Refractory Intracranial Hypertension Research Articles

Successful management of intracranial hemorrhage with brain herniation in a postpartum patient on extracorporeal membranous oxygenation: A case report.

Managing intracranial hemorrhage in patients supported by extracorporeal oxygenation (ECMO) presents significant clinical challenges. We report a case of a postpartum patient with severe acute respiratory distress syndrome (ARDS) necessitating venovenous ECMO support, complicated by multicompartmental intracranial hemorrhage resulting in brain herniation and necessitating emergent medical and surgical management of refractory intracranial hypertension. Care was guided by multimodal neuromonitoring, including intracranial pressure monitoring and electroencephalography. Despite these challenges, the patient achieved excellent neurological recovery. This case underscores the intricacies of managing neurological complications during ECMO and highlights the potential benefits of comprehensive neuromonitoring strategies.

Effects of Early and Late Cranioplasty on Neurocognitive Outcome and Cerebral Glucose Metabolism using PET Scan - A Comparative Study.

Brain protection and cosmetic aspects are the major indications of cranioplasty (CP) after decompressive craniectomy. CP can avoid the recurrence of brain damage, achieve the plastic effect, protect the patient from seizures, and relieve the syndrome of trephine. This was a prospective, observational study done over a period of 2 years from April 2017 to April 2019 in the Department of Neurosurgery at Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati. Patients of age group 20-60 years who underwent CP after decompressive craniectomy for traumatic brain injury or cerebrovascular accidents with refractory intracranial hypertension were included. The study population was divided into two groups: early and late CP groups. Neurocognitive assessment was done 72 h before and 3 months after CP by mini-mental state examination (MMSE), Glasgow outcome score (GOS), and PGI battery of brain dysfunction (PGIBBD) scores. Cerebral glucose metabolism was assessed by 18F-FDG PET scan. In both early and late CP groups, there was a highly significant difference between the mean pre- and postoperative values of MMSE, GOS, and PGIBBD, suggesting significant improvement in neurocognitive parameters of patients postoperatively. There was no significant difference between early and late CP groups for mean standard uptake values (SUVs) on PET scan for both affected (P-value- 0.40) and nonaffected (P-value- 0.30) sides. CP improves the cerebral metabolism and neurocognitive outcome, weather it is done early or late.

External lumbar drainage for the management of refractory intracranial hypertension in pediatric severe traumatic brain injury: a retrospective single-center case series

OBJECTIVE Guidelines for the management of pediatric severe traumatic brain injury (TBI) recommend external ventricular drainage for CSF drainage as a first-tier treatment in the intracranial pressure (ICP) pathway. However, ventriculostomy in children can sometimes be challenging because of the small size of the lateral ventricles. External lumbar drainage (ELD) may be a useful alternative; therefore, the authors analyzed the outcome of a cohort of pediatric patients who underwent ELD to manage intracranial hypertension (ICH). METHODS This study retrospectively enrolled pediatric patients with ICH following severe TBI who underwent ELD. Radiological and clinical severity scores (Marshall classification, Rotterdam score, Injury Severity Score, and Pediatric Trauma Score) were noted. ICP and cerebral perfusion pressure (CPP) curves were analyzed 12 hours before and after the procedure. Any change in medical therapy was recorded, as well as the total volume and duration of drainage. Cerebellar tonsillar position according to the McRae line was noted before and after ELD. Glasgow Outcome Scale-Extended score at follow-up was also noted. RESULTS Thirty patients were included, with a mean age of 8 ± 4.4 years, and a median admission Glasgow Coma Scale score of 7 ± 4 (range 3–13). ELD was performed after a median delay of 1 day (range 0–7 days), mean drainage volume/day was 296 ± 129 ml, and median duration of drainage was 7 ± 5 (range 2–12) days. Forty-three percent of the patients underwent ELD as a part of the first-tier therapy. ICP decreased after ELD (mean difference 13.4 ± 6.2 mm Hg, p < 0.001), whereas CPP increased (mean difference 10.6 ± 6.4 mm Hg, p < 0.001). Fifty-three percent of the cohort did not need any further second-tier therapy after ELD. The study found 1 case of drain revision and 3 cases of cerebellar tonsil herniation. CONCLUSIONS These preliminary data suggest ELD is a valuable option to treat ICH in severely head-injured children, limiting the use of second-tier treatments. This pilot study should lay the foundation for a multicenter prospective trial.

Decompressive craniectomy in trauma: What you need to know.

Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.

Daily life without cranial bone protection while awaiting cranioplasty: a qualitative study

PurposeDecompressive craniectomy is occasionally performed as a life-saving neurosurgical intervention in patients with acute severe brain injury to reduce refractory intracranial hypertension. Subsequently, cranioplasty (CP) is performed to repair the skull defect. In the meantime, patients are living without cranial bone protection, and little is known about their daily life. This study accordingly explored daily life among patients living without cranial bone protection after decompressive craniectomy while awaiting CP.MethodsA multiple-case study examined six purposively sampled patients, patients’ family members, and healthcare staff. The participants were interviewed and the data were analyzed using qualitative content analysis.ResultsThe cross-case analysis identified five categories: “Adapting to new ways of living,” “Constant awareness of the absence of cranial bone protection,” “Managing daily life requires available staff with adequate qualifications,” “Impact of daily life depends on the degree of recovery,” and “Daily life stuck in limbo while awaiting cranioplasty.” The patients living without cranial bone protection coped with daily life by developing new habits and routines, but the absence of cranial bone protection also entailed inconveniences and limitations, particularly among the patients with greater independence in their everyday living. Time spent awaiting CP was experienced as being in limbo, and uncertainty regarding planning was perceived as frustrating.ConclusionThe results indicate a vulnerable group of patients with brain damage and communication impairments struggling to find new routines during a waiting period experienced as being in limbo. Making this period safe and reducing some problems in daily life for those living without cranial bone protection calls for a person-centered approach to care involving providing contact information for the correct healthcare institution and individually planned scheduling for CP.

Intracranial venous manometry in patients with idiopathic intracranial hypertension

Objective ‒ to analyse the results of cerebral angiography and venography with venous manometry in patients with medically refractory sdiopathic intracranial hypertension (IIH) and venous sinus stenosis.Materials and methods. Informed consent was obtained from each patient (parent or guardian) enrolled in the study and the study protocol conforms to the ethical guidelines of the Declaration of Helsinki as reflected in a priori approval by the Institutional Ethical Review Board (Institution's Human Research Committee). A retrospective analysis of the clinical and neuroimaging features of 9 patients with suspected IIH was performed. All patinets were treated at the SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine» from January 2022 to January 2024. The criteria for inclusion in the study were: clinical symptoms of IIH without any other intracranial pathology according to imaging, lumbar pressure >20 cm H2O, and symptoms refractory to medication treatment (optic disc edema, pulsatile tinnitus, etc.). Pressure gradients in contiguous sites were calculated for each patient in standard anatomical sites (superior sagittal sinus ‒ sinus drain, sinus drain ‒ transverse sinus, transverse sinus ‒ sigmoid sinus, sigmoid sinus ‒ internal jugular vein). The adjacent anatomical gradients were defined as the difference between the mean venous sinus pressure measurements in the venous sinuses where the manometry was performed. Pathological pressure gradients in the venous sinuses were defined as pressure gradients >8 mm Hg based on established guidelines. Results. Out of the 9 patients with suspected IIH treated at the clinic, 2 patients were excluded. One female with combination of thrombosis in posterior third of superior sagittal sinus with left transverse sinus stenosis, the second (male) with bilateral jugular vein occlusions. Of the 7 patients (4 women and 3 men) with a mean age of 39.7 years, 4 (57.1 %) had pressure gradients >8 mm Hg (transverse sine ‒ sigmoidal sine) and underwent sinus stenting. All procedures were successful. After stent implantation, control manometry was performed, which showed the gradient decreasing to 0‒2 mm Hg at the level of stenosis. The control examination after stenting was performed in all patients and showed regression of general cerebral symptoms, as well as varying degrees of ocular improvement. Conclusions. Our study evaluated the degree of pressure reduction in the anatomical sites of the cerebral venous system and showed a progressive decrease in pressure from the sigmoid sinus to the jugular vein. The venous sinus stenting leads to elimination of the pressure gradient, as well as neurological and ophthalmic improvement in carefully selected patients with refractory to conservative therapy IIH with a transstenotic pressure gradient >8 mm Hg.

Vaulting further: cranial vault expansion for craniocerebral disproportion without primary craniosynostosis.

Treatment of subjects with refractory idiopathic intracranial hypertension (IIH) or shunted hydrocephalus with chronic shunt complications is challenging. What is the role for cranial vault expansion, particularly utilizing posterior vault distraction osteogenesis (PVDO), in these cases? This study assesses medium-term efficacy of cranial vault expansion in this unique patient population. A retrospective review was conducted of patients who underwent cranial vault expansion from 2008 to 2023 at the Children's Hospital of Philadelphia. Subjects who did not have a diagnosis of primary craniosynostosis were included in the study. Demographic information, medical history, and perioperative details were collected from medical records. Primary outcomes were the rate of CSF diversion procedures and resolution of presenting signs and symptoms. Secondary outcomes were perioperative and 90-day complications and reoperation requirement. Among 13 included subjects, nine (69.2%) patients had a primary diagnosis of shunted hydrocephalus and 4 (30.8%) patients had IIH. Twelve (92.3%) subjects underwent posterior vault distraction osteogenesis (PVDO) and one (7.7%) underwent posterior vault remodeling (PVR). All 4 patients with IIH demonstrated symptomatic improvement following PVDO, including resolution of headaches, vomiting, and/or papilledema. Among 9 patients with shunted hydrocephalus, CSF diversion requirement decreased from 2.7 ± 1.6 procedures per year preoperatively to 1.2 ± 1.8 per year following cranial vault expansion (p = 0.030). The mean postoperative follow-up was 4.1 ± 2.1years and four (30.8%) patients experienced complications within 90days of surgery, including infection (n = 2), CSF leak (n = 1), and elevated ICP requiring lumbar puncture (n = 1). Four (30.8%) patients underwent repeat cranial vault expansion for recurrence of ICP-related symptoms. At most recent follow-up, 7 of 9 patients with shunted hydrocephalus demonstrated symptomatic improvement. Cranial vault expansion reduced intracranial hypertension-related symptomology as well as the rate of CSF diversion-related procedures in patients with refractory IIH and shunted hydrocephalus without craniosynostosis, and should be considered in those who have significant shunt morbidity.

Influence of cerebrospinal fluid drainage in the first days after aneurysm rupture on the severity of early brain injury following aneurysmal subarachnoid hemorrhage

PurposeProgressive cerebral edema with refractory intracranial hypertension (ICP) requiring decompressive hemicraniectomy (DHC) is a severe manifestation of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of the study was to investigate whether a more pronounced cerebrospinal fluid (CSF) drainage has an influence on cerebral perfusion pressure (CPP) and the extent of EBI after aSAH.MethodsPatients with aSAH and indication for ICP-monitoring admitted to our center between 2012 and 2020 were retrospectively included. EBI was categorized based on intracranial blood burden, persistent loss of consciousness, and SEBES (Subarachnoid Hemorrhage Early Brain Edema Score) score on the third day after ictus. The draining CSF and vital signs such as ICP and CPP were documented daily.Results90 out of 324 eligible aSAH patients (28%) were included. The mean age was 54.2 ± 11.9 years. DHC was performed in 24% (22/90) of patients. Mean CSF drainage within 72 h after ictus was 168.5 ± 78.5 ml. A higher CSF drainage within 72 h after ictus correlated with a less severe EBI and a less frequent need for DHC (r=-0.33, p = 0.001) and with a higher mean CPP on day 3 after ictus (r = 0.2351, p = 0.02).ConclusionA more pronounced CSF drainage in the first 3 days of aSAH was associated with higher CPP and a less severe course of EBI and required less frequently a DHC. These results support the hypothesis that an early and pronounced CSF drainage may facilitate blood clearance and positively influence the course of EBI.

Venous Manometry Insights: Diagnostic Criteria Utility and Clinical Correlation in Patients with Refractory Idiopathic Intracranial Hypertension (S20.003)

Venous Manometry Insights: Diagnostic Criteria Utility and Clinical Correlation in Patients with Refractory Idiopathic Intracranial Hypertension (S20.003)

Reasons for Discontinuation of Medical Management in Refractory Idiopathic Intracranial Hypertension (P3-12.007)

Reasons for Discontinuation of Medical Management in Refractory Idiopathic Intracranial Hypertension (P3-12.007)

Endovascular stenting for cerebral venous sinus stenosis secondary to meningioma invasion.

Symptomatic intracranial hypertension (IH) due to venous outflow obstruction secondary to dural venous sinus (DVS) tumoral invasion affects up to 3% of intracranial meningioma patients. The literature regarding endovascular therapies of such patients is limited to a few case reports and a recent single-centre case series. We describe our single-centre experience of endovascular therapy in patients with clinically symptomatic IH secondary to DVS meningioma invasion. We performed a retrospective review of clinical and radiological data of all patients with refractory IH and meningiomas invading the DVS who were referred for possible DVS venoplasty and stenting. Seven endovascular procedures in six female patients were done. Presumed secondarily induced lateral transverse sinus stenosis was also stented in four patients as part of the primary intervention. All patients experienced complete symptomatic resolution at 6-month follow-up. Five patients had no symptom recurrence over a mean follow-up period of 3.5 years. One patient with multiple meningiomas developed recurrent IH 2 years following stenting secondary to in-stent tumour re-invasion. This was re-stented with consequent 6 months post-retreatment symptomatic relief at the time of writing. No procedure-related complications occurred. In the setting of DVS stenosis secondary to meningioma invasion, endovascular therapy is a safe and successful therapeutic option with promising mid-term results. The procedure should be considered in cases where complete surgical tumour resection is unlikely or carries a significant risk. If present, secondarily induced stenoses at the lateral ends of the transverse sinuses should also be considered for treatment.

The use of tier three therapies in acute brain injured patients

BACKGROUND In patients with acute brain injury (ABI) and refractory intracranial hypertension, the so-called ‘tier three therapies’ (TTT) (hypothermia, metabolic suppression with barbiturates, and decompressive craniectomy) may be used. OBJECTIVE We aimed to describe the incidence of use of TTT, and to assess their effect on outcome. DESIGN A secondary analysis of the ENIO observational study. SETTING Seventy-three intensive care units (ICUs) in 18 countries worldwide between June 2018 and November 2020. PATIENTS One thousand five hundred and twelve adult patients admitted to an intensive care unit (ICU) with ABI were included and categorised according to use or not of one or more TTT. RESULTS Three hundred and ninety-six patients (26.2%) received at least one TTT during the ICU stay. Five patients (0.3%) received all three TTT. TTT patients were younger (P < 0.0001), less likely to have a preinjury history of hypertension (P = 0.0008), and less frequently anisocoric within 24 h from ICU admission (P < 0.0001) than those with no tier three therapy. TTT were used less frequently in high-income countries than in upper income and lower middle-income countries (no TTT in 78% of patients in high-income countries, in 60.6% of patients in upper middle-income countries, and in 56.6% of patients in lower middle-income countries; P < 0.0001). TTT were more frequent in patients with traumatic brain injury (TBI) compared with other types of ABI and in patients with invasive intracranial pressure (ICP) monitoring (P < 0.0001). TTT use was associated with a higher incidence of ventilator-associated pneumonia (P < 0.0001), need for tracheostomy (P = 0.0194), and prolonged ICU length of stay (LOS; P < 0.0001) but not with increased ICU or hospital mortality (P = 0.999). CONCLUSION Patients with ABI are frequently managed using at least one TTT. Their use varies according to a country's economic resources, the type of ABI, and ICP monitoring and is associated with a higher risk of complications but not with ICU or hospital mortality.

In Reply to the Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

In Reply to the Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Hyperemia in head injury: can transcranial doppler help to personalize therapies for intracranial hypertension?

An increase in cerebral blood flow is frequent after traumatic brain injury (TBI) and can lead to brain swelling and refractory intracranial hypertension. We hypothesized that Transcranial EcoDoppler (TCD) monitoring could be useful to detect the cause of intracranial hypertension in these patients. Our main objective was to investigate if the increase of velocity in the middle cerebral artery (MCA) on TCD could be associated with intracranial hypertension. We retrospectively studied TBI patients consecutively monitored with TCD. Hyperemia was defined as MCA mean velocity higher than 80 cm/s. Intracranial hypertension was considered when hyperosmolar therapy, hyperventilation, or deep sedation was used. We found hyperemia in 40 patients out of 118 (33.9%). On average, it started at day 2.1 ± 0.9 from admission and significantly increased (MCA velocity at day 1: 74 ± 25 cm/s vs. 109 ± 36 cm/s at day 4; p < 0.001). Intracranial hypertension was significantly associated with hyperemia, occurring in 92.5% of hyperemic and 51.3% of non-hyperemic patients (p < 0.001). Moreover, we found that hyperemia preceded severe intracranial hypertension (p < 0.0001). In a logistic regression model, hyperemia was the only variable significantly correlated with intracranial hypertension (OR 10.64; p < 0.001). Hyperemia was frequent in our population of TBI patients and preceded intracranial hypertension. TCD monitoring, if performed on a daily regular basis, can be a useful method to detect this phenomenon and to guide the therapy. It could be a tool for a cause-oriented therapy of intracranial hypertension.

Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units.

Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.

Erratum: Decompressive Laparotomy as a Treatment Option for Refractory Intracranial Hypertension in Patients With Traumatic Brain Injury: A Systematic Review

Erratum: Decompressive Laparotomy as a Treatment Option for Refractory Intracranial Hypertension in Patients With Traumatic Brain Injury: A Systematic Review

1128 Outcomes of Early and Late Decompressive Craniectomies in Contrast to Standard Medical Management in Patients with Traumatic Brain Injury with Refractory Intracranial Hypertension: Systematic Review and Meta-Analysis Study

Abstract Aim The meta-analysis explored the effectiveness of early and late decompressive craniectomies versus medical management in patients with refractory intracranial hypertension after sustaining traumatic brain injury. The clinical outcomes analysed were grouped into 2 categories: favourable (good recovery and moderate disability) and unfavourable outcomes (death, vegetative state, and severe disability). Intracranial pressure has been measured post-randomisation in the studies included. Method Google Scholar, Cochrane and Medline search engines were utilised for data collection ranging from 1999 until present. The searched keywords encompassed: decompressive craniectomy, refractory intracranial hypertension, medical management, and traumatic brain injury. Thereafter, the data was uploaded to Review Manager for statistical analysis. Results Of the 122 articles, 10 randomized controlled trials were included in the meta-analysis. The analysis yielded that relative risk (RR) of overall mortality in decompressive craniectomy group vs medical management is 0.58 95% CI [0.41, 0.81] (P = 0.001). The standardised mean difference (SMD) for intracranial pressure is -2.59 95% CI [-3.72, -1.46] (P &amp;lt; 0.00001) between the two groups. The odds ratio considering favourable outcomes (Glasgow Outcome Scale) for patients undergoing surgery vs medical care is 1.02 95% [0.57, 1.82] (P = 0.95). Conclusions This meta-analysis demonstrates that decompressive craniectomy significantly reduces the overall mortality and intracranial pressure in patients with TBI and refractory intracranial hypertension versus medical management. Decompressive craniectomy has a greater potential to treat TBI patients with refractory intracranial hypertension than medical care alone however more randomised clinical trials are needed to ascertain the effectiveness of the superiority of these treatments in the future research.

417 Factors Associated with the Development of Post-Traumatic Hydrocephalus Following a Decompressive Craniectomy: A Single Centre Experience

Abstract Introduction A decompressive craniectomy (DC) is a surgical procedure sometimes utilised to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). Previous studies have established a relationship between DC and post-traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable post-traumatic hydrocephalus in patients who underwent DC following sTBI. Method A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical centre in northwest England between January 2012 and May 2022 was performed. Post-traumatic hydrocephalus was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for CSF diversion (i.e. a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS vs 28.0.1. Results 65 patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38+/-14.67, while the mean age of the non-PTH group was slightly higher at 39.96 +/- 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (MOI) (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with post-traumatic hydrocephalus (p = 0.006). Conclusions This study concludes that cerebellar hematoma (and contusions) are associated with developing post-traumatic hydrocephalus in patients undergoing decompressive craniectomy.

Computed tomography-guided stereotactic surgery in the management of brain lesions: A single-center experience.

The present study presents our experience with computed tomography (CT)-guided stereotactic surgery in managing deep-seated brain lesions and provides a background in the expanding fields of morphological stereotactic neurosurgery. We conducted this retrospective cohort study on 80 patients managed at the Department of Neurosurgery, Zagazig University Hospitals, Zagazig, Egypt, between January 2019 to January 2021. We targeted patients with morphological stereotactic surgeries performed as the primary management modality of their treatment. A total of 80 patients, with a mean age of 44.3 years, were included in the study. The stereotactic targets were supratentorial in 71 patients (88.75%), infratentorial in seven patients (8.75%), and both supraand infratentorial in two patients (2.5%). The lesions showed enhancements with IV contrast in 55 patients (68.75%). Stereotactic procedures were performed under local anesthesia in 64 patients and general anesthesia in 16 patients. Of the 80 stereotactic procedures, 52 were biopsies (65%). We observed a significant improvement in the postoperative Karnofsky performance score compared to the postoperative score (63.4 ± 19.8 vs. 56.7 ± 15.4, P = 0.001). The level of agreement between clinical, radiological, and final pathological diagnosis was assessed; it was complete in 47.5% of the patients. The postprocedural CT scan demonstrated intracranial hemorrhage in five patients (6.25%); four (5%) were silent with no neurological complications. This study provided evidence that the stereotactic procedure is easy to perform, accurate in targeting the lesion, and spares patients from undergoing major surgical procedures. Stereotactic applications of spontaneous intracerebral hemorrhage, deep-seated abscesses, encysted tumors, or medically refractory benign intracranial hypertension can improve the outcome even in medically high-risk patients.