The Unique Relationship between Neuro-Critical Care and Critical Illness-Related Corticosteroid Insufficiency : Implications for Neurosurgeons in Neuro-Critical Care

The brain houses vital hormonal regulatory structures such as the hypothalamus and pituitary gland, which may confer unique susceptibilities to critical illness-related corticosteroid insufficiency (CIRCI) in patients with neurological disorders. In addition, the frequent use of steroids for therapeutic purposes in various neurological conditions may lead to the development of steroid insufficiency. This abstract aims to highlight the significance of understanding these relationships in the context of patient care and management for physicians. Neurological disorders may predispose patients to CIRCI due to the role of the brain in hormonal regulation. Early recognition of CIRCI in the context of neurological diseases is essential to ensure prompt and appropriate intervention. Moreover, the frequent use of steroids for treating neurological conditions can contribute to the development of steroid insufficiency, further complicating the clinical picture. Physicians must be aware of these unique interactions and be prepared to evaluate and manage patients with CIRCI and steroid insufficiency in the context of neurological disorders. This includes timely diagnosis, appropriate steroid administration, and careful monitoring for potential adverse effects. A comprehensive understanding of the interplay between neurological disease, CIRCI, and steroid insufficiency is critical for optimizing patient care and outcomes in this complex patient population.

Surgical Outcomes of Sphenoid Wing Meningioma with Periorbital Invasion

Objective@#: The aim of this study was to evaluate the clinical outcome of sphenoid wing meningioma with periorbital invasion (PI) after operation. @*Methods@#: Sixty one patients with sphenoid wing meningioma were enrolled in this study. Their clinical conditions were monitored after the operation and followed up more than 5 years at the outpatient clinic of a single institution. Clinical and radiologic information of the patients were all recorded including the following parameters : presence of PI, presence of peri-tumor structure invasion, pathologic grade, extents of resection, presence of hyperostosis, exophthalmos index (EI), and surgical complications. We compared the above clinical parameters of the patients with sphenoid wing meningioma in the presence or absence of PI (non-PI), then linked the analyzed data with the clinical outcome of the patients. @*Results@#: Of 61 cases, there were 14 PI and 47 non-PI patients. PI group showed a significantly higher score of EI (1.37±0.24 vs. 1.00±0.01, p<0.001), more frequent presence of hyperostosis (85.7% vs. 14.3%, p<0.001), and lower rate of gross total resection (GTR) (35.7% vs. 68.1%, p=0.032). The lower score of pre-operative EI, the absence of both PI and hyperostosis, smaller tumor size, and the performance of GTR were associated with lower recurrence rates in the univariate analysis. However, in the multivariate analysis, the performance of GTR was the only significant factor to determine the recurrence rate (p=0.043). The incidences of surgical complications were not statistically different between the subtotal resection (STR) and GTR groups, but it was strongly associated tumor size (p=0.017). @*Conclusion@#: The GTR group showed lower recurrence rate than the STR group without differences in the surgical complications. Therefore, the GTR is strongly recommended to treat sphenoid wing meningioma with PI for the better clinical outcome.

Missed Skeletal Trauma Detected by Whole Body Bone Scan in Patients with Traumatic Brain Injury

Objective@#: Unclear mental state is one of the major factors contributing to diagnostic failure of occult skeletal trauma in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the overlooked co-occurring skeletal trauma through whole body bone scan (WBBS) in TBI. @*Methods@#: A retrospective study of 547 TBI patients admitted between 2015 and 2017 was performed to investigate their cooccurring skeletal injuries detected by WBBS. The patients were divided into three groups based on the timing of suspecting skeletal trauma confirmed : 1) before WBBS (pre-WBBS); 2) after the routine WBBS (post-WBBS) with good mental state and no initial musculoskeletal complaints; and 3) after the routine WBBS with poor mental state (poor MS). The skeletal trauma detected by WBBS was classified into six skeletal categories : spine, upper and lower extremities, pelvis, chest wall, and clavicles. The skeletal injuries identified by WBBS were confirmed to be simple contusion or fractures by other imaging modalities such as X-ray or computed tomography (CT) scans. Of the six categorizations of skeletal trauma detected as hot uptake lesions in WBBS, the lesions of spine, upper and lower extremities were further statistically analyzed to calculate the incidence rates of actual fractures (AF) and actual surgery (AS) cases over the total number of hot uptake lesions in WBBS. @*Results@#: Of 547 patients with TBI, 112 patients (20.4 %) were presented with TBI alone. Four hundred and thirty-five patients with TBI had co-occurring skeletal injuries confirmed by WBBS. The incidences were as follows : chest wall (27.4%), spine (22.9%), lower extremities (20.2%), upper extremities (13.5%), pelvis (9.4%), and clavicles (6.3%). It is notable that relatively larger number of positive hot uptakes were observed in the groups of post-WBBS and poor MS. The percentage of post-WBBS group over the total hot uptake lesions in upper and lower extremities, and spines were 51.0%, 43.8%, and 41.7%, respectively, while their percentages of AS were 2.73%, 1.1%, and 0%, respectively. The percentages of poor MS group in the upper and lower extremities, and spines were 10.4%, 17.4%, and 7.8%, respectively, while their percentages of AS were 26.7%, 14.2%, and 11.1%, respectively. There was a statistical difference in the percentage of AS between the groups of post-WBBS and poor MS (p=0.000). @*Conclusion@#: WBBS is a potential diagnostic tool in understanding the skeletal conditions of patients with head injuries which may be undetected during the initial assessment.

Delayed Traumatic Subarachnoid Hemorrhage in a Polytraumatized Patient with Disseminated Intravascular Coagulation / 대한중환자의학회지

The precise mechanism involved in DIC and delayed traumatic subarachnoid hemorrhage (DT-SAH) remains unclear in multiple-trauma patients. Hereby, we describe a polytraumatized patient with DIC who died due to DT-SAH. A 75-year-old female patient was admitted to our Emergency Department complaining of abdominal pain and drowsiness after a pedestrian accident. Her initial brain computerized tomography (CT) finding was negative for intracranial injury. However, her abdominal CT scan revealed a collection of retroperitoneal hematomas from internal iliac artery bleeding after a compressive pelvic fracture. This event eventually resulted in shock and DIC. An immediate angiographic embolization of the bleeding artery was performed along with transfusion and anti-thrombin III. Her vital signs were stabilized without neurological change. Fourteen hours after admission, she suddenly became comatose, and her follow-up brain CT scan revealed a dense DT-SAH along the basal cisterns with acute hydrocephalus. This event rapidly prompted brain CT angiography and digital subtraction angiography, which both confirmed the absence of any cerebrovascular abnormality. Despite emergency extraventricular drainage to reverse the hydrocephalus, the patient died three days after the trauma. This paper presents an unusual case of DT-SAH in a polytraumatized patient with DIC.

Clinical Analysis of Delayed Surgical Epidural Hematoma / 대한신경손상학회지

OBJECTIVE: A small epidural hematoma (EDH) that has been diagnosed to be nonsurgical by initial brain computed tomography (CT) can increase in size and need surgical removal, resulting in a poor prognosis. However, there have been few studies, which focused delayed operated EDH. Therefore, we analyzed the clinical factors to determine the predicting factors of delayed operated EDH. METHODS: Between January 2011 and January 2014, 90 patients, who were admitted due to EDH, were enrolled in this study. None of the patients were indicated for operation initially. Based on the presence of surgery, we classified the patients into a delayed-surgery group (DG) and a non-surgical group (NG). Additionally, we analyzed them according to the following: time interval between the trauma and the initial CT, gender, age, medical history, drinking, change of mean arterial pressure (MAP), volume of EDH and other traumatic brain lesion. RESULTS: Among the 90 patients, the DG was 19 patients. Compared with NG, the DG revealed increased MAP, less presence of drinking, and a short time interval (DG vs. NG: +9.684 mm Hg vs. -0.428 mm Hg, 5.26% vs. 29.58%, 1.802 hours vs. 5.707 hours, respectively, p<0.05). Analyzing the time interval with receiver operating characteristic, there was 88.2% sensitivity and 68.3% specificity at the 2.05-hour cut-off value (area under the curve=0.854). CONCLUSION: According to our results, the time interval between the trauma and the initial CT along with blood pressure change are potential predicting factors in the cases of delayed operation of EDH.

Delayed Traumatic Subarachnoid Hemorrhage in a Polytraumatized Patient with Disseminated Intravascular Coagulation / 대한구급학회지

The precise mechanism involved in DIC and delayed traumatic subarachnoid hemorrhage (DT-SAH) remains unclear in multiple-trauma patients. Hereby, we describe a polytraumatized patient with DIC who died due to DT-SAH. A 75-year-old female patient was admitted to our Emergency Department complaining of abdominal pain and drowsiness after a pedestrian accident. Her initial brain computerized tomography (CT) finding was negative for intracranial injury. However, her abdominal CT scan revealed a collection of retroperitoneal hematomas from internal iliac artery bleeding after a compressive pelvic fracture. This event eventually resulted in shock and DIC. An immediate angiographic embolization of the bleeding artery was performed along with transfusion and anti-thrombin III. Her vital signs were stabilized without neurological change. Fourteen hours after admission, she suddenly became comatose, and her follow-up brain CT scan revealed a dense DT-SAH along the basal cisterns with acute hydrocephalus. This event rapidly prompted brain CT angiography and digital subtraction angiography, which both confirmed the absence of any cerebrovascular abnormality. Despite emergency extraventricular drainage to reverse the hydrocephalus, the patient died three days after the trauma. This paper presents an unusual case of DT-SAH in a polytraumatized patient with DIC.

Retrieval of Unintended Migrated Detached Coil: Case Report

Owing to the rapid development of intervention techniques and devices, endovascular coil embolization of cerebral arteries has become standardized. It is particularly preferred when a patient presents with an unruptured intracranial aneurysm of the posterior communicating artery (PcomA). However, the risk of thrombogenic complications of the coil migration may also result in a large cerebral infarction. When coil migration occurs during embolization, a procedure for removal of the embolic coil should be performed immediately. We experienced a clinically rare case of migration of a framing coil to the distal middle cerebral artery aneurysm during endovascular embolization of an unruptured PcomA aneurysm. The migrated coil was barely retrieved using snare techniques.

Comparison of the Pattern in Semi-Quantitative Sputum Cultures Based on Different Endotracheal Suction Techniques / 대한구급학회지

BACKGROUND: The endotracheal suction was one of the critical requirements for severe neurosurgical patients in the prevention of the airway-obstruction, pneumonia, atelectasis, and so on. There were two types of suction methods, closed and open. In the literature, many reported the comparison of the two methods with variable factors, yet, it was still controversial. In this study, we compared the two types of endotracheal suction methods based on the pattern of the sputum cultivation, which was not discussed in the previous studies. METHODS: In 2010, 85 patients who had intubation tube for more than 10 days were evaluated in this study. A total of 55 patients were managed with an open suction method, while the other 30 patients were managed with a closed suction method. All patients' sputum culture was reported semi-quantitatively, and had been classified into 3 different groups, according to the culture pattern. The control group was defined in which the bacterial count was not increased, whereas the non-control group was those with bacterial count increased. We investigated patients' age, gender, disease-type, suction techniques and the pattern of sputum cultivation. RESULTS: The non-control group was 45.45% in the open suction group, while it was 16.67% in the closed suction group. On the other hand, more control group was observed in the closed suction group (36.67%), than in the open suction group (25.45%) (p < 0.05). There was no statistically significant difference in the analysis based on the pattern of sputum cultivation, age, gender, and disease-type. CONCLUSIONS: We suggest that the closed suction methods were more effective in the management of endotracheal tube, according to the pattern of sputum culture.

Initial Evaluation of Patients with Head Injury using CT Brain Perfusion Imaging in the Emergency Room: Two Cases

Acute subdural hematoma (SDH) is a neurological trauma that can lead to death or life-long disability of the patient. It is usually diagnosed by examination of the patient's brain computed tomography (CT) images. While macroscopic change in the posttraumatic brain can be identified using this mode of diagnosis, visualization of abnormal change in cerebral blood flow and the resulting brain damage following a head injury is often difficult. The two patients studied in this case report were similar in terms of thickness and volume of subdural hematoma and severity of midline shift. However, their perfusion parameters were markedly different and so were their outcomes. According to findings of our study, with its perfusion parameters, CT brain perfusion imaging is a practical tool for use in initial evaluation of patients with traumatic brain injury and for prediction of the clinical prognosis. Subsequently, we may use the information for help in planning of treatment and in preparation for post-operative complication based on the severity of brain damage.