scholarly journals Decompressive craniectomy versus conservative treatment: limits and possibilities in malignant stroke

2020 ◽  
Vol 78 (6) ◽  
pp. 349-355
Author(s):  
Isaac Holanda Mendes MAIA ◽  
Thaissa Pinto de MELO ◽  
Fabrício Oliveira LIMA ◽  
João José de Freitas CARVALHO ◽  
Francisco José Arruda MONT’ALVERNE ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Surgical Treatment ◽  
Conservative Treatment ◽  
Decompressive Craniectomy ◽  
Statistical Significance ◽  
Northeastern Brazil ◽  
Malignant Infarction ◽  
To Receive ◽  
Surgical Group

ABSTRACT Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4‒5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.

Asymptomatic lipomas of the medullary conus: surgical treatment versus conservative management

2014 ◽  
Vol 14 (3) ◽  
pp. 245-254 ◽  
Author(s):  
Giuseppe Talamonti ◽  
Giuseppe D'Aliberti ◽  
Michele Nichelatti ◽  
Alberto Debernardi ◽  
Marco Picano ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Treatment Group ◽  
Conservative Treatment ◽  
Statistical Significance ◽  
Tethered Cord ◽  
Conus Medullaris ◽  
Tethered Cord Syndrome ◽  
Prophylactic Surgery ◽  
Long Term Results

Object The goal of this study was to compare long-term results of surgery with the outcomes of conservative treatment in patients with asymptomatic lipomas of the conus medullaris. Methods The parents of 56 consecutive children with a diagnosis of asymptomatic lipoma of the conus medullaris underwent detailed neurosurgical consultation. The pros and cons of both prophylactic surgery and conservative treatment were carefully presented. Both options were offered, and the parents were free to choose the preferred management. A total of 32 children underwent surgical treatment, and 24 were conservatively treated. Afterward, all patients entered the same protocol of serial neurological and urological follow-up at the Centro Spina Bifida. The mean follow-up periods were 9.7 years in the surgical treatment group and 10.4 years in the conservative treatment group. Results Permanent surgical morbidity was 3.1% (1 patient). During follow-up, tethered cord syndrome occurred in 9.7% of the surgically treated patients (3 of 32 patients) and in 29.1% of the conservatively managed children (7 of 24 patients). This difference did not result in statistical significance, but a clear trend in favor of surgery emerged. Young age at surgery and a cord/sac ratio < 50% appeared to be determining factors in the prevention of subsequent tethered cord syndrome. Conclusions The small size of this series does not provide enough statistical evidence that surgical treatment can really improve the natural history of asymptomatic lipomas of the conus medullaris. Nevertheless, surgery appears at least advisable since it reduces by 75% the odds of TCS (p = 0.067), which is quite close to statistical significance.

scholarly journals Effect of childhood overweight on distal metaphyseal radius fractures treated by closed reduction

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Yu Liu ◽  
Chunjie Liu ◽  
Dongmei Guo ◽  
Ning Wang ◽  
Ying Zhao ◽  
...  
Keyword(s):  
Risk Factors ◽  
Surgical Treatment ◽  
Conservative Treatment ◽  
Closed Reduction ◽  
Pediatric Population ◽  
Normal Weight ◽  
Medical Community ◽  
Overweight Children ◽  
Radius Fractures

Abstract Background The medical community has recognized overweight as an epidemic negatively affecting a large proportion of the pediatric population, but few studies have been performed to investigate the relationship between overweight and failure of conservative treatment for distal radius fractures (DRFs). This study was performed to investigate the effect of overweight on the outcome of conservative treatment for DRFs in children. Methods We performed a retrospective study of children with closed displaced distal metaphyseal radius fractures in our hospital from January 2015 to May 2020. Closed reduction was initially performed; if closed reduction failed, surgical treatment was performed. Patients were followed up regularly after treatment, and redisplacement was diagnosed on the basis of imaging findings. Potential risk factors for redisplacement were collected and analyzed. Results In total, 142 children were included in this study. The final reduction procedure failed in 21 patients, all of whom finally underwent surgical treatment. The incidences of failed final reduction and fair reduction were significantly higher in the overweight/obesity group than in the normal-weight group (P = 0.046 and P = 0.041, respectively). During follow-up, 32 (26.4%) patients developed redisplacement after closed reduction and cast immobilization. The three risk factors associated with the incidence of redisplacement were overweight/obesity [odds ratio (OR), 2.149; 95% confidence interval (CI), 1.320–3.498], an associated ulnar fracture (OR, 2.127; 95% CI, 1.169–3.870), and a three-point index of ≥ 0.40 (OR, 3.272; 95% CI, 1.975–5.421). Conclusions Overweight increases the risk of reduction failure and decreases the reduction effect. Overweight children were two times more likely to develop redisplacement than normal-weight children in the present study. Thus, overweight children may benefit from stricter clinical follow-up and perhaps a lower threshold for surgical intervention.

The treatment of spontaneous intracerebral hemorrhage

1989 ◽  
Vol 70 (5) ◽  
pp. 755-758 ◽  
Author(s):  
Seppo Juvela ◽  
Olli Heiskanen ◽  
Antti Poranen ◽  
Simo Valtonen ◽  
Timo Kuurne ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Conservative Treatment ◽  
Intracerebral Hematoma ◽  
Content Type ◽  
Conservative Group ◽  
Level Of Consciousness ◽  
A Prospective Study ◽  
To Receive ◽  
Surgical Group

✓ In a prospective study, 52 patients with a spontaneous supratentorial intracerebral hematoma (ICH) were randomly assigned to receive emergency surgery or conservative treatment within 48 hours after the bleed. Patients with a decreased level of consciousness and/or a severe neurological deficit were admitted to the study. The overall mortality rate at 6 months was 42%: 10 (38%) of the 26 patients in the conservative group and 12 (46%) of the 26 in the surgical group. Six (20%) of the 30 survivors at 6 months were able to conduct their activities of daily living independently: five (31%) of the 16 patients in the conservative group and one (7%) of the 14 in the operative group. These differences are not statistically significant. The mortality rate of semicomatose or stuporous patients (Glasgow Coma Scale score 7 to 10) was statistically significantly lower in the surgical group (none of the four patients) than in the conservative group (four of five patients) (p < 0.05); however, all surviving patients in this subgroup were severely disabled. The study suggests that surgical treatment of this category of patients with ICH does not offer any definite advantage over conservative treatment. In semicomatose or stuporous patients, surgery may improve the length of survival, but the quality of life remains poor.

scholarly journals Grisel’s Syndrome in Children: Two Case Reports and Systematic Review of the Literature

2020 ◽  
Vol 2020 ◽  
pp. 1-11
Author(s):  
Nicole Pini ◽  
Martina Ceccoli ◽  
Patrizia Bergonzini ◽  
Lorenzo Iughetti
Keyword(s):  
Systematic Review ◽  
Surgical Treatment ◽  
Conservative Treatment ◽  
Early Diagnosis ◽  
Head And Neck ◽  
Case Reports ◽  
Atlantoaxial Joint ◽  
Review Of The Literature ◽  
Grisel’S Syndrome

Background and Objective. Grisel’s syndrome is a rare syndrome characterized by nontraumatic rotatory subluxation of the atlantoaxial joint. It usually affects children and typically presents with torticollis after ear, nose, and throat (ENT) surgery or head and neck infections. In the pediatric literature, there is only a small amount of available data; moreover, no systematic review has been previously done with focus on the pediatric population. We report our experience of two cases, and we provide a systematic review on Grisel’s syndrome in children in order to offer a deeper insight about its clinical presentation, its current diagnosis, and principles of treatment. Case Reports and Review. We describe two boys of 9 and 8 years old, who developed atlantoaxial subluxation after adenoidectomy. Considering the early diagnosis, a conservative treatment was chosen, with no recurrence and no sequelae at follow-up. We identified 114 case reports, of which 90 describe children, for a total of 171 pediatric patients. Of the 154 cases in which cause was reported, 59.7% presented a head and neck infection and 35.7% had previous head and neck surgery. There is no sex prevalence (49.7% males versus 50.2% females). Mean delay in diagnosis is 33 days. Eight % of the patients had neurological impairment of the 165 cases which mentioned treatment, 96% underwent a conservative treatment, of whom the 8.8% recurred with the need of surgery. As a whole, 12% underwent surgery as a first- or second-line treatment. 3 6% of the patients whose follow-up was reported developed a sequela, minor limitation of neck movement being the most frequent. Conclusion. Grisel’s syndrome should be suspected in children with painful unresponsive torticollis following ENT procedures or head and neck inflammation. CT scan with 3D reconstruction is the gold standard for diagnosis, allowing the identification of the subluxation and the classification according to the Fielding–Hawkins grading system. Surgical treatment is indicated in case of high-grade instability or failure of conservative treatment. Review of the literature shows how early diagnosis based on clinical and radiological evaluation is crucial in order to avoid surgical treatment and neurologic sequelae.

Investigating the mechanisms of perioperative ischemic stroke in the Carotid Occlusion Surgery Study

2013 ◽  
Vol 119 (4) ◽  
pp. 988-995 ◽  
Author(s):  
Matthew R. Reynolds ◽  
Robert L. Grubb ◽  
William R. Clarke ◽  
William J. Powers ◽  
Gregory J. Zipfel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Bypass Graft ◽  
Graft Patency ◽  
Carotid Occlusion ◽  
Perioperative Stroke ◽  
Occlusion Time ◽  
Mca Occlusion ◽  
Operative Notes ◽  
Surgical Group

Object The Carotid Occlusion Surgery Study (COSS) was a large, prospective clinical trial that examined whether superficial temporal artery–middle cerebral artery (STA-MCA) bypass, in addition to best medical therapy, reduced the risk of ipsilateral ischemic stroke in patients with carotid artery occlusion and hemodynamic cerebral ischemia. Despite improved cerebral hemodynamics and excellent bypass graft patency rates, COSS failed to show a benefit for the surgical group with respect to ipsilateral stroke recurrence at 2 years after treatment. This was due to a lower than expected rate of recurrent ipsilateral stroke in the medically treated group and a high rate of perioperative ipsilateral strokes in the surgical group. Critics of the trial have cited surgeon inexperience and technical difficulties related to the performance of the bypass graft as a leading cause of failure of the trial. Methods The authors retrospectively identified all patients from the COSS with an ipsilateral, perioperative (< 30 days) ischemic stroke after STA-MCA cortical branch anastomosis. Study records, operative notes, stroke adjudication forms, and imaging studies were reviewed. Ischemic strokes were characterized as bypass graft related or non–bypass graft related based on clinical and radiographic findings. Results Fourteen of 93 surgically treated patients experienced an ipsilateral, perioperative ischemic stroke. Postoperatively, the mean oxygen extraction fraction (OEF) ratio between the symptomatic and asymptomatic cerebral hemisphere significantly improved in these patients (1.30 ± 0.18 preoperative vs 1.12 ± 0.11 postoperative; p = 0.02), but did not normalize. In this cohort, total MCA occlusion time during the anastomosis (54.3 ± 23.5 minutes) was no different from the MCA occlusion time in those surgical patients who did not have a perioperative stroke (45.4 ± 24.2 minutes, p = 0.2). Bypass graft patency rates in patients with a perioperative stroke were 92% at 30 days (11 of 12 patients with patency data) and 83% at last follow-up visit (10 of 12 patients with patency data). These patency rates were not significantly different from those achieved at 30 days (100%; 76 of 76 patients with patency data; p = 0.14) and at last follow-up (99%; 71 of 72 patients with patency data; p = 0.052) in patients without a perioperative stroke. Eighty-six percent (12 of 14 patients) of strokes were likely attributable to factors unrelated to the STA-MCA anastomosis. Only 21% of strokes (3 of 14 patients) were in the territory of the recipient vessel and likely related to technical performance of the anastomosis itself. One patient was thought to have dual stroke mechanisms. Conclusions Only a small minority of ipsilateral, perioperative ischemic strokes in the COSS could be attributed to technical problems of the bypass anastomosis. The majority of ischemic strokes could not be ascribed to this cause and were most likely due to patient hemodynamic fragility and the inability of patients to tolerate surgery.

scholarly journals Traumatic lesions of internal saphenous nerve and branches

2009 ◽  
Vol 67 (3b) ◽  
pp. 897-899
Author(s):  
Flávio Freinkel Rodrigues ◽  
Issac Skartz ◽  
Diego Cassol Dozza ◽  
Maurício Moscovici ◽  
Mendel Suchmacher
Keyword(s):  
Surgical Treatment ◽  
Surgical Technique ◽  
Conservative Treatment ◽  
Saphenous Nerve ◽  
Nerve Lesion ◽  
Vascular Disorder ◽  
Total Pain ◽  
Traumatic Lesions ◽  
Rare Lesion

OBJECTIVE: To show a rare lesion that sometimes simulates vascular disorder of the lower extremities. METHOD: Three patients were operated and the follow-up period was eight months, the surgical technique was neurotomy of the infrapatellar and descendent branches. RESULTS: In two cases there were almost total pain resolution, and in other case improvement only. CONCLUSION: Surgical treatment yields good results in this type of internal saphenous nerve lesion, and could be useful as an alternative to conservative treatment.

Abstract 2208: Sex Differences in Ischemic Stroke Mortality

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
James S McKinney ◽  
Yingzi Deng ◽  
Ugo Paolucci ◽  
John B Kostis
Keyword(s):  
Sex Differences ◽  
Ischemic Stroke ◽  
New Jersey ◽  
Cerebral Infarction ◽  
Cox Regression ◽  
Statistical Significance ◽  
Primary Diagnosis ◽  
Stroke Mortality ◽  
Hospital Deaths ◽  
To Receive

Introduction--- Stroke is becoming increasingly more prevalent in women. Prior studies of sex differences in stroke mortality have reported variable findings. Although crude stroke fatality is higher in women, this appears to be mediated by age and other baseline differences. We hypothesized that no differences existed between genders in in-hospital and longer term mortality, as well as in cause of death, after stroke admission. Methods--- We used the Myocardial Infarction Data Acquisition System (MIDAS) database, which includes demographic and clinical data on patients discharged with a primary diagnosis of cerebral infarction from all non-federal acute care hospitals in New Jersey between 1996 and 2007. Out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files. In-hospital, 1-year, and interval (discharge to 1-year) mortality were calculated. Total, cardiovascular disease (CVD), and non-CVD mortality were calculated. Multivariate logistic and Cox regression models were used to measure the effect of sex on in-hospital, 1-year, and interval mortality after adjusting for demographics, comorbidities, hospital type, year of admission, and treatment. Statistical significance was defined as a P -value ≤ 0.01. Results--- 134,441 patients (54.8% female) were admitted with a primary diagnosis of cerebral infarction during the study period. Women were on average 5.1 years older than men. Although the average Charlson Index was lower for women, hypertension, atrial fibrillation, congestive heart failure, dementia, and connective tissue disorders were all more common (p<0.0001). Women were significantly less likely to be treated with intravenous tPA than men (OR = 0.81; 95% CI = 0.73 to 0.89). In-hospital and 1-year mortality rates were 9.3% and 27.2% for women and 8.0% and 22.6% for men. After adjusting for available covariates, women had significantly higher in-hospital (OR = 1.04; 95% CI = 1.01 to 1.09) and 1-year (HR = 1.03; 95% CI = 1.01 to 1.05) mortality than men. Comparisons of in-hospital and interval CVD and non-CVD death rates are presented in the Figure . Conclusion--- Adjusted in-hospital and 1-year mortality was significantly higher for women than men hospitalized for a first ischemic stroke in New Jersey. This excess in morality appears to be driven by significant differences in non-CVD related in-hospital deaths in women. Women were also less likely to receive IV tPA then men after adjusting for available covariates.

FA02.08: LONG FOLLOW UP OF BARRETT’S TREATMENT, CLINICAL OR SURGICAL TREATMENT, WHICH ONE BRING BETTER RESULTS TO BARRETT’S EPITHELIUM?

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 5-5
Author(s):  
Sergio Szachnowicz ◽  
Andre Duarte ◽  
Edno Bianchi ◽  
Ary Nasi ◽  
Julio Mariano Rocha ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Barrett’S Esophagus ◽  
Barrett's Esophagus ◽  
Columnar Epithelium ◽  
Clinical Group ◽  
Multiple Biopsies ◽  
Group A ◽  
Group B ◽  
Surgical Group

Abstract Background Background: Barrett’ s esophagus is a complication of severe gastroesophageal reflux disease. The major concern aspect is its association to dysplasia and esophageal adenocarcinoma. Endoscopic surveillance of patients treated surgically or clinically allows early detection of cancer. Aim: Compare clinical and surgical treatment of Barrett's esophagus. Methods Methods: from January 1980 to December 2017, 565 patients with Barrett's esophagus were followed up at our service. 214 were submitted to Nissen fundoplication and 221 to clinical treatment with PPI. These 434 patients were submitted to a long follow up with routine endoscopic examination each 2 years with multiple biopsies. The statistical analysis was performed through Fisher's exact test and Propensity score regarding epidemiologic and epithelium data. Results Comparing the surgical group (Group A) and the clinical group (Group B), we could observe the development of 11 Adenocarcinoma, 3 in the group A e 8 in group B. Any grade of dysplasia was observed in 9 patients of the group B, and six of them developed adenocarcinoma. The clinical group showed a tendency to develop more adenocarcioma and dysplasia than the surgical group (P = 0.38) and statistically significant increase in the development of dysplasia (P = 0032). 16% of patients in Group A showed progression in Columnar epithelium length against 20% in Group B (ns). 23,4% of the patients in group A keep symptoms and use of PPI, and 28.7 in group B (ns). Conclusion In our series as in many recent data in international literature, the surgical treatment for GERd in patients with Barrett's esophagus seems to be a good option to keep the columnar epithelium without progression to dysplasia or adenocarcinoma, with good control of the symptoms and the length of the Barrett's esophagus. Disclosure All authors have declared no conflicts of interest.

Conservative versus surgical treatment of venous leg ulcers: 10-year follow up of a randomized, multicenter trial

2015 ◽  
Vol 30 (1_suppl) ◽  
pp. 35-41 ◽  
Author(s):  
WB van Gent ◽  
FS Catarinella ◽  
YL Lam ◽  
FHM Nieman ◽  
IM Toonder ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Compression Therapy ◽  
Multicenter Trial ◽  
Leg Ulcers ◽  
Conservative Group ◽  
Perforating Veins ◽  
Significant Difference ◽  
Disease Specific ◽  
Surgical Group

Introduction Leg ulcers have a large socio-economic impact. Treatment modalities are either conservative or surgical. Conservative treatment involves local treatment and compression therapy. Surgical treatment of venous ulcers is based on correcting venous hypertension, by treating incompetent superficial, deep, and perforating veins. A prospective randomized multicenter trial comparing surgical treatment (combined superficial and perforating vein surgery) with ambulatory compression therapy was conducted during 1998 and 2001. This paper presents the results of a 10-year follow-up period of this trial. Materials and methods All patients enrolled in the original prospective trial were approached and invited for additional examination and duplex ultrasound evaluation. Secondary, disease specific and generic quality-of-life (QoL) was assessed. Current ulcer state and recurrence during the follow-up period was assessed. Results After a mean of 97 months follow up, 80 (41%) out of 196 legs could be inspected. The incidence of “ulcer-free”, the main outcome, was significantly ( p = 0.007) higher in the surgical group (58.9%), compared to the conservative group (39.6%). Observed ulcer recurrence was 48.9% for the surgical group and 94.3% for the conservative group. The number of incompetent perforating veins appears to be a significant ( p < 0.001) risk factor for not being ulcer-free. Disease specific QoL showed no significant difference between the surgical and conservative groups. Conclusions The addition of surgical treatment in patients with venous ulceration leads to a significantly higher chance of being ulcer-free, than just ambulatory compression therapy. This effect persists after 10 years of follow up. The number of incompetent perforating veins has a significant effect on the ulcer-state and recurrence.

Assessment of computed tomography perfusion software in predicting spatial location and volume of infarct in acute ischemic stroke patients: a comparison of Sphere, Vitrea, and RAPID

2020 ◽  
pp. neurintsurg-2020-015966 ◽  
Author(s):  
Ryan A Rava ◽  
Kenneth V Snyder ◽  
Maxim Mokin ◽  
Muhammad Waqas ◽  
Xiaoliang Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Conservative Treatment ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Spatial Location ◽  
Endovascular Intervention ◽  
Vessel Occlusion

BackgroundCT perfusion (CTP) infarct and penumbra estimations determine the eligibility of patients with acute ischemic stroke (AIS) for endovascular intervention. This study aimed to determine volumetric and spatial agreement of predicted RAPID, Vitrea, and Sphere CTP infarct with follow-up fluid attenuation inversion recovery (FLAIR) MRI infarct.Methods108 consecutive patients with AIS and large vessel occlusion were included in the study between April 2019 and January 2020 . Patients were divided into two groups: endovascular intervention (n=58) and conservative treatment (n=50). Intervention patients were treated with mechanical thrombectomy and achieved successful reperfusion (Thrombolysis in Cerebral Infarction 2b/2 c/3) while patients in the conservative treatment group did not receive mechanical thrombectomy or intravenous thrombolysis. Intervention and conservative treatment patients were included to assess infarct and penumbra estimations, respectively. It was assumed that in all patients treated conservatively, penumbra converted to infarct. CTP infarct and penumbra volumes were segmented from RAPID, Vitrea, and Sphere to assess volumetric and spatial agreement with follow-up FLAIR MRI.ResultsMean infarct differences (95% CIs) between each CTP software and FLAIR MRI for each cohort were: intervention cohort: RAPID=9.0±7.7 mL, Sphere=−0.2±8.7 mL, Vitrea=−7.9±8.9 mL; conservative treatment cohort: RAPID=−31.9±21.6 mL, Sphere=−26.8±17.4 mL, Vitrea=−15.3±13.7 mL. Overlap and Dice coefficients for predicted infarct were (overlap, Dice): intervention cohort: RAPID=(0.57, 0.44), Sphere=(0.68, 0.60), Vitrea=(0.70, 0.60); conservative treatment cohort: RAPID=(0.71, 0.56), Sphere=(0.73, 0.60), Vitrea=(0.72, 0.64).ConclusionsSphere proved the most accurate in patients who had intervention infarct assessment as Vitrea and RAPID overestimated and underestimated infarct, respectively. Vitrea proved the most accurate in penumbra assessment for patients treated conservatively although all software overestimated penumbra.

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