Cisternal MgSO4 Not Beneficial For Clinical Vasospasm

Preventive effect of continuous cisternal irrigation with magnesium sulfate solution on angiographic cerebral vasospasms associated with aneurysmal subarachnoid hemorrhages: a randomized controlled trial.

Takuji Yamamoto MD, Kentaro Mori MD, Takanori Esaki MD, et al. (JNS)

In this single institution prospective randomized controlled study which was done in Japan, the investigators studied the efficacy of continuous direct infusion of MgSO4 solution into the intrathecal cistern in patients with an aneurysmal SAH after surgical clipping. This study included 70 consecutive patients presenting with SAH within 72 hours from ictus from April 2008 to March 2013. They had two groups, first one patients who received MgSO4 treatment protocol and the second control group of patients who did not receive MgSO4 treatment. They used transcranial Doppler (TCD) and cerebral angiography to evaluate the efficacy of intrathecal Mg infusion for preventing cerebral vasospasms (CV) and monitored both Mg2+ serum and Mg2+ CSF to assess the safety of this treatment. Also they used mRS after 3 months to assess the improvements in functional outcome. During clipping, the Liliequist membrane was opened to allow CSF circulation between the supratentorial and infratentorial compartments, and the cisternal drainage tube was placed into the basal cistern and a spinal drainage tube was also inserted. Continuous infusion of MgSO4 solution was performed at 20 ml/hr from day 4 until Day 14 through the cisternal to spinal drainage. A decline in consciousness and bradypnea possibly caused by the sedative effect of Mg were observed in Mg group. The TCD results indicated that velocity in MCA increased more in the control group. A delayed cerebral ischemia identified on CT or MRI scans was observed in 9 patients in the control group and in 5 patients in the Mg group. The clinical outcomes at the 3-month follow-up examination did not significantly differ in these outcomes. They concluded that continuous cisternal infusion with MgSO4 solution reduces the incidence of angiographic CV in patients with aneurysmal SAH, particularly of severe spasms on their angiographic CV scale. However this Mg treatment protocol did not reduce the incidence of delayed cerebral ischemia and did not improve clinical outcomes among the patients.

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Odontoid Screw Fixation May Produce Better Outcome than Posterior C1-2 Fixation

Comparison of Clinical Outcomes of Posterior C1-C2 Temporary Fixation without Fusion and C1-C2 Fusion for Fresh Odontoid Fractures

Guo Q, Deng Y, Wang J, Wang L, Lu X, Guo X, et al. (Neurosurgery)

In this retrospective case series, the authors compared patients with odontoid fractures undergoing posterior C1-C2 fixation using anterior odontoid screws to patients undergoing C1-C2 fixation using posterior instrumentation. In the 22 patients included in the odontoid screw group (deemed candidates for the technique and who underwent screw placement), 21 of them experienced fracture healing and motion preservation at the C1-C2 level. These 21 patients then were compared to 21 randomly selected patients who had undergone C1-C2 posterior fixation for odontoid fractures. The two groups were analyzed at the time of final follow up (varied between patients) using the visual analog scale score for neck pain and stiffness, Neck Disability Index, and 36-Item Short Form Health Survey and were analyzed for time to fracture healing. The odontoid screw group had significantly better results in all of these categories with fracture healing time being not statistically significantly different between the groups (about four and a half months on average). In patients who are candidates for odontoid screw fixation of C1-C2 with odontoid fractures and who heal well following surgery, this data suggests that these patients may have better outcomes than similar patients treated with C1-C2 fusion with posterior instrumentation.

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Toradol Safe for Postoperative Pain Management in Pediatric Population

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients

Richardson, Palmeri, Williams et al. (JNS)

Retrospective review of 2657 consecutive cases and 1593 patients at Children’s Hospital Colorado from 2006 to 2012. After exclusion criteria (recent hemorrhage or high risk of hemorrhage), 1451 procedures comprised the study sample. Procedures were stratified into 5 different categories (Type 1: Intradural craniotomy/craniectomy except Chiari I malformation, Type 2: Intradural catheter/endoscope placement, Type 3: Extradural craniotomy/craniectomy + Chiari I malformation, Type 4: Spinal procedure, Type 5: Minor procedure (e.g., EVD, intracranial pressure monitor). Exposure was considered if the patients received 1 dose of ketorolac within 72 hours of their neurosurgical procedure. Outcomes measured were clinically significant hemorrhage, radiographic evidence of hemorrhage, or renal/GI complications related to ketorolac. Ketorolac was administered in 65.8% of cases. 2 patients developed GI tract ulceration and 2 patients developed renal failure. These events were not felt by the authors to be specifically related to the ketorlac. 7 patients developed clinically significant (requiring reoperation) hematomas. 4 of the patients received ketorolac perioperatively while 3 did not, suggesting no statistically significant difference. The authors claim that there is no association between ketorolac use and clinically or radiographically significant hemorrhage.

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HRT May Increase Risk of SAH in the Presence of Unruptured Intracranial Aneurysms

Hormone replacement therapy and risk of subarachnoid hemorrhage in postmenopausal women

Adnam I. Quereshi, Ahemed A. Malik, Omar Saeed, et al. (JNS)

In this paper they analyzed 93,676 women between 50-79 years old. They studied the effect of hormone replacement therapy (HRT) on the risk of subarachnoid hemorrhage (SAH) through 12 years. Also they identified the risk associated with “estrogen only” and “estrogen and progesterone together” as HRT. Only 114 (0,1%) participants developed SAH during the follow up period. The absolute difference among women on active HRT (0.14%) compared to those without HRT use (0.11%) was 0,03%. When the analysis is unadjusted for age, systolic blood pressure, cigarette smoking, alcohol consumption, body mass index, race/ethnicity, diabetes and cardiovascular disease the risk of SAH were 60% more likely woman on active use of HRT after adjusting to be higher. Mainly the combination of cigarette smoking and oral contraceptive use resulted in a synergistic increase of the risk. There is no any difference between uses ”estrogen and progesterone”, both were associated with an increased risk of SAH. Presence of unruptured aneurysms, family history, or cardiovascular risk factors were identify as risk for SAH. Postmenopausal women with those conditions should be counseled against use HRT.

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ETV Acceptable Option for Hydrocephalus in Adults Except in NPH

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus: Patient Selection, Outcomes, and Complications.

Grand W, Leonardo J, Chamczuk AJ, et al. (Neurosurgery)

This is a single center, retrospective review of 250 patients over 14.5 years who received Endoscopic Third Ventriculostomy (ETV) for hydrocephalus. The patients were categorized into several groups that included the following: Aqueduct stenosis, intraventricular hemorrhage, communicating hydrocephalus (including normal pressure hydrocephalus, non-NPH, remote head trauma, hydrocephalus post craniotomy for posterior fossa tumor without residual tumor, SAH without ventricular hemorrhage), obstruction from tumor or cyst, VP shunt obstruction, miscellaneous cause (obstruction), and other. A successful ETV was defined as now further CSF diverting procedures and clinical improvement. The overall success rate of ETV for treating hydrocephalus was 72.8%. The groups that demonstrated the best success score were those treated for aqueductal stenosis (91% success), IVH (90%), hydrocephalus post craniotomy for posterior fossa tumor without residual tumor (85.7%), and obstruction from tumor or cyst (85.7%). The group with the worst success score was the communicating hydrocephalus with a successful ETV in 43.8% of the time. This lead the authors to conclude that ETV in adults is a reasonable alternative to VP shunt placement in certain causes of hydrocephalus; however, it is not a proper alternative in certain cases, specifically in cases of normal pressure hydrocephalus.

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1st Quadrennial Meeting Recap

Dear Colleagues,

We just completed our highly successful 1st Dandy Quadrennial Meeting in Dubai:

Awarding of the Dandy 2015 Medal

The Dandy Medal is the highest honor the society bestows. Prof. Ghaus Malik (USA) received the 2015 medal. (Pictured: Prof. Abdulrauf (USA), Dandy President, awarding the medal and official Dandy Leadership pin). Dandy Board members, Profs. Herrera (Argentina), Dolenc (Slovenia), Broggi (Italy) conducted the official ceremony.

Introducing the President and the Presidential Address

Prof. Abdulrauf was introduced by Dr. Aneela Darbar. Pictured in the background is a photograph of the President’s father (Capt. Abdulrauf), a decorated pilot, who has been a key mentor for our President.  The Presidential Address emphasized the integral issue of outcomes of patients undergoing neurosurgical procedures.

Special Session: Performing Under Pressure: The NASCAR  Experience

Trent Cherry, Head Pit Crew Coach, Team Penske, delivered an engaging presentation about challenges and team development in the car racing world. The panel discussion drew lessons for us in neurosurgery.

Special Session: Simulation in Neurosurgery: What We Can Learn From Fighter Pilots

Lt. Colonel Joe “Hooter” Feheley, United States Air Force, delivered an engaging presentation on the lessons learned by fighter pilots and the importance of simulation. The panel drew comparisons to training in Neurosurgery.

Families are welcome

Dandy Society Meetings are designed for members to bring their families to participate in the social program and in the special sessions of the scientific meeting. (Pictured: the daily lunch, which included family members)

The Leadership and Scientific Program Committee

At the official Gala Dinner honoring Prof. Malik. This gives me the opportunity to acknowledge and thank our leadership (Profs. Abdulrauf, Herrera, Dolenc, Gonzalez-Llanos, Xiao) as well as the Scientific Program Committee (Drs. Coppens, Vilasboas, Alfayate, Darbar, Nery, Sabbagh, Grasso, Andrei).
I would like to sincerely thank the Gulf and the Emirates Neurosurgical Societies, with special thanks to Dr. Mohamed Al-Olama, President of the Emirates Society, for his yeoman’s work in making this meeting a success.
This was a unique neurosurgical meeting that addressed the concept of complications in a very open manner, with special sessions that allowed for lessons from outside our specialty and welcomed neurosurgeons’ spouses and families to be fully involved. This was a game changer!

Miki Fujimura, M.D., Ph.D.
Annual Meeting Chairman
Dandy 2015 Fourth Annual Meeting  (1st Quadrennial Meeting)
Dubai, UAE