Machine learning in action: Revolutionizing intracranial hematoma detection and patient transport decision-making.

Objectives: Traumatic intracranial hematomas represent a critical clinical situation where early detection and management are of utmost importance. Machine learning has been recently used in the detection of neuroradiological findings. Hence, it can be used in the detection of intracranial hematomas and furtherly initiate a management cascade of patient transfer, diagnostics, admission, and emergency intervention. We aim, here, to develop a diagnostic tool based on artificial intelligence to detect hematomas instantaneously, and automatically start a cascade of actions that support the management protocol depending on the early diagnosis. Materials and Methods: A plot was designed as a staged model: The first stage of initiating and training the machine with the provisional evaluation of its accuracy and the second stage of supervised use in a tertiary care hospital and a third stage of its generalization in primary and secondary care hospitals. Two datasets were used: CQ500, a public dataset, and our dataset collected retrospectively from our tertiary hospital. Results: A mean dice score of 0.83 was achieved on the validation set of CQ500. Moreover, the detection of intracranial hemorrhage was successful in 94% of cases for the CQ500 test set and 93% for our local institute cases. Poor detection was present in only 6-7% of the total test set. Moderate false-positive results were encountered in 18% and major false positives reached 5% for the total test set. Conclusion: The proposed approach for the early detection of acute intracranial hematomas provides a reliable outset for generating an automatically initiated management cascade in high-flow hospitals.

Postoperative cerebral infarction after evacuation of traumatic epidural hematoma in children younger than two years: Single-center experience.

Background: Epidural hematoma (EDH) forms about 2-3% of all head injuries in the pediatric population. We evaluated clinical data and risk factors for postoperative infarction in children younger than 2 years presented with traumatic EDH. Methods: We retrospectively reviewed and analyzed the data of 28 children with traumatic EDH operated in our institute during a period of 26 months (from December 2016 to Febuary 2019). Results: Nineteen children were boys (68%) and nine were girls (32%), the mean age was 15 months (range from 5 to 24 months). Postoperative cerebral infarction was detected in seven cases (25%). Factors could be linked to postoperative cerebral: preoperative pediatric Glasgow Coma Scale (P = 0.036), neurological deficit on admission (P = 0.023), size of hematoma (P < 0.001), time between trauma and surgery (P = 0.004), midline shift (MLS) (P = 0.001), and basal cistern compression (P = 0.004). Conclusion: Traumatic EDH in young children represents a neurosurgical challenge that needs rapid surgical intervention for the best surgical outcome. Delay in the time of surgery for more than 6 h, large hematoma volume >100 ml3, MLS >10 mm, and basal cisterns compression will push the intracranial pressure to the point of decompensation and the resultant ischemic sequel occurs.

Short-term outcomes of endoscopic evacuation of supratentorial spontaneous intracerebral hematoma: Early experience from developing country.

BACKGROUND: Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage (ICH). However, the technique still needs improvement. METHODS: We report our early clinical experience of using this technique to evacuate supratentorial spontaneous intracerebral hematomas and evaluate its short-term outcomes. RESULTS: The study included 15 patients, basal ganglia hematoma was the most common location 62.5%, mean preoperative hematoma volume was 61.07 cc, mean ICH score was 3, and mean rate of hematoma evacuation was 89.27%. Factors that could be related to mortality were Glasgow Coma Score (GCS) on admission (P = 0.001), ICH score (P = 0.004); postoperative GCS (P < 0.001), postoperative hematoma volume (P = 0.006); intraventricular extension (P = 0.001), and rate of evacuation (P = 0.001). CONCLUSION: Endoscopic technique is a safe surgical option for evacuation of spontaneous supratentorial ICH. This minimally invasive technique could be helpful to provide better short-term outcomes for selected patients. However, in our experience, this minimally invasive technique did not change the outcome for cases presented with poor GCS on admission 4/15. Our results warrant a future prospective, randomized, controlled efficacy trial.

Extent of Hyperostotic Bone Resection in Convexity Meningioma to Achieve Pathologically Free Margins.

OBJECTIVE: Hyperostosis in meningiomas can be present in 4.5% to 44% of cases. Radical resection should include aggressive removal of invaded bone. It is not clear however to what extent bone removal should be carried to achieve pathologically free margins, especially that in many cases, there is a T2 hyperintense signal that extends beyond the hyperostotic bone. In this study we try to investigate the perimeter of tumour cells outside the visible nidus of hyperostotic bone and to what extent they are present outside this nidus. This would serve as an initial step for setting guidelines on dealing with hyperostosis in meningioma surgery. METHODS: This is a prospective case series that included 14 patients with convexity meningiomas and hyperostosis during the period from March 2017 to August 2018 in two university hospitals. Patients demographics, clinical, imaging characteristics, intraoperative and postoperative data were collected and analysed. In all cases, all visible abnormal bone was excised bearing in mind to also include the hyperintense diploe in magnetic resonance imaging (MRI) T2 weighted images after careful preoperative assessment. To examine bony tumour invasion, five marked bone biopsies were taken from the craniotomy flap for histopathological examinations. These include one from the centre of hyperostotic nidus and the other four from the corners at a 2-cm distance from the margin of the nidus. RESULTS: Our study included five males (35.7%) and nine females (64.3%) with a mean age of 43.75 years (33-55). Tumor site was parietal in seven cases (50%), fronto-parietal in three cases (21.4%), parieto-occipital in two cases (14.2%), frontal region in one case and bicoronal (midline) in one case. Tumour pathology revealed a World Health Organization (WHO) grade I in seven cases (50%), atypical meningioma (WHO II) in five cases (35.7%) and anaplastic meningioma (WHO III) in two cases (14.2%). In all grade I and II meningiomas, bone biopsies harvested from the nidus revealed infiltration with tumour cells while all other bone biopsies from the four corners (2 cm from nidus) were free. In cases of anaplastic meningiomas, all five biopsies were positive for tumour cells. CONCLUSION: Removal of the gross epicentre of hyperostotic bone with the surrounding 2 cm is adequate to ensure radical excision and free bone margins in grade I and II meningiomas. Hyperintense signal change in MRI T2 weighted images, even beyond visible hypersototic areas, doesn't necessarily represent tumour invasion.

Report of a case of cavernous haemangioma of the cavernous sinus.

Cavernous haemangioma of the cavernous sinus is a rare vascular malformation. It's often confused with other parasellar masses. Here, we report a case of a female with a left parasellar mass which was misdiagnosed as schwannoma vs meningioma using CT and MRI. The patient was operated via the pterional approach but resection had been halted due to severe haemorrhage and only tumour biopsy could be obtained. The diagnosis of cavernous sinus haemangioma was established by histopathology and confirmed by subsequent digital subtraction angiography. The patient refused second surgery or adjuvant radiosurgery and the treatment strategy was observation and follow-up. Retrospectively, we included the key radiographic features of cavernous sinus haemangioma which would facilitate pre-operative diagnosis and avoid unforeseen operative complications. Diagnostic radiographic features include a well-defined mass in the cavernous sinus which shows isodense to slightly hyperdense attenuation on non-contrast CT scan with possible adjacent pressure bone remodelling. On MRI, it shows remarkable high T 2 signal; intense homogenous enhancement or characteristic progressive contrast enhancement on sequential enhanced images. On digital subtraction angiography, it may demonstrate a vascular blush.

Managing military penetrating brain injuries in the war zone: lessons learned.

OBJECTIVEManaging penetrating military brain injuries in a war zone setting is different than managing common civilian penetrating brain injuries. Triage, i.e., deciding on which patients to treat or not treat, and which to be flown back home, is essential to avoid wasting valuable limited resources. In this study the authors aim to identify reliable predictors of mortality and poor outcome to help develop a protocol for treating their patients in the battlefield. They also demonstrate all the lessons learned from their collective experience regarding some of the controversial management issues.METHODSThis study was a retrospective review of 102 patients with penetrating military missile head injuries treated by the authors in various facilities in northern Sinai between 2011 and 2018. Patient demographics, clinical characteristics, imaging characteristics, postoperative complications, and Glasgow Outcome Scale (GOS) scores were recorded for each patient. Several variables associated with mortality and poor outcome that were derived from the literature were analyzed, in addition to variables obtained by direct observation by the authors over time.RESULTSThere were 50 patients (49%) with GOS score of 1 (death), 12 patients (11.8%) with GOS score of 2 (survivors in persistent vegetative state), and 40 survivors (39.2%) with varying degrees of disability on the last follow-up evaluation. The authors identified an anatomical danger zone that was found to predict mortality when traversed. Bilateral dilated fixed pupils and low Glasgow Coma Scale score on admission were also found to be independent predictors of mortality and poor outcome. Based on these findings, a protocol was developed for managing these patients in the war zone.CONCLUSIONSManaging military penetrating head injuries in the war zone is different than civilian gunshot head injuries encountered by most neurosurgeons in urban cities. The authors developed a simple protocol for managing military penetrating injuries in the war zone. They also describe important lessons learned from this experience.

Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment.

BACKGROUND: Endovascular techniques have gained importance in recent years in the treatment of acutely ruptured aneurysms. Sometimes artificial anticoagulation or antiplatelet agents are indicated after endovascular aneurysm occlusion to prevent thromboembolic complications. Because many patients require ventriculostomy secondary to hydrocephalus, we analyzed ventriculostomy-related hemorrhage in patients with and without anticoagulant therapy. METHODS: Between January 2007 and December 2013, 444 patients with aneurysmal subarachnoid hemorrhage and acute hydrocephalus received treatment requiring ventriculostomy. Treatment-related complications were entered in a prospectively conducted database and analyzed retrospectively. All patients received low-molecular-weight heparin in prophylactic dosage starting 24 hours after aneurysm treatment. Heparin (dosage depending on patient weight) was administered during all endovascular procedures. RESULTS: In 117 of 444 patients (26%), additional anticoagulation or antiplatelet agents were administered after treatment of the ruptured aneurysm. Heparin was used in 70 of 117 patients (60%), acetylsalicylic acid was used in 61 (52%), clopidogrel was used in 25 (21%), and tirofiban was used in 23 (20%). In 42 patients (36%), anticoagulants and antiplatelet drugs were combined. Ventriculostomy-related hemorrhage was observed in 55 patients (12%). A ventriculostomy-related hemorrhage occurred in 28 of 117 patients (24%) with anticoagulation therapy and in 27 of 327 patients (8%) without anticoagulation therapy (P < 0.001). The hemorrhage rate in all patients receiving endovascular treatment was significantly higher than in patients receiving microsurgical treatment (P < 0.05). Hemorrhage was more likely to be observed when ventriculostomy was performed before the additional anticoagulation was started, although this was not statistically significant. No surgical intervention was necessary to treat ventriculostomy-related bleeding. CONCLUSIONS: Patients receiving endovascular treatment were at higher risk for ventriculostomy-related hemorrhage, especially when anticoagulation was administered after aneurysm occlusion. Although no clinically relevant external ventricular drain-related hemorrhage occurred, ventriculostomy should be performed before anticoagulation whenever possible.