Neurosurgical Emergency Research Articles

Portable ultrasound-guided Trans-sylvian minimally invasive intracerebral hemorrhage surgery: how I do it.

Intracerebral hemorrhage (ICH) is a common neurosurgical emergency with high morbidity and mortality. The trans-sylvian microsurgical evacuation of ICH in the basal ganglia is a classic but technically challenging approach. We describe a novel technique using handheld portable ultrasound to guide trans-sylvian, trans-insular evacuation of basal ganglia hematomas, allowing for rapid identification, precise evacuation, and post-evacuation assessment from a small Sylvian fissure opening. Intraoperative portable ultrasonography is a rapid, simple, and inexpensive technique that provides real-time visualization of ICH and key cortical structures, minimizing potential damage during exposure and exploration.

Literature Review: Historical Review of Traumatic Brain Injury Caused by Fishing Speargun & a New Suicide Case

Traumatic brain injury (TBI) is a severe neurosurgical emergency and a significant public health concern. Fishing spearguns TBIs are included in nonmissile injuries and have been implicated in only few cases of TBI in the past 68 years, mainly of accidental etiology. To introduce a novel case report of a TBI in a 38-year-old man shot himself with a speargun in a suicide attempt and to present a thorough review of related case reports along with the management strategies, prognosis, and outcomes. We conducted a literature review of case reports in accordance with the PRISMA guidelines, including incidents of TBI by speargun published in Pubmed, Scopus, and Web of Science until January 2024. A total of 22 publications, reporting 26 cases of speargun-related TBIs formulated the 27 investigated cases including the current patient which were used in this descriptive and inferential statistical analysis. Predominantly affecting males (88.89%) with a median age of 29 years, these injuries were primarily due to accidents (65.38%), with a noticeable shift towards suicide. Outcome variability ranged from intact recovery (48.15%) in majority of cases to a range of unfavorable outcomes. Significant factors impacting outcomes included initial GCS score <8, major initial CT head findings, and major complications. Survival analysis indicated early manifestation of unfavorable outcomes. In summary, the diverse presentation, management, outcomes and identified influencing factors highlight the complexity of managing speargun-related injuries, and the need for personalized approaches and further research to enhance care protocols.

Evaluation of incidence and outcomes of compressive extradural haematoma-related infarcts in the paediatric population.

Traumatic extradural haematoma (EDH) is one of the neurosurgical emergencies in the paediatric population. One of the rare complications of extradural haematoma is adjacent parenchymal infarct from the compressive effect of haematoma leading to further morbidity. We aimed to evaluate the incidence and outcomes of this rare complication in paediatric trauma patients. We undertook a retrospective review of all operative extradural haematoma cases in single centre paediatric neurosurgical unit between the years 2008 and 2024. Cases with postoperative imaging were analysed for demographics, age, sex, dimensions of haematoma and underlying infarct, pre-operative GCS and pupillary abnormality and time interval from scan to surgery. Infarct was defined as well-defined parenchymal hypodensity corresponding to vascular territory and not attributable to contusions on postoperative CT head performed at 24-72 h. All patients suspected of stroke had further MRI brain for evaluation. Statistical analysis was then performed comparing groups with and without infarct. Overall, 115 cases of extradural haematoma were identified during the study period. Eighty cases had adequate postoperative imaging to allow assessment for infarcts; 7.5% demonstrated evidence of infarct underlying extradural haematoma. Mean age in the infarct group was 1.8 years (M:F ratio 2:1) with mean EDH dimensions of 77 mm × 31.4 mm × 79.7 mm). Mean age in the non-infarct group was 8.6 years (M:F ratio 2:1) with mean EDH dimensions of (57.5 mm × 19.6 mm × 62.6 mm). Children with infarcts were significantly younger with larger haematoma dimensions and hada higher proportion of pupillary abnormalities. There was no significant difference in pre-operative GCS and scan-to-surgery time-lapse between the groups with and without infarct. Compressive effect of EDH can lead to underlying parenchymal infarct. Children with extradural haematoma-related infarct were younger with larger haematoma size and a higher proportion of pupillary abnormalities.

Traumatic Tension Pneumocephalus with mount Fuji sign and air bubble sign

Introduction: Tension Pneumocephalus is a rare but a life threatening neurosurgical emergency which may need urgent surgical intervention. For diagnosis Brain imaging preferably Brain CT scan is mandatory. Case presentation: We present a rare case case of post traumatic tension Pneumocephalus in 40 years old man who sustained a road traffic accident. Brain CT scan shows Mount Fuji sign and air bubble sign, which are the typical signs of tension Pneumocephalus. Emergency burr-hole evacuation was carried out and after the procedure the patient was followed by control lateral skull X-ray and then discharged after 10 days of hospital Stay with GCS of 15. Conclusion: Tension Pneumocephalus is a clinical diagnosis. History with Brain Imaging can easily diagnose it but invasive surgical intervention may be Mandatory to overcome the problem. Knowledge of risk factors ,radiographic findings and clinical signs/symptoms associated with Tension Pneumocephalus is crucial to its Prompt identification and treatment.

Clinical management of a ruptured intracranial aneurysm

BackgroundIntracranial hemorrhage due to a ruptured aneurysm is one of the most serious neurosurgical emergencies. The patient mostly presents with severe headaches and neurological deterioration. A rapid diagnosis and an interdisciplinary approach play a major role in the fate of these patients. The treatment can vary from endovascular to surgical and must be carefully and individually planned. Neurovascular expertise and an interdisciplinary approach are of vital importance and obligatory for the best possible outcome.MethodsIn this narrative review, we scrutinize the current literature and discuss the actual data and guidelines in order to emphasize the importance of the interdisciplinary expertise and approach in patients with ruptured intracranial aneurysm.ResultsThe current approach to patients with ruptured aneurysm is inhomogeneous and often ineffective due to internal disputes between different disciplines. Although there is plenty of literature and hard evidence to “show the way,” many still choose to base their decisions on personal experience or opinion.ConclusionsEvery ruptured brain aneurysm should be approached in an interdisciplinary manor and treated according to the current evidence and guidelines.

Pituitary Apoplexy: Comorbidities, Management and Outcomes. A Spanish Observational Multicenter Study

Abstract Background Pituitary apoplexy (PA) is the paradigm of endocrine and neurosurgical emergency. Objective To evaluate the comorbidities, risk factors, clinical presentation, pituitary apoplexy score (PAS) and the outcomes of surgical vs. conservative management of PA in Spain. Methods Spanish multicenter, observational study of 301 patients with acute PA. Statistical analyses compared risk factors, clinical presentation and outcomes between the surgical and conservative treatment groups, adjusting for potential confounders. The prevalence of cardiovascular risk factors in patients with pituitary apoplexy was compared with the Spanish population and with patients with non-functioning pituitary adenomas. Results Median age was 59.3 years, 201 (66.8%) were men and non-functioning adenomas (77.9%) were the most common tumor type. The prevalence of diabetes (20.3% vs 13.9%, p&amp;lt;0.01), hypertension (48.8% vs 33.4%, p&amp;lt;0.01) and dyslipidemia (44.2% vs 23.3%, p&amp;lt;0.01), exceeded the Spanish age-adjusted population prevalence. Overall, 209 (69.4%) underwent surgery and 92 (30.6%) received conservative treatment. Surgical patients had larger tumors (26.2 vs 21.0 mm, p&amp;lt;0.01), chiasmal compression more frequently (77.2% vs 53.4%, p&amp;lt;0.01) and higher values of PAS. In the follow-up, while there were no statistically significant differences in anterior pituitary hormonal deficits between treatments, permanent vasopressin deficiency was more frequent after surgery (14.8% vs 3.3%, p&amp;lt;0.01). Conclusion There is a high burden of cardiovascular risk factors among patients with PA suggesting that metabolic factors may play a potential role in the development of PA. This underscores the need for comprehensive management of these conditions in addition to treating the apoplexy itself in this population. Surgical management has a relevant place in PA approach mainly in patients with higher PAS. However, it leads permanent vasopressin deficit more frequently than conservative approach.

Cervical epidural hematoma: a case series highlighting uncommon causes

BackgroundCervical epidural hematoma (CEH) is a rare but potentially devastating condition, characterized by the accumulation of blood within the epidural space of the cervical spine, leading to spinal cord compression (Perron AD, Huff JS. Spinal cord disorders. In: Marx JA, et al. editors. Rosen’s emergency medicine: concepts and clinical practice. 8th ed. Philadelphia: Saunders; 2013. pp. 1419–27.); (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Ryo Yamamoto M, Ito H, Shimuzu K, Wakabayashi H, Oyama. Two cases of cervical epidural hematoma presenting with left-sided hemiplegia and requiring surgical drainage. Cureus. 2022;14(4):e23915. https://doi.org/10.7759/cureus.23915.). While trauma and iatrogenic causes are well-documented, cases attributed to neck strain and acupuncture are uncommon. (Raasck K, Habis AA, Aoude A, Simoes L, Barros F, Reindl R. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. https://doi.org/10.1038/scsandc.2016.43.); (Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of an acupuncture. Neurology. 1979;29(8):1188–90. https://doi.org/10.1212/wnl.29.8.1188.) Here, we present two cases of CEH secondary to these unusual aetiologies. Both cases highlight the importance of considering uncommon causes of CEH to ensure early recognition and prompt treatment.Case presentationsCase 1 is an 81-year-old lady who presented with left hemiparesis and paraesthesia following a fall with neck strain. Magnetic resonance imaging (MRI) of cervical spine revealed left C3-C7 epidural haematoma with severe cord compression. In Case 2, a 35-year-old gentleman experienced sudden onset numbness and weakness in all limbs just 10 minutes after receiving acupuncture. MRI showed an epidural hematoma at the C2-C4 levels. Both patients underwent immediate surgical decompression and had significant recovery.ConclusionAlthough CEH is a rare occurrence, it can potentially be a neurosurgical emergency. Physicians must remain cognizant of the diverse aetiologies associated with CEH and the necessity for early recognition and immediate treatment.

Cauda equina syndrome successfully treated with microdiscectomy and methylprednisolone therapy: A case report

Cauda equina syndrome (CES) caused by lumbar disc herniation is a rare neurosurgical emergency in young adults that requires immediate decompression. A surgical delay over 48 hours may result in irreversible ramifications, underscoring a crucial timeframe for managing this condition. We presented a 26-year-old man with lower limb weakness persisting for one week, accompanied with exacerbating bowel and bladder issues after massage. The patient had a history of low back pain and tingling sensations radiating to the left leg over the past year. His physical examination showed right motor strength of 5/4 and left motor strength of 5/3, with weakened bowel peristalsis, loose anal sphincter and saddle anaesthesia. A spinal MRI revealed protruded discs extending to the intervertebral levels of L4-L5 and L5-S1, implicating herniated discs as the likely cause of CES. He underwent a microdiscectomy with a posterior approach, and intravenous methylprednisolone was administered before the procedure. The next surgery demonstrated enhancements in motor strength, bowel and bladder function, and it also reduced pain. He was discharged with persistent tingling sensations in his both legs. We concluded that CES represents a critical neurosurgical emergency, which is diagnosed through clinical symptoms and neuroimaging. Rapid decompression and intravenous administration of methylprednisolone are associated with better prognosis.

Portable ultrasound-guided keyhole evacuation of intracerebral hemorrhage: a detailed case report highlighting technical nuances.

Intracerebral hemorrhage (ICH) is a common neurosurgical emergency that is associated with high morbidity and mortality. Minimally invasive or endoscopic hematoma evacuation has emerged in recent years as a viable alternative to conventional large craniotomies. However, accurate trajectory planning and placement of the tubular retractor remains a challenge. We describe a novel technique for handheld portable ultrasound-guided minimally invasive endoscopic evacuation of supratentorial hematomas. A 64-year-old male diagnosed right hematoma (48.5 mL) at the basal ganglia was treated with emergent ultrasound-guided endoscopic transtubular evacuation through a small craniotomy. Ultrasound-guidance facilitated optimal placement of the tubular retractor into the long axis of the hematoma, and allowed for near-total evacuation, reducing iatrogenic tissue damage by mitigating the need for wanding or repositioning of the retractor. The emergence of a new generation of small portable phased array ultrasound probes with improved resolution and clarity has broadened ultrasound's clinical applications.

Pituitary Apoplexy: a re-appraisal of risk factors and best management strategies in the COVID-19 era.

Pituitary apoplexy (PA) is a clinical syndrome caused by acute hemorrhage and/or infarction of the pituitary gland, most commonly in the setting of a pituitary macroadenoma. PA generally presents with severe headache, nausea, vomiting, visual disturbance, and, in more severe cases, altered mental status. Many factors have been attributed to the risk of developing PA, including most recently, numerous reports showcasing an association with COVID-19 infection or vaccination. Initial management of PA includes evaluation and correction of deficient hormones and electrolytes and an assessment if surgical decompression to relieve pressure on optic nerves and other brain structures is needed. While prompt recognition and treatment are crucial to avoid morbidity and mortality, in the modern era, PA is less commonly considered a true neurosurgical emergency requiring immediate (< 24h) surgical decompression. Traditionally, surgical decompression has been the standard of care for significant mass effects. However, several studies have shown similar outcomes in visual and hormonal recovery with either surgical decompression or conservative medical management. Unfortunately, most evidence on optimal management strategies is limited to retrospective case series, small prospective studies, and one multi-center observational study. This review aims to provide the most up-to-date evidence on the role of COVID-19 in PA and best management strategies.

Post-Operative Complications of Traumatic Thoracolumbar Spine Surgery: Experience of the P11 Neurosurgical Emergency Department—CHU Ibnou Rochd Casablanca (2018–2022)

This retrospective study focuses on 110 cases of thoracolumbar trauma operated on between 2018 and 2022 in the neurosurgical emergency department. The objective is to analyze the complication rates of surgery for traumatic thoracolumbar spine pathology, identify high-risk patients and understand these complications in order to improve preoperative planning and advice to patients for better care. The results show that the frequency of complications of thoracolumbar spine surgery in this department was 28.18%. The average age of patients with complications was 41.5 years, with a male predominance (65%). The main complications were post-operative infections (38.70%) and discharge of pus through the surgical wound with infectious syndrome (32.35%). The most frequent pathological histories in patients were toxic habits (alcohol and chronic smoking), diabetes and psychiatric disorders.

Letter to the Editor: “Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan”

Letter to the Editor: “Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan”

982 Timing of MRI Spine for Patients Presenting with Suspected Cauda Equina Syndrome (CES)

Abstract Introduction Cauda Equina Syndrome (CES) is a neurosurgical emergency requiring urgent intervention within 24 to 48 hours to prevent irreversible paralysis and incontinence. Recognizing the gravity of CES, The Society of British Neurosurgeons and the British Association of Spine Surgeons set care standards in 2017, emphasizing the necessity for a 24/7 MRI service in every healthcare trust. The recently released GIRFT National Suspected CES Pathway also advocates for performing an MRI scan within 4 hours of presentation. Aim This study aimed to assess adherence to the 4-hour target for MRI scans in suspected CES cases at the Royal Surrey Hospital and examine the impact of delays on hospital stay length. Method Data from a 6-month period (August 2022 to January 2023) involving 70 patients were collected using the Cerner electronic system and inpatient lists, excluding cases of outpatient MRI and urgent transfers to Saint George's Hospital. Results Results showed an average time from Emergency Department admission to scanning of 21.3 hours (range: 3.5 to 87.4 hours), with a mean wait from request to scan of 14.5 hours (range: 0.7 to 76.7 hours). Hospital stay duration averaged 4.5 days (range: 1 to 22 days). Conclusions Recommendations include empowering ED clinicians to order MRI scans, implementing an MRI Safety questionnaire on Cerner, collaborating with radiographers to meet the 4-hour target, and advocating for a 24/7 MRI service within the trust. Subsequent re-audit efforts will evaluate the impact of these recommendations and identify factors influencing the achievement or non-achievement of the 4-hour target.

Time to traumatic intracranial hematoma evacuation: contemporary standard and room for improvement.

Traumatic intracranial hematoma (TICH) is a neurosurgical emergency with high mortality and morbidity. The time to operative decompression is a modifiable but inconsistently reported risk factor for TICH patients? We aimed to provide contemporary time to evacuation data and long-term trends in timing of TICH evacuation in a trauma system. A 13-year retrospective cohort study ending in 2021 at a trauma system with one level-1 trauma center included all patients undergoing urgent craniotomy or craniectomy for evacuation of TICH. Demographics, injury severity and key timeframes of care were collected. Subgroups analyzed were polytrauma versus isolated head injury, direct admissions versus transfers and those who survived versus those who died. Linear regression of times from injury to operating room was performed. Seventy-eight TICH patients (Age: 35 (22-56); 58 (74%) males; ISS: 25(25-41); AIS head: 5 (4-5); mortality: 21 (27%) patients) were identified. Initial GCS was 8 (3.25-14) which decreased to 3 (3-7) by arrival in the trauma center. There were 46 (59%) patients intubated prior to arrival. Median time from injury to operation was 4.88 (3.63-6.80) hours. Linear regression of injury to OR showed increasing times to operative intervention for direct admissions to the trauma center over the study period (p=0.04). There was no associated change in mortality or Glasgow outcome score over the same time. This contemporary data shows timing from injury to evacuation is approaching 5 hours. Over the 13-year study period the time to operative intervention significantly increased for direct admissions. This study will guide our institutions response to TICH presentations in the future. Other trauma systems should critically appraise their results with the same reporting standard.

Early Hydrogen–Oxygen Gas Mixture Inhalation in Patients with Aneurysmal Subarachnoid Hemorrhage (HOMA): study protocol for a randomized controlled trial

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening neurosurgical emergency with a high mortality rate. Delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) are delayed products of early brain injury (EBI), which may constitute the principal determinant of an unfavorable patient prognosis. Consequently, the mitigation of DCI and CVS assumes paramount significance in the pursuit of enhanced patient outcomes. However, except for oral nimodipine, there is no effective therapy available in the current guideline. Hence, the exigency arises to proffer novel treatment paradigms. The diversity of hydrogen therapeutic targets has been largely reported in basic research, unveiling its latent capacity to ameliorate EBI in aSAH patients.MethodsEarly Hydrogen–Oxygen Gas Mixture Inhalation in Patients with Aneurysmal Subarachnoid Hemorrhage (HOMA), a single-center, prospective, open-labeled, randomized controlled clinical trial, endeavors to evaluate the efficacy and safety of hydrogen–oxygen gas mixture inhalation therapy in aSAH patients. A cohort of 206 patients will be randomized to either hydrogen–oxygen gas mixture inhalation group (8 h per day, 3 L/min, hydrogen concentration of 67%, oxygen concentration of 33%) or oxygen inhalation group (8 h per day, 3 L/min, oxygen concentration of 33%) within 72 h after aSAH and treated for 7 days in the ICU ward. The primary outcomes are the incidence of DCI and CVS during hospitalization.DiscussionThe HOMA aims to evaluate the effectiveness of hydrogen–oxygen gas mixture inhalation therapy in preventing DCI or CVS and improving outcomes in aSAH patients. Notably, this is the first large-scale trial of hydrogen therapy in aSAH patients. Given that the Chinese population represents a significant portion of the global population and the increasing incidence of stroke due to aging, optimizing patient care is vital. Given the current challenges in aSAH patient outcomes, initiating more prospective clinical trials is essential. Recent research has shown hydrogen’s therapeutic potential, aligning with EBI in aSAH, driving our exploration of hydrogen therapy’s mechanisms in post-aneurysm rupture damage.Ethics and disseminationThe protocol for the HOMA study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KY 2022–020-02). All results of the present study will be published in peer-reviewed journals and presented at relevant conferences.Trial registrationClinicalTrials.gov NCT05282836. Registered on March 16, 2022.

Self-Trephination in Cranial Excoriation Disorder.

Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.

Paediatric Neurosurgical emergency operations:Clinical spectrum, Presentation-Intervention Interval and Early operative outcome in Regional Neurosurgical center, Nigeria

BACKGROUND: Pediatric neurosurgical emergencies are prevalent worldwide, often triggered by acute, life-threatening conditions that necessitate immediate surgery to prevent disability and death. Managing these conditions perioperatively poses significant challenges for neurosurgeons and anesthetists due to potential complications like anemia, seizures, electrolyte imbalances, intracranial hypertension, and vision threats, alongside the primary neurosurgical issues. Proper correction and optimization of these physiological derangements before surgery are crucial for favorable postoperative outcomes. PATIENTS AND METHODS: This retrospective study analyzes emergency neurosurgical operations performed on children aged sixteen and under at a neurosurgical center in Sokoto, Nigeria, from January 2018 to December 2021. The center caters to a population of approximately twenty million people from three north-western and one north-central Nigerian states, as well as neighboring Niger and Benin republics. The area features a mostly arid climate with limited seasonal rainfall and experiences the Sahara’s harmattan winds. RESULTS A total of 131 children underwent emergency neurosurgical procedures during the study period. The majority were males (71%), with an average age of 5.6 years. Hydrocephalus was the most frequent emergency condition, leading to 44.3% of surgeries, primarily through ventriculoperitoneal shunt procedures, which accounted for 42.7% of interventions. Anemia was the most common comorbid condition. The mean time from presentation to intervention was 10 days. Postoperatively, 17.9% of patients suffered from surgical site infections, yet 67.9% had favorable outcomes with a mortality rate of 7.1%. CONCLUSION: This study underscores the importance of timely surgical interventions and highlights the predominance of ventriculoperitoneal shunts in treating pediatric hydrocephalus in the region, with generally positive outcomes despite delays

Pseudosubarachnoid hemorrhage sign in a patient with tetralogy of Fallot

Subarachnoid hemorrhage (SAH) constitutes a common neurosurgical emergency. Non-contrast computerized tomography (NCCT) head has very high specificity and sensitivity in detecting SAH. However, in certain conditions, the computed tomography (CT) may be falsely positive, termed as pseudo-SAH. We hereby report a rare case of pseudo-SAH in a patient with tetralogy of Fallot and discuss the possible etiopathogenesis and the pertinent literature. We present here a case of a 15-year-old male patient, who was diagnosed with tetralogy of Fallot (TOF) physiology. He presented to the cardiology outpatient clinic with complaints of dyspnea on exertion, headache, and drowsiness. The NCCT head revealed diffuse hyperdensity in the basal cisterns and sulcal spaces, which were suggestive of diffuse SAH. However, in the setting of negative CT and magnetic resonance angiography along with high hematocrit levels (84%), diagnosis of pseudo-SAH was considered. The patient was appropriately managed with beta-blockers, intravenous fluids, and serial phlebotomies. The patient underwent a palliative shunt connecting the ascending aorta to the main pulmonary artery (central shunt), following which his saturation improved, and hematocrit decreased (40%) leading to significant symptomatic improvement. Knowledge of pseudo-SAH signs is essential for the treating physician and plays an important part in the management of this patient population.

255 Frailty Is Associated With Decreased 365-day Survival in Adult Patients With Operative and Nonoperative Traumatic Subdural Hemorrhage

INTRODUCTION: Traumatic subdural hematoma (tSDH) is observed frequently in traumatic brain injury (TBI) patients and is one of the commonest neurosurgical emergencies. tSDH patients require rapid evaluation and treatment in order to achieve the best possible results. There is a paucity of literature on frailty’s impact in TBI patients. METHODS: We performed a retrospective review of tSDH patients in the ACS-TQIP® database between 2007-2020. We employed multivariable regression models to examine the independent relationship of frailty, identified by the modified frailty index-5 (mFI-5) with the endpoints of major complications, length of stay (LOS), mortality, and discharge to a higher level of care. Additionally, we employ Kaplan-Meier (K-M) plots to examine the probability of survival following tSDH across the various mFI-5 frailty risk strata. RESULTS: 340,096 patients were managed nonoperatively and 41,658 operatively. The median age of the patients was 70.0 (IQR: 54.0, 81.0) nonoperative, and 71.0 (57.0, 80.0) operative cohorts. Multivariate analysis demonstrates a stepwise dose response relationship with outcomes p &lt; 0.001. In both cohorts, there was an 18-86% in mortality i.e. nonoperative: frail (OR: 1.18 [95% CI 1.13, 1.23]), very frail (OR: 1.75 [95% CI 1.65, 1.86]); and operative: frail (OR: 1.21 [95% CI 1.12, 1.32]), very frail (OR: 1.86 [95% CI 1.66, 2.09]). Survival probability markedly decreased across frailty strata within the first 100 days. CONCLUSIONS: Frailty was associated with major complications, LOS, mortality, and discharge to a higher-level care facility in patients with tSDH. Rapid deployment of point of care frailty risk-assessment allows clinicians to improve prognostication for patients and their families and allocate resources more precisely in order to try to achieve better outcomes.

O202: Clinical characteristics and outcomes of traumatic brain injury in a high-volume tertiary hospital in India

Abstract Background Traumatic brain injury (TBI) is a common neurosurgical emergency but its epidemiological and clinical characteristics vary across country income levels. High-quality TBI data from low and lower-middle income countries are required to inform trials and public policy in these settings. Methods We performed a prospective cohort study of patients admitted to a high-volume tertiary hospital in Vellore, India following a TBI between 2013 and 2019. We collected data on patient characteristics and measured their outcomes using the Glasgow Outcome Scale-Extended (GOSE). Results We identified 3,172 patients (84% males) with a mean age of 35 years (SD = 18). Two-wheeler road traffic accidents caused 2,259/3,172 (71%) injuries, in which 13 (0.5%) patients were wearing a helmet. The median time from injury to admission was 3 hours (IQR = 2–7). 2,363/3,172 (75%) patients did not undergo surgery and 405/3,172 (13%) underwent decompressive craniectomy and haematoma evacuation. Inpatient mortality was 5.6% (median length of stay = 6 days [IQR = 4–10]) and overall mortality at discharge from follow-up (median = 6 months [IQR = 3–9]) was 18%. Inpatient deaths most frequently occurred within two days of admission (82/174 [47%]). 2,066/3,082 (67%) patients had upper- or lower-good recovery. The IMPACT (AUC = 83%, CI: 79–87%) and Rotterdam CT prognostic scores (AUC = 79%, CI: 75–83%) predicted inpatient mortality with good performance. Conclusions We describe the TBI population of a high-volume tertiary hospital in India, including inpatient mortality, medium-term functional status, and the performance of commonly used prognostic tools.