Mean Preoperative Glasgow Coma Scale Research Articles

Intraoperative ultrasonographic-guided surgery of intracerebral hemorrhage

Abstract Background The location of the cortical incision and maximum evacuations of parenchymal intracerebral hematoma are crucial points. Intraoperative ultrasonography is a real-time tool with great benefit at these points Methods A retrospective study of patients with parenchymal intracerebral hemorrhage that underwent evacuation using intraoperative ultrasound guidance was included. Preoperative clinical and radiological assessments were studied. The postoperative imaging and clinical outcome were assessed. A late follow-up after 6 months was done. Results The age of study patients ranged from 9 to 73 (mean 45.3 ± 20.4 years). There were 14 males (58.3%). The mean preoperative Glasgow Coma Scale (GCS) was 9.8 ± 2.9. The preoperative hematoma volume ranged from 32 to 135 cm3 with a mean of 68.5 ± 30.5 cm3. The rate of evacuation ranged from 90 to 100%. The mean postoperative GCS was 11.7 ± 2.5. None of the patients had a recurrent hemorrhage. There was a significant rate of evacuation of the hematomas (P value < 0.001*). Also, there was a marked improvement in postoperative GCS and the late modified Rankin Scale (P value < 0.001*). Conclusion Ultrasonography is a useful, efficient, real-time tool for the localization and evacuation of parenchymal intracerebral hemorrhage. It maximizes evacuation and decreases parenchymal insult. It is an important aid to the neurosurgeon.

Surgical Modality as a Determinant of Survival and Neurological Outcome Following the Evacuation of Acute Subdural Hematomas

Objective: We designed the present study to compare the clinical outcomes of the craniotomy and the decompressive craniectomy procedures that we had performed in our department for evacuating traumatic acute subdural hematomas.
 Material and Methods: We retrospectively analyzed the medical data of all the adult patients in whom a craniotomy or a decompressive craniectomy had been performed for evacuating acute traumatic subdural hematoma. The demographic data, the preoperative Glasgow Coma Scale (GCS), and the clinical outcome were studied.
 Results: A craniotomy had been carried out in five patients for traumatic AcSDH evacuation while in twelve patients a decompressive craniectomy had been performed. The mean preoperative GCS was 9 in the patients that underwent a craniotomy, whereas the mean preoperative GCS in the decompressive craniectomy group was 6.8. The overall mortality was 47%. In the craniotomy group, 4 (80%) patients survived and 1 (20%) patient expired. In the decompressive craniectomy group, 5 (41.7%) patients survived and 7 (58.3%) patients expired. The outcome in all the 9 surviving patients was favorable based on the Glasgow Outcome scale and all of them were independent of follow-up.
 Conclusion: Better clinical outcome was observed in patients who had undergone a craniotomy compared to those in whom a decompressive craniectomy had been performed. Patients that underwent a craniotomy were also in a better clinical status preoperatively compared to patients who underwent a decompressive craniectomy.

Management Challenges and Outcomes of Traumatic Brain Injury due to Bear Maul in Tribal Areas of Chhattisgarh, India-Man versus Wild.

Objectives Neurosurgeons working in the vicinity of tribal areas face traumatic brain injury (TBI) cases due to bear maul which is on the rise in Chhattisgarh. Most of the literature is focused on the management of maxillofacial injuries. This study intends to describe the challenges in management and outcomes of TBI due to bear maul. Materials and Methods A retrospective review was conducted from May 2018 to April 2020. The patients without TBI were excluded. The variables studied were age, gender, timing and mode of conflict, Glasgow coma scale (GCS) at arrival, injury spectrum, hospital stay, the modified Rankin score (MRS), mini mental status examination (MMSE), and surgical site infections (SSI). Results Twenty-eight patients were eligible for analysis. The mean age of presentation was 40.67 ± 13.99 years. There were 23 males (82.15%). Most common time of attack was during dawn ( n = 11, 39.28%) followed by dusk ( n = 9, 32.14%) and day ( n = 8, 28.57%) time. Provoked conflicts were seen in 64.28%. The mean preoperative GCS was 11.07 ± 3.54 and hospital stay was 18.71 ± 9.51 days. Skull fractures were found in 24/28 (85.71%). The mean MRS was 1.67 ± 1.38 at a mean follow-up of 14.53 ± 6.59 months. Favorable outcome (MRS ≤ 2) was seen in 64.28% of patients. The mean MMSE score was 22.28 ± 5.36. Eight patients developed SSI (28.57%). Conclusion Outcomes of TBI due to bear maul depend on preoperative GCS. There are higher incidences of skull fractures and SSI. Humans need to avoid infiltration in wildlife territory to reduce the number of conflicts.

Effects of Primary Decompressive Craniectomy on the Outcomes of Serious Traumatic Brain Injury with Mass Lesions, and Independent Predictors of Operation Decision

Although operative indications for traumatic brain injury (TBI) are known, neurosurgeons are unsure whether to remove the bone flap after mass lesion extraction, and an efficient scoring system for predicting which patients should undergo decompressive craniectomy (DC) does not exist. Nine parameters were assessed. In total, 245 patients with severe TBI were retrospectively assessed from June 2015 to May 2019, who underwent DC or craniotomy to remove mass lesions. The 6-month mortality and Extended Glasgow Outcome Scale scores were compared between the DC and craniotomy groups. Using univariable and multivariable logistic regression equations, receiver operating characteristic curves were obtained for predicting the decision for DC. The overall 6-month mortality in the entire cohort was 11.43% (28/245). Patients undergoing DC had lower mean preoperative Glasgow Coma Scale scores (P= 0.01), and higher amounts of individuals with a Glasgow Coma Scale score of 6 (P= 0.007), unresponsive pupillary light reflex (P < 0.001), closed basal cisterns (P < 0.001), and diffuse injury (P= 0.025), compared with the craniotomy group. Because of high disease severity, individuals administered primary DC showed increased 6-month mortality compared with the craniotomy group. However, in surviving patients, favorable Extended Glasgow Outcome Scale rates were similar in both groups. Pupillary light reflex and basal cisterns were independent predictors of the DC decision. Based on receiver operating characteristic curves, the model had sensitivity and specificity of 81.6% and 84.9%, respectively, in predicting the probability of DC. These preliminary data showed that primary DC may benefit some patients with severe TBI with mass lesions. In addition, unresponsive preoperative pupil reaction and closed basal cistern could predict the DC decision.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

Outcomes of Decompressive Craniectomy for Spontaneous Deep Supratentorial Intracerebral Hemorrhage

AbstractBackground: Spontaneous Intracerebral Hemorrhage (ICH) is one of the most devastating forms of cerebrovascular disease and is associated with high mortality and morbidity rate. Mass-effects of hematoma and surrounding edema lead to increase intracranial pressure and subsequent brain herni-ation. Decompressive Craniectomy (DC) provide space for the edematous brain to expand away from the midline structures and reduce intracranial pressure.Aim of Study: The aim of this study was to evaluate the outcome of Outcomes of Decompressive Craniectomy for Spontaneous Deep Supratentorial Intracerebral Hemorrhage.Patient and Methods: We retrospectively reviewed the medical records of the patients with spontaneous deep su-pratentorial ICH who underwent DC without evacuation of hematoma within 24 hour of ictus. Outcome was assessed by the Glasgow Outcome Scale (GOS) 6 months after surgery.Results: A total of 12 patients were included in this study. The mean age was 45 years. Mean pre-operative Glasgow Coma Scale (GCS) score was 6.7. Mean hematoma volume was 68ml. At 6 months after surgery, 8 patients (67%) had favorable outcome while 4 (33%) had unfavorable outcome, 2 patients (17%) died. 83% of patients with pre-operative GCS score 8-9 compared to 50% with pre-operative GCS score 5-7 had favorable outcome. 71% of patients with he-matoma volume less than or equal to 70ml compared with 60% with hematoma volume more than 70ml had favorable outcome.Conclusions: Decompressive craniectomy can be benefi-cial in treatment of spontaneous deep supratentorial ICH in selected patient group. Patients with high pre-operative GCS score and small hematoma volume are more likely to have favorable outcome.

Decompressive craniectomy in malignant middle cerebral artery infarctions: outcome of 25 cases

BackgroundLarge space-occupying middle cerebral artery (MCA) infarctions with signs of elevated intracranial pressure and brain herniation have overall mortality rates of 80%. Several studies have suggested that decompressive surgery reduces mortality and improves outcome of these patients.AimThe aim of this study was to evaluate the clinical and radiological outcome of decompressive craniectomy in the setting of malignant MCA infarctions.Patients and methodThis is a prospective study conducted on patients presenting with manifestations of malignant MCA infarction. All cases were operated upon by decompressive craniectomy and duroplasty within 6 h of presentation or deterioration in Glasgow Coma Scale (GCS). Functional outcome was assessed in terms of mortality and modified Rankin Scale (mRS) for neurologic disability. Radiological outcome was assessed by comparing the midline shift in the preoperative CT and 24 to 96 h postoperatively.ResultsTwenty-five patients were included in this study. The mean age was 64.4 years. The mean preoperative GCS score was 8.14. The mean preoperative midline shift was 7.9 mm. All cases showed radiological improvement in the early follow-up period. Good functional outcome based on mRS was achieved in 64% and poor outcome in 36% of cases. The overall mortality in this study was 28%.ConclusionEarly decompressive hemicraniectomy had a proven role in reduction of mortality and improving functional outcome in cases with malignant MCA infarction. Among other factors, timing of surgery and the preoperative clinical condition were factors that affected the final outcome.

Surgical Outcome of Acute and Subacute Subdural Hematoma with Endoscopic Surgery

Acute subdural hematoma (ASDH) and subacute subdural hematoma(SASDH)evacuations are commonly performed through a large craniotomy or with external decompression surgery to avoid secondary brain injury. In the field of head trauma, minimally invasive surgeries performed with neuroendoscopy were recently reported. We report 12 patients with ASDH( n=9) and SASDH (n=3)w ho underwent endoscopic hematoma evacuation via a small craniotomy between November 2013 and May 2015. All patients were over 65 years of age(mean age, 78.8 years[range, 65-91 years]) and had subdural hematomas without extensive contusion. The mean preoperative Glasgow Coma Scale(GCS)score was 8.75 (range, 4-13). In three patients, we observed the bleeding point and substantially coagulated it. Decompression in all patients was adequate after surgery. Patients with a preoperative GCS score of 4-6 showed poor outcomes, whereas those with a score >9 showed relatively good outcomes. We performed the operations safely in patients who were on antithrombotic therapy or had a systemic bleeding tendency pre-injury. Endoscopic hematoma evacuation via a small craniotomy is a safe and minimally invasive procedure in patients older than 65 years with comorbidities.

Retrospective comparison of decompressive hemicraniectomy and hematoma evacuation for spontaneous supratentorial intracerebral hematoma

Objectives: The aim of this study was to test the hypothesis that decompressive hemicraniectomy (DHC), compared with craniotomy with evacuation of hematoma, and would improve clinical outcomes of patients with supratentorial intracerebral hemorrhage (SICH).Methods: We compared patients (November 2008–February 2014) with supratentorial ICH treated with DHC without hematoma evacuation and craniotomy with hematoma evacuation. DHC measured at least 150 mm and included opening of the dura. We analyzed clinical, radiological, and surgical characteristics. Outcome at 6 months was divided into good (modified Rankin Scale 0–4) and poor (modified Rankin Scale 5–6).Results: Fifteen patients (mean age 58 years) with ICH were treated by DHC. Median hematoma volume was 61 ml and mean preoperative Glasgow Coma Scale (GCS) was 7. Ten patients had good and five had poor outcomes. In hematoma evacuation group 29 patients were treated. Median hematoma volume was 55 ml and mean preoperative Glasgow Coma Scale (GCS) was 8. Seventeen patients had good and twelve had poor outcomes.Conclusions: DHC is more effective than hematoma evacuation in patients with SICH. Based on this small cohort, DHC may reduce mortality. Larger prospective study is warranted to assess safety and efficacy.Pulse Vol.7 January-December 2014 p.16-21

Decompressive hemicraniectomy in malignant middle cerebral artery infarction: an analysis of long-term outcome and factors in patient selection

Middle cerebral artery infarction often occurs at a younger age than other strokes and is associated with significant rates of mortality and morbidity. After a period of pessimism regarding decompressive hemicraniectomy in the management of acute stroke, the method has reemerged in the past decade. The present study was undertaken to assess the immediate and long-term outcome of this intervention and to help better define the selection criteria for surgery. The authors conducted a nonrandomized prospective study using decompressive hemicraniectomy with duraplasty in patients at various stages of clinical deterioration due to a space-occupying middle cerebral artery infarct. Patients were assessed at 6 and 12 months postinfarction by using functional scales. Subjective reconsideration was assessed using a questionnaire. Twenty-six patients were included in the study. The mean age was 48.4 +/- 11.2 years, and the mean preoperative Glasgow Coma Scale score was 9.9 +/- 3.2. The median time from ictus to surgery was 54 hours (range 13-288 hours). The rate of survival at 1 year postsurgery was 73%. Among survivors, 33.3% were independent (Barthel Index [BI] > 95) and 55.6% were partially dependent (BI 60-95) at 1 year postsurgery, with 72% attaining the ability to walk independently by 1 year postsurgery. No patient remained in a vegetative state. The 1-year BI score was inversely related to patient age (r = -0.47, p = 0.048). Survival after decompressive hemicraniectomy was better than previously reported using medical management alone. A vegetative state was avoided and functional independence was possible, especially in younger patients. Increasing age was a statistically significant predictor of disability and long-term functional dependence.

Outcomes after decompressive craniectomy for severe traumatic brain injury in children

Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution. Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months. Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

Is decompressive craniectomy for acute cerebral infarction of any benefit?

BACKGROUND Acute occlusion of the major cerebral arteries results in ischaemic changes to the brain, without time for reperfusion by the collateral circulation. The subsequent cellular events lead to a breakdown of the blood-brain barrier, causing malignant cerebral edema manifested clinically by a rapid neurological deterioration. The aim of this study was to determine the value of surgical decompression in patients who present with acute cerebral infarction. METHODS Retrospective review of patients with deteriorating consciousness level from massive cerebral ischemia and secondary edema, treated by decompressive craniectomy. RESULTS There were 10 patients over a 2-year period from 1997–99, consisting of seven male and three female patients (mean age 47.56 years) with a mean preoperative Glasgow Coma Scale (GCS) score of 6/15. Three patients had dominant middle cerebral artery (MCA) infarction, four had nondominant MCA infarction, one had posterior cerebral artery infarction, and the remaining two had cerebellar infarction. At a mean follow-up period of 7 months, two patients had died (20% mortality), four patients (40%) were vegetative or severely disabled, and the remaining four patients (40%) had mild disability or good outcome. Favorable prognostic factors were younger age (less than 50 years) and good initial GCS score (14 or better). CONCLUSION Decompressive craniectomy in the setting of acute brain swelling from cerebral infarction is a life-saving procedure and should be considered in younger patients who have a rapidly deteriorating neurologic status.