Glasgow Outcome Scale Score Research Articles

Outcome Predictor of Spontaneous Supratentorial Intracerebral Hemorrhage Management

Background: Spontaneous intracerebral hemorrhage (SICH) is responsible for higher morbidity and mortality rates than ischemic stroke. Although SICH is less common than ischemic stroke. Identifying the predictors of outcome after spontaneous supratentorial intracerebral hemorrhage is crucial for a clinical decision-making framework and implementing efficient therapeutic measures. Aims: The study aimed to analyze the clinical profile, assess the outcome, and identify the outcome prognosticators after supratentorial SICH in the Neurosurgery Department of a tertiary care hospital in the southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 183 patients with computerized tomography (CT) evidence of supratentorial SICH above 18 years of age from the Department of Neurosurgery of Chittagong Medical College Hospital between September 2021 and February 2023.The variables analyzed were age, sex, comorbidities, Glasgow coma scale (GCS) score on admission, radiological features, treatment modality and outcome at 90-day. Glasgow outcome scale (GOS) score was used to assess the outcome. GOS score 4-5 was considered good outcome and GOS score 1-3 was considered as poor outcome. Results: The mean age of the patients was 58.9±14.4 years and 52.5% were male. The 90-day mortality rate was 50.8% and 55.2% patients had poor outcomes. On bivariate analysis, higher age, comorbid CKD state, low GCS score, higher hematoma volume, midline shift, hydrocephalus and intraventricular hematoma (IVH) were associated with poor outcome. Independent predictors of poor outcome included a higher baseline age (OR: 1.07, 95% CI:1.02-1.11, p=0.002), lower GCS on admission (OR: 0.55, 95% CI: 0.39- 0.76, p<0.001), and medical management (OR = 30.56, 95% CI = 7.15-130.69, P <0.001). Conclusions: In conclusion, SICH is associated with high mortality and morbidity. Higher age, low GCS on admission and medical management independently predicted poor outcome in the present study. Patients with a lower age, higher GCS on admission and who were managed surgically were more likely to have a good outcome. Bang. J Neurosurgery 2024; 13(2): 96-103

Factors Influencing Surgical Outcome of Patients with Traumatic Acute Subdural Hematoma

Background: Traumatic acute subdural hematoma (ASDH) is a catastrophic devastating component of brain injury in neurosurgical arena. Due to its significant mortality rate, potential for functional disability and disastrous consequence of complications, it is considered as a challenge for neurosurgeons worldwide. Consequently, precise recognition of predictive outcome factors is crucial for appropriate neurosurgical management and prognostication for patients with traumatic ASDH. Aims: The study aimed to determine the demographic, clinical, radiological and therapeutic factors associated with the surgical outcomes in patients with traumatic acute subdural hematoma (ASDH) who managed surgically in the Neurosurgery Department at a tertiary level hospital in Bangladesh. Materials and Methods: This prospective observational study included 40 radiologically diagnosed cases of traumatic ASDH age more than 18 years who were admitted and operated in the Department of Neurosurgery of Chittagong Medical College Hospital from May 2022 to April 2023. Data regarding demographic, clinical, radiographic, surgical procedure and findings were recorded. Three months mortality rate with clinical outcome was assessed by Glasgow Outcome Scale (GOS) score and analyzed. The outcome was divided into favorable outcomes (GOS score >3) and unfavorable outcomes (GOS score d”3). Results: The median age of the patients was 45 years (range: 19-82 years), and there was a male predominance (82.5%) with a male to female ratio of 4.7:1. Road traffic accident (RTA) was the most common cause of trauma (65%), followed by fall from height (15%), and physical assault (12.5%). Craniotomy was done in 16 (40%) patients and other 24 (60%) patients had decompressive craniectomy. Overall, 21 (52.5%) patients had good outcome and other 19 (47.5%) had poor outcome, and three months mortality rate was 42.5%. Regression analysis revealed that, increasing age [Odds ratio (OR): 1.12, 95% Confidence interval CI: 1.02-1.22. p=0.014], preoperative GCS of d”8 (OR: 13.98, 95% CI:1.22-160.00, p=0.034), and presence of Anisocoria with non-reacting pupil (OR; 17.99, 95% CI: 1.32-244.08, p=0.030) were independently associated with poor outcome. Conclusions: This study identified higher age, preoperative low GCS score and pupillary abnormality as the independent predictors for 3-months poor outcome in patients who underwent surgical treatment for traumatic ASDH Bang. J Neurosurgery 2024; 13(2): 140-148

Factors Influencing the Outcome of Patients with Surgically Managed Intracranial Meningioma

Background: Intracranial Meningiomas are the most common primary brain tumor in adult which are predominantly non-malignant. Surgical intervention is the goldstandard treatment option for intracranial meningiomas but the surgical outcomes are influenced by various epidemiological risk factors. Understanding these factors is essential for a precise decision-making process, application of effective therapeutic intervention and prognostication. Aims: This study aimed to identify the possible predictive factors influencing surgical outcome in patients with intracranial meningioma. Materials and Methods: This Prospective Observational Study included 34 patients of intracranial Meningioma who had surgery in the Department of Neurosurgery, Chittagong Medical College Hospital between February 2022 to August 2023. Outcome measures were the Glasgow Outcome Scale (GOS) and Karnofsky Performance Status (KPS) score at the immediate postoperative period, “0” postoperative day, at the time of discharge, 1 month, 3 months, and 6 months post-surgery. GOS score 1-3 was considered as poor outcome. Results: The mean age of the patients was 46.8±12.6 years and 70.6% were female. Most of the patients were in either ASA class I (35.3%) or Class II (55.9%), and the median KPS score was 80% before surgery. Twenty-eight (82.4%) patients survived at least six months following surgery and the 6-months mortality rate was 17.6%. Twenty-seven (79.4%) patients had a good outcome and 7 (20.6%) patients had a poor outcome. Preoperative KPS score (p=0.024), tumor location (p=0.019), and tumor volume (p=0.003) were found to have a significant association with outcome in univariate analysis. However, none of these factors retained a significant association in multivariate analysis. Conclusions: In conclusion, specific influencing factors for postoperative poor outcomes revealed in univariate analysis in the present study were low preoperative KPS score, skull base meningioma, and large-size tumor Bang. J Neurosurgery 2024; 13(2): 121-129

Prognostic Factors of Outcome in Patients Undergoing Surgical Intervention following Traumatic Intracerebral Haemorrhage

Background: Intracerebral hemorrhage is a common complication after traumatic brain injury. While it is accepted practice to remove extra-axial (extradural and subdural) haematoma following traumatic brain injury, but surgical practice in the treatment of traumatic intracerebral hemorrhage (TICH) differs widely, and prognostic factors associated with outcome following surgery have not yet been well established. Aims: The study aimed to determine the prognostic factors of outcome in patients undergoing surgical intervention following traumatic intracerebral hemorrhage in a tertiary care hospital in southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 45 patients requiring craniotomies for decompression and evacuation of an intracranial hemorrhage following traumatic intracerebral hemorrhage in the Neurosurgery Department of Chittagong Medical College Hospital between December 2021 to June 2023. Demographic features, perioperative clinical and radiological characteristics of these patients were examined in relation to favorable/good outcome, defined as Glasgow Outcome Scale (GOS) score >3 at 3months follow-up, and unfavorable/poor outcome, defined as 3months mortality or GOS score d”3 at 3months after surgery. Results: The median age was 45 (range 8-75) years, 82.2% were male, and road traffic accident was the commonest cause (73.3%). Initial loss of consciousness was found in 75.7% of patients and the median GCS on admission was 9 (Interquartile range 8-10). Craniotomy and evacuation was done in 23(51.1%) of the cases, followed by craniectomy and evacuation in 22 (48.9%)patients. In-hospital and 3 months mortality rate was 28.9%. At three months post surgery, all of the survived patients(32) had good outcomes; 29 (92.3%) had GOS scores of 5, while the remaining 3 had GOS scores of 4. In bivariate analysis, age, history of comorbidity and loss of consciousness, GCS on admission, hematoma volume, and injury to surgery interval was found to have significant association with poor outcome (p<0.05). Age (OR: 1.211, 95% CI: 1.012-1.241, p=0.009) and GCS score on admission (OR: 0.301, 95% CI: 0.086-0.827, p=0.004) were independent predictors of 3-months poor outcome or mortality in multivariate logistic regression analysis. Conclusions: This study presented that older age(60 years) and lower GCS(7-10) on admission were the independent predictors of poor outcome after 3 months of surgery. Multicenter studies are needed to provide accurate data on traumatic intracerebral hemorrhage in Bangladesh. Bang. J Neurosurgery 2024; 13(2): 104-111

The Effect of sCOX-2 inhibitor on S100B Protein Level, Cognitive Dysfunction and Glasgow Outcome Scale (GOS) in Moderate Traumatic Brain Injury Patients

The aim of this study was to explore the relationship between the protein S100B level, cognitive dysfunction, and Glasgow Outcome Scale (GOS) in moderate traumatic brain injury patients. Thirty patients suffering from head injuries undergoing neurosurgery in Dr. Hasan Sadikin General Hospital Bandung, Indonesia, and who were considered eligible based on the inclusion and exclusion criteria participated in this double-blind experimental Randomized Controlled Trial (RCT). The treatment groups (COX-2) were assigned as COX2-I, COX2II, and COX3-IV, six patients in each group. The treatment group was given another dose of sCOX-2 inhibitor 12 hours, 12 and 24 hours after the first dose, and 12, 24 and 36 hours after pre-induction sCOP-2 inhibitor was administered. The GOS score was obtained during the before the surgery and 1 month, 1.5 months, and 2 months postoperative days. The MMSE was performed preoperatively and then on the first to seventh day after the surgery. The results showed that there was a significant decrease in the protein level in all treatment groups including the control group, where the resulting p-value was less than 0.05. Moreover, the treatment group showed a faster time in reaching GOS 5 or be discharged from the hospital compared to the control. In conclusion, it has been demonstrated that the provision of 3 or 4 times of the sCox-2 inhibitor leads to the achievement of a score of 5, while the recovery of the cognitive dysfunction into the normal level is obtained when the SCox2 inhibitor is given 4 times.

Tranexamic Acid in Pediatric Traumatic Brain Injury: A Multicenter Retrospective Observational Study

ObjectiveTranexamic acid (TXA) can be used after trauma to prevent bleeding. Our goal was to examine the impact of TXA on morbidity and mortality for children with severe traumatic brain injury (TBI). MethodsWe identified children aged <18 years with a severe TBI [Glasgow Coma Scale score <8) presenting to one of the 291 hospitals contributing to the Japanese Trauma Data Bank between 2019 and 2023. The primary outcomes was in-hospital death and the secondary outcome was poor neurologic outcome defined with Glasgow Outcome Scale score of 1–3 at hospital discharge. Our primary exposure was any TXA administered in the hospital. Using propensity score-based inverse probability weighting, we used logistic regression to measure the association between TXA administration and death as well as poor neurologic outcome. ResultsOf the 342 included patients, 30 (14%) died and 102 (45%) had a GCS score <8 at discharge. After inverse propensity weighting, TXA administration was not associated with either mortality [adjusted odds ratio (aOR) 1.25, 95% confidence interval (CI) 0.61–2.54) or poor neurologic outcome (aOR 0.86, 95% CI 0.47–1.56). ConclusionsTXA administration was not associated with either death or poor neurologic outcome. Prospective clinical trials of TXA usage in children with severe TBI are needed.

Wartime penetrating traumatic brain injury of the anterior skull base involving the paranasal sinuses: a single-center, first-year experience from Dnipro, Ukraine.

Since February 2022, the number of casualties in the Russian-Ukrainian war have dramatically increased, with a high incidence of penetrating traumatic brain injuries (pTBIs). To date, there has been limited evaluation of pTBI of the anterior skull base involving the paranasal sinuses. The objective of this study was to highlight the authors' experience with this injury pattern and identify specific factors associated with favorable short-term (1-month) outcome and survival. The authors conducted a single-institution retrospective review of patient data collected from the 1st year of the Russian-Ukrainian war at a frontline civilian Ukrainian hospital. To prevent complications from conservative treatment of pTBI with paranasal sinus injury, a protocol of early primary neurosurgical treatment including debridement/hematoma evacuation, repair of dural defects with vascularized pericranial flaps, and titanium plating of external/skull base defects was implemented. Using 1-month postoperative Glasgow Outcome Scale scores, the authors defined a favorable outcome as good recovery/moderate disability and a poor outcome as severe disability/vegetative state/death. Patient demographics, injury characteristics, imaging findings, and postoperative complications were assessed. Logistic regression models were used to estimate the effect of patient characteristics on unfavorable outcome or survival. From February 2022 to February 2023, there were 141 pTBIs (20%) involving the paranasal sinuses, 134 (95%) due to blast fragmentation. One hundred eighteen patients (84%) had a favorable outcome. Most patients with pTBIs (69%) had other nonbrain-related injuries. While 48 patients (34%) presented with preoperative CSF leak, only 1 patient (0.7%) had persistent postoperative CSF leak, which was managed with lumbar drainage. High admission Glasgow Coma Scale (GCS) score, favorable injury lateralization (single hemisphere involved), and low Injury Severity Score (ISS) were associated with significantly increased odds of favorable short-term outcome, whereas high admission GCS scores and no midline shift were associated with significantly increased odds of survival. This was the largest single-year study on neurosurgical treatment of wartime pTBI involving the paranasal sinuses. Implementation of primary neurosurgical intervention at the time of presentation demonstrated promising early results and a shift away from expectant management of this injury pattern. The association of high admission GCS score, low ISS, favorable injury lateralization, and no midline shift on favorable short-term outcomes or survival has not been previously documented with this injury pattern.

Antiseizure Medication Use and Outcomes After Suspected or Confirmed Acute Symptomatic Seizures

Antiseizure medications (ASMs) are frequently prescribed for acute symptomatic seizures and epileptiform abnormalities (EAs; eg, periodic or rhythmic patterns). There are limited data on factors associated with ASM use and their association with outcomes. To determine factors associated with ASM use in patients with confirmed or suspected acute symptomatic seizures undergoing continuous electroencephalography, and to explore the association of ASMs with outcomes. This multicenter cohort study was performed between July 1 and September 30, 2021, at 5 US centers of the Post Acute Symptomatic Seizure Investigation and Outcomes Network. After screening 1717 patients, the study included 1172 hospitalized adults without epilepsy who underwent continuous electroencephalography after witnessed or suspected acute symptomatic seizures. Data analysis was performed from November 14, 2023, to February 2, 2024. ASM treatment (inpatient ASM continuation ≥48 hours). Factors associated with (1) ASM treatment, (2) discharge ASM prescription, and (3) discharge and 3-month Glasgow Outcome Scale score of 4 or 5 were ascertained. A total of 1172 patients (median [IQR] age, 64 [52-75] years; 528 [45%] female) were included. Among them, 285 (24%) had clinical acute symptomatic seizures, 107 (9%) had electrographic seizures, and 364 (31%) had EAs; 532 (45%) received ASM treatment. Among 922 patients alive at discharge, 288 (31%) were prescribed ASMs. The respective frequencies of inpatient ASM treatment and discharge prescription were 82% (233 of 285) and 69% (169 of 246) for patients with clinical acute symptomatic seizures, 96% (103 of 107) and 95% (61 of 64) for electrographic seizures, and 64% (233 of 364) and 48% (128 of 267) for EAs. On multivariable analysis, acute and progressive brain injuries were independently associated with increased odds of inpatient ASM treatment (odds ratio [OR], 3.86 [95% CI, 2.06-7.32] and 8.37 [95% CI, 3.48-20.80], respectively) and discharge prescription (OR, 2.26 [95% CI, 1.04-4.98] and 10.10 [95% CI, 3.94-27.00], respectively). Admission to the neurology or neurosurgery service (OR, 2.56 [95% CI, 1.08-6.18]) or to the neurological intensive care unit (OR, 7.98 [95% CI, 3.49-19.00]) was associated with increased odds of treatment. Acute symptomatic seizures and EAs were significantly associated with increased odds of ASM treatment (OR, 14.30 [95% CI, 8.52-24.90] and 2.30 [95% CI, 1.47-3.61], respectively) and discharge prescription (OR, 12.60 [95% CI, 7.37-22.00] and 1.72 [95% CI, 1.00-2.97], respectively). ASM treatment was not associated with outcomes at discharge (OR, 0.96 [95% CI, 0.61-1.52]) or at 3 months after initial presentation (OR, 1.26 [95% CI, 0.78-2.04]). Among 623 patients alive and with complete data at 3 months after discharge, 30 (5%) had postdischarge seizures, 187 (30%) were receiving ASMs, and 202 (32%) had all-cause readmissions. This study suggests that etiology and electrographic findings are associated with ASM treatment for acute symptomatic seizures and EAs; ASM treatment was not associated with functional outcomes. Comparative effectiveness studies are indicated to identify which patients may benefit from ASMs and to determine the optimal treatment duration.

Associations of serum Dickkopf-1 levels with disease severity and 90-day Prognosis after spontaneous intracerebral hemorrhage: results from the prospective cohort study.

Dickkopf-1 (DKK-1) may be involved in inflammatory response and secondary brain injury after acute brain injury. We gauged serum DKK-1 levels and further assessed its correlation with disease severity and investigated its predictive value for 90-day prognosis in patients with spontaneous intracerebral hemorrhage (sICH). Serum DKK-1 levels were measured in 128 sICH patients and 128 healthy controls. The severity of sICH was assessed using the Glasgow Coma Scale (GCS) scores and hematoma volumes. Poor prognosis was referred to as a Glasgow Outcome Scale (GOS) score of 1-3 at 90days after stroke. Multivariate analysis was performed to identify associations of serum DKK-1 levels with disease severity, early neurological deterioration (END) and poor prognosis. Receiver operating characteristic curve (ROC) was built to investigate the prognostic predictive capability. The serum DKK-1 levels of patients were significantly higher than those of controls (median, 4.74ng/mL versus 1.98ng/mL; P < 0.001), and were independently correlated with hematoma volumes (ρ = 0.567, P < 0.001; t = 3.444, P = 0.001) and GCS score (ρ = -0.612, P < 0.001; t = -2.048, P = 0.043). Serum DKK-1 significantly differentiated patients at risk of END (area under ROC curve (AUC), 0.850; 95% confidence interval (CI), 0.777-0.907; P < 0.001) and poor prognosis (AUC, 0.830; 95% CI, 0.753-0.890; P < 0.001), which had similar prognostic ability, as compared to GCS scores and hematoma volumes. Subsequent Logistic regression model affirmed that GCS score, hematoma volume, and serum DKK-1 levels were independently associated with END and poor prognosis at 90days after sICH. The models, which contained them, performed well using ROC curve analysis and calibration curve analysis. Serum DKK-1 levels are markedly associated with disease severity, END and 90-day poor prognosis in sICH. Hence, serum DKK-1 is presumed to be used as a potential prognostic biomarker of sICH.

Impact of ultra-early enteral nutrition support on the prognosis of young and middle-aged postoperative patients with cerebral hemorrhage

To investigate the effect of ultra-early enteral nutrition (UEEN) support on the prognosis of young and middle-aged postoperative patients with cerebral hemorrhage. The clinical data of young and middle-aged patients (aged 18-59 years) admitted to Tianjin Fifth Central Hospital from January 2020 to June 2023 after surgery for intracerebral hemorrhage were retrospectively analyzed, and the general data, nutritional indexes, gastrointestinal complications, neurological function recovery and long-term prognosis of the patients were recorded. According to the time of initiation of enteral nutrition (EN) support, patients were divided into UEEN group (EN implementation within 12 hour after surgery) and early enteral nutrition (EEN) group (EN implementation within 24 to 48 hour after surgery). The differences of the above indexes between the two groups were analyzed and compared. A total of 64 young and middle-aged postoperative patients with cerebral hemorrhage were enrolled, including 32 cases in the UEEN group and 32 cases in the EEN group. There were no significant differences in gender, age, proportion of hypertension and diabetes, Glasgow coma score (GCS) on admission and surgical methods between the two groups. In terms of nutritional indexes, serum total protein, albumin and hemoglobin levels of patients in both groups on day 7 after admission were lower than those on day 1, and higher than those on day 3, and the above indexes levels in UEEN group were significantly higher than those in EEN group on day 7 [total protein (g/L): 63.05±5.79 vs. 59.02±6.63, albumin (g/L): 40.40±5.26 vs. 37.66±4.63, hemoglobin (g/L): 133.33±12.58 vs. 123.80±22.12, all P < 0.05]. In terms of gastrointestinal complications, the incidence of stress ulcer in the UEEN group within 14 days after admission was significantly lower than that in the EEN group [12.5% (4/32) vs. 31.3% (10/32), P < 0.05], but there was no statistically significant difference in feeding intolerance symptoms between the two groups. In terms of neurological recovery and long-term prognosis, GCS scores and Barthel index scores of 14 days after admission were higher than those of 1 day after admission, but there was no statistical significance between the two groups. Six months after surgery, Glasgow outcome scale (GOS) and Barthel index score of the UEEN group were significantly higher than those of the EEN group (GOS score: 3.81±1.06 vs. 3.18±1.07, Barthel index score: 60.78±7.24 vs. 54.52±5.13, both P < 0.05). UEEN support can improve the nutritional level of young and middle-aged postoperative patients with cerebral hemorrhage, reduce the occurrence of postoperative gastrointestinal complications, promote the recovery of neurological function, and improve the long-term prognosis.

The effect of different surgical methods and timing of surgery on the clinical efficacy in patients with hypertensive intracerebral hemorrhage in basal ganglia

Objective: To explore the effect of different surgical methods and timing on the clinical efficacy of patients with hypertensive intracerebral hemorrhage (HICH) in basal ganglia. Methods: A total of 200 patients with HICH in basal ganglia were divided into traditional craniotomy (TC) group, small bone window craniotomy (SBWC) group and neuroendoscopic minimally invasive surgery (NMIS) group. And they were also divided into ultra-early group, early group and delayed group, depending on the timing of surgery. The operation time, intraoperative blood loss, hematoma clearance rate and incidence of complications among different groups were recorded and analyzed. The National Institutes of Health Stroke Scale (NIHSS) and Glasgow outcome scale (GOS) were used to evaluate the neurological function and prognosis. Results: The NMIS group was superior to the TC group and SBWC group in terms of operation time, and intraoperative blood loss, hematoma clearance rate, complication 6-months NIHSS scores and the GOS scores (P&lt;0.05). There was no significant differences in operation time, intraoperative blood loss, hematoma clearance rate and complication among the ultra-early group, the early group and the delayed group (P&gt;0.05). While the ultra-early group was superior to the early group and the delayed group in terms of 6-month NIHSS scores and the GOS scores. Conclusion: NMIS could reduce the operation time, intraoperative blood loss, and complications, and improve the hematoma clearance rate and prognosis of patients with HICH in basal ganglia. And the ultra-early surgical treatment improved the prognosis of patients with IHCH in basal ganglia.

Changes of NLRP3 in serum and cerebrospinal fluid of patients after moderate to severe traumatic brain injury and their predictive values for prognosis.

Traumatic brain injury (TBI) remains a major concern for global health. Recent studies have suggested the role of NOD-like receptor pyrin domain-containing protein 3 (NLRP3), an inflammatory marker, in the cerebrospinal fluid (CSF) and serum as potential indicators of TBI prognosis. The objective of the study was to characterize NLRP3 as a clinically applicable tool for predicting the outcomes of TBI patients. A total of 270 patients with moderate to severe TBI were included in this retrospective analysis. Serum and CSF samples were collected at 1-, 3-, 7-, and 21-day post-injury to measure NLRP3 levels. The prognosis of patients was evaluated after 3 months using the Glasgow Outcome Scale (GOS). Patients were categorized into good prognosis (GOS score >3) and poor prognosis (GOS score ≤3) groups. The relationship between NLRP3 levels and prognosis was analyzed. Patients with poor prognosis had significantly elevated NLRP3 levels in their serum on days 1 and 3 post-injury compared with those with a good prognosis. The difference was more pronounced during these early days compared with days 7 and 21. However, NLRP3 levels in CSF consistently showed a large difference between the two groups throughout the observation period. Receiver operating characteristic analysis revealed that the level of NLRP3 in the CSF on day 3 post-injury had the highest predictive value for prognosis, with an area under the curve of 0.83, followed by the level of NLRP3 in the serum on day 3 post-injury. The levels of NLRP3, especially in the CSF on day 3 post-injury, can serve as a potential biomarker for predicting prognosis in moderate to severe TBI patients. Early measurement of NLRP3 levels can provide valuable insights into patient outcomes and guide therapeutic strategies.

Add-on homeopathic treatment to institutional management protocol in children suffering from acute encephalitis syndrome: A retrospective comparative cohort study

Background and objectives: Acute encephalitis syndrome is a health burden to a populous country like India. It is characterized by a sudden onset of fever, altered sensorium with or without seizures, irritability, abnormal behaviour, or unconsciousness. This study aims to augment further evidence on the effects of add-on homeopathic treatment in reducing mortality and morbidity in children. Methods: This comparative retrospective study included children hospitalized with acute encephalitis syndrome between July 2016 to December 2016. We compared the parameters of children for whom decisions on Glasgow Outcome scale and Liverpool outcome score aided by add-on homeopathy against those of children from the same year when the add-on homeopathy was not used. All the children were on conventional supportive care and treatment tailored to each child. We also counted the days until the resumption of oral feeding and the length of hospital stay. Results: Ordinal regression analysis on analyses on 622 children (IH +CSC=329; IMP only=293) was done. Odds of a shift towards increased recovery were superior in the homeopathy-added group than in the IMP group without adjustment (crude OR 2·30, 95% CI 1·66 to 3·20; p=0·0001) and with adjustment (adjusted OR 3.38, 95% CI 2·38 to 4.81; p=0·0001). There was 14.8% less mortality and 17.4% more recovery in the add-on homeopathy group compared to CSC alone. Individualized homeopathic remedies commonly used were: Belladonna (n =238), Stramonium (n =17), Opium (n = 14), Sulphur (n=11) and Hyoscyamus niger (n = 7). Conclusion : This retrospective cohort study advocates for add-on homoeopathy in children suffering acute encephalitis which can produce notable improvements in terms of mortality and morbidity. Further studies in different settings are warranted.

Feasibility Study of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage with Large Hematoma: a Comparison with Craniotomy Using Propensity Score Matching Analysis.

Spontaneous intracerebral hemorrhage (ICH) with large hematomas is commonly treated with craniotomy combined with decompressive craniectomy, procedures that involve huge trauma and require subsequent cranioplasty. Recently, endoscopic surgery has shown significant promise in treating ICH, but its feasibility for large hematomas remains uncertain. Therefore, this study aims to compare endoscopic surgery with craniotomy and to evaluate the efficacy and safety of endoscopic surgery in treating large hematomas ICH. A retrospective analysis was conducted on the clinical data from patients with spontaneous supratentorial ICH and hematoma volumes exceeding 50 mL who underwent either endoscopic surgery or craniotomy. Propensity score matching analysis was employed to reduce selection bias. The efficacy and safety of endoscopic surgery were evaluated by analyzing blood loss, postoperative edema, mortality rate, complications, and the Glasgow Outcome Scale (GOS) at 6-month follow-up. A total of 113 cases that met the criteria were collected, with 65 in the endoscopic surgery group and 48 in the craniotomy group. After propensity score matching, each group contained 34 cases. The mean hematoma volume was 64.84 ± 11.02 mL in the endoscopy group and 66.57 ± 12.77 mL in the craniotomy group (p = 0.554). Hematoma evacuation rates were 93.27% in the endoscopy group and 89.34% in the craniotomy group (p = 0.141). The endoscopy group exhibited lower blood loss, shorter surgical time, and reduced postoperative edema volume at 24 h compared to the craniotomy group. The rate of pulmonary infection was slightly lower in the endoscopy group compared to the craniotomy group (70.59% vs. 91.18%, p = 0.031), but there were no statistically significant differences in overall complications and mortality rate between the two groups. GOS scores were similar in both groups at the 6-month follow-up. Endoscopic surgery is safe and feasible for treating spontaneous supratentorial ICH with large hematomas, demonstrating efficacy similar to that of craniotomy with decompressive craniectomy.

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

IntroductionAcute subdural hemorrhage (ASDH) from traumatic brain injury is a life-threatening situation, often requiring surgical intervention. This meta-analysis is done to update the literature regarding the choice of procedure for the treatment of ASDH. MethodsPubMed, Scopus, and Cochrane were searched from the year 2000 up to September 2023. Randomized controlled trials and observational studies were included. The odds ratio with 95% confidence interval (CI) mean difference and standardized mean difference were calculated for dichotomous and continuous outcomes, respectively. ResultsA total of 14 studies comprising 4686 patients were included in the analysis. Pooled Glasgow Outcome Scale/Extended Glasgow Outcome Scale scores were compared based on their means, with the craniotomy (CO) group having better mean scores than decompressive craniectomy (DC) (standardized mean difference −0.37, 95% CI −0.68 to −0.06, P = 0.02). The risk for poor outcomes was statistically greater in the DC group compared to the CO group (1.32, 95% CI 1.05-1.66, P value = 0.02). There were fewer residual subdural hematoma cases in the DC group as compared to CO (odds ratio 0.40, 95% CI 0.22-0.73, P value < 0.005). ConclusionsOur meta-analysis showed that the ASDH patients had better functional outcomes when treated with CO as compared to DC. However, there were fewer odds of residual subdural hematoma with DC.

A two-center prospective cohort study of serum RIP-3 as a potential biomarker in relation to severity and prognosis after severe traumatic brain injury.

Receptor-interacting protein kinase-3 (RIP-3) is a key component for inducing necroptosis following acute brain injury. Purpose of this study is to unveil whether serum RIP-3 levels are related to severity and clinical outcomes after human severe traumatic brain injury (sTBI). In this two-center prospective cohort study, serum RIP-3 levels were detected in 127 healthy controls coupled with 127 sTBI patients. The prognostic indicators encompassed posttraumatic 180-day mortality, overall survival and poor prognosis (defined as extended Glasgow outcome scale scores of 1-4). The prognosis associations were verified via multivariate analysis. There was a significant incremental serum RIP-3 levels in patients with sTBI, relative to the controls. RIP-3 levels of patients were independently correlated with Rotterdam Computed Tomography (CT) scores and Glasgow coma scale (GCS) scores, as well as were independently predictive of mortality, overall survival and poor prognosis. Mortality and poor prognosis were effectively predicted by serum RIP-3 levels under the receiver operating characteristic curve. Linear relationships between RIP-3 levels and their risks were verified. Mortality and poor prognosis models of serum RIP-3 levels combined with GCS and Rotterdam CT scores displayed efficient predictive abilities. The two models were graphically represented, which were of clinical stability and value by employing the calibration and decision curves. Increased serum RIP-3 levels after sTBI are closely linked to heightened trauma severity and poor prognosis, signifying that serum RIP-3 may be an encouraging biomarker for evaluating severity and predicting clinical outcome of sTBI.

Comparative Analysis of Duroplasty Techniques in Decompressive Craniectomy: The CANDID Study.

At present, there is no consensus regarding the most optimal dural substitute to use for duroplasty in primary decompressive craniectomy (PDC) for traumatic brain injury (TBI). The author's objective was to conduct a retrospective analysis comparing 2 techniques of PDC: duroplasty using anterior-based vascularized galea pericranium (VP group) with synthetic dural substitute duroplasty (SR group). From April 2015 to February 2022, 379 craniotomies were done for TBI. The outcome of eligible 97 consecutive patients receiving PDC treatment were examined. Out of 97, 60 received vascularized galea pericranium and 37 received synthetic dural graft for dural augmentation. Propensity matching generated 28 pairs (56 patients) for analysis. The primary outcome was extended Glasgow Outcome Scale (GOS-E) measured at 6 months after injury. Secondary outcomes included were incidence of surgical complications (neurosurgical site infections, and hemorrhagic and hydrodynamic complications), surgical time, days in intensive care unit, hospital length of stay, hospital mortality, and GOS-E at 1 year after injury. Patients in VP group, compared with those in SR group had better GOS-E score at 6 months (P = .011) and 1 year (P = .026). Hospital mortality (P = .342), days in intensive care unit (P = .574), hospital stay (P = .155), surgical time (P = .131), medical and surgical complications including neurosurgical infections, and hemorrhagic and hydrodynamic complications did not differ significantly in both groups. Complication of brain abscess was found exclusively in the SR group (P = .327). In this retrospective study, adults who underwent PDC for TBI using anterior-based vascularized galea pericranial graft were associated with better clinical outcomes at 6 months and 1 year compared with standard repair group using synthetic dural substitute (G patch).

Outcomes and Mechanisms Associated With Selective Thalamic Neuronal Loss in Chronic Traumatic Brain Injury

The chronic neuronal burden of traumatic brain injury (TBI) is not fully characterized by routine imaging, limiting understanding of the role of neuronal substrates in adverse outcomes. To determine whether tissues that appear healthy on routine imaging can be investigated for selective neuronal loss using [11C]flumazenil (FMZ) positron emission tomography (PET) and to examine whether this neuronal loss is associated with long-term outcomes. In this cross-sectional study, data were collected prospectively from 2 centers (University of Cambridge in the UK and Weill Cornell Medicine in the US) between September 1, 2004, and May 31, 2021. Patients with TBI (>6 months postinjury) were compared with healthy control participants (all aged >18 years). Individuals with neurological disease, benzodiazepine use, or contraindication to magnetic resonance imaging were excluded. Data were retrospectively collated with nonconsecutive recruitment, owing to convenience and scanner or PET ligand availability. Data were analyzed between February 1 and September 30, 2023. Flumazenil voxelwise binding potential relative to nondisplaceable binding potential (BPND). Selective neuronal loss identified with FMZ PET was compared between groups on voxelwise and regional scales, and its association with functional, cognitive, and psychological outcomes was examined using Glasgow Outcome Scale (GOS) scores, measures of sustained executive attention (animal and sustained fluency), and 36-Item Short Form Health Survey (SF-36) scores. Diffusion tensor imaging was used to assess structural connectivity of regions of cortical damage, and its association with thalamic selective neuronal loss. In this study, 24 patients with chronic TBI (mean [SD] age, 39.2 [12.3] years; 18 men [75.0%]) and 33 healthy control participants (mean [SD] age, 47.6 [20.5] years; 23 men [69.7%]) underwent FMZ PET. Patients with TBI had a median time of 29 (range, 7-95) months from injury to scan. They displayed selective neuronal loss in thalamic nuclei, over and above gross volume loss in the left thalamus, and bilateral central, mediodorsal, ventral-lateral dorsal, anterior, and ventral anterior thalamic nuclei, across a wide range of injury severities. Neuronal loss was associated with worse functional outcome using GOS scores (left thalamus, left ventral anterior, and bilateral central, mediodorsal, and anterior nuclei), worse cognitive outcome on measures of sustained executive attention (left thalamus, bilateral central, and right mediodorsal nuclei), and worse emotional outcome using SF-36 scores (right central thalamic nucleus). Chronic thalamic neuronal loss partially mirrored the location of primary cortical contusions, which may indicate secondary injury mechanisms of transneuronal degeneration. The findings of this study suggest that selective thalamic vulnerability may have chronic neuronal consequences with relevance to long-term outcome, suggesting the evolving and potentially lifelong thalamic neuronal consequences of TBI. FMZ PET is a more sensitive marker of the burden of neuronal injury than routine imaging; therefore, it could inform outcome prognostication and may lead to the development of individualized precision medicine approaches.

A nomogram model for predicting postoperative prognosis in patients with aneurysmal subarachnoid hemorrhage using preoperative biochemical indices

ObjectiveThe nutritional status and inflammatory responses of patients with aneurysmal subarachnoid hemorrhage (aSAH) play a vital prognostic role. We investigated the relationship between preoperative prognostic nutritional index (PNI)、neutrophil/albumin ratio (NAR)、platelet/albumin ratio (PAR) and other factors and the clinical prognosis of patients who underwent clipping for aSAH and its predictive model.MethodsThe clinical data of 212 patients with aSAH who underwent neurosurgery at Nanyang Central Hospital between 2018 and 2023 were retrospectively analyzed. Based on the Glasgow Outcome Scale (GOS) score at 6 months postoperatively, the patients were categorized into two groups: poor (GOSI-III) and good (GOSIV-V) prognosis groups. Multivariate logistic regression analysis was performed to determine the predictive value of preoperative PNI、NAR、PAR、hyperlipidemia and Glasgow Coma Scale (GCS) for prognosis. Furthermore, nomograms and prognostic prediction models were constructed. Receiver operating characteristic curves and area under the curve (AUC) were utilized to determine the predictive values.ResultsMultivariate logistic regression analysis revealed that PNI (OR = 1.250, 95%CI 1.060 ~ 1.475, P = 0.008), NAR (OR = 0.000, 95%CI 0.000 ~ 0.004, P = 0.000), PAR(OR = 0.515, 95%CI 0.283 ~ 0.937, P = 0.030), hyperlipidemia (OR = 4.627, 95%CI 1.166 ~ 18.367, P = 0.029), and GCS(OR = 1.446, 95%CI 1.041 ~ 2.008, P = 0.028) are independent risk factors for poor postoperative prognosis. The total score of the nomogram was 200, and the AUC value was 0.972.ConclusionsPNI and NAR can reflect the nutritional status and inflammatory responses of patients.They are significantly associated with the postoperative prognosis of patients with aSAH. Comprehensively analyzing PNI and NAR combined with other clinical indicators can more effectively guide treatment and help predict prognosis.

Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis.

Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.