Search Results (35)

Background/Objectives: Fast-track (FT) protocols have been developed to reduce the surgical burden and enhance recovery, but they still need to be established for carotid endarterectomy (CEA). In this scenario, carotid stenting has gained momentum by answering the need for a less invasive treatment, despite a still debated clinical advantage. We aim to propose a FT protocol for CEA and to analyze its clinical outcomes. Methods: This retrospective, monocentric study enrolled consecutive patients who underwent CEA for asymptomatic carotid stenosis using an FT protocol between January 2016 and December 2024. Patients undergoing CEA for symptomatic carotid stenosis, carotid bypass procedures, and combined interventions were excluded. Our FT protocol comprises same-day hospital admission, exclusive use of local anesthesia, non-invasive assessment of cardiac and neurological status, and selective utilization of cervical drainage. Discharge criteria were goal-directed and included the absence of pain, electrocardiographic abnormalities, hemodynamic instability, neck hematoma, or cranial nerve injury, with a structured plan for rapid readmission if required. Postoperative pain was assessed using the numerical rating scale (NRS), administered to all patients. The perioperative clinical impact of the protocol was evaluated based on complication rates, pain control, length of hospital stay, and early readmission rates. Results: Among 1051 patients who underwent CEA, 853 met the inclusion criteria. General anesthesia was required in 17 cases (2%), while a cervical drain was placed in 83 patients (10%). The eversion technique was employed in 765 cases (90%). Postoperative intensive care unit (ICU) monitoring was necessary for 7 patients (1%). The mean length of hospital stay was 1.17 days. Postoperatively, 17 patients (2%) required surgical revision. Minor stroke occurred in three patients (0.4%), and acute myocardial infarction requiring angioplasty in two patients (0.2%). Inadequate postoperative pain control (NRS > 4) was reported by five patients (0.6%). Hospital readmission was required for one patient due to a neck hematoma. Conclusions: The reported fast-track protocol for elective carotid surgery was associated with a low rate of postoperative complications. These findings support its clinical value and highlight the need for further validation through controlled comparative studies. Furthermore, the implementation of fast-track protocols in carotid surgery should prompt comparative medico-economic research. Full article

Neuroprotective strategies in coronary artery interventions are essential due to the rising number of high-risk patients undergoing procedures like coronary artery bypass grafting (CABG), totally endoscopic coronary artery bypass (TECAB), and hybrid revascularization. In this review article, we summarize the neurological complications associated with coronary artery disease intervention and the risk mitigation strategies. CABG carries significant risks, including ischemic stroke, encephalopathy, seizures, and peripheral nerve injuries. Risk factors include advanced age, hypertension, diabetes, and atherosclerosis. Off-pump CABG minimizes stroke risk by avoiding aortic manipulation and CPB. TECAB and hybrid revascularization have fewer reported neurological complications but still pose risks of stroke and cranial nerve injuries. Pharmacological neuroprotection includes agents such as barbiturates, volatile anesthetics, lidocaine, NMDA receptor antagonists, magnesium, nimodipine, corticosteroids, and aprotinin. Deep hypothermic circulatory arrest (DHCA) is reserved for complex aortic cases requiring a bloodless surgical field. Intraoperative strategies involve cerebral perfusion monitoring, embolic protection devices, and therapeutic hypothermia. Preoperative optimization targets risk factors, arrhythmia prevention, and antiplatelet therapy management. Postoperatively, timely antiplatelet administration, glucose control, hemodynamic stabilization, and cognitive monitoring are critical. Comprehensive neuroprotective approaches, spanning pre- to postoperative phases, aim to reduce neurological complications and enhance outcomes in coronary interventions. Full article

Background: Jugular foramen syndrome (JFS) is a rare condition characterized by the compression or impairment of one or more terminal cranial nerves passing through the jugular foramen. Although malignancies are the primary cause of JFS. Methods: In this report, we present the first documented case of JFS caused by acute otitis media in an adult patient. Results: A 74-year-old woman presented with ear pain, hoarseness, dysphagia, dizziness, tinnitus, and hearing loss. A physical examination revealed a reddish-bulging tympanic membrane, left-sided hearing loss, right uvula deviation, and cranial nerve palsies affecting the ninth and tenth nerves. Imaging studies confirmed temporal bone inflammation, thrombosis of the sigmoid sinus extending into the internal jugular vein, and signs of thrombophlebitis of the jugular vein. The patient underwent a cortical mastoidectomy, sigmoid sinus decompression, and ventilation tube insertion, along with antibiotic, steroid, and anticoagulant therapy. Postoperatively, the patient’s condition improved significantly. Conclusions: This case highlights the importance of considering complicated acute otitis media in the differential diagnosis of neurological abnormalities associated with JFS. A thorough evaluation of the patient’s medical history and radiological imaging can assist in identifying the cause of the symptoms and guide appropriate surgical or conservative treatment. Further research is essential to gain more comprehensive insights into the pathophysiology and therapeutic interventions of JFS affecting the ears. Full article

Background/Objectives: Resection of tumors invading the cavernous sinus (CS) carries a risk of injury to the cranial nerves and internal carotid artery. Therefore, radical surgery involving lesions around the CS remains challenging, especially for lesions invading the CS, optic sheath, and oculomotor cave. Here, we describe a surgical strategy for meningiomas invading these structures and report on the clinical outcomes. Methods: Surgical resection was indicated in patients with neurological symptoms or rapid tumor growth for the restoration of cranial nerve function. We investigated 13 patients who had preoperative images of CS invasion, underwent surgical resection, and were followed-up with magnetic resonance imaging for at least 1 year between July 2017 and July 2024. Their preoperative symptoms, postoperative course, adjuvant therapy, postoperative complications, degree of resection, and recurrence were evaluated. Results: The mean patient age was 59.1 years (range, 23–73 years), and 10 were female. Major preoperative symptoms included oculomotor nerve paresis in 8 patients (61.5%), abducens nerve paresis in 6 (46.2%), visual disturbance in 7 (53.8%), and brain swelling in 3 (23.1%). These symptoms improved at least partially after surgery in 7 (87.5%), 5 (83.3%), 7 (100%), and 3 (100%) patients, respectively. Major postoperative complications included contralateral visual deterioration in 1 patient (7.7%) and brief transient slight hemiparesis caused by internal carotid vasospasm or dissection in 2 (15.4%). Four patients with residual atypical meningioma in the CS underwent intensity-modulated radiotherapy (IMRT). The lesions in 6 patients recurred or regrew, resulting in additional treatment with stereotactic radiosurgery in 2 patients, IMRT in 3, and resection in 1. Conclusions: Our surgical strategy for the surgical resection of meningiomas in and around the CS for the restoration of cranial nerve function is safe and effective, with only transient acceptable injuries. Even if the tumor in the CS is too stiff to be removed, it is important to open the optic nerve sheath and oculomotor cave widely to effectively remove the tumor. Full article

Skull base tumors such as meningiomas and schwannomas are often pathologically benign. However, surgery for these tumors poses significant challenges because of their proximity to critical structures such as the brainstem, cerebral arteries, veins, and cranial nerves. These structures are compressed or encased by the tumor as they grow, increasing the risk of unintended injury to these structures, which can potentially lead to severe neurological deficits. Preoperative imaging is crucial for assessing the tumor size, location, and its relationship with adjacent vital structures. This study reviews advanced imaging techniques that allow detailed visualization of vascular structures and cranial nerves. Contrast-enhanced computed tomography and digital subtraction angiography are optimal for evaluating vascular structures, whereas magnetic resonance imaging (MRI) with high-resolution T2-weighted images and diffusion tensor imaging are optimal for evaluating cranial nerves. These methods help surgeons plan tumor resection strategies, including surgical approaches, more precisely. An accurate preoperative assessment can contribute to safe tumor resection and preserve neurological function. Additionally, we report the MRI contrast defect sign in skull base meningiomas, which suggests cranial nerve penetration through the tumor. This is an essential finding for inferring the course of cranial nerves completely encased within the tumor. These preoperative imaging techniques have the potential to improve the outcomes of patients with skull base tumors. Furthermore, this study highlights the importance of multimodal imaging approaches and discusses future directions for imaging technology that could further develop preoperative surgical simulations and improve the quality of complex skull base tumor surgeries. Full article

According to the Centers for Disease Control and Prevention (CDC), the national public health agency of the United States, traumatic brain injury is among the leading causes of mortality and disability worldwide. The consequences of TBI include diffuse brain atrophy, local post-traumatic atrophy, arachnoiditis, pachymeningitis, meningocerebral cicatrices, cranial nerve lesions, and cranial defects. In 2019, the economic cost of injuries in the USA alone was USD 4.2 trillion, which included USD 327 billion for medical care, USD 69 billion for work loss, and USD 3.8 trillion for the value of statistical life and quality of life losses. More than half of this cost (USD 2.4 trillion) was among working-age adults (25–64 years old). Currently, the development of new diagnostic approaches and the improvement of treatment techniques require further experimental studies focused on modeling TBI of varying severity. Full article

Purpose: The purpose of this study was to analyze the prevalence of and complications resulting from temporal bone fractures in adult and pediatric patients evaluated for cranio-facial trauma in an emergency setting. Methods: A retrospective blinded analysis of CT scans of a series of 294 consecutive adult and pediatric patients with cranio-facial trauma investigated in the emergency setting was conducted. Findings were compared between the two populations. Preliminary reports made by on-call residents were compared with the retrospective analysis, which was performed in consensus by two experienced readers and served as reference standard. Results: CT revealed 126 fractures in 116/294 (39.5%) patients, although fractures were clinically suspected only in 70/294 (23.8%); p < 0.05. Fractures were longitudinal, transverse and mixed in 69.5%, 10.3% and 19.8% of cases, respectively. Most fractures were otic-sparing fractures (95.2%). Involvement of the external auditory canal, ossicular chain and the osseous structures surrounding the facial nerve was present in 72.2%, 8.7% and 6.3% of cases, respectively. Temporal bone fractures extended into the venous sinuses/jugular foramen and carotid canal in 18.3% and 17.5% of cases, respectively. Vascular injuries (carotid dissection and venous thrombosis) were more common in children than in adults (13.6% versus 5.3%); however, the observed difference did not reach statistical significance. 79.5% of patients with temporal bone fractures had both brain injuries and fractures of the facial bones and cranial vault. Brain injuries were more common in adults (90.4%) than in children (63.6%), p = 0.001. Although on-call residents reliably detected temporal bone fractures (sensitivity = 92.8%), they often missed trauma-associated ossicular dislocation (sensitivity = 27.3%). Conclusions: Temporal bone fractures and related complications are common in patients with cranio-facial trauma and need to be thoroughly looked for; the pattern of associated injuries is slightly different in children and in adults. Full article

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical. Full article

Background: Given that the temporal bone is one of the most complex regions of the human body, cadaveric dissection of this anatomical area represents the first necessary step for the learning and training of the young oto-surgeon in order to perform middle ear surgery, which includes the management of inflammatory pathology, hearing rehabilitation, and also cognitive decline prevention surgery. The primary objective of this study was to identify common mistakes and critical passages during the initial steps of temporal bone dissection, specifically cortical mastoidectomy and posterior tympanotomy. Methods: A survey among 100 ENT residents was conducted, gathering insights into the most prevalent errors encountered during their training to uncover the most challenging aspects faced by novice surgeons during these procedures. Results: The most common mistakes included opening the dura of the middle cranial fossa (MCF), injury of the sigmoid sinus (SS), chorda tympani (CT), and facial nerve (FN) injury while performing the posterior tympanotomy. The most important critical steps to prevent mistakes are related to the absence of wide exposure during cortical mastoidectomy and the consequent impossibility of identifying the landmarks of the facial recess before performing posterior tympanotomy. Injury of these structures was more common in younger surgeons and in the ones who performed less than five temporal bone dissection courses. Conclusions: Numerous temporal bone dissections on cadavers are mandatory for ENT residents looking forward to performing middle ear surgery. Full article

Painful traumatic trigeminal neuropathy (PTTN) is a chronic neuropathic pain that may develop following injury to the trigeminal nerve. Etiologies include cranio-orofacial trauma that may result from dental, surgical, or anesthetic procedures or physical trauma, such as a motor vehicle accident. Following nerve injury, there are various mechanisms, including peripheral and central, as well as phenotypic changes and genetic predispositions that may contribute to the development of neuropathic pain. In this article, we review current literature pertaining to the cellular processes that occur following traumatic damage to the trigeminal nerve, also called cranial nerve V, that results in chronic neuropathic pain. We examine the neurobiology and pathophysiology based mostly on pre-clinical animal models of neuropathic/trigeminal pain. Full article

There is substantial experimental and clinical interest in providing effective ways to both prevent and slow the onset of hearing loss. Auditory hair cells, which occur along the basilar membrane of the cochlea, often lose functionality due to age-related biological alterations, as well as from exposure to high decibel sounds affecting a diminished/damaged auditory sensitivity. Hearing loss is also seen to take place due to neuronal degeneration before or following hair cell destruction/loss. A strategy is necessary to protect hair cells and XIII cranial/auditory nerve cells prior to injury and throughout aging. Within this context, it was proposed that cochlea neural stem cells may be protected from such aging and environmental/noise insults via the ingestion of protective dietary supplements. Of particular importance is that these studies typically display a hormetic-like biphasic dose–response pattern that prevents the occurrence of auditory cell damage induced by various model chemical toxins, such as cisplatin. Likewise, the hormetic dose–response also enhances the occurrence of cochlear neural cell viability, proliferation, and differentiation. These findings are particularly important since they confirmed a strong dose dependency of the significant beneficial effects (which is biphasic), whilst having a low-dose beneficial response, whereas extensive exposures may become ineffective and/or potentially harmful. According to hormesis, phytochemicals including polyphenols exhibit biphasic dose–response effects activating low-dose antioxidant signaling pathways, resulting in the upregulation of vitagenes, a group of genes involved in preserving cellular homeostasis during stressful conditions. Modulation of the vitagene network through polyphenols increases cellular resilience mechanisms, thus impacting neurological disorder pathophysiology. Here, we aimed to explore polyphenols targeting the NF-E2-related factor 2 (Nrf2) pathway to neuroprotective and therapeutic strategies that can potentially reduce oxidative stress and inflammation, thus preventing auditory hair cell and XIII cranial/auditory nerve cell degeneration. Furthermore, we explored techniques to enhance their bioavailability and efficacy. Full article

Mandibular Distraction Osteogenesis (MDO) is now the preferred procedure to alleviate airway obstruction in infants with severe Robin Sequence (RS). However, there have been very few studies investigating complications related to MDO surgery performed on patients affected by isolated RS. In this study, age at distraction, weight at distraction, preoperative intubation, repeat MDO and complications associated with MDO were included as variables. Minor, moderate and major problems were evaluated and recorded as surgical site infections (SSI), injuries to the facial nerve, self-extinction hypertrophic scars, temporomandibular joint ankylosis, device failures, early ossification and fibrous non-union. One hundred and fifty one patients with isolated RS were included. At distraction, the mean age was 72 days (12–540 days) and the mean weight was 4.05 kg (2.4–12.2 kg). Only one patient needed tracheostomy after MDO, and none required further distraction. Ultimately, the complication rate was 15.23%, and there was a total of 7.95% minor, 9.27% moderate and 0% major complications. Minor incidents included surgical site infection (SSI) managed with antibiotics taken orally (n = 8), neuropraxia in the VII cranial nerve (CN) (n = 1), and hypertrophic scarring (n = 3). Incidents reported as moderate were SSIs managed with intravenous antibiotics (n = 9), incision and drainage (n = 3) and self-extubation (n = 2). There was no case of TMJ ankylosis. There were no cases of early or premature ossification, fibrous non-union and device fracture. In conclusion, MDO is an effective and appropriate management technique for infants with isolated RS and severe airway obstruction. Infections at the surgery site accounted for the vast majority of the complications. Further investigations may be needed to determine the long-term consequences of MDO. Full article

Peripheral nerve injury (PNI) remains a medical challenge with no easy resolution. Over the last few decades, significant advances have been achieved in promoting peripheral nerve regeneration, and new assessment tools have been developed, both functional and imaging, to quantify the proportion and quality of nerve recovery. The exploration of new animal models, larger, more complex, and with more similarities to humans, has made it possible to reduce the gap between the results obtained in classic animal models, such as rodents, and the application of new therapies in humans and animals of clinical interest. Ultrasonography is an imaging technique recurrently used in clinical practice to assess the peripheral nerves, allowing for its anatomical and topographic characterization, aiding in the administration of anesthesia, and in the performance of nerve blocks. The use of this technique in animal models is scarce, but it could be a useful tool in monitoring the progression of nerve regeneration after the induction of controlled experimental lesions. In this work, sheep, a promising animal model in the area of peripheral nerve regeneration, were subjected to an ultrasonographic study of three peripheral nerves of the hind limb, the common peroneal, and tibial and sciatic nerves. The main aim was to establish values of dimensions and ultrasound appearance in healthy nerves and landmarks for their identification, as well as to perform an ultrasound evaluation of the cranial tibial muscle, an effector muscle of the common peroneal nerve, and to establish normal values for its ultrasound appearance and dimensions. The results obtained will allow the use of these data as control values in future work exploring new therapeutic options for nerve regeneration after induction of common peroneal nerve injuries in sheep. Full article

Recently, stable gastric pentadecapeptide BPC 157 therapy by activation of collateral pathways counteracted various occlusion/occlusion-like syndromes, vascular, and multiorgan failure, and blood pressure disturbances in rats with permanent major vessel occlusion and similar procedures disabling endothelium function. Thereby, we revealed BPC 157 cytoprotective therapy with strong vascular rescuing capabilities in glaucoma therapy. With these capabilities, BPC 157 therapy can recover glaucomatous rats, normalize intraocular pressure, maintain retinal integrity, recover pupil function, recover retinal ischemia, and corneal injuries (i.e., maintained transparency after complete corneal abrasion, corneal ulceration, and counteracted dry eye after lacrimal gland removal or corneal insensitivity). The most important point is that in glaucomatous rats (three of four episcleral veins cauterized) with high intraocular pressure, all BPC 157 regimens immediately normalized intraocular pressure. BPC 157-treated rats exhibited normal pupil diameter, microscopically well-preserved ganglion cells and optic nerve presentation, normal fundus presentation, nor- mal retinal and choroidal blood vessel presentation, and normal optic nerve presentation. The one episcleral vein rapidly upgraded to accomplish all functions in glaucomatous rats may correspond with occlusion/occlusion-like syndromes of the activated rescuing collateral pathway (azygos vein direct blood flow delivery). Normalized intraocular pressure in glaucomatous rats corresponded to the counteracted intra-cranial (superior sagittal sinus), portal, and caval hypertension, and aortal hypotension in occlusion/occlusion-like syndromes, were all attenuated/eliminated by BPC 157 therapy. Furthermore, given in other eye disturbances (i.e., retinal ischemia), BPC 157 instantly breaks a noxious chain of events, both at an early stage and an already advanced stage. Thus, we further advocate BPC 157 as a therapeutic agent in ocular disease. Full article

Peripheral nerve injuries impair the patient’s functional capacity, including those occurring in the facial nerve, which require effective medical treatment. Thus, we investigated the use of heterologous fibrin biopolymer (HFB) in the repair of the buccal branch of the facial nerve (BBFN) associated with photobiomodulation (PBM), using a low-level laser (LLLT), analyzing the effects on axons, muscles facials, and functional recovery. This experimental study used twenty-one rats randomly divided into three groups of seven animals, using the BBFN bilaterally (the left nerve was used for LLLT): Control group—normal and laser (CGn and CGl); Denervated group—normal and laser (DGn and DGl); Experimental Repair Group—normal and laser (ERGn and ERGl). The photobiomodulation protocol began in the immediate postoperative period and continued for 5 weeks with a weekly application. After 6 weeks of the experiment, the BBFN and the perioral muscles were collected. A significant difference (p < 0.05) was observed in nerve fiber diameter (7.10 ± 0.25 µm and 8.00 ± 0.36 µm, respectively) and axon diameter (3.31 ± 0.19 µm and 4.07 ± 0.27 µm, respectively) between ERGn and ERGl. In the area of muscle fibers, ERGl was similar to GC. In the functional analysis, the ERGn and the ERGI (4.38 ± 0.10) and the ERGI (4.56 ± 0.11) showed parameters of normality. We show that HFB and PBM had positive effects on the morphological and functional stimulation of the buccal branch of the facial nerve, being an alternative and favorable for the regeneration of severe injuries. Full article