Intracranial pressure monitoring for severe traumatic brain injury: A retrospective study of 273 consecutive patients.

Background: Intracranial pressure (ICP) monitoring is essential in severe traumatic brain injury (sTBI) cases; yet, the frequency of high ICP occurrences remains debated. This study presents a 9-year analysis of ICP monitoring using intraventricular catheters among sTBI patients. Methods: A retrospective review of 1760 sTBI patients (Glasgow Coma Score <9) admitted between January 2011 and December 2019 was conducted. Of these, 280 patients meeting monitoring criteria were included based on Brain Trauma Foundation (BTF) Guidelines. ICP was monitored using intraventricular catheters through right frontal burr holes. Initial ICP readings were recorded intraoperatively, followed by continuous monitoring. Patients with ICP >20 mmHg for 10-15 min during 72 h were categorized with high ICP. Data collected included demographics, computed tomography (CT) findings, intra- and post-operative ICP, and complications. Results: Of 273 patients, 228 were male and 45 females, aged 18-80 (71.30% aged 18-45). Traffic accidents were the primary cause (90.48%). Fifty-two-point seventy-five percent experienced high ICP, correlating significantly with subdural hematoma (P < 0.001), intraventricular hemorrhage (P < 0.013), and compressed basal cisterns (P = 0.046) on initial CT. Twenty patients (7.3%) developed meningitis. Lower mortality rates and improved outcomes were observed in the low ICP group across discharge 3-and 6-month follow-ups. Conclusion: Adherence to BTF guidelines yielded a 52.75% high ICP rate. Significant correlations were found between high ICP and specific CT abnormalities. This study underscores the benefits of ICP monitoring in selected sTBI cases, suggesting a need to review criteria for initiating monitoring protocols.

Benefits of Combined MRI Sequences in Meningioma Consistency Prediction: A Prospective Study of 287 Consecutive Patients.

Objective Consistency of meningiomas is one of the most important factors affecting the completeness of removal and major risks of meningioma surgery. This study used preoperative magnetic resonance imaging (MRI) sequences in single and in combination to predict meningioma consistency. Methods The prospective study included 287 intracranial meningiomas operated on by five attending neurosurgeons at Chiang Mai University Hospital from July 2012 through June 2020. The intraoperative consistency was categorized in four grades according to the method of surgical removal and intensity of ultrasonic aspirator, then correlated with preoperative tumor signal intensity pattern on MRI including T1-weighted image, T2-weighted image (T2WI), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted image (DWI), which were described as hypointensity, isointensity, and hyperintensity signals which were blindly interpreted by one neuroradiologist. Results Among 287 patients, 29 were male and 258 female. The ages ranged from 22 to 83 years. A total of 189 tumors were situated in the supratentorial space and 98 were in the middle fossa and infratentorial locations. Note that 125 tumors were found to be of soft consistency (grades 1, 2) and 162 tumors of hard consistency (grades 3, 4). Hyperintensity signals on T2WI, FLAIR, and DWI were significantly associated with soft consistency of meningiomas (relative risk [RR] 2.02, 95% confidence interval [CI] 1.35-3.03, p = 0.001, RR 2.19, 95% CI 1.43-3.35, p < 0.001, and RR 1.47, 95% CI 1.02-2.11, p = 0.037, respectively). Further, chance to be soft consistency significantly increased when two and three hyperintensity signals were combined (RR 2.75, 95% CI 1.62-4.65, p ≤ 0.001, RR 2.79, 95% CI 1.58-4.93, p < 0.001, respectively). Hypointensity signals on T2WI, FLAIR, and DWI were significantly associated with hard consistency of meningiomas (RR 1.82, 95% CI 1.18-2.81, p = 0.007, RR 1.80, 95% CI 1.15-2.83, p = 0.010, RR 1.67, 95% CI 1.07-2.59, p = 0.023, respectively) and chance to be hard consistency significantly increased when three hypointensity signals were combined (RR 1.82, 95% CI 1.11-2.97, p = 0.017). Conclusion T2WI, FLAIR, and DWI hyperintensity signals of the meningiomas was solely significantly associated with soft consistency and predictive value significantly increased when two and three hyperintensity signals were combined. Each of hypointensity signals on T2WI, FLAIR, and DWI was significantly associated with hard consistency of tumors and tendency to be hard consistency significantly increased when hypointensity was found in all three sequences.

Modified McKenzie-Dandy operation for a cervical dystonia patient who failed selective peripheral denervation: A case report and literature review.

BACKGROUND: Cervical dystonia (CD) is a rare and difficult-to-treat disorder. Various neurosurgical options are available, each with its own set of advantages and disadvantages. We investigated using the modified McKenzie-Dandy operation for a patient with CD who failed selective peripheral denervation (SPD). CASE DESCRIPTION: A 42-year-old man presented left-sided rotational torticollis for 3 years. He was referred for surgery after treating with a variety of oral medications and repeated botulinum toxin injections that became ineffective. For the first operation, the patient underwent SPD (modified Bertrand's operation); unfortunately, the postoperative outcome was unsatisfactory, and the operation was considered a failure. After his symptoms did not improve after 6 months, the modified McKenzie-Dandy operation was performed. Immediately following surgery, he experienced satisfactory outcomes. He was able to resume his normal activities and employment after 1 month after recovering from his temporary swallowing difficulties. He only complained of minor neck pain and no recurrence was observed after 3 years follow-up. CONCLUSION: For patients who have failed SPD, a modified McKenzie-Dandy procedure is a feasible and effective option. The procedure is relatively safe when performed properly, and the long-term effects can be maintained.

Influence of clivo-axial angle on outcome after foramen magnum decompression in adult symptomatic Chiari type 1 malformation.

OBJECTIVE: A significant number of patients with Chiari type 1 malformation (CM1) have abnormal clivo-axial angle (CXA) without other radiographic indicators of basilar invagination or craniovertebral junction (CVJ) instability. This study aimed to investigate whether abnormal CXA alone influences postoperative outcomes among patients who underwent foramen magnum decompression (FMD). METHODS: A total of 44 adult patients with symptomatic CM1 undergoing FMD without CVJ fixation were enrolled. Preoperative clinical characteristics and radiographic measurement include the CXA as well as the radiographic indicators of basilar invagination and instability were recorded. The univariate and multivariate binary logistic regression tests were used to identify the potential prognostic factors for favorable outcomes. RESULTS: Eighteen patients (41%) and 26 patients (59%) were divided into unfavorable and favorable outcome groups, respectively. Baseline demographic and imaging characteristics were similar between the two patient groups. The mean CXA was 132.3 ± 15.8 and 145 ± 13.6 degrees in the unfavorable and favorable groups, respectively (P = 0.091). In the favorable outcome group, the proportion of patients with CXA > 135 degrees was significantly higher than that of the unfavorable outcome group (77% vs. 44%; P = 0.05). The CXA > 135 degrees was found to be the only independent predictor associated with favorable outcomes (adjusted risk ratio 2.16; 95% CI 1.01-4.76; P = 0.047). CONCLUSION: The preoperative CXA of greater than 135 degrees was identified as a prognostic factor associated with a favorable outcome at one-year follow-up after FMD among adult patients with symptomatic CM1 without basilar invagination or CVJ instability. This factor should be incorporated into preoperative considerations.

Age as a prognostic factor of 30-day mortality in hemorrhagic stroke patients: A Thai large tertiary care referral center.

OBJECTIVE: The aim of the present study was to identify incidences and prognostic factors for 30-day mortality of hemorrhagic strokes (HS) and divide them into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). METHODS: This retrospective cohort study was conducted using medical records of patients who underwent surgery due to HS, between January 2013 and April 2017, at Chiang Mai University Hospital, a large tertiary referral center, in Northern Thailand. 30-day mortality was followed after surgery. Prognostic factors included patients' characteristics, and clinical date related to early death, were determined. Data analysis was performed using Cox's proportional hazards model. RESULTS: 460 patients were enrolled. The 30-day mortality rate was 8.8% and 12.3%, in ICH and SAH patients, respectively. Multivariable analyses demonstrated that the prognostic factors of early mortality in ICH patients were age 65-70 years (Adjusted HR 3.10 (95%CI 1.14-8.41)), >70 years (Adj.HR 2.64 (95%CI 1.09-6.36)) and hypertension (HT) (Adj.HR 2.98 (95%CI 1.25-7.12)). In SAH patients, prognostic factors were HT (Adj.HR 7.32 (95%CI 2.12-25.29)), and atrial fibrillation (AF) (Adj.HR 5.48 (95% CI 1.57-19.09)). CONCLUSIONS: Ages over 65 years and HT were an important predictor of 30-day mortality in a subgroup of ICH patients, whereas HT and AF were significant prognostic factors in SAH. To reduce early death, management for stroke cases needed to take into account the specifics for older age patients with HT, and AF.

Intracranial fetus-in-fetu with numerous fully developed organs.

Fetus in fetu (FIF) is an extremely rare anomaly featuring a monozygotic, diamniotic, parasitic twin, enclosed within its host twin. It is characterized by the presence of vertebrae and well-developed organs in a fetiform mass. Only 18 cases of intracranial FIF have been published. Of them, only five cases were prenatally detected. This study prenatally demonstrated triplet FIFs at 31 weeks within amniotic-like sac in the fetal skull, consisting of multiple well-defined organs. The FIF attached to the host twin via body stalk containing a single main feeding artery and vein, representing umbilical vessels. Surgical removal was performed at the age of two months. Pathological examination showed the triplet FIF, consisting of numerous well-developed organs (musculocutaneous-skeletal, nervous, respiratory, gastrointestinal systems etc.), with soft tissue/skin coverings, but no vertebral body was seen. Molecular genetic analysis revealed identical genetic mapping among the three FIFs and the host. This case provides strong evidence against Willis's hypothesis but supports Spencer's theory of abnormal twinning.

Silicone injected cadaveric head for neurosurgical dissection: Prepared from defrosted cadaver.

BACKGROUND: Most reports of cadaveric specimen preparation for neurosurgical dissection describe methods using fresh cadavers. Our cultural limitations prevent us from obtaining fresh cadaveric heads. OBJECTIVE: To study and report on an alternative method of preparation of head specimens for neurosurgical dissection using defrosted cadavers. MATERIALS AND METHODS: Twenty-four head specimens were procured through the Department of Anatomy, received by donation three to seven days after funeral activity. The specimens were sectioned through the neck, and preserved by refrigeration at a temperature of -10°C for a period of one week to three months prior to preparation. The process began with defrosting the frozen head specimens for 48 hours in a refrigerator, in which the temperature was controlled within the range of -2° to -8°C. The great vessels were identified and cannulated. These were then irrigated with tap water until clear, following which colored silicone was injected. The specimens were preserved in 95% ethyl alcohol, and were assessed for quality one week after the preparation process. They were then re-assessed at monthly intervals for 12 months. RESULTS: When compared with specimens prepared from fresh cadavers, our method provided similar quality specimens for dissection. The scalp and muscles of all specimens remained soft. The vasculature was good, and the colored silicone made identification easy. The brain tissues were soft and easily retracted, and still in good condition for dissection after a long preparation period (12 months). CONCLUSION: The head specimens prepared with this method were of good quality for dissection, and were comparable in quality to those prepared from fresh cadavers as in published methods. We were thus able to provide a suitable substitute to fresh head specimens in situations where access to fresh cadavers is unavailable.

Factors influencing the outcome of decompressive craniectomy used in the treatment of severe traumatic brain injury.

OBJECTIVE: To evaluate risk factors that influences the outcome of decompressive craniectomy (DC) in severe traumatic brain injury patients. MATERIAL AND METHOD: The authors' retrospective review of data collected from 826 severe traumatic brain injury patients admitted to the Chiang Mai University Hospital between January 1, 2006 and December 31, 2008. During this period, 159 of 826 patients (19.25%) underwent DC and the craniectomy size was not smaller than a fronto-temporo-parietal or a bifrontal bone flap. Data collected included demographics, pre- and post-operative Glasgow coma scores (GCS), timing of surgery, complications, and Glasgow outcome score (GOS) at discharge and six months after surgery. At our institution, patients are managed using the Brain Trauma Foundation guidelines. RESULTS: One hundred fifty nine patients were identified, 130 (81.76%) male and 29 (18.23%) female. One hundred twenty two patients were operated within the first 24 hours after admission. Overall mortality rate was 44.65%. The survival group was younger (30.73 years vs. 43.46 years, p < 0.001) and had a higher pre-craniectomy GCS (6 vs. 5, p = 0.002). Of the 88 survivors, favorable outcome was achieved in 21 patients (13.20%) at discharge and increased to 38 patients (23.89%) at six months after surgery. Those with favorable outcome were younger (25.43 years vs. 38.35 years, p = 0.001) and had a higher pre-craniectomy GCS (p = 0.013). CONCLUSION: Younger age group patients and higher pre-operative GCS are two factors that influence the outcome of DC. Early decompressive craniectomy in patients with higher GCS may result in better functional outcomes.