Spontaneous supratentorial intracerebral hemorrhage (SSICH) is a critical condition with a high risk of morbidity and mortality, often requiring prompt intervention. Various surgical approaches have been employed to enhance outcomes; however, their comparative effectiveness remains uncertain.Databases including PubMed, Cochrane Central, and ScienceDirect were searched from inception till February 2025 for Randomized controlled trials (RCTs) investigating neuroendoscopy (NE), stereotactic aspiration (SA), craniopuncture surgery (CP), craniotomy (CR), decompressive craniectomy (DC), and conservative medical treatment (CMT). A frequentist network meta-analysis was conducted using R version 4.2.1 and the "netmeta" package, employing the random effects model. Treatment ranking was performed using p-scores, and the risk of bias was assessed using the ROB 2.0 tool. Publication bias was evaluated visually through funnel plots and statistically through Egger's Regression test.The analysis included 25 RCTs involving 4,324 patients. Compared to CMT, NE (RR = 1.77, 95% CI: [1.43,2.20]; p < 0.0001), SA (RR = 1.65, 95%CI: [1.38,1.98]; p < 0.0001), and CR (RR = 1.26, 95%CI: [1.04,1.54]; p = 0.019) showed significant improvement in good functional outcome (GFO) and NE was ranked the best for functional improvement (p-score = 0.93). Mortality was significantly reduced in NE (RR = 0.67, 95%CI: [0.52,0.85]; p = 0.001), and CR (RR = 0.82, 95%CI: [0.69,0.98]; p = 0.028) compared to CMT. NE was considered the most optimal treatment for reducing mortality (p-score = 0.81). Compared to CMT, the risk of rebleeding and overall complications was not significantly different with the surgical interventions.NE, SA and CR significantly improved functional outcomes whereas NE and CR reduced mortality in patients with SSICH compared to CMT. NE may be the most optimal treatment for improving functional scores and mortality according to p-score ranking. Further, high-quality multicenter randomized clinical trials are required.

Basal ganglia hemorrhage (BGH) is a prevalent site for intracerebral hemorrhage. Although neuroendoscopy (NE) surgery has emerged as a less invasive alternative to craniotomy (CT), the optimal surgical method remains debatable. This systematic review and meta-analysis aimed to compare the efficacy and safety of NE versus CT in the management of BGH. A systematic search of PubMed, Embase, Cochrane Library, and Web of Science databases was conducted to identify eligible randomized controlled trials (RCTs) comparing NE surgery with CT in BGH patients. Outcomes included mortality, hematoma evacuation rate, good functional outcome (GFO), operative time, infection, pulmonary infection, and postoperative complication. Risk of bias was assessed with Cochrane's ROB-2 tool. Four RCTs were included, comprising 423 patients. NE surgery showed no significant benefit in mortality (p = 0.12) and GFO (p = 0.18). However, NE was associated with a higher hematoma evacuation rate (p = 0.007), shorter operative time (p < 0.00001), and lower rates of infection (p < 0.0001), pulmonary infection (p < 0.0001), and postoperative complications (p < 0.00001). Future research should be designed to assess whether hematoma evacuation using either technique improves outcomes in comparison to optimal medical management in this population.

Acute subdural hematomas are major causes of morbidity which warrant immediate treatment. If surgical intervention is warranted, craniotomy (CO) and decompressive craniectomy (DC) are employed, largely based on a loosely defined criteria and the neurosurgeon's best judgment. The primacy of one approach over another is a matter of dispute. We attempt to further clarify any advantages in the two techniques, and include a propensity score matched (PSM) subgroup analysis to eliminate bias. This meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature review was conducted on PubMed/Medline, Cochrane Central, and Google Scholar from inception to September 2023. 15 studies were extracted, and three outcomes were meta-analyzed: Mortality, Glasgow Outcome Scale (GOS) scores and patients undergoing re-operations/revisions. Odds Ratios (OR) and Mean Difference (MD) were used in dichotomous and continuous variables respectively. PSM data was used wherever possible. A subgroup analysis was conducted with 5 PSM studies and a trial. Heterogeneity was addressed if above 40% and the P-value is significant (≤ .05). A total of 15 studies were meta-analyzed with a total of 2327 and 2171 patients undergoing CO and DC respectively. Patients undergoing DC had a significantly worse GOS 5 outcome (OR: .63 [95% CI: .45-.87]; P = .005; I2 = 0%) and higher mortality (OR: 1.58 [95% CI: 1.20-2.08]; P = .001; I2 = 67%). In subgroup analysis of adjusted studies, DC still had significantly higher mortality. (OR: 1.50 [95% CI: 1.03-2.18]; P = .001; I2 = 83%). This meta-analysis determines that CO is more viable than DC as a surgical option due to its less invasive nature. DC can be employed, albeit under strict preprocedural patient selection and for highly specific indications.

Traumatic acute subdural hematoma (ASDH) is a medical emergency that requires prompt neurosurgical intervention. Urgent surgical evacuation may be performed with craniotomy (CO) and decompressive craniectomy (DC). However, a meta-analysis evaluating confounders, pooled functional outcomes, and mortality analyses at different time points has not been performed. A systematic search was conducted until August 28, 2023. We identified studies performing ASDH evacuation with CO or DC. Outcomes included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), GOS-Extended, mortality, procedure-related complications, and reoperation. Variables were assessed using risk ratio (RR) and mean difference. Among 684 published articles, we included the Randomized Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation of ASDH (RESCUE-ASDH) trial, 4 propensity score-matched (PSM) cohorts, and 13 observational cohort studies. A total of 8886 patients underwent CO or DC. GCS at admission in unmatched cohorts was significantly worse in the DC group (mean difference = 2.20 [95% CI = 1.86-2.55], P < .00001). GOS-Extended scores were similar among CO and DC (RR = 1.10 [95% CI = 0.85-1.42], P = .49), including the RESCUE-ASDH trial. GOS at the last follow-up in unmatched cohorts significantly favored CO (RR = 1.66 [95% CI = 1.02-2.70], P = .04). Similarly, while short-term mortality favored CO over DC (RR = 0.69 [95% CI = 0.51-0.93], P = .02), both the RESCUE-ASDH trial and the PSM-cohorts yielded similar mortality rates among groups (P > .05). Mortality at the last follow-up in unmatched patients favored CO (RR = 0.60 [95% CI = 0.47-0.77], P < .0001). Procedure-related complications (RR = 0.74 [0.50-1.09], P = .12) and reoperation rates (RR = 0.74 [0.50-1.09], P = .12) were similar. Patients with ASDH undergoing DC across unmatched cohorts had a worse GCS at admission. Although ASDH mortality was lower in the CO group, these findings are derived from unmatched cohorts, potentially confounding previous analyses. Notably, population-matched studies, such as the RESCUE-ASDH trial and PSM cohorts, showed similar effectiveness in mortality and functional outcomes between CO and DC. Reoperation and complication rates were comparable among surgical approaches. Considering the prevalence of unmatched cohorts, our findings highlight the need of future clinical trials to validate the findings of the RESCUE-ASDH trial.

Minimally invasive surgery (MIS) and craniotomy (CI) are the current treatments for spontaneous supratentorial cerebral haemorrhage (SSTICH). To compare the efficacy and safety of MIS and CI for the treatment of SSTICH. Clinical and imaging data of 557 consecutive patients with SSTICH who underwent MIS or CI between January 2017 and December 2022 were retrospectively analysed. The patients were divided into two subgroups: The MIS group and CI group. Propensity score matching was performed to minimise case selection bias. The primary outcome was a dichotomous prognostic (favourable or unfavourable) outcome based on the modified Rankin Scale (mRS) score at 3 months; an mRS score of 0-2 was considered favourable. In both conventional statistical and binary logistic regression analyses, the MIS group had a better outcome. The outcome of propensity score matching was unexpected (odds ratio: 0.582; 95%CI: 0.281-1.204; P = 0.144), which indicated that, after excluding the interference of each confounder, different surgical modalities were more effective, and there was no significant difference in their prognosis. Deciding between MIS and CI should be made based on the individual patient, considering the hematoma size, degree of midline shift, cerebral swelling, and preoperative Glasgow Coma Scale score.

Comparison of Decompressive Craniectomy Versus Craniotomy for Evacuation of Subdural Hemorrhage: A Systematic Review and Meta-Analysis

Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures. The authors performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513 , Supplemental Digital Content 2, http://links.lww.com/JS9/C514 ) Statement protocol and assessing the methodological quality of systematic reviews (AMSTAR) (Supplemental Digital Content 3, http://links.lww.com/JS9/C515 ) guideline. The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included. A total of 15 articles with 4853 patients [2531 (52.2%) receiving CO and 2322 (47.8%) receiving DC] were included in this meta-analysis. DC was associated with higher mortality [31.5 vs. 40.6%, odds ratio (OR)=0.58, 95% CI: 0.43-0.77] and rate of patients with poorer neurological outcomes (54.3 vs. 72.7%; OR=0.43, 95% CI: 0.28-0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5 vs. DC 38.1%, OR=0.80, 95% CI: 0.62-1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8 vs. DC 66.0%; OR=0.82, 95% CI: 0.57-1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1 vs. DC 16.0%; OR=0.95, 95% CI: 0.61-1.48). Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

BackgroundEarly operative intervention, craniotomy (CO), and/or craniectomy (DC) are occasionally warranted in severe traumatic brain injury (TBI). Persistent increased intracranial pressure (ICP) or accumulation of intracranial hematoma post-surgery can result in higher mortality and morbidity. There is a gap in information regarding the outcome of repeat surgery (RS) in pediatric patients with severe TBI. MethodsAn observational cohort study titled Approaches and Decisions in Acute Pediatric Trial (ADAPT) of severe TBI data was obtained from the Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System. All pediatric patients who underwent CO or DC, survived more than 44 hours and were found to have persistent elevated ICP >20 for two consecutive hours were included in the study. The purpose of the study was to find the outcomes of RS in pediatric severe TBI. Propensity based matching was used to find the outcomes. The primary outcome was 60-day mortality. ResultsOut of 1000 total patients enrolled in the ADAPT trial, 160 patients qualified for this study. Propensity score matching created 13 pairs of patients. There were no significant differences found between the groups who had RS vs. those who did not have repeat surgery (NRS). There were no significant differences found between the groups regarding 60-day mortality, median hospital days, median ICU days, and 6-month favorable outcome on Glasgow Outcome Scale Extended (GOS-E) score. ConclusionThere was no difference in mortality between patients who underwent a second surgery and patients who did not have to undergo a second surgery.

Craniotomy versus craniectomy for traumatic acute subdural hematoma—coarsened exact matched analysis of outcomes

Decompressive craniectomy (DC) and craniotomy (CT) to treat increased intracranial pressure after brain injury are common but controversial choices in clinical practice. Studying a large cohort of patients with traumatic brain injury (TBI) and hemorrhagic stroke (HS) on rehabilitation pathways, we aimed to determine the impact of DC and CT on functional outcome/mortality, and on seizures occurrence. This observational retrospective study included patients with either TBI, or HS, who underwent DC or CT, consecutively admitted to our unit for 6-month neurorehabilitation programs between January 1, 2009 and December 31, 2018. Neurological status using Glasgow Coma Scale (GCS), and rehabilitation outcome with Functional Independence Measure, both assessed at baseline and on discharge, post-DC cranioplasty, prophylactic antiepileptic drug use, occurrence of early/late seizures, infectious complications, and death during hospitalization were evaluated and analyzed with linear and logistic regression models. Among 278 patients, DC was performed in 98 (66.2%) with HS, and in 98 (75.4%) with TBI, whilst CT in 50 (33.8%) with HS, and in 32 (24.6%) with TBI. On admission, GCS scores were lower in patients treated with CT than in those with DC (HS, p = 0.016; TBI, p = 0.024). Severity of brain injury and older age were the main factors affecting functional outcome, without between-group differences, but DC associated with worse functional outcome, independently from severity or type of brain injury. Unprovoked seizures occurred post-DC cranioplasty more frequently after HS (OR = 5.142, 95% CI 1.026–25.784, p = 0.047). DC and CT shared similar risk of mortality, which associated with sepsis (OR = 16.846, 95% CI 5.663–50.109, p < 0.0001), or acute symptomatic seizures (OR = 4.282, 95% CI 1.276–14.370, p = 0.019), independently from the neurosurgery procedures. Among CT and DC, the latter neurosurgical procedure is at major risk of worse functional outcome in patients with mild-to-severe TBI, or HS undergoing an intensive rehabilitation program. Complications with sepsis or acute symptomatic seizures increase the risk of death.

Objective This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC).Methods In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient.Results Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) (p = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) (p = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group (p = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group (p < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups (p = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group (p = 0.14).Conclusion The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control. Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate. Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB. In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.

The purpose of the study is to evaluate the in-hospital mortality of patients who presented with acute subdural hematoma (SDH) and underwent emergency decompressive craniectomy (DC) or craniotomy (CO) within 4 hours of hospital arrival. The National Trauma Data Bank (NTDB) dataset of the calendar year of 2007 through 2010 was accessed for the study. All blunt severe head injury patients who presented with acute SDH were included in the study. Severe head injury is defined as a head Abbreviated Injury Scale (AIS) score ≥3 and a Glasgow Coma Scale (GCS) score ≤8. Univariate followed by propensity-matched analyses were performed to compare the two procedure groups: DC and CO. Out of 2370 patients, 518, (21.9%) patients underwent DC. There were significant differences found in the univariate analysis between the DC and CO groups for median age (38 (IQR: 22.0, 55.0) vs 49 (IQR: 27, 67), P < .001), mechanism of injury (fall: 33.2% vs 50.7%; motor vehicle crashes: 58.3% vs 40.9%, P < .001), and median injury severity score (ISS: 26.0 (IQR: 25, 38) vs 26 (IQR: 25.0, 33.0), P < .001). After propensity score matching and pair-matched analysis, no differences were found with any of the above characteristics. The pair-matched analysis also showed no significant difference in in-hospital mortality (42.7% vs 37.5%, P = .10) between the DC vs CO groups. The overall in-hospital mortality for emergency CO or DC for the evacuation of SDH remains high. The preference of one operative procedure over the other did not impact overall mortality.

All neurologists need to be able to recognise and treat cerebral venous thrombosis (CVT). It is difficult to diagnose, partly due to its relative rarity, its multiple and various clinical manifestations (different from 'conventional' stroke, and often mimicking other acute neurological conditions), and because it is often challenging to obtain and interpret optimal and timely brain imaging. Although CVT can result in death or permanent disability, it generally has a favourable prognosis if diagnosed and treated early. Neurologists involved in stroke care therefore also need to be aware of the treatments for CVT (with varying degrees of supporting evidence): the mainstay is prompt anticoagulation but patients who deteriorate despite treatment can be considered for endovascular procedures (endovascular thrombolysis or thrombectomy) or neurosurgery (decompressive craniotomy). This review summarises current knowledge on the risk factors, diagnosis, treatment and prognosis of CVT in adults, and highlights some areas for future research.

Background: Many signs in relation to vascular events and consequent loss of consciousness could be easily incorrectly explained (unclear) in a setting of trauma, especially when these events are a result of the car accident. Third cranial nerve palsy widely occurs due to internal carotid and posterior communicating artery aneurysm. An anterior communicating(ACOM) aneurysm is a rare reason that could lead to oculomotor dysfunction. ACOM ruptured aneurysm may present with sub arachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) but isolated IVH is a rare finding for ACOM ruptured aneurysm. Case Description: A 56-year-old male presented to the hospital emergency department because of trauma after a car accident. He was unconscious with left-sided dilated pupil and ptosis with a brain CT indicating IVH. Brain CT angiography that performed two weeks after the accident revealed ACOM aneurysm. The patient underwent craniotomy and clipping the aneurysm. He was discharged, after completing the period of the following treatmentA combination of neuropathic agents and opioids helped to control pain. These analgesic included amitriptyline, gabapentin, pregabalin, tramadol and morphine in various regimens. Paracetamol and ibuprofen were also used. Conclusion: This report is a unique case of synchronization of third cranial nerve palsy and isolated IVH without SAH due to ACOM aneurysm. In addition, it could be interesting to re-emphasize the need for a comprehensive assessment of traumatic patients for finding some primary pathologies, which could result in an accident.

Pituitary abscess is a rare but potentially life-threatening disease. Headache, visual disturbance, and hypopituitarism are the most common presenting symptoms of pituitary abscess. On magnetic resonance imaging(MRI), pituitary abscess may present as a round sellar cystic lesion, hypo- or isointense on T1 imaging and hyper- or isointense on T2 imaging with peripheral gadolinium enhancement. Diagnosis usually is made during surgical exploration when pus is found in a cystic lesion. The mainstay of treatment is transsphenoidal surgical resection in combination with antibiotic therapy, although a craniotomy approach is warranted in select conditions. Here we report 3 cases of pituitary abscess in our hospital and review the literatures. Key words: Pituitary abscess; MRI; Diagnosis; Therapy

Objective To investigate the effect of large bone flap craniotomy on acute craniocerebral trauma and its influence on stress response. Methods From January 2015 to December 2018, 80 patients with acute craniocerebral trauma were randomly divided into control group (40 cases) and observation group (40 cases) by random number table method.The patients in the control group were treated with conventional craniotomy and decompression, while the patients in the observation group were treated with craniotomy with large bone flaps.The changes of intracranial pressure, Glasgow coma index (GCS score), stress response index, prognosis and complications after 6 months were compared between the two groups before treatment and 2 weeks after treatment. Results Two weeks after treatment, the intracranial pressure in the observation group [(8.48±2.10)mmHg] was lower than that in the control group [(11.86±1.74) mmHg], while the GCS score[(10.35±1.87)points] was higher than that in the control group [(7.69±1.15)points](t=19.434, 7.663, all P<0.05). Two weeks after treatment, the serum levels of ACTH [(35.19±5.46)mg/L] and cortisol [(17.41±4.56)mg/L] in the observation group were lower than those in the control group [(48.91±4.95)mg/L and (28.93±7.48)mg/L] (t=11.774, 8.317, all P<0.05). Six months after treatment, the prognosis of the observation group(60.00%) was better than that of the control group (32.50%) (χ2=6.084, P<0.05). The incidence of complications of the observation group (5.00%) was lower than that of the control group (22.50%) (χ2=5.165, P<0.05). Conclusion Craniotomy with large bone flaps has good effect in the treatment of patients with acute craniocerebral trauma, and can reduce stress response and with fewer complications, which is worthy of clinical reference. Key words: Craniotomy; Decompression, surgical; Craniocerebral trauma; Intracranial pressure; Glasgow coma index; Stress response

The purpose of the study was to evaluate the impact of craniotomy (CO) and decompressive craniectomy (DC) for evacuation of acute subdural hematoma (SDH) on pulmonary complications and sepsis. Study data were obtained from the National Trauma Data Bank (2007-2010). Only patients who met all of the following criteria were included in this analysis: sustained blunt injuries, presented with severe traumatic brain injury, sustained an associated SDH, presented with an initial Glasgow Coma Scale (GCS) score ≤ 8 and an Abbreviated Injury Scale score of head ≥ 3, and underwent a CO or DC within 4 hours of hospital arrival. Patient characteristics and outcomes were compared between CO and DC, the two procedural groups. The data were first compared between the two unmatched groups; then propensity score matching and a matched pairs analysis were performed. From the total population of 2,370 patients, 1,852 (78%) of them underwent CO, and the remaining 518 (22%) underwent DC. Some differences were found between the CO and DC groups regarding age (mean [standard deviation (SD)]: 47.9 years [22.8] versus 39.6 years [20.1]; p < 0.001), sex (male: 70.1% versus 74.7%; p = 0.05), race (white: 77.4% versus 73.4%; p = 0.06), the injury mechanism (fall: 50.7% versus 33.2%; p < 0.001), Injury Severity Score (mean [SD]: 28.0 [9.3] versus 30.5 [10.0]; p < 0.001), and GCS score (median [interquartile range] 3 [3-5] versus 3 [3-4])). After the propensity score matching, no significant differences were found between the groups on the variables just listed (all p > 0.05). No significant differences were seen between the CO and DC groups in the incidences of these conditions: acute respiratory distress syndrome (ARDS) (12.0% versus 8.1%; p = 0.20), pneumonia (34.9% versus 37.6%; p = 0.60), pulmonary embolism (PE) (3.5% versus 1.6%; p = 0.30), and systemic sepsis (6.2% versus 8.1%; p = 0.5). Although most of the patients underwent CO for acute SDH, no significant differences were observed in the incidence of ARDS, pneumonia, PE, or systemic sepsis when compared with patients who underwent DC.

Objective To explore the effect of direct electrical stimulation in awake craniotomy for glioma resection in the motor area. Methods We conducted a retrospective analysis of clinical data of 34 patients with gliomas in the motor area who were admitted to Department of Neurosurgery, General Hospital of Southern Theatre Command from March 2015 to July 2017. The tumor was located in the left hemisphere in 16 patients and right hemisphere in 18. The gliomas were in supplementary motor area or premotor cortex in 23 cases, the central area in 9 cases, and supplementary motor area or premotor cortex invading the central area in 2 cases. All patients underwent awake craniotomy under general anesthesia. Neuronavigation and/or intraoperative ultrasound were employed to locate the lesion. Direct electrical stimulation was used for cortical and subcortical mapping of the important eloquent areas. The tumors were removed according to the functional boundary.Neural function and the degree of tumor resection were evaluated after operation. Results Of the 34 patients, 24 had a motor response after direct cortical electrical stimulation, 13 had abnormal sensations, and 10 revealed language-related cortices through mapping. For subcortical electrical stimulation, there were 24 cases of motor response, 1 case of abnormal sensation, and 8 cases of language disorders. A total of 30 cases (88.2%) of tumor removal reached functional boundaries, and subcortical electrical stimulation did not identify functional fiber in the remaining 4 (11.8%) cases which were all high-grade gliomas. Within 48 hours post surgery, the head MRI indicated total resection of tumor in 22 cases (64.7%), subtotal resection in 9 (26.5%), and partial resection in 3 (8.8%). The follow-up time of 34 patients was (23.6 ± 8.6) months (11.3-39.3)months.There were 29 cases (85.3%) which showed early postoperative neurofunctional disorders or worsening of pre-existing neurological deficits. Three cases (8.8%) developed late postoperative neurological dysfunction worse than preoperative conditions, of which 1 case was mild, 1 case was moderate and 1 case (2.9%) was severe. Of the 16 patients with preoperative neurological dysfunction or increased intracranial pressure, 13 had improved neurological function in 3 months after surgery, 2 were maintained in preoperative state and 1 had severe neurological deficits. Conclusions Functional mapping through direct electrical stimulation and continuous monitoring of the cortical and subcortical white fibers in the motor area during awake craniotomy could maximize the safe resection of glioma in the motor area, the incidence of long-term severe neurological deficits is low, and the quality of life could be improved after surgery. Key words: Glioma; Motor area; Supplementary motor area; Pyramid tract; Direct electrical stimulation