Figure 32. Spina bifida occulta,

meningocele, myelomeningocele +

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XS42 Neurosurgery Toronto Notes 2023

Intraventricular Hemorrhage

Definition

• hemorrhage originating in the periventricular subependymal germinal matrix

Epidemiology

• incidence and severity increases as gestational age (GA) and birth weight (BVV ) decrease

• 50% of IVH occurs within 8 h of birth; 90% occurs by day 3

Papile Classification

• Grade I:germinal matrix hemorrhage

• Grade II:IVH without ventricular

dilation

• Grade III:IVH with ventricular dilation

• Grade IV:IVH with parenchymal

extension

Risk Factors

• prematurity (<32 wk GA), BW <1500 g, need for vigorous resuscitation at birth, pneumothorax,

ventilated preterm infants, hemodynamic instability, respiratory distresssyndrome (RDS),

chorioamnionitis, coagulopathy

Clinical Features

• many infants with IVH are asymptomatic

• subtle signs: altered LOG, decreased tone and/or activity, hypoventilation/apnea

• catastrophic deterioration: may have bulging fontanelle, apnea / hypoventilation, hypotension,

bradycardia, cranial nerve abnormalities,sudden drop in hematocrit, metabolic acidosis,seizures,

coma

Diagnosis

• head U/S is preferred imaging modality

• routine head U/S screening conducted for all preterm infants <32 wk GA or <1500 g gestation

throughout NICU stay

• IVH graded using Papile classification

• parenchymal hemorrhage may also occur in the absence of IVH

Management of Acute Hemorrhage

• supportive care to maintain blood volume, cerebral perfusion, and acid-base status

• follow up with serial imaging

Prognosis

• outcome largely dependent on grade of IVH, with grades 1 and 11 having a relatively favourable

prognosis

• greatest morbidity and mortality is seen with grade IV IVH and development of posthemorrhagic

hydrocephalus requiring VP shunt placement

• short-term sequelae for severe IVH: mortality, extension ofbleed, posthemorrhagic hydrocephalus,

posthemorrhagic infarction, cyst formation

• possible long-term major neurological sequelae: cerebral palsy (CP), cognitive deficits, motor deficits,

visual and hearing impairment

Hydrocephalus in Paediatrics

Etiology

• congenital

aqueductal anomalies,primary aqueductal stenosis in infancy

secondary gliosis due to intrauterine viral infections (mumps, varicella, TORCH)

Dandy-Walker malformation (2-4%)

Chiari malformation,especially type 11

myelomeningocele

• acquired

post meningitis

post hemorrhage (SAH,IVH)

masses (vascular malformation, neoplastic)

Clinical Features

• symptoms and signs of hydrocephalus are age related in paediatrics

• increased head circumference,bulging anterior fontanelle, widened cranialsutures

• irritability,lethargy, poor feeding,and vomiting

• “cracked pot” sound on cranial percussion

• scalp vein dilation (increased collateral venous drainage)

• sunsetsign (forced downward deviation of eyes)

• episodic bradycardia and apnea

Investigations

• skull x-ray, U/S,Cl'

, MR1,1CP monitoring

Treatment

• similar to adults (see Hydrocephalus Treatment, NS10)

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Dandy-Walker Malformation

Definition

• atresia of foramina of Magendie and Luschka, resulting in:

• complete or incomplete agenesis of the cerebellar vermis with widely separated, hypoplastic

cerebellar hemispheres

• posterior fossa cyst, enlarged posterior fossa

dilation of 4th ventricle (also 3rd and lateral ventricles)

• can be detected in utero

• associated anomalies

hydrocephalus (90%)

agenesis of corpus callosum (17%)

occipital encephalocele (7%)

Epidemiology

• 2-4% of paediatric hydrocephalus

Clinical Features

• 20% are asymptomatic, seizures occur in 15%

• symptoms and signs of hydrocephalus combined with a prominent occiput in infancy

• ataxia,spasticity, poor fine motor control common in childhood

Investigations

• ultrasound, CT, MR1

Treatment

• asymptomatic patients require no treatment

• associated hydrocephalus requires surgical treatment

• e.g. VP shunt, cystoperitoneal shunt, lumboperitoneal shunt, VA shunt, lumbar drain

Prognosis

• 75-100% survival, 50% have normal IQ

Chiari Malformations

Definition

• malformations at the medullary-spinal junction

Etiology

• unclear, likely maldevelopment/dysgenesis during fetal life

Categories C liar

Table 29. Categories of Chiari Malformations

Type I Type II

Cerebellar tonsils le below thelevel olthe foramen

magnum

Part of cerebellar vermis,medulla.and 4th ventricle

extend through the foramenmagnum often to

midcervical region

Present in infancy

Definition

Epidemiology

ClinicalFeatures

Average age at presentation1Syr

Many are asymptomatic Findings due to brainstem and lower cranial nerve

Pain 169%). weakness (56'

4.numbness (52%).loss of dysfunction

temperature sensation(40%)

Central cord syndrome (65%)

Foramen magnum compression syndrome (22%).

cerebellarsyndrome (11%).syringomyelia (50%).

hydrocephalus (10%)

Chiari II 2

Neurogenic dysphagia (69%).apnea (58%).stridor

(56%).aspiration (40%).arm weakness (27%).downbeat

nystagmus

Respiratory arrest is the most commoncause of mortality

Usually associatedwrth myelomeningoceleand

hydrocephalus

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Figure 33.Chiari malformations

Investigations

Treatment

MRI MRI

Symptomatic pabents (early surgery recommended: Preserved

<2 yr post symptom onset) »suboccipital

craniectomy,duraplasty

When symptomabc.check the shunt first.Ihen consider

surgical decompression (which does not reverse intrinsic

brainstem abnormalibes)•cervical laminectomy,

duraplasty r1

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Craniosynostosis

Definition

• premature closure of the cranialsuturefs)

Classification

• sagittal (most common):long narrow head with ridging sagittal suture (scaphocephaly)

• coronal: expansion in superior and lateral direction (brachycephalv)

• metopic (trigonocephaly)

• lambdoid:least common

Epidemiology

« 0.6 in 1000 live births, most cases are sporadic;familial incidence is 2% of sagittal and 8% of coronal

synostosis

Clinical Features

• skull deformity, raised ICP ± hydrocephalus

• ophthalmologic problems due to increased 1CP or bony abnormalities of the orbit

• must ditferentiate from positional plagiocephaly (secondary to persistently/exclusively sleeping on

back)

Investigations

• plain radiographs,CT scan

Treatment

• parental counselling about nature of deformity,associated neurologicalsymptoms

• surgery for cosmetic purposes, except in cases of elevated ICP (>2 suturesinvolved)

Paediatric Brain Tumours

• seeCNS Tumours,SSI 1

Epidemiology

• 20% of all paediatric cancers (second only toleukemia)

• 60% of paediatric brain tumours are infratentorial

• paediatric brain tumours arise from various cellularlineages

• neural (stem) cells:low-grade astrocytoma (supra- or infratentorial),high-grade astrocytoma,

glioblastoma (largely supratentorial) (see Adult Diffuse Gliomas,SS15)

• primitive nerve cells:supratentorial PNET

• 90% of neonatal brain tumours, infratentorial (medulloblastoma), pineal gland (pineoblastoma)

• non-neuronal (stem) cells:germ cell tumour, craniopharyngioma, dermoid, meningioma, neurinoma

(schwannoma), pituitary adenoma,others

Clinical Features

• vomiting,seizure, macrocrania, hydrocephalus

• developmental delay, poor feeding,failure to thrive

• often initially escapes diagnosis due to expansile cranium and neural plasticity in children

Most Common Paediatric Brain

Tumours

. Astrocytoma, low-grade

• Supratentorial

• Infratentorial

• Medulloblastoma

• Ependymoma

• Glioblastoma

Table 30.Overview of Childhood Primary Brain Tumours*

Type Overview

Pilocytic (low-grade) Astrocytoma Usually inposterior fossa

Well circumscribed

Benign,goodprognosis

Medulloblastoma PHEI

Incerebellum compresses 4th ventricle »hydrocephalus

Highly malignant

In 4th ventricle

-hydrocephalus

Poor prognosis

Often cerebellar

Associatedwith vonHippel-lmdau syndrome withretinalangiomas

Canproduceerythropoietin|EP0)

*

secondarypolycythemia

Causes bitemporal hemianopia (thus oftenconfused withpituitary adenoma)

Most common supratentorial childhood tumour

Benign

Ependymoma

Hemangioblastoma

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Functional Neurosurgery

Movement Disorders

• see Neurology, Parkinson s Disease, N33, Dystonia, N34, and Multiple Sclerosis, N55

Table 31,Surgical Targets for Movement Disorders

Disorder Indications Procedures Outcomes Morbidity

Parkinson’s

Disease

39 -48 improvement

in UnifiedParkinson'

s

Disease Rating Scale

Preferred target:anterodorsal fUPDRS) scores

subthalamic nucleus

Other targets:stereotactic

ablation (pallidotomy) or

stimulation of posteroventral

Simultaneous,bilateral

surgeryi'stimulation is most

common

ID.infection,seizure

(1%-4%)

Paresthesias

Involuntary movements

Cognitive functionmg:

Decreased lexical fluency,

impaired executive function

(STN>GPi)

Psychiatric:depression,

mania,anxiety,apathy

(STN>GPi)

Intractable contralateral

bradykinesialtremor

failure of medical

management (advanced

disease)

Drug-induced dyskinesias

(see dystonia,below)

Reduced dosage of

medications (SIN)

More effective than

medical managementin

advanced Parkinson's

Disease (PD)

Early intervention may

reduce severity,course,

and progression ofdisease

Less effective for patients

with atypical presentations

GPi

Stimulation of caudal zona

incerta

Parkinsonian tremor:

stereotactic ablation

(thalamotomy) or stimulation

of ventral intermediate (Vim)

nucleus of thalamus

Dystonia Contralateral primary

(generalized) dystonias:

cervical and tardive dystonias (pallidotomy) orstimulation of Marsden Dystonia Scale

Contralateral secondary posteroventral GPi

dyskinesia (i.e.drug-induced: Secondary dystonia:

L-dopa,neuroleptics)

Preferred target (primary Primary dystonia:51%

dystonia):Stereotactic ablation reductionin Burke-FahnICH.infection,seizure

(1%-4%)

Minor effects on cognitive

functioning (especially

decreased lexical fluency;

SIN>GPi)

(BFMDS) score

Secondary dystonia:

stimulation of anterodorsal 62-89% improvement in

dystonias

Stimulation of ventral posterior Delayed effects:wk to mo

lateral (VPL) thalamic nucleus

SIN

Contralateral appendicular Preferred target:Stereotactic Durable reductions in

essential tremor (El)(first ablation (thalamotomy) or essential tremor rating

disorder lobe treated by DBS; stimulation of Vim nudeusof scale (EIRS) scores

D8S is viable alternative to Rx) thalamus Reduced dosage of

Intention tremor resulting Other targets:stimulation of medications

from demyelination of caudal ZDna incerta

cerebellar outflow tracts (e.g. Parkinsonian tremor:

in multiple sclerosis)

Brainstem tremor (Holmes SIN

tremor)

ICH.infection,seizure

(1V4%)

Paresthesiaspain

Dysarthria

Ataxia

Conflicting data on vocal.

1 Minor effects on cognitive

facial tremor functioning (especially

decreased lexical fluency)

tolerance may develop

over time

Tremor

stimulation of anterodorsal

Neuropsychiatric Disorders

• seeNeurology, N21 and Psychiatry. Obsessive Compulsive Disorder,PS19 and Depressive Disorders,

PSI 2

• psychiatric neurosurgery indicated only for severe symptoms that are refractory to medical

management

Table 32.Surgical Targets for Neuropsychiatric Disorders

Disorder Procedures Outcomes Morbidity

Obsessive Compulsive

Disorder (OCD)

Anterior capsulotomy/stimulation of the Currently under investigation

anterior limb of the 1C

ICH (1-2%)

Reportedly 25-75% response rate Mild effects on cognitive

functioning

Anxietytpanic disorder (case

report)

ICH (1-2%)

Mild sexual dysfunction

Consensus on Guidelines for Stereotactic

Neurosurgery forPsychiatric Disorders

iuraalof le.rg ogy.Neu-osurgeryiPsychiaSy

2C14;35(9t1C03-1CCS

•Stereotect.c ehative procedures such as

cingukitomy and capsulotoay forKDa:d OCD lack

levelIevidence.

•DBS inasy brain ta-get attempted so far 8

considered'

investgational.'

•UaKdsopknary teams are mandatory to

ensure safe andethical coedjctiu psycathc

re.rosjgery.

*

2particular attenton deeded

to essunng treatment refractoriness,consent

procedures,patient capacity andautonomy,and

eitensve pre

-postoperatne assessments.

Stimulation of midlineintralarainar

nuclei of the thalamus

Stimulation of motor and limbic

portions of GPi

Stimulation of the anterior limb of

the 1C

Stimulation of the subgenual cingulate

cortex

Anterior capsulotomy or stimulation of

the anterior limb of the 1C

Currently under investigation

Reportedly >70% reduction in

vocal or motor tics andurge

Tourette’s Syndrome

ICH (1-2%)

Pain.H/A

Worsening mood,irritabdity

Major Depressive Disorder

(MDD)

Currently under investigation

Reportedly 60% response rale:

35% remission rate

• other experimental indications include: anorexia nervosa,substance use disorders,Tourette’s

syndrome, and functional neurological disorders, amongst others

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Chronic Pain

Table 33. Surgical Targets for Chronic Pain

Disorder Indications Procedures Outcomes Morbidity

Neuropathic Pain Severe, intractable.

organic neuropathic

pain|e.g. poststroke

pain, phantom limb pain,

trigeminal neuralgia. contralateral 1C

chronic low-back pain. Stimulation ol the contralateral

postoperative neuropathic motor cortei

pain, compleiregional

pain syndrome)

Preferred targetstimulation

of the contralateral VPl VPIt

47% improvement in ICH (1-2%)

perception of pain intensity Paresthesia

thalamic nucleiz PVt PAG lessfavourable resultsin Anxiety panic disorder

Other targets:stimulation of the central pain syndromes

and poorly localized pain

For postoperative nevopathK

pain,surgical procedure may

be aimed al correcting any

idenbfiable residual deformity

from priorspinesurgery

Surgery is not primary modalrty

if no structurally correctable

radiologic findings

Bilateral(most common)

stimulation of the PV6 PM

Nociceptive Pain Severe,intractable.

organic nociceptive pain

Reportedly 63%

improvementinpercepbon Paresthesia

of pain intensity

ICH (1-2%)

Anxiety r panic disorder

Surgical Management of Epilepsy

•see Neurology.N19 for the medical treatment of epilepsy

Indications

•medically refractory seizures, usually defined asrecurrentseizures resistant to two first-line antiseizure medications used in succession

•identification of a distinct epileptogenic region through clinical history, EEG,MRI,and

neuropsychological testing otherlocalizing investigationsinclude magnetoencephalography,SPEC!

'

,

and PET

•if a distinct epileptogenic region cannot be identified,the patient may be a candidate for a palliative

procedure such as corpus callosotomy

Procedure

•adults:resection of the hippocampus and parahippocampal gyrusfor mesial temporal lobe epilepsy

arisingfrom mesial temporalsclerosis

•children:resection of an epileptogenic space-occupying lesion

•hemispherectomy and corpus callosotomy are less common

•vagus nerve stimulation

. UBS

Outcomes

•41-79% of adult patients are seizure-free for 5 vr after temporal lobe resection

•58-78% of children are seizure-free aftersurgery

•surgery is associated with improvements in preexisting psychiatric conditions,such as depression and

anxiety, as well asimprovement in quality of life measures

Morbidity

•0.4- 4% of surgical patients will have partial hemianopia, aphasia, motor deficit,sensory deficit, or CN

palsy following anteromedial temporal lobectomies

•most patients will have some decline in verbal memory following dominant temporal lobectomy and

in visuospatial memory in non-dominant temporal resection

•the degree of memory decline stabilizes after 1-2 yr

Predictors

•positive predictive factorsforseizure freedom following anteromedial temporal lobectomy include:

• hippocampal sclerosis (unilateral)

focal localization of interictal epileptiform discharges

• absence of preoperative generalized seizures

• tumoural etiology'

complete resection of the lesion

•ongoing research on neuroimaging biomarkeTS to predict treatment response,especially to

neuromodulation

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Surgical Management for Trigeminal Neuralgia

•reserved for cases refractory to medical management;see Neurology. N44 for medical management

Surgical Options

•trigeminal nerve branch procedures

• local blocks (phenol, alcohol)

neurectomy of the trigeminal branch

• nerve branches

Vi block at the supraorbital, supratrochlear nerves

V2 block at the foramen rotundum or infraorbital nerves

V.

i block at the foramen ovale

•percutaneous trigeminal rhizotomy

• glycerol injection

• mechanotrauma via catheter balloon

•radiofrequency thermocoagulation

•Gamma Knife* radiosurgery

•microvascular decompression

posterior fossa craniotomy with microsurgical exploration of the root entry zone, displacement of

the vessel impinging on the nerve with placement of non-absorbable Teflon’felt

Landmark Neurosurgery Trials

Trial Name Reference Clinical Trial Details

CHS TUMOURS

Radiotherapyplus Concomitant NEJM 2005:352:987-996

and Adjuvant lemozolomide for

Glioblastoma

Title:Radiotherapy plus Concomitant andAdjuvant lemozolomide lor Glioblastoma

Purpose:lo compare the safety and efficacy of adjuvant radiotherapy alone with adjuvant radiotherapy plus lemozolomide.

given with and after radiotherapy.

Methods:Patients withnewly diagnosed glioblastoma were randomly assigned to receive radiotherapy alone oiradiotherapy

plus continuousdaily lemozolomide.followed by G cycles ol adjuvant lemozolomide. The primary endpoint was oveiall survival.

Results:The two- yeai survival rale was 26.5% with radiotherapy plus lemozolomide compared to 10.4% with radiothciapy

alone. The addition of lemozolomide resulted in grade 3 or 4 hematologic Ionic elfeels in 7%ol patients.

Conclusions: The addition of lemozolomide to ladiotheiapy provides a significant suivival benefit lor newly diagnosed

glioblastoma.

Title:Postoperative Radiotherapy in the Treatment of Single Melastases to the Brain:A Randomized Trial

Purpose:To determine whether postoperative radiotherapy following complete surgicalresection of a single brain metastasis

would result in disease control andimproved overall survival.

Methods:Patients withsingle brain melastases whohad undergone complete surgitalresection were randomized into two

groups:1.whole brain radiotherapy,2.no further treatment.

Results:Postoperative radiotherapy of single brainmelastases reduced tumour recurrence in the brain and the likelihood ol

death duelo neurologic causes. No difference was noted in overall suivival or length of time being functionally independent.

Conclusions: Radiotherapy of single brain melastases posloperalively teduccs frequency ol tumour recurrence.

Postoperative Radiotherapy JAMA 1998:280|17|:1485-14S9

in the Treatment of Single

Metastases to the Brain:A

Randomized Trial

CEREBROVASCULAR DISEASE

ISUIA lancet 2003:362:103 110 Title:Unruptured Intracranial Aneurysms:Natural History,Clinical Outcome,and Risks olSurgical and Endovascular Treatment

Purpose:To assess the natural history of unruplured Intracranial aneurysms and to measure the risk associated with the repair.

Methods:4060 patients were enrolled andnon-randomly assigned to operative(surgical or endovascular repair)oi

nonoperative groups based on the planned management.Patients were eligible if they had at least one UIA with or without

aneurysmal symptoms.

Results:Without surgery. 5 yr rupture rates for aneurysms wereprogressively higher for larger sized aneurysms. These rates are

slightly higher for aneurysm in theposteiior circulation.These rates were similar or worse withsurgical or endovascular repair

of similar lesions,with age olthe patient and size and location ol the aneuiysm being predictors oloutcome.

Conclusions:In clinical decision-making,site. size,and group specific risks ol the natural history should be weighed against the

site.site,and age specilic risks of repair for each patient.

Title:Early Surgery versus Initial Conservative Treatment inPatients with Spontaneous Supratentorial IntracerebralHaemalomas

in the InternationalSurgical Trial in Intracerebral Haemorrhage (SUCH):a Randomised Trial

Purpose:To compare early surgery and inilialconservative treatment for intracerebral haemorrhage.

Methods:Patients were randomized to either the early surgery group (combined haematoma evacuation vrith medical treatment

within 24h) or the initial conservative treatment group (medical treatment,later evacuation if necessary).Pabents were divided

based on prognosis at 6 mo,with a good prognosis group (favourable outcome) being defined as good recovery or moderate

disability on theGlasgow outcome scale.

Results: 26% olpatients with intracerebral hemorrhage healed with early suigery had lavouiable outcomes compared to 24%

of patients with intracerebral hemorrhage heated with inilial conservative treatment,but this difference was not statistically

significant (P'0.414)

Conclusions: Theic isno additional benefit ol early surgeiy compared to initial conservative treatment in the treatment ol

patients with spontaneous intracerebral hemorrhage.

Title:DecompressiveSurgery lor the Treatment olMalignant Infarction of the Middle Cerebral Artery (DESTINY):a randomized,

controlled trial

Purpose:To assess the role of decompressive surgery in reducing mortality followingmassive cerebral infarction.

Methods:32patients were randomizedlo either the hemicraniectomy or conservative managementgroup.

Results:88% and 47% of patients in the decompressive surgery and conservative management group survived 30 days following

cerebral infarction (P'0.02).

Conclusions:In patients with malignant infarction olthe middle ceiebral artery,hemicraniectomy reducesmortalily.

SUCH lancet 2005;365|9457|:387-97

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DESTINY Stroke 2007:38(9):2518-2526 t

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Trial Name Reference Clinical TrialDetails

DECIMAL Title:Sequential Design.Multicenter.Randomized Decompressive Craniectomy inMalignant Middle Cerebral Artery Infarction

(DECIMAL Trial)

Purpose:1o assess trie efficacy of early decompressive craniectomy in patients with malignant MCA infarction.

Methods: 38 patients were randomired to receive eariy decompressive craniectomy plus standard medical therapy or standard

medical therapy alone.

Results:Moderate disability at 6 mo and1yr were 2S% and50 a for the surgery group and 5 6% and 22 a for the no surgety

group.There was a52.8% absolute reduction of death following surgery compared tomedical management

Conclusions:Early decompressive craniectomy in patients with malignant MCA infarction reduces mortality rate,butwith

greater rates of moderate disability.

Lancet Neurol 2009;8(4):326 -333 Title:Surgical Decompression for Space-occupying Cerebral Infarction (theHemicrar ectomy After MiddleCerebral Artery

infarction withlife-threatemng Edema Inal[HAMLET]):A Multicefltie.Open Randomised Trial

Purpose: To assess the effect of decompressive surgery within 4 d of onset of symptoms m patients with space-occupying

hemispheric infarction.

Methods: 64 patients wereassigned within 4 d of stroke onset to either surgicaldecompression or best medical treatment.

Results:Surgical decompression hadno effect on functional outcome at T yr.bat resultedin a case fatality absolute risk

reduction of 38%.

A meta-analysis of DESTINY.DECIMAL,and HAMLET studies showed that patients who were randomired to surgical

decompression within 48 hof stroke onset hadreduced poor outcomes and case fatality.

Conclusions:Surgical decompression reduces case fatal ty and poor outcomeinpatients with space-occupying infarctions when

initiated within 48h of stroke onset No evidence of improved functional outcomeif delayed up to 96h after stroke onset.

Lancel 2017:389(10069):603-611 Title:Thrombolytic Removal of Intraventricular Haemorrhage inTreatment of SevereStroke:Results of theRandomised.

Multicentre.Multiregion.Placebo-conttolled CLEAR IIITrial

Purpose: To study the effect of alteplase versus saline irrigation on improving functional outcomes in patients with

intraventricular hemorrhage.

Methods: The study involved500 patients who had aneitrarentricular drain,stable,non-traumatic intracerebralhemorrhage

volume under 30 mL.intraventricular hemorrhageobstructing the 3rdor 4th ventricles,and no underlying pathology.The

participants were randomiied toreceive either1mg alteplase.12 doses 8 h apart or 0.9% saline through the extraventricular

drain.

Results:A good functional outcome (modified Rankin score) of 3 or less at180 d was reached in 43% and 45% in the alteplase

and saline group respectively (risk ratio1-06 [95% Cl 0-88-1-28:P‘0 554'

).

Conclusions:Patients with intraventricular hemorrhagewho have an eitraventncular dram do nothave significantly improved

functional outcomeswith alteplaseirrigation as compared with salineirrigation.

Stroke 2007;38:2506-2507

HAMLET

CLEAR III

NEUROTRAUMA

MRC CRASH Lancet 2004:365:1321-1328 Title:Final Results of MRC CRASH,a RandomisedPlacebo-controlledTnai of Intravenous Corticosteroid in Adults with HeadInjury

- Outcomes at 6 Months

Purpose: To examine the effect of corticosteroids on death and disability after head injury.

Methods:10008 patents with headinjury and a 6CSs14 withm 8h of injury were randomized to receive a 48-hinfusion of

corticosteroid(methylprednisolone) or placebo.

Results:The risk of death was higher in the corticosteroid group compared to the placebo group (P-0.0001).as was the risk of

death or severe disability (P-0.079).There was no evidence thatthe effect of corticosteroids differedby injury severity or time

since injury.

Conclusions:Corticosteroids should not be used to treathead injury of any severity.

Title:Decompressive Craniectomy inDiffuse Traumabc Brain Injury

Purpose: To determine if decompressive craniectomy improves funcbonal outcomes in pabents withsevere traumatic brain

injury and refractory elevated intracranial pressure.

Methods:155 pabents with severe diffuse baumabc brain in.ury and refractory intracranial hypertension were randomized

to receive either bifrontotemporoparietal decompressive craniectomy or standard care.The final primary outcome was the

Extended Glasgow Outcome kale 6mopost-injury.

Results:Compared to patients who received standard care,those inthe craniectomy group had less bme with intracranial

pressures above thetreatment threshold (P<0.001) and fewer days in theintensive care unit(P<0.001).However,those witha

craniectomy had poorer scores on theExtended Glasgow OutcomeScale (P'0-03) and a greater risk of unfavourable outcome

(P-0.02).

Conclusions:In patients with severe diffuse traumabc brain injury and persistent intracranial hypertension,early

bifrontotemporoparietal decompressive craniectomy decreases intracranial pressureandICU stay butis associated withpoorer

outcomes.

Title:A Trial of Inbacranial-Pressure Momtoiing in Traumabc 8rain Injury

Purpose: To determine whether the informabon derived from the monitoring of ICPm pabents with severeIBIimprovesmedical

practiceand patient outcomes.

Methods:324 patients with severe 161being treatedinKUs were randomized to either thepressure-monitoring group (used a

protocol for monitoring intraparenchymal ICP)or the imaging-clinical examination group,(used a protocol based on imaging and

clinical examination).

Results: Therewas no significant between group diHerence ntheprimary outcome,which was a combination of survival bme.

impaired consciousness,and functional status at 3 moand 6mo and neuropsychologicalstatus at 6mo.Serious adverse events

were similar in the two groups.

Conclusions: Care focused on ICP monitoring isno better than care based on imaging and clinical examinationinpatients with

severe T8I.

Title:EHett of Early Sustained Prophylactic Hypothermia on NeurologicOutcomes AmongPatients With Severe Traumatic Brain

Injury:The POLAR Randomized Clinical Trial

Purpose: To assess the effect of early sustained prophylactic hypothermia versus normothermic management inpabents with

severe traumatic brain injury.

Methods:511patients withsevere traumatic brain injury were randomized toreceive either prophylacbc hypothermia or

normothermic managemenL Prophylactic hypothermia involved temperatures between 33 35’Cfor >72 h and*

7 d.

Results:favourable outcomes (6lasgow Outcome Scale-Extended score.5-8) 6months post-injurywerepresent in 48.8% and

49.1% of the hypothermia and normothermia group,respecbvely (risk difference.0.4% [95% Cl.-9.4% to 8.7%[:relativensk with

hypothermia.0.99[95% 0.0.82-1.19]:P‘0.94).

Conclusions:Compared withnormothermic management,early prophylacbc hypothermia didnot improve neurologic outcomes

at 6 mo in thosewithsevere TBI.

DECRA NEJM 2011:364:1493-1502

BEStIRIP NEJM 2012:367:2471-2481

POLAR JAMA 2018:320(21):2211-2220

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NS49 Neurosurgery Toronio Notes 2023

Trial Name Reference Clinical Trial Details

PAEDIATRIC NEUROSURGERY

Shunt Design Trial Neurosurgery 1998;43:294-304 Title:Randomized Trial of Cerebrospinal Fluid Shunt Valve Design in Pediatric Hydrocephalus

Purpose:To compare treatment failure rales of the Delta valve and the Orbis-Sigma valve (both designed to limit excess flow) to

the standard differential-pressure valves.

Methods:344 hydrocephalic children undergoing their first CSF shunt insertion were randomized to receive one of three valves:

standard differential-pressure valve,a Oelta valve,or an Orbis-Sigma valve.Shunt failure was defined as resulting from either

shunt obstruction,overdrainage,loculationsof the cerebral ventricles,or infection.

Results:61% were shunt failure-lree at1yr and 47% at 2 years,with a median shunl failure- free duration of 6S6 d. There was no

difference in shunl failure-lree duralion among the three valves (P-0.24).

Conclusions: There Is no significant difference inIhe tale ol CSF shunl failure among shunts with different valve types lor

pedialtic hydrocephalus

Neurosurgery 2010;67(3):588-593. Tille:Endoscopic Third Ventriculostomy vs.Cerebrospinal FluidShunt in the Treatment ol Hydrocephalus inChildren:a Propensity

Score-adjusted Analysis

Purpose: Todetermine whether Endoscopic third ventriculostomy (ETV) survival is superior to shunt survival in the treatmentol

hydrocephalus inchildren.

Methods:Analysis of a cohort of children with newly diagnosed hydrocephalus treated withETV or shunt.

Results:The relative risk of ETV failure isinitiallyhigher than that for shunt,but after aboul3 mo,the relative risk becomes

progressively lower for ETV.

Conclusions:After the initial early period,patients could have a long- term survival benefit withETV compared to shunt.

Endoscopic third

ventriculostomy vs.

cerebrospinal fluidshunt in the

treatment of hydrocephalus in

children:a propensity scoreadjusted analysis

FUNCTIONAL SURGERY

EARIYSTIM NEJM 2013;368:610- 622 Title: Neurostimulation for Parkinson's Discascwilh Early Motor Complications

Purpose: loassess whether neurostimulation would be beneficialinIhc treatment ol earlier stage Parkinson's disease.

Methods:Patients with carly-stage Parkinson's disease were randomized to neurostimulation plus medical therapy or medical

therapy alone.The primary endpoint was quality of hie (POO- 39 summary index).

Results:the quality of life in the neurostimulation group improved by 7.8 points compaicd to a worsening ol quality of lifeby

0.2in the medical- therapy group|P~0.002).Neurostimulation provided benefitin lermsof motor disability,activities of daily

living,levodopa-induced motor complications,and lime with good mobility andno dyskinesia.Serious adverse events related to

surgery occurred in 17.7% of patients.

Conclusions:Neurostimulation was superior tomedical therapy for the treatment of early stageParkinson’s disease.

Title:A Randomized,Controlled Trial ofSurgery for Temporal

-lobe Epilepsy

Purpose: To assess the efficacy and safety of surgery for temporal-lobe epilepsy.

Methods:80 with temporal-lobe epilepsy were randomized to either surgery or treatment with antiepileptic drugs for1yr.The

primary outcome wasabsence of seizures that impair awareness of sell and surroundings.

Results:S8% of patients in the surgery- group were fiee of seizures impairing awareness compared lo 8% in the medical

group (P'

0.001). Compared to the medical group,patients in Ihc surgical group had fewer seizuresImpairing awareness and a

significantly better quality ol life (P'

0.001).

Conclusions:In temporal lobe epilepsy,surgety is superior to piolongedmedical therapy in reducing seizures.

Title:SpinalCord Stimulation versus Conventional Medical Management for NeuropathicPain:a MulticentreRandomised

Controlled Trial inPatients with Failed Back Surgery Syndrome

Purpose:To determine whether spinal cord stimulation (SCS) is an effective therapy in addition to conventional medical

management (CMM) in patients withneuropathic pain secondary to failed back surgery syndrome (FBSS).

Methods:100 FBSS patients with predominant leg pain of neuropathic radicular origin were randomized to the SCS group

(receivespinal cord stimulation plus conventional medicalmanagement) or CMM group (conventional medical management

alone for at least 6mo).

Results:Significantly more patients in the SCS- group achieved 50% or more pain relief in the legs compared to the CMM- group

(48% vs.9%,P'

0.001).The SCS group experienced improved leg and back pain relief,quality of life,and functional capacity,

and greater treatment satisfaction compared lo the CMM group (P'

0.05 for all comparisons).At 12 mo.32% of SCS patients

experienced device-related complications.

Conclusions: Compared lo medical management. SCS provides superior pain relief and greater improvements lo quality ol life in

patients with neuropathic leg pain of radicular originsecondary lo FBSS.

A randomized,controlled trial NEJM 2001:345(5):311-318

of surgery for temporal-lobe

epilepsy

PROCESS Pain 2007:132:179 188

SPINE SURGERY

Direct decompressive surgical Lancet 2005;366(9486):643-648 Title:Direct Decompressive Surgical Resection in the Treatment of Spinal Cord Compression caused by Metastatic Cancer:A

resection in the treatment

olspinal cord compression

caused by metastatic cancer:a

randomised trial

Randomised Trial

Purpose:To evaluate the role of direct decompressive surgery in the treatment of spinal cord compression due to metastabc

cancer.

Methods:101patients withspinal cord compression due to metastatic cancer were randomly assigned to either treatmentwith

surgery and radiotherapy or treatment withradiotherapy alone.

Results:More patients in the surgery group (84%) were able to walk alter treatment compared to those who received

radiotherapy alone (57%) (odds ratio 6.2 (95% Cl 2.0-19.8) P-0.001).

Conclusions:For patients with spinal cord compression secondary lo metastatic cancer,direct decompressive surgery followed

by radiotherapy is superior lo treatment withradiotherapy alone.

Title: Surgical vs.Non-Operative Treatment lor lumbar Disc Herniation: Eight-Year Results lor Ihc Spine Patient Outcomes

Research Trial (SPORT)

Purpose: To assess the 8 yr outcomes of surgery vs.non- operative care in patients with imaging confirmed lumbar

intervertebral disc herniation

Methods:In the RCT arm of the study.501patients with imaging-confirmed lumbar disc herniabon were randomized to open

discectomy vs.standard non-operative management.

Results:Surgery was superior in intention-to-treat analysis for sciatica severity (P'

0.005),patient satisfaction (P'

0.013),and

self-rated improvement (P'0.013) at 8 yr follow-up.Improvements in pain,physical function,and disability were only seen in an

as-treated analysis due to significant non-adherence to treatment assignment.

Conclusion:Patients whoare carefully selected for surgical intervention show greater symptom improvement compared to

non-operative management.

SP0RI:Surgicalvs. NonOperative Treatment lor

lumbar Disc Herniation

Spine 2014:39(1):3-16

r -»

L J

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Trial Name Reference Clinical Trial Details

Title: Long- Term Outcomes o(

lumbar Spinal Stenosis:Sight Year Results of the Spine Patient Outcomes Research Irial (SPORT)

Purpose:locompaie 8- ycar outcomesof surgery vs.nonopetalive care for symptomatic lumbar spinal stenosis.

Methods: In the RC!arrn ol the study. 289 patients were randomired to decompressive laminectomy (n-138) or standard nonoperative care (n-151).

Results: intention to-tieat analyses showed no differencein pain,physicalfunction,and disability outcome measures,because

$2% randomired lonon- operative management had undergone surgery at 8 yr. As-treated analyses showed early benefits tor

surgery until 4 yr.however effects in primary outcomes converged between 5-8 yr.

Conclusion:Decompressive laminectomy for symptomatic spinal stenosismay show diminishing symptomatic benefits beyond

SP0R1: Long-Term Outcomes of Spine 2015;40|2):63-76

lumbar Spinal Stenosis

4 yr.

STASCIS PloS ONE 2012:7

*

32037 Title:Early vs.Delayed Decompression for Traumatic Cervical Spinal Cord Injury:Results of the Surgical Timing in Acute Spinal

Cord InjuryStudy (STASCIS)

Purpose:This study sought to determine the relative effectiveness of early (<24h after injury) vs.late (»24 h after injury)

decompressive surgery following a traumatic cervical SCI.

Methods:A prospective cohort study completed in 2002-2009 involving 6 North American institutions.Participants were16-80

yr with a cervical SCI.Outcomes evaluated were changes inAmerican Spinal Injury Association Impairment Scale (AIS) grade at 6

mo follow-up,complication rates,and mortality.

Results:Of 313 participants enrolled.182 underwentearly surgery and131underwent late surgery.222 participants were

available for follow-up at 6 mo.Ihe odds of > 2 grade AIS improvement were greater for those who had early surgery compared

to those with late surgery (OR 2.83.95% Cl1.10,7.28) after adjusting for preoperative neurological status and steroid

administration. Mortality was observed for each group during the fust 30 d post injury,only1mortality occurred in both of the

surgical groups. No statistically significant differences were observed for complications|P*0.21).

Conclusion:Early decompression surgery following a SCI is sale and associated with higher AIS improvement at 6 mo following

injury.

Title: Effect of Ventral vs.Dorsal Spinal Surgery on Patient- Reported PhysicalFunctioning inPatients With Cervical Spondylotic

Myelopathy:A Randomired Clinical Trial

Purpose:lo compare ventral surgery to dorsal surgery for cervical spondylotic myelopathy in improving patient-reporting

physical functioning 1yr post-injury.

Methods: 163 patients with multilevel cervical spondylotic myelopathy were randomired toundergo either ventral or dorsal

surgery.Physical functioning at1 yr was reported using Ihe Short Form 36 physical component summary score.

Results: Meanimprovement inpatient-reported physical functioning at 1yr was not significantly different between ventral

surgery (5.9 points) and dorsal surgery (6.2 points)(estimated mean difference.0.3:95% Cl.-2.6 to 3.1; P-0.86).

Conclusions:In patients with cervical spondylotic myelopathy, ventralsurgery was notsuperior in improving patient-reported

physical functioning at1yr compared to dorsal surgery.

Title:Safety and Efficacy of Rituzole inPatients Undergoing Decompressive Surgery for Degenerative Cervical Myelopathy (CSMProtect):A Multicentre. Double-blind,Placebo-controlled.Randomised.Phase 3 Trial

Purpose:To assess whether rituzole improves outcomes for patients with degenerative cervical myelopathy undergoing

decompression surgery.

Methods:290 patients undergoing decompression surgery randomly received either oralrituzole (50 mg twice a day for14 d

before surgery and then for 28 d after surgery) or placebo.

Results:There was no difference inthe change in modified Japanese Orthopaedic Association score between the two groups

(difference -0.38 points,-0.90 to 0.13:p-0.14).

Conclusions:In patients with degenerative cervical myelopathy,adjuvant treatment with rituzole did not enhance functional

recovery beyond decompressive surgery.

Lancet Neurology 2021:20(2):117- Title:Ihe influence of timing of surgical decompression lor acute spinal cordinjury:a pooled analysis of individual patient data

Purpose:loevaluate the effect of liming of decompressive surgery for acute SCI on long term neurological outcomes.

Methods: Pooled analysis ol Individual patient data derived from four independent, prospective, mulllcentre data sources,

including data from December,1991lo March, 2017.

Results: Patients who underwent early surgical decompression|n-528) cnpenenccd greater recovery than patients who hadlate

decompression surgery (n-1020) at 1 year after spinal injury:totalmotor scores improved by 23- 7 points (96% Cl 19 -2-28- 2) in

Ihe early surgery gioup versus 19-7 points (15- 3-24 0)in Ihe late surgery group (MD 4 0 points|1-7-6-3); p‘0- 0006),light touch

scores improved by 19-0 points (15-1-23-0) vs.14-8 points (11- 2-18- 4; MD 4- 3 (1-6-7 0);p-0-0021), and pin prick scores improved

by 18 3 points (13-7-22 9) versus 14-2 points (9-8-18 6; M0 4 0(1 5-6 6):p-0 0020).

Conclusions:Surgical decompression within 24 h olacute SCI is associated with improved sensorimotor recovery.Ihe first

24-36 h after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive

surgery following acute SCI.

Effect of Ventral vs.Dorsal JAMA 2021.325(10):942 951

Spinal Surgery on PatientReported PhysicalFunctioning

inPatients With Cervical

Spondylotic Myelopathy:A

Randomized Clinical Trial

CSM -Protect Lancet 2021;20(2):98-106

Ihe influence of timing of

surgical decompression for 26

acute spinal cord Injury: a

pooled analysis ol individual

patient data

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