Prognostic significance of hematoma thickness to midline shift ratio in patients with acute intracranial subdural hematoma: a retrospective study.

Acute intracranial subdural hematoma (ASDH) is commonly associated with a grave prognosis citing a high incidence of morbidity and mortality. The parameters to decide on surgical evacuation of the hematoma are sometimes controversial. In this study, we theorized that the ratio between maximal hematoma thickness and midline shift would be varied by associated intrinsic brain pathology emanating from the trauma and would thus objectively evaluates the prognosis in ASDH. The records of patients diagnosed with ASDH who were submitted to surgical evacuation through a craniotomy were revised. Data collected included basic demographic data, preoperative general and neurological examinations, and radiological findings. The maximal thickness of the hematoma (H) on the preoperative CT brain was divided by the midline shift at the same level (MS) formulating the H/MS ratio. Postoperative data obtained included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), and follow-up period. Sixty-seven eligible patients were included in the study, of which 53 (79.1%) patients were males. Mean age was 34 years. The H/MS ratio ranged from 0.69 to 1.8 with a mean of 0.93. Age above 50 years (P = 0.0218), admission GCS of less than 6 (0.0482), and H/MS ratio of 0.79 or less (P = 0.00435) were negative prognostic factors and correlated with a low postoperative GCS and GOS. H/MS ratio is a useful prognostic tool in patients diagnosed with ASDH and can be added to the armamentarium of data to improve the management decision in this cohort of patients.

Decompressive craniectomy and expansive duraplasty with evacuation of hypertensive intracerebral hematoma, a randomized controlled trial.

Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34-79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p = 0.407). High admission GCS (p = 0.0032), younger age (p = 0.0023), smaller hematoma volume (p = 0.044), subcortical hematoma location (p = 0.041), absent or minimal preoperative (p = 0.0068), and postoperative (p = 0.0031) midline shift as well as absent intraventricular extension of the hematoma (p = 0.036) contributed significantly to a better outcome. Selected patients' subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p = 0.0015) and from 50 to less than 70 (p = 0.00619) as well as immediate preoperative GCS from 6 to 8 (p = 0.000436) and from 9 to 12 (p = 0.00774). At 6 months' follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p = 0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.

Percutaneous radiofrequency facet capsule denervation as an alternative target in lumbar facet syndrome.

OBJECTIVES: Percutaneous radiofrequency denervation of the medial dorsal branch is often used in chronic low back pain of intervertebral facet etiology, which is sometimes difficult to perform and recurrence of pain often ensues. We theorized that shifting the target of RF coagulation to the facet joint capsule would provide an easier target and a longer-lived pain relieving response. PATIENTS AND METHODS: A prospective randomized controlled trial where 120 patients diagnosed with CLBP of a confirmed facet origin were randomly divided into three equal groups, the first was submitted to percutaneous radiofrequency coagulation of the facet joint capsule, the second underwent percuataneous denervation of the medial dorsal branch and the third did not receive radiofrequency lesioning. All the three groups received local injection of a mixture of local anesthetic and steroid. Cases were followed for up to 3 years. RESULTS: 87(72.5%) patients were females. By 3 months' post procedure, improvement in VAS was significantly better than pretreatment levels in all groups (p<0.05). The control group lost improvement by 1-year follow-up (p=0.017). At 2 years' follow-up, the joint capsule denervation group maintained significant improvement (p=0.033) whereas the medial branch denervation group lost its significant effect (p=0.479). By the end of follow-up period, only joint capsule denervation group kept significant improvement (p=0.026). CONCLUSION: In CLBP of facet origin, shifting the target of percutaneous radiofrequency to the facet joint capsule provides an easier technique with an extended period of pain relief compared to the medial dorsal branch of the facet joint.

Prophylactic use of anticoagulation and hemodilution for the prevention of venous thromboembolic events following meningioma surgery.

OBJECTIVES: Brain tumors may be associated with postoperative venous thromboembolic (VTE) events with possible devastating consequences. Meningioma has the highest incidence of postoperative VTE events among all brain tumors. Hemodilution and anticoagulation both proved efficacy in deep venous thrombosis (DVT) prophylaxis that is why we theorized that this regimen would be beneficial for VTE prophylaxis in operated intracranial meningioma patients without added risk to the patients. PATIENTS AND METHODS: A retrospective double-blinded study, where the records of consecutive intracranial meningioma patients were revised comparing the efficacy of two regimens of postoperative VTE prophylaxis. Patients were divided into 2 groups; group A was submitted to the use of compressive stockings, low-molecular weight heparin (LMWH) administration and hemodilution, while group B was submitted only to the use of compressive stockings. RESULTS: The study included 194 patients. Mean age of patients was 55 years (range from 27 to 78 years). VTE events were diagnosed in 16 patients (8.2%) all of them belonged to group B. The median time for VTE events was 12 days. Older age (P=.0001), larger size tumor (p=0.0438), delayed ambulation postoperatively (p=0.0351) as well as skull base location of meningioma (p=0.0163) were associated with higher incidence of postoperative VTE. Overall, group A patients showed more favorable outcome as compared to group B. CONCLUSION: In addition to the use of elastic stockings, we recommend starting hemodilution at the outset of surgery, LMWH administration starting 12h postoperatively as well as refraining from the use of diuretics during and after intracranial meningioma surgery till the patient became fully ambulatory to reduce the incidence of postoperative VTE events.

Efficacy of postoperative antibiotic injection in and around ventriculoperitoneal shunt in reduction of shunt infection: A randomized controlled trial.

OBJECTIVES: Infection is a common complication of ventriculoperitoneal (VP) shunt surgery. The incidence of shunt infection is still high despite routine administration of perioperative antibiotics. A lower incidence of shunt infection was observed when antibiotic-impregnated shunts (AIS) were used to treat hydrocephalus and a rapid cure was reported in cases of ventriculitis when antibiotics were injected into external ventricular drain (EVD). That is why we theorized that postoperative prophylactic injection of antibiotics in and around the shunt hardware would reduce the incidence of shunt infection. PATIENTS AND METHODS: A randomized controlled clinical trial where 60 patients up to one year old, diagnosed with congenital hydrocephalus and submitted to VP shunt insertion, were randomly assigned to one of 3 groups. The treatment groups received the conventional perioperative antibiotics in addition to vancomycin and gentamicin injection in the reservoir and around the peritoneal catheter either once (group A) or twice (group B), while the control group (C) received only the conventional perioperative antibiotics. Cases were followed-up for up to 1 year. RESULTS: The majority of patients were less than 1 month old. The follow-up period ranged from 2 to 12 months with a mean of 8.9 months. The mean duration of onset of infection after surgery was 30 days. Prematurity (p=0.00236), age less than one month (p<0.0001) and duration of surgery of 90 min or more (p<0.00001) were significant risk factors for postoperative shunt infection. Significantly more cases of shunt infection occurred within one month after surgery (p=0.021). The control group had significantly more cases of postoperative shunt infection than the treatment groups (p=0.0042). CONCLUSIONS: In congenital hydrocephalus patients submitted to VP shunt insertion, injection of prophylactic vancomycin and gentamicin in and around the shunt hardware significantly reduced the incidence of postoperative shunt infection.

Management and outcome of low velocity penetrating head injury caused by impacted foreign bodies.

BACKGROUND: Penetrating head injuries with impacted foreign bodies are rare, associated with a high incidence of morbidity and potentially life-threatening. In this study, we aimed at investigating the outcome of these cases as well as analyzing the factors affecting the prognosis. METHODS: A retrospective study in which the records of 16 patients who had penetrating head injuries caused by low-velocity impacted foreign bodies were revised. All patients were males with a mean age of 28.9 years (range, 18 to 50 years). The follow-up period ranged from 4 to 13 months with a mean of 8.1 months. Causes of injury were construction accidents in 6 (37.5 %) patients, assault in 6 (37.5 %) and road traffic accidents in 4 (25 %). The impacted objects included a bar of iron, a piece of wood, a nail, a sickle and a piece of glass. Diagnostic computerized tomography (CT) of the brain was carried out on admission in all patients. Thirteen (81.3 %) patients were submitted to surgery, and all had the appropriate management in the form of antibiotics and dehydrating measures as required. The primary outcome measure was the Glasgow Outcome Scale (GOS) at the end of follow-up. RESULTS: At the end of follow-up, ten (62.5 %) patients had a GOS score of 5, two (12.5 %) patients had a score of 4, and four (25 %) patients had a score of 1. CONCLUSIONS: Low-velocity penetrating head injuries are most common in young adult males. With the appropriate management, a majority of even the most severe cases can have a favorable outcome.

Combined thrombin and autologous blood for repair of lumbar durotomy.

Lumbar durotomy can be intended or unintended and can result in persistent cerebrospinal fluid (CSF) leak. Several methods are used to manage this complication including bed rest and CSF diversion. In this study, we theorize that the use of thrombin-soaked gel foam together with autologous blood laid on the sutured dural tear can prevent persistent CSF leak. A retrospective review of the records of patients who underwent lumbar surgery and had an unintended dural tear with CSF leak, comparing the outcome of patients who were submitted to thrombin-soaked gel foam together with autologous blood (group A) to patients treated by subfacial drain, tight bandage, and bed rest (group B). A total of 1371 patients had lumbar surgery, of whom 131 had dural tear. Group A included 62 patients, while group B included 69 patients. 8.1 % of group A patients had CSF leak as compared to 17.4 % of group B patients at postoperative day 14. The incidence of postoperative CSF leak and duration of postoperative hospital stay were statistically lower in group A than in group B (p < 0.05). Combining thrombin and autologous blood for repair of lumbar durotomy is an effective and a relatively cheap way to decrease CSF leak in the early postoperative period as well as decreasing postoperative hospital stay. It also resulted in decreased complications rate in the late postoperative period.