. One of the questions they frequently ask themselves is: how quickly can the anticoagulant treatment be introduced/resumed after brain surgery?   In this presentation we will try to answer these important questions. For this, we will study patients with cerebral pathology who are on anticoagulation for various health issues (VTE, afib, hearth valves etc.). First of all, we have to assess the thrombosis risk for each patient. And we have:     Low risk patients Moderate risk patients   High risk patients   Very high-risk patients 1. VTE with target INR 2.0-3.0 unless:   § VTE in prior 3 months = high risk   §Associated with malignancy = moderate risk   2. Non-valvular AF with target INR 2.0-3.0 unless:   § Previous stroke or TIA = high risk   1. VTE provoked by malignancy   1. VTE in prior 6-12 weeks   2. Aortic caged ball/disc heart valves   3. AF with previous stroke / TIA   4. Valvular heart disease   5. Any indication with target INR 3.0-4.0   1. VTE in prior 6 weeks   2. Metallic mitral valves     In balance with the thrombotic risk, there is the postoperative haemorrhagic risk. In this matter, we must emphasize that any brain surgery is considered high bleeding risk intervention!   Regarding the pre-operative management of patients with anticoagulant treatment, we have some clear guidelines.   Therefore, for low-risk patients, we have to: • Stop VKA 5 days before surgery to allow INR to normalise; • Check INR 1 day prior (ideally) or the morning of the procedure (urgently); • If on DOAC’s stop 2 days before surgery.   N.B: Safe INR is <1,4 for brain surgery For moderate and high risk patients, we must: • Stop VKA 5 days before surgery to allow INR to normalise; • Start prophylactic dose of LMWH 3 days pre-operatively (start at 08.00h); • Check INR 1 day prior (ideally) or the morning of the procedure (urgently); • On day of procedure omit LMWH dose at 08.00h; • If on DOAC’s bridging with LMWH is not mandatory.   The use of LMWH between the time of stopping the VKA and the operation is called bridging therapy, and the goal is that the patient is not left completely non-anticoagulated.   For very high-risk patients, the attitude is: • VTE in prior 6 weeks: ideally avoid surgery. Consider use of temporary inferior vena cava (IVC) filter. Then manage as per high risk. • Metallic mitral valves. LMWH is not recommended in metallic valves; UFH may be preferable. Then manage as per high risk.   But what about anticoagulation after craniotomy? This is a more controversial issue than the previous and we should keep in mind that, in operated neurosurgical patients, the consequences of either haemorrhage or thromboembolism can be devastating. We have 2 indications of postoperative anticoagulation: - VTE prophylaxis; - resuming preoperative anticoagulation.   For the first situation, a study regarding VTE prophylaxis was published in 2021 (1) and its conclusion is that initiating anticoagulant prophylaxis with subcutaneous enoxaparin sodium 40 mg once per day within 72 h of surgery can be done safely while reducing the risk of developing lower extremity DVT. What about therapeutic doses of anticoagulants in operated patients? When can we start them? Few studies to date have attempted to determine the optimal time to resume anticoagulation after craniotomy. As a result, the decision of when to restart anticoagulation remains largely subjective and highly variable between surgeons.   A Brazilian study from 2020 (2) showed that: -    Postop. VTE was statistically associated with a delay in starting therapeutic AC of more than two days. -    ICH was not statistically associated with AC started after the 2nd postop. day, which may encourage the strategy of early AC treatment. -    The frequency of bleeding complication was statistically significant higher in patients treated with warfarin(13.8 % vs. 0% in NOAC group).   A very recent study published this year (3) has an interesting conclusion: therapeutic AC in postoperative craniotomy patients from postoperative days 2 to 10 did not result in any major complications.   Another recent study (4) draws the following conclusions: -    The risk of postoperative hemorrhage is most significant within the first 24 hours after intervention, and anticoagulation must be avoided during this time period. -    From postop day 2, the use of low doses of LMWH is recommended in patients at high risk of DVT. -    AC can be safely resumed starting with postop.   At the end of this presentation, we can draw some conclusions that could serve as future guidelines for postoperative anticoagulant treatment:   -    From postop day 2, low doses of LMWH can be used in patients at risk of DVT. -    In patients with high thrombotic risk LMWH in prophylactic dose is started 8-12 hours postoperatively. -    If low bleeding risk, VKA can be resumed in postoperative day 2 together with LMWH until desired INR is reached. -    Full anticoagulation can be safely restored 7 days postoperatively even in high bleeding risk patients. -    DOAC’s can be resumed 24 hr post-operatively at normal dose. If patient has high VTE risk consider prophylactic dose of LMWH on evening of surgery.     References Robert G. Briggs, Yueh-Hsin Lin, Nicholas B. Dadario, Isabella M. Young, Andrew K. Conner, Wenjai Xu, Onur Tanglay, Sihyong J. Kim, R. Dineth Fonseka, Phillip A. Bonney, Arpan R. Chakraborty, Cameron E. Nix, Lyke R. Flecher, Jacky T. Yeung, Charles Teo, Michael E. Sughrue. Optimal timing of post-operative enoxaparin after neurosurgery: A single institution experience. Clin Neurol Neurosurg 2021 Aug. 207: 106792. Jose Orlando de Melo Junior, Marcia Aparecida Lodi Campos Melo, Luiz Antonio da Silva Lavradas Junior, Plinio Gabriel Ferreira Lopes, Ingra Ianne Luiz Ornelas, Paula Lacerda de Barros, Paulo Jose da Mata Pereira, Paulo Niemeyer Filho. Therapeutic anticoagulation for venous thromboembolism after recent brain surgery: Evaluating the risk of intracranial haemorrhage. Clin Neurol Neurosurg. 2020 Oct 197: 106202. John M. Wilson, Kierany B. Shelvin, Sarah E. Lawhon, George A. Crabill, Ellery A. Hayden. Safety and timing of early therapeutic anticoagulation therapy after craniotomy. Surg Neurol Int. 2024; 15: 31. Vikram A. Mehta, Timothy Y. Wang, Eric W. Sankey, Elizabeth P. Howell, C. Rory Goodwin, Jerrold H. Levy, Allan H. Friedman. Restarting Therapeutic Anticoagulation After Elective Craniotomy for Patients with Chronic Atrial Fibrillation: A Review of the Literature. World Neurosurg. 2020 May 137: 130-136

Parasagittal meningiomas – literature review and a case report

Meningiomas are tumors that can develop anywhere along the neuraxis, but with increased concentration in some specific areas. Parasagittal meningiomas have the dural attachment on the external layer of the superior sagittal sinus (SSS) and invade the parasagittal angle displacing brain away from its normal position. Among meningiomas, the parasagittal location is the most common (22%). Taking into account their anatomic insertion along SSS, parasagittal meningiomas can have their dural attachment in the anterior, the middle or the posterior third of the SSS. Most frequently parasagittal meningiomas are located in the middle third of the superior sagittal sinus (between coronal suture and lambdoid suture). The clinical picture of parasagittal meningiomas depends on the tumor location along the SSS and so is the attitude towards ligation and reconstruction of the sinus. Controversial issues regarding surgical management of parasagittal meningiomas concerning leaving a tumor remnant that invades the SSS instead attempting total resection, or the attitude in the case of totally occluded segment of a sinus are summarized in this paper. The special care for the venous system is emphasized. The recurrence matter is also approached underlining the importance of adjuvant radiosurgery for the management of residual tumors. Results described in the main papers of the literature are reviewed. Conclusions are referring to the historical evolution regarding the surgical management of parasagittal meningiomas: aggressiveness of resection, sinus reconstruction, importance of adjuvant techniques: radiosurgery, endovascular surgery and to the importance of microsurgery and careful and meticulous planning of the approach in order to avoid interference with venous collaterals. A suggestive clinical case from the authors experience is presented

A rare case of multiple meningiomas with different histology

Meningiomas are generally benign tumors but sometimes they manifest tendency to progress towards malignancy. It is not yet clear if anaplastic meningiomas have an innate malignancy characteristic, or an initially beginning histological appearance that degenerates malignantly in time. According to literature data, the risk of a benign meningioma to progress towards malignant phenotype is about 0.16-2%, such malignant transformation occurring after a variable period of time (2-16 years). A still unanswered question is how many of the malignant meningiomas present this appearance as an innate feature and how many of them originate from benign meningiomas. Multiple meningiomas are defined as the presence of two or more distinct meningiomas. They occur in 6-10% of all patients that present meningiomas. Multiple meningiomas with a distinct histological appearance are rarely discovered. They support the theory of meningiomas that develop independently in the same patient. Different histology of multiple meningiomas is found in less than a third of the patients who suffer from this pathology. We are presenting the case of a patient with multiple meningiomas with distinct histology, one being benign and the other malignant. In connection with this case we are raising a question of therapeutic management in patients diagnosed with malignant meningiomas, namely if other possible small/ benign meningiomas should be also entirely resected

RISKS AND OUTCOME IN PATIENTS WITH ACUTE SUBDURAL HEMATOMAS UNDER ANTICOAGULANT TREATMENT WITH VITAMIN K ANTAGONISTS

In this study we tried to determine the existence of a link between the INR at admission of patients with acute subdural hematomas and their subsequent evolution, the risk of requiring decompressive surgery and the mortality rate. We thus formulate the following questions to be researched, in correlation with the objectives of the study: • Does anticoagulant treatment with VKA increase the risk of needing surgery in patients with acute SDH? • Are acute subdural hematomas larger in patients anticoagulated with VKA? • Is mortality in patients with acute subdural hematomas higher in the case of association with anticoagulant treatment with VKA?   Material and Methods Retrospective study.   Inclusion criteria: Patients discharged from the “Neurosurgery” Department of the “Sf. Pantelimon” from Bucharest with the main diagnosis at discharge “Traumatic subdural hemorrhage”, identified in the ICD-10 system with code S06.5.   Exclusion criteria: -    Patients with other post-traumatic intracerebral injuries (lacerations, cerebral contusions, epidural hematomas) that required surgical treatment. -    Patients with severe polytrauma. -    Patients with severe thrombocytopenia (< 50000 platelets / mmc). -    Patients with increased INR due to other causes (hepatopathies, alcoholism, etc.). -    Patients with chronic subdural hematomas with rebleeding.   Thus, in the interval 01.01.2020 – 31.12.2023 (4 years), after applying the inclusion and exclusion criteria, we obtained a group of 294 patients who had an acute subdural hematoma as their main or secondary diagnosis. Of these, 130, representing 44.2%, underwent a surgical intervention to evacuate the hematoma through craniotomy. Mortality for the entire group was 36.7% (108 deaths). In the case of operated patients, the postoperative mortality was 47.7% (62 deaths out of 130 patients), and in that of conservatively treated patients the mortality from various causes was 28.1% (46 cases out of 164).   Having this general information, we began the analysis of the situation of patients who, at the time of the trauma, were under anticoagulant treatment with vitamin K antagonists (Thrombostop or Sintrom). We found 42 such patients, most of them on anticoagulant therapy for atrial fibrillation, but there were also a few cases of valve prostheses. Of these patients, 20 (47.6%) underwent decompression surgery by evacuation of acute HSD. By comparison, 110 patients without anticoagulant treatment out of 252 underwent surgery (43.6%). Only a small difference is observed, at the limit of statistical significance, between the 2 groups, which made us analyze this aspect in more detail. First, we observed the INR in all 42 patients under VKA treatment and found a surprising fact: only 20 patients (47.6%) had an altered INR. Of these, 11 (55%) were operated and 9 (45%) treated conservatively. If we compare these numbers with those of all patients with a normal INR (274 of which 119 were operated on, i.e. 43.4%) we will find a significant difference between the 2 groups, a fact that confirms the assumption that patients with a modified INR and HSD acute have a higher risk of requiring surgery to evacuate the hematoma. Going even further with this analysis, we tracked the indication for surgery in patients on anticoagulant treatment by hematoma size and Glasgow score. Thus, we found that 25 of the 42 (59.5%) anticoagulated patients had an indication for surgical treatment. If we look only at patients with altered INR (20), we find that 16 of them (80%) had a surgical indication. Where does this difference between the surgical indication and the actual number of operations come from? The explanation is simple: 5 patients in the anticoagulant group, all with modified INR (average INR in this group 3.33) and aged over 70 years, were in such a serious condition that they died before they could be operated on, either in the EU or in the ICU, during attempts to stabilize the coagulant balance.   At this point in the presentation, we can answer the first question of this study: “Does anticoagulant treatment with VKA increase the risk of requiring surgery in patients with acute SDH?” The answer is yes, provided the treatment is properly administered and changes the INR. If we nuance things a little, we will notice that there are 13 patients with an INR below 3 and 7 with an INR above 3. In the first group, the surgical indication was present in 10 out of 13 patients (76.9%) and in the second in 6 from 7 patients (85.7%), so we can conclude that the higher the INR, the more the subdural hematoma risks to become a surgical lesion.   We also analyzed the average thickness of the hematoma in the patients in the group receiving anticoagulant treatment and found a significant difference between the group of patients with normal INR (0.9 cm) and that of patients with modified INR (1.55 cm). And within this group we have a difference between patients with an INR below 3 (1.36 cm) and those with an INR above 3 (2.04 cm). Therefore, the answer to the question: “Are acute subdural hematomas larger in patients anticoagulated with VKA?”, is clearly affirmative.   Next, we tried to highlight the causal relationship between the INR value at the time of trauma and the mortality rate. Thus, in patients with normal INR, the overall mortality was 33.9% (93 deaths out of 274 cases) and the postoperative mortality was 45.4% (54 deaths out of 119 cases). In those with modified INR, it was 70% (14 deaths out of 20 cases), respectively 63.6% (7 deaths out of 11 cases). Paradoxically, in patients with altered INR operated the mortality is lower than in non-operated ones (7 deaths out of 9 cases i.e. 77.7%), which would suggest that a more aggressive surgical approach could be beneficial in patients with acute subdural hematomas and anticoagulant treatment. Of the 7 patients with INR above 3, the only one who survived was an operated patient. Therefore, the answer to question 3: Is mortality in patients with acute subdural hematomas higher in the case of association with VKA treatment with modified INR? is also affirmative   Conclusions • Properly administered vitamin K anticoagulant treatment resulting in elevated INR increases the risk of patients with acute subdural hematomas, who will be more likely to require decompressive surgery, have larger hematomas, and have a higher mortality rate, regardless of therapeutic conduct. • In these patients, early surgical intervention, even if the INR has not been completely brought under control, is a therapeutic approach associated with a lower mortality than conservative treatment until the normalization of the INR