Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India.

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n = 190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3-month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0-3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4-5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p = <0.001, OR 4.806, 95% CI 3.064-7.54), admission GCS <8 (p = <0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p = <0.001, OR 2.45, 95% CI 1.626-3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p < 0.015, CI 1.105-2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Outcomes of Cranioplasty from a Tertiary Hospital in a Developing Country.

INTRODUCTION: Although cranioplasty (CP) is a straightforward procedure, it may result in a significant number of complications. These include infections, seizures, intracranial hematomas, and others. Many reports have stated that early CP is associated with higher complications; however, more recent articles have contradicted this opinion. We intend to share our experience and results on outcomes of CP from our university hospital. MATERIALS AND METHODS: This is a 3-year retrospective analysis of patients undergoing CP. Demographic profile, etiology of decompressive craniectomy (DC), DC-CP interval, operative details, complications, and follow-up data were analyzed. Correlation of complications with timing of CP and other factors was studied to look for statistical significance. RESULTS: A.total of 93 cases were analyzed. The majority were traumatic and ischemic stroke etiologies. There were eight open/compound head injuries (HIs). Eleven were bilateral and the rest unilateral cases. The mean and median CP interval were 8.5 weeks (range 4-28 weeks) and 8 weeks, respectively. All patients received 48 h to up to 5 days of postoperative antibiotics. Ten complications (10.7%) were noted (including one death). Poor Glasgow Outcome Scale at CP was the only statistically significant factor associated with higher complication rates. There was no statistical difference with respect to gender, CP material, and etiology; however, early CP had slightly fewer complications. CONCLUSION: Patients with poor neurological condition at the time of CP have a significantly higher risk of complications. Contrary to earlier reports, early CP (<12 weeks) was not associated with higher complications but rather fewer complications than delayed procedures. Adherence to a few simple steps may help reduce these complications.

Study on Acute Kidney Injury in Patients with Spontaneous Intracerebral Hemorrhage: an Overview from a Tertiary Care Hospital in South India.

INTRODUCTION: Acute kidney injury (AKI) is an independent risk factor for adverse clinical outcomes in patients with hemorrhagic stroke. There is limited data regarding the occurrence and impact of AKI in the setting of spontaneous intracerebral hemorrhage (SICH). Considering this, we sought to determine the incidence and risk factors for AKI in patients with SICH and to determine the role of AKI on SICH mortality in our population. MATERIALS AND METHODS: This is a retrospective analysis of the data recorded in the stroke registry maintained by the Department of Neurosurgery, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education after ethical committee clearance. Information regarding clinical features, demographics, laboratory data, prescribing patterns, and the use of contrast-mediated imaging were collected. AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria. Logistic multivariate regression was used to determine predictors of AKI. Analysis of variance was used to measure the effect of AKI on SICH outcome. RESULTS: Of 316 patients with SICH admitted to the hospital, 20% of patients developed AKI. It was found that risk factors for AKI were lower baseline estimated glomerular filtration rate (odds ratio, 1.60; 95% confidence interval, 1.21 SICH 2.2; P < 0.001) and infectious complications (odds ratio, 3.37; 95% confidence interval, 1.9-5.7; P < 0.001). The incidence of 30 days' mortality was higher in the group with AKI (14% vs. 5.5%). There was a significant association between AKI severity and short-term mortality (P < 0.001). Patients with AKI had a lower Glasgow Coma Scale on admission (11.81 ± 3.17 vs. 10.83 ± 3.2) and discharge (12.44 ± 3.44 vs. 10.38 ± 3.2) compared to patients without AKI (P < 0.001). Greater severity of AKI was associated with worse neurologic outcome (P < 0.001). DISCUSSION: Various studies in literature have evaluated the incidence of AKI after a stroke episode. The incidence of AKI was ranging from 8%-21% in those studies. In our study, we found that 20% of SICH patients developed AKI. The incidence of AKI in our study falls along the spectrum described in these previous studies. CONCLUSIONS: AKI is a common complication of SICH. Lower estimated glomerular filtration rate at admission and infections were the significant risk factors. Patients with AKI had poor neurologic outcome and higher mortality and it increased with the severity of AKI.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma.

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Nontuberculous Antineutrophil Cytoplasmic Antibody-Positive Pachymeningitis Presenting as High Cervical Myelopathy.

High cervical myelopathy is a common entity and often encountered in clinical practice. Various pathologies can present with this symptomatology. Detailed history and a meticulous neurological examination can help us differentiate and rule out some of the close differentials. Non tuberculous ANCA positive pachymeningitis is a rare entity and a diagnosis of exclusion or following histopathological confirmation. Here we describe a case of high cervical myelopathy, the presentation, imaging and the various differentials considered and how we arrived at the diagnosis.

Spontaneous Intracerebral Bleed Post Snake Envenomation.

Snakebite envenomation is a commonly encountered emergency in tropical countries with potentially fatal complications. Life threatening neurosurgical complications are rare and infrequently documented in literature. We discuss the case of 28-year-old gentleman, managed successfully for an intracerebral haemorrhage following a viper bite and attempt to obviate some management dilemmas often encountered in viperine envenomation.