Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury.

AIMS AND OBJECTIVES: Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking. SUBJECTS AND METHODS: We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically. RESULTS: During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair. CONCLUSIONS: BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7-10 days has high risk of developing meningitis and likely to need surgical intervention.

Rationale Behind the Use of Double-Layer Polypropylene Patch (G-patch) Dural Substitute During Decompressive Craniectomy as an Adhesion Preventive Material for Subsequent Cranioplasty with Special Reference to Flap Elevation Time.

OBJECTIVE: Dural substitutes are used in decompressive craniectomy (DC) to prevent adhesions during subsequent cranioplasty. Current literature attributes them to reduced blood loss and reduction in operative time of cranioplasty. The use of double-layer substitute has rarely been documented. We studied the use of double-layer G-patch as a dural substitute in DC and evaluated its outcome during subsequent cranioplasty with special focus on flap elevation time and blood loss during cranioplasty. METHODS: We performed emergency frontotemporoparietal decompressive craniectomy using a double layer of G-patch as dural substitute. Subsequent cranioplasty was done in these 35 patients. The development of adhesion formation between the tissue layers, amount of blood loss, and flap elevation time were recorded. RESULTS: During the cranioplasty, a clear and smooth plane of dissection was found between the 2 layers of G-patch in all cases. Average flap elevation time was 21.8 minutes, and average time taken for cranioplasty was 124.12 minutes. Average blood loss was 83 mL. None of the patients required re-exploration for infection of bone flap or postoperative bleed. CONCLUSIONS: While evaluating the use of dural substitute during DC as an adhesion preventive material for subsequent cranioplasty, flap elevation time and blood loss should be taken into account rather than operative time. Double-layer G-patch during DC facilitates subsequent cranioplasty by preventing adhesions between the layers, resulting in easier dissection and reduced blood loss.

Single Parietal Burr-hole Craniostomy with Irrigation and Drainage for Unilateral Chronic Subdural Hematoma in Young Adults <40 Years: A Rationale behind the Procedure.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. It is mostly a disease of elderly population with very little data about the young patients. There is also the debate regarding treatment strategies. We decided to determine the overall efficacy of the single burr-hole craniostomy (SBHC) for unilateral CSDH in young adults <40 years. SUBJECTS AND METHODS: We performed a retrospective study of young patients undergoing SBHC for unilateral CSDH between January 2013 and June 2016 at our institution. Medical records were assessed based on patient characteristics in the form of sex of the patient, etiology, presenting symptoms, comorbidities, and signs including Glasgow Coma Scale, computed tomography (CT) brain findings (site and thickness of SDH with midline shift), and intraoperative presence of chronic/subacute component. RESULTS: Mean age of the patient was 33.69 years (range 18-40 years), mean thickness of SDH was 15.47 mm, and mean midline shift was 11.26 mm. 61.54% patients were male, trauma being the most common etiology (92.31%) with most common presenting complaint being headache (90.38% patients). 69.23% patients presented within 1 day of onset of symptoms. On CT scan, most of the patients were having SDH thickness between 11 and 20 mm (67.31%) with midline shift of 6-10 mm (53.85%). Right-sided SDH was present in 53.85%. Intraoperatively, 63.46% patients had subacute SDH whereas 34.61% had chronic component. There were total 2 recurrences (3.85%). CONCLUSIONS: Young adults who present with unilateral CSDH usually have a history of trauma. They have shorter duration of symptoms and present mainly with the features of raised intracranial pressure such as headache and vomiting. SBHC with irrigation and drainage has excellent result for unilateral CSDH in young adults compared to other methods of drainage and should be considered treatment of choice unless contraindicated.

Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: evaluation and determinants of success.

OBJECTIVE: To determine the overall efficacy and predictors of success of the penile preputial flap in the management of complex urethral strictures >2.5 cm in length. PATIENTS AND METHODS: We performed a retrospective and prospective study of 58 patients undergoing single-stage penile preputial flap urethroplasty for complex long-segment urethral strictures, without lichen sclerosus, repaired between May 2005 and April 2012 at our institution. For obvious reasons circumcised patients were excluded from the study. Results were assessed by univariate analysis of various patient characteristics, preoperative and postoperative patient satisfaction (based on symptoms), and urethral ultrasonography, retrograde urethrography and uroflowmetry. RESULTS: The median (range) follow-up was 42 (6-90) months, the median (range) intra-operative stricture length was 48.5 (26-85) mm and the median (range) operating time was 90 (85-125) min. A total of 87.93% of patients had a satisfactory outcome, with an overall success rate of 81.03%. Diabetes mellitus (relative risk [RR] 5.21, confidence interval [CI] 2.31-64.68, P = 0.003) and smoking (RR 4.19, CI 1.54- 45.0, P = 0.01) were predictors of failure, while postinfective aetiology (RR 2.19), panurethral stricture (RR 2.73), stricture length >70 mm (RR 3.25), previous urethroplasty (RR 2.4) and severe peri-urethral fibrosis (RR 2.37) were also associated with a higher risk of failure. CONCLUSIONS: A urologist should try to gain experience of all the methods of urethroplasty as the techniques may vary according to the circumstances. Single-stage preputial skin flap urethroplasty, in experienced and expert hands, has results equivalent to all other methods of urethroplasty in complex urethral strictures. We prefer this technique in this part of the world where buccal mucosa cannot be used because of dyskeratotic changes as a result of consumption of gutkha, tobacco, pan masala, betel nut.