Need For Neurosurgical Intervention Research Articles

Impact of age and anticoagulation

Of the 500,000 brain injuries in the United States annually, 80% are considered mild (mild traumatic brain injury). Unfortunately, 2% to 3% of them will subsequently deteriorate and result in severe neurologic dysfunction. Intracerebral changes in the elderly, chronic oral anticoagulation, and platelet inhibition may contribute to the development of intracranial bleeding after minor head injury. We sought to investigate the association of age and the use of anticoagulation and antiplatelet therapy with neurologic deterioration and the need for neurosurgical intervention in patients presenting with mild traumatic brain injury. A retrospective review of all adult (>14 years) patients admitted to our Level I trauma service with a Glasgow Coma Scale (GCS) score of 14 to 15 who underwent neurosurgical intervention during their hospital stay was performed. Patients were stratified into two groups, age <65 years and age ≥ 65 years. Each group was then further stratified by the use of anticoagulants: warfarin, aspirin, clopidogrel, or a combination. Mechanism of injury, prehospital complaints, admission GCS, type of neurosurgical intervention, intensive care unit length of stay, hospital length of stay, and discharge disposition were evaluated. Z test and logistic regression were used to compare proportions or percentages from different groups. Of the 7,678 patients evaluated during the study period, 101 (1.3%) required neurosurgical intervention. The ≥ 65 years population underwent significantly more interventions as did those patients on anticoagulants. All patients aged 65 years or older who present with a GCS score of >13 after head trauma should undergo a screening computed tomography of the head regardless of prehospital use of anticoagulation. Patients younger than 65 years can be selectively screened based on presenting complaints and mechanism of injury provided they are not on anticoagulation.

Serum levels of ubiquitin C-terminal hydrolase distinguish mild traumatic brain injury from trauma controls and are elevated in mild and moderate traumatic brain injury patients with intracranial lesions and neurosurgical intervention

This study compared early serum levels of ubiquitin C-terminal hydrolase (UCH-L1) from patients with mild and moderate traumatic brain injury (TBI) with uninjured and injured controls and examined their association with traumatic intracranial lesions on computed tomography (CT) scan (CT positive) and the need for neurosurgical intervention (NSI). This prospective cohort study enrolled adult patients presenting to three tertiary care Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score 9 to 15. Control groups included normal uninjured controls and nonhead injured trauma controls presenting to the emergency department with orthopedic injuries or motor vehicle crash without TBI. Blood samples were obtained in all trauma patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for UCH-L1 (ng/mL ± standard error of the mean). There were 295 patients enrolled, 96 TBI patients (86 with GCS score 13-15 and 10 with GCS score 9-12), and 199 controls (176 uninjured, 16 motor vehicle crash controls, and 7 orthopedic controls). The AUC for distinguishing TBI from uninjured controls was 0.87 (95% confidence interval [CI], 0.82-0.92) and for distinguishing those TBIs with GCS score 15 from controls was AUC 0.87 (95% CI, 0.81-0.93). Mean UCH-L1 levels in patients with CT negative versus CT positive were 0.620 (± 0.254) and 1.618 (± 0.474), respectively (p < 0.001), and the AUC was 0.73 (95% CI, 0.62-0.84). For patients without and with NSI, levels were 0.627 (0.218) versus 2.568 (0.854; p < 0.001), and the AUC was 0.85 (95% CI, 0.76-0.94). UCH-L1 is detectable in serum within an hour of injury and is associated with measures of injury severity including the GCS score, CT lesions, and NSI. Further study is required to validate these findings before clinical application. II, prognostic study.

Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center

This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with "clinically important" brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15. This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of "any traumatic intracranial injury" on CT. Secondary outcomes included "clinically important brain injury" on CT and need for neurosurgical intervention. Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had "clinically important" brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For "clinically important" brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention. In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?

More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13-15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12-24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics. A retrospective review of all patients admitted to a Level I trauma center from January 2007 through December 2008 was performed using the hospital Trauma Registry Database, medical records, and imaging data. The inclusion criteria were as follows: 1) an admission GCS score ≥ 13; 2) an isolated head injury with no other injury requiring ICU admission; 3) an initial head CT scan positive for ICH; and 4) an initial management plan that was nonoperative. Collected data included age, etiology, initial GCS score, time of injury, duration of ICU stay, duration of hospital stay, and anticoagulation status. Primary outcomes measured were the occurrence of neurological or medical decline and the need for neurosurgical intervention. Imaging data were analyzed and classified based on the predominant blood distribution found on admission imaging. Data were further categorized based on the Marshall CT classification, Rotterdam score, and volume of intraparenchymal hemorrhage (IPH). Progression was defined as an increase in the Marshall classification, an increase in the Rotterdam score, or a 30% increase in IPH volume. Three hundred twenty-one of 1101 reviewed cases met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%. Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age over 65 years, and a volume of ICH > 10 ml. Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.

Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation

BACKGROUND Patients with minor head injury [Glasgow Coma Scale (GCS) score 13-15] have a small but important risk of intracranial injury (ICI) that requires early identification and neurosurgical treatment. Diagnostic assessment can use either a clinical decision rule or unstructured assessment of individual clinical features to identify those who are at risk of ICI and in need of computerised tomography (CT) scanning and/or hospital admission. Selective use of CT investigations helps minimise unnecessary radiation exposure and resource use, but can lead to missed opportunities to provide early treatment for ICI.

Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury

The Glasgow Coma Scale (GCS) score is widely used to assess patients with head injury but has been criticized for its complexity and poor interrater reliability. A 3-point Simplified Motor Score (SMS) (defined as obeys commands=2, localizes pain=1, and withdraws to pain or worse=0) was created to address these limitations. Our goal is to validate the SMS in the out-of-hospital setting, with the hypothesis that it is equivalent to the GCS score for discriminating brain injury outcomes. This was a secondary analysis of an urban Level I trauma registry. Four outcomes and their composite were studied: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The out-of-hospital GCS score and SMS were evaluated by comparing areas under the receiver operating characteristic curve with a paired nonparametric approach. Multiple imputation was used for missing data. A clinically significant difference in areas under the receiver operating characteristic curve was defined as greater than or equal to 0.05, according to previous literature. We included 19,408 patients, of whom 18% were tracheally intubated, 18% had brain injuries, 8% required neurosurgical intervention, and 6% died. The difference between the area under the receiver operating characteristic curve for the out-of-hospital GCS score and SMS was 0.05 (95% confidence interval [CI] -0.01 to 0.11) for emergency tracheal intubation, 0.05 (95% CI 0 to 0.09) for brain injury, 0.04 (95% CI -0.01 to 0.09) for neurosurgical intervention, 0.08 (95% CI 0.02 to 0.15) for mortality, and 0.05 (95% CI 0 to 0.10) for the composite outcome. In this external validation, SMS was similar to the GCS score for predicting outcomes in traumatic brain injury in the out-of-hospital setting.

Comparison of Clinical Performance of Cranial Computed Tomography Rules in Patients With Minor Head Injury: A Multicenter Prospective Study

The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma. This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules. A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to 48.5%). The sensitivity and specificity for neurosurgical intervention were as follows: CCHR, 100% (95% CI = 59.0% to 100.0%) and 38.3% (95% CI = 34.5% to 41.9%); NOC, 100% (95% CI = 54.1% to 100.0%) and 20.4% (95% CI = 17.4% to 23.7%); and NEXUS-II, 95.1% (95% CI = 90.1% to 98.0%) and 41.4% (95% CI = 39.5% to 43.2%). Among the enrolled population, intersection patients of CCHR, NOC, and NEXUS-II totaled 588. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 73 of 98 (74.5%, 95% CI = 64.7% to 82.8%) and 201 of 490 (41.0%, 95% CI = 36.6% to 45.5%); NOC, 89 of 98 (90.8%, 95% CI = 83.3% to 95.7%) and 112 of 490 (22.9%, 95% CI = 19.2% to 26.8%); and NEXUS-II, 82 of 98 (83.7%, 95% CI = 74.8% to 90.4%) and 172 of 490 (35.1%, 95% CI = 30.9% to 39.5%). The potential reduction in emergency CT scans by using these decision rules would have been higher with the NEXUS-II rule (39.6%, 95% CI = 37.8% to 41.4%) than with the CCHR rule (27.0%, 95% CI = 23.7% to 30.3%) or NOC rule (20.2%, 95% CI = 17.2% to 23.3%). For clinically important TBI, the three cranial CT decision rules had much lower sensitivities in this population than the original published studies, while the specificities were comparable to those studies. The sensitivities for neurosurgical intervention, however, were comparable to the original studies. The NEXUS-II rule showed the highest reduction rate for CT scans compared to other rules, but failed to identify all undergoing neurosurgical intervention for their original inclusion cohort.

Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need. The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded. During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15. Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.

317: Glasgow Coma Scale of 15 Excludes Need for Immediate Neurosurgical Care but Not Presence of Intracranial Hemorrhage In EMS-Transported Trauma Patients

Accurate triage of head injured patients is an essential function of EMS systems. Identification of critical injuries in otherwise well-appearing patients is challenging and complicated by underlying co-morbidities and patient medication use. 1) To assess whether a normal Glasgow Coma Scale (GCS=15) may be used to exclude need for emergent treatment for intracranial injury in patients without physiologic or anatomic criteria for emergent triage in EMS transported patients; 2) To assess whether use of anti-coagulants or anti platelet drugs impact this triage decision. A secondary analysis of a cohort of EMS patients transported to a single Level 1 trauma Center. As part of a multicenter trial, EMS providers who transported injured patients were interviewed immediately after hospital arrival during a two-year period. The interview collected patient physiologic condition, apparent anatomic injury, mechanism of injury (MOI), medical history and medications. Initial GCS on scene was used for analysis. Our outcome was need for neurosurgical care within 4 hours, or administration of blood products (FFP, platelets or concentrated clotting factors) within 8 hours for intracranial injury. Odds ratios and 95% CI are presented. During this study period, there were 2310 patients transported by EMS, 1872 had a GCS =15 on EMS arrival, and a completed interview. Of this 1872, 118 met physiological or anatomic criteria for emergent triage and were excluded. Of the remaining 1753, 121(6.9%) patients were on coumadin, and 357(20.3%) were on one or more anti-platelet drugs ( aspirin, 305, clopidogrel 101 aggrenox, 15). Overall, 27 (1.5%) patients had intracranial hemorrhages, of which two required craniotomy: one at 8 hours; and a second at 30 hours. Of those with intracranial hemorrhage, 16 (64%) received blood products within 8 hours. There was an increased incidence of intracranial hemorrhage in patients on coumadin (OR 4.3, 95% CI 1.5, 12.4) and antiplatelet drugs (OR 3.2, 95% CI 1.4, 7.2) versus patients on no medications. In this population, an initial GCS =15, excluded the need for rapid neurosurgical intervention but not emergent care (reversal of anti-coagulation) for intracranial injury. We cannot assess whether early treatment with blood products may have obviated the need for neurosurgical intervention. Triage decisions regarding these patients must balance the low rate for injury and potential need for treatment in this population

86: Comparison of the Canadian CT Head Rule and the New Orleans Criteria In Minor Head Injury Patients With Glasgow Coma Scale 15/15

To compare clinical performance of Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) for detecting need for neurosurgical intervention and clinically important brain injury in minor head injury patients with Glasgow Coma Scale 15/15.

Clinical Predictors of Minor Head Injury Patients Presenting with Glasgow Coma Scale Score of 14 or 15 and Requiring Neurosurgical Intervention

IntroductionMinor head injury is the most common type of head injury assessed in accident and emergency departments. Emergency physicians have concerns in discharging patients with intracranial injuries which require neurosurgical interventions. The aim of this study is to find out the clinical signs and symptoms which can help to predict who need neurosurgical intervention following minor head injury.MethodsThis was a retrospective case‐control study. Patients with head injury and GCS score of 14 or 15 and requiring neurosurgical intervention were recruited. Another group of patients with head injury and GCS score of 14 or 15 but not requiring neurosurgical intervention were enrolled as control. In all cases, clinical signs and symptoms were collected by chart review of the clinical records retrieved by the computerized Clinical Data Analysis &amp; Reporting System (CDARS). The relationship between clinical features and need of neurosurgical intervention was analyzed by chi‐square test with 95% confidence interval.ResultsA total of 22 cases were found and compared with 288 controls to study on the clinical variables for the prediction of the need of neurosurgical intervention. Six warning signs were found statistically significant by univariate analysis: severe headache (p=0.0206), vomiting more than once (p&lt;0.0006), drop in GCS (p&lt;0.0001), confusion/restlessness (p&lt;0.0001), bleeding from ear (p&lt;0.0001) and skull fracture in the X‐ray (p&lt;0.0001).ConclusionPatients with minor head injury presenting with GCS score of 14 or 15 to the accident and emergency department rarely require neurosurgical intervention. Some clinical risk factors can be used as a guide to identify those who need neurosurgical intervention following minor head injury.

Association between linear skull fractures and intracranial hemorrhage in children with minor head trauma

To determine whether skull fractures can be used to associate intracranial hemorrhage with minor head trauma (MHT). We conducted a retrospective study evaluating the association between linear skull fractures and intracranial hemorrhage among children with MHT. Furthermore, we evaluated the significance of small intracranial hemorrhages by assessing the need for neurosurgical interventions. The case group included 114 children with a diagnosis of a linear skull fracture and the control group included 125 children without the diagnosis. We conducted multivariable logistic regression analyses to estimate the odds ratio (OR) between linear skull fractures and intracranial bleeding. Among the cases, 29 of 114 (25%) children were diagnosed with an intracranial hemorrhage on CT, compared to only 14 of 125 (11%) among the controls. The multivariable OR for intracranial hemorrhages comparing cases and controls adjusted for age and gender was 2.17 (95% confidence interval [CI]: 1.01, 4.68). All the intracranial hemorrhages were small (3.8 +/- 2.3 mm) and none of them required any neurosurgical intervention. The presence of a linear skull fracture is an independent risk factor for intracranial hemorrhage. However, all the intracranial hemorrhages associated with the skull fractures were small and did not require any neurosurgical interventions.

Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions. A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores. There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up. Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

Is it Necessary to Operate All Split Cord Malformations Before Corrective Surgery for Patients With Congenital Spinal Deformities?

Retrospective case series. To evaluate the necessity of neurosurgical interventions for split cord malformations (SCMs) before correction and instrumentation for patients with congenital spinal deformity(CSD)s. SCMs are commonly associated with CSD. As pathology of SCMs understood well, the common belief of all SCM must be operated before any orthopedic intervention is needed to be revised. Sixty-one consecutive patients with CSD and spinal dysraphism treated by correction and posterior instrumentation between 1994 and 2005 were retrospectively evaluated. Inclusion criteria were patients with CSD and SCM, who were treated with long segment instrumentation (more than 6 functional units) with at least 2 years of follow-up. Thirty-two patients (8 male and 24 female) with an age average of 11 years +8 months (4-18 years) fulfilled the criteria. While all patients with Type I SCM were managed with neurosurgical intervention (spur excision and dural reconstruction) before corrective surgery, Type II SCM cases were treated by instrumented fusion without neurologic intervention. There were 18 patients with Type I and 14 patients with Type II SCM. The average follow-up was 52 (24-144) months. The correction rate of deformity was 44% in type I and 47% in Type II SCM. Two patients with Type II SCM had transient neurologic deterioration while there were no neurologic events in patients with Type II SCM. Due to high incidence of SCMs, all patients with CSDs must be evaluated with MRI, before surgery. Neurosurgical interventions are recommended even for neurologically asymptomatic Type I SCM before spinal deformity surgery; however, patients with Type II SCM can be treated safely without a need of neurosurgical intervention.

Intracranial complications of sinusitis: what is the role of endoscopic sinus surgery in the acute setting

Objective Intracranial complications of sinusitis (ICS) are uncommon in the antibiotic era. The role of neurosurgical drainage of ICS is fairly well established, but the role for acute surgical intervention for the sinus disease is not well defined. We retrospectively reviewed our experience with ICS to see if we could identify the role and effectiveness of endoscopic sinus surgery (ESS) in the acute setting of ICS. Methods The study used a retrospective review of patients presenting to a tertiary care academic medical center for a 6-year period. Results Twenty-three patients were identified with ICS, including epidural (8), subdural (10), intracerebral abscesses (2), and meningitis (3). Males were more affected than females (7:1). Twenty patients were 21 years old or younger. Twenty-two patients (96%) had radiologic evidence of frontal sinusitis with prefrontal or frontal lobe ICS at presentation. Medical therapy alone was successful in avoiding craniotomy in only 3 of 8 cases. Endoscopic sinus surgery and intravenous antibiotics as initial treatment was successful in avoiding craniotomy in only 1 of 6 patients. Of 23 patients, 18 underwent neurosurgical procedures—9 emergent procedures for abscesses more than 1 cm and 9 delayed procedures for persistent disease despite ICS less than 1 cm at presentation. Conclusions Intracranial complications of sinusitis usually result from indirect spread of acute frontal sinusitis. The role of ESS in the initial treatment of ICS is not clear. In our series, ESS did not appear to alter the need for neurosurgical intervention, which was ultimately necessary in most patients with ICS, even with lesions less than 1 cm.

Outcome of Severe Head Injured Patients Admitted to Intensive Care During Weekday Shifts Compared to Nights and Weekends

Some studies have demonstrated an increased risk of death for patients admitted at nights or during weekends. This study was undertaken to investigate the demographic profile, medical interventions and outcome of severe head injury patients stratified according to day and time of admission to a specialised neurosciences intensive care unit (NICU). A retrospective study using a prospectively maintained severe head injury database in a tertiary hospital. Admissions to the NICU were grouped into weekdays, weeknights and weekends. A comparison of patients admitted during the day and night hours were also made. A total of 838 severe head injury patients admitted to NICU were included in the study, of which 263 were admitted on weekdays, 327 on weeknights and 248 on weekends. More patients were admitted during the night (496) compared to during the day (342). There were no significant differences in the demographic profile, mechanism of injury, severity of injury, need for neurosurgical intervention, and duration of mechanical ventilation, intensive care unit (ICU) stay and mortality associated with day and time of admission. In multivariate analyses controlling for confounding factors, no statistically significant difference in ICU mortality was found with the day and time of admission. There were more severe head injury patients admitted to ICU at night and on weekends, with no significant difference in demographic profile, types of injuries, need for neurosurgical interventions and duration of ICU stay and mortality in a specialised NICU with adequate staffing and requisite diagnostic and therapeutic modalities available.

Intracranial mass lesions in HIV/AIDS patients from developing countries endemic for neurocysticercosis

In HIV-infected patients neurological signs and symptoms can be frequent first clinical presentations; the detection of intracranial mass lesions on computed tomography (CT) or magnetic resonance imaging (MRI) is a frequent problem because of difficult diagnosis and management. Opportunistic infections such as Mycobacterium tubercolosis Toxoplasma gondii Cryptococcus neoformans as well as primary central nervous system lymphoma can show the same radiological imaging. Correct diagnosis is necessary to prescribe appropriate therapy and also to obviate the need for neurosurgical intervention. Smego et al. have presented a simplified and therapeutic algorithm for approaching intracranial mass which is useful for both developed and resourced-limited countries. The algorithm is based upon CD4+ lymphocyte count specific serology chest X-ray neuroradiology and routine lumbar puncture study. We would also like to underline the possibility of inserting in these screenings serological testing for Neurocysticercosis at least for patients coming from developing countries of Central and South America sub-Saharan Africa and east and south Asia where the disease is endemic. (excerpt)

Images in Neurology: Giant Tumefactive Perivascular Spaces Associated with Pediatric Hemiplegic Migraine

A 17 year old right handed female with a past medical history of migraine presented with left hemisensory paresthesias and transcient hemiparesis lasting 2 hours. Diffusion MRI revealed no evidence of acute infarction. Additional MRI sequences demonstrated large non-enhancing cystic structures of the left cerebellum and pons. The patient was placed on daily Topiramate migraine prophylaxis without reoccurrence of symptoms at 2 years. Giant tumefactive perivascular spaces, otherwise known as prominent Virchow-Robin spaces, are pial-lined structures containing interstitial fluid and penetrating arteries/arterioles.1-2 They may be confused with cystic neoplasms and can occasionally be associated with headache and hydrocephalus. This case illustrates the importance of distinguishing enlarged perivascular spaces from a vascular malformation or cystic neoplasm; obviating the need for neurosurgical intervention.

Prediction of Outcome at Discharge From Acute Care Following Traumatic Brain Injury

To compute outcome probabilities for persons with traumatic brain injury at discharge from acute care. Three hundred thirty-nine patients with traumatic brain injury (239 mild, 48 moderate, 52 severe). Level I trauma center. Predictor variables considered were age, education, Glasgow Coma Scale score, duration of posttraumatic amnesia, cerebral imaging results, and need for neurosurgical intervention. Outcome measures were Extended Glasgow Outcome Scale and discharge destination. Logistic regressions showed that a shorter posttraumatic amnesia decreased the probability of moderate to severe disability. Moreover, discharge home was less probable for patients with positive cerebral imaging. This model can help predict rehabilitation needs upon discharge from an acute care hospital.

Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children

Background: A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at...