1. Effects of statins-use for patients with aneurysmal subarachnoid hemorrhage: a meta-analysis of randomized controlled trials
Shao-Hua Su et al {Nature 2014}
"Aneurysmal subarachnoid hemorrhage (aSAH)-induced cerebral vasospasm and delayed ischemic neurological deficit (DIND) are the major causes of morbidity and mortality in patients with aSAH. The effects of statins-use for patients with aSAH remain controversial. Here,a total of 249 patients from six randomized controlled trials(RCTs) were subjected to meta-analysis. No significant decrease was found in the incidence of vasospasm(RR, 0.80; 95% CI, 0.54–1.17), with substantial heterogeneity (I2 = 49%, P = 0.08), which was verified by the further sensitivity analysis and subgroup meta-analysis. Furthermore, no significant difference was presented in the incidence of poor neurological outcome(RR, 0.94; 95% CI, 0.77–1.16), and potential side effects(RR, 2.49; 95% CI, 0.75–8.33). Nevertheless, significant difference was reported in the occurrence of DIND (RR, 0.58; 95% CI, 0.37–0.92) and mortality(RR, 0.30; 95% CI, 0.14–0.64). At present, although statins-use in the patients with aSAH should not be considered standard care at present, statins-use may have the potential effects in the prevention of mortality in patients with aSAH."
2. Thoughts on endoscopic sinus surgery:
- Insert endoscope, remove midline mucosa, drill out vomer and drill out midline bone in sphenoid sinus that divides it down the middle
- Hollow out the tumor to let any suprasellar element drop into the sphenoid sinus
- Go inferior and medial to avoid going into cavernous sinus/ICA
- Patch with mucosal graft, generally people do not attempt a primary dural closure with sutures as it is too cramped of a space.
3. Thoughts on closures:
- running skin stitch best watertight seal- good for posterior fossa crani's where you worry more about csf leak
- locked running stitch-- higher ischemia risk?
- probably OK to use modern gut for running stitch; the older stuff was reactive but the newer stuff probably isn't.
- vertical mattress gets you the best approximation- good for cases where you worry it won't heal (ie skin edges look like crap). Must stay in for a while, and are more painful to take out (vs staples).
- When you close the galea, if you take it low without any overlying fat you'll get a more symmetric/more perfectly approximated close.
4. Thoughts on meningiomas:
- 2/3s are avascular, 1/3 are hemorrhaghic and bleed (a lot!). Unfortunately no way to tell the difference on imaging... no BBB so these things always light up on perfusion imaging. Just go in slowly and carefully when you go to resect.
- If you see blood coming out of the skull before opening.. this is not a good sign.
- Can cause changes/growth of the overlying bone.. you have to drill it out.
5. Intraop brain swelling
- Some surgeons diurese at least 1L off before they enter the dura to avoid herniation
- If the brain herniates through durotomy/skull defect, you can get ischemia
- Manage with increasing venous drainage (look at the neck to make sure no veins are kinked, put bed in reverse trendelenburg)
- Have anesthesia hyperventilate to an end tidal of 25 to 35, depending on how much swelling and how concerned you are about it.
- Diurese: Mannitol 1gm/kg bolus, lasix
- Etiologies: bleeding - extraparenchymal or intraparenchymal, hypercarbia, venous outflow obstruction, diffuse edema
6. Post op orders - crani 
Monitoring
- Admit to ICU
- Vital signs and neuro checks q1
- I+O q1
Vitals
- Goal SBP <160
- PRN labetalol/hydralazine vs nicardipine drip
- Goal afebrile: use tylenol (big studies show modest effect) and cooling blankets.
Drugs
- Keppra 500 BID (supratentorial surgery only-- people don't seize from infratentorial pathology). Maintain for 2-3 months.
- Dex 4q6 (ISS/Accuchecks/Pepcid). If already on steroids, give stress dose steroids
- Ancef 24 hours, if they have a drain then ancef for as long as the drain is in.
Labs
- CBC, BMP postop and in the AM
Imaging
- MRI in AM (for tumor)
- CT postop (if any concern for postop hemorrhage)
- DVT prophylaxis: SCD boots/stockings
- Diet: NPO except for meds
- Activity: HOB 20-30, bed rest
7. Postop deterioration ddx: 
- Bleed (HCT, back to OR)
- Seizure (EEG, keppra/dilantin)
- Ischemia
- Hydrocephalus (HCT, EVD)
- Penumocephalus (just having air in the skull can cause neuro symptoms even without tension... lethargy, confusion, HA, n/v, seizures... air usually resorbs with improvement in sx in 1-3 days)
- Edema (HCT, steroids)
- Persistent anesthesia effects - unlikely if someone got better initially and then deteriorated. You can try naloxone if you think its opiate induced... be careful though.. if people go nuts that can cause elevated ICP
- Vasospasm
8. New {guidelines} on acute spinal cord injury: joint report by AANS and CNS: class 1 evidence - no steroids.
"Administration of methylprednisolone
(MP) for the treatment of acute spinal cord injury is
not recommended. Clinicians
considering MP therapy should bear in
mind that the drug is not FDA
approved for this application. There is
no Class I or Class II medical evidence
supporting the clinical benefit of MP in
the treatment of acute SCI. Scattered
reports of Class III evidence claim
inconsistent effects likely related to
random chance or selection bias.
However, Class I, II, and III evidence
exists that high-dose steroids are
associated with harmful side effects
including death."
9. Vertebral osteomyelitis and spinal epidural abscess often go together (the former often causes the latter) so finding one should prompt a search for the other.
10. Vertebral osteo: Risk factors
- IV drug use
- Diabetes (weird bacteria/fungal)
- Immunocompromised- AIDS, chronic steroids, alcoholism
- Dialysis patients (radiographic changes that look like osteo can occur even without infection)

- Postop 

- Endocarditis