Chronic subdural hematomas and the elderly: Surgical results from a series of 125 cases: Old "horses" are not to be shot!

BACKGROUND: To present the accumulated experience from treating chronic subdural hematomas (CSDH) in a local hospital of a third world country. METHODS: One hundred and twenty-five consecutive patients with CSDH who were surgically treated in the Neurosurgical Department of the Hospital da Restauração, Recife-PE, Brazil, between January 2006 and May 2008, were retrospectively studied. Glasgow Outcome Scale (GOS) was employed to define outcome at 6 months as good (GOS 4 and 5) or poor (GOS ≤ 3). Age, admission Glasgow Coma Scale (GCS), location of hematomas (unilateral/bilateral), drainage system placement and recurrence were all analyzed for potential impact on final outcome. RESULTS: The median age was 69 years, with a male/female ratio of 102/23. History of trauma was present in 60.8% of the patients. The median GCS on admission was 14. In 64 patients, the hematoma was on the left side, while in 42 patients it was on the right side. Bilateral hematomas were present in 19 cases (15.2%). Drainage systems were used in 93.6% of the cases. Recurrence occurred in 8.8% of the patients. One hundred and three patients obtained a good outcome at 6 months. The mortality rate was 11.2%. Patients with GCS ≥9 on admission presented better outcome (P < 0.05). Recurrent cases presented a poor outcome (P < 0.05). CONCLUSIONS: This study suggests that the main factors associated with outcome in patients harboring CSDH are the admission GCS score and the recurrence status. Advanced age is not a contraindication for surgical treatment. This study, solely focused on the Brazilian population, is the first of its kind in the English literature, and it could serve as a useful introduction to a more complex, multivariate, debate.

COMPARATIVE MACROSCOPIC STUDY OF OSTEOCHONDRAL DEFECTS PRODUCED IN FEMURS OF RABBITS REPAIRED WITH BIOPOLYMER GEL CANE SUGAR.

OBJECTIVE: To study the surface, coloring, consistency, continuity and healing of osteochondral defects produced in the femoral condyles of rabbits and filled with sugar cane biopolymer gel (SCBG), after 90, 120 and 180 days, and in comparison with a control group. METHOD: Sixteen adult New Zealand white rabbits aged 6 to 7 months, weighing between 2 and 2.5 kg and without locomotor system abnormalities were studied. In all the animals, a defect was made in the femoral condyles of the right and left knees, measuring 3.2 mm in diameter and 4 mm in depth, using a trephine. The animals were divided into two groups: study group formed by the right knees, in which the medial and lateral condyles received implants of SCBG; and control group formed by the left knees, in which the medial and lateral condyles were allowed to heal naturally. The knees were assessed 90, 120 and 180 days after the operation. After the animals had been sacrificed, the anatomical specimens were resected and placed in Bouin's solution. They were then photographed with a Nikon Coolpix 5400(®) coupled to a Nikon SM2800(®) stereoscopic loupe, to analyze the surface, coloring, consistency, continuity and healing. RESULTS: The results were evaluated using the chi-square test. There were no significant differences in the macroscopic assessments of healing between the study and control groups. CONCLUSION: With regard to the surface, coloring, consistency, continuity and healing of the defects, the macroscopic appearance of the tissue repaired with SCBG was similar to that of the control group.

"In-window" craniotomy and "bridgelike" duraplasty: an alternative to decompressive hemicraniectomy.

OBJECT: The object of this study was to propose an alternative procedure to the classic decompressive hemicraniectomy using an "in-window" craniotomy and a "bridgelike" duraplasty. METHODS: The authors performed a large, almost rectangular craniotomy involving the frontal, temporal, and parietal bones and part of the occipital squama in 5 patients. The dura mater is opened and its area is enlarged using a rectangular dural patch of the surgeon's choice in the form of a bridge between the anterior and posterior dural edges. With a vertical cut, the bone flap is divided into 2 similarly sized pieces that function as "window lids." The outer frontal and occipital sides of the bone are tied to the skull border at 2 points to function as a hinge joint. The angle of the bone cut must be beveled outward (inclination ~ 45° of the bone drill or saw) to allow the bone flap to rest on the adjacent skull and prevent its slippage toward the intracranial cavity. RESULTS: The above procedures were performed with effective control of intracranial hypertension due to cerebral venous sinus thrombosis, brain trauma, intracerebral hematoma, or malignant cerebral ischemia. CONCLUSIONS: Decompressive surgery, which uses an in-window craniotomy that gradually opens according to the intracranial pressure, is an alternative solution for deploying autologous material. The procedure has the advantage of obviating the need for a second surgical procedure to close the bone defect, and thus preventing the metabolic cerebral impairment associated with the absence of an overlying skull.

Hypertonic saline more efficacious than mannitol in lethal intracranial hypertension model.

BACKGROUND: Medical management of brain edema and elevated intracranial pressure (ICP) is a crucial challenge in neurosurgical practice. Depending on the cause, the treatments for brain edema fall into three categories: stabilization of the blood-brain barrier, depletion of brain water and surgical decompression. Although mannitol is the mainstay of hyperosmolar therapy, hypertonic saline (HS) is emerging as an effective alternative to traditional osmotic agents. METHODS: Experimental elevated ICP (50 mmHg) was induced in rabbits using an intracranial balloon. The effects of mannitol and HS (10% NaCl) were compared in this specific physiopathological model. Twelve animals were divided into three groups (control, HS and mannitol) according to intravenous administration of 0.9% NaCl, 10% NaCl or 20% mannitol 5 minutes after the elevation of ICP. The doses of 10% NaCl and 20% mannitol were iso-osmolar. During 90 minutes, continuous recording of ICP, mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) was realized. RESULTS: The control group had a median survival of only 53 minutes, significantly lower than the treated groups (p=0.0002). There was statistical difference between mannitol and HS; the 10% NaCl group had lower values of ICP (p=0.0116) and higher values of MAP (p<0.0001) and CPP (p<0.0001). CONCLUSION: The findings demonstrate higher efficacy of the 10% NaCl treatment in this comparison with 20% mannitol. Further efforts should be directed toward development of clinical studies using iso-osmotic doses of mannitol and HS in specific etiologies of intracranial hypertension.

[Calvarial tuberculosis: case report]. / Tuberculose óssea craniana: relato de caso.

Tuberculosis is endemic in developing countries. However, calvarial tuberculosis is rare and only few cases have been reported with computed tomographic findings. We report on a 49-year-old woman with a occipital painless nodule. The microscopic examination indicated typical tuberculosis granulomas. Clinical presentation and management are discussed.