The coagulopathy in acute head injury: comparison of cerebral versus peripheral measurements of haemostatic activation markers.

Brain injury is known to result in various degrees of disordered haemostasis. Moreover, the recently developed assays of molecular markers of haemostasis can give an accurate reflection of its activation in vivo. The aim of this study was to monitor the levels of prothrombin fraction 1 + 2 (F1 + 2), thrombin antithrombin complexes (TAT) and D-dimer on the admission of patients to the ICU and up to the fourth day postinjury. Seventeen patients with head injury (Glasgow Coma scale 12 or less) were studied at King Khalid University Hospital, Riyadh. Their ages ranged from 10 to 40 years (mean 26). Blood samples were collected from the internal jugular vein, peripheral vein and artery. The mean levels of TAT and F1 + 2 in the internal jugular vein was significantly higher than in both peripheral venous and arterial blood on admission and 24 h later. Thereafter, the levels in the three locations dropped significantly, but remained elevated above controls. D-dimer levels were very markedly elevated to a similar extent in the three locations throughout the study period. The prothrombin time was significantly prolonged in the three locations in the first two days. Plasma fibrinogen levels dropped very significantly in the jugular vein, and increased to above reference values later. Protein S and factor VII showed a significant drop in the first two days and increased to normal range thereafter. Outcome was evaluated using the Glasgow Outcome Scale at 6 months postinjury. Haemostatic measurements could not predict good outcome (12 patients) or bad outcome (four deaths). It was concluded that haemostatic activation is a transient, but common phenomenon after head injury and is more prominent in cerebrovascular than in peripheral blood. The number of patients studied is too small to allow reliable association to be drawn between haemostatic changes on admission and prediction of outcome.

Ventricular failure as a cause of unsuccessful endoscopic third ventriculostomy.

INTRODUCTION: In spite of extensive studies on cerebrospinal fluid (CSF) dynamics, the mechanism of its circulation is still obscure. The aim of this study is to evaluate the effect of an insult to the brain tissue on the success or failure of an endoscopic procedure. METHODS: During the period from May 1995 to December 1998 we studied 21 children, ages from 2 to 48 months (mean 15 months) with non-communicating hydrocephalus. The intracranial pressure was measured at the time of endoscopic surgery. The follow-up period was from 2 - 5 years. They were divided into 2 groups. Group I were 8 patients with no history of brain insult. Group II (13 cases) had a previous brain insult (infective and/or vascular). Endoscopic third ventriculostomy (ETV) was done in 17 cases; 5 in Group I and 12 in Group II. Fenestration of cyst/s was done in all of Group I and in 9 cases of Group II. Failure was considered whenever shunt implantation was required. RESULTS: The mean intracranial pressure in Group I was 13.0 mmHg as compared to 9.7 mmHg in Group II (p = 0.015). The failure rate of the endoscopic procedure/s was 25 % and 54 % in Groups I and II, respectively. DISCUSSION: The success of ETV and/or fenestration of cyst/s depends on a sufficient pressure gradient. The pressure gradient is generated by a normal or compensated ventricular function. CONCLUSION: Brain tissue damage can result in ventricular failure. The quality of ventricular wall function has a significant role on the success of ETV.

The incidence of bradycardia during endoscopic third ventriculostomy.

UNLABELLED: The incidence of bradycardia during endoscopic third ventriculostomy (ETV) is unknown. In an attempt to determine that incidence, we studied 49 pediatric patients with obstructive hydrocephalus who underwent ETV during general anesthesia. The median age was 54.5 mo (range 1-108 mo) and the median weight was 12.2 kg (range 2.4-22 kg). The heart rate was measured continuously in which four stages were identified for data analysis. Stage A is the preoperative phase, stage B is 5 min before perforating the floor of the third ventricle, stage C during perforation, and stage D after perforating the floor of the third ventricle. Three readings were recorded at each stage, then averaged. The mean values of the heart rate at stages A, B, C, and D were 146 +/- 27, 151 +/- 26, 87 +/- 32, and 143 +/- 24 bpm respectively. A significant decrease in the heart rate was determined in stage C compared with stage B (P: < 0.05). The incidence of bradycardia was 41%. Alerting the surgeon to perforate the floor of the third ventricle or withdraw the scope away from it was sufficient to resolve the bradycardia. We concluded that serious bradycardia might occur during ETV, mostly because of mechanical factors and can be resolved without medications. IMPLICATIONS: The use of endoscopy for treating pediatric patients with increased intracranial pressure is a new surgical procedure. These patients require general anesthesia with continuous heart rate monitoring. We have observed a high incidence of decrease in heart rate. If a decrease in heart rate occurs, alerting the surgeon to speed the procedure would be an effective treatment.

Endoscopic third ventriculostomy: towards more indications for the treatment of non-communicating hydrocephalus.

OBJECTIVE: Since its reintroduction during the last 2 decades, third ventriculostomy has shown promising results. However, with more experience and better selection of cases, the indications and contraindications are likely to change. METHODS: During the period from November 1994 to December 1996, we have treated 27 patients with non-communicating hydrocephalus by endoscopic third ventriculostomy at the King Khalid University Hospital. Their ages ranged from 35 weeks preterm to 26 years of age. Sixteen (59%) patients were one year old or younger. Their follow-up ranged from 9 months to 2.5 years. According to the etiology of the non-communicating hydrocephalus, patients were divided into 4 subgroups. These were as follows: 11 aqueduct stenosis, 6 post ventriculitis, 6 cysts, and 4 posterior fossa tumours. The outcome was graded into 3 grades: Grade III were patients who improved after the procedure. Grade II were patients who improved after adding a VP-shunt to the procedure. Grade I were failure patients. RESULTS: An overall outcome of Grade III was achieved in 22 patients (81%). This was broken down according to subgroups as follows: 8/11 (73%) patients of subgroup 1, 5/6 in each of the patients of subgroup 2 and 3, and all of the patients with posterior fossa tumours. DISCUSSION: The overall results were very encouraging and so for the subgroups as compared with the reported cases in the literature. CONCLUSION: Better selection of the cases and increased experience with the procedure is expected to improve the outcome.

Intracavitary administration of amphotericin B in the treatment of cerebral aspergillosis in a non immune-compromised patient: case report and review of the literature.

A 24-year-old man presented with cerebral aspergillus fungal granuloma involving the left frontal region secondary to pulmonary aspergillosis. He was otherwise healthy with no evidence of immune-suppression. Because of poor penetration of amphotericin B into the brain and cerebrospinal fluid (CSF), this patient was treated by a combination of systemic and local therapy in addition to surgical excision resulting in a cure with follow up for more than three years. This form of treatment produced no untoward long-term side effects or neurological sequel. On review of the literature on aspergillosis of the central nervous system (CNS), we found that six patients, including the present case, have been reported who survived longer than 1 year; their treatment included local administration of antifungal agent in the abscess cavity or into cerebral ventricles in order to control this devastating, treatment-resistant pathological fungal infection.

Epidemiology of infantile hydrocephalus in Saudi Arabia: birth prevalence and associated factors.

INTRODUCTION: Hydrocephalus is a common central nervous system disorder in children. In spite of its importance, it has not been subjected to sufficient epidemiological studies, particularly in the developing countries. The aim of this study was to provide information from a representative series of newly diagnosed cases of infantile hydrocephalus on the birth prevalence, associated factors and mortality. METHODOLOGY: A prospective study was conducted over a 1-year period from April 1996 to March 1997 in the city of Al-Madinah Al-Munawarah, Saudi Arabia. Except for neural tube defects and brain tumors, all cases of hydrocephalus diagnosed within the first 28 days of life were included. A control group of 104 subjects was studied for comparison. Information about antenatal, natal and early postnatal periods were obtained by interviewing the mothers of the newborns. RESULTS: During the study period, 26 cases of infantile hydrocephalus were detected. The birth prevalence was 1. 6 per 1,000 live births. There was no sex preponderance as the male to female ratio was 1.2:1. Multiple pregnancies were detected in 21 (81%) cases. Nineteen (73%) cases were the product of consanguineous parent and 4 patients had a positive family history of hydrocephalus. The number of preterm infants was 16 (62%). The number of low birth weights (less than 2,500 g) was 18 (69%). An Apgar score of less than 8 occurred in 18 (69%) cases. The mode of delivery was vaginal in 15 (58%) women. The 6 months mortality rate was 23% (6 infants). CONCLUSION: The birth prevalence of infantile hydrocephalus in this study was significantly higher than in the developed countries. A positive family history of hydrocephalus, low birth weight, low Apgar score and abdominal delivery were found to be associated factors. The mortality rate in the first 6 months of life was significantly higher in hydrocephalus infants than in controls.

Spina bifida in Saudi Arabia: is consanguinity among the parents a risk factor?

INTRODUCTION: Spina bifida is an important birth defect. Its incidence differs from one country to another due to different factors. The aims of this study were: (1) to estimate the incidence of spina bifida in Al-Madinah Al-Munawarah and compare it with the Eastern part of the Kingdom, and (2) to find out if consanguinity is a risk factor. METHODOLOGY: A prospective study was conducted over the period from April 1996 to March 1997 in the city of Al-Madinah Al-Munawarah, Western Province, Saudi Arabia. New cases of spina bifida were studied and compared to a control group of 72 cases. RESULTS: During the study period, 18 cases of spina bifida were detected. The incidence was 1.09 per 1,000 live births. The male to female ratio was 2:1; however, this was not statistically significant. Consanguinity of the parents was found in 89% of the spina bifida parents and only 67% of the controls (p < 0.0005). CONCLUSION: (1) The incidence of spina bifida in the city of Al-Madinah Al-Munawarah was similar to that reported from the Eastern Province of Saudi Arabia. (2) The consanguinity of the parents was a significant risk factor.

Management of minor head injuries: admission criteria, radiological evaluation and treatment of complications.

The clinical course of patients admitted following minor head injuries (Glasgow Coma Score [GCS] 13-15) has been studied less extensively than in severely head injured patients. Admission criteria, methods and indications for radiological evaluation are controversial. To study this further, a retrospective review of 633 patients admitted following such injuries to King Khalid University Hospital between 1986 and 1993 was undertaken. Their ages ranged from one month to 80 years (average 17 years). The mechanisms of injury were mainly falls in 339 (53.5%) cases and road traffic accidents in 234 (37%). None of the cases resulted from a non-accidental injury. Radiological evaluation was by skull radiography in 616 (97.3%) cases followed by CT scan in 131 (20.7%). These studies revealed a skull fracture in 78 (12.7%) cases. Six of these 78 patients with skull fracture required a neurosurgical procedure during the first week post injury. These represented 0.97% of the cases who had skull radiographs. A base of skull fracture was an ominous sign, since 3 of the 5 cases with such fractures required ventilation of which one resulted in the only mortality of this series, the fourth developed meningitis. Of the cases studied, 3 (0.5%) developed growing skull fractures all had the initial injury during their first year of life. Other complications were as follows: 25 (3.9%) early post-traumatic seizures, 10 (1.6%) chronic subdural haematomas, 9 (1.4%) extradural haematomas, 2 (0.3%) post-traumatic hydrocephalus and one (0.2%) cerebral abscess. We conclude that patients who have an abnormal GCS, a neurological deficit, post-traumatic seizure, signs or suspicion of basal or depressed skull fracture should be admitted for observation because of the risk of deterioration. Patients with a history of loss of consciousness or amnesia without any of the previous may be discharged to be observed at home by a competent observer, otherwise, will need admission for observation. Radiological evaluation once indicated must be by CT scan. There is no benefit from immediate skull radiography in the initial evaluation of minor head injuries. The indications for CT are an abnormal GCS, presence of neurological deficit, signs of basilar or depressed fracture and persistent or progressive headache or vomiting. Infants with minor injuries should be followed up at least once after two to three months for possible growing fractures.

Brain tumors in the first 2 years of life in Saudi Arabia.

Thirty-four patients with brain tumors were diagnosed and treated during the first 2 years of life, representing 8% of the 273 children treated for primary brain tumors from 1981 to 1990 inclusive. Large head circumference, vomiting, and altered level of consciousness were the chief findings at the time of presentation. Overall, the tumors were located mainly supratentorially; in patients in the 1st year of life they were equally distributed above and below the tentorium, while two-thirds of the patients presenting in the 2nd year of life had supratentorial tumors. The most common histological types were astrocytomas and medulloblastomas. Treatment methods were ventricular peritoneal shunt, craniotomy with total or partial removal of the tumor, adjuvant radiotherapy, and in a few cases chemotherapy. The 2-month mortality rate was 5.9%. The follow-up period ranged from 3 to 50 months.

Spontaneous cerebral haemorrhage from cerebral amyloid angiopathy.

Three cases of spontaneous intracerebral haemorrhage treated by acute evacuation of haematoma are described. All cases proved to have cerebral amyloid angiopathy as the primary cause of the haemorrhage. Only one patient survived. Previous reports are discussed.

Growing skull fractures: classification and management.

Seven patients with growing skull fractures treated between 1983 and 1993 are described. These growing fractures constituted 1.6% of all the cases of skull fractures seen during the period (a total of 449 cases). Based on aetiopathogenesis, computed tomography (CT) appearances, operative findings and management strategies required, three main types of growing skull fractures were recognized. In type I (n = 3) a leptomeningeal cyst, in type II (n = 3) damaged and gliotic brain, and in type III (n = 2) a porencephalic cyst extended through the skull defect into the subgaleal space. A combination of type I and type III co-existed in one patient. Initial head injury and neurological deficit were judged to be mild to moderate in all the seven cases. Continued growth of skull fractures correlated closely to the increasing neurological deficit in five cases. In two patients natural arrest of fracture growth at 5 and 7 months after trauma was accompanied by arrest in progress of neurological deficit. Available surgical options are discussed and general guidelines for the management are given.

Tophaceous gout of the spine causing spinal cord compression.

Tophaceous gout of the spine rarely causes spinal cord compression. Only eight cases have been reported previously. We report a further case presenting with progressive quadriparesis caused by gouty tophi at C1, treated successfully by decompressive laminectomy and internal fixation. This case and the previously reported cases are reviewed.

Role of skull radiography in the initial evaluation of minor head injury: a retrospective study.

The use of skull radiography in the initial evaluation of minor head injured patients is controversial. In an attempt to evaluate its benefits, a retrospective study of 566 cases subjected to skull radiography following close minor head trauma (Glasgow Coma Scale 13-15), is presented. A skull fracture (linear vault, depressed or base of skull) was present in 64 (11%) cases. Only three (5%) who were found to have a skull fracture on skull radiography developed an intracranial injury which required surgery. Intracranial injuries developed in 19 (3%) cases and were followed by surgery in six (32%). All, except for one case, had a decreased level of consciousness and a Glasgow Coma Scale less than 15, few had focal neurological deficits. Management had not been altered by the results of skull radiography in any of the cases. We concluded that skull radiographs are unnecessary for the decision process in closed minor head injury because management decisions are based primarily on a careful neurological examination. When intracranial injuries are a concern, a CT scan should be obtained.

Neurosurgical management of intraventricular haemorrhage in preterm infants.

A review of intraventricular haemorrhage (IVH) diagnosed in 103 preterm infants from 1983 to 1993 describes the presenting features and management of this condition. In this 10-year period, 37 infants with IVH developed post-haemorrhagic hydrocephalus (PHH), defined as ventriculomegaly, raised intracranial pressure and increasing head circumference. PHH was treated by external ventricular drainage and/or ventriculo-peritoneal shunting; but other drainage procedures like lumbar punctures and subcutaneous ventricular reservoir were used occasionally. Relative indications, merits and demerits of these various surgical options is discussed and results summarized. High incidence of neuro-developmental handicap and its correlation with the grade of haemorrhage and PHH is emphasized. External ventricular drainage (EVD) was found to be an effective and safe therapy for rapidly progressive PHH and increased intracranial pressure. Ultimate outcome depended mainly on the grade of haemorrhage, severity of PHH and promptness of its neurosurgical management.