Presence Of Midline Shift Research Articles

A comprehensive study of risk factors predicting hydrocephalus following decompressive craniectomy in traumatic brain injuries

IntroductionDecompressive craniectomy [DC] is one of the leading armaments to lower refractory intracranial pressure. Post-DC hydrocephalus [PDCH] occurs in 11.9–36% of patients undergoing DCs for TBIs. Various theories have been given regarding pathophysiological mechanism of PDCH but remain dubious. Risk factors predicting PDCH still under research. Exact timeline regarding developmental process of PDCH remains undefined.MethodThis retrospective study was conducted on 422 patients who underwent DCs in our tertiary care trauma center over the period of one year. 60 patients out of 422 who developed PDCH were analyzed with respect to demographic variables and preoperative and postoperative risk factors. A total of 20 randomly selected patients, who underwent DCs but did not develop hydrocephalus, were selected and compared with patients who developed PDCH. Outcome analysis was done by dichotomizing the groups into independent and dependent groups.ResultsAmong 422 patients undergoing DC, 14.21%[n = 60] developed PDCH. Younger [34.2 y vs 43.3 y, p = 0.0004] male age group was predominant in our study. Age [p = 0.021, multivariate analysis] and midline shift [p = 0.008, multivariate analysis] were significant preoperative predicting risk factors for PDCH. Interhemispheric hygroma [p = 0.031], brain bulge [ p = 0.008], and blood in postoperative scan [p = 0.029] were significant postoperative risk factors. Lower GCS score at admission [p = 0.0003], postoperative day 10 and at the time of establishment of PDCH were significantly predicted surgery to hydrocephalus time. Midline shift [p = 0.007] and thickness of interhemispheric hygroma [p = 0.021] were associated with poor outcome in patients with PDCH.ConclusionYounger age group and presence of midline shift are significant preoperative predictors of PDCH. Blood in postoperative scan, interhemispheric hygroma and brain bulge in postoperative period are significant predictors for PDCH. Deterioration in GCS score in postoperative period following DC should be taken as high index of suspicion for developing PDCH.

Predicting Progression of Intracranial Hemorrhage in the Prehospital TXA for TBI Trial.

Progression of intracranial hemorrhage is a common, potentially devastating complication after moderate/severe traumatic brain injury (TBI). Clinicians have few tools to predict which patients with traumatic intracranial hemorrhage on their initial head computed tomography (hCT) scan will progress. The objective of this investigation was to identify clinical, imaging, and/or protein biomarkers associated with progression of intracranial hemorrhage (PICH) after moderate/severe TBI and to create an accurate predictive model of PICH based on clinical features available at presentation. We analyzed a subset of subjects from the phase II double-blind, multi-center, randomized "Prehospital Tranexamic Acid Use for TBI" trial. This subset was limited to the placebo arm of the parent trial with evidence of hemorrhage on the initial hCT and a follow-up hCT 6 h after. PICH was defined as an increase in hemorrhage size by 30% or more, or the development of new hemorrhage in the intra- and extra-axial intracranial vault between the initial and the follow-up hCT. Two independent radiologists evaluated each hCT, and conflicts were adjudicated by a third. Clinical and radiographic characteristics were collected, along with plasma protein biomarkers at admission. Principal component analysis (PCA) was performed, and each principal component (PC) was interrogated for its association with PICH. Finally, expert opinion and recursive feature extraction (RFE) were used to select input features for the construction of several supervised classification models. Their ability to predict PICH was quantified and compared. In this subset of subjects (n = 104), 46% (n = 48) demonstrated PICH. Univariate analyses showed no association between PICH and age, sex, admission Glasgow Coma Scale (GCS), GCS motor subscore, presence of midline shift, admission platelet count or admission INR. Radiographic severity scores (Marshall score [p = 0.007], Rotterdam score [p = 0.004]), and initial hematoma volume [p = 0.005] were associated with PICH. Higher levels of admission glial fibrillary acidic protein (p < 0.001) and MAP (p = 0.011) were also associated with PICH. Of the PCs, PC1 was significantly associated with PICH (p = 0.0125). Using multimodal data input, machine learning classifiers successfully discriminated patients with or without PICH. Models composed of machine-selected features performed better than models composed of expert-selected variables (reaching an average of 77% accuracy, AUC = 0.78 versus AUC = 0.68 for the expert-selected variables). Predictive models utilizing variables measured at admission can accurately predict PICH, confirmed by the 6-hour follow-up hCT. Our best-performing models must now be externally validated in a separate cohort of TBI patients with low GCS and initial hCT positive for hemorrhage.

Fall from Height in Pediatric Age Group: A Retrospective Review from a Tertiary Neurosurgical Center in India

Abstract Introduction: Unintentional falls from height are a major cause of pediatric traumatic injury. This retrospective study investigated the characteristics, clinic-radiological features, and associated outcomes in a tertiary referral neurosurgical center. Materials and Methods: This study is a retrospective review of children below 16 years who presented to our neurosurgery referral center from January 2018 to 2019 with a history of fall from height. The demographic data, clinical parameters at presentation, imaging findings, clinical status at discharge, and outcome at the follow-up period were analyzed. Results: Of the 1,310 children with a history of neurotrauma, 520 (39.7%) of them had a history of fall from height, among which 67% were falls from short height. The mean age was 5.99 ± 4.9 years. Of these 82.8% of children had mild, 13.8% moderate, and 3.2% had severe head injury. The imaging findings were normal in 59%, subgaleal hematoma in 18.6%, extradural hematoma in 9.9%, and spinal injuries in 1.4%. The regression analysis showed age, gender, the height of the fall, loss of consciousness, and seizure as predictors of the severity of the head injury. The Median Glasgow Outcome Scale-Extended at the follow-up period was one. About 2.3% of children had mortality within 1 week after the injury. The midline shift and associated injury had a significant impact on the outcome. Conclusion: In our retrospective study age, gender, height of fall, loss of consciousness, and seizures were associated with the severity of head injury. The presence of midline shift and other associated injuries was associated with the outcome at follow-up.

Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke.

The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients. This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS. A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model. Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.

Validation of a deep learning model for traumatic brain injury detection and NIRIS grading on non-contrast CT: a multi-reader study with promising results and opportunities for improvement.

This study aimed to assess and externally validate the performance of a deep learning (DL) model for the interpretation of non-contrast computed tomography (NCCT) scans of patients with suspicion of traumatic brain injury (TBI). This retrospective and multi-reader study included patients with TBI suspicion who were transported to the emergency department and underwent NCCT scans. Eight reviewers, with varying levels of training and experience (two neuroradiology attendings, two neuroradiology fellows, two neuroradiology residents, one neurosurgery attending, and one neurosurgery resident), independently evaluated NCCT head scans. The same scans were evaluated using the version 5.0 of the DL model icobrain tbi. The establishment of the ground truth involved a thorough assessment of all accessible clinical and laboratory data, as well as follow-up imaging studies, including NCCT and magnetic resonance imaging, as a consensus amongst the study reviewers. The outcomes of interest included neuroimaging radiological interpretation system (NIRIS) scores, the presence of midline shift, mass effect, hemorrhagic lesions, hydrocephalus, and severe hydrocephalus, as well as measurements of midline shift and volumes of hemorrhagic lesions. Comparisons using weighted Cohen's kappa coefficient were made. The McNemar test was used to compare the diagnostic performance. Bland-Altman plots were used to compare measurements. One hundred patients were included, with the DL model successfully categorizing 77 scans. The median age for the total group was 48, with the omitted group having a median age of 44.5 and the included group having a median age of 48. The DL model demonstrated moderate agreement with the ground truth, trainees, and attendings. With the DL model's assistance, trainees' agreement with the ground truth improved. The DL model showed high specificity (0.88) and positive predictive value (0.96) in classifying NIRIS scores as 0-2 or 3-4. Trainees and attendings had the highest accuracy (0.95). The DL model's performance in classifying various TBI CT imaging common data elements was comparable to that of trainees and attendings. The average difference for the DL model in quantifying the volume of hemorrhagic lesions was 6.0mL with a wide 95% confidence interval (CI) of - 68.32 to 80.22, and for midline shift, the average difference was 1.4mm with a 95% CI of - 3.4 to 6.2. While the DL model outperformed trainees in some aspects, attendings' assessments remained superior in most instances. Using the DL model as an assistive tool benefited trainees, improving their NIRIS score agreement with the ground truth. Although the DL model showed high potential in classifying some TBI CT imaging common data elements, further refinement and optimization are necessary to enhance its clinical utility.

Measures of intracranial compartments in acute intracerebral haemorrhage: data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial (RIGHT-2)

Background and purposeIntracerebral haemorrhage volume (ICHV) is prognostically important but does not account for intracranial volume (ICV) and cerebral parenchymal volume (CPV). We assessed measures of intracranial compartments in acute...

267. Therapeutic Management of Bacterial Brain Abscess: An Overview of Diagnosis and Outcomes

BackgroundWe describe and compare the clinical, diagnostic evaluation and outcomes of patients who underwent therapeutic management for pyogenic brain abscess.MethodsWe retrospectively reviewed adults who presented with pyogenic brain abscess from January 1, 2009 through June 30, 2020.Results231 patients were identified during the study period. Sixty-one (26.4%) patients received antibiotic therapy alone, and 170 (73.6%) had a combination of antibiotic therapy and surgical intervention. The median age for the medical and combined therapy group was 59 years and 58 years, respectively. Patients who received medical treatment had a higher prevalence of infective endocarditis than those who received combined therapy (6.6% vs. 0.6%; P=0.005). The medical therapy group was more likely to have brain MRI and cranial CT than the patients with combined therapy (75.4% vs. 63.5%; P=0.041). Midline shift (11.5% vs. 31.2%; P=0.002), a single (21% vs. 83%; P=0.001) and greater size (1.4 cm vs. 2.5 cm; P=0.007) brain abscess was significant when comparing medical vs. surgically managed abscess. Stereotactic surgical technique was the preferred diagnostic approach for the medical group (65.6% vs. 46.5%; P=0.010), and excision/craniotomy for the combined group (31.1% vs. 53.5%; P=0.002). Streptococcus viridans group was the predominant organism (32.8% and 25.9%; P=0.30). Compared to those who received combined therapy, patients with medical therapy alone were most likely to receive cephalosporin (72.1% vs. 41.2%; P=< 0.0001), vancomycin (23% vs. 12.4%; P=0.047) and metronidazole (27.9% vs. 14.7%; P=0.022). In both groups, median duration of antimicrobial therapy was 42 days (P=0.12). Patients with medical therapy alone had a higher mortality rate (18% vs. 7.1%; p=0.014) but less neurologic sequelae (21.3% vs. 30.6%; P=0.16) compared with combined therapy. Medical Management. Organism isolated in the medical management group Combined Management. Organism isolated in the combined management group Demographic and Clinical Characteristics of Patients with Brain Abscess who Underwent Therapeutic Management ConclusionMost patients with pyogenic brain abscess had no identified risk factors, and brain MRI and cranial CT were the diagnostic imaging modalities of choice. Compared to those who received medical therapy alone, patients with combined treatment had a single and greater size fluid collection with the presence of midline shift. A prompt combined surgical and medical approach with prolonged antimicrobial therapy can cure the infection.Outcomes of Patients with Bacterial Brain Abscess Radiologic and Surgical Diagnosis of Patient with Brain Abscess who Underwent Therapeutic Management Disclosures John C. O’Horo, Sr., MD, MPH, Bates College and Elsevier Inc (Consultant) M. Rizwan Sohail, MD, Medtronic Inc., Philips, and Aziyo Biologics, Inc (Consultant) M. Rizwan Sohail, MD, Aziyo Biologics (Individual(s) Involved: Self): Consultant; Philips (Individual(s) Involved: Self): Consultant

Freehand external ventricular drain insertion - is there a learning curve?

Background: Accuracy of freehand insertion of external ventricular drains (EVDs) is influenced by many factors including etiology and presence of midline shift. We sought to assess if junior neurosurgical trainees’ performance in accurately inserting EVDs improves with experience, using a radiological grading system.Methods: EVD insertion procedures from the first 3 years of training were identified from the operative logbooks of three trainees. Postoperative CT head scans were graded for accuracy of placement and intraventricular catheter length.Results: 40 frontal EVDs performed primarily by the trainees were identified, after 34 assists, revision surgeries, parietal, or occipital insertions were excluded from the study. The mean number (±1 SD) of procedures was 7.7 ± 4.5 at ST3, 4.7 ± 2.5 at ST2, and 1 ± 1 at ST1. About 80% of EVDs were optimally inserted. There was no statistically significant difference in placement accuracy between the three training grades (P = 0.669), nor any difference in intraventricular catheter length (P = 0.697). There were no statistically significant differences between surgeons’ accuracy at each grade.Conclusion: We report good accuracy of EVDs tip position inserted by junior neurosurgery trainees. Trainees perform more procedures independently as they progress in their career. Further studies including senior years of training performance, other procedure factors and outcome should be considered.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14–15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38).In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma.

Acute traumatic subdural hematoma (atSDH) can be a life-threatening neurosurgical emergency that necessitates immediate evacuation. The elderly population can be particularly vulnerable to tearing bridging veins. The aim of this study was to evaluate inpatient morbidity and mortality, as well as predictors of inpatient mortality, in a national trauma database. The authors queried the 2016-2017 National Trauma Data Bank registry for patients aged 65 years and older who had undergone evacuation of atSDH. Patients were categorized into three age groups: 65-74, 75-84, and 85+ years. A multivariable logistic regression model was fitted for inpatient mortality adjusting for age group, sex, race, presenting Glasgow Coma Scale (GCS) category (3-8, 9-12, and 13-15), Injury Severity Score, presence of coagulopathy, presence of additional hemorrhages (epidural hematoma [EDH], intraparenchymal hematoma [IPH], and subarachnoid hemorrhage [SAH]), presence of midline shift > 5 mm, and pupillary reactivity (both, one, or none). A total of 2508 patients (35% females) were analyzed. Age distribution was as follows: 990 patients at 65-74 years, 1096 at 75-84, and 422 at 85+. Midline shift > 5 mm was present in 72% of cases. With regard to additional hemorrhages, SAH was present in 21%, IPH in 10%, and EDH in 2%. Bilaterally reactive pupils were noted in 90% of patients. A major complication was observed in 14.4% of patients, and the overall mortality rate was 18.3%. In the multivariable analysis, the presenting GCS category was found to be the strongest predictor of postoperative inpatient mortality (3-8 vs 13-15: OR 3.63, 95% CI 2.68-4.92, p < 0.001; 9-12 vs 13-15: OR 2.64, 95% CI 1.79-3.90, p < 0.001; 30% of overall variation), followed by the presence of SAH (OR 2.86, 95% CI 2.21-3.70, p < 0.001; 25% of overall variation) and the presence of midline shift > 5 mm (OR 2.40, 95% CI 1.74-3.32, p < 0.001; 11% of overall variation). Model discrimination was excellent (c-index 0.81). Broken down by age decile group, mortality increased from 8.0% to 15.4% for GCS 13-15 to around 36% for GCS 9-12 to almost as high as 60% for GCS 3-8, particularly in those aged 85 years and older. The present results from a national trauma database will, the authors hope, assist surgeons in preoperative discussions with patients and their families with regard to expected postoperative outcomes following surgical evacuation of an atSDH.

Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors.

Objective Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior–posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm ( p = 0.033). Conclusion The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.

Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part.

Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part.

Outcomes and prognostic factors of pediatric patients with a Glasgow Coma Score of 3 after blunt head trauma.

This study aims to assess outcomes of pediatric patients with blunt traumatic brain injury (TBI) with a presenting Glasgow Coma Score (GCS) of 3. After local institutional review board approval, we identified patients ages 0 to15years with blunt TBI and a reported GCS of 3 between 2007 and 2017 from a pediatric level 1 trauma center prospective registry. Exclusion criteria were cardiac death on arrival and penetrating injury. We recorded clinical variables from patients with a non-pharmacologic GCS of 3 and pupillary exam documented by a neurosurgical attending or resident. The original Glasgow Outcome Scale (GOS) was used to compare with other studies. Importance of variables to survival was calculated. A total of 88 patients (mean age 6.9years) were included with a mortality rate of 68%. Twelve percent had a poor long-term outcome (GOS 2 or 3) while 20% had a good long-term outcome (GOS 4 or 5). Median follow-up was 1.8years. Initial group comparison revealed patients in group 1 (survivors) had less hypotension on arrival (14% SBP < 90mmHg vs. 66%, p< 0.0001), higher temperatures on arrival (36.3°C vs 34.9°C, p= 0.0002), lower ISS (29.7 vs 39.5, p= 0.003), less serious injury to other major organs (34% vs 61%, p= 0.02), more epidural hematomas (24% vs 7%, p= 0.04), and less evidence of brain ischemia on CT (7% vs 39%, p= 0.002) or brainstem infarct, hemorrhage, or herniation (0% vs 27%, p= 0.002). Differences between the 2 groups in age, sex, race, MOI, AIS score, presence of midline shift > 5mm, or time from injury to hospital arrival or time to surgery were not statistically significant. Classification tree analysis showed that the most important variable for survival was pupillary exam; mortality was 92% in presence of bilateral, fixed dilated pupils. The relative importance of initial temperature, MOI, and hypotension to survivability was 0.79, 0.75, and 0.47, respectively. Twenty percent of our pediatric non-pharmacologic GCS 3 cohort had a good functional outcome. Lack of bilaterally fixed and dilated pupils was the most important factor for survival. Temperature, MOI, and hypotension also correlated with survival. The data support selective aggressive management for these patients.

Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans.

To characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans. The Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors. Of 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78-213.72); dyslipidemia, 2.95 (1.84-4.74); meat consumption, 1.55 (1.01-2.38); family history of CVD, 2.22 (1.41-3.50); nonconsumption of green vegetables, 3.61 (2.07-6.31); diabetes mellitus, 2.11 (1.29-3.46); stress, 1.68 (1.03-2.77); and current tobacco use, 14.27 (2.09-97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43-2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00-1.01); presence of midline shift, 1.54 (1.11-2.13); lobar ICH, 1.72 (1.16-2.55); and supratentorial bleeds, 2.17 (1.06-4.46). Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.

Abstract TMP24: Soluble St2 Links Innate Inflammation to Secondary Injury After Stroke and Subarachnoid Hemorrhage

Background: We recently found that soluble ST2 (sST2) is a plasma marker that predicts neurological outcome after ischemic stroke and aneurysmal subarachnoid hemorrhage. We sought to extend these findings by studying sST2 associations with markers of secondary brain injury and peripheral innate immunity. Methods: We studied 241 acute ischemic stroke (AIS) patients with sST2 level measured on admission (7.4 ± 3.7 hrs after stroke onset) and at least one follow-up brain imaging study, obtained at a mean of 2.2 ± 1.4 days after stroke onset. A subgroup (n=147) had a second sST2 measurement at a mean of 2.1 ± 1.7 days after stroke onset. A separate cohort of 110 subarachnoid hemorrhage (SAH) patients were studied who had plasma sST2 measured at approximately 3.5 ± 1.2 days after ictus. Markers of secondary brain injury included edema after AIS (midline shift), and delayed cerebral ischemia (DCI) or epileptiform discharges on EEG after SAH. The relationships between sST2 level and outcome measures were assessed. Primary blood mononuclear cells from SAH patients and elective aneurysm controls were analyzed by multiparameter flow cytometry to phenotype the peripheral immune response. Results: In the AIS cohort, baseline plasma sST2 level was associated with the presence of midline shift (46.1 vs. 41.8 ng/mL, p=0.017), which further increased at 48 hr after stroke onset (50.6 vs. 38.4 ng/mL, p=0.006). In the SAH cohort, median sST2 in patients who developed new epileptiform abnormalities was higher compared to patients who did not (114.8 ng/ml vs. 74.7 ng/ml, p=0.024). Higher median sST2 concentration was also observed in those patients with DCI (90.8 vs 53.7ng/mL, p=0.003). In patients with high sST2, flow cytometry identified a peripheral monocyte population with decreased expression of CD14 (4.27x105 ± 2950 A.U. vs. 5.64x105 ± 1290 A.U., p&lt;0.001), and increased expression of CD16 (39,960 ± 272 A.U. vs. 34,869 ± 183 A.U., p&lt;0.001). Conclusion: Plasma sST2 independently predicts edema after stroke, and DCI and epileptiform abnormalities after subarachnoid hemorrhage. Elevated sST2 is also associated with changes in peripheral innate immune cells. These data suggest that sST2 links the innate immune response to secondary brain injury.

Role of repeat CT in mild to moderate head injury: an institutional study.

Patients with traumatic brain injury (TBI) often undergo repeat head CT scans to identify the possible progression of injury. The objective of this study is to evaluate the need for routine repeat head CT scans in patients with mild to moderate head injury and an initial positive abnormal CT scan. This is a retrospective study of patients presenting to the emergency department from January 2016 to December 2017 with Glasgow Coma Scale (GCS) scores > 8 and an initial abnormal CT scan, who underwent repeat CT during their in-hospital medical management. Patients who underwent surgery after the first CT scan, had a GCS score < 9, or had a normal initial CT scan were excluded. Demographic, medical history, and physical examination details were collected, and CT scans were reviewed. Radiological deterioration, neurological deterioration, and/or the need for neurosurgical intervention were the primary outcome variables. A total of 1033 patients were included in this study. These patients underwent at least two CT scans on an inpatient basis. Of these 1033 patients, 54.1% had mild head injury and 45.9% had moderate head injury based on GCS score at admission. The most common diagnosis was contusion (43.8%), followed by extradural hematoma (28.8%) and subdural hematoma (26.6%). A total of 2636 CT scans were performed for 1033 patients, with a mean of 2.55 per patient. Of these, 25 (2.4%) had neurological deterioration, 90 (8.7%) had a progression of an existing lesion or appearance of a new lesion on repeat CT, and 101 (9.8%) required neurosurgical intervention. Seventy-five patients underwent surgery due to worsening of repeat CT without neurological deterioration, so the average number of repeat CT scans required to identify one such patient was 21.3. On multiple logistic regression, GCS score at admission (p = 0.024), abnormal international normalized ratio (INR; p < 0.001), midline shift (p = 0.005), effaced basal cisterns (p < 0.001), and multiple hemorrhagic lesions (p = 0.010) were associated with worsening of repeat CT, neurological deterioration, and/or need for neurosurgical intervention. The role of routine repeat head CT in medically managed patients with head injury is controversial. The authors have tried to study the various factors that are associated with neurological deterioration, radiological deterioration, and/or need for neurosurgical intervention. In this study the authors found lower GCS score at admission, abnormal INR, presence of midline shift, effaced basal cisterns, and multiple lesions on initial CT to be significantly associated with the above outcomes.

Bedside Percutaneous Twist Drill Craniostomy of Chronic Subdural Hematoma-A Single-Center Study.

Background Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. Objectives This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC). Patients and Methods A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Statistical Analysis Statistical analysis is done using Epi Info software. Results The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD. Conclusions CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

Factors Associated With Worsened Neurological Outcomes in Traumatic Subarachnoid Hemorrhage

Abstract INTRODUCTION Patients are often admitted for observation due to isolated traumatic subarachnoid hemorrhage (tSAH). However, factors that are associated with worsening neurological outcomes are unclear. METHODS Patients who presented with tSAH from January 2017 to May 2017 to our ED were identified. Initial patient characteristics on presentation associated with a neurological decline, neurosurgical intervention, hospital readmission, or death were identified via univariate and multivariate regression. Of note, we did not include patient characteristics that are not available on initial evaluation. We then tested this model by identifying those without risk factors and reported their outcome. RESULTS A diagnosis of intracranial hemorrhage was identified in 401 consecutive patients over 5 mo, of which 165 (41.1%) had tSAH. On univariate analysis, patient characteristics associated with a neurological decline, neurosurgical intervention, hospital readmission, or death included depressed skull fractures (P = .02), GCS &lt; 13 (P &lt; .001), cranial nerve palsies (P = .01), any disorientation to self, place, or time (P &lt; .001), concomitant epidural (P = .027) or acute subdurals (P &lt; .001), the presence of midline shift (P &lt; .001), and INR &gt; 1.5 (P = .03). On multivariate analysis, disorientation [odds ratio (OR): 3.53 (1.24-10.0), P = .018] and the presence of midline shift [OR: 6.8 (1.87-24.66), P = .003] were associated with worsened neurological outcomes. Out of the 165 patients, 104 patients had one or more risk factors, and 44 experienced worsened neurological outcomes; 61 patients did not have any of the above risk factors, and 0/61 (0%) experienced a neurologic decline, intervention, hospital readmission, or death. This corresponds to a test sensitivity of 100%, specificity of 50.4%, and a negative predictive value of 100%. CONCLUSION Patients with tSAH who are fully oriented and who do not have a midline shift on initial head computed tomography (CT) are less likely to have a neurological decline, require neurosurgical intervention and hospital readmission, or have mortality. Although the presence of risk factors alone does not necessitate worsened outcomes, patients without any risk factors are unlikely to have a neurological decline.

Clinico-Radiological Factors Affecting Outcome of Supratentorial Spontaneous Intracerebral Hemorrhage: A Single Institute Experience

Introduction: Intracerebral bleeds are the second most common cause of stroke. The initial consciousness level and progressive deterioration and various radiological parameters like hematoma volume, its expansion, mass effect and location has been implicated with poor outcomes of Intracerebral Hematoma (ICH) regardless of the management methods. In this study we aimed to study various clinical and radiological parameters associated with outcome of spontaneous supratentorial ICH.&#x0D; Methods: This prospective study was carried out in 89 patients of spontaneous supratentorial ICH admitted to National Institute of Neurological and Allied Sciences, Nepal in between January 2015 to December 2015 to assess various parameters associated with its outcome. Outcome of the patients were assessed against various clinic-radiological and demographic variables using chi square test and student’s t test respectively for categorical and continuous variables using IBM SPSS 20 software.&#x0D; Results: Glasgow Coma Scale (GCS) (p=0.00), size of hematoma (p=0.034), presence of midline shift (0.000) and presence of intraventricular hematoma (p=0.020) were found to have statistically significant difference when compared in between good and poor outcome group.&#x0D; Conclusion: GCS at admission, size of hematoma, midline shift in cerebral tomography scan (CT scan) and presence of intraventricular hemorrhage (IVH) were significantly associated with outcome of spontaneous Supratentorial ICH.

Hubungan antara Diameter Optic Nerve Sheath pada Grey Scale Ultrasound dengan Peningkatan Tekanan Intrakranial pada Pasien dengan Lesi Intrakranial

The study aims to determine the correlation between diameter of optic nerve sheath on grey scale with increased intracranial pressure in patients with intracranial lesion. The research was conducted in Radiology Department of Dr. Wahidin Sudirohusodo Makassar from January 2019 – May 2019. The sample were 39 people aged ³18 years old with intracranial lesion. Axial computed tomography (CT) examination was performed to evaluate intracranial lesions and the presence of midline shift. The diameter of the optic nerve sheath was measured using eye ultrasonography. Data analyses used Spearman’s correlation test. The results showed that there was a correlation between the dilatation of the right and left optic nerve sheath diameter with midline shift (p value 0.04; p less than 0.05) on the diameter of the right optic nerve sheath showing a weak positive relationship (p value 0.02) for the diameter the optic nerve sheath left showing a medium positive relationship where the higher the midline shift, the wider the diameter of the left and right optical nerve sheath. There is a correlation between the right and left optic nerve sheath diameter (p less than equal 0.001) showing a strong positive relationship where the wider the diameter of the right optic nerve sheath, the wider the diameter of the left optic nerve sheath at high intracranial pressure. Statistically other results also obtained no relationship between dilatation of the diameter of the optic nerve sheath with clinical symptoms of increased intracranial pressure and type of lesion.