Outcome of extensive compound fractures associated with brain fungation

Head injury patients may present with extensive compound fractures associated with brain fungation. This type of injury may associated with craniofacial injuries, orbital injuries and skull base fractures. The management and outcome of those patients is still unclear. To evaluate the outcome of those patients who had this type of injuries and highlighted the methods of their management. During the last four years, 18 patients were admitted to department of neurosurgery in Al-Noor Specialist Hospital in Holy Makkaha, They were suffering from extensive compound fractures associated with brain fungation. Cause of injury included R.T.A in 11 patients, fall from height in 2 children, work injury in 2 patients, fall of heavy object in one patient, history of assault in one patient, and a kick by a horse in one child. Fourteen patients were males and 4 females. Mean age was 21 years [range from 4 to 37 years]. On admission, Fourteen patients had severe and 4 had moderate head injuries according to GCS. Eight patients had associated maxillofacial injuries, six had orbital injuries, two had nasal injuries and 11 had skull base fractures and 10 of them had CSF rhinorrhea. After resuscitation, CT Scan was done for the brain, orbit, facial bones and cervical spine. Urgent surgical repair was done for 18 patients by cleaning of the wound, control of bleeding, excision of lacerated brain, repair of the dura using fascia lata, reposition of skull bone fragments, and scalp repair. Optic nerve decompression was done in 2 patients to elevate compressing bone fragments. Open facial, nasal and orbital injuries were managed in the same time by concerned specialities. Closed maxillofacial fractures were managed after 10-14 days. All patients were managed initially in ICU by mechanical ventilation. Mean follow-up period was 22 months [range from 6- 42 months. Bilateral loss of vision occurred in one patient and unilateral blindness in 3 patients. CSF rhinorrhea stopped spontaneously within 10 days in seven patients and external lumber drainage for several days was done in 3 patients to control the condition. Postoperative meningitis developed in 3 [16.7%] out of 18 operated patients, two of them recovered and one died because of the infection after three months, another patient died due to severe brain injury and postoperative the patient became brain death and died after 24 hours. Outcome was evaluated according to Glasgow Outcome Scale, seven patients had Glasgow outcome score [GOS] of 4, another 6 patients had COS of 3, and 3 patients had GOS of 2. The mortality rate [2 patients 11%]. Urgent neurosurgical repair for extensive compound fractures associated with brain fungation would be associated with good outcome and had low mortality rate due to infection and severe injury. These results are better than that of closed head injury. However, traumatic unilateral or bilateral loss of vision may develop in one third of those patients. In future this study needs large number of patients to be involved and intracranial pressure monitoring during the initial course of treatment in intensive care unit

Early experience with surgical management of cerebral aneurysms: report of 32 cases

To review the results of surgical intervention in 32 patients with cerebral aneurysms aiming to find out the pitfalls and lessons one can learn from this early experience with aneurysm surgery. The clinical, radiological and operative data of 32 patients operated for cerebral aneurysms were correlated with 3-month clinical outcome. Clinical data included: age, gender and clinical grading according to the World Federation of Neurological surgeons classification. Radiological data included site, size, neck size of the aneurysm, and the presence of associated vasospasm, intracerebral hemorrhage, and/or hydrocephalus. Operative data included brain swelling, intraoperative aneurysm rupture, temporary clipping of parent vessels, and difficult clipping. Outcome was assessed according the Glasgow outcome score [GOS]. Out of 32 patients, 25 [78.1%] had favorable outcome [GOS 3 and 4], and 7 [21.9%] had unfavorable outcome [GOS 0, 1 and 2]. All early-operated grade 4- and 5-patients died [n=4]. On the other hand, unfavorable outcome was observed in 22% of grade 3-patients and in 5% only of grade 1- and 2-patients. Meanwhile, the following factors were associated with unfavorable outcome: brain edema [40%], vasospasm [33.3%], temporary clipping [55.5%], intraoperative rupture of aneurysm [57%]. These factors were frequently observed in early-operated grade 3-, 4- and 5-patients. In grade 3-, 4- and 5-patients, unfavorable outcomes associated with early- and late-surgery were 83% and 14%, respectively. When early-operated grade 3-, 4- and 5-patients were eliminated from the analysis, the incidence of unfavorable outcome decreased to less than 8%.In order to minimize the postoperative morbidity and mortality in newly-developed neurovascular centers, it would be recommended to avoid early surgical intervention for patients in grade 3, 4 and 5

Use of thallium-201 sepct to differentiate recurrent glioma from radiation necrosis

Recurrent glioma in patients who are symptomatic after high dose of radiotherapy is difficult to differentiate from radiation necrosis by conventional imaging techniques [CT] scan and MR imaging. Thailuim-201 SPECT is useful in prediction the viable tumour cells in patients with glioma. To clarify the usefuillness of TL-201 SPECT in differentiating the tumour recurrence from radiation necrosis and to evaluate the relationship between tumour perfusion and early TL-201 uptake. Thirty-six patients [age ranged from 16 to 65 years old 26 males and 10 females] deteriorated clinically after high dose of radiation therapy. CT scan or MR imaging performed in all patients, but failed to differentiate between the recurrence of tumour and radiation necrosis 111 MBQ of Thallium-201 were injected and first minute perfusion, early [15 minutes post injection] and late [3 hours post injection] SPECT images were acquired. The results were assessed by both visual [semi quantitative] and Quantitative evaluation. We found a sensitivity, specificity and accuracy of 97.2% 93.2 and 94.4% respectively for visual evaluation. And for the quantitative evaluation the sensitivity, specificity and accuracy were 100%, 94.4% and 97.2% respective. The mean Thallium-201index [T1] and retention index [R1] for recurrent gliomas were 2.6 and 2.0 for both early and delayed Scans respectively: while in radiation necrosis the indices were [1.1 +/- SD 0.1] in early scans and [1.1 +/- SD0] for delayed scans. Two patients in our study had a contradictory results; one had a recurrent glioma with TL-201 index [T1] 1.8 and retention index [R1] 13% [false negative] while the other patient diagnosed pathologically as radiation necrosis and had a T1 and R1 of 2.7 and 18,5% respectively [false positive]. The mean retention indices for both recurrence and radiation necrosis in our study were 21% and 8.7% respectively. Also we found a poor correlation between perfusion and early TL-201 uptake in the study group [rho= 0.41]. The quantitative 201 TL SPECT is a useful noninvasive tool for differentiating recurrent glioma from post radiation necrosis

Use of thallium-201 spect to differentiate recurrent glioma from radiation necrosis

Recurrent glioma in patients who are symptomatic after high dose of radiotherapy is difficult to differentiate from radiation necrosis by conventional imaging techniques [CT] scan and MR imaging. Thallium-201 SPECT is useful in prediction of the viable tumour cells in patients with glioma. This study was proposed to clarify the usefullness of TL-201 SPECT in differentiating the tumour recurrence from radiation necrosis and to evaluate the relationship between tumour perfusion and early TL-201 uptake. Thirty-six patients [age ranged from 16 to 65 years old, the mean of the age 40.5, 26 males and 10 females] deteriorated clinically after high dose of radiation therapy. CT Scan or MR imaging performed in all patients, but failed to deferentaite between the recurrence of tumour and radiation necrosis. Ill MBQ of Thallium-201 were injected and first minute perfusion, early [15 minutes post-injection] and late [3 hours post-injection] SPECT images were acquired. The results were assessed by both visual [semiqunatitative] and Quantitative evaluation. We found a sensitivity, specificity and accuracy of 97.2% 93.2% and 94.4% respectively for visual evaluation. And for the quantitative evaluation the sensitivity specificity and accuracy were 100%, 94.4% and 97.2% respectively. The mean Thallium-201 index [T l] for recurrent gliomas were 2.6 and 2.0 for both early and delayed scans respectively; while in radiation necrosis the indices were [1.1 +/- SD 0.1] in early scans and [1.1 +/- SDo] for delayed scans. Two patients in our study had a contradictory results; one had a recurrent glioma with TL-201 index [T l] 1.8 and retention index [R l]13% [false negative] while the other patient diagnosed pathologically as radiation necrosis and had a Tl and Rl of 2.7 and 18.5% respectively [false positive]. The mean retention indices for both recurrence and radiation necrosis in our study were 21% and 8.7% respectively. Also we found a poor correlation between perfusion and early TL-201 uptake in the study group [rho=0.41]. In conclusion we believe that quantitative 201 TL SPECT is a useful non-invasive tool for differentiating recurrent glioma from postradiation necrosis

Study of percentage of population in s-phase in primary meningioma by dna flow cytometry as predictor for recurrence: correlation with clincopathologic prognostic factors

Despite the gross total resection of meningiomas, there is a significant rate of recurrence approaching 20% at 20 years. The prediction of recurrence by clinical and histopathological factors are inadequate, Flow cytometric analysis of deoxyribonucleic acid [DNA] in meningiomas has shown a correlation between a high proliferative index based on tumor cell- cycle stage [percentage of S and percentage of G2/M] and clinically aggressive behavior. Accordingly the DNA analysis of meningioma may be of value in predicting recurrence of the tumors. A series of 130 meningiomas with gross total resection were analyzed. All available microscopic slides were reclassified according to the revised World Health Organization system [WHO].Sections were then taken for flow cytometry study. Thirty-eight [29%] of primary meningiomas associated with recurrence. Only strong significant correlation of histological grading, mitotic index and tumor necrosis with recurrence [the recurrence indices were respectively 27% in Gl meningioma, 75% in GII and 100% in GIII meningiomas [p < 0.001]. Mitotic counts were statistically higher in the recurrent group [6.32 +/- 5.44 for recurrent meningioma and 0.51 +/- 0.53 for non-recurrent. The difference between the two groups was statistically significant [p< 0.001], and necrosis was more observed in recurrent meningioma in 15 cases of 27 cases had tumor necrosis. DNA flow cytometry analysis showed that recurrent benign meningiomas had high SPF in comparison with that benign without recurrence. [SPF mean 10.86 +/- 5.5 and 7.35 +/- 2.8 respectively]. In conclusion these results support the suggestion of that flow cytometry may be of value in the prediction of recurrence of histologically benign macsroscopically removed meningiomas

new scoring system for lumbar disc prolapse

The object of this study was to introduce a new scoring system for the severity of lumbar disc that has a significant stratification of outcome between individual scores of patients, and in this way, it can help in selecting patients who will most likely benefit from surgical treatment. To identify potential factors in a risk prediction tool, we conducted a multivariate logistic regression analysis of patients-and lesion-specific factors suspected to be associated with outcome in a series of 383 patients with lumbar disc prolapse, of whom 160 patients were managed conservatively and 223 patients were managed surgically. Factors that were strongly associated with outcome were used to develop a comprehensive scoring system for the severity of lumbar disc prolapse. Our results showed that 10 factors were strongly associated with outcome; 4 factors in the patient's history, 3 in clinical examination and 3 in the finding of CT scan or MR imaging. In the system, one point was given for each of those 10 factors. By adding the total points, a 10-point scoring system was obtained. According to this scoring system, while the outcome was directly related to the preoperative score in the surgical group [r=0.63 and P> 0.001], it was inversely related to the preoperative score in the conservative group [r=0.59 and P<0.001]. Our results indicate that the prototype of our scoring system is easy to apply, highly predictive of outcome, and can be used as a guide for the usefulness of surgical intervention