Cranial CT Research Articles

CT Trends After Minor Head Injury Guideline Implementation

Source: Corwin DJ, Durbin DR, Hayes KL, et al. Trends in emergent head computed tomography utilization for minor head trauma after implementation of a clinical pathway. Pediatr Emerg Care. 2021;37(9);437-441; doi:10.1097/PEC.0000000000001728Investigators from the Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, conducted a retrospective study to assess changes in neuroimaging among children seen in the ED for mild traumatic brain injury (TBI) following implementation of guidelines designed to reduce unnecessary CT scans. The guidelines, implemented in 2011, were adapted from guidelines published by the Pediatric Emergency Care Applied Research Network (PECARN) that included specific clinical criteria for identifying children at low risk.1 Study participants were patients ≤21 years old seen in the ED at CHOP between 2012 and 2016 with TBI (identified using ICD-9 and ICD-10 codes) with a Glasgow Coma Scale score of 13–15 who were discharged home following evaluation. Data abstracted on these children included demographics, time of day, provider type (general pediatrician, pediatrician emergency physician, or nurse practitioner), whether a CT was obtained, and Emergency Severity Index (ESI) score. ESI scores range from 1–5, with 1 being the most acute. The medical records of a random sample of 10% of patients on whom a CT was obtained were reviewed to assess the reason for obtaining the scan and to classify the child’s risk for intracranial injury based on PECARN criteria. The primary outcome was change in rate of CT utilization during the study period, assessed using Wilcoxon rank sum test for trend. Secondary outcomes included rate of ordering CT scans by provider type, using logistic regression and adjusting for ESI scores.Data were analyzed on 21,129 patients with a mean age of 6.6 years; 62% were male. Overall, CT scans were obtained on 6.3% (95% CI, 5.9%, 6.6%) of these patients. During the study period the rate of CT scan utilization fell from 8.3% in 2012 to 4.9% in 2016 (average decrease 0.9% per year; P <0.001 for trend). After adjusting for ESI score, general pediatricians were more likely to obtain a CT scan than pediatric emergency physicians (OR, 1.37; 95% CI, 1.02, 1.83); there was no difference in likelihood of ordering a CT between nurse practitioners and pediatric emergency physicians (OR, 0.63; 95% CI, 0.33, 1.17). In the 10% random sample of patients on whom CT scans were obtained, 30% met PECARN criteria for being low risk. The most common indications for ordering a CT in children <2 years old were concern for non-accidental trauma and vomiting, while for older patients the most common reasons were parental preference and presence of a scalp hematoma.The authors conclude the rate of CT scan ordering in children with mild TBI decreased after implementation of guidelines designed to reduce unnecessary neuroimaging.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Clinical pathways (CPWs) are tools to promote evidence-based healthcare delivery and strive to standardize care for a specific clinical problem in a specific population.2 Thus, compliance with a CPW by a diverse swath of healthcare providers is ultimately the best indicator of its relevance and utility. The primary objective of the current well-done study was to assess the pattern of change in CT utilization in discharged children with mild TBI following the implementation of a CPW in a children’s ED.The authors found that for 5 years, the rate of obtaining CT in children discharged with minor TBI declined by 0.9% per year, a statistically significant decrease, without an accompanying increase of LOS in the ED. However, despite these guidelines, 30% of surveyed Electronic Health Records (EHRs) of discharged children were characterized as low risk by the guidelines and still had a CT obtained. When documented in the EHR, the most common indications for obtaining a CT in this population were age specific. For example, in children younger than 2 years, providers were more concerned about the presence of abusive trauma and vomiting, whereas, in children older than 2 years, parental preference and scalp hematomas drove CT utilization. It may be noted that updated PECARN guidelines do not use vomiting as a risk factor, while parental preference is still a consideration in choosing CT over observation.3 The other interesting finding was that general pediatricians were more likely to order a CT compared with emergency medicine providers. Thus, the dissemination of this CPW to general pediatricians would be helpful to reduce CT use further. (See AAP Grand Rounds. 2017;37[6]:68.)4A CPW for the management of minor closed head trauma in children can lead to the reduction in the utilization of head CTs in childrenAbove and beyond decreasing unnecessary use of expensive resources and decreasing length of ED stay, decreased cranial CT frequency in children with minor TBI reduces exposure to potentially harmful ionizing radiation.4

Predicting factors for abnormal brain computed tomography in children with minor head trauma

BackgroundDeciding whether a cranial Computed Tomography (CT) scan in a patient with minor head trauma (MHT) is necessary or not has always been challenging. Diagnosing Traumatic Brain Injury (TBI) is a fundamental part of MHT managing especially in children who are more vulnerable in terms of brain CT radiation consequences and TBI. Defining some indications to timely and efficiently predict the likelihood of TBI is necessary. Thus, we aimed to determine the impact of clinical findings to predict the need for brain CT in children with MHT.MethodsIn a prospective cohort study, 200 children (2 to 14 years) with MHT were included from 2019 to 2020. The data of MHT-related clinical findings were gathered. The primary and secondary outcomes were defined as a positive brain CT and any TBI requiring neurosurgery intervention, respectively. In statistical analysis, we performed Binary Logistic regression analysis, Fisher’s exact test and independent samples t-test using SPSS V.26.ResultsThe mean age of participants was 6.5 ± 3.06 years. Ninety patients underwent brain CT. The most common clinical finding and injury mechanism were headache and falling from height, respectively. The results of brain CTs were positive in seven patients (3.5%). We identified three predicting factors for an abnormal brain CT including headache, decreased level of consciousness, and vomiting.ConclusionWe showed that repetitive vomiting (≥2), headache, and decreased level of consciousness are predicting factors for an abnormal brain CT in children with MHT.

Optimized Intraoperative Imaging for Stereotactic Planning with a Multiaxial Robotic C-arm System: Technical Note and Case Series.

The preoperative preparation of the planning dataset for frame-based stereotactic brain biopsy is often associated with logistical effort and burden on the patient. Intraoperative imaging modalities need to be investigated to overcome these limitations. The objective of the study was to develop and apply a new method for the intraoperative acquisition of the planning dataset with the multiaxial robotic C-arm system Artis zeego. An indication-customized dose-reduced protocol for Artis zeego was developed and implemented into the workflow. A sample of 14 patients who had undergone intraoperative imaging with Artis zeego was analyzed. A sample of 10 patients with conventional preoperative imaging by cranial computed tomography (CT) was used as a control group. Outcomes were compared with regard to target deviation, diagnostic value of the biopsies, complications, and procedure time. In all patients, a suitable intraoperative planning dataset could be acquired with Artis zeego. Total procedure time was shorter for the Artis zeego group (p = 0.01), whereas time in the operating room area was longer in the Artis zeego group (p = 0.04). Biopsy results were diagnostic in 12 patients (86%) in the Artis zeego group and in 8 patients (80%) in the control group. There were no significant differences in target size, trajectory length, or target deviation. Intraoperative imaging for frame-based stereotactic brain biopsy with Artis zeego is an easy and feasible method. Accuracy is comparable to conventional CT, whereas radiation exposure could be additionally reduced. It allows a significant reduction of the total procedure length and improves the comfort for the patient and staff.

Comparison of intracranial injury predictability between machine learning algorithms and the nomogram in pediatric traumatic brain injury.

The overuse of head CT examinations has been much discussed, especially those for minor traumatic brain injury (TBI). In the disruptive era, machine learning (ML) is one of the prediction tools that has been used and applied in various fields of neurosurgery. The objective of this study was to compare the predictive performance between ML and a nomogram, which is the other prediction tool for intracranial injury following cranial CT in children with TBI. Data from 964 pediatric patients with TBI were randomly divided into a training data set (75%) for hyperparameter tuning and supervised learning from 14 clinical parameters, while the remaining data (25%) were used for validation purposes. Moreover, a nomogram was developed from the training data set with similar parameters. Therefore, models from various ML algorithms and the nomogram were built and deployed via web-based application. A random forest classifier (RFC) algorithm established the best performance for predicting intracranial injury following cranial CT of the brain. The area under the receiver operating characteristic curve for the performance of RFC algorithms was 0.80, with 0.34 sensitivity, 0.95 specificity, 0.73 positive predictive value, 0.80 negative predictive value, and 0.79 accuracy. The ML algorithms, particularly the RFC, indicated relatively excellent predictive performance that would have the ability to support physicians in balancing the overuse of head CT scans and reducing the treatment costs of pediatric TBI in general practice.

Automated Identification of Skull Fractures With Deep Learning: A Comparison Between Object Detection and Segmentation Approach.

Objective: Skull fractures caused by head trauma can lead to life-threatening complications. Hence, timely and accurate identification of fractures is of great importance. Therefore, this study aims to develop a deep learning system for automated identification of skull fractures from cranial computed tomography (CT) scans.Method: This study retrospectively analyzed CT scans of 4,782 patients (median age, 54 years; 2,583 males, 2,199 females; development set: n = 4,168, test set: n = 614) diagnosed with skull fractures between September 2016 and September 2020. Additional data of 7,856 healthy people were included in the analysis to reduce the probability of false detection. Skull fractures in all the scans were manually labeled by seven experienced neurologists. Two deep learning approaches were developed and tested for the identification of skull fractures. In the first approach, the fracture identification task was treated as an object detected problem, and a YOLOv3 network was trained to identify all the instances of skull fracture. In the second approach, the task was treated as a segmentation problem and a modified attention U-net was trained to segment all the voxels representing skull fracture. The developed models were tested using an external test set of 235 patients (93 with, and 142 without skull fracture).Results: On the test set, the YOLOv3 achieved average fracture detection sensitivity and specificity of 80.64, and 85.92%, respectively. On the same dataset, the modified attention U-Net achieved a fracture detection sensitivity and specificity of 82.80, and 88.73%, respectively.Conclusion: Deep learning methods can identify skull fractures with good sensitivity. The segmentation approach to fracture identification may achieve better results.

O21 A case of thromboembolic ischaemic cardiomyopathy and intracardiac thrombus in a patient with antiphospholipid syndrome

Abstract Case report - Introduction Commonly found in association with lupus, antiphospholipid syndrome (APLS) is a potentially life-threatening disease of which an understanding is essential for rheumatologists. In addition to well-recognised sequelae such as pulmonary embolism and obstetric complications, APLS can provoke thrombi ranging from microscopic to massive in size in a wide range of arterial and venous territories. We present the case of a young woman with APLS who suffered significant morbidity as a result of intracardiac and coronary thromboembolism shortly after becoming pregnant and switching anticoagulant therapy, highlighting the importance of vigilance and investigation for rarer thromboses in APLS patients. Case report - Case description A 34-year-old woman with known APLS and 5 weeks pregnant was admitted to hospital with a history of headache, nausea/vomiting and mild photophobia followed by fever, shortness of breath, confusion, pleuritic chest pain and lower limb swelling. She had commenced enoxaparin in place of warfarin on becoming pregnant. Examination was suggestive of cardiac failure. Troponin and NTproBNP were markedly elevated, without ischaemic ECG changes. A brain CT venogram was reported as normal, but echocardiogram revealed a dilated LV with reduced ejection fraction (39%), inferior and lateral wall hypokinesia and possible LV thrombus. She was treated initially for myocarditis (presumed viral or autoimmune) and received antibiotics given her raised WCC and CRP. Treatment dose enoxaparin was continued. Bloods revealed anaemia, thrombocytopenia, and positive immunology: cardiolipin IgG 123U/ml, IgM 612, anti-B2GP1 IgG 19/IgM 607, ANA (1/320) and RNP 70. C3 was normal (0.8) and C4 low (0.03). A livedoid rash consistent with APLS was present on the trunk, but there were no other clinical manifestations of connective tissue disease. Repeat CT venogram performed after the patient reported worsening headaches revealed a small tentorial subdural haematoma, resulting in the reversal of enoxaparin with protamine. Later review of these images suggested a stable 5mm haematoma that was present on the earlier scan, and enoxaparin was recommenced. Cardiac MRI revealed extensive infarct with contained LV wall rupture. Coronary angiography showed normal vessels. LVEF on repeat echocardiogram fell to 28%. Surgical pregnancy termination was performed in accordance with patient wishes, with subsequent reversion to warfarin anticoagulation. Repeat MRI showed thinned anterior/lateral LV walls, evidence of transmural myocardial fibrosis and residual laminar thrombus, and bubble echo demonstrated no PFO. The patient was ultimately managed for presumed microembolic myocardial infarction with resulting heart failure, and has been referred to a cardiac transplant centre. Case report - Discussion This case highlights the potential risk associated with a relatively common scenario: anticoagulant switching in females with APLS at the start (or in anticipation) of pregnancy. In this case our patient started enoxaparin 80mg BD 48 hours after discontinuing warfarin, developing symptoms consistent with intracerebral thrombosis shortly afterwards, followed by those of heart failure. The possible diagnoses on the basis of the patient’s initial presentation were numerous, and she was appropriately investigated in the first instance for a possible cerebral thrombotic event with cranial CT and venogram. On development of cardiorespiratory symptoms, there was a delay in requesting investigations (troponin, BNP) that may have pointed towards myocardial pathology, and once these investigations were noted to be abnormal the patient was managed as a probable myocarditis in keeping with most other patients of her age without a significant past medical history. Perhaps insufficient diagnostic weight was given to her known thrombophilia and recent medication change, which may have prompted closer review of her brain imaging leading to earlier detection of the subdural haematoma. It may also have led to more rapid investigation for possible thrombus elsewhere via earlier echo, CTPA or cardiac MRI. The latter investigation was ultimately crucial in definitively showing myocardial injury to be the result of infarction rather than inflammation, where prior ECGs had not suggested ischaemia. The subsequent unremarkable coronary angiogram added weight to the likely thromboembolic nature of the infarction, potentially via multiple microemboli being thrown off the LV thrombus. The precise timing of the presumed embolisation to our patient’s coronary circulation is unclear, and the absence of overt ischaemic cardiac symptoms suggests this may have been a relatively prolonged, subacute process. Earlier recognition of the thrombotic nature of this event may have prevented myocardial injury if embolic showers continued into her inpatient stay. Case report - Key learning points

Running on Empty: Of Hypopinealism and Human Seasonality.

The pineal hormone melatonin is the natural transducer of the environmental light–dark signal to the body. Although the responsiveness to photoperiod is well-conserved in humans, only about 25 percent of the human population experiences seasonal changes in behavior. As a consequence, humans seem to have adapted—at least partly—to the seasonal changes in day length. The aim of the study was to demonstrate that the individual melatonin deficit marker DOC (degree of pineal calcification) is related to variation of seasonal phenomena in humans. Out of 3,011 patients in which cranial computer tomography (cCT) was performed for diagnostic reasons, 97 consecutive “healthy” subjects (43 female, 54 male; age 18–68 yrs, mean ± SD: 35.0 ± 13.1) were included. Exclusion criteria were pathological finding in cCT, acute/chronic illness including alcohol/drug abuse, shift work, and medication, which are known to influence melatonin excretion. The degree of pineal calcification (DOC) was semiquantitatively determined using the previously validated method. The Seasonal Pattern Assessment Questionnaire (SPAQ) was performed in a telephone interview. Twenty-six subjects fulfilled the criteria for seasonal affective disorder (SAD) or subsyndromal (S) SAD. Seasonality was more pronounced in women than in men (SPAQ seasonality score: 7.8 ± 4.0 vs. 4.9 ± 4.5; p = 0.001) and negatively and significantly associated with age (r = −0.178; p = 0.04). The subjective sleep length significantly varied between seasons (one-way repeated measures ANOVA: F = 45.75; p < 0.0001), with sleep during winter being 53 min (±70 min) longer than during summer. Controlling for age, the total seasonality score was negatively and significantly associated with DOC (r94 = −0.214; p = 0.036). Data confirm earlier studies with respect to distribution of seasonality with sex and age. The survival of seasonality in the sleep length of people living in an urban environment underlines functionality of the circadian timing system in modern societies. Moreover, data confirm for the first time that diminished experience of seasonality in behavior is associated with a reduced individual capacity to produce melatonin.

Troponin Elevation on Admission Along With Dynamic Changes and Their Association With Hemorrhagic Transformation After Thrombolysis.

Background: Hemorrhagic transformation (HT) is a common complication of intravenous thrombolysis with alteplase. Cardiac troponin has been found to be associated with poor prognosis and cognitive impairment in acute ischemic stroke. But studies on the relationship between troponin and HT after thrombolysis are scarce.Methods: This study retrospectively analyzed thrombolytic patients from June 2015 to June 2021 in the Second Affiliated Hospital of Wenzhou Medical University. Cardiac troponin I were measured on admission and on following days to determine the presence of elevation and dynamic changes. HT within 24–36 h after treatment was identified by cranial computed tomography (CT). Besides, a score on the modified Rankin Scale (mRS) > 2 at discharge was defined as unfavorable outcome. Univariate analysis was used to explore the factors related to the troponin elevation on admission and troponin dynamic changes. Multivariate logistic regression model was used to investigated the association between troponin elevation on admission, troponin dynamic changes and HT after thrombolysis, respectively.Results: Troponin levels on admission were measured in 377 patients, and follow-up assay was performed in 292 patients (77.5%). 39 patients (10.3%) had troponin elevation on admission, and 66 patients (22.6%) had troponin dynamic changes comprising rising and falling pattern. The pre-existing heart disease, renal insufficiency and higher stroke severity are related to both troponin elevation on admission and the subsequent troponin dynamic changes. After adjusting the potential confounding factors, logistic regression model showed that patients with troponin elevation on admission had insignificant trend to develop HT (OR 2.23, 95%CI 0.96–5.21, p = 0.063), while patients with troponin dynamic changes had significantly higher risk of HT (OR 2.27, 95%CI 1.06–4.85, p = 0.034). Compared to the troponin elevation, a statistically stronger association was present between rising troponin dynamic changes and unfavorable outcome (OR 2.20, 95%CI 1.05–4.60, p = 0.037).Conclusion: Troponin dynamic changes are associated with HT after thrombolysis. Serial measurements are quite necessary in thrombolytic patients with risk factors associated with troponin dynamic changes (e.g., advanced age, pre-existing heart disease, higher NIHSS score, and troponin elevation on admission).

323 Risk Factors, Management Strategies, and Outcomes in Patients with Isolated Parafalcine or Tentorial Subdural Hematomas

Parafalcine and tentorial subdural hematomas (SDH) are infrequent but regularly occurring traumatic brain injuries (TBI). Appropriate management of patients with these injuries is unclear. The study objective is to derive and validate a clinical decision rule that identifies patients with parafalcine/tentorial SDHs that are at low risk for complications such that hospitalization may be avoided. This was a multicenter retrospective trauma registry and medical record review. Patients with parafalcine or tentorial SDHs had their data from the trauma registry collected and additional data was abstracted from the medical record using standard chart review methodology. The outcome considered was significant injury. This was defined as: any injury that underwent neurosurgery, death, or discharge to a rehabilitation/skilled nursing facility. The clinical decision rule was derived by identifying variables independently associated with the outcome of interest using multivariable logistic regression. The decision rule was then validated on a separate cohort of patients abstracted without knowledge of the decision rule. In the derivation sample, 136 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years and 84 (62%) were male. Seventy-two (53%) had significant injuries. Variables independently associated with a significant injury included: age ≥ 60 years, adjusted odds ratio (aOR) = 3.71, (95% CI 1.37, 10.06), initial Glasgow Coma Scale score < 15, aOR = 8.30 (95% CI 3.14, 21.93) and additional TBIs on CT, aOR = 6.35 (95% CI 2.67, 15.13). In the derivation set, these three high risk variables had a sensitivity = 72/72 (100%, 95% CI 96, 100%) and specificity = 13/64 (20%, 95% CI 11, 32%). In the validation sample, the mean age was 62 ± 21 years and 48 (59%) were male. The three high risk variables had a sensitivity for significant injury of 26/26 (100%, 95% CI 89, 100%) and specificity = 7/55 (13%, 95% CI 5.3, 24%). All 35 patients who underwent neurosurgery had additional TBI findings on their cranial CT scan. Patients with parafalcine/tentorial SDHs who have initial GCS score < 15, are 60 years of age or older, and have other TBIs on their CT are at increased risk of complications and require hospitalization.

Meaning of Headache at the Emergency Department

AIM: We investigated the meaning of headache in the emergency room, as a precursor symptom of structural or systemic disorders, especially life-threatening neurological disorders, or as one of the other headaches unrelated to structural disorders in patients who applied to the emergency department with headache complaints. The causes of primary and secondary headaches should be carefully differentiated from each other at the emergency situations. METHODS: Patients aged 18 years and older, who applied to the Emergency Department of the Faculty of Medicine of 19 Mayis University, with a complaint of headache were included in the study. Primary headaches were divided into subtypes according to the IHS (International Headache Society) classification. Secondary headaches were divided into two subgroups as neurological and nonneurological. RESULTS: 200 patients, 112 women and 88 men, who applied to the emergency department with the complaint of headache, were included in the study. Migraine was found in 48 patients, tension-type headache in 29 patients, cerebrovascular disease in 52 patients, CNS infection in 4 patients, intracranial mass in 11 patients, traumatic bleeding in 6 patients, psychiatric disorders in 8 patients, sinusitis in 9 patients, and metabolic disease in 22 patients. Cranial CT was normal in 10 patients with primary headache, cerebral hemorrhage in one patient and cerebral edema was found in one patient. Cranial CT was normal in 18 patients with secondary headache, SAH in 40 patients, intracerebral hemorrhage in 4 patients, intracranial mass in 10 patients, subdural hematoma in 4 patients, cerebral edema and ischemia in 6 patients, and epidural hematoma were found in 1 patient. CONCLUSION: The causes of patients presenting to the emergency department with headache were cerebrovascular disease, migraine, and tension-type headache. In our study, the most common cause was cerebrovascular disease. The prevalence of migraine varies between 3.4-6.1% in men and 12.9-17.7% in women. In our study, the incidence of migraine was 23%, and it was seen 3 times more in women than in men.

Türkiye’de COVID-19 Kısıtlamaları Sırasındaki ve Öncesindeki Kraniyal Bilgisayarlı Tomografi Oranları

Aim: In this study, we aimed to compare the admission and examination data of patients who presented to our emergency department with neurological symptoms in April 2019 (before) and April 2020 (during the COVID-19 pandemic).Methods: The study included patients who underwent cranial computed tomography (CT), including patients who additionally underwent CT angiography for suspected stroke. Thus, the study sample consisted of a total of 960 patients, of whom 676 (Group) presented before the COVID-19 pandemic and 284 (Group II) during the course of the pandemic. The data were reviewed retrospectively.Results: The rates of the indications for cranial CT did not statistically significantly (p=0.143) differ between Group I and II: suspected stroke, 76.2% vs. 72.9%; trauma, 22.5% vs. 23.6%; and tumors 1.3% vs. 3.5%, respectively. The rate of finding vessel obstruction on CT angiography was significantly (p&amp;lt;0.05) higher in Group II (25% vs. 65%). The rate of confirmed cases of stroke was significantly (p&amp;lt;0.001) higher in Group II (6.7% vs. 18.7%). Also, the rates of ischemic and hemorrhagic stroke were both significantly higher in Group II (p&amp;lt;0.001 and p=0.043, respectively).Conclusion: While measures for the prevention of the spread of COVID-19 infection have led to a decrease in hospital admissions, a conspicuous increase was observed in the rate of patients with stroke during the same period of time.

Neurological complications after pediatric cardiac surgery

BackgroundThe number of pediatric patients who survive open-heart surgery has increased in recent years and the complications seen in this patient group continue to decrease with each technological advance, including new surgical and neuroprotective techniques and the improvement in surgeons’ experience with this patient population. However, neurological complications, which are the most feared and difficult to manage, require long-term follow-up, and increase hospital costs remain a leading cause of mortality and morbidity in this cohort.ResultsWe evaluated the neurological physical examination, cranial computed tomography (CT), and magnetic resonance (MRI) records of 162 pediatric patients with neurological symptoms lasting more than 24 h after undergoing heart surgery in our clinic between June 2012 and May 2020. The patients’ ages ranged from 0 to 205 months, with a mean of 60.59 ± 46.44 months.Of the 3849 pediatric cardiac surgery patients we screened, 162 had neurological complications in the early period (the first 10 days after surgery). The incidence was calculated as 4.2%; 69 patients (42.6%) experienced seizures, 17 (10.5%) experienced confusion, 39 (24.1%) had stupor, and 37 (22.8%) had hemiparesis. Of the patients who developed neurological complications, 54 (33.3%) died. Patients with neurological complications were divided into 3 groups: strokes (n = 90), intracranial bleeding (n = 37), and no radiological results (n = 35). Thirty-four patients (37.8%) in the stroke group died, as did 15 (40%) in the bleeding group, and 5 (14.3%) in the no radiological results group.ConclusionsStudies on neurological complications after pediatric heart surgery in the literature are currently insufficient. We think that this study will contribute to a more detailed discussion of the issue. Responses to neurological events and treatment in the pediatric group may differ compared to the adult age group. Primary prevention methods should be the main approach in combating neurological complications; their formation mechanisms should be carefully monitored and preventive treatment strategies should be developed.

A rare occurrence of primary basal ganglia germinoma in an adult patient

Background: Basal ganglia germinomas (BGGs) represent a diagnostic and management neurosurgical dilemma. Because of the rarity of these tumors in adults, the management strategies are not well defined. Case description: A 24-year-old man was presented with progressive left-sided hemiparesis. Cranial computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a heterogeneous lesion with few microcystic nodules, seen involving the right basal ganglia with calcification. A stereotactic brain biopsy (SBB) was obtained. Histopathology revealed BGG. The patient received whole-brain radiation therapy (WBRT) and reported marked improvement in symptoms with no recurrence during a follow-up period of four years. Conclusion: BGG should be considered a part of the differential diagnosis in young adults presented with hemiparesis and a heterogeneous lesion in the basal ganglia. Standard recommendations for the management of such rare lesions in adults are needed.

Traumatic injury of dural venous sinus as cause of epidural hematoma: importance of recognition and adequate surgical planning

Background: Although most traumatic epidural hematomas are secondary to arterial injuries, particularly rupture of the middle meningeal artery, around 9.7% of cases are associated with dural venous sinus injury, leading to poorer prognosis and greater complications. We report a case of a patient presenting cranial trauma with bone fracture and laceration of the transverse sinus producing epidural hematoma, and discuss the main aspects of this condition. Case description: A 47-year-old man struck by a motorcycle was admitted to the Emergency Room with a score of 15 on the Glasgow Coma Scale, evolving over 5 hours with reduced level of consciousness. A cranial CT scan was performed disclosing right parieto- occipital hyperdensity, consistent with acute epidural hematoma, and a parieto-occipital fracture line crossing the path of the ipsilateral transverse sinus. Parietal craniotomy was performed to drain the hematoma, revealing a venous sinus injury requiring immediate repair. Conclusions: This case and discussion highlight the many details and technical specificities to be taken into account by neurosurgeons when encountering intracranial hematoma caused by traumatic injury of the dural venous sinus, and which are pivotal in determining the efficacy of the treatment approach and prognosis of the patient.

Subarachnoid hemorrhage as the key to the diagnosis

A 70-year-old woman was admitted at the emergency department due to abdominal pain progressing over the last six hours. She had been feeling sick for the last month, with nausea and persistent fever. Initial work-up revealed mild anemia, elevated inflammatory markers and an unremarkable abdominal ultrasound. While at the emergency department, she suddenly progressed to coma, with admission to the intensive care unit. Both cranial CT scan and angiography were conducted, showing a cortical artery aneurysm surrounded by a sulcal subarachnoid hemorrhage on the left parietal convexityFig. 1.

Analysis of Brain Natriuretic Peptide Levels after Traumatic Acute Subdural Hematoma and the Risk of Post-Operative Cerebral Infarction.

Traumatic acute subdural hematoma (aSDH) is associated with a high mortality rate caused by post-operative cerebral infarction. Recently, brain natriuretic peptide (BNP) was considered a reliable biomarker in the acute phase of traumatic brain injuries. We therefore aimed in this study to analyze BNP levels on admission, identify the predictors of their elevation, and assess the relationship between BNP and the risk of post-operative cerebral infarction. Patients with isolated, unilateral, traumatic aSDH who were admitted to our department between July 2017 and May 2020 were enrolled in this study. On admission, cranial computer tomography (CCT) and BNP sampling were simultaneously performed. Additionally, the time between head trauma and BNP sampling (TTS) was assessed. Admission radiographic variables included hematoma volumes, midline shift, and degree of brain edema. Cerebral infarction was detected on postoperative CCT. In total, 130 patients were included in this study. Surgical treatment was performed in 82.3% (n = 107) of cases. The multiple regression analysis showed that larger hematoma volumes (p = 0.032) and advanced age (p = 0.005) were independent predictors of elevated BNP when TTS <24 h. The binomial logistical regression analysis identified BNP with a cutoff value of <29.4 pg/mL (TTS = 3-12 h, adjusted odds ratio [aOR] = 16.5, p = 0.023) as an independent predictor of post-operative cerebral infarction. Elevated BNP levels in the first 24 h post-trauma were related to larger hematoma volumes and advanced age. Further, an increased risk of post-operative cerebral infarction was identified in patients with lower BNP levels in the post-traumatic period 3-12 h.

Chronic subdural hematoma as a complication of medicinal leech therapy

Applications related to the use of leeches in medical therapies date back for centuries. We present here a case of self-administered leech application for chronic low back pain who subsequently developed complication of chronic subdural hematoma. We are not aware of similar report in the literature. This was a 34-year-old man who was admitted to our Emergency Department with headache, right side numbness, and intermittent difficulty in speaking. During the neurological examination, it was observed that the patient had difficulty in speaking and pronouncing words intermittently while taking his medical history. Motor examination was normal. The patient did not report any recent trauma. There was no known history of systemic or hereditary disease, drug or substance abuse. Cranial CT and MR imaging showed a left frontoparietal chronic subdural hematoma. Further history was obtained that leech was applied to the patient for low back pain in the last 45 days, two times at 15 days intervals. The patient’s drowsiness and speech difficulties improved after the surgical operation. On one month follow-up, neurological examinations were normal. Our patient shows that leech therapy can be complicated by subdural hematoma.

Mild Traumatic Brain Injury in Older Adults: Are Routine Second cCT Scans Necessary?

Fall-related hospitalizations among older adults have been increasing in recent decades. One of the most common reasons for this is minimal or mild traumatic brain injury (mTBI) in older individuals taking anticoagulant medication. In this study, we analyzed all inpatient stays from January 2017 to December 2019 of patients aged > 75 years with a mTBI on anticoagulant therapy who received at least two cranial computer tomography (cCT) scans. Of 1477 inpatient stays, 39 had primary cranial bleeding, and in 1438 the results of initial scans were negative for cranial bleeding. Of these 1438 cases, 6 suffered secondary bleeding from the control cCT scan. There was no significance for bleeding related to the type of anticoagulation. We conclude that geriatric patients under anticoagulant medication don’t need a second cCT scan if the primary cCT was negative for intracranial bleeding and the patient shows no clinical signs of bleeding. These patients can be dismissed but require an evaluation for need of home care or protective measures to prevent recurrent falls. The type of anticoagulant medication does not affect the risk of bleeding.

Serum biomarkers for risk assessment of intrahospital transports in neurosurgical intensive care unit patients.

Intrahospital transport (IHT) of Neurosurgical Intensive Care Unit (NICU) patients for cranial computed tomography (CCT) scans is associated with a high rate of complications. The potential of serum biomarkers to estimate the risk for complications associated with IHT and improve their safety remains underexplored. The present study investigated the influence of several serum biomarkers on IHT-associated complications in brain-injured NICU patients. A total of 523 IHTs in 223 NICU patients were prospectively analyzed (05/2019-05/2020). Hemoglobin, hematocrit, serum sodium, and albumin levels were evaluated as serum biomarkers. Each patient's demographic data, CCT scan, NICU parameters and modified Rankin Scale at discharge as well as indications, consequences, and complications of IHTs were analyzed. In 58.7% of all IHTs, at least one IHT-associated complication was observed with 60.1% of all IHTs having no therapeutic consequence. Significantly lower rates of increased intracranial pressure (ICP; P<0.0001), decreased cerebral perfusion pressure (CPP; P=0.03) as well as hemodynamic (P<0.0001) and pulmonary events (P=0.01) were observed in patients with higher hemoglobin levels prior to IHT. Additionally, higher hematocrit levels before IHT were associated with a fewer rate of hemodynamic (P<0.0001), pulmonary (P=0.006), ICP (P<0.0001), and CPP (P=0.01) events. Higher levels of hemoglobin and hematocrit are associated with less complications with respect to ICP, CPP, hemodynamic and pulmonary events during IHT in NICU patients. Therefore, these biomarkers may be helpful for risk assessment of potential complications prior to IHT.

Pineal Region Brain Tumour Treatment Revisited: A Case Report

Pineal region tumours may affect only a relatively small subset of neurosurgical patients, but they present enormous surgical challenge to the neurosurgeon due to their inaccessibly deep locations and compounded by the complex surrounding neurovascular structures. We present a case report of a patient who had combination chemoradiation without histological diagnosis but had complete tumour regression. Cyclical combination chemotherapy with cisplatin, etoposide and bleomycin and radiotherapy followed pre- chemoradiation ventriculo-peritoneal shunt insertion for obstructive hydrocephalus. The patient’s clinical condition improved following the ventriculoperitoneal shunt insertion as walking became re-established. Post – chemoradiotherapy cranial CT scan showed complete tumour regression. Tissue diagnosis may allow for precise, targeted management of pineal region tumours. However, in the absence of facilities which enable safe neurosurgery, resorting to the traditional chemo-radiation is still a viable alternative