Extracranial pressure (ECP) monitoring in severe traumatic brain injury (TBI): A prospective study validating intra-abdominal pressure (IAP) measurement for predicting intracranial pressure (ICP).

Background: Intracranial pressure (ICP)--guided therapy is the standard of care in the management of severe traumatic brain injury (TBI). Ideal ICP monitoring technique is not yet available, based on its risks associated with bleeding, infection, or its unavailability at major centers. Authors propose that ICP can be gauged based on measuring pressures of other anatomical cavities, for example, the abdominal cavity. Researchers explored the possibility of monitoring intra-abdominal pressure (IAP) to predict ICP in severe TBI patients. Methods: We measured ICP and IAP in severe TBI patients. ICP was measured using standard right frontal external ventricular drain (EVD) insertion and connecting it to the transducer. IAP was measured using a well-established technique of vesical pressure measurement through a manometer. Results: A total of 28 patients (n = 28) with an age range of 18-65 years (mean of 32.36 years ± 13.52 years [Standard deviation]) and the median age of 28.00 years with an interquartile range (21.00-42.00 years) were recruited in this prospective study. About 57.1% (n = 16) of these patients were in the age range of 18-30 years. About 92.9% (n = 26) of the patients were male. The most common mode of injury (78.6%) was road traffic accidents (n = 22) and the mean Glasgow Coma Scale at presentation was 4.04 (range 3-9). The mean ICP measured at the presentation of this patient cohort was 20.04 mmHg. This mean ICP (mmHg) decreased from a maximum of 20.04 at the 0 h' time point (at the time of insertion of EVD) to a minimum of 12.09 at the 96 hr time point. This change in mean ICP (from 0 h to 96 h) was found to be statistically significant (Friedman Test: χ2 = 87.6, P ≤ 0.001). The mean IAP (cmH2O) decreased from a maximum of 16.71 at the 0 h' time point to a minimum of 9.68 at the 96 h' time point. This change was statistically significant (Friedman Test: χ2 = 71.8, P ≤ 0.001). The per unit percentage change in IAP on per unit percentage change in ICP we observed was correlated to each other. The correlation coefficient between these variables varied from 0.71 to 0.89 at different time frames. It followed a trend in a directly proportional manner and was found to be statistically significant (P < 0.001) in each time frame of the study. The rise in one parameter followed the rise in another parameter and vice versa. Conclusion: In this study, we established that the ICP of severe TBI patients correlates well with IAP at presentation. This correlation was strong and constant, irrespective of the timeframe during the treatment and monitoring. This study also established that draining cerebrospinal fluid to decrease ICP in severe TBI patients is reflected in IAP. The study validates that IAP is a strong proxy of ICP in severe TBI patients.

Basal Cisternostomy in Head Injury: More Questions than Answers.

Background: Cisternostomy has recently been reintroduced in the setting of severe TBI as an adjuvant surgical technique for decreasing brain edema and refractory intracranial hypertension. However, there is not much clarity regarding its role in head injury. Objective: Study the effect of cisternostomy on intracranial pressure, morbidity, and mortality in head-injured patients. Material and Methods: We conducted a single-center quasi-experimental study between November 2018 and November 2020. All candidates for decompressive hemicraniectomy (DHC) were divided into two groups: DHC-BC (undergoing basal cisternostomy with DHC) and DHC (undergoing DHC alone). We compared the impact of surgery on decreasing ICP and clinical outcomes in both groups. Results: During the study duration, we admitted 659 head-injury patients. Forty patients were included in the study (9 in the DHC-BC group and 31 in the DHC group). Both the groups were comparable in terms of baseline clinical characteristics such as age, gender, preoperative GCS, head injury severity, radiological features, and opening ICP. Patients in both groups had a decline in ICP following surgery. The mean closing pressure in the DHC-BC group (11.3 ± 5.9) was significantly higher than that in the DHC group (5.3 ± 3.5) (P = 0.003). The mean drop in ICP in the DHC-BC group was 14.4 ± 11.5 while that in the DHC group was 18.9 ± 12.4 (P = 0.359). The average total number of hours of ICP >20 mm Hg and intracranial hypertension index were higher for the DHC-BC group. The average number of days of stay in the ICU and hospital were lower for the DHC-BC group (7.0 ± 6.1 and 15.0 ± 20.2, respectively) compared to the DHC group (10.6 ± 9.3 and 19.3 ± 13.9, respectively). The 30-day mortality rate was higher for the DHC-BC group (66.6%) than the DHC group (32.2%). The mean GCS at discharge was better in the DHC-BC group (11.7 ± 2.9) compared to 10.5 ± 3.7 in the DHC group, while 11.1% of patients in the DHC-BC group had a favorable outcome (1-month GOS-E) compared to 9.7% patients in the DHC group. Conclusions: Our preliminary single-center study failed to show a clear benefit of adding basal cisternostomy to decompressive hemicraniectomy in patients with head injuries.

Bilateral sixth cranial nerve palsy, the first presenting feature of hemorrhagic apoplexy of pituitary macroadenoma: A case report.

INTRODUCTION AND IMPORTANCE: We report on apoplexy of undiagnosed pituitary macroadenoma presenting as sudden onset bilateral sixth nerve palsy. CASE PRESENTATION: A 36-year-old male patient presented with a complaint of sudden onset diplopia for one week associated with chronic headache for two years. On further investigations, isolated bilateral sixth cranial nerve palsy was found to cause diplopia in lateral gaze and at distance. Magnetic resonance imaging of the brain showed a well-defined lobulated mass of 19 × 22 × 24 mm in the sellar and suprasellar region with hemorrhage, compressing optic chiasma superiorly with extension into the superior cavernous sinus compartment on the left side. The neurosurgery team excised the tumour through an endoscopic endonasal transsphenoidal approach. Abducens nerve palsy recovered within one week. CLINICAL DISCUSSION: In our case diplopia due to bilateral sixth cranial nerve palsy was the first clinical presentation of hemorrhagic apoplexy of pituitary macroadenoma which is a potentially life-threatening condition. There was no other significant ocular symptoms. High index of suspicion, prompt diagnosis and multidisciplinary team management resulted into favourable outcome. CONCLUSION: Sudden onset diplopia and isolated bilateral sixth nerve palsy should be added to the spectrum of clinical presentations of hemorrhagic apoplexy of previously undiagnosed pituitary macroadenoma.

Efficacy and safety profile of selumetinib in symptomatic inoperable plexiform neurofibromas.

INTRODUCTION: Selumetinib is a MEK inhibitor, which is effective with an acceptable safety profile in reducing the volume of symptomatic inoperable plexiform neurofibromas in some clinical trials and also has been recently approved by FDA for use in children aged 2 years or older. However, no systematic review has yet been performed to provide a collective estimate of the results of all these trials. EVIDENCE ACQUISITION: Articles describing the use of selumetinib in patients with neurofibromatosis type-1 (NF1) with inoperable plexiform neurofibromas were searched from different electronic databases. The objectives were to provide a pooled estimate of efficacy evaluated by direct measurement and also by various functional measures, as well as the proportion of patients with adverse events. For determining pooled estimates, we included only studies with a minimum sample size of 15 with a prospective study design. EVIDENCE SYNTHESIS: A total of eight articles with 137 patients were found and 134 patients in six uncontrolled trials were included in the quantitative review. Out of these 26 were adults (69% male; 33.2±18.4 years, range 18-60 years) and 108 were in the pediatric age group (74% boys, 10.9±2.3 years, range-2-18 years,). Total 77.86% (95% CI: 55.91-99.81%) patients had a partial response, 71.24% (95% CI: 53.62-89.93%) had a confirmed partial response, and 56.25% (95% CI: 37.53-72.49%) had a durable partial response. The average time to initial response was 7.3±2.9 cycles (range, 4 to 20), and the median time to best response was 15.4±5.8 cycles (range, 4 to 36). The average change in neurofibroma volume at best response was -28.15% (95% CI: -17.95%, -38.34%, range, -55.1% to 2.2%). Progression-free survival was observed in 93.12% of patients at the time of data cut-off. Overall, 73.26% (95% CI: 54.07%, 92.45%) patients had improvement in at least one of the functional or patient-reported outcome assessments. The most common adverse effects were grade 1 and 2 gastrointestinal symptoms (65%), an asymptomatic increase in the creatine phosphokinase level (31%), paronychia (6%), and acneiform rash (17%). A total of 17% patients required dose reduction due to these toxic effects and 10.5% (95% CI: 4.0%, 17.0%) of patients discontinued due to toxic effects. CONCLUSIONS: Selumetinib can produce sustained shrinkage in the majority of patients with NF1 and symptomatic plexiform neurofibroma to provide clinically meaningful benefit in functional ability, with more robust evidence in children. The acceptable safety profile and absence of cumulative toxic effects permit long-term treatment with selumetinib.

Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision.

BACKGROUND: Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor. MATERIAL AND METHODS: This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications. RESULTS: Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit. CONCLUSION: Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.

Efficacy and Safety of Thalidomide in Patients with Complicated Central Nervous System Tuberculosis: A Systematic Review and Meta-Analysis.

Thalidomide, an anti-inflammatory and immunomodulatory agent, has a potential role in cases with central nervous system tuberculosis (CNS-TB) with paradoxical reactions. Although several articles have described the use of thalidomide in CNS-TB, no systematic review has been performed in this regard. Different electronic databases were searched for articles describing the use of thalidomide in patients with CNS-TB. For determining pooled estimates in the quantitative review, studies with a minimum sample size of 5 were only considered, whereas for qualitative synthesis even single case reports were included. Fixed or random effect models were used suitably depending on the degree of heterogeneity. Fourteen articles describing a total of 107 patients (98 children and 9 adults) were selected from 156 records. A favorable clinical response was observed in 89% of patients with CNS-TB who had paradoxical reactions refractory to corticosteroids. Majority of the studies used a dose of 2-6 mg/kg/day and around 24% suffered from at least one adverse effect, with a mortality of 5%. Predominant adverse effects were rash (9.5%), neuropathy (6%), and elevated liver transaminases (9.5%). Only one placebo-controlled trial has been performed till now, which showed that high-dose thalidomide has numerous adverse effects, without any clinically significant improvement as compared with placebo. While in HIV-positive patients with TB-immune reconstitution inflammatory syndrome thalidomide was helpful in around 82% of cases. Low-dose thalidomide is helpful in patients with CNS-TB who had a paradoxical reaction and unresponsive to corticosteroids. Large, randomized trials are needed to provide more concrete information regarding the safety and efficacy of thalidomide.

Efficacy and safety of corpus callosotomy and ketogenic diet in children with Lennox Gastaut syndrome: a systematic review and meta-analysis.

BACKGROUND: Both corpus callosotomy (CC) and the ketogenic diet (KD) are commonly used in patients with Lennox Gastaut syndrome (LGS), as a significant proportion of these patients develop pharmacoresistant epilepsy. But no systematic review has yet compared the efficacy and safety of these two measures. METHODS: We conducted a systematic search on various databases to collating all available literature until 30th November 2020 with a primary objective to compare the efficacy of KD and CC in terms of the proportion of patients with complete seizure freedom, at least 75% and 50% reduction in seizure frequency at various time points after the institution of these modalities. We also attempted to compare the proportion and nature of adverse effects, impact on EEG, cognition, and behavior with these modalities. We only included original articles enrolling at least 10 patients with CC or KD for quantitative synthesis to determine a pooled estimate. We used a fixed or random effects model, depending on the degree of heterogeneity. RESULTS: We selected 23 and 7 articles describing the efficacy of CC and KD in 436 and 185 LGS patients out of 217 search items, but none of the studies compared directly these two entities. The indirect comparison between the pooled estimate of all patients with individual modalities revealed more patients with CC had seizure freedom, at least 75% and 50% reduction in seizure frequency (p=0.0001, 0.01, and 0.04 respectively). The proportion of patients with adverse effects was also higher for CC patients (p=0.01), although the proportion with serious adverse effects was not significantly different between the two modalities. Patients selected for CC were older, had higher seizure burden, more lag time after the onset of seizures, and received more number of antiseizure medications previously. Due to the availability of limited data, a firm conclusion could not be determined regarding the effect on EEG, cognition, and behavior with CC and KD. CONCLUSION: CC is more efficacious than KD in reducing seizure frequency in patients with LGS, although it has relatively more adverse effects during the immediate perioperative period.

Frontotemporal Branch of the Facial Nerve and Fascial Layers in the Temporal Region: A Cadaveric Study to Define a Safe Dissection Plane.

BACKGROUND: Anatomy of the temporal region is complex with controversy over the relationship of fascial planes with the upper division of the facial nerve. OBJECTIVE: This study aimed to identify the safe surgical landmarks to preserve the frontotemporal branch of the facial nerve during surgery and define the safest approach for surgical procedures in this region. MATERIAL AND METHODS: The anatomical relationship of the frontal branch of the facial nerve, superficial temporal artery (STA), fascial planes, and fat pads was determined after dissection on 10 cadaveric heads, that is (20 sides) Dissection was performed layer by layer from skin to bone. RESULTS: The temporoparietal fascia was made up of multiple (3-4) layers above the zygomatic arch and these layers were integrated with thin fibrous septa. The frontotemporal branch of the facial nerve (FTFN) was observed in a deeper part of temporoparietal fascia and superficial fat pad. The frontotemporal branch of the facial nerve (FTFN) crossed the zygomatic arch as two branches in 25%, as three branches in 65% and as four branches in 10% of specimens. CONCLUSIONS: Interfascial dissection between two layers of deep temporal fascia through the intermediate fat pad is superior to other approaches because of the lack of facial nerve branches in this plane. The Intermediate fat could be easily separated from deep layer of deep temporal fascia.