Mean Glasgow Outcome Scale Score Research Articles

Improved Precision and Safety of Supra-Tentorial Intracranial Hematoma Puncture Using C-Arm CT Four-Dimensional Navigation.

BACKGROUND Spontaneous intracerebral hemorrhage has a high fatality rate within the initial month after onset. This study determined the safety and therapeutic efficacy of minimally invasive puncture for supra-tentorial intracranial hematoma under C-arm computed tomography (CT) 4-dimensional navigation. MATERIAL AND METHODS We retrospectively analyzed 64 patients with supra-tentorial cerebral hemorrhage from June 2020 to May 2023; 31 patients were assigned to the study group (C-arm CT navigation puncture) and 33 patients were in the control group (conventional CT-guided puncture). The analysis focused on assessment of puncture error, postoperative complication rate, and the Glasgow Outcome Scale (GOS) and National Institute of Health Stroke Scale (NIHSS) scores 30 and 90 days after surgery. RESULTS C-arm CT navigation puncture had improved precision, with significantly reduced transverse (3.17±1.75 mm) and longitudinal (1.83±1.21 mm) deviations, compared with the control group (7.88±1.74 mm and 5.50±1.84 mm, respectively; P<0.05). The overall postoperative complication rate was significantly lower in the study group than in the control group (12.90% vs 36.36%, P<0.05). The mean GOS score was higher in the study group than in the control group 30 and 90 days postoperatively (3.42±0.96 and 3.97±0.95 vs 2.94±0.79 and 3.46±0.90, respectively; P<0.05), while the mean NIHSS score was lower in the study group than in the control group 30 and 90 days postoperatively (10.58±6.52 and 5.97±4.55 vs 14.42±8.13 and 9.55±8.31, respectively; P<0.05). CONCLUSIONS Supra-tentorial intracranial hematoma puncture under C-arm CT 4-dimensional navigation is accurate, safe, and beneficial.

IV Flat Detector CT Angiography in Flat Detector CT Image-Guided Minimally Invasive Surgery for the Treatment of Intracerebral Hypertensive Hemorrhage.

Spontaneous intracerebral hemorrhage is a serious stroke subtype with high mortality and morbidity. Minimally invasive surgery plus thrombolysis is a promising treatment option, but it requires accurate catheter placement and real-time monitoring. The authors introduced IV flat detector CT angiography (ivFDCTA) into the minimally invasive surgery procedure for the first time, to provide vascular information and guidance for hematoma evacuation. Thirty-six patients with hypertensive intracerebral hemorrhage were treated with minimally invasive surgery under the guidance of ivFDCTA and flat detector CT (FDCT) in the angiography suite. The needle path and puncture depth were planned and calculated using software on the DSA workstation. The hematoma volume reduction, operation time, complications, and clinical outcomes were recorded and evaluated. The mean preoperative hematoma volume of 36 patients was 35 (SD, 12) mL, the mean intraoperative volume reduction was 19 (SD, 11) mL, and the mean postoperative residual hematoma volume was 15 (SD, 8) mL. The average operation time was 59 (SD, 22) minutes. One patient had an intraoperative epidural hematoma, which improved after conservative treatment. The mean Glasgow Outcome Scale score at discharge was 4.3 (SD, 0.8), and the mean mRS score at 90 days was 2.4 (SD, 1.1). The use of ivFDCTA in the evacuation of an intracerebral hemorrhage hematoma could improve the safety and efficiency of minimally invasive surgery and has shown great potential in hemorrhagic stroke management in selected patients.

Safe and time-saving treatment method for acute cerebellar infarction: Navigation-guided burr-hole aspiration - 6-years single center experience.

While patients with medically intractable acute cerebellar infarction typically undergo suboccipital craniectomy and removal of the infarcted tissue, this procedure is associated with long operating times and postoperative complications. This study aimed to investigate the effectiveness of minimally invasive navigationguided burr hole aspiration surgery for the treatment of acute cerebellar infarction. Between January 2015 and December 2021, 14 patients with acute cerebellar infarction, who underwent navigation-guided burr hole aspiration surgery, were enrolled in this study. The preoperative mean Glasgow Coma Scale (GCS) score was 12.7, and the postoperative mean GCS score was 14.3. The mean infarction volume was 34.3 cc at admission and 23.5 cc immediately following surgery. Seven days after surgery, the mean infarction volume was 15.6 cc. There were no surgery-related complications during the 6-month follow-up period and no evidence of clinical deterioration. The mean operation time from skin incision to catheter insertion was 28 min, with approximately an additional 13 min for extra-ventricular drainage. The mean Glasgow Outcome Scale score after 6 months was 4.8. Navigation-guided burr hole aspiration surgery is less time-consuming and invasive than conventional craniectomy, and is a safe and effective treatment option for acute cerebellar infarction in selected cases, with no surgery-related complication.

A Prospective Comparative Evaluation of Surgery and Conservative Treatment for Compound Depressed Skull Fractures

The Brain Trauma Foundation issued level III evidence guidelines for surgical management of compound depressed fractures. However, some patients undergo successful conservative treatment. This study compares these 2 treatment modalities. This prospective study included 67 patients with compound depressed skull fractures with surgical indications and a minimum follow-up of 6 months. Depressed fractures in front of the hairline (operated on for cosmetic reasons) and associated with significant intracranial injuries were excluded. Those who gave consent for surgery were included in the surgical group, and those who denied were included in the conservative group. The surgical group had 38 patients and the conservative group had 29. Both groups were comparable in mean age, gender, Glasgow Coma Scale score, head injury severity, depth of fractures, and follow-up duration. Focal neurologic deficits were observed in 19 patients at presentation and were higher in the surgical group. Mean hospital stay was significantly shorter in the conservative group. Mean Glasgow Outcome Scale score at follow-up was statistically similar in both groups (P= 0.13). Focal neurologic deficits improved equally in both groups (P= 0.67). The severity of traumatic brain injury (P= 0.004) and the presence of focal neurologic deficits (P < 0.001) affected the neurologic outcomes. The age, gender, mode of treatment (surgery vs. conservative), surgical site infections, and seizures did not affect neurologic outcomes. The overall complication rates were similar among groups (P= 0.50). New-onset focal neurologic deficits, seizures, and infection rates were not significantly different among the groups (P= 0.98, P= 0.72, P= 0.69). Conservative management has equivalent neurologic outcomes and complications compared with surgical management.

Giant Pediatric Supratentorial Tumor: Clinical Feature and Surgical Strategy.

PurposeTo analyze the clinical character of giant pediatric supratentorial tumor (GPST) and explore prognostic factors.Materials and MethodsWe analyzed the clinical data comprising of 35 cases of GPST from a single center between January 2015 and December 2020. The tumor volume was measured by 3D slicer software based on preoperative magnetic resonance imaging (MRI). Glasgow Outcome Scale (GOS) was used to evaluate the short-term prognosis.ResultThe tumor volume varied from 27.3 to 632.8 ml (mean volume 129.8 ml/ median volume 82.8 ml). Postoperative histopathological types include ependymoma, pilocytic astrocytoma, choroid plexus papilloma (CPP), craniopharyngioma, primitive neuroectoderm tumor (PNET), choroid plexus carcinoma (CPC), immature teratoma, atypical teratoid rhabdoid tumor (AT/RT), anaplastic astrocytoma, and gangliocytoma. Tumors in children younger than 3 years and tumors located at the hemispheres appeared to be larger than their respective counterparts, though no statistical significance was found. A patient with giant immature teratoma died during the operation because of excessive bleeding. Postoperative complications include cerebrospinal fluid subgaleal collection/effusion, infection, neurological deficits, and seizures. The mean GOS score of patients with GPST in 6 months is 3.43 ± 1.12, and 83% of patients (29/35) showed improvement. Favorable GPST characteristics to indicated better GOS included small tumor (≤100 ml) (p = 0.029), low-grade (WHO I-II) (p = 0.001), and gross total resection (GTR) (p = 0.015). WHO grade was highly correlated with GOS score (correlation coefficient = −0.625, p < 0.001). GTR and tumor volume were also correlated (correlation coefficient = −0.428, p = 0.010).ConclusionThe prognosis of GPST is highly correlated with the histopathological type. Smaller tumors are more likely to achieve GTR and might lead to a higher GOS score. Early diagnosis and GTR of the tumor are important for GPST management.

A Comprehensive Analysis of the Association of Psoas and Masseter Muscles with Traumatic Brain Injury Using Computed Tomography Anthropometry.

ObjectivePsoas and masseter muscles are known markers of sarcopenia. However, the relative superiority of either muscle as a marker is unclear. Therefore, this study analyzed the two muscles in patients with a prognosis of traumatic brain injury (TBI). MethodsPatients with TBI visiting a regional trauma center between January 2017 and December 2018 were selected, and their medical records were reviewed. TBI patients with an abbreviated injury score (AIS) of 4 or 5 were selected. Patients with an AIS of 4 or 5 at the chest, abdomen, and extremity were excluded. Patients with a hospital stay of 1 to 2 days were excluded. Both muscle areas were measured based on the initial computed tomography. The psoas muscle index (PMI) and the masseter muscle index (MMI) were calculated by dividing both muscle areas by height in meters squared (cm2/m2). These muscle parameters along with other medical information were used to analyze mortality and the Glasgow outcome scale (GOS). ResultsA total of 179 patients, including 147 males (82.1%), were analyzed statistically. The mean patient age was 58.0 years. The mortality rate was 16.8% (30 patients). The mean GOS score was 3.7. Analysis was performed to identify the parameters associated with mortality, which was a qualitative study outcome. The psoas muscle area (16.9 vs. 14.4 cm2, p=0.028) and PMI (5.9 vs. 5.1 cm2/m2, p=0.004) showed statistical differences between the groups. The PMI was also statistically significant as a risk factor for mortality in logistic regression analysis (p=0.023; odds ratio, 0.715; 95% confidence interval, 0.535–0.954). Quantitative analyses were performed with the GOS scores. Bivariate correlation analysis showed a statistically significant correlation between PMI and GOS scores (correlation coefficient, 0.168; p=0.003). PMI (p=0.004, variation inflation factor 1.001) was significant in multiple regression analysis. The masseter muscle area and MMI did not show significance in the study. ConclusionLarger PMI was associated with statistically significant improved survival and GOS scores, indicating its performance as a superior prognostic marker. Further analyses involving a larger number of patients, additional parameters, and more precise settings would yield a better understanding of sarcopenia and TBI.

Computed Tomography–Guided Catheter Aspiration and Thrombolysis of Hypertensive Basal Ganglionic Hematomas: Technique and Short-Term Outcome Comparison

Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes compared to open surgical evacuation. However, there is a dearth of literature in developing nations. The objective in this study was to evacuate spontaneous hypertensive basal ganglionic hemorrhages using computed tomography (CT)-guided catheter insertion, hematoma aspiration, and lysis with thrombolytic agents and analyze the efficacy and outcomes. Ten patients with spontaneous basal ganglionic hemorrhage underwent CT-guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25,000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiologic findings, efficacy of the technique, functional outcomes during follow-up, length of stay, and cost were recorded. Relevant details for 12 age- and sex-matched conservatively treated patients were compared. Functional outcome in the catheter group at 6 months was better than the medically managed group, with improved mean Glasgow Outcome Scale score (0.4 vs. 0.08), reduced modified Rankin scale score (-0.8 vs.-0.25), and reduced National Institutes of Health Stroke Scale score (-6.8 vs.-1.5 points). However, it was not statistically significant. Average hematoma volume reduction in the catheter group was 83.14%. In the medically managed group, 2 of 12 patients (16.6%) had hematoma expansion, 6 patients (50%) developed hydrocephalus, and 2 patients (16.6%) died. In the catheter group, 4 of 10 patients (40%) developed mild pneumocephalus that resolved. The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources (e.g., CT scan) with improved functional outcome compared with conservative treatment alone.

Prehospital Conditions and Outcomes After Craniotomy for Traumatic Brain Injury Performed Within 72 Hours in Central Cameroon: A Cross-Sectional Study

Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but <40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon. This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery >72 hours after injury were excluded. Analyses of covariance were performed, and a P value >0.05 was considered significant. A Kaplan-Meier survival curve was computed. The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted <3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4. Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes.

Comparison of Two Endovascular Interventions with Low-Profile Visualized Intraluminal Support or Pipeline Embolization Device in Middle Cerebral Arterial Aneurysms Patients

Purpose/Aim This study aims to compare efficacy and safety of Low-profile Visualized Intraluminal Support (LVIS) stent and Pipeline Embolization Device (PED)-assisted endovascular interventions in patients with middle cerebral arterial aneurysms. Materials and methods This retrospective study included a total of 144 MCA patients, who went to our hospital from January 2013 to December 2017. These patients were divided into two groups: LVIS group, 81 cases; PED group, 63 cases. Then, the basic clinical characteristics were collected. The Raymond grade was used to evaluate the embolism immediately after the surgery and at six months after surgery. The Glasgow Outcome Scale (GOS) and modified Rankin scale were used at six months after surgery, and the recurrence rate was also recorded. Results The mean aneurysm diameter was 7.7 ± 5.1, which range from 2-25 mm. There were 25 cases with ruptured aneurysms. The results revealed that 57 (70.4%) cases in the LVIS group and 41 (65.1%) cases in the PED group presented with complete embolisms immediately after the surgery. The mean GOS score after six months was 4.6 ± 0.9 in the LVIS group and 4.6 ± 0.9 in the PED group. Furthermore, a total of 86.4% cases had a good prognosis in the LVIS group, while 87.3% cases had a good prognosis in the PED group. Moreover, recurrence was found in six (7.4%) cases in the LVIS group and in five (7.9%) cases in the PED group. Conclusion Both these two methods are effective and safe, with a high good prognosis rate and low recurrence. However, there was no significant difference between the PED and LVIS stent methods.

Treatment of traumatic intracranial aneurysm: Experiences at a single center

ObjectiveTo report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China. Patients and methodsAll patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998. ResultsA total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture. ConclusionAlthough the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.

Outcomes of microsurgical clipping vs coil embolization for ruptured aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a complex neurovascular syndrome with high disability and mortality. SAH patients may be managed with surgical clipping or coil embolization. In this study, we provided a real-world analysis of the outcome and prognostic factors of aneurysmal SAH in patients treated with coil embolization or microsurgical clipping.We retrospectively analyzed the medical records of aneurysmal SAH patients (n = 583) who underwent treatment at the First Hospital and the Second Hospital of Hebei Medical University, and Tangshan Worker's Hospital in China. All patients were evaluated by a combined neurosurgery and interventional neuroradiology team. Microsurgical aneurysmal clipping was performed using the skull base approach, while coil embolization was performed with bare platinum coils (with or without balloon assistance). The primary outcome was the Glasgow Outcome Scale (GOS) score at discharge.A total of 583 patients were included in this study, of which 397 (68.1%) of them underwent clipping and 186 (31.9%) received coil embolization. The patient cohort consisted of both poor grade and good grade aneurysmal SAH: 441 (75.6%) patients had good-grade (Hunt and Hess grade II or III) and 142 (24.4%) had poor grade (Hunt and Hess grade IV or V). Overall, 123 (21%) patients had unfavorable neurologic outcome (GOS score 1–3) and 460 (78.9%) patients had favorable neurologic outcome (GOS score 4 or 5). The mean GOS score at discharge was comparable for patients who underwent clipping and those received coil embolization (P > .05). Multivariate analysis showed that clipping only [OR (95%CI): 0.03 (0.01, 0.36); P = .000] and clipping with CSF drainage [OR (95%CI): 0.41 (0.18, 0.89); P = .001] were independent factors of a favorable outcome in patients with aneurysmal SAH. Coil embolization with hematoma removal [OR (95%CI): 0.03 (0.01, 0.36); P = .000] was also an independent determinant of a favorable outcome. High baseline Fisher grades were associated with significantly increased risk of an unfavorable outcome [OR (95%CI): 2.08 (1.30, 3.33); P = .002].Our findings suggested that both coil embolization and microsurgical clipping are viable treatment options for aneurysmal SAH patients. Procedures, such as CSF drainage and hematoma removal, performed in parallel with coil embolization and chipping should be considered when treating individual patients.

Microsurgical Management of Fourth Ventricle Astrocytoma via Median Suboccipital Keyhole Approach: Review of 12 Cases

To investigate the clinical effect and surgical techniques of fourth ventricle astrocytoma resection through the median suboccipital keyhole approach. Twelve patients received tumor resection through the median suboccipital keyhole approach in our department. A 4-cm median suboccipital excision starting 1 cm under the foramen magnum region and directed vertically upward was applied. The fourth ventricle was exposed through a cerebellomedullary fissure approach within a bone hole ≈2.5 cm in diameter. All clinical data (including preoperative/postoperative symptoms, magnetic resonance imaging scan, intraoperative findings, tumor resection rate, and surgical complications) were collected and analyzed. In our treatment group, the mean maximum tumor diameter was 3.48 ± 1.3 cm and the mean tumor volume was 34.79 ± 20.70 cm3. The complete resection rate was 92%. The average operative blood loss was 127.0 ± 24.6 mL; the mean craniotomy time was 26.4 ± 6.0 minutes; the mean tumor resection time was 190.3 ± 31.2 minutes; the mean cranial closure time was 42.3 ± 6.1 minutes; and the average hospitalization time was 13.6 ± 2.4 days. The mean Glasgow Outcome Scale score before discharge was 4.92. If appropriate microneurosurgical techniques are used via the median suboccipital keyhole approach, the fourth ventricle astrocytoma may be accessed and resected safely with shorter surgery time, reduced hemorrhage during operation, low incidence of postoperative complications, good recovery, and shorter hospitalization time.

The Special Considerations in the Surgical Management of Proximal Anterior Cerebral Artery Aneurysms

Proximal anterior cerebral artery (A1) aneurysms are difficult to clip because of their frequent proximity to perforators, location behind the parent artery, or adherence to surrounding structures. We retrospectively reviewed a consecutive series of patients with A1 aneurysms and report the clinical status, radiologic findings, treatment methods, and outcome. This series included 19 male and 12 female patients with a mean age of 50 years. The morphology of the A1 aneurysms was fusiform in 2 patients and saccular in the remaining 29 patients. Multiple aneurysms were presented in 9 patients (29.0%). On admission, 26 patients (83.9%) presented with subarachnoid hemorrhage, 3 of whom had an additional intracerebral hematoma. All surgeries were performed with a standard pteriomal craniotomy. The mean Glasgow Outcome Scale score at final follow-up was 4.8 (interquartile range, 5, 5), with 26 patients (83.9%) rated as 5. The mean follow-up time was 38.5 months (range, 12-60 months). A1 aneurysms are rare but have their own complex characteristics and are difficult to treat. Meticulous analysis of the relevant angiographs is needed for their diagnosis. An important consideration in surgery is the preservation of perforators and prevention of rupture. Wide opening of the sylvian fissure and temporary control of the parent artery can facilitate dissection of the A1 aneurysms dome. Multiple intraoperative monitoring methods, such as microvascular Doppler ultrasonography and somatosensory and motor evoked potential monitoring, can reduce the relevant complications of surgery.

Mechanical Recanalization Using Solitaire AB Device for Severe Thromboembolic Events in Endovascular Treatment of Intracranial Aneurysms.

Severe thromboembolism with complete occlusion of the proximal arteries during or after coil embolization can cause serious neurologic deficits. The study aimed to assess the effectiveness and safety of Solitaire AB device as a rescue therapy for severe thromboembolic complications in the endovascular treatment of intracranial aneurysms. Between February 2013 and April 2016, 1047 intracranial aneurysms treated with endovascular procedures were retrospectively reviewed in our center. Severe thromboembolisms occurred in ten patients and were treated by Solitaire AB device including clot retriever and permanent stent deployment. The location of arterial occlusion was distal to the aneurysm rather than the coil/parent artery interface or in-stent area. Four patients had distal thromboembolic events before coil embolization, and six patients had it after coiling. The complete arterial recanalization (TICI 3) was achieved in all patients, and no cerebral hemorrhage was related to the procedure after the rescue therapy. Among these patients with the aforementioned neurovascular procedures, the mean Glasgow Outcome Scale (GOS) score was 4.5 (ranging 3-5) and eight cases had good outcome with a score of GOS 4-5 at discharge, while eight patients presented mRS ≤2 at 3-month follow-up. These results demonstrate that mechanical recanalization using Solitaire AB device seems to be effective and safe as a rescue therapy for severe thromboembolic events during cerebral aneurysm embolization.

Role of Magnetic Resonance Imaging in Unconscious Patients due to Diffuse Axonal Injury and Its Prognostic Value

Aim To study the long-term prognostic value of early magnetic resonance imaging (MRI) in unconscious patients with traumatic brain injury with findings of NCCT of the brain suggestive of diffuse axonal injury (DAI). Background Studies addressing the correlation of MRI with the pattern and duration of loss of consciousness due to DAI are few. The utility of MRI in predicting the functional outcome has not been reported in the Indian population. Materials and Methods In patients with DAI, MRI sequences including T1, T2*GRE (gradient recall echo), fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and susceptibility-weighted imaging (SWI) were obtained. Glasgow coma scale (GCS) and Glasgow outcome scale (GOS) scores were documented at admission, on discharge, and at 3 months. Results A total of 54 patients (53 males, 1 female) were included in the study. The mean age was 27 ± 11.7 years. The mean GCS score on admission and at follow-up were 9.14 ± 2.3 and 11.7 ± 2.3, respectively. The mean GOS score on discharge and at 3 months were 2.6 ± 0.8 and 3.18 ± 1.02, respectively. SWI sequence detected maximum number of lesions followed by GRE and DWI. Patients with lesions in brainstem and basal ganglia were found to have a less favorable outcome as assessed by GCS and GOS at 3 months. There was no correlation between the total lesion load and outcome at 3 months. Conclusion In patients with DAI, SWI was found to be the most sensitive MRI sequence detecting maximum number of lesions. Patients with lesions in the brainstem and basal ganglia appear to have longer duration of unconsciousness and poorer outcome at 3 months.

Techniques and outcomes of microsurgical management of ruptured and unruptured fusiform cerebral aneurysms.

OBJECTIVE Fusiform cerebral aneurysms represent a small portion of intracranial aneurysms; differ in natural history, anatomy, and pathology; and can be difficult to treat compared with saccular aneurysms. The purpose of this study was to examine the techniques of treatment of ruptured and unruptured fusiform intracranial aneurysms and patient outcomes. METHODS In 45 patients with fusiform aneurysms, the authors retrospectively reviewed the presentation, location, and shape of the aneurysm; the microsurgical technique; the outcome at discharge and last follow-up; and the change in the aneurysm at last angiographic follow-up. RESULTS Overall, 48 fusiform aneurysms were treated in 45 patients (18 male, 27 female) with a mean age of 49 years (median 51 years; range 6 months-76 years). Twelve patients (27%) had ruptured aneurysms and 33 (73%) had unruptured aneurysms. The mean aneurysm size was 8.9 mm (range 6-28 mm). The aneurysms were treated by clip reconstruction (n = 22 [46%]), clip-wrapping (n = 18 [38%]), and vascular bypass (n = 8 [17%]). The mean (SD) hospital stay was 19.0 ± 7.4 days for the 12 patients with subarachnoid hemorrhage and 7.0 ± 5.6 days for the 33 patients with unruptured aneurysms. The mean follow-up was 38.7 ± 29.5 months (median 36 months; range 6-96 months). The mean Glasgow Outcome Scale score for the 12 patients with subarachnoid hemorrhage was 3.9; for the 33 patients with unruptured aneurysms, it was 4.8. No rehemorrhages occurred during follow-up. The overall annual risk of recurrence was 2% and that of rehemorrhage was 0%. CONCLUSIONS Fusiform and dolichoectatic aneurysms involving the entire vessel wall must be investigated individually. Although some of these aneurysms may be amenable to primary clipping and clip reconstruction, these complex lesions often require alternative microsurgical and endovascular treatment. These techniques can be performed with acceptable morbidity and mortality rates and with low rates of early rebleeding and recurrence.

Outcome After Decompressive Craniectomy in Different Pathologies

We compare the outcome after decompressive craniectomy for various neurologic diseases with the final common pathway of coma, compression of the basal cisterns, a midline shift, or refractory intracranial hypertension. Between January 2005 and June 2009, 134 patients underwent decompressive craniectomy for traumatic brain injury (n= 74), intracerebral hemorrhage (n=21), spontaneous subarachnoid hemorrhage (n= 11), malignant cerebral infarction (n= 27), or encephalitis (n= 1). The outcome was classified at discharge and up to 12 months after treatment in accordance with the Glasgow Outcome Scale (GOS), as well as the Glasgow Coma Scale, Marshall classification, or National Institutes of Health Stroke Scale. Significance was established as P ≤ 0.05. Median and mean scores on the Glasgow Coma Scale at time of neurosurgical assessment in all patients were ≤7. Midline shift was reduced in each subset as a result of surgery (mean, 0.26-0.46 cm; P ≤ 0.049). Overall outcome based on the median GOS score at discharge ranged from death to severe disability. After 12 months, the median range narrowed to a range of death to persistent vegetative state. At various time points, mean GOS score was not found to differ significantly between the subsets. Unfavorable outcome after 3 months was found in a smaller group of patients after traumatic brain injury than was found in patients with other diseases (P= 0.016). The outcome after decompressive craniectomy does not differ significantly in different diseases once the final pathophysiologic pathway of refractory intracranial hypertension, coma, compression of the basal cisterns, or midline shift has been reached.

Techniques and Outcomes of Gore-Tex Clip-Wrapping of Ruptured and Unruptured Cerebral Aneurysms

Some aneurysms without a definable neck and associated parent vessel pathology are particularly difficult to treat and may require clipping with circumferential wrapping. We report the largest available contemporary series examining the techniques of Gore-Tex clip-wrapping of ruptured and unruptured intracranial aneurysms and patient outcomes. The presentation, location, and shape of the aneurysm; wrapping technique; outcome at discharge and last follow-up; and any change in the aneurysm at last angiographic follow-up were reviewed retrospectively in 30 patients with Gore-Tex clip-wrapped aneurysms. Gore-Tex clip-wrapping was used in 8 patients with ruptured aneurysms and 22 patients with unruptured aneurysms. Aneurysms included 23 fusiform, 3 blister, and 4 otherwise complex, multilobed, or giant aneurysms. Of the 30 aneurysms, 63% were in the anterior circulation. The overall mean patient age was 52.5 years (range, 17-80 years). Postoperatively, there were no deaths or worsening of neurologic status and no parent vessel stenoses or strokes. The mean Glasgow Outcome Scale score at last follow-up was 4.7. The mean follow-up time was 42.3 months (median, 37.0 months; range, 3-96 months). There were 105.8 patient follow-up years. Aneurysms recurred in 2 patients with Gore-Tex clip-wrapping. No patients developed rehemorrhage. Overall risk of recurrence was 1.9% annually. Gore-Tex has excellent material properties for circumferential wrapping of aneurysms and parent arteries. It is inert and does not cause a tissue reaction or granuloma formation. Gore-Tex clip-wrapping can be used safely for microsurgical management of ruptured and unruptured cerebral aneurysms with acceptable recurrence and rehemorrhage rates.

Techniques and long-term outcomes of cotton-clipping and cotton-augmentation strategies for management of cerebral aneurysms.

OBJECTIVE To address the challenges of microsurgically treating broad-based, frail, and otherwise complex aneurysms that are not amenable to direct clipping, alternative techniques have been developed. One such technique is to use cotton to augment clipping ("cotton-clipping" technique), which is also used to manage intraoperative aneurysm neck rupture, and another is to reinforce unclippable segments or remnants of aneurysm necks with cotton ("cotton-augmentation" technique). This study reviews the natural history of patients with aneurysms treated with cotton-clipping and cotton-augmentation techniques. METHODS The authors queried a database consisting of all patients with aneurysms treated at Barrow Neurological Institute in Phoenix, Arizona, between January 1, 2004, and December 31, 2014, to identify cases in which cotton-clipping or cotton-augmentation strategies had been used. Management was categorized as the cotton-clipping technique if cotton was used within the blades of the aneurysm clip and as the cotton-clipping technique if cotton was used to reinforce aneurysms or portions of the aneurysm that were unclippable due to the presence of perforators, atherosclerosis, or residual aneurysms. Data were reviewed to assess patient outcomes and annual rates of aneurysm recurrence or hemorrhage after the initial procedures were performed. RESULTS The authors identified 60 aneurysms treated with these techniques in 57 patients (18 patients with ruptured aneurysms and 39 patients with unruptured aneurysms) whose mean age was 53.1 years (median 55 years; range 24-72 years). Twenty-three aneurysms (11 cases of subarachnoid hemorrhage) were treated using cotton-clipping and 37 with cotton-augmentation techniques (7 cases of subarachnoid hemorrhage). In total, 18 patients presented with subarachnoid hemorrhage. The mean Glasgow Outcome Scale (GOS) score at the time of discharge was 4.4. At a mean follow-up of 60.9 ± 35.6 months (median 70 months; range 10-126 months), the mean GOS score at last follow-up was 4.8. The total number of patient follow-up years was 289.4. During the follow-up period, none of the cotton-clipped aneurysms increased in size, changed in configuration, or rebled. None of the patients experienced early rebleeding. The annual hemorrhage rate for aneurysms treated with cotton-augmentation was 0.52% and the recurrence rate was 1.03% per year. For all patients in the study, the overall risk of hemorrhage was 0.35% per year and the annual recurrence rate was 0.69%. CONCLUSIONS Cotton-clipping is an effective and durable treatment strategy for intraoperative aneurysm rupture and for management of broad-based aneurysms. Cotton-augmentation can be safely used to manage unclippable or partially clipped intracranial aneurysms and affords protection from early aneurysm re-rupture and a relatively low rate of late rehemorrhage.

The Effectiveness of Subdural Drains Using Urokinase after Burr Hole Evacuation of Subacute Subdural Hematoma in Elderly Patients: A Prelimilary Report.

ObjectiveA subdural drain using urokinase after a burr hole hematoma evacuation was performed for subacute subdural hematoma (SASDH), and its effectiveness and safety in elderly patients were evaluated.MethodsBetween January 2013 and May 2015, subdural drains using urokinase after burr hole hematoma evacuation were performed in 19 elderly patients. The inclusion criteria were as follows: 1) a subdural hematoma occurring between 4 and 20 days after injury; 2) worsening neurological symptoms, from mild to moderate or severe, due to injury during the subacute stage; 3) a mix of solid clots (high-density lighter shadow) and fluid hematoma (low-density darker shadow) on the computed tomography (CT) scan; 4) a score of ≥9 on the Glasgow Coma Scale (GCS) assessed immediately before surgery; and 5) an age of ≥65 years. When the majority of the hematoma was evacuated on the CT, we removed the catheter.ResultsUnder local anesthesia, a catheter was inserted into the hematoma through a burr hole. The mean age of the patients was 73.7 years (range, 65-87 years). The mean preoperative GCS score was 11.2 (range, 10-13), and the mean Glasgow Outcome Scale score for all patients was 5 at discharge. No recurrences of hematomas or surgical complications were observed.ConclusionA subdural drain using urokinase after burr hole hematoma evacuation under local anesthesia is thought to be an effective and safe method of blood clot removal with low morbidity. This surgical method is less invasive for treating elderly patients with SASDH.