Firearm-Related Traumatic Brain Injuries in Adults: A Scoping Review.

BACKGROUND AND OBJECTIVES: Firearm-related traumatic brain injury (TBI) has emerged as a significant public health issue in the United States, coinciding with a rapid increase in gun-related deaths. This scoping review aims to update our understanding of firearm-related TBI in adult populations. METHODS: A comprehensive search of 6 online databases yielded 22 studies that met the inclusion criteria. The reviewed studies predominantly focused on young adult men who were victims of assault, although other vulnerable populations were also affected. RESULTS: Key factors in evaluating patients with firearm-related TBI included low Glasgow Coma Scale scores, central nervous system involvement, hypotension, and coagulopathies at presentation. Poor outcomes in firearm-related TBIs were influenced by various factors, including the location and trajectory of the gunshot wound, hypercoagulability, hemodynamic instability, insurance status, and specific clinical findings at hospital admission. CONCLUSION: Proposed interventions aimed to reduce the incidence and mortality of penetrating TBIs, including medical interventions such as coagulopathy reversal and changes to prehospital stabilization procedures. However, further research is needed to demonstrate the effectiveness of these interventions. The findings of this scoping review hope to inform future policy research, advocacy efforts, and the training of neurosurgeons and other treating clinicians in the management of firearm-related TBI.

Cerebral microdialysis and glucopenia in traumatic brain injury: A review.

Traditionally, intracranial pressure (ICP) and partial brain tissue oxygenation (PbtO2) have been the primary invasive intracranial measurements used to guide management in patients with severe traumatic brain injury (TBI). After injury however, the brain develops an increased metabolic demand which may require an increment in the oxidative metabolism of glucose. Simultaneously, metabolic, and electrical dysfunction can lead to an inability to meet these demands, even in the absence of ischemia or increased intracranial pressure. Cerebral microdialysis provides the ability to accurately measure local concentrations of various solutes including lactate, pyruvate, glycerol and glucose. Experimental and clinical data demonstrate that such measurements of cellular metabolism can yield critical missing information about a patient's physiologic state and help limit secondary damage. Glucose management in traumatic brain injury is still an unresolved question. As cerebral glucose metabolism may be uncoupled from systemic glucose levels due to the metabolic dysfunction, measurement of cerebral extracellular glucose concentrations could provide more predictive information and prove to be a better biomarker to avoid secondary injury of at-risk brain tissue. Based on data obtained from cerebral microdialysis, specific interventions such as ICP-directed therapy, blood glucose increment, seizure control, and/or brain oxygen optimization can be instituted to minimize or prevent secondary insults. Thus, microdialysis measurements of parenchymal metabolic function provides clinically valuable information that cannot be obtained by other monitoring adjuncts in the standard ICU setting.

The impact of a night float system on operative experience in neurosurgery residency.

OBJECTIVE: Since the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions in 2003, many residency programs have adopted a night float system to comply with time constraints. However, some surgical subspecialities have been concerned that use of a night float system deprives residents of operative experience. In this study, the authors describe their training program's transition to a night float system and its impact on resident operative experience. METHODS: The authors conducted a single-program study of resident surgical case volume before and after implementing the night float system at 3 of their 5 hospitals from 2014 to 2020. The authors obtained surgical case numbers from the ACGME case log database. RESULTS: Junior residents received a concentrated educational experience, whereas senior residents saw a significant decrease from 112 calls/year to 17. Logged cases significantly increased after implementation of the night float system (8846 vs 10,547, p = 0.04), whereas cases at non-night float hospitals remained the same. This increase was concurrent with an increase in hospital cases. This difference was mainly driven by senior resident cases (p = 0.010), as junior and chief residents did not show significant differences in logged cases (p > 0.40). Lead resident cases increased significantly after implementation of the night float system (6852 vs 8860, p = 0.04). When normalized for increased hospital cases, resident case increases were not statistically significant. CONCLUSIONS: Transitioning to a night float call system at the authors' institution increased overall resident operative cases, particularly for lead resident surgeons. Based on the results of this study, the authors recommend the use of a night float call system to consolidate night calls, which increases junior resident-level educational opportunities and senior resident cases.

Neurolymphomatosis of the brachial plexus from atypical primary central nervous system lymphoma lesions: A case report and review of the literature.

Background: Primary central nervous system lymphoma (PCNSL) is an aggressive and extranodal non-Hodgkin lymphoma limited to the neuroaxis. In immunocompetent individuals, PCNSL is more common in older adults and lacks the association with the Epstein-Barr virus found in individuals with AIDS-associated PCNSL. Because the clinical presentation and radiographic findings of PCNSL are highly variable, stereotactic brain biopsy is typically required for definitive diagnosis. High-dose methotrexate, in combination with other chemotherapeutic agents with or without whole brain radiation, is the mainstay of treatment. Case Description: A 70-year-old HIV-negative woman presented with confusion, acute flaccid left arm weakness, and left hand numbness. Head computed tomography without contrast demonstrated a 1 cm hyperdense round lesion in the suprasellar cistern that prompted further evaluation. Gadolinium-enhanced brain magnetic resonance imaging demonstrated enhancing lesions with heterogeneous signal intensity in the suprasellar, pineal, and right periatrial regions that did not explain the limb weakness and numbness. Serum and cerebrospinal fluid (CSF) studies were unrevealing, and a diagnosis of PCNSL was made following stereotactic biopsy. The patient's liver cirrhosis precluded chemotherapy, but treatment with whole-brain radiation was pursued. Conclusion: The myriad clinical presentations and insidious course of PCNSL contribute to diagnostic difficulties, delays in treatment, and poor outcomes. Stereotactic brain biopsy is the primary method of PCNSL diagnosis since malignant cells are typically not detected in CSF. PCNSL should be considered in the differential diagnosis when immunocompetent elderly patients present with multiple intracranial lesions, even in the presence of lower motor neuron findings.

Racial and Socioeconomic Disparities in Patients With Meningioma: A Retrospective Cohort Study.

BACKGROUND: Meningiomas are the most common intracranial neoplasms. Although genomic analysis has helped elucidate differences in survival, there is evidence that racial disparities may influence outcomes. African Americans have a higher incidence of meningiomas and poorer survival outcomes. The etiology of these disparities remains unclear, but may include a combination of pathophysiology and other factors. OBJECTIVE: To determine factors that contribute to different clinical outcomes in racial populations. METHODS: We retrospectively reviewed 305 patients who underwent resection for meningiomas at a single tertiary care facility. We used descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses to study clinical, radiographical, and histopathological differences. RESULTS: Minority patients were more likely to present through the emergency department than an outpatient clinic (P < .0001). They were more likely to present with more advanced clinical symptoms with lower Karnofsky Performance scores, more frequently had peritumoral edema (P = .0031), and experienced longer postoperative stays in the hospital (P = .0053), and African-American patients had higher hospitalization costs (P = .046) and were more likely to be publicly insured. Extent of resection was an independent predictor of recurrence freedom (P = .039). Presentation in clinic setting trended toward an association with recurrence-free survival (P = .055). We observed no significant difference in gross total resection rates, postoperative recurrence, or recurrence-free survival. CONCLUSION: Minority patients are more likely to present with severe symptoms, require longer perioperative hospitalization, and generate higher hospitalization costs. This may be due to socioeconomic factors that affect access to health care. Targeting barriers to access, especially to subspecialty care, may facilitate more appropriate and timely diagnosis, thereby improving patient care and outcomes.

Intracranial Solitary Fibrous Tumor of the Skull Base: 2 Cases and Systematic Review of the Literature.

BACKGROUND: Intracranial solitary fibrous tumors (ISFTs) are rare neoplasms of mesenchymal origin that originate from the meninges. ISFTs of the skull base can be challenging to treat, as resection can be complicated by skull base anatomy. We present 2 cases of ISFT, the first manifesting with compressive cranial neuropathy from Meckel cave involvement and the second a posterior fossa lesion causing symptomatic hydrocephalus. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed database was queried with title/abstract keywords "intracranial," "solitary fibrous tumor," "hemangiopericytoma," "SFT," and "HPC." Search results were reviewed to exclude cases not involving the skull base. References from all selected articles were reviewed for potential additional cases. Patient demographic and clinical data from 58 identified skull base cases were collected for qualitative synthesis. RESULTS: Visual disturbances were the most common presenting symptom (30 cases, 52%) followed by headache (22 cases, 38%). The most common site of involvement was the sellar/parasellar region (18 cases, 31%) followed by middle fossa/temporal bone (14 cases, 24%). Resection was performed in 55 cases; gross total resection was reported in 26 cases (45%) and subtotal resection was reported in 21 cases (36%). Tumor recurrence was documented in 15 cases (26%) with median and mean follow-up periods of 16 and 29.9 months, respectively. CONCLUSIONS: We discuss presentation, imaging, histopathology, and management considerations for ISFTs while highlighting the potentially complex nature of skull base lesions and need for multidisciplinary approach to treatment.

Molecular profiling predicts meningioma recurrence and reveals loss of DREAM complex repression in aggressive tumors.

Meningiomas account for one-third of all primary brain tumors. Although typically benign, about 20% of meningiomas are aggressive, and despite the rigor of the current histopathological classification system there remains considerable uncertainty in predicting tumor behavior. Here, we analyzed 160 tumors from all 3 World Health Organization (WHO) grades (I through III) using clinical, gene expression, and sequencing data. Unsupervised clustering analysis identified 3 molecular types (A, B, and C) that reliably predicted recurrence. These groups did not directly correlate with the WHO grading system, which classifies more than half of the tumors in the most aggressive molecular type as benign. Transcriptional and biochemical analyses revealed that aggressive meningiomas involve loss of the repressor function of the DREAM complex, which results in cell-cycle activation; only tumors in this category tend to recur after full resection. These findings should improve our ability to predict recurrence and develop targeted treatments for these clinically challenging tumors.

Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury.

OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor prognosis is responsible for the majority of in-house deaths in severe traumatic brain injury (TBI). With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. METHODS The authors reviewed prospectively collected data obtained in 1241 patients with head injury who were treated between 1986 and 2012. Patients with severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating moderate disability or good recovery) at 6 months were selected. Baseline demographic, clinical, and imaging data were analyzed. The time from injury to the first record of following commands (mGCS score of 6) after injury was recorded. The temporal profile of GOS scores from discharge to 6 months after the injury was also assessed. RESULTS The authors studied 218 patients (183 male and 35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were able to follow commands (mGCS score of 6) within the 1st week after injury (71.4%), with the highest percentage of patients in this group recovering on Day 1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the injury was seen in 14.8% of patients, who experienced significantly longer durations of intracranial pressure monitoring (p = 0.001) and neuromuscular blockade (p < 0.001). In comparison with patients with moderate disability, patients with good recovery had a higher initial GCS score (p = 0.01), lower incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p < 0.001) and total hospital stay (p < 0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks after the injury. These data caution against early withdrawal of life-sustaining treatment in patients with severe TBI.

Quantitative cerebral blood flow using xenon-enhanced CT after decompressive craniectomy in traumatic brain injury.

OBJECTIVE Few studies have reported on changes in quantitative cerebral blood flow (CBF) after decompressive craniectomy and the impact of these measures on clinical outcome. The aim of the present study was to evaluate global and regional CBF patterns in relation to cerebral hemodynamic parameters in patients after decompressive craniectomy for traumatic brain injury (TBI). METHODS The authors studied clinical and imaging data of patients who underwent xenon-enhanced CT (XeCT) CBF studies after decompressive craniectomy for evacuation of a mass lesion and/or to relieve intractable intracranial hypertension. Cerebral hemodynamic parameters prior to decompressive craniectomy and at the time of the XeCT CBF study were recorded. Global and regional CBF after decompressive craniectomy was measured using XeCT. Regional cortical CBF was measured under the craniectomy defect as well as for each cerebral hemisphere. Associations between CBF, cerebral hemodynamics, and early clinical outcome were assessed. RESULTS Twenty-seven patients were included in this study. The majority of patients (88.9%) had an initial Glasgow Coma Scale score ≤ 8. The median time between injury and decompressive surgery was 9 hours. Primary decompressive surgery (within 24 hours) was performed in the majority of patients (n = 18, 66.7%). Six patients had died by the time of discharge. XeCT CBF studies were performed a median of 51 hours after decompressive surgery. The mean global CBF after decompressive craniectomy was 49.9 ± 21.3 ml/100 g/min. The mean cortical CBF under the craniectomy defect was 46.0 ± 21.7 ml/100 g/min. Patients who were dead at discharge had significantly lower postcraniectomy CBF under the craniectomy defect (30.1 ± 22.9 vs 50.6 ± 19.6 ml/100 g/min; p = 0.039). These patients also had lower global CBF (36.7 ± 23.4 vs 53.7 ± 19.7 ml/100 g/min; p = 0.09), as well as lower CBF for the ipsilateral (33.3 ± 27.2 vs 51.8 ± 19.7 ml/100 g/min; p = 0.07) and contralateral (36.7 ± 19.2 vs 55.2 ± 21.9 ml/100 g/min; p = 0.08) hemispheres, but these differences were not statistically significant. The patients who died also had significantly lower cerebral perfusion pressure (52 ± 17.4 vs 75.3 ± 10.9 mm Hg; p = 0.001). CONCLUSIONS In the presence of global hypoperfusion, regional cerebral hypoperfusion under the craniectomy defect is associated with early mortality in patients with TBI. Further study is needed to determine the value of incorporating CBF studies into clinical decision making for severe traumatic brain injury.

Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury.

OBJECTIVE Posttraumatic hydrocephalus (PTH) affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) and is an important cause of morbidity after traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. There is limited data on predictors of shunting for PTH after DC for TBI. METHODS Prospectively collected data from the erythropoietin severe TBI randomized controlled trial were studied. Demographic, clinical, and imaging data were analyzed for enrolled patients who underwent a DC. All head CT scans during admission were reviewed and assessed for PTH by the Gudeman criteria or the modified Frontal Horn Index ≥ 33%. The presence of subdural hygromas was categorized as unilateral/bilateral hemispheric or interhemispheric. Using L1-regularized logistic regression to select variables, a multiple logistic regression model was created with ventriculoperitoneal shunting as the binary outcome. Statistical significance was set at p < 0.05. RESULTS A total of 60 patients who underwent DC were studied. Fifteen patients (25%) underwent placement of a ventriculoperitoneal shunt for PTH. The majority of patients underwent unilateral decompressive hemicraniectomy (n = 46, 77%). Seven patients (12%) underwent bifrontal DC. Unilateral and bilateral hemispheric hygromas were noted in 31 (52%) and 7 (11%) patients, respectively. Interhemispheric hygromas were observed in 19 patients (32%). The mean duration from injury to first CT scan showing hemispheric subdural hygroma and interhemispheric hygroma was 7.9 ± 6.5 days and 14.9 ± 11.7 days, respectively. The median duration from injury to shunt placement was 43.7 days. Multivariate analysis showed that the presence of interhemispheric hygroma (OR 63.6, p = 0.001) and younger age (OR 0.78, p = 0.009) were significantly associated with the need for a shunt after DC. CONCLUSIONS The presence of interhemispheric subdural hygromas and younger age were associated with shunt-dependent hydrocephalus after DC in patients with severe TBI.

Management of Acute Unilateral Nondisplaced Subaxial Cervical Facet Fractures.

BACKGROUND: Few studies have focused on the management of patients with nondisplaced cervical facet fractures. OBJECTIVE: To determine the rate of successful nonoperative management and risk factors for instability in patients with acute traumatic, unilateral, nondisplaced cervical facet fractures. METHODS: We reviewed patients with single or multilevel unilateral nondisplaced or minimally displaced subaxial cervical facet fractures between 2008 and 2014. Facet fractures were classified as type A1 fractures: superior facet fracture of caudal vertebra; type A2: inferior facet fracture of rostral vertebral; and type A3: floating lateral mass (fracture of pedicle and vertical laminar fracture). All patients were given a trial of nonoperative management with external immobilization using a hard cervical collar. Follow-up clinical data and cervical spine radiographs were analyzed to determine factors associated with instability. RESULTS: Thirty-five patients (34 males, mean age 40.2 ± 2.4 yr) were reviewed. The mean follow-up duration was 2.7 ± 0.4 mo. The distribution of fracture types was type A1 (n = 15), type A2 (n = 4), type A3 (n = 5), type A1 and A2 fractures (n = 10), and type A1 and A3 fractures (n = 1). Nonoperative management was successful in 29 patients (82.9%), and 6 patients developed instability requiring surgery. All patients who failed nonoperative management had associated injuries suggesting a more severe mechanism of injury. No significant association was found between the type of facet fracture and outcome (Fisher's exact test, P = .18). CONCLUSION: In our series, more than 80% of the patients with unilateral, nondisplaced cervical facet fractures underwent successful nonoperative management in the short term.

Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injury.

OBJECTIVE Hypernatremia is independently associated with increased mortality in critically ill patients. Few studies have evaluated the impact of hypernatremia on early mortality in patients with severe traumatic brain injury (TBI) treated in a neurocritical care unit. METHODS A retrospective review of patients with severe TBI (admission Glasgow Coma Scale score ≤ 8) treated in a single neurocritical care unit between 1986 and 2012 was performed. Patients with at least 3 serum sodium values were selected for the study. Patients with diabetes insipidus and those with hypernatremia on admission were excluded. The highest serum sodium level during the hospital stay was recorded, and hypernatremia was classified as none (≤ 150 mEq/L), mild (151-155 mEq/L), moderate (156-160 mEq/L), and severe (> 160 mEq/L). Multivariate Cox regression analysis was performed to determine independent predictors of early mortality. RESULTS A total of 588 patients with severe TBI were studied. The median number of serum sodium measurements for patients in this study was 17 (range 3-190). No hypernatremia was seen in 371 patients (63.1%), mild hypernatremia in 77 patients (13.1%), moderate hypernatremia in 50 patients (8.5%), and severe hypernatremia in 90 patients (15.3%). Hypernatremia was detected within the 1st week of admission in 79.3% of patients (n = 172), with the majority of patients (46%) being diagnosed within 72 hours after admission. Acute kidney injury, defined as a rise in creatinine of ≥ 0.3 mg/dl, was observed in 162 patients (27.6%) and was significantly associated with the degree of hypernatremia (p < 0.001). At discharge, 148 patients (25.2%) had died. Hypernatremia was a significant independent predictor of mortality (hazard ratios for mild: 3.4, moderate: 4.4, and severe: 8.4; p < 0.001). Survival analysis showed significantly lower survival rates for patients with greater degrees of hypernatremia (log-rank test, p < 0.001). CONCLUSIONS Hypernatremia after admission in patients with severe TBI was independently associated with greater risk of early mortality. In addition to severe hypernatremia, mild and moderate hypernatremia were significantly associated with increased early mortality in patients with severe TBI.

Occipital Artery Pseudoaneurysm After Posterior Fossa Craniotomy.

BACKGROUND: Pseudoaneurysms of scalp arteries have been reported in rare cases after iatrogenic injury; however, they are far more commonly seen after traumatic injuries. They are usually associated with the superficial temporal artery; however, there have been a few reports of psuedoaneurysms of the occipital artery (OA). CASE DESCRIPTION: We present a unique case of an OA pseudoaneurysm presenting with delayed postoperative hemorrhage after a retrosigmoid craniotomy. The pseudoaneurysm was treated by coil embolization. CONCLUSIONS: The patient recovered fully after endovascular embolization. Other treatment options for pseudoaneurysms of facial, temporal, and scalp arteries include surgical clipping/trapping with excision, Hunterian ligation, or direct compression. Pseudoaneurysms of extracranial scalp arteries are rare and most often caused by traumatic compression of the artery against a bony ridge. Despite their rarity, pseudoaneurysms secondary to iatrogenic injury to extracranial arteries should be considered in the differential diagnosis in patients presenting with delayed incisional pain, redness, and swelling.

Clinical application of near-infrared spectroscopy in patients with traumatic brain injury: a review of the progress of the field.

Near-infrared spectroscopy (NIRS) is a technique by which the interaction between light in the near-infrared spectrum and matter can be quantitatively measured to provide information about the particular chromophore. Study into the clinical application of NIRS for traumatic brain injury (TBI) began in the 1990s with early reports of the ability to detect intracranial hematomas using NIRS. We highlight the advances in clinical applications of NIRS over the past two decades as they relate to TBI. We discuss recent studies evaluating NIRS techniques for intracranial hematoma detection, followed by the clinical application of NIRS in intracranial pressure and brain oxygenation measurement, and conclude with a summary of potential future uses of NIRS in TBI patient management.

Intracranial Hypertension Caused by Occipital Calvarial Hemangioma: Case Report.

BACKGROUND: Primary intraosseous calvarial hemangiomas (PICHs) are generally rare and predominate (3:1) in women. Occurrence in the frontal and parietal bones is most common, but involvement of the occipital bone is exceedingly rare, representing 3 of 125 cases in a series of PICHs studied by Heckl et al. in 2000. Histopathology establishes the diagnosis of cavernous hemangioma, which represents the most common subtype of intraosseous hemangiomas. Others include sclerosing, cellular, and capillary. When they do occur in the calvarium, they are most often asymptomatic and discovered incidentally or due to a palpable defect in the skull. CASE DESCRIPTION: In this case, a calvarial hemangioma was found to be the cause of elevated intracranial pressure in a 35-year-old woman. Resection of the hemangioma and reconstruction of the calvarium provided a complete cure for her symptoms. CONCLUSIONS: Primary intraosseous hemangiomas are rarely symptomatic but must be considered in the differential for calvarial lesions as part of safe surgical planning. Formulating an accurate differential diagnosis by acquiring proper imaging studies and specifically recognizing the classical "starburst" appearance, as well as considering the highly vascular pathology to avoid excess blood loss, is important. This unique case of a hemangioma-induced venous sinus compression and subsequent elevated intracranial pressure illustrates that hemangiomas can arise from any part of the calvarium and cause a wide variety of clinical symptoms.

Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds.

OBJECT There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1-4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI.

Shunting in cryptococcal meningitis.

OBJECT Patients with cryptococcal meningitis often develop symptomatic intracranial hypertension. The need for permanent CSF diversion in these cases remains unclear. METHODS Cases of cryptococcal meningitis over a 5-year period were reviewed from a single, large teaching hospital. Sources of identification included ICD-9 codes, operative logs, and microscopy laboratory records. RESULTS Fifty cases of cryptococcal meningitis were identified. Ninety-eight percent (49/50) of patients were HIV positive. Opening pressure on initial lumbar puncture diagnosing cryptococcal meningitis was elevated (> 25 cm H2O) in 33 cases and normal (≤ 25 cm H2O) in 17 cases. Thirty-eight patients ultimately developed elevated opening pressure over a follow-up period ranging from weeks to years. Serial lumbar punctures for relief of intracranial hypertension were performed in 29 cases. Thirteen of these patients ultimately had shunting procedures performed after failing to improve clinically. Two factors were significantly associated with the need for shunting: patients undergoing shunt placement were more likely to be women (5/13 vs 0/16; p = 0.01) and to have a pattern of increasing CSF cryptococcal antigen (10/13 vs 3/16 cases; p = 0.003). All patients re-presenting with mycological relapse either underwent or were offered shunt placement. CONCLUSIONS Neurosurgeons are often asked to consider CSF diversion in cases of cryptococcal meningitis complicated by intracranial hypertension. Most patients do well with serial lumbar punctures combined with antifungal therapy. When required, shunting generally provided sustained relief from intracranial hypertension symptoms. Ventriculoperitoneal shunts are the favored method of diversion. To the authors' knowledge, the present study is the largest series on diversionary shunts in primarily HIV-positive patients with this problem.

Predictors of outcome in civilians with gunshot wounds to the head upon presentation.

OBJECT: Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome. METHODS: The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model. RESULTS: Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome. CONCLUSIONS: Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

Malignant peripheral nerve sheath tumor of the cauda equina with craniospinal metastasis.

Intradural spinal malignant peripheral nerve sheath tumors (MPNST) are extremely rare, with only 20 adult patients reported to our knowledge, and only four primary tumors arising from the cauda equina. A 49-year-old man presented with back pain, constipation, and lower extremity weakness and was found to have a large intradural lesion involving the cauda equina. Imaging of the rest of his neuraxis revealed additional small left temporal lobe, cervical, and thoracic lesions. The patient underwent laminectomy for tumor debulking and biopsy, as gross total resection was not possible due to envelopment of the cauda equina. Histopathology revealed a MPNST with high cellularity, elevated proliferative indices, and nerve fascicle invasion. After the debulking, the patient reported improvement in his symptoms. However, 6 weeks later, the patient began having severe headaches, and his left temporal lobe lesion was found to have increased significantly in size, requiring craniotomy for palliative resection. The authors report the first adult patient with sporadic spinal MPNST with craniospinal metastasis to our knowledge. Imaging of the entire neuraxis is recommended for initial workup of these lesions, which are capable of intradural spread. The best treatment approach is unclear, but total surgical resection should be attempted, barring infiltration and engulfment of the nerve roots or widespread dissemination.