Development Of New Neurological Deficits Research Articles

Laboratory biomarkers for multiple sclerosis and their role in clinical practice

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) most commonly diagnosed in young adults. In recent decades, new treatments have emerged that have radically changed the prognosis and quality of life of these patients. However, this has also raised new challenges in predicting the course and activity of the disease before the development of new neurological deficits that aggravate the disability and in prescribing the most appropriate disease-modifying therapy for the individual patient in a timely manner. One of the possible solutions that could help answer these questions is the use of laboratory biomarkers in MS. In addition to the oligoclonal bands (OGB) and the immunoglobulin G index, which are already well known and clinically useful laboratory tests, other biomarkers have been discovered that can assess the inflammatory and neurodegenerative processes occurring in the CNS. Kappa free light chains and K-index have been identified as new potential diagnostic biomarkers for MS, with similar sensitivity and specificity to OGB. Some biomarkers have also shown the ability to differentiate a clinically isolated syndrome from MS and to identify the clinical course of MS. The concentration of chitinase-3-like protein in the cerebrospinal fluid is currently the only biomarker that can help distinguish MS from a clinically isolated syndrome. Levels of glial fibrillary acidic protein in cerebrospinal fluid and blood serum can help distinguish primary progressive MS from the relapsing-remitting course of this disease. Serum neurofilament light chain levels are considered the most useful biomarker for monitoring disease activity and treatment efficiency. This article discusses the most promising biomarkers for MS diagnosis, disease activity, and treatment response.

Prediction of Long-term Survival After Status Epilepticus Using the ACD Score

Early prediction of long-term mortality in status epilepticus is important given the high fatality rate in the years after diagnosis. To improve prognostication of long-term mortality after status epilepticus diagnosis. This retrospective, multicenter, multinational cohort study analyzed adult patients who were diagnosed with and treated for status epilepticus at university hospitals in Odense, Denmark, between January 1, 2008, and December 31, 2017, as well as in Oslo, Norway; Marburg, Germany; and Frankfurt, Germany. They were aged 18 years or older and had first-time, nonanoxic status epilepticus. A new scoring system, called the ACD score, for predicting 2-year (long-term) mortality after hospital discharge for status epilepticus was developed in the Danish cohort and validated in the German and Norwegian cohorts. The ACD score represents age at onset, level of consciousness at admission, and duration of status epilepticus. Data analysis was performed between September 1, 2019, and March 31, 2020. Long-term follow-up using data from national and local civil registries in Denmark, Norway, and Germany. The predefined end point was 2-year survival for all patients and for a subgroup of patients with status epilepticus causes that were not damaging or were less damaging to the brain. Neurological deficits before and after onset, demographic characteristics, etiological categories of status epilepticus, comorbidities, survival, time points, treatments, and prognostic scores for different measures were assessed. A total of 261 patients (mean [SD] age, 67.2 [14.8] years; 132 women [50.6%]) were included, of whom 145 patients (mean [SD] age, 66.3 [15.0] years; 78 women [53.8%]) had status epilepticus causes that were not damaging or were less damaging to the brain. The validation cohort comprised patients from Norway (n = 139) and Germany (n = 906). At hospital discharge, 29.8% of patients (n = 64 of 215) had new moderate to severe neurological deficits compared with baseline. New neurological deficits were a major predictor of 2-year survival after hospital discharge (odds ratio, 5.1; 95% CI, 2.2-11.8); this association was independent of etiological category. Nonconvulsive status epilepticus in coma and duration of status epilepticus were associated with development of new neurological deficits, and a simple 3-factor score (ACD score) combining these 2 risk factors with age at onset was developed to estimate survival after status epilepticus diagnosis. The ACD score had a linear correlation with 2-year survival (Pearson r2 = 0.848), especially in the subset of patients with a low likelihood of brain damage. This study found that age, long duration, and nonconvulsive type of status epilepticus in coma were associated with the development of new neurological deficits, which were predictors of long-term mortality. Accounting for risk factors for new neurological deficits using the ACD score is a reliable method of prediction of long-term outcome in patients with status epilepticus causes that were not damaging or were less damaging to the brain.

Stereotactic radiosurgery versus active surveillance for incidental, convexity meningiomas: a matched cohort analysis from the IMPASSE study.

The optimal treatment strategy of asymptomatic, convexity meningiomas, remains unclear. The purpose of this study was to define the safety and efficacy of stereotactic radiosurgery (SRS) in the management of patients with asymptomatic convexity meningiomas. Data of SRS-treated patients from 14 participating centers and patients managed conservatively for an asymptomatic, convexity-located meningioma were compared. Local tumor control rate and development of new neurologic deficits were evaluated in the active surveillance and in the SRS-treated cohorts. In the unmatchedcohorts, there were 99 SRS-treated patients and 140 patients managed conservatively for an asymptomatic, convexity meningioma. Following propensity score matching for age, there were 98 patients in eachcohort. In the matched cohorts, tumor control was achieved in 99% of SRS-treated, and in 69.4% of conservatively managed patients (p < 0.001). New neurological deficits occurred in 2.0% of patients in each of the matched cohorts(p = 1.00).Increasing age was predictive of tumor growth [(OR 1.1; 95% CI (1.04 -1.2), (p < 0.001)]. This is one of the first reports to suggest that SRS is a low risk and effective treatment strategy for asymptomatic incidentally discovered convexity meningiomas. In this study, tumor control was achieved in significantly more patients after radiosurgery compared to those managed with active surveillance. SRS may be offered at diagnosis of an asymptomatic convexity meningioma and should be recommended when meningioma growth is noted on follow-up.

Stereotactic Radiosurgery for Incidentally Discovered Cavernous Sinus Meningiomas: A Multi-institutional Study

The initial management of asymptomatic, incidentally discovered, cavernous sinus (CS) meningiomas remains incompletely defined. This study evaluated the safety and efficacy of stereotactic radiosurgery (SRS) for patients presenting with an asymptomatic CS meningioma. This is an international, retrospective study included patients treated with upfront SRS for an asymptomatic CS meningioma. Local tumor control, tumor and SRS-related complications, and the development of new neurologic deficits after SRS were evaluated. A total of 37 patients (29 men; mean ± SD age: 55.05 ± 11.56 years) treated with upfront SRS for an asymptomatic, CS meningioma were included in the study. The mean ± SD margin dose was 12.27 ± 2.3 Gy. The median clinical and radiological follow-up periods were 66 (IQR 84) and 72 (IQR 84) months, respectively. At the last follow-up, tumor regression and stability were noted in 19 (51.35%) and 18 (48.65%) of CS meningiomas, respectively. SRS-related complications occurred in 2 patients (5.4%) and were managed conservatively. Upfront SRS is a safe and effective treatment option for asymptomatic CS meningiomas. SRS may be considered at the time of initial diagnosis of a CS meningioma. If observation is the initial management chosen, SRS should be recommended when CS meningioma growth is documented on follow-up imaging.

Quantitative Assessment of Ventriculostomy-Related Hemorrhage: A Volume-Based Classification System to Predict New Neurological Symptoms.

Hemorrhage is one of the most feared complications following ventriculostomy placement. Current studies have assessed factors associated with increased risk of ventriculostomy-related hemorrhage (VRH). However, the clinical significance of VRH has not been determined. To correlate quantitative volumetric measurements of VRH with new neurological symptoms. A retrospective review of our institutional database of ventriculostomy patients during the last decade was performed. Patients' demographics and procedural details such as indication, number of passes and position of the catheter were recorded. VRH volume was quantified on noncontrast head computed tomography using the Picture Archiving Communication System (Carestream Vue®, Rochester, New York) semi-automated livewire segmentation tool. Patients with new neurological symptoms within 48 h of VRH were considered symptomatic. Several clinical confounders were ruled out. Logistic regression analyses were performed. The best volumetric cut-offs in predicting symptomatic VRH were determined through receiver operating characteristic (ROC) curve analysis. A total of 3090 patients underwent ventriculostomy procedures and 179 (∼6%) developed VRH. A total of 41 (1.06%) patients with VRH developed new neurological symptoms. Only 12 (0.39%) were attributable to a new VRH. Multivariable logistic regression showed that volume of the hemorrhage (OR 1.17, P=.006) is the only significant predictor of symptomatic VRH. ROC curve analysis demonstrated that VRH volume <1.10 cc has 91.7% sensitivity to rule out symptomatic VRH, whereas a volume >7.59 cc has 95.5% specificity to predict symptomatic VRH. Approximately 6% of patients developed postprocedural VRH, but only 0.4% were symptomatic. VRH volumes <1 cc are extremely unlikely to become symptomatic, whereas volumes >7.5 cc may predict development of new neurological deficits.

318. Severe pediatric deformity surgery had frequent IOM alerts but a low rate of permanent deficits at two years

BACKGROUND CONTEXT Surgical treatment of severe pediatric spinal deformity is challenging and can have a high risk of neurologic injury. We investigated the incidence of intraoperative monitoring (IOM) alerts during surgery and the development of new neurologic deficits in a prospective multicenter cohort. PURPOSE The purpose of this study was to evaluate the frequency of IOM alerts during surgery for severe pediatric deformity and determine the incidence of new permanent deficits at 2 years postoperative. STUDY DESIGN/SETTING Prospective observational multicenter cohort of severe pediatric deformity patients treated surgically for minimum curves of 100° or planned vertebral column resection (VCR). PATIENT SAMPLE Patients with a minimum spinal deformity curve of 100° or who were scheduled for a VCR procedure were prospectively enrolled at 17 sites. OUTCOME MEASURES IOM alerts, radiographic parameters, surgical procedures, neurological status. METHODS Patients with severe spinal deformity with minimum curves of 100°; or planned VCR were followed for a minimum 2 years postoperative. We studied x-ray parameters, IOM changes, postop deficits and recovery at minimum 2 years. RESULTS A total of 228 of the 312 patients enrolled had a minimum two years follow-up (QOLs and x-rays). Of these, 110 patients had a VCR and 1 a PSO. Two hundred twelve had a post-only approach and 16 a combined anterior/posterior. Two hundred twenty-eight patients had a total of 272 procedures including all stages; IOM alerts occurred in 102/272 procedures (38%). IOM alerts occurred in 98 pts (43%), with a total of 147 IOM alerts. An analysis was completed between a VCR, ant/post, coronal deformity angular ratio (C–DAR), the sagittal deformity angular ratio (S–DAR), and any IOM alert, SSEP, TCeMEP or both. Only S-DAR was predictive for any IOM alert (p CONCLUSIONS Pediatric patients with severe deformity had a 43% incidence of IOM alerts but after addressing the alerts intraop, only 2 patients had new deficits at 2 years. Of the 19 patients with preoperative neurologic deficit, 16 patients improved or recovered. Neural monitoring should be mandatory in these cases. Sagittal DAR is associated with IOM alerts and new neurologic deficits. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Serum albumin level in spontaneous subarachnoid haemorrhage: More than a mere nutritional marker!

Background: The role of nutritional markers on outcome following subarachnoid hemorrhage (SAH) has been scarcely described.Methods: This is a prospective study of 273 patients with SAH, in which haemoglobin, serum protein and albumin were measured within 24 hours and again at one week following ictus, and analysed with respect to other variables. New neurologic deficits (NND), infarct, mortality and Glasgow outcome scale (GOS) at 3 months were assessed.Results: The values of haemoglobin, total protein and albumin showed significant (p < .001) decline over the first week of SAH. Patients who developed NND had significantly lower serum albumin levels at admission compared to others (median 3.6 vs 3.9 g/dL, p < .001). Patients having lower albumin (≤3.5 gm/dL) levels at admission had significantly higher rates of NND (52% vs 20%), infarct (35% vs 23%), mortality (28% vs 16%) and unfavourable GOS (38% vs 25%). Hunt & Hess (H&H) grade and Fisher grade also affected all the outcome parameters significantly. Percentage decrease in albumin levels at one week following ictus significantly affected mortality and unfavourable GOS. On multivariate analyses, Fisher grade and lower admission albumin levels had significant impact on NND, while percentage decrease in albumin levels had significant impact on mortality and unfavourable GOS, independent of other nutritional markers and known prognostic variables.Conclusions: Serum albumin levels following SAH can be useful to predict development of NND, while its further weekly decrease correlates independently with unfavourable outcome at 3 months. Albumin assessment being readily available may serve as more than a mere nutritional parameter in SAH.

Risk factor analysis of the development of new neurological deficits following supplementary motor area resection

Supplementary motor area (SMA) resection often induces postoperative contralateral hemiparesis or speech disturbance. This study was performed to assess the neurological impairments that often follow SMA resection and to assess the risk factors associated with these postoperative deficits. The records for patients who had undergone SMA resection for pharmacologically intractable epilepsy between 1994 and 2010 were gleaned from an epilepsy surgery database and retrospectively reviewed in this study. Forty-three patients with pharmacologically intractable epilepsy underwent SMA resection with intraoperative cortical stimulation and mapping while under awake anesthesia. The mean patient age was 31.7 years (range 15-63 years), and the mean duration and frequency of seizures were 10.4 years (range 0.1-30 years) and 14.6 per month (range 0.1-150 per month), respectively. Pathological examination of the brain revealed cortical dysplasia in 18 patients (41.9%), tumors in 16 patients (37.2%), and other lesions in 9 patients (20.9%). The mean duration of the follow-up period was 84.0 months (range 24-169 months). After SMA resection, 23 patients (53.5%) experienced neurological deficits. Three patients (7.0%) experienced permanent deficits, and 20 (46.5%) experienced symptoms that were transient. All permanent deficits involved contralateral weakness, whereas the transient symptoms patients experienced were varied, including contralateral weaknesses in 15, apraxia in 1, sensory disturbances in 1, and dysphasia in 6. Thirteen patients recovered completely within 1 month. Univariate analysis revealed that resection of the SMA proper, a shorter lifetime seizure history (<10 years), and resection of the cingulate gyrus in addition to the SMA were associated with the development of neurological deficits (p=0.078, 0.069, and 0.023, respectively). Cingulate gyrus resection was the only risk factor identified on multivariate analysis (p=0.027, OR 6.530, 95% CI 1.234-34.562). Resection of the cingulate gyrus in addition to the SMA was significantly associated with the development of postoperative neurological impairment.

Multimodality management of Spetzler-Martin Grade III arteriovenous malformations

Grade III arteriovenous malformations (AVMs) are diverse because of their variations in size (S), location in eloquent cortex (E), and presence of central venous drainage (V). Because they may have implications for management and outcome, the authors evaluated these variations in the present study. Between 1984 and 2010, 100 patients with Grade III AVMs were treated. The AVMs were categorized by Spetzler-Martin characteristics as follows: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The occurrence of a new neurological deficit, functional status (based on modified Rankin Scale [mRS] score) at discharge and follow-up, and radiological obliteration were correlated with demographic and morphological characteristics. One hundred patients (49 female and 51 male; age range 5-68 years, mean 35.8 years) were evaluated. The size of AVMs was less than 3 cm in 28 patients, 3-6 cm in 71, and greater than 6 cm in 1; 86 AVMs were located in eloquent cortex and 38 had central drainage. The AVMs were Type 1 in 28 cases, Type 2 in 60, Type 3 in 11, and Type 4 in 1. The authors performed embolization in 77 patients (175 procedures), surgery in 64 patients (74 surgeries), and radiosurgery in 49 patients (44 primary and 5 postoperative). The mortality rate following the management of these AVMs was 1%. Fourteen patients (14%) had new neurological deficits, with 5 (5%) being disabling (mRS score > 2) and 9 (9%) being nondisabling (mRS score ≤ 2) events. Patients with Type 1 AVMs (small size) had the best outcome, with 1 (3.6%) in 28 having a new neurological deficit, compared with 72 patients with larger AVMs, of whom 13 (18.1%) had a new neurological deficit (p < 0.002). Older age (> 40 years), malformation size > 3 cm, and nonhemorrhagic presentation predicted the occurrence of new deficits (p < 0.002). Sex, eloquent cortex, and venous drainage did not confer any benefit. In 89 cases follow-up was adequate for data to be included in the obliteration analysis. The AVM was obliterated in 78 patients (87.6%), 69 of them (88.5%) demonstrated on angiography and 9 on MRI /MR angiography. There was no difference between obliteration rates between different types of AVMs, size, eloquence, and drainage. Age, sex, and clinical presentation also did not predict obliteration. Multimodality management of Grade III AVMs results in a high rate of obliteration, which was not influenced by size, venous drainage, or eloquent location. However, the development of new neurological deficits did correlate with size, whereas eloquence and venous drainage did not affect the neurological complication rate. The authors propose subclassifying the Grade III AVMs according to their size (< 3 and ≥ 3 cm) to account for treatment risk.

Gamma knife radiosurgery for jugular foramen schwannomas

Jugular foramen schwannomas are very rare tumors. Advances in skull base surgery have led to more aggressive resection of these tumors, but surgery may associate with development of new neurological deficits. In this report, we analyze the long-term results for 17 patients with newly diagnosed or residual/recurrent jugular foramen schwannoma who underwent gamma-knife treatment. During a mean 64 months of follow-up, magnetic resonance imaging revealed reduced tumor size in 13 cases and no size change in four cases. The tumor growth control rate was 100% and only one patient had transient hoarseness. For patients who have small- to moderate-sized jugular foramen schwannomas, gamma-knife radiosurgery is associated with good tumor control and carries minimal risk of adverse radiation effects.

O-011 Multimodality management of spetzler-martin grade III arteriovenous malformations

IntroductionGrade 3 AVMs are diverse due to variations in size (S), location in eloquent cortex (E) and presence of central venous drainage (V). These variations may have implications for management...

Characterization of a novel bidirectional distraction spinal cord injury animal model

Scoliosis corrective surgery requires the application of significant multidirectional stress forces, including distraction, for correction of the curved spine deformity and the application of fixation rods. If excessive, spine distraction may result in the development of new neurological deficits, some as severe as permanent paralysis. Current animal models of spinal cord injury, however, are limited to contusion, transection, or unidirectional distraction injuries, which fail to replicate the multidirectional forces that occur during spine corrective surgery. To address such limitation, we designed a novel device that relies on intervertebral grip fixation and linear actuators to induce controllable bidirectional distraction injuries to the spine. The device was tested in three (i.e., 3, 5, and 7mm) distention paradigms of the rat T9–T11 vertebra, and the resulting injuries were evaluated through electrophysiological, behavioral, and histological analysis. As expected, 3mm bilateral spine distractions showed no neurological deficit. In contrast, those with 5 and 7mm showed partial and complete paralysis, respectively. The relationship between the severity of the spine distraction and injury to the spinal cord tissue was determined using glial fibrillary acidic protein immunocytochemistry for visualization of reactive astrocytes and labeling of ED1-positive activated macrophages/microglia. Our results demonstrate that this device can produce bidirectional spine distraction injuries with high precision and control and, thus, may be valuable in contributing to the testing of neuroprotective strategies aimed at preventing unintended new neurological damage during corrective spine surgery.

Neuraxial Blockade in Patients with Preexisting Spinal Stenosis, Lumbar Disk Disease, or Prior Spine Surgery

Patients with spinal canal pathology, including spinal stenosis and lumbar disk disease, are often not considered candidates for neuraxial blockade because of the risk of exacerbating preexisting neurologic deficits or developing new neurologic dysfunction. In contrast, a history of spine surgery is thought to increase the likelihood of difficult or unsuccessful block. In this retrospective study we investigated the risk of neurologic complications and block efficacy in patients with preexisting spinal canal pathology, with or without a history of spine surgery, after neuraxial anesthesia. During the 15-year study period, all patients with a history of spinal stenosis or lumbar radiculopathy undergoing a neuraxial technique were studied. Patient demographics, preoperative neurologic diagnoses and neurologic findings at the time of surgery/neuraxial block, details of the neuraxial block including technique (spinal vs. epidural, single injection vs. continuous), injectate, technical complications (paresthesia elicitation, bloody needle/catheter placement, inability to advance catheter, accidental dural puncture), and block success were noted. New or progressive neurologic deficits were identified. All patients were followed until resolution or last date of evaluation. There were 937 patients included, 207 (22%) of whom had undergone spinal surgery. A history of spinal stenosis was present in 187 (20%), lumbar radiculopathy in 570 (61%), and peripheral neuropathy in 210 (22%) patients; 180 patients (19%) had multiple neurologic diagnoses. A majority of patients had active but stable neurologic symptoms at the time of surgery. Overall block success was 97.2%. A history of spine surgery did not affect the success rate or frequency of technical complications. Ten (1.1%; 95% confidence interval [CI] 0.5%-2.0%) patients experienced new deficits or worsening of existing symptoms. Three (1.4%) complications occurred in patients with a history of spinal surgery, and the remaining 7 (1.0%) in patients without prior surgical decompression or stabilization (P = NS). Although an orthopedic procedure was not a risk factor, in 5 of the 6 patients in which the surgery was a unilateral lower extremity procedure, the postoperative deficit involved the operative side. Likewise, in both patients undergoing bilateral orthopedic procedures who developed bilateral deficits, the outcome was worse on the previously affected side. A surgical cause was presumed to be the primary etiology in 4 (40%) of 10 patients. The primary etiology of the remaining 6 (60%) complications was judged to be nonsurgical (including anesthetic-related factors). The presence of a preoperative diagnosis of compressive radiculopathy (P = 0.0495) or multiple neurologic diagnoses (P = 0.005) increased the risk of neurologic complications postoperatively. We conclude that patients with preexisting spinal canal pathology have a higher incidence of neurologic complications after neuraxial blockade (1.1%; 95% CI 0.5%-2.0%) than that previously reported for patients without such underlying pathology. However, in the absence of a control group of surgical patients with similar anatomic pathology undergoing general anesthesia, we cannot determine whether the higher incidence of neurologic injury is secondary to the surgical procedure, the anesthetic technique, the natural history of spinal pathology, or a combination of factors and the relative contributions of each.

Neurodestruktive Verfahren in der Schmerztherapie

Although surgical ablative procedures can be effective in the management of chronic pain of malignant and non-malignant origin, they are often disregarded as treatment options due to the fact that in the past these procedures were associated with high complication rates. The complications include the development of new neurological deficits and in cases of long-term follow-up, the occurrence of the old or new pain syndromes by deafferentation. On the other hand there exist many less invasive, e.g. neuromodulatory procedures or non-invasive measures (systemic oral or transdermal opioids) which are able to considerably reduce chronic pain. Nevertheless, there remain certain very restricted indications for the use of neuroablative procedures for the treatment of chronic pain even today.

Early post-ischemic hyperemia on transcranial cerebral oxygen saturation monitoring in carotid endarterectomy is associated with severity of cerebral ischemic insult during carotid artery clamping

Background and objective: In animal models, the magnitude of early post-ischemic hyperemia tends to correlate with the duration and intensity of prior ischemic insult. The aim of this study was to determine whether early post-ischemic hyperemia in human brain during carotid endarterectomy (CEA) is associated with the severity of cerebral ischemic insult during clamping of the internal carotid artery (ICA).Methods: Transcranial cerebral oxygen saturation using near-infrared spectroscopy was monitored intraoperatively in 171 patients undergoing CEA for ipsilateral ICA stenosis (>70%) to assess the intensity of cerebral hemispheric ischemia during ICA clamping and the magnitude of early post-ischemic hyperemia after ICA declamping.Results: Early post-ischemic hyperemia peaked within 3 minutes after ICA declamping and resolved at 20 minutes after ICA declamping. A significant correlation was observed between the magnitude of early post-ischemic hyperemia and the intensity of cerebral ischemia (r=0.697; p<0.0001). Eight patients recovered from anesthesia with a new minor neurological deficit on the side contralateral to the CEA (4.7%). Analysis by receiver operating characteristics (ROC) curve was used to estimate the ability to discriminate between patients with and without post-operative development of new neurological deficits. Area under the ROC curve was significantly greater when analysing the magnitude of early post-ischemic hyperemia (1.00; 95% CI: 0.99–1.00) when compared with the intensity of cerebral ischemia (0.93; 95% CI: 0.89–0.98) (p<0.01).Conclusion: Early post-ischemic hyperemia in CEA is correlated with the severity of cerebral ischemic insult during clamping of the ICA.

Management of subdural hematoma in immune thrombocytopenic purpura: Report of seven patients and a literature review

Intracranial hemorrhage is a devastating complication of immune thrombocytopenic purpura (ITP). Subdural hematoma (SDH) is rare and the optimal management unsettled. We report a series of seven patients of ITP who developed isolated SDH and subsequently review the literature. Three patients had acute ITP (mean duration 2.3 months) while four had chronic ITP (mean duration 8.3 years). Mean platelet count at admission was 25 × 10 9/L (range 16 × 10 9/L to 30 × 10 9/L). Mean age at which SDH occurred was 38 years. Headache and bilateral papilloedema were the commonest clinical features at presentation. Diagnosis was made by CT/MR imaging and SDH was acute in two patients and chronic in five. Precipitating factors could not be identified in any patient. Neurological parameters were closely monitored including level of consciousness, pupillary size and development of new neurological deficits. Two patients with acute SDH developed worsening neurological parameters, underwent craniotomy and hematoma evacuation, and survived. Of the two patients who expired, one was brought in an advanced stage that precluded surgery and the other developed metabolic complications due to underlying lupus nephritis. Reports of isolated SDH in ITP are infrequent. Compared to those developing intracerebral hemorrhage, SDH occurs more in patients who are older, having chronic ITP and having a higher platelet count. Medical management with close monitoring of neurological parameters is a viable treatment option in patients of ITP developing SDH.

Intraoperative Navigation and Fluorescence Imagings in Malignant Glioma Surgery

The current basic goals in glioma surgery are radical tumor resection without triggering the development of new neurological deficits. Although complete removal of malignant gliomas is extremely difficult because of the tumors' infiltrative characteristics, gross total resection of the tumor is known to be associated with improved outcome in the patients. To enable safe and radical resection of malignant gliomas, especially those adjacent to eloquent brain areas, rapid progress has been made in the development of operative support techniques; e.g., navigation systems to provide information about the anatomical and functional locations in the brain and a fluorescence imaging technique for differentiating brain tumors from normal brain tissue. These intraoperative imaging techniques in glioma surgery have improved the functional outcomes of glioma patients.

Gamma-knife radiosurgery in the treatment of trigeminal schwannomas

Trigeminal nerve schwannomas account for 0.07%-0.28% of all intracranial tumours. Advances in skull base surgery have led to more aggressive resection of these tumours, but surgery may associated with development of new neurological deficits. In this report, we analyse the long-term results 15 patients with newly diagnosed or residual/recurrent trigeminal schwannoma who underwent gamma-knife treatment. During a mean 61 months of follow-up, MRI revealed reduction of tumour size in 13 and no size change in 2 patients. The tumour growth control rate was 100% and only 1 patient had transient facial numbness and diplopia. For patients with small to moderate size trigeminal schwannomas, gamma-knife radiosurgery is associated with good tumour control and a minimal risk of adverse radiation effects.

Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries: Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran-Iraq conflict

Background During military conflicts, surviving victims traditionally underwent large enough craniectomy or craniotomy to achieve extensive debridement of the in-driven bone, shell fragments, and debris. Meanwhile, the completely as well as the partially devitalized adjacent brain tissue would also be debrided. This might have led to additional neurologic deficit or lesser degree of recovery of functions. Method We studied the efficacy and safety of much more limited or even absence of surgical intervention in a selected group of wartime head-wounded patients. Among 1,150 war victims with penetrating head wounds referred to two major centers affiliated with Tehran University of Medical Sciences during the 8-year period spanning the Iran-Iraq conflict, there were 191 head-wounded patients who underwent either no surgical intervention or a very limited debridement. We have attempted to follow up as closely as possible for more than 8 years. Ninety-nine of them fulfilled the criteria to be included in this series. Close follow-up for development of cerebral infections, functional recovery, or development of new neurologic deficits and epilepsy were performed. At least 3 contrast-enhanced CT scans were taken for each patient. All patients were victims of the battle-field areas with low- to moderate-velocity missile or shell fragment injury. The Glasgow Coma Scale (GCS) scores of the patients were between 8–14 when visited by the first attending neurosurgery staff. The factors considered to be effective in the outcome analysis were the entry point, the number of the in-driven bone fragments, the retained shell fragments, the brain compartments affected, and the paranasal sinus or skull base involvement with or without cerebrospinal fluid (CSF) fistula. Results There were 13 unilobar, 44 bilobar, 4 trilobar, 38 transventricular, and 3 skull base lesions. The number of retained metal fragments varied between 1 to 6. The number of retained bone fragments varied between 1 to 5 in 73 victims and more than five chips in other cases. The outcome was good (back to work) in 90 patients and poor (severely disabled) in 4. Five patients died because of severity of brain damage and meningitis. The effect of the different enumerated variables upon the outcome was measured using χ 2 and Fisher exact test, which was nonsignificant for all of the variables except for the orbitofacial entry point of injury ( p = 0.00006). Conclusion This study seems to indicate that not only is reoperation for retained bone or shell fragments unnecessary, but surgeons having modern neuroradiological instruments available to detect the proper explanation for changes in GCS of the patients may decide not to proceed with any surgical intervention in a good number of patients. As a result of the “no surgical treatment protocol,” one can preserve cerebral tissue without exposing the patient to undue risk of seizures, infection, or death by leaving behind some or all the in-driven bone and shell fragments.

Transcranial doppler monitoring and clinical decision-making after subarachnoid hemorrhage

Our objective was to examine the impact of transcranial Doppler ultrasound (TCD) vasospasm monitoring on clinical decision-making following subarachnoid hemorrhage (SAH). The records of 50 randomly selected patients undergoing serial TCD monitoring following SAH were reviewed. Dates and results of TCDs and cerebral angiograms, the use of hypertensive hemodilution (HH) therapy, and the development of new neurological deficits were recorded. The independent effects of TCD-defined vasospasm and new neurological deficits on patient management were determined with multiple logistical regression. Results were validated in a second randomly selected, 50 patient cohort. Mild or moderate TCD-defined vasospasm developed in 76% of patients 5.8 ± 0.5 days after SAH; 38% developed severe TCD-defined vasospasm after 7.9 ± 0.7 days. Focal neurological deficits occurred in 50% after 5.7 ± 0.6 days with TCD abnormalities preceding the deficit by 2.5 ± 0.7 days in 64%. TCD-defined vasospasm or a new neurological deficit explained 60% of the variance in the use of HH therapy (P =.005). New neurological deficits increased the odds of HH therapy 33-fold (P =.004) whereas there was no independent effect of TCD-defined vasospasm. These variables explained 64% of the variance in the performance of angiography (P =.0002). An abnormal TCD did not increase the odds of angiography whereas its use increased 28-fold (P =.01) after a neurological deficit developed. These results were confirmed in an independent cohort. We concluded that TCD-defined vasospasm did not independently influence the use of HH therapy or angiography with both decisions associated with the development of new neurological deficits. As TCD-defined vasospasm preceded the neurological deficit in 64%, earlier intervention might reduce the incidence of vasospasm-related stroke in institutions with similar practice patterns. Copyright © 2003 by National Stroke Association