Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming ...evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
The endoscopic approach has gained popularity in cerebrospinal fluid (CSF) rhinorrhea repair with high success rates, yet recurrence is frequent. We analyzed our cases to determine the outcomes of ...endoscopic repair of CSF rhinorrhea and the effect of several perioperative factors on the success of repair.
A retrospective review of 50 patients who underwent endoscopic repair of CSF rhinorrhea between January 2013 and July 2023 was performed, collecting details of presentation, surgery, and postoperative period.
The most frequent etiology was nontraumatic CSF rhinorrhea (76%), in which the defect was most commonly located at the left cribriform plate, followed by traumatic CSF rhinorrhea (24%), in which sphenoid defects were most frequent. Traumatic CSF rhinorrhea was more common among male patients and was significantly associated with anosmia. Success rate at first repair attempt was 84%. Persistent CSF rhinorrhea was present in 3 patients (6%), and 5 patients (10%) developed recurrence of CSF rhinorrhea. Overall, 7 patients required reoperation, with 100% success rate after the second surgery. The use of 3-layered repair with fat, fascia lata, and mucosal flap was protective against repair failure, whereas bilateral defects and duration of symptoms >1 year were significantly associated with repair failure. The use of lumbar drain did not demonstrate a difference in repair success rate.
Endoscopic repair of CSF rhinorrhea appears to be safe and effective when performed with accurate localization of the site of the lesion and multilayered repair. Potential predictors of recurrence include bilateral and long-standing defects.
In an international trial involving 450 patients with acute subdural hematoma, craniotomy (bone flap replaced) and decompressive craniectomy (bone flap left out) yielded similar disability-related ...outcomes at 12 months.
Background
The Glasgow Coma Scale (GCS) is considered the gold standard for assessment of unconsciousness in patients with traumatic brain injury (TBI) against which other scales are compared. To ...overcome the disadvantages of GCS, the Full Outline Of Unresponsiveness (FOUR) score was proposed. We aimed to compare the predictability of FOUR score and GCS for early mortality, after moderate and severe TBI.
Methods
This is a prospective observational study of patients with moderate and severe TBI. Both FOUR and GCS scores were determined at admission. The primary outcome was mortality at the end of 2 weeks of injury.
Results
A total of 138 (117 males) patients were included in the study. Out of these, 17 (12.3 %) patients died within 2 weeks of injury. The mean GCS and FOUR scores were 9.5 (range, 3–13) and 11 (0–16), respectively. The total GCS and FOUR scores were significantly lower in patients who did not survive. At a cut-off score of 7 for FOUR score, the AUC was 0.97, with sensitivity of 97.5 and specificity of 88.2 % (
p
< 0.0001). For GCS score, AUC was 0.95, with sensitivity of 98.3 % and specificity of 82.4 % with cut-off score of 6 (
p
< 0.0001). The correlation coefficient was 0.753 (
p
< 0.001) between the GCS and FOUR scores.
Conclusions
T
he predictive value of the FOUR score on admission of patients with TBI is no better than the GCS score.
This study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using ...Google community mobility and alcohol sales data.
A retrospective time-series analysis.
Emergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care.
Daily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail.
An optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ
=130, df=1, p<0.001). Two principal components of community mobility, alcohol sales and weekday explain the change in the number of TBI cases (pseudo R
=58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period.
Decongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.
Hinge craniotomy (HC) is a technique that allows for a degree of decompression whilst retaining the bone flap in situ, in a ‘floating’ or ‘hinged’ fashion. This provides expansion potential for ...ensuing cerebral oedema whilst obviating the need for cranioplasty in the future. The exact indications, technique and outcomes of this procedure have yet to be determined, but it is likely that HC provides an alternative technique to decompressive craniectomy (DC) in certain contexts. The primary objective was to collate and describe the current evidence base for HC, including perioperative parameters, functional outcomes and complications. The secondary objective was to identify current nomenclature, operative technique and operative decision-making. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Fifteen studies totalling 283 patients (mean age 45.1 and M:F 199:46) were included. There were 12 different terms for HC. The survival rate of the cohort was 74.6% (
n
= 211). Nine patients (3.2%) required subsequent formal DC. Six studies compared HC to DC following traumatic brain injury (TBI) and stroke, finding at least equivalent control of intracranial pressure (ICP). These studies also reported reduced rates of complications, including infection, in HC compared to DC. We have described the current evidence base of HC. There is no evidence of substantially worse outcomes compared to DC, although no randomised trials were identified. Eventually, a randomised trial will be useful to determine if HC should be offered as first-line treatment when indicated.
Driving under the influence of alcohol is one of the leading causes of road traffic accidents in India. Individuals with acute injuries often present to emergency hospital services. Carrying out ...brief interventions in the emergency can prevent further injury and even progression to severe patterns of drinking. However, there are no known studies from India examining the effectiveness of such interventions in emergency settings. Against this background, the objective of this randomized controlled trial was to evaluate the effectiveness of a nurse-led Brief Focused Intervention (BFI) in comparison with the minimal intervention for patients with mild Traumatic Brain Injury (TBI) reporting to the emergency and casualty services of a tertiary hospital in Bengaluru, South India, who screened positive for alcohol use.
The BFI comprised a video portraying the effects of alcohol on the brain and muscles and brief advice on how to reduce or avoid alcohol use. Subjects (
= 90) were randomly allocated to two groups: BFI (
= 45) or Minimal Intervention Group (MIG) (
= 45). Standardized tools were used to assess both groups on specific outcomes for up to six months following discharge from the emergency and casualty services. At the end of six months, complete data wasavailable for 73 patients.
Participants' (
= 73) mean age was 35 years (standard deviation SD-11). Over the six-month follow-up, the BFI group reported significantly lesser quantity of alcohol consumption (Alcohol Use Disorder Identification Test AUDIT Score - 5.03, SD 4.09, 95% confidence interval CI = 3.70, 6.35) compared to MIG (AUDIT Score - 9.76, SD 2.96, 95% CI = 8.73, 10.80), and fewer alcohol use-related problems in BFI group (Mean - 4.18, SD 3.21, 95% CI = 3.14, 5.22) compared to MIG (Mean - 5.88, SD 2.59, 95% CI = 4.98, 6.79). Results of logistic regression showed that being in MIG as well as baseline hazardous use of alcohol were associated with unfavorable outcomes at the end of six months follow-up.
Findings provide the first known evidence from India for the effectiveness of nurse-led BFI in the emergency and casualty services in improving post-discharge outcomes for patients with alcohol use-related mild TBI. While the findings of the study are statistically significant, these findings also have significant clinical relevance, as they have shown that the BFI improved clinical outcomes. Thus, brief interventions should be implemented for these patients whenever possible in the Emergency setting.
Background: Autonomic nervous system (ANS) is invariably affected by craniovertebral junction (CVJ) anomalies. The usual presentation is sudden after trivial trauma. When symptomatic, most of this ...autonomic dysfunction is clearly elicited clinically with bedside tests. Nonetheless, ANS functionality in relatively less symptomatic or asymptomatic patients is not known as no studies exist.
Methodology: We performed a longitudinal prospective study of 40 less symptomatic patients who underwent surgery with conventional autonomic function tests (AFT) in pre- and post-operative periods. Correlation of its association with such anomalies is studied.
Results: All 40 had both pre- and post-operative clinical follow-up, pre-operative AFT, whereas only 22 patients had follow-up AFT. The mean age for the group was 32 years and male: female ratio was 2.3:1. Mean Nurick's grade was 1.8, whereas Barthel's index was 83.75%. Clinical improvement was seen in almost 98% at follow-up. Orthostatic test showed a significant association with Nurick's grade. Barthel's index was significantly associated with degree of compression. The mean follow-up was 17.4 months. Most conventional AFTs were significantly decreased in the preoperative period (P ≤ 0.01). Both parasympathetic and sympathetic tone improved on follow-up with better improvement later. Overall clinical involvement of ANS was seen in 22.5% whereas subclinical involvement in the form of AFT impairment was seen in 100%.
Conclusion: There is a definite involvement of subclinical ANS in all patients of CVJ anomalies irrespective of their symptomatology. Knowing the extent of involvement in the preoperative period can help prognosticate, prioritize regarding surgery as well as correlate with the extent of improvement.
4 The indications for ICP monitoring were not based on the guidelines, but the ICP monitored was performed in younger patients, diffuse injury III-IV, evacuated mass lesions, perimesencephalic ...cistern compression, and midline shift of ≥5 mm. The patients in ICP-monitoring group received more hyperventilation, hyperosmolar diuretics, sedatives, anticonvulsants, surgical treatment, and temperature management. Besides maximum ICP value, age, Glasgow Coma Scale (GCS) score, papillary abnormalities, and perimesencephalic cisterns were significant determinants of outcome. Patients with ICP monitor placement experienced lower in-hospital mortality (adjusted relative risk: 0.50 0.29, 0.87) than patients without ICP monitoring. The ICP monitoring placement was found to be an independent risk factor for mortality, mechanical ventilation, intensive care unit (ICU) length of stay, systemic complications, and decreased functional independence at discharge.
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