Need For Craniotomy Research Articles

The efficacy of using the allogeneic osteoplastic material in skull trepanation

Introduction. When performing osteoplastic craniotomy, there is a need to fill the diastasis between the skull bone and the explanted bone fragment. Grafts based on allogeneic bone chips and collagen (bone-plastic material) may be very effective for cranial bone repair in diastasis area.Aim. To evaluate the safety and clinical efficacy of osteoplastic material during the osteoplastic craniotomy.Material and methods. A retrospective and prospective clinical study was conducted at the N.V. Sklifosovsky Research Institute for Emergency Medicine and included 12 patients treated in Urgent Neurosurgery Department with diagnoses suggesting the need for craniotomy. Allogenic osteoplastic material was obtained from a 0.7-0.9% solution of type I collagen and spongy bone chips with a fraction size of 315-630 microns. Osteoplastic material grafts were used intraoperatively at the cranioplastic stage of the operation after the main stages had been completed. The efficacy and safety of the use of osteoplastic material were evaluated clinically and radiologically in the early postoperative period.Results. In the early postoperative period, the study patients had no pyo-septic complications, severe pain or soft tissue swelling. All patients were discharged from the hospital in satisfactory condition to be followed-up by the physician or neurologist at the out-patient facility. The computed tomography performed in the early postoperative period visualized the diastasis lines along the bone flap line in the comparison group patients (without osteoplastic material); and in the main group, the osteoplastic material was clearly visualized. At computed tomography of the skull performed after 6–9 months and after 2–18 months, the signs of bone tissue consolidation were visualized in the patients of the main group. The radiodensity of the autologous bone flap in both groups did not significantly change at any periods. In the diastasis area, the radiodensity of diastasis in the main group was significantly higher than in the comparison group. After 1-1.15 years the radiodensity values in the diastasis area increased by average of 1.95 times (p<0.05) in the patients of the main group, while in the patients without osteoplastic material, this parameter did not significantly change during the entire follow-up period.Conclusions. In patients with intraoperative cranioplasty osteoplastic material grafts did not cause complications in the early and late postoperative period. Intraoperative cranioplasty performed with using osteoplastic allogeneic material caused no complications in either early or late postoperative periods. The presence of osteoplastic material contributed to the consolidation of the autologous bone flap and healthy bone.

Brain abscess: Epidemiological study in a Pediatric Neurosurgery Department of Bangladesh

Background: Brain abscess is a relatively uncommon but life-threatening infection in children. It can originate from contiguous site infections (eg, chronic otitis media, mastoiditis, sinusitis, meningitis), from distant pathologic states (eg, cyanotic congenital heart disease, chronic lung infections), after head trauma or neurosurgical procedures, or from cryptogenic sources. Predominant etiologic microorganisms vary depending on these predisposing factors. Proper selection of antimicrobial agents with good penetration of the central nervous system and with adequate coverage of both anaerobic and aerobic bacteria is critical for the medical management of brain abscess. Delay in surgical drainage can be associated with high morbidity and casefatality rates. Methods: The study was carried out at Department of Paediatric Neurosurgery, NINS&H, Dhaka from November 2017 to till date. Data collection sheet was used to collect the necessary information. Subjects was included from a NINS Pediatrics neurosurgery electronic registry. Structured questionnaire was used to collect the necessary information. Risks and benefits of this study were explained to the patient and patient’s legal guardian/parents in an easily understandable local language. Informed written consent was taken from each guardian before data collection. Results: Most of the patients were within >5 years age group 21 (38.3%). Second large were <2 years age group 19 (34.5%). According to gender. 33 (60%) patients were males and 22 (40%) patients were females. Distribution of subjects among OPD patients and admitted patients. 41 patients were admitted indoor among 55 patients. Predisposing factors were identified in 24 of 41 admitted cases. 11 abscesses developed in a child with cyanotic congenital heart disease (CCHD) and 2 occurred after head trauma. 2 abscesses were secondary to ear infections. In 28 patients, the abscess was drained through a burr hole, without the need for craniotomy; the other 4 underwent open craniotomy. 9 patients improved only with conservative management. Among the admitted patients, 34 patients were discharged from the ward in clinically stable conditions and 7 patients expired. Conclusion: Advances in the diagnosis and treatment of brain abscess and subdural empyema with neuroimaging techniques such as computerized tomography, magnetic resonance imaging, magnetic resonance spectroscopy, the availability of new antimicrobials, and the development of novel surgical techniques have significantly contributed to the decreased morbidity and mortality associated these infections. Bang. J Neurosurgery 2022; 11(2): 70-74

Pediatric pineal region tumors: institutional experience of surgical managements with posterior interhemispheric transtentorial approach.

Resecting pineal region tumors in children is often challenging. Several approaches have been proposed and practiced. A personal series of pediatric pineal region tumors resected through craniotomy with posterior interhemispheric occipital transtentorial (OT) approach are reviewed. We present the surgical techniques, pitfalls, and their results. Eighty patients ranging in age from 3months to 21years old, and treated over 3 decades were reviewed. Hydrocephalus caused the main presenting symptoms and was noted in 74 patients. It was treated prior to the craniotomy for tumor resection with endoscopic third ventriculostomy (ETV) in 33, external ventricular drainage in 26, and precraniotomy shunt in 15. Nine patients had ETV together with endoscopic biopsy. All patients had a parieto-occipital craniotomy in a prone position. Through a tentorial section, a gross total resection of the tumor was attempted except for germinomas. The tumor pathology showed 32 germ cell tumors (GCT), 22 benign astrocytomas, 13 pineal parenchymal tumors, 5 ATRTs, 3 papillary tumors, and 5 others. Of GCTs, 18 were teratomas. The extent of resection consisted of 55 gross total resections, 13 subtotal resections, 10 partial, and 2 biopsies with one postoperative death. Hemiparesis in 2, cerebellar ataxia in another 2, and hemiballismus in 1 were transient and improved over time. One had permanent hemisensory loss and another patient had bilateral oculomotor palsy. Postoperative homonymous hemianopia occurred in 2 patients but subsided over a short period of time. Parinaud's sign was noted in 24 patients, of which 16 were transient. The posterior interhemispheric OT approach provides a safe route and comfortable access to the pineal region inchildren. A great majority of postoperative neurological complications are the results of direct manipulations of the midbrain at tumor resection. Identification and preservation of the tumor-brain interface are of paramount importance. GCTs other than teratomas are treated with neoadjuvant chemotherapy and may eliminate the need for craniotomy. Exophytic midbrain JPAs are amenable to resection.

Reduced Platelet Activity in Patients with Acute Intracranial Hemorrhage.

Acquired platelet dysfunction is a common element of trauma-induced coagulopathy and has been linked to increased mortality. The aim of the study was to describe the prevalence of platelet dysfunction in patients with acute intracranial bleeding. Patients diagnosed with acute intracranial bleeding were screened for eligibility. Patients with an urgent need for craniotomy were enrolled in this prospective monocentric study. Platelet function analyses using multiple electrode aggregometry (TRAPtest, ASPItest and ADPtest) and conventional coagulation tests were performed. The area under the aggregation curves of the ASPItest and ADPtest were defined as primary outcome variables. Seventy-seven patients were screened for eligibility, and 49 patients were ultimately enrolled in the study. In 14 patients (29%), clinically relevant platelet dysfunction was observed. Of those, 8 patients were treated with antiaggregatory medication at the time of study inclusion. Six patients (12%) were diagnosed with acute acquired platelet dysfunction. Decreased platelet function was present in nearly one-third of patients with acute intracranial bleeding. Hemotherapy algorithms for the treatment of coagulopathy in this cohort should incorporate aggregometric measures to enable rapid goal-directed therapy.

Combined head and abdominal blunt trauma in the hemodynamically unstable patient: What takes priority?

The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness. National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures. Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004). The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage. Therapeutic, Level IV.

The impact of delayed time to first CT head in traumatic brain injury.

PurposeTrauma team activation (TTA) criteria trigger early mobilization of resources for the sickest trauma patients. Patients with moderately depressed GCS who do not trigger the highest level activation are at risk for adverse outcomes, potentially from delayed time to intervention. The study objective was to define the impact of time to first CT Head (CTH) on outcomes among blunt trauma patients with moderately depressed GCS.MethodsPatients from the Trauma Quality Improvement Program (TQIP) databank (2013–2016) with first ED GCS 9–12 were included. Transfers, penetrating mechanisms, death < 24 h, AIS = 6 in any body region, and patients with severe associated injuries were excluded. Study groups were defined by time to first CTH after ED arrival: immediate (≤ 1 h) vs. delayed (1–6 h). Primary outcomes were time to neurosurgical intervention and time to ED discharge.ResultsAfter exclusions, 4997 patients were identified. Of these, 79% (n = 3,954) underwent immediate CTH and 21% (n = 1,043) had delayed CTH. Median GCS was 11 [10–12] in both groups and there was no difference in median Head AIS (4 [3–4] vs. 4 [3–4], p = 0.586). Time to craniotomy and ICP monitor insertion were longer in the delayed group (4.2 h [3.0–7.6] vs. 3.1 h [2.1–8.7], p = 0.001; and 5.7 h [3.8–13.0] vs. 4.4 h [2.6–12.0], p = 0.008), as was time in the ED (4.3 h [2.7–6.5] vs. 2.1 h [1.2–3.7], p < 0.001). There was no difference in need for craniotomy (11% vs. 10%, p = 0.287), need for ICP monitor (12% vs. 12%, p = 0.899), or mortality (11% vs. 9%, p = 0.160). On multivariate analysis, age > 65 (OR 2.813, p < 0.001), SBP < 90 mmHg (OR 2.934, p < 0.001), ED intubation (OR 1.486, p = 0.001), and Head AIS scores of 4 (OR 1.884, p < 0.001) and 5 (OR 6.729, p < 0.001) were independently associated with death.ConclusionsImmediate CTH for blunt trauma patients with moderately depressed GCS decreases time to intervention and reduces ED time. A protocol to shorten time to CTH may be beneficial for both patients and hospitals.

Pautas de tratamiento del tumor inflamatorio de Pott. Revisión bibliográfica

Introducción y objetivo: El objetivo de este estudio es proporcionar una revisión actualizada del tratamiento médico y quirúrgico en pacientes con abscesos subperiósticos secundarios a la osteomielitis del hueso frontal. Método: Se realizó una búsqueda en la base de datos PubMed, BVS (biblioteca virtual en salud España) y Scopus de las distintas opciones terapéuticas del tumor de Pott. La revisión se realizó siguiendo los criterios PRISMA. Resultados: Se seleccionaron 20 artículos en la búsqueda bibliográfica. Un total de 30 pacientes (24 varones, con media de edad de 27 años) fueron revisados. En un 90% la causa fue una rinosinusitis crónica, seguida por traumatismos locales. En la mayoría de los casos se realizó un drenaje endoscópico tipo Draf 2 (60%), 5 pacientes fueron sometidos a un Draf 3, tres a un Draf 1 y sólo uno a un Draf 2B. Un paciente fue tratado con sinuplastia con balón y otro con craneotomía externa aislada. Todos los pacientes tenían antibióticos orales o intravenosos de duración variable; aunque predomina el esquema terapéutico de vancomicina y ceftriaxona endovenosa durante 6 semanas. No hubo más complicaciones después de la intervención endoscópica sinusal. La presencia de fístulas, cicatrizaron sin necesidad de desbridamiento quirúrgico o cierre. Discusión: el tumor inflamatorio de Pott es una patología muy infrecuente. Debido a la rareza de la patología, muchos casos han sido infradiagnosticados desembocando en complicaciones intracraneales. El abordaje externo ha sido el tratamiento de elección durante años; actualmente se aboga por un abordaje endonasal guiada en ocasiones por neuronavegador sumado a la antibioticoterapia correspondiente durante un largo periodo de tiempo. Conclusiones: La mayoría de los casos de tumor inflamatorio de Pott pueden manejarse endoscópicamente. La disponibilidad de instrumentos en ángulo motorizados, videos de alta definición y sistemas de guía de imágenes han proporcionado a los otorrinolaringólogos una alternativa creíble a las técnicas tradicionales. Además, la biodisponibilidad mejorada de los antibióticos puede obviar la necesidad de una craneotomía y drenajes externos.

Subdural Drain versus Subdural Evacuating Port System for the Treatment of Nonacute Subdural Hematomas: A Single-Center Retrospective Cohort Study

Subdural drain (SDD) and Subdural Evacuating Port System (SEPS) are bedside options for management of nonacute subdural hematomas (SDHs). These interventions have not been compared with each other. Our objective is to compare the need for second bedside procedure, need for craniotomy, complication rate, and other outcomes related to bedside drainage of SDH with SDD or SEPS. We hypothesized that SDD would be associated with superior outcomes to SEPS. Database queries and direct patient chart reviews were used to gather patient data. t-Tests, Fisher exact tests, and proportional odds models were performed. Of 41 SDDs and 25 SEPS, baseline characteristics were similar except more isodense SDHs were present in SDD (P= 0.0312). SEPS was associated with significant risk of requiring a second bedside procedure (odds ratio, 3.2381; 99% confidence interval, 1.0345-10.1355) relative to SDD. Need for craniotomy did not differ between groups (12.1% SDD vs. 16% SEPS; P= 0.721). The complication rate was similar between groups (2.4% SDD vs. 12% SEPS; P= 0.1484). Symptom resolution, condition at latest follow-up, and posthospital disposition were similar between groups, but SEPS was associated with longer intensive care unit and total hospital length of stay (P= 0.02 and 0.04, respectively). SEPS was associated with higher risk for need of second bedside procedure and longer intensive care unit and hospital length of stay than SDD, although not increased need for craniotomy. Additional studies are needed to confirm our findings and determine if SDD may be more effective than SEPS for the treatment of nonacute SDH.

Stereoelectroencephalography in Pediatric Epilepsy Surgery.

Stereoelectroencephalography (SEEG) is an invasive technique used during the surgical management of medically refractory epilepsy. The utility of SEEG rests in its ability to survey the three-dimensional organization of the epileptogenic zone as well as nearby eloquent cortices. Once concentrated to specialized centers in Europe and Canada, the SEEG methodology has gained worldwide popularity due to its favorable morbidity profile, superior coverage of deep structures, and ability to perform multilobar explorations without the need for craniotomy. This rapid shift in practice represents both a challenge and an opportunity for pediatric neurosurgeons familiar with the subdural grid approach. The purpose of this review is to discuss the indications, technique, and safety of long-term SEEG monitoring in children. In addition to reviewing the conceptual and technical points of the diagnostic evaluation, attention will also be given to SEEG-based interventions (e.g., radiofrequency thermo-coagulation).

Endovascular delivery of leads and stentrodes and their applications to deep brain stimulation and neuromodulation: a review.

Neuromodulation and deep brain stimulation (DBS) have been increasingly used in many neurological ailments, including essential tremor, Parkinson's disease, epilepsy, and more. Yet for many patients and practitioners the desire to utilize these therapies is met with caution, given the need for craniotomy, lead insertion through brain parenchyma, and, at many times, bilateral invasive procedures. Currently endovascular therapy is a standard of care for emergency thrombectomy, aneurysm treatment, and other vascular malformation/occlusive disease of the cerebrum. Endovascular techniques and delivery catheters have advanced greatly in both their ability to safely reach remote brain locations and deliver devices. In this review the authors discuss minimally invasive endovascular delivery of devices and neural stimulating and recording from cortical and DBS targets via the neurovascular network.

Craniotomy Does Have its Share in the Management of Chronic Subdural Hematoma

Abstract Background Burr hole drainage (BHD) is the most popular technique for surgical management of chronic subdural hematoma (CSDH) and is able to successfully address the problem in majority of patients. However, in a select few cases, the formation of subdural membrane necessitates a wider surgical approach to relieve the compressed cerebral parenchyma. We evaluated the need for craniotomy and associated issues in management of CSDH in a consecutive series of 114 patients. Material and Method Data of 114 patients, who underwent surgical management of CSDH in our neurosurgical unit were analyzed. We specifically looked for the cases requiring craniotomy, it's indication and surgical outcome. Results Craniotomy was required in 12 patients (8.6%)—as primary procedure in 8 patients and as add-on secondary procedure in 4 patients. Clinical outcome was good. Mild subdural bleed, not requiring any surgical intervention, was observed in two patients as postoperative complication. There was no mortality. Conclusion In the presence of thick subdural membranes, BHD alone may not help relieve the cerebral compression. Wider surgical approach in form of craniotomy and membranectomy is the answer in such situations and can be safely performed with low complications. Good quality computed tomography and magnetic resonance imaging are essential in preoperative identification of membrane and appropriate surgical planning.

Focused ultrasound in neurosurgery: a historical perspective.

Focused ultrasound (FUS) has been under investigation for neurosurgical applications since the 1940s. Early experiments demonstrated ultrasound as an effective tool for the creation of intracranial lesions; however, they were limited by the need for craniotomy to avoid trajectory damage and wave distortion by the skull, and they also lacked effective techniques for monitoring. Since then, the development and hemispheric distribution of phased arrays has resolved the issue of the skull and allowed for a completely transcranial procedure. Similarly, advances in MR technology have allowed for the real-time guidance of FUS procedures using MR thermometry. MR-guided FUS (MRgFUS) has primarily been investigated for its thermal lesioning capabilities and was recently approved for use in essential tremor. In this capacity, the use of MRgFUS is being investigated for other ablative indications in functional neurosurgery and neurooncology. Other applications of MRgFUS that are under active investigation include opening of the blood-brain barrier to facilitate delivery of therapeutic agents, neuromodulation, and thrombolysis. These recent advances suggest a promising future for MRgFUS as a viable and noninvasive neurosurgical tool, with strong potential for yet-unrealized applications.

Minimally Invasive Surgery for Pott's Puffy Tumor: Is It Time for a Paradigm Shift in Managing a 250-Year-Old Problem?

The aim of this study was to review the clinical outcomes and efficacy of endoscopic sinus surgery (ESS) in the management of Pott's puffy tumor (PPT). Literature PubMed review using a combination of MeSH terms and keywords was undertaken, combined with a single surgeon case series of 3 patients. A total of 29 (20 males, median age 25 years) cases were reviewed. The most common etiology was acute frontal sinusitis (62%), followed by a history of chronic rhinosinusitis (28%). Two patients presented with concomitant preseptal cellulitis and cutaneous fistula each, while another had pneumocephalus. The majority of cases (59%) had Draf 1 procedure. Three cases had Draf 3 procedure. Five cases were successfully treated by sinus balloon sinuplasty. Postoperatively, most patients had either oral or intravenous antibiotics of varying duration. There were no further complications following ESS. Both fistulas healed without requiring surgical debridement or closure. Some PPT cases can be managed endoscopically. The availability of powered angled instruments, high-definition video, and image guidance systems have provided the modern otolaryngologists with a credible alternative to traditional techniques. Furthermore, improved bioavailability of modern antibiotics may obviate the need for craniotomy and external drains.

Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients

Trauma victims are frequently triaged to a trauma center according to the patient's calculated Glasgow Coma Scale (GCS) score despite its known inconsistencies. The substitution of a simpler binary assessment of GCS-motor (GCS-m) score less than 6 (ie, "patient does not follow commands") would simplify field triage. We compare total GCS score to this binary assessment for predicting trauma outcomes. This retrospective analysis of a statewide trauma registry includes records from 393,877 patients from 1999 to 2013. Patients with initial GCS score less than or equal to 13 were compared with those with GCS-m score less than 6 for outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24, death, ICU admission, need for surgery, or need for craniotomy. We judged a priori that differences less than 5% lack clinical importance. The relative differences between GCS and GCS-m scores less than 6 were less than 5% and thus clinically unimportant for all outcomes tested, even when statistically significant. For the 6 outcomes, the differences in areas under receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS score less than or equal to 13 was slightly more sensitive (difference 3.3%; 95% confidence interval 3.2% to 3.4%) and slightly less specific (difference -1.5%; 95% confidence interval -1.6% to -1.5%) than GCS-m score less than 6 for predicting ISS greater than 15, with similar overall accuracy (74.1% versus 74.2%). Replacement of the total GCS score with a simple binary decision point of GCS-m score less than 6, or a patient who "does not follow commands," predicts serious injury, as well as the total GCS score, and would simplify out-of-hospital trauma triage.

Incidence of Intracranial Hemorrhage and Outcomes after Ground-level Falls in Geriatric Trauma Patients Taking Preinjury Anticoagulants and Antiplatelet Agents

Antiplatelet and anticoagulant medication increases the risk of intracranial hemorrhage (ICH) after a fall in geriatric patients. We sought to determine whether there were differences in ICH rates and outcomes based on type of anticoagulant or antiplatelet agent after a ground-level fall (GLF). Our institutional trauma registry was used to identify patients 65 years old or older after a GLF while taking warfarin, clopidogrel, or aspirin over a 2-year period. Rates and types of ICH and patient outcomes were evaluated. Of 562 patients who met inclusion and exclusion criteria, 218 (38.8%) were on warfarin, 95 (16.9%) were on clopidogrel, and 249 (44.3%) were on aspirin. Overall ICH frequency was 15 per cent with no difference in ICH rate, type of ICH, need for craniotomy, mortality, or intensive care unit or hospital length of stay between groups. Patients with ICH were more likely to present with abnormal Glasgow Coma Score, history of hypertension, and/or loss of consciousness.

Glasgow motor scale alone is equivalent to Glasgow Coma Scale at identifying children at risk for serious traumatic brain injury

Glasgow Coma Scale (GCS) is a validated assessment of neurologic state. Assessment of the eye and verbal components is difficult to reliably obtain in children. We hypothesized that an abnormal Glasgow motor scale (GMS) score alone will reliably identify children with serious traumatic brain injury (TBI). We reviewed all children with a diagnosis of TBI from 2002 to 2011 at two urban Level I pediatric trauma centers. We used logistic regression to model GCS, GMS, Glasgow verbal scale (GVS), and Glasgow eye scale (GES) for seven outcomes: need for craniotomy, intracranial pressure monitoring, admission to the intensive care unit, hospital stay of 5 days or longer, discharge to rehabilitation, dependence on caretakers at follow-up, and survival to hospital discharge. We then used three measures of fit analysis to determine which scale offered the best fit for each of the outcomes. A total of 2,341 patients (mean [SD] age, 6.9 [5.8] years; 64.7% male) with TBI and GCS data available were identified. The median GCS on presentation was 15 (interquartile range [IQR], 8-15); the median GMS on presentation was 6 (IQR, 4-6). The median GVS was 5 (IQR, 1-5), and the median GES was 4 (IQR, 2-4). GCS as a whole offered the best fit for the data in predicting need for intensive care unit admission, need for intracranial pressure monitoring, prolonged hospital length of stay, and discharge to rehabilitation but was equivalent to GMS in predicting need for craniotomy, survival to hospital discharge, or dependence on a caretaker at follow-up. Further analysis revealed that GMS was more predictive of these outcomes than GVS + GES, indicating that GMS provides the greatest contribution to the predictive ability of the GCS. GMS score alone and GCS do not differ in identifying children with serious TBI. Eliminating the eye and verbal components of GCS does not adversely affect the accuracy of this tool to identify children at risk for serious TBI. Prognostic study, level III.

Berengario's drill: origin and inspiration

Craniotomies are among the oldest neurosurgical procedures, as evidenced by early human skulls discovered with holes in the calvaria. Though devices change, the principles to safely transgress the skull are identical. Modern neurosurgeons regularly use electric power drills in the operating theater; however, nonelectric trephining instruments remain trusted by professionals in certain emergent settings in the rare instance that an electric drill is unavailable. Until the late Middle Ages, innovation in craniotomy instrumentation remained stunted without much documented redesign. Jacopo Berengario da Carpi's (c. 1457-1530 CE) text Tractatus de Fractura Calvae sive Cranei depicts a drill previously unseen in a medical volume. Written in 1518 CE, the book was motivated by defeat over the course of Lorenzo II de'Medici's medical care. Berengario's interchangeable bit with a compound brace ("vertibulum"), known today as the Hudson brace, symbolizes a pivotal device in neurosurgery and medical tool design. This drill permitted surgeons to stock multiple bits, perform the craniotomy faster, and decrease equipment costs during a period of increased incidence of cranial fractures, and thus the need for craniotomies, which was attributable to the introduction of gunpowder. The inspiration stemmed from a school of thought growing within a population of physicians trained as mathematicians, engineers, and astrologers prior to entering the medical profession. Berengario may have been the first to record the use of such a unique drill, but whether he invented this instrument or merely adapted its use for the craniotomy remains clouded.

Detection of Spreading Depolarization with Intraparenchymal Electrodes in the Injured Human Brain

Spreading depolarization events following ischemic and traumatic brain injury are associated with poor patient outcome. Currently, monitoring these events is limited to patients in whom subdural electrodes can be placed at open craniotomy. This study examined whether these events can be detected using intra-cortical electrodes, opening the way for electrode insertion via burr hole. Animal work was carried out on adult Sprague-Dawley rats in a laboratory setting to investigate the feasibility of recording depolarization events. Subsequently, 8 human patients requiring craniotomy for traumatic brain injury or aneurysmal subarachnoid hemorrhage were monitored for depolarization events in an intensive care setting with concurrent strip (subdural) and depth (intra-parenchymal) electrode recordings. (1) Depolarization events can be reliably detected from intra-cortically placed electrodes. (2) A reproducible slow potential change (SPC) waveform morphology was identified from intra-cortical electrodes on the depth array. (3) The depression of cortical activity known to follow depolarization events was identified consistently from both intra-cortical and sub-cortical electrodes on the depth array. Intra-parenchymally sited electrodes can be used to consistently identify depolarization events in humans. This technique greatly extends the capability of monitoring for spreading depolarization events in injured patients, as electrodes can be sited without the need for craniotomy. The method provides a new investigative tool for the evaluation of the contribution of these events to secondary brain injury in human patients.

Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

Repeat head computed tomography after minimal brain injury identifies the need for craniotomy in the absence of neurologic change

In this era of cost containment, the value of routine repeat head computed tomography (CT) in patients with mild TBI (mTBI) and no interval neurologic change has been challenged. The purpose of this study was to test the hypothesis that routine repeat head CT provides critical information after mTBI even with no neurologic change. From January 1996 to May 2010, records from all patients admitted to our Level I trauma center with an arrival Glasgow Coma Scale (GCS) score of 13 to 15 and at least one head CT were retrospectively reviewed. In 360 patients with mTBI and positive initial head CT finding, the most common abnormalities were subarachnoid hemorrhage (64%), intraparenchymal hemorrhage (57%), and subdural hemorrhage (40%). Scans were repeated in 8 ± 6 hours; 11% were recalled, 59% remained stable, but 30% showed injury progression. Those patients with worsening repeat head CT finding had higher Injury Severity Score (ISS), were more likely to be intubated and require craniotomy, had longer stay, and had higher mortality (all p < 0.001). On multiple logistic regression, altered GCS score (odds ratio, 3.1-4.0), ISS (odds ratio, 1.1), and presence of mass effect (odds ratio, 2.0) were independently associated with worsening repeat head CT finding. In patients receiving a neurosurgical operative intervention, 32% to 59% had no clinical decline before the worsening repeat CT finding. After mTBI, worsening of repeat head CT finding is seen in a third of patients and is associated with worse outcomes. A substantial fraction of patients who require operative intervention will have no clinical changes in the first 8 hours, supporting the value of repeat head CT within this time frame. Care management study, level III.