Adnan Hussain Shahid

BACKGROUND: Burr hole craniostomy and conventional craniotomy are respectively associated with high recurrence rates and morbidities in the evacuation of septated chronic subdural hematomas (CSDHs). The safety and efficacy of endoscope-assisted septectomy and membranectomy (ESM) via a mini-craniotomy are investigated in this subset of patients. OBSERVATIONS: Thirteen patients with a mean age of 75 ± 11.5 years and a median modified Rankin Scale (mRS) score of 4 were included. Surgeries had a mean craniotomy size of 3.6 ± 0.5 cm and a median duration of 142 minutes. Initial postoperative CT imaging confirmed complete hematoma evacuation. Six patients (46.2%) underwent perioperative middle meningeal artery embolization (MMAE) without complications. The mean length of hospital stay (LOS) was 8 ± 3.9 days. Lower preoperative Glasgow Coma Scale (GCS) scores (p = 0.049) and larger midline shifts (p = 0.024) were significantly associated with LOS > 5 days. Median mRS scores significantly improved at discharge (p < 0.015) and at the last follow-up (p < 0.009), yielding a low-tier mRS score (≤ 2) in 53.8% of patients at discharge and 92.3% favorable last follow-up outcomes. A higher admission GCS score was associated with a low-tier at-discharge mRS score (p = 0.048). Complete brain reexpansion occurred within a mean time of 6.2 ± 4.1 months, with no significant correlation with radiological and operative features or MMAE history. During a mean follow-up of 17.4 ± 13.4 months, no recurrences were observed. LESSONS: ESM is an effective, minimally invasive alternative for treating septated, multiloculated CSDH, offering minimal recurrences. Although operative times are longer, reduced reoperation rates and improved safety justify this strategy for complex hematomas. https://thejns.org/doi/10.3171/CASE25446

Burr hole craniostomy and conventional craniotomy are respectively associated with high recurrence rates and morbidities in the evacuation of septated chronic subdural hematomas (CSDHs). The safety and efficacy of endoscope-assisted septectomy and membranectomy (ESM) via a mini-craniotomy are investigated in this subset of patients. Thirteen patients with a mean age of 75 ± 11.5 years and a median modified Rankin Scale (mRS) score of 4 were included. Surgeries had a mean craniotomy size of 3.6 ± 0.5 cm and a median duration of 142 minutes. Initial postoperative CT imaging confirmed complete hematoma evacuation. Six patients (46.2%) underwent perioperative middle meningeal artery embolization (MMAE) without complications. The mean length of hospital stay (LOS) was 8 ± 3.9 days. Lower preoperative Glasgow Coma Scale (GCS) scores (p = 0.049) and larger midline shifts (p = 0.024) were significantly associated with LOS > 5 days. Median mRS scores significantly improved at discharge (p < 0.015) and at the last follow-up (p < 0.009), yielding a low-tier mRS score (≤ 2) in 53.8% of patients at discharge and 92.3% favorable last follow-up outcomes. A higher admission GCS score was associated with a low-tier at-discharge mRS score (p = 0.048). Complete brain reexpansion occurred within a mean time of 6.2 ± 4.1 months, with no significant correlation with radiological and operative features or MMAE history. During a mean follow-up of 17.4 ± 13.4 months, no recurrences were observed. ESM is an effective, minimally invasive alternative for treating septated, multiloculated CSDH, offering minimal recurrences. Although operative times are longer, reduced reoperation rates and improved safety justify this strategy for complex hematomas. https://thejns.org/doi/10.3171/CASE25446

Background: Non-acute or chronic subdural hematoma (cSDH) is commonly treated with surgical evacuation followed by middle meningeal artery embolization (MMAe). This two step approach increases procedural complexity and redundancy, hospitalization duration, and patient risk. We hypothesized that cSDH could be managed through a single session endovascular procedure and conducted a multimodal preclinical study to evaluate feasibility. Methods: We performed three-dimensional heat mapping of hematoma distribution from preoperative CT scans (n=69) and analyzed middle meningeal artery (MMA) and superior sagittal sinus (SSS) anatomy and perforation trajectories using imaging from 107 patients. Rheological properties of 41 SDH samples were assessed using hybrid rheometry and modeled with the Carreau equation. Aspiration feasibility was tested using a 0.027 inch microcatheter (n=16), and dura perforation forces were quantified with a 28 G needle in fresh cadaveric dura (n=10). Results: Heat mapping localized cSDH to the parietal convexities (>80% probability) under the branches of the MMA, with limited midline involvement and proximity to the SSS (90% of cases, with perforation trajectories targeting high probability hematoma zones in 105 of 107 cases. SDH samples exhibited shear thinning viscosity ( η _₀ =172 mPa×s, η _∞ =2.78 mPa×s), with mean aspiration times of 1.21±0.54 min per 10 mL. Perforation forces averaged 0.68±0.24 N in normal and 1.29±0.48 N in calcified dura (P=0.05). Conclusion: Anatomical, rheological, and biomechanical data from this study support the feasibility of endovascular drainage of cSDH through the MMA.

Background Ventriculoperitoneal shunt (VPS) represents one of the most classic and widely used treatments for hydrocephalus in pediatric patients. Migration and externalization of the distal end of the catheter through the rectum are extremely rare complications of intestinal perforation with devastating consequences such as meningitis or peritonitis due to enteric bacteria that are significantly life-threatening. Besides, one of the biggest topics with that is that it can happen without producing symptoms, like the patient we present in this case report, which further masks the condition and puts the patient's life more at risk. Case presentation We present a case of a 9-month-old infant patient, with a history of prematurity, tuberculous meningitis (TBM), and hydrocephalus, who came to ED with a functional VPS and the distal end of the catheter protruding outside the rectum for 7 days, without presenting neurological or intestinal symptoms accompanying. One of the parameters that guided the diagnosis and made us suspicious of asymptomatic intestinal perforation (IP) was the background of TMB. The patient was immediately transferred to the OR where both ends of the shunt were removed: in the first instance, the shunt tube was disconnected through the abdomen, thus withdrawing through the anus, and subsequently, the proximal end of the catheter was exteriorized. In turn, the intestinal fistula was successfully repaired laparoscopically, and prophylactic antibiotic treatment was early administered. On the 6th postop day, a shunt was internalized, and a child was discharged on postop day 15 without complications with alarm guidelines. Conclusions The authors of this article strongly suggest that (1) anal extrusion of catheters is an uncommon complication but real: for this reason, its development should be considered in all patients with VPS, especially in infants. (2) The patients are often asymptomatic since false tracts can form around the catheter protecting it from spillage, and thus can be removed without complications. (3) Special care should be taken in patients with conditions that increase the risk of developing IP, such as TMB.

Objective To test the equivalence for clinical effectiveness between microdecompression and laminectomy in patients with central lumbar spinal stenosis. Design Multicentre observational study. Setting Prospective data from the Norwegian Registry for Spine Surgery. Participants 885 patients with central stenosis of the lumbar spine who underwent surgery at 34 Norwegian orthopaedic or neurosurgical departments. Patients were treated from October 2006 to December 2011. Interventions Laminectomy and microdecompression. Main outcome measures The primary outcome was change in Oswestry disability index score one year after surgery. Secondary endpoints were quality of life (EuroQol EQ-5D), perioperative complications, and duration of surgical procedures and hospital stays. A blinded biostatistician performed predefined statistical analyses in unmatched and propensity matched cohorts. Results The study was powered to detect a difference between the groups of eight points on the Oswestry disability index at one year. 721 patients (81%) completed the one year follow-up. Equivalence between microdecompression and laminectomy was shown for the Oswestry disability index (difference 1.3 points, 95% confidence interval −1.36 to 3.92, Pv 9.8%, P=0.018), but after propensity matching for complications the groups did not differ (P=0.23). The duration of surgery for single level decompression was shorter in the microdecompression group (difference 11.2 minutes, 95% confidence interval 4.9 to 17.5, P<0.001), but after propensity matching the groups did not differ (P=0.15). Patients in the microdecompression group had shorter hospital stays, both for single level decompression (difference 1.5 days, 95% confidence interval 1.7 to 2.6, P<0.001) and two level decompression (0.8 days, 1.0 to 2.2, P=0.003). Conclusion At one year the effectiveness of microdecompression is equivalent to laminectomy in the surgical treatment of central stenosis of the lumbar spine. Favourable outcomes were observed at one year in both treatment groups. Trial registration ClinicalTrials.gov NCT02006901.

Background: Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. Methods: We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments. Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.

Objective To estimate the contributions of biological aging, historical trends, and birth cohort effects on trends in pre-eclampsia in the United States. Design Population based retrospective study. Setting National hospital discharge survey datasets, 1980-2010, United States. Participants 120 million women admitted to hospital for delivery. Main outcome measures Temporal changes in rates of mild and severe pre-eclampsia in relation to maternal age, year of delivery, and birth cohorts. Poisson regression as well as multilevel age-period-cohort models with adjustment for obesity and smoking were incorporated. Results The rate of pre-eclampsia was 3.4%. The age-period-cohort analysis showed a strong age effect, with women at the extremes of maternal age having the greatest risk of pre-eclampsia. In comparison with women delivering in 1980, those delivering in 2003 were at 6.7-fold (95% confidence interval 5.6-fold to 8.0-fold) increased risk of severe pre-eclampsia. Period effects declined after 2003. Trends for severe pre-eclampsia also showed a modest birth cohort effect, with women born in the 1970s at increased risk. Compared with women born in 1955, the risk ratio for women born in 1970 was 1.2 (95% confidence interval 1.1 to 1.3). Similar patterns were also evident for mild pre-eclampsia, although attenuated. Changes in the population prevalence of obesity and smoking were associated with period and cohort trends in pre-eclampsia but did not explain the trends. Conclusions Rates of severe pre-eclampsia have been increasing in the United States and age-period-cohort effects all contribute to these trends. Although smoking and obesity have driven these trends, changes in the diagnostic criteria may have also contributed to the age-period-cohort effects. Health consequences of rising obesity rates in the United States underscore that efforts to reduce obesity may be beneficial to maternal and perinatal health.