Contralateral subdural effusion after decompressive craniectomy in patients with severe traumatic brain injury: clinical features and outcome.

BACKGROUND: Contralateral subdural effusion (SDE) is usually considered as an uncommon complication after decompressive craniectomy (DC) for head trauma. This complication may need more aggressive treatment because of its tendency to cause midline shift and neurologic deterioration. In this article, we present our experience with this group of patients and discuss the diagnosis and management of this entity. METHODS: This study included 13 patients with severe traumatic brain injury who developed contralateral SDE after DC. Clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs. RESULTS: The average time from the procedure of DC to the diagnosis of contralateral SDE was 13 days. Deterioration of clinical condition or appearance of new symptoms/signs related to the contralateral SDE was noted in four patients. In the remaining nine patients without apparent clinical deterioration, the contralateral SDE was discovered on routine computed tomography scan. Six patients were treated conservatively and the contralateral SDE resolved gradually. In six patients who underwent burr hole craniectomy to evacuate the SDE, the operation had successfully drained the SDE in four patients. Two patients received subsequent subduroperitoneal shunt to manage the reaccumulation of SDE. In one patient, subduroperitoneal shunt and cranioplasty were performed simultaneously to treat the SDE. Subsequently, six patients (46.2%) developed hydrocephalus and underwent ventriculoperitoneal shunt operation. CONCLUSIONS: Contralateral SDE may not be a rare complication after DC. Its diagnosis may be delayed or missed when it is asymptomatic or the clinical condition of the patient masks its clinical manifestations. It may be reasonable to repeat a computed tomography scan to detect contralateral SDE 2 weeks to 3 weeks after DC, irrespective of the clinical condition. In addition, posttraumatic hydrocephalus is a common late consequence in these patients. Close surveillance in these patients is indicated to prompt appropriate management.

Predictors and outcome of acute symptomatic cerebral infarctions following aneurysmal subarachnoid hemorrhage.

The leading cause of unfavorable outcomes following aneurysmal subarachnoid hemorrhage (SAH) is cerebral infarction. In this 3-year retrospective study, we have retrospectively evaluated 172 hospitalized patients with aneurysmal SAH, and compared those who developed a complicated cerebral infarction with those who did not. In this study, acute symptomatic cerebral infarctions accounted for 22.6% (39/172) of all episodes. Significant statistical analysis between the two patient groups included age at onset, hypertension as the underlying disease, presence of symptomatic vasospasm, mean hospitalization days and Glasgow Outcome Score at the time of discharge. After a minimum 1.5-year follow-up period, the median (interquantile range) Barthel index score was 75 (6-85) for those patients who had cerebral infarctions, and 80 (0-90) for those who had no cerebral infarctions. Multiple logistic regression analysis demonstrated that the presence of symptomatic vasospasm was independently associated with the presence of acute symptomatic cerebral infarctions. The presence of symptomatic vasospasm implies the danger of acute symptomatic cerebral events after aneurysmal SAH. Although our study demonstrates a worse short-term outcome and longer duration of hospitalization in this special group of patients, the functional outcome for patients with cerebral infarction was not inferior to those patients without cerebral infarction after a follow-up of at least 1.5-years.

Nocardial brain abscess.

Nocardial infections, although rare, are challenging for clinicians to treat. The associated mortality rate remains high; such infections usually occur in immunocompromised patients who have predisposing factors such as malignancy, diabetes mellitus, malnutrition and uremia. However, there have been increasing reports of nocardial infections being observed in immunocompetent patients. Nocardial organisms are mostly isolated from plants and soil, and infection occurs most often as a result of inhalation or direct skin inoculation. Nocardial infections disseminate hematogenously from the primary location to distant end organs, including the brain, kidneys, joints and eyes. Sulfonamides are the drug of choice, based on empirical data. Given the high rate of relapse and the characteristic resistance pattern, treatment should be aggressive and continued for months, with antibiotic treatment being adjusted according to the drug sensitivity test. In our institution, there have been three documented patients with a nocardial brain abscess. All patients were treated with surgical evacuation followed by antibiotics. Here, we report on one patient and review the literature.

Breast carcinoma metastasis to intracranial meningioma.

Meningiomas and breast cancers are common tumors among women in the fifth to seventh decade. However, metastasis from breast cancer to an intracranial meningioma is rare. A 63-year-old woman presented with headache, nausea and vomiting, and progressive right hemiparesis for one month. She had undergone a right modified radical mastectomy in another hospital 10 years prior. At that time, the pathological diagnosis was infiltrating ductal carcinoma. She required adjuvant radiotherapy and chemotherapy for a local recurrence 7 years later. On admission to our hospital, cranial CT scans showed a brightly enhancing, irregularly shaped lesion over the left high parietal lobe with surrounding parenchymal edema. Histopathological examination of the lesion revealed two distinct tumor types, meningioma and metastatic carcinoma of breast tissue origin. Although meningiomas have well-known radiological features, other tumors, including metastases from breast cancers may simulate them. In the clinical setting of previously diagnosed breast cancer, prompt craniotomy for removal of meningioma-like intracranial lesions is recommended to avoid missing the diagnosis of breast cancer metastasis which carries a poorer prognosis than meningioma and requires a different treatment strategy.

Systemic and local reactions of a water-soluble copolymer bone on a bony defect of rabbit model.

BACKGROUND: Ostene, a synthetic water-soluble bone hemostatic agent, is commercially available. In the current study, we evaluated the systemic and local effects of this copolymer in a rabbit model. METHODS: Eighteen rabbits underwent creation of a bony defect at right iliac crest. These rabbits were then evenly divided into 3 groups. In group 1, the defect surfaces were treated with bone wax; in group 2, the defect surfaces were treated with Ostene; in group 3, the defect surfaces were not treated with anything. Then, the animals underwent blood examinations, including WBC count, CRP, and ESR at 0, 1, 3, and 6 weeks, and were killed at 6 weeks for histologic examination. Another 6 rabbits (group 4) underwent the same surgical treatment of group 2 animals but had blood examinations of BUN and creatinine. RESULTS: The blood examinations showed that the WBC count, CRP, and ESR of all the animals in the first 3 groups were within normal limits in the postoperative periods. Microscopic examinations demonstrated residual bone wax and fibrotic tissue at the defect surfaces in group 1 animals. However, there was no Ostene at the defect surfaces in group 2 animals. The groups 2 and 3 animals showed no fibrotic tissue at the defect surfaces. The group 4 animals showed normal serum levels of BUN and creatinine in the postoperative periods. CONCLUSION: Ostene is absorbable and induces no systemic inflammation (including acute renal damage) and local inflammation in animal bodies.

Acute contralateral subdural hygroma following craniectomy.

We report a case of acute contralateral subdural hygroma (SDG) following decompressive craniectomy and discuss the potential aetiologies of the SDG. A 63-year-old man experienced drowsiness (Glasgow coma scale score 13) after a fall that resulted in head trauma. Brain CT revealed a subdural haematoma at the right fronto-temporo-parietal region with a midline shift to the left. Craniectomy for evacuation of the subdural haematoma was performed immediately. A delayed intracerebral haematoma with mass effect in the right frontotemporal region developed later, and was removed in a second operation. Although the patient's neurological status improved postoperatively, gradual deterioration was observed during the follow-up period. Contralateral SDG with a midline shift to the right was noted in a follow-up brain CT scan. The patient's condition improved after drainage of the SDG and he was discharged 1 week later.