Gender differences in adult traumatic brain injury according to the Glasgow coma scale: A multicenter descriptive study.

PURPOSE: Patients' gender, which can be one of the most important determinants of traumatic brain injury (TBI) outcomes, is also likely to interact with many other outcome variables of TBI. This multicenter descriptive study investigated gender differences in epidemiological, clinical, treatment, mortality, and variable characteristics in adult TBI patients. METHODS: The selection criteria were defined as patients who had been diagnosed with TBI and were admitted to the hospital between January 1, 2016 and December 31, 2018. A total of 4468 adult TBI patients were enrolled at eight University Hospitals. Based on the list of enrolled patients, the medical records of the patients were reviewed and they were registered online at each hospital. The registered patients were classified into three groups according to the Glasgow coma scale (GCS) score: mild (13-15), moderate (9-12), and severe (3-8), and the differences between men and women in each group were investigated. The risk factors of moderated and severe TBI compared to mild TBI were also investigated. RESULTS: The study included 3075 men and 1393 women and the proportion of total males was 68.8%. Among all the TBI patients, there were significant differences between men and women in age, past history, and GCS score. While the mild and severe TBI groups showed significant differences in age, past history, and clinical symptoms, the moderate TBI group showed significant differences in age, past history, cause of justice, and diagnosis. CONCLUSION: To the best of our knowledge, this multicenter study is the first to focus on gender differences of adult patients with TBI in Korea. This study shows significant differences between men and women in many aspects of adult TBI. Therefore, gender differences should be strongly considered in TBI studies.

Clinical Significance of Decompressive Craniectomy Surface Area and Side.

OBJECTIVE: Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side. METHODS: A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side. RESULTS: DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively). CONCLUSION: DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.

Temperature Difference between Brain and Axilla according to Body Temperature in the Patient with Brain Injury.

OBJECTIVE: Commonly, brain temperature is estimated from measurements of body temperature. However, temperature difference between brain and body is still controversy. The objective of this study is to know temperature gradient between the brain and axilla according to body temperature in the patient with brain injury. METHODS: A total of 135 patients who had undergone cranial operation and had the thermal diffusion flow meter (TDF) insert were included in this analysis. The brain and axilla temperatures were measured simultaneously every 2 hours with TDF (2 kinds of devices: SABER 2000 and Hemedex) and a mercury thermometer. Saved data were divided into 3 groups according to axillary temperature. Three groups are hypothermia group (less than 36.4°C), normothermia group (between 36.5°C and 37.5°C), and hyperthermia group (more than 37.6°C). RESULTS: The temperature difference between brain temperature and axillary temperature was 0.93±0.50°C in all data pairs, whereas it was 1.28±0.56°C in hypothermia, 0.87±0.43°C in normothermia, and 0.71±0.41°C in hyperthermia. The temperature difference was statistically significant between the hypothermia and normothermia groups (p=0.000), but not between the normothermia and hyperthermia group (p=0.201). CONCLUSION: This study show that brain temperature is significantly higher than the axillary temperature and hypothermia therapy is associated with large brain-axilla temperature gradients. If you do not have a special brain temperature measuring device, the results of this study will help predict brain temperature by measuring axillary temperature.

Laboratory Predictors of Contrast-Induced Nephropathy After Neurointervention: A Prospective 3-Year Observational Study.

OBJECTIVE: The purpose of this study was to assess the natural course of contrast-induced nephropathy (CIN) and to determine the predictive abilities of preprocedural high-sensitivity C-reactive protein (hs-CRP) and urine neutrophil gelatinase-associated lipocalin for CIN after neurointervention procedures. METHODS: We prospectively enrolled 176 patients who underwent an elective neurointervention procedure (diagnostic angiography or endovascular surgery). CIN was defined as an increase in serum creatinine of more than 0.5 mg/dL or an increase of at least 25% from the baseline value within 48 hours of contrast media exposure. The predictive value of hs-CRP and serial urine NGAL (baseline, 6, 24, and 48 hours) for the risk of CIN was assessed using multivariate logistic regression. RESULTS: CIN occurred in 17 patients (9.46%). Multivariate analysis revealed that the CIN incidence was significantly associated with high baseline hs-CRP. All patients with CIN had creatinine return to baseline levels within 7 days. No patients required dialysis or suffered permanent sequelae as a result of a creatinine increase. During the 3-year follow-up period, no cerebro- or cardiovascular events occurred in the CIN group. However, 3 patients in the non-CIN group suffered a vascular event. One was a myocardial infarction, and 2 were ischemic strokes. CONCLUSIONS: The incidence of CIN after neurointervention procedures was relatively high (9.46%). The natural course of CIN was favorable, however, and did not affect cerebrovascular events. Additionally, patients with CIN typically recovered with supportive care within 7 days. Elevated preprocedural hs-CRP levels (>5 mg/dL) were a significant and independent predictor of CIN after neurointervention procedures.

A simple prediction score system for malignant brain edema progression in large hemispheric infarction.

Malignant brain edema (MBE) due to hemispheric infarction can result in brain herniation, poor outcomes, and death; outcome may be improved if certain interventions, such as decompressive craniectomy, are performed early. We sought to generate a prediction score to easily identify those patients at high risk for MBE. 121 patients with large hemispheric infarction (LHI) (2011 to 2014) were included. Patients were divided into two groups: those who developed MBE and those who did not. Independent predictors of MBE were identified by logistic regression and a score was developed. Four factors were independently associated with MBE: baseline National Institutes of Health Stroke Scale (NIHSS) score (p = 0.048), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (p = 0.007), collateral score (CS) (p<0.001) and revascularization failure (p = 0.013). Points were assigned for each factor as follows: NIHSS ≤ 8 (= 0), 9-17 (= 1), ≥ 18 (= 2); ASPECTS≤ 7 (= 1), >8 (= 0); CS<2 (= 1), ≥2 (= 0); revascularization failure (= 1),success (= 0). The MBE Score (MBES) represents the sum of these individual points. Of 26 patients with a MBES of 0 to 1, none developed MBE. All patients with a MBES of 6 developed MBE. Both MBE development and functional outcomes were strongly associated with the MBES (p = 0.007 and 0.002, respectively). The MBE score is a simple reliable tool for the prediction of MBE.

Microsurgical resection of deep-seated lesions using transparent tubular retractor: pediatric case series.

BACKGROUND: To facilitate effective resection of deep-seated brain lesions without causing significant trauma to the overlying cortex, the authors used a transparent plastic tubular retractor to approach these lesions. METHODS: Between July 2009 and January 2011, we used an 11-mm diameter transparent plastic tubular retractor in combination with a frameless stereotactic navigation system to remove 18 deep lesions. RESULTS: Gross total resection of the lesions was achieved in 14 of 18 patients, and subtotal removal occurred in four patients. Effective resection of lesions was achieved in all patients through small size craniotomy window and small cortical incision. The histopathologic diagnosis was established in all 18 patients: 3 hematomas, 3 cavernous angioma, 7 low-grade glioma, 2 dysembryoplastic neuroepithelial tumor, 1 choroid plexus papilloma, 1 abscess, and 1 meningioma. CONCLUSION: Microsurgery using a transparent tubular retractor guided by a neuronavigation system facilitated accurate and effective removal of these deep-seated brain lesions.

Efficacy of endoport-guided endoscopic resection for deep-seated brain lesions.

Surgery for deep-seated brain lesions without causing significant trauma to the overlying cortex is difficult because brain retraction is required to approach these lesions. The aim of this study was to determine the efficacy of endoport-guided endoscopic or microscopic removal for deep-seated lesions using the neuronavigation system. Between October 2008 and December 2009, 21 patients (17 men and 4 women; average age, 40.8 years) underwent endoport-guided endoscopic tumor removal. We adapted the transparent tubular conduit, so-called "endoport," to target the lesions under the guidance of neuronavigation. We then determined the efficacy and limitations of this technique with fully endoscopic removal, compared with standard approaches using a spatula retractor. Gross total resection of the lesions was achieved in 14 of 21 patients (66%), and partial removal occurred in four (19%) patients. However, there was failure to remove the lesion through the endoport in three patients (14.3%), requiring the use of blade spatula retractors. In reviewing the seven cases with either failure or partial removal, it was found that a large tumor size (≥ 3 cm) and calcified lesions were the major factors limiting the application of this technique. Endoport-guided endoscopic surgery facilitated an accurate and minimally invasive technique for removal of these deep-seated brain lesions. This procedure required a protracted learning curve although, when successful, this approach can minimize brain retraction and provide satisfactory visualization.

Motion-preserving reduction and fixation of C1 Jefferson fracture using a C1 lateral mass screw construct.

The treatment of C1 Jefferson fractures is controversial. Non-surgical treatment with halo fixation always bears the risk of insufficient healing with further instability and increasing neck pain. However, a C1-2 fusion can markedly decrease the rotatory motion of the neck. The aim of this report is to describe a new treatment for C1 Jefferson fractures. We used open reduction and C1 fixation using a bilateral C1 lateral mass screw construct. The screws were connected with a rod and nuts to reduce lateral spread of the lateral masses. This method is an alternative surgical option for C1 Jefferson fractures in select patients and can maintain important C1-2 joint motion.

The patterns and risk factors of hearing loss following microvascular decompression for hemifacial spasm.

OBJECTIVE: The aim of this study was to reveal the risk factors including intraoperative brain stem auditory evoked potential (BAEP) changes and to define parameter and warning values of BAEP beyond which the probability of hearing impairment rises significantly. METHODS: From April 1997 to February 2009, 1156 patients underwent microvascular decompression (MVD) for hemifacial spasm (HFS) and their medical records and audiologic data. The intraoperative BAEP monitoring was performed in all operations during surgery from the time of administration of general anesthesia until the time of skin closure. Pure tone audiometry (PTA) and Speech Discrimination Score (SDS) were performed on all patients before and after surgery for categorizing the patterns of hearing loss. There were 825 females and 331 males with a mean age of 48.7 years (range 17-75 years). The mean symptom duration was 67.8 months (range 1-420 months). RESULTS: At the 1-year follow-up examination, 1091 (94.4%) patients of the total 1156 patients exhibited a cured state, and 65 (5.6%) patients had residual spasms. Hearing loss occurred in 46 patients (3.9%). In 26 patients, PTA was decreased more than 15 dB with a proportional decrease of the SDS. In 10 patients, poor SDS without hearing loss occurred. Total deafness was developed in 10 patients. A higher incidence of BAEP change and a poor recovery especially amplitude in wave V during surgery was observed in patients with poor SDS (eight patients) and total deafness (seven patients) (p = 0.000). Reduction of amplitude more than 50% in wave V was a strong indicator for a worse outcome of the hearing capacity. The difference in other risk factors according to hearing loss pattern was not statistically significant (p > 0.05). Only female was significant (p = 0.005). CONCLUSIONS: The intraoperative BAEP change and a poorer recovery, especially reduction of amplitude more than 50% in wave V, was a strong indicator for a worse outcome of the hearing capacity. Vigilant intraoperative monitoring of the BAEP and adequate steps for recovery of the BAEP change could prevent hearing loss after MVD for HFS.

Treatment modalities and outcomes for asymptomatic meningiomas.

OBJECTIVES: The aim of this study is to investigate the outcomes of asymptomatic meningiomas (MNGs) after a variety of treatment modalities, including observation, microsurgery (MS), and gamma knife radiosurgery (GKRS). METHODS: From 1996 to 2008, 154 patients with asymptomatic MNGs were treated, and their medical records and imaging data were retrospectively analyzed. There were 121 females and 33 males with a mean age of 59.2 years (range 27-87). Treatment modalities were essentially chosen by patient preference from observation, MS, and GKRS. The mean follow-up duration was 61.2 months (range 24-157) from diagnosis. RESULTS: Of our patient sample, 77 patients initially opted for observation. Tumor volume increased in 24 (31.2%) of these patients. MS or GKRS was required in nine of these patients, and the mean duration until intervention was 48.8 months (range 13-134). MS was performed as an initial treatment in eight patients without resulting in permanent neurologic deficit. No tumor recurrence occurred after surgery (mean follow-up 59.6 months; range 24-108). GKRS was performed in 69 patients. After GKRS, tumor size was stable in 57 and decreased in 12 patients, while no patient showed an increase in tumor size (mean follow-up 63.0 months; range 24-110). Transient complications developed in 27 patients (39.1%), though permanent neurologic deficit did not develop in any patient. The progression-free survival (PFS) rates at 4 and 5 years with observation were 77.2 ± 5.5% and 61.8% ± 7.7%. The difference in PFS between GKRS and observation was statistically significant (p = 0.001). CONCLUSIONS: There is a substantial probability of growth of asymptomatic MNGs. GKRS can lower this possibility, but the risk of transient complications due to irradiation exists. There are no significant differences in final outcome according to initial treatment. Considering the clinical course and final outcome, both observation with regular follow-up and GKRS may be reasonable choices for asymptomatic MNGs according to preference of the patients.

Primary thoracic epidural melanoma : a case report.

A 68-year-old woman with progressive paraparesis and altered sensation lasting approximately five days was admitted to our clinic. Magnetic resonance imaging (MRI) revealed an advanced stage T7-8 epidural mass ventral to the spinal cord, which was believed to be a metastatic tumor considering the patient's age. A highly enhanced epidural mass and pedicle appeared during the MR scan. However, the pathologic findings were compatible with the diagnosis of a primary meningeal melanocytic tumor. Primary epidural melanomas are extremely rare lesions. This case was finally diagnosed as a primary thoracic spinal epidural melanoma.