Effacement Of Cisterns Research Articles

A case report of a brain herniation secondary to cryptococcal meningitis with elevated intracranial pressure in a patient with Human Immunodeficiency Virus/Acquired immunodeficiency syndrome (HIV/AIDS)

BackgroundCryptococcal meningitis is a major opportunistic infection in individuals with HIV. The worldwide annual incidence is estimated to be approximately one million cases per year, with the most significant burden in sub-Saharan Africa. HIV-associated cryptococcal meningitis continues to have a high mortality rate despite widespread availability and use of HAART.Case36-year-old male with a past medical history of AIDS and a CD4 count of 35 cells/mm3 presented with altered mental status initially thought to be related to using crystalline methamphetamine as reported by EMS. However, a lumbar puncture performed in the emergency department showed elevated CSF opening pressure of 29 cmH2O and positive CSF and serum cryptococcal antigen. The patient was admitted and commenced treatment according to the current IDSA guideline but continued to have waxing and waning mental status. On the fourth day of admission, he complained of headache, had a witnessed seizure, and was taken emergently for a CT scan of the brain, which was negative for any acute intracranial process, but suffered a cardiac arrest before it could be done. He was intubated and transferred to the intensive care unit. CT brain follow-up showed anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation; he continued to deteriorate and expired on the seventh day of admission.Objectives1.Describe a case of brain death secondary to increased intracranial pressure due to cryptococcal meningitis in a patient with HIV/AIDS.2.Explain the mechanisms of elevation in intracranial pressure in patients with cryptococcal meningitis.3.Discuss the options for managing elevated intracranial pressure in patients with cryptococcal meningitis.4.Create awareness in the medical community about the importance of prompt and efficient management of increased intracranial pressure in patients with cryptococcal meningitis.ConclusionThis case highlights the importance of aggressive management of elevated intracranial pressure in cryptococcal meningitis. It reiterates the need for more data regarding the optimal timing and frequency of therapeutic lumbar puncture and the use of temporary lumbar drainage catheters and ventriculostomy to manage this potentially fatal complication.

Predictors and Dynamic Nomogram to Determine the Individual Risk of Malignant Brain Edema After Endovascular Thrombectomy in Acute Ischemic Stroke.

Background and PurposeThis study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET).MethodsWe enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET.ResultsMBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728).ConclusionsOur web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.

Clinico-radiological related to early brain death factors

ObjectiveTo identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h. DesignA retrospective cohort study was made covering the period 2015−2017. SettingAn adult Intensive Care Unit (ICU). Patients/methodsEpidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. ResultsA total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. ConclusionsEarly BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria.

It is unclear if the presence of compartmental brain herniation on neuroimaging should be a prerequisite to the clinical confirmation of death using neurological criteria. The World Brain Death Project has posed this as a research question. The final computed tomography of the head scans before death of 164 consecutive patients confirmed dead using neurological criteria and 41 patients with devastating brain injury who died following withdrawal of life sustaining treatment were assessed by a neuroradiologist to compare the incidence of herniation and other features of cerebral swelling. There was no difference in the incidence of herniation in patients confirmed dead using neurological criteria and those with devastating brain injury (79% vs 76%, OR 1.23 95%, CI 0.56-2.67). The sensitivity and specificity of brain herniation in patients confirmed dead using neurological criteria was 79% and 24%, respectively. The positive and negative predictive value was 81% and 23%, respectively. The most sensitive computed tomography of the head findings for death using neurological criteria were diffuse sulcal effacement (93%) and basal cistern effacement (91%) and the most specific finding was loss of grey-white differentiation (80%). The only features with a significantly different incidence between the death using neurological criteria group and the devastating brain injury group were loss of grey-white differentiation (46 vs 20%, OR 3.56, 95% CI 1.55-8.17) and presence of contralateral ventricular dilatation (24 vs 44%, OR 0.41, 95% CI 0.20-0.84). Neuroimaging is essential in establishing the cause of death using neurological criteria. However, the presence of brain herniation or other signs of cerebral swelling are poor predictors of whether a patient will satisfy the clinical criteria for death using neurological criteria or not. The decision to test must remain a clinical one.

Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke

BackgroundAlteplase improves functional outcomes of patients with acute ischaemic stroke, but its effects on symptomatic infarct swelling, an adverse complication of stroke and the influence of CT hyperdense artery sign...

Admission Features Associated With Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: A Case-Control Study.

Paroxysmal sympathetic hyperactivity occurs in a subset of critically ill traumatic brain injury patients and has been associated with worse outcomes after traumatic brain injury. The goal of this study was to identify admission risk factors for the development of paroxysmal sympathetic hyperactivity in traumatic brain injury patients. Retrospective case-control study of age- and Glasgow Coma Scale-matched traumatic brain injury patients. Neurotrauma ICU at the R. Adams Cowley Shock Trauma Center of the University of Maryland Medical System, January 2016 to July 2018. Critically ill adult traumatic brain injury patients who underwent inpatient monitoring for at least 14 days were included. Cases were identified based on treatment for paroxysmal sympathetic hyperactivity with institutional first-line therapies and were confirmed by retrospective tabulation of established paroxysmal sympathetic hyperactivity diagnostic and severity criteria. Cases were matched 1:1 by age and Glasgow Coma Scale to nonparoxysmal sympathetic hyperactivity traumatic brain injury controls, yielding 77 patients in each group. None. Admission characteristics independently predictive of paroxysmal sympathetic hyperactivity included male sex, higher admission systolic blood pressure, and initial CT evidence of diffuse axonal injury, intraventricular hemorrhage/subarachnoid hemorrhage, complete cisternal effacement, and absence of contusion. Paroxysmal sympathetic hyperactivity cases demonstrated significantly worse neurologic outcomes upon hospital discharge despite being matched for injury severity at admission. Several anatomical, epidemiologic, and physiologic risk factors for clinically relevant paroxysmal sympathetic hyperactivity can be identified on ICU admission. These features help characterize paroxysmal sympathetic hyperactivity as a clinical-pathophysiologic phenotype associated with worse outcomes after traumatic brain injury.

Ultrasound assessment of optic nerve sheath diameter for evaluation of elevated intracranial pressure in patient with head trauma: A comparative study with CT head

Purpose: Increased intracranial pressure (ICP) is complication of traumatic brain injury. Early detection of raised ICP is helpful in timely treatment. Bed side ultrasound of optic nerve sheath is easier for detection of raised intracranial pressure by measuring its diameter. Our aim was to determine whether bedside ultrasound measurement of optic nerve sheath diameter (ONSD) can accurately predict raised intracranial pressure in head injury patients and to calculation of validity of test. Methods and Materials: Total 150 patients with head injury was first examined by ultrasound. The ONSD was measured 3 mm behind the globe perpendicular to long axis of globe in both eyes than mean binocular ONSD was calculated. Diameter more than 5 mm was considered abnormal. CT scan was performed in all patients and result was considered positive for elevated ICP if mid line shift, effacement of sulci, ventricles and cisterns are seen. Results: Out of total 150 patients 61 was female and 89 was male, age was ranging from 23-61 years. 30 patients showed mean binocular ONSD >5mm by ultrasound out of them 26 patients showed positive signs of raised intracranial pressure on CT. Sensitivity and negative predictive value of ultrasound to detect raised ICP was 100%, Specificity was 96.7 % and negative predictive value was 86.6 %. Conclusions: Ultrasound can be used as bed side screening tool to detect raised ICP in ICU patients and head trauma patients especially in hospital with high patient flow in emergency department.

O023 / #832: PROGNOSTIC IMPLICATION OF EARLY BRAIN CT SCAN IMAGES IN CHILDREN ADMITTED IN PEDIATRIC INTENSIVE CARE UNIT FOLLOWING CARDIAC ARREST.

Aims & Objectives: Cardiac arrest (CA) is often associated to unfavorable outcome. Early evaluation of brain injury is crucial to define neuroprognosis. Our aim is to develop a severity score based on clearly identifiable features of brain computerized tomography (CT), and, secondly, to combine this score with clinical variables to produce a valuable prognostic tool. Methods: This single-center retrospective study included patients admitted to PICU after CA from 2010 to 2019. All children underwent a standardized post-ROSC protocol including targeted temperature management. Five qualitative neuroradiological variables were obtained from a brain CT scan performed in the first 24 hours after CA: cerebral hemorrhage, qualitative alteration of gray/white matter ratio, sulcal effacement, basilar cistern effacement, cerebellar reversal sign. Each variable was considered according to its correlation with the Pediatric Cerebral Performance Category (PCPC) score to elaborate the Early Brain Injury (EBI) score. Results: 48 children victims of CA were included in the study (median age 4.0 years). 23 patients (47.9%) survived after ROSC and 16 (69.6%) had a favorable clinical outcome (PCPC 1-3). On admission, 33 patients (68.8%) presented an abnormal CT scan. The EBI score showed significant correlation with PCPC score (Spearman’s rho 0.49, p<0.01). The multimodal model containing time to ROSC, EBI score and early lactate levels had extreme specificity and sensibility for predicting poor prognosis (AUC 1.000).Conclusions: EBI score, composed by easy-detectable neuroradiological variables, resulted correlated to outcome and, combined with time to ROSC e early lactate levels, provided an accurate model to early predict prognosis in children with CA.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (β = -25.2, p < 0.01) and complete cisternal effacement (β = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7, p < 0.05) and cognitive DFQ (β = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

A Novel Automated Calculation of Basal Cistern Effacement Status on Computed Tomographic Imaging in Traumatic Brain Injury

IntroductionTo predict patient outcomes in traumatic brain injury (TBI) lesions, various scores have been proposed, which use objective assessments. These scores, however, rely on the observer's ability to determine them. This study presents a comprehensive, reproducible, and more anatomically stratified objective measurement of the degree of basal cistern effacement in brain computed tomographic (CT) scan images.MethodsPatients with TBI admitted from August 2015 to February 2016 were included. The control group consisted of non-trauma patients, who had normal brain CT scans. The images were analyzed by an automated volumetric compression ratio (CR) defined as the volume ratio between the parenchymal tissue and the cerebrospinal fluid (CSF) in the basal cisterns. This value was compared with the TBI severity recorded at each patient's admission and a consensus score of the basal cisterns' degree of effacement by manual analysis.ResultsSeventy-three TBI patients were admitted. The mean admission Glasow Coma Scale (GCS) score was 9. In the non-TBI control group, 29 patients were enrolled. The average kappa value for the inter-observer agreement was 0.583. The CR had an inverse linear relationship with the severity of the TBI and the degree of effacement of the basal cisterns. The correlation between the CR value in the midbrain and the specialists' consensus determination was statistically significant (p < 0.01). The CR also showed a difference between the TBI and the control groups (p 0.0001).ConclusionsThe automated CR is a useful objective variable to determine the degree of basal cistern effacement. The proposed ratio has a good correlation with the classical basal cistern effacement classification and TBI severity.

Coagulopathy as a Surrogate of Severity of Injury in Penetrating Brain Injury.

Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /μL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21-35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48-0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2-12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08-10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation.

Radiographic predictors of clinical outcome in traumatic brain injury after decompressive craniectomy.

Primary decompressive craniectomy (DC) is considered for traumatic brain injury (TBI) patients with clinical deterioration, presenting large amounts of high-density lesions on computed tomography (CT). Postoperative CT findings may be suitable for prognostic evaluation. This study evaluated the radiographic predictors of clinical outcome and survival using pre- and postoperative CT scans of such patients. We enrolled 150 patients with moderate to severe TBI who underwent primary DC. They were divided into two groups based on the 6-month postoperative Glasgow Outcome Scale Extended scores (1-4, unfavorable; 5-8, favorable). Radiographic parameters, including hemorrhage type, location, presence of skull fracture, midline shifting, hemispheric diameter, effacement of cisterns, parenchymal hypodensity, and craniectomy size, were reviewed. Stepwise logistic regression analysis was used to identify the prognostic factors of clinical outcome and 6-month mortality. Multivariable logistic regression analysis revealed that age (odds ratio [OR] = 1.09; 95% confidence interval [CI] 1.032-1.151; p = 0.002), postoperative low density (OR = 12.58; 95% CI 1.247-126.829; p = 0.032), and postoperative effacement of the ambient cistern (OR = 14.52; 95% CI 2.234-94.351; p = 0.005) and the crural cistern (OR = 4.90; 95% CI 1.359-17.678; p = 0.015) were associated with unfavorable outcomes. Postoperative effacement of the crural cistern was the strongest predictor of 6-month mortality (OR = 8.93; 95% CI 2.747-29.054; p = 0.000). Hemispheric hypodensity and effacement of the crural and ambient cisterns on postoperative CT after primary DC seems to associate with poor outcome in patients with TBI.

Traumatic Cerebellar Hematoma: A Tertiary Care Experience of 23 Conservatively Managed Cases.

Context:Traumatic cerebellar hematomas are rare in comparison to nontraumatic cerebellar hematomas.Aims:The aim of this study is to evaluate the prognostic factors and outcome determining factors with regard to conservatively managed isolated traumatic cerebellar hematoma.Settings and Design:Retrospective cohort study.Materials and Methods:A retrospective study of 23 patients of conservatively managed isolated posterior fossa hematoma, admitted between August 2018 and May 2020, was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Each of the patients was evaluated in terms of age, sex, mode of injury, clinical presentation, comorbidity, the severity of injury, best motor response, Glasgow Coma Scale (GCS) at admission, computed tomography findings, and Glasgow Outcome Scale at discharge/death.Statistical Analysis:Chi-square test and unpaired t-test were used. P < 0.05 was deemed statistically significant.Results:Mean volume of posterior fossa contusion was 8.9 ml. The cerebellar hemispheric (60.9%) location of hematoma was more common. Age at presentation (P = 0.0086), best motor response (P < 0.0001), severity of injury (P = 0.0002), GCS at admission (P < 0.0001), effacement of basal cistern (P < 0.0001), fourth ventricular compression and intraventricular hemorrhage (P = 0.0008), presence of hydrocephalus (P = 0.0142), subarachnoid hemorrhage (P = 0.0008), and volume of posterior fossa contusion (P = 0.0002) were significantly associated with outcome of posterior fossa contusion.Conclusion:Traumatic cerebellar hematoma is rare. Conservatively managed cerebellar hematoma patients must be monitored closely for neurological and radiological status. Patients who show deterioration in neurological or radiological status require surgical intervention.

Risk factors and novel prognostic score for predicting the 14-day mortality of severe traumatic brain injury patients

Introduction: The mortality of severe traumatic brain injury (TBI) is contributed by the severity of the head injury, associated trauma, and complication during treatment. This study aimed to develop a prognostic scoring system of risk factors that contribute to the 14-day mortality of severe TBI.Methods: This was a prospective cohort study including 105 severe TBI patients recruited consecutively from March to October 2016. Multivariate analysis with logistic regression was performed to determine the most contributing risk factors. The validation of prognostic factor was performed with ROC, sensitivity and specificity analysis.Result: There were five significant risk factors of 14-day mortality, which were age &gt; 60 years old (RR: 15.6, 95% CI: 1.88 – 129.95), hypoxia (RR: 17.78, 95% CI: 2.05 – 154.11), GCS 3 – 5 (RR: 34.71, 95% CI: 6.85 – 175.98), effacement of basal cistern (RR: 12.71, 95% CI: 2.61 – 61.95), and traumatic subarachnoid hemorrhage (tSAH) (RR:7.57, 95% CI: 1.19 – 48.36). The prognostic score ranged from 0 to 6 with the best cut-off point of 1. The best predictive AUC with ROC analysis was 0.817, 81.2% of sensitivity, and 75.0% of specificity.Conclusion: The proposed prognostic score has shown good predictive ability.

Novel risk factors and management of brain sag after brain tumor surgery

ObjectiveLumbar drains (LD) have been identified to cause brain sag (BS), which is a serious intracranial hypotension that causes coma; however, other contributing risk factors should also be considered. Therefore, this study aims to identify the BS risk factors and determine the proper treatment plan after brain tumor surgery for patients with BS. MethodsThis retrospective study included patients who underwent brain tumor surgery between 2011 and 2015. BS was diagnosed based on the clinical signs of cerebrospinal fluid hypovolemia along with the radiological findings of the basal cistern effacement. Based on the data on the clinical features, the symptoms were used to determine the BS risk factors using logistic regression. ResultsOverall, among the 412 patients included in this study, 12 (2.91%) were found to develop BS, 10 experienced altered consciousness, and 2 experienced orthostatic headaches. In all cases, radiological images at onset showed epidural/subdural fluid collection, along with basal cistern effacement. LD was inserted just before surgery in 11 cases, while a ventriculoperitoneal shunt was placed in one patient. The treatment strategies used are as follows: Ringer’s solution infusion (n = 4), Trendelenburg position (n = 2), intrathecal injection of saline (n = 1), or no care due to misdiagnosis (n = 5). Moreover, the significant BS risk factors were determined to be the LD (odds ratio [OR] 30.70, CI 2.77–339.86), supratentorial skull base approach (SBA) (OR 35.71, CI 9.1922–138.7250), surgical time (1693.07, CI 69.5621–41207.448), and postoperative hyperosmotic diuretic use (OR 8.092, CI 2.485–26.345) after surgery. ConclusionsIn the brain tumor surgery, aside from the LD, the application of supratentorial SBA, use of HD, and lengthy surgery are also found to be contributing risk factors for BS. Therefore, BS should be considered in the differential diagnosis of high-risk patients with postoperative altered consciousness.

A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction

BackgroundFor large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE.MethodsOne hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction.ResultsAfter adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934).ConclusionsIndependent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis.

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

Clinico-radiological related to early brain death factors.

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24hours. A retrospective cohort study was made covering the period 2015-2017. An adult Intensive Care Unit (ICU). Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24h (p=0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9ml in early BD versus 82.7ml in BD>24h (p=0.54). The mean midline shift was 10.7mm in early BD versus 7.8mm in BD>24h (p=0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p=0.021). Thirty-six patients with early BD versus 24 with BD>24h presented complete effacement of basal cisterns (p=0.005), sulcular effacement (p=0.013), loss of cortico-subcortical differentiation (p=0.0001) and effacement of the suprasellar cistern (p=0.005). The optic nerve sheath measurements showed no significant differences between groups. Early BD (>24h) was associated to GCS<5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Craniectomy size for subdural haematomas and the impact on brain shift and outcomes.

Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported. A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement. Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5months (range 2.2-109.6). The median craniectomy size was 88.7cm2 and the median subtemporal decompression was 15.0mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05). This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

Comparative Radiographic Factors Predicting Functional Outcome After Decompressive Craniectomy in Severe Traumatic Brain Injury

Decompressive craniectomy (DC) is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury (TBI). We report the association of comparative radiographic factors in predicting functional outcomes after DC in patients with severe TBI. A retrospective analysis of a prospectively maintained database of cases between 2015 and 2018 at an academic tertiary care hospital was carried out. Univariate and multivariable regression analyses were performed for an array of comparative radiographic variables (pre- and post-DC) in relationship to functional outcome according to Glasgow Outcome Scale Extended (GOSE) at 180 days. GOSE was further dichotomized into favorable (GOSE:5-8) and unfavorable (GOSE:0-4) functional outcomes. All associations were reported as odds ratio (OR) with 95% confidence interval (CI). Statistical analysis included a cohort of 43patients with a median age of 30.5 years (range: 18-62 years). The median GOSE at 180 days was 7. Multivariable regression analysis after adjusting for confounding variables (age, sex, comorbidities, site of surgery and size of decompression) showed that comparative radiographic findings of midline shift (MLS) > 10 mm (OR 3.2 (95% CI 1.25-8.04); P= 0.01); external cerebral herniation (ECH) >2.5 cm (OR 2.5 [95% CI 1.18-5.2]; P= 0.02); and effacement of basal cisterns (OR 3.9 [95%CI 1.1-13.9]; P= 0.03), were significant independent predictors of poor functional outcome at 180 days after DC for severe TBI. However, the presence of infarction (OR 2.7 [95%CI 0.43-17.2]; P= 0.28) and absence of gray-white matter differentiation (OR 0.18 [95%CI 0.03-1.2]; P= 0.07) did not reach statistical significance. The comparative radiographic findings that include MLS > 10mm, ECH > 2.5cm, and effacement of basal cisterns are predictive of poor functional outcome in severe TBI.