Management strategy of depressed skull fractures

The aim of the study is to examine the efficacy of a conservative approach in the management of depressed skull fractures. A prospective study of 120 patients with depressed skull fractures treated at Salmaniya Medical Complex from January 1998 to December 2006. There were 108 males and 12 females, age range was 12 months to 80 years, and the mean age was 40 years. All patients underwent skull x-ray and cranial CT scan. Depressed fractures due to missile injuries were excluded from the study. Selective criteria for conservative and surgical managements were specified. The group treated conservatively compared favourably with surgical group in outcome. Object fall on the head was the cause of depressed fracture in 30% of our patients, fall from a height in 19%, road traffic accident in 20%, sports injury in 10%, assault in 19.8% and suicidal attempt in 1.2%. Parietal bone was injured in 44%, frontal bone in 32%, temporal bone in 18% and occipital bone in 6%. Seventy-two percent were compound depressed fractures and 28% were simple depressed fractures. Eighty-four patients were managed conservatively, 56 patients with compound fractures [66.7%] and 28 patients [33.3%] with simple fractures. Significant extra-axial haematoma was the indication for elevation of the fracture in 40% of the surgical group, significant wound contamination, brain tissue and CSF in the wound in 5%, frontal sinus involvement in 15%, cosmetic deformity in 25%, fracture on the superior sagittal sinus in 10% and right sided hemiplegia in 5%. Our study demonstrates that 70% of patients with depressed skull fractures can be safely managed conservatively without major surgical intervention. The major proportion of compound depressed skull fractures [66.7%] can be selected for conservative treatment without compromise of health and with a major socioeconomic advantage and short hospital stay

Infection of cerebrospinal fluid shunt

Aims of this study were to determine the infection rate in patients who underwent cerebrospinal fluid shunt [CSF], and to identify the risk factors in aetiology of the infection. Retrospective analysis of 94 patients underwent some form of CSF shunt surgery [177 procedures] at Salmaniya Medical Complex. Medical records were reviewed; patient's age, diagnosis, and cause of hydrocephalus were confirmed; type of shunt, number of procedures in each patient, infection and causative microorganisms were identified. Infection of CSF shunt was defined by the presence of microorganisms in the CSF or shunt colonisation with microorganism seen on microscopic examination or grown from culture of CSF, or the catheter, in association with clinical features of infection. All patients received antibiotics at induction of anaesthesia and at least 48 hours postoperatrvely. All shunts were flushed and primed with antibiotic containing solution. Exclusion criteria: 1. Patients underwent external ventricular drainage only. 2. Patient underwent endoscopic third ventriculostomy only. 3. Patients underwent CSF diversion in other hospital. 4. Patients with sepsis not related to their CSF shunt. A total of 94 patients underwent 177 CSF shunt surgeries between January 1993 and December 2002. Age range was 0-20 years. Mean age was 8 years. There were 56 males and 38 female. Cerebrospinal fluid shunt included ventriculoperitoneal shunt [VP shunt] 173 [97.7%] procedures, lumboperitoneal shunt [LP shunt] 1 [0.6%] procedure, subdural peritoneal shunt 2 [1.1%] procedures, and Dandy-Walker cystoperitoneal shunt 1 [0.6%] procedure. Infection was documented in 14 [14.89%] patients out of 94 shunted individuals. Infection rate was 17.5% in 31 procedures out of 177 over a period of 10 years. Staphylococcus aureus was isolated in 25.8% of procedures, staphylococcus epidermides in 19.4%, klebsiella pneumonia 14%, pseudomonas aeruginosa in 9.7%, enterococci in 14%, beta-haemolytic streptococci in 7%, E coli in 7%, Candida albicans in 3%, and Mozzarrolla catarrhalis in 3%.Risk factors included premature infants, repeated revisions of the shunts, and environment at which the shunt was reviewed. Our infection rate was higher than other Neurosugical centres. The risk of cerebrospinal shunt infection may be reduced or minimised and risk factors should be identified. Prematurity in hydrocephalic newboms is considered as a risk factor for shunt infection; precautions and alternatives to shunt placement in premature infants may be adopted like delaying the CSF diversion if neurological condition of the infant permits and infants body weight exceeds 2 kgs. Strict adherence to meticulous non-touch surgical technique of shunt system is an essential factor in prevention of infection. Minimising the operative time is another factor that should be respected. Cerebrospinal fluid shunt procedures must be performed in a clean neurosurgical operating room, even in emergency situations. If infection takes place, it should be managed by antibiotics with removal of the infected shunt and external ventricular drainage

Clinicopathological analysis of brain tumours

The purpose of this study is to define the incidence of brain tumours in Bahrain, and to provide an overview of the management of newly diagnosed brain tumours. Retrospective clinicopathological analysis of newly diagnosed brain tumours in the neurosurgical unit at Salmaniya Medical Complex. Between 1990 and 1999 a total of 139 patients, newly diagnosed with brain tumours, 76 [54.7%] were males and 63 were females [45.3%]. Ninety-seven [69.78%] patients were Bahraini and 42 [30.22%] patients were non- Bahraini. The incidence rate was 2.09 per 100,000 per year. The main presenting symptom at the time of diagnosis was headache in 83 cases [59.71%]. Thirty-six [25.90%] patients were operated abroad and followed up postoperatively in our department, while 69 [49.64%] were operated in Bahrain. Gross total surgical resection was done for 62 cases [44.60%], debulking and/or biopsy for 43 [30.94%] cases, and no surgery for 34 [24.46%] cases. Afollow-up period of 30 days postoperatively was achieved in 69 cases. There were 5 deaths [7.25%], 9 [13.04%] sustained new neurological deficits, 12 [17.39%] transient operative complications, and 7 [10.14%] showed transient medical complications, while 36 [52%] improved or showed no change. The incidence of brain tumours in the Kingdom of Bahrain is 2.09 per 100,000 per year. It is lower than that detailed in several other studies. A national brain tumour registry is required to document these tumours and to obtain a reliable reference. Several cases present at a later stage of their disease to the neurosurgeon and this is partly related to lack of clinical awareness of general practitioners in local health centres and the private sector. Some patients are still traveling overseas to undergo surgery and return with unclear medical reports and histological diagnosis