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1.
Endoscopic Surgery Versus Stereotactic Aspiration in Spontaneous Intracerebral Hemorrhage Treatment: A Systematic Review and Meta-analysis
Yang, L., Yang, M., He, M., Zhou, X., Zhou, Z.
World neurosurgery. 2024
Abstract
OBJECTIVE To comprehensively compare the safety and efficacy of endoscopic surgery (ES) and stereotactic aspiration (SA) in patients with spontaneous intracerebral hemorrhage (sICH). METHODS We searched Web of Science, PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to July 31, 2023. Studies comparing ES and SA for sICH treatment were also included. Outcome measures included primary outcomes (mortality and good functional outcome (GFO)) and secondary outcomes (evacuation rate, residual hematoma, perihematomal edema (PHE), operation time, volume of intraoperative blood loss, hospital stay duration, intensive care unit (ICU) stay duration, hospital cost, complications, and reoperation). Subgroup analyses assessed the influence of age, hematoma volume, Glasgow Coma Scale (GCS) score, and time to surgery on the outcomes. RESULTS Nine studies (one randomized controlled trial and eight observational studies) with 2105 patients (705 and 1400 in the ES and SA groups, respectively) were included in this meta-analysis. The final analysis indicated that compared with SA, ES was associated with enhanced GFO and a higher evacuation rate 1 d post-surgery along with reduced mortality and residual hematoma. Conversely, ES did not confer benefits in terms of perihematomal edema, operation time, intraoperative blood loss volume, or hospital stay duration compared with SA. Subgroup analysis highlighted the significant influences of age and hematoma volume on mortality, whereas hematoma volume and GCS score affected GFO. CONCLUSIONS ES is a safe and effective approach for sICH treatment, leading to improved patient prognosis and quality of life compared to SA.
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2.
Minimally Invasive Surgery With Thrombolysis for Intracerebral Hemorrhage Evacuation: Bayesian Re-analysis of a Randomized Controlled Trial
Bako, A. T., Potter, T., Pan, A. P., Tannous, J., Britz, G., Ziai, W. C., Awad, I., Hanley, D., Vahidy, F. S.
Neurology. 2023
Abstract
BACKGROUND AND OBJECTIVES Bayesian analysis of randomized controlled trials (RCTs) can extend the value of trial data beyond interpretations based on conventional p-value-based binary cutoffs. We conducted an exploratory post-hoc Bayesian re-analysis of the minimally invasive surgery with thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE-3) trial and derived probabilities of potential intervention effect on functional and survival outcomes. METHODS MISTIE-3 was a multicenter phase-3 RCT designed to evaluate the efficacy and safety of the MISTIE intervention. 506 adults (≥18 years) with spontaneous, non-traumatic, supratentorial ICH of ≥30mL were randomized to receive either the MISTIE intervention (n=255) or standard medical care (n=251). We provide Bayesian-derived estimates of the effect of the MISTIE intervention on achieving a good 365-day Modified Rankin Scale score (mRS score:0-3) as relative risk (RR) and absolute risk difference (ARD), and the probabilities that these treatment effects are greater than pre-specified thresholds. We used two sets of prior distributions: 1) reference priors, including minimally informative, enthusiastic, and skeptical priors; and 2) Data-derived prior distribution, using a hierarchical random-effects model. We additionally evaluated the potential effects of the MISTIE intervention on 180-day and 30-day mRS and 365, 180, and 30-day mortality using data-derived priors. RESULTS The Bayesian-derived probability that MISTIE intervention has any beneficial effect (RR>1) on achieving a good 365-day mRS score was 70% using minimally informative prior, 87% with enthusiastic prior; 68% with skeptical prior; and 73% with data-derived prior. However, these probabilities were ≤ 55% for RR>1.10, and 0% for RR>1.52 across a range of priors. The probabilities of achieving RR>1 for 180 and 30-day mRS scores are 65% and 80% respectively. Furthermore, the probabilities of achieving RR<1 for 365, 180, and 30-day mortality are 93%, 98%, and 99%, respectively. CONCLUSIONS Our exploratory analyses indicate that across a range of priors, the Bayesian-derived probability of MISTIE intervention having any beneficial effect on 365-day mRS for ICH patients is between 68% to 87%. These analyses do not change the frequentist-based interpretation of the trial. However, unlike the frequentist p-values, which indirectly evaluate treatment effects and only provide an arbitrary binary cut-off (such as 0.05), the Bayesian framework directly estimates probabilities of potential treatment effects. TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01827046 CLASSIFICATION OF EVIDENCE This study provides Class II evidence that minimally invasive surgery (MIS) + rt-PA does not significantly improve functional outcome in patients with intracerebral hemorrhage. However, The study lacks the precision to exclude a potential benefit of MIS + rt-PA.
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3.
Evaluating the Efficacy of Water-Soluble Bone Wax (Tableau Wax) in Reducing Blood Loss in Spinal Fusion Surgery: A Randomized, Controlled, Pilot Study
Kim, J. G., Ham, D. W., Zheng, H., Kwon, O., Kim, H. J.
Medicina (Kaunas, Lithuania). 2023;59(9)
Abstract
Background and Objectives: Lumbar decompression with fusion surgery is an effective treatment for spinal stenosis, but critical postoperative hematoma is a concern. Bone wax has been widely used to control bone bleeding but it has some drawbacks. This study aimed to evaluate the efficacy of Tableau wax, a bioabsorbable hemostatic material, in patients undergoing spinal fusion surgery through a pilot study design. Materials and Methods: A total of 31 patients were enrolled in this single-surgeon, single-institution study. The participants underwent transforaminal lumbar interbody fusion surgery and were randomly assigned to the control group (Bone wax) or test group (Tableau wax). Demographic data, pre- and post-operative hemoglobin levels, blood loss volume, surgical time, Oswestry Disability Index, and EQ-5D scores were recorded. Results: The study showed no significant difference in preoperative and postoperative hemoglobin levels, Oswestry Disability Index, and EQ-5D scores between the groups. However, the Tableau wax group had a significantly lower reduction in hemoglobin levels (1.3 ± 1.0 g/dL) and blood loss (438.2 mL) compared to the Bone wax group (2.2 ± 0.9 g/dL and 663.1 mL, respectively; p = 0.018 and p = 0.022).
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4.
Three-dimensional laser combined with C-arm computed tomography-assisted puncture of intracerebral hemorrhage
Zhao, H., Zhang, T., Li, M., Gao, Y., Wang, S., Jiang, R., Li, Z.
Frontiers in endocrinology. 2023;14:1198564
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is the deadliest subtype of stroke, with a 30-day case fatality rate of approximately 40%. Timely and accurate treatment is essential to facilitate recovery. The introduction of stereotactic instruments and navigation systems has greatly improved the accuracy of surgical treatment. In this study, we explored the application and effects of a three-dimensional (3D) laser combined with C-arm computed tomography (CT) on ICH puncture. MATERIALS AND METHODS According to the principle of randomness, 118 patients with ICH were divided into control and experimental groups. The control group was treated with CT-guided puncture, and the experimental group was treated with 3D laser combined with C-arm CT puncture. The hematoma clearance rates at 3, 5, and 7 days after surgery and the prognosis at 1, 3, and 6 months after surgery were compared between the two groups. RESULTS The hematoma clearance rates of the group using 3D laser combined with C-arm CT at 3, 5, and 7 days after surgery were significantly higher than those of the control group, and the difference was statistically significant (p < 0.05). One month postoperatively, the daily living ability (ADL) grading and recovery of the patients in the test group was significantly better than those of the control group (p < 0.05), but there was no statistically significant difference in ADL 3 and 6 months after surgery (p > 0.05). CONCLUSION 3D laser combined with C-arm CT puncture has the advantages of real-time guidance, accurate positioning, and simple operation. It is an effective minimally invasive surgical method that is easy to master.
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5.
Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis
Qiao, R., Ma, R., Zhang, X., Lun, D., Li, R., Hu, Y.
European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2023
Abstract
PURPOSE The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. METHODS A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. RESULTS The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3 mL in the NE group and 1716.4 mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15 mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). CONCLUSIONS PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.
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6.
Clinical application of 3DSlicer and Sina in minimally invasive puncture drainage of elderly patients with spontaneous intracerebral hemorrhage under local anesthesia
Hou X, Li D, Yao Y, Zeng L, Li C
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2023;32(8):107192
Abstract
BACKGROUND Decreased organ function and poor physical compensatory capacity in elderly patients diagnosed with spontaneous intracerebral hemorrhage (ICH) can make surgical treatment procedures challenging and risky. Minimally invasive puncture drainage (MIPD) combined with urokinase infusion therapy is a safe and feasible method of treating ICH. This study aimed to compare the treatment efficacy of MIPD conducted under local anesthesia using either 3DSlicer + Sina application or computer tomography (CT)-guided stereotactic localization of hematomas in elderly patients diagnosed with ICH. METHODS The study sample included 78 elderly patients (≥ 65 years of age) diagnosed with ICH for the first time. All patients exhibited stable vital signs and underwent surgical treatment. The study sample was randomly divided into two groups, either receiving 3DSlicer+Sina or CT-guided stereotactic assistance. The preoperative preparation time; hematoma localization accuracy rate; satisfactory hematoma puncture rate; hematoma clearance rate; postoperative rebleeding rate; Glasgow Coma Scale (GCS) score after 7 days; and modified Rankin scale (mRS) score 6 months after surgery were compared between the two groups. RESULTS No significant differences in gender, age, preoperative GCS score, preoperative hematoma volume (HV), and surgical duration were observed between the two groups (all p-values > 0.05). However, the preoperative preparation time was shorter in the group receiving 3DSlicer + Sina assistance compared to that receiving CT-guided stereotactic assistance (p-value < 0.001). Both groups exhibited significant improvement in GCS scores and reduction in HV after surgery (all p-values < 0.001). The accuracy of hematoma localization and puncture was 100% in both groups. There were no significant differences in surgical duration, postoperative hematoma clearance rate, rebleeding rate, postoperative GCS and mRS scores between the two groups (all p-values > 0.05). CONCLUSIONS A combination of 3DSlicer and Sina is effective in accurately identifying hematomas in elderly patients with ICH exhibiting stable vital signs, thus simplifying MIPD surgeries conducted under local anesthesia. This procedure may also be preferred over CT-guided stereotactic localization in clinical practice due to its ease of use and accuracy in hematoma localization.
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7.
Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial
Noiphithak, R., Yindeedej, V., Ratanavinitkul, W., Duangprasert, G., Nimmannitya, P., Yodwisithsak, P.
Neurosurgical review. 2023;46(1):136
Abstract
Minimally invasive surgery (MIS) has been repeatedly evaluated in patients with ICH as a promising procedure for improved survival and functional outcome. Among MIS techniques, endoscopic surgery (ES) has shown superior efficacy for ICH removal due to rapid clot evacuation and immediate bleeding control. However, the results of ES are still uncertain due to insufficient data. In this study, participants with spontaneous supratentorial ICH who were indicated for surgery were randomly assigned (1:1) to undergo ES or conventional craniotomy (CC) between March 2019 and June 2022. The primary outcome was a difference in favorable modified Rankin Scale (mRS) outcome (0 to 3) at 180-day follow-up evaluated by blind assessors. There were 188 participants, 95 in the ES group and 93 in the CC group, who completed the trial. At 180-day follow-up, 46 (48.4%) participants in the ES group achieved favorable outcomes, compared to 33 (35.5%) in the CC group (risk difference [RD] 12.9, 95% CI - 1.1-27.0, p = 0.07). After covariate adjustment, the difference was slightly higher and significant (adjusted RD 17.3, 95% CI [4.6-30.0], p = 0.01). Moreover, the ES group had less operative duration and less intraoperative blood loss than the CC group. Clot evacuation rate and complications were similar between the two groups. Subgroup analyses showed a potential benefit of ES in age < 60 years, time to surgery ≥ 6 h, and deep ICH. This study showed that ES was safe and effective in ICH removal and provided a better functional outcome compared to CC.
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8.
A prospective randomised controlled trial evaluating prophylactic Floseal, a gelatin and thrombin-based haemostatic matrix, in postoperative drain output and blood transfusion in transforaminal lumbar interbody fusion surgery
Ng EP, Tung KL, Yip SL, Tse MS, Kwok TK, Wong KK
European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2023
Abstract
PURPOSE To evaluate the prophylactic use of Floseal in reducing postoperative blood loss in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). TLIF is a lumbar spine decompression and fusion procedure with potential for postoperative blood loss. Prophylactic application of Floseal, a gelatin and thrombin-based haemostatic matrix to the surgical wound before closure was shown to be effective in reducing postoperative drain output in anterior cervical discectomy and fusion. This study postulated that prophylactic use of Floseal before wound closure would reduce postoperative blood loss in patients who underwent TLIF. METHODS Randomised controlled trial comparing prophylactic use of Floseal and control in patients undergoing single level or two-level TLIF. Primary outcomes included postoperative drain output within 24 h and postoperative transfusion rate. Secondary outcomes included days of drain placement, length of stay and haemoglobin level. RESULTS A total of 50 patients was recruited. Twenty six patients were allocated to the Floseal group and 24 were allocated to the control group. There were no baseline characteristic differences between the groups. There were no statistically significant differences in primary outcomes which included postoperative drain output within 24 h and postoperative transfusion rate between patients who received prophylactic Floseal and control. There were no statistically significant differences in secondary outcomes which included haemoglobin level, days of drain placement and length of stay between the two groups. CONCLUSION Prophylactic use of Floseal was not shown to reduce postoperative bleeding in single level or two-level TLIF.
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9.
Dexmedetomidine induced hypotension and hemostatic markers
Eid, G. M., Mostafa, S. F., Abu Elyazed, M. M.
Journal of anaesthesiology, clinical pharmacology. 2023;39(1):18-24
Abstract
BACKGROUND AND AIMS The hemostatic system undergoes extensive alterations following surgical trauma leading to a hypercoagulable state. We assessed and compared the changes in platelet aggregation, coagulation, and fibrinolysis status during normotensive and dexmedetomidine-induced hypotensive anesthesia in patients undergoing spine surgery. MATERIAL AND METHODS Sixty patients undergoing spine surgery were randomly allocated into two groups: normotensive and dexmedetomidine-induced hypotensive groups. Platelet aggregation was assessed preoperatively, 15 min after induction, 60 min, and 120 min after skin incision, at the end of surgery, 2 h and 24 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet count, antithrombin III, fibrinogen, and D-dimer levels were measured preoperatively, 2 h and 24 h postoperatively. RESULTS Preoperative platelet aggregation (%) was comparable between both groups. Platelet aggregation significantly increased intraoperative at 120 min after skin incision and postoperatively in the normotensive group compared to the preoperative value (P < 0.05) but it was insignificantly decreased during the intraoperative induced hypotensive period in the dexmedetomidine-induced hypotensive group (P > 0.05). Postoperative PT, aPTT significantly increased and platelet count, and antithrombin III significantly decreased in the normotensive group compared to the preoperative value (P < 0.05) but they were not significantly changed in the hypotensive group (P > 0.05). Postoperative D-dimer significantly increased in the two groups compared to the preoperative value (P < 0.05). CONCLUSION Intraoperative and postoperative platelet aggregation significantly increased in the normotensive group with significant alterations of the coagulation markers. Dexmedetomidine-induced hypotensive anesthesia prevented the increased platelet aggregation that occurred in the normotensive group with better preservation of platelet and coagulation factors.
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10.
Comparing the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery
Hajilo, P., Imani, B., Zandi, S., Mehrafshan, A.
Frontiers in surgery. 2023;10:1264519
Abstract
BACKGROUND Due to the sensitivity of the surgical site and a higher probability of injury, the use of a scalpel and electrocautery to create an incision in the spine is discussed. In this study, we will compare the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery. MATERIALS AND METHODS This study was conducted in Iran as a randomized controlled trial with double-blinding (1,401). Sixty candidates for spine surgery were randomly divided into two groups of 30 using electrocautery (A) and a scalpel (B) based on available sampling. The VAS scale was used to assess postoperative pain. The duration of the incision and intraoperative blood loss were recorded. The infection and fluid secretions were determined using the Southampton scoring scale. Utilizing the Manchester scar scale, the wound healing status was evaluated. The SPSS version 16 software was used for data analysis (t-test, Mann-Whitney U, ANOVA). RESULTS The electrocautery group had substantially lower bleeding, pain, and wound healing rates than the scalpel group (P > 0.05). However, the electrocautery group had significantly longer surgical times, more secretions, and a higher infection rate than the scalpel group (P > 0.05). In terms of demographic and clinical characteristics, there was no significant difference between the two groups (P < 0.05). CONCLUSION Electrocautery reduces postoperative hemorrhage and, potentially, postoperative pain in patients. However, as the duration of surgery increases, so does the duration of anesthesia, and patient safety decreases. Additionally, the risk of infection increases in the electrocautery group compared to the scalpel group, and the rate of wound healing decreases. CLINICAL TRIAL REGISTRATION https://www.irct.ir/, identifier (IRCT20230222057496N1).