Surgical Evacuation Of Hematoma Research Articles

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy.

Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges. Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission. National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

Surgical Treatment for Severe Primary Midbrain and Upper Pons Hemorrhages Using a Subtemporal Tentorial Approach.

Objectives It is unclear whether surgical hematoma evacuation should be performed in cases of primary brainstem hemorrhages (PBH). Here, we analyzed 15 cases with severe primary midbrain and upper pons hemorrhages to assess the associations between the subtemporal tentorial approach and patient functional outcomes and mortality. Design A total of 15 patients diagnosed with severe primary midbrain and upper pons hemorrhages who had previously received the subtemporal tentorial approach at our facility from January 2018 and March 2019 were analyzed. All surviving cases received a follow-up at 6 months after surgery. The Glasgow Coma Scale and Glasgow Outcome Scale (GOS) scores were analyzed 1 and 6 months after surgery, respectively. Demographic data, lesion characteristics, and follow-up data were retrospectively collected. Results All patients successfully underwent surgical evacuation for hematomas using the subtemporal tentorial approach. The overall survival rate for these cases was 66.7% (10/15). At the last follow-up, 26.7% of patients (4/15) exhibited healthy function (GOS score: 4), 20.0% (3/15) showed disability (GOS score: 3) and 20.0% (3/15) were in a vegetative state (GOS score: 2). Conclusions Based on the results uncovered in this study, the subtemporal tentorial approach was found to be both safe and feasible and may be beneficial for the treatment of severe primary midbrain and upper pons hemorrhages, but a more comprehensive and comparative study is required to further confirm these results.

The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study.

Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score [GOS] 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH. We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1, 2016, and December 31, 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index [CCI], antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and χ2 Tests and logistic regression models were used to assess differences in and associations between clinical-radiological characteristics and functional outcomes. We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other post-traumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group. A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

BackgroundThe rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDHMethodsIn total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.DiscussionThe study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.Trial registrationNederlands Trial Register (NTR), Trial NL9012. ClinicalTrials.gov, Trial NCT04648436.

Impact of Frailty on Morbidity and Mortality in Adult Patients Undergoing Surgical Evacuation of Acute Traumatic Subdural Hematoma

To determine whether baseline frailty is an independent predictor of extended hospital length of stay (LOS), nonroutine discharge, and in-hospital mortality after evacuation of an acute traumatic subdural hematoma (SDH). A retrospective cohort study was performed. All adult patients who underwent surgery for an acute traumatic SDH were identified using the National Trauma Database from the year 2017. Patients were categorized into 3 cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI= 0, mFI= 1, or mFI= 2+. A multivariate logistic regression analysis was used to identify independent predictors of extended LOS, nonroutine discharge, and in-hospital mortality. Of the 2620 patients identified, 41.7% were classified as mFI= 0, 32.7% as mFI= 1, and 25.6% as mFI= 2+. Rates of extended LOS and in-hospital mortality did differ significantly between the cohorts, with the mFI= 0 cohort most often experiencing a prolonged LOS (mFI= 0: 29.41% vs. mFI= 1: 19.45% vs. mFI= 2+: 19.73%, P < 0.001) and in-hospital mortality (mFI= 0: 24.66% vs. mFI= 1: 18.11% vs. mFI= 2+: 21.58%, P=0.002). On multivariate regression analysis, when compared with mFI= 0, mFI= 2+ (odds ratio 1.4, P=0.03) predicted extended LOS and nonroutine discharge (odds ratio 1.61, P= 0.001). Our study demonstrates that baseline frailty may be an independent predictor of extended LOS and nonroutine discharge, but not in-hospital mortality, in patients undergoing evacuation for an acute traumatic SDH. Further investigations are warranted as they may guide treatment plans and reduce health care expenditures for frail patients with SDH.

Results of a French pilot database of standard of care of chronic subdural hematoma

BackgroundA registry of chronic subdural hematoma does not exist in France yet. ObjectiveTo present a monocentric pilot project of a French registry of surgical management of chronic subdural hematoma. MethodA monocentric pseudonymized formal database was created. From May 2020 to May 2021, all patients undergoing surgical evacuation of chronic subdural hematoma were entered into the database. ResultsOne hundred and twenty four surgeries from 113 patients were entered in the database. Patients’ demographic and surgical data as well as follow-up are described. ConclusionA local database is easy to implement. We propose a national registry of chronic subdural hematoma management.

Time to medical fitness for discharge following surgical evacuation of chronic subdural haematoma with general or regional anaesthesia: a prospective randomised trial.

General or regional anaesthesia can be used for chronic subdural haematoma evacuation, but no study has compared these types of anaesthesia in terms of peri-operative outcomes. This single-centre, prospective, randomised study included adult patients (age ≥ 18 years) undergoing surgical chronic subdural haematoma evacuation. Patients were randomly allocated to general (target-controlled total intravenous anaesthesia with propofol and remifentanil) or regional anaesthesia (bilateral scalp block with remifentanil sedation if required). The primary outcome measure was duration of hospital stay, based on the day patients were judged by an investigator blinded from the allocation group to be medically fit for discharge. Secondary outcomes included: rate of regional anaesthesia failure; rate of intra-operative and postoperative adverse events at 24 hours; and pain scores at 24 hours. Data from 60 patients were analysed (30 general anaesthesia and 30 regional anaesthesia). Median (IQR [range]) time until patients were judged medically fit for discharge was 3 (3-3 [2-10]) days and 3 (2-5 [2-15]) days for general and regional anaesthesia, respectively (p = 0.700). Regional anaesthesia failed in two patients. There were more intra-operative adverse events in patients who received general anaesthesia (25 vs. 11, respectively; p = 0.001). The occurrence of postoperative adverse events was similar for general and regional anaesthesia (16 vs. 13 patients, respectively; p = 0.605). In patients requiring chronic subdural haematoma evacuation, general and regional anaesthesia are comparable in terms of duration of time until medically fit for discharge and occurrence of postoperative complications. The rate of intra-operative adverse events (mainly arterial hypotension) is greater with general anaesthesia.

306 Nationwide Readmission Rates and Costs for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1—Craniotomy

INTRODUCTION: Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. METHODS: Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS: Among 49,013 patients, 10,643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38,370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period (P = 0.74). The most common primary causes of 30-day readmissions were recurrent SDH (37.1%), venous thromboembolism (12.9%), and delayed hyponatremia and SIADH (syndrome of inappropriate antidiuretic hormone secretion) (12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure (P = 0.03). Household income in the 51st-75th percentile was associated with a decreased risk of readmission. CONCLUSION: National trends in 30-day readmission rates after nontraumatic SDH treatment via craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

Pretibial hematomas – A real-world single-center study

SummaryWe analyzed treatment, outcome, and risk factors for skin necrosis of 60 patients aged ≥65 years treated for a pretibial hematoma in the province of Kymenlaakso, Finland, between 2015 and 2019. Reviewing patients’ medical records revealed two cohorts with distinct trajectories in outcome. By comparing the cohorts, we were able to discover factors associated with the prognosis for generating skin necrosis and the need for operative treatment.Thirty-five (58.3%) patients healed without any management, and 25 (41.7%) patients were treated with hematoma evacuation, mostly for having generated skin necrosis (72%). Among operatively treated patients’ descriptions, such as “parchment skin” and “poor skin quality” were observed frequently (80%) in the medical records. This pathology, dermatoporosis, was statistically significant (p<0.0001) among patients with a complicated outcome of a pretibial hematoma. In addition to dermatoporosis, patients with hematoma evacuation were more fragile having a higher Charlson comorbidity index (p = 0.005), a greater need for a walking aid (p = 0.0002), and overall compromised independency (p = 0.033). Hospitalization and rehabilitation were prolonged in the operatively treated cohort, 6.4 days vs. 2 days, respectively.We recorded a delay in the diagnosis and hematoma evacuation (mean 6, range 0–51 days). In addition, six (10%) patients were misdiagnosed for having erysipelas or deep vein thrombosis indicating that pretibial hematomas are not recognized. Skin quality should be documented, and prompt surgical hematoma evacuation should be executed in fragile patients with dermatoporosis. This could prevent skin necrosis and the further need of wound care or surgical care, long hospitalization, and rehabilitation periods.

Otvorena reparacija aneurizme aorte u endovaskularnoj eri

Open repair (OR) of aortic aneurysms is still relatively mutilating and risky in older and high-risk patients. Since the introduction of EVAR, a significantly lower perioperative mortality has been noted. Apart from advantages, endovascular treatment has some disadvantages as well, due to which OR still has a very important role in the endovascular era. In a vast majority of the patients younger than 65, with good overall condition, long life expectancy and favorable anatomy, as well as in patients with hostile aneurysm neck anatomy, heritable connective tissue disorders, complete thrombosis of abdominal aortic aneurysm (AAA) and potent accessory renal arteries, OR is the first treatment option in comparison with the endovascular treatment. EVAR is recommended as the first treatment option in patients with inflammatory aneurysms and OR should be considered only in better shaped patients with inflammatory AAA and significant hydronephrosis. Late open surgical conversion (LOSC) is a noted event after endovascular treatment and is associated with a significantly higher perioperative mortality and other serious perioperative complications compared to primary OR. Multicenter randomized controlled trials (RCT) did not find a significant difference regarding 30-day mortality between open and endovascular repair of ruptured AAA. However, not all ruptured AAA are suitable for endovascular repair. In a hemodynamically unstable patients, when there is no time for MDCT angiography, EVAR is not possible, and OR is the only option. The incidence of abdominal compartment syndrome after OR is significantly lower in comparison with EVAR thanks to surgical evacuation and drainage of retroperitoneal hematoma. The improvement of the results of aortic aneurysm treatment largely depends on the volume of yearly aortic operations. Having in mind all the mentioned advantages and disadvantages of OR and endovascular repair, we can conclude that in high volume centers, younger generations of vascular surgeons should be educated in standard and complex open aortic surgery.

Postcraniotomy hematoma may not associate with worse outcome or survival following surgical evacuation of traumatic acute subdural hematomas

Postcraniotomy hematoma may not associate with worse outcome or survival following surgical evacuation of traumatic acute subdural hematomas

Management of non-obstetric traumatic vulvar haematoma: a retrospective review of 33 cases

The cases of non-obstetric traumatic vulvar haematomas are rare, and there is a lack of consensus statements for the necessity of surgical intervention. We retrospectively analysed the data of 33 cases (mean age: 25.7 years) of non-obstetric traumatic vulvar haematoma (mean haematoma size: 8.4 cm). Women who underwent surgery (surgery group) were compared to those who received conservative management (conservative group). Twenty-four patients underwent surgery; most cases were of haematoma removal and primary closure. Nine patients received conservative management, such as ice bag application, antibiotics, or analgesia. The rate of deviation of the contralateral vulva because of haematoma was higher (54.2% versus 11.1%, p = .047) and the mean haematoma size was larger (9.5 versus 5.2 cm, p = .004) in the surgical than in the conservative group. While conservative management affects cases of minor vulvar haematoma, surgical evacuation of haematoma can be performed in cases of large haematoma (mean size: 9.5 cm), severe pain, distorted vulvar anatomy, and invisible urethral opening for indwelling urinary catheter. IMPACT STATEMENT What is already known on this subject? Cases of non-obstetric traumatic vulvar haematomas are rare. There are no consensus statements for the necessity of surgical intervention. What do the results of this study add? The study showed that surgical evacuation of haematoma can be performed in cases of large haematoma (mean size: 9.5 cm), severe pain, distorted vulvar anatomy, and invisible urethral opening for indwelling urinary catheter. Moreover, surgical management could hasten recovery. What are the implications of these findings for clinical practice and/or further research? The results of this study can be used in counselling non-obstetric traumatic vulvar haematomas. Further research is needed to confirm these findings.

Mortality of spontaneous intracerebral haemorrhage patients and high serum caspase-8 concentrations

PurposeApoptotic changes in brain samples have been found in haematoma areas of patients with spontaneous intracerebral haemorrhage (SIH) undergoing surgical haematoma evacuation. However, circulating caspase-8 concentrations in SIH patients have not been described. Thus, we carried out this study with the aim to explore whether there is an association of circulating caspase-8 concentrations and mortality in patients with SIH. MethodsWe included patients with severe and supratentorial SIH. We established that the SIH was severe if Glasgow Coma Scale (GCS) was lower than 9. Intensive Care Units from 5 Spanish hospitals carried out the recruitment of patients of this observational and prospective study. We registered serum caspase-8 levels at moment of severe SIH diagnosis and 30-day mortality. ResultsSurviving (n = 41) in respect to non-surviving SIH patients (n = 38) showed lower serum caspase-8 levels (p < 0.001). The area under the curve to estimate 30-day mortality ability by serum caspase-8 levels was 0.75 (95% CI = 0.64–86; p < 0.001). Kaplan-Meier analysis found that patients with serum caspase-8 levels > 17.8 ng/mL showed higher death risk (Hazard ratio = 3.9; 95% CI = 1.99–7.63; p < 0.001). Multiple logistic regression analysis revealed the association of serum caspase-8 concentrations (controlling for intracerebral haemorrhage score, midline shift and early haematoma evacuation) with mortality at 30 days (Odds Ratio = 1.048; 95% CI = 1.018−1.079; p = 0.002). ConclusionsThe association of serum caspase-8 concentrations with mortality of SIH patient mortality is the main of novel findings that have been revealed in our study.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation

The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery. We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05. Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score= 0, 4.3% of SHE score= 1, 14.5% of SHE score= 2, 39.3% of SHE score= 3, and 37.5% of SHE score= 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P= 0.4). The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Memantine Improves Recovery After Spreading Depolarization in Brain Slices and can be Considered for Future Clinical Trials.

Spreading depolarization (SD) has been identified as a key mediator of secondary lesion progression after acute brain injuries, and clinical studies are beginning to pharmacologically target SDs. Although initial work has focused on the N-Methyl-D-aspartate receptor antagonist ketamine, there is also interest in alternatives that may be better tolerated. We recently showed that ketamine can inhibit mechanisms linked to deleterious consequences of SD in brain slices. The present study tested the hypothesis that memantine improves recovery of brain slices after SD and explored the effects of memantine in a clinical case targeting SD. For mechanistic studies, electrophysiological and optical recordings were made from hippocampal area CA1 in acutely prepared brain slices from mice. SDs were initiated by localized microinjection of K+ in conditions of either normal or reduced metabolic substrate availability. Memantine effects were assessed from intrinsic optical signals and extracellular potential recordings. For the clinical report, a subdural strip electrode was used for continuous electrocorticographic recording after the surgical evacuation of a chronic subdural hematoma. In brain slice studies, memantine (10-300µM) did not prevent the initiation of SD, but impaired SD propagation rate and recovery from SD. Memantine reduced direct current (DC) shift duration and improved recovery of synaptic potentials after SD. In brain slices with reduced metabolic substrate availability, memantine reduced the evidence of structural disruption after the passage of SD. In our clinical case, memantine did not noticeably immediately suppress SD; however, it was associated with a significant reduction of SD duration and a reduction in the electrocorticographic (ECoG) suppression that occurs after SD. SD was completely suppressed, with improvement in neurological examination with the addition of a brief course of ketamine. These data extend recent work showing that N-Methyl-D-aspartate receptor antagonists can improve recovery from SD. These results suggest that memantine could be considered for future clinical trials targeting SD, and in some cases as an adjunct or alternative to ketamine.

Demographics, Clinical profile, Causes and Outcome of Intracerebral Hemorrhage in Neurosurgical Unit in Manipal Teaching Hospital of Western Nepal

Background: This research article aims to evaluate the demographic variables, clinical profile, causes and outcome determinants of spontaneous intracerebral hematoma (SICH) in a population of Western Nepal. The study represents the cases of SICH reported from Manipal Teaching Hospital, a tertiary center at Gandaki province of Western Nepal.&#x0D; Materials and methods: Retrospective data collection and analysis were done with consecutive cases of SICH admitted to our center between January 2018 and March 2019. The variables analyzed include age, gender, chronic conditions like hypertension, diabetes mellitus, history of tobacco abuse, alcohol abuse, Glasgow coma score (GCS) on admission, radiological(CT scan) findings, treatment modality, an outcome at 6 months period, etc. Modified Rankin score (mRS) was used to assess the outcome at discharge and after six months. &#x0D; Results: Our study group of 237 patients included 171 males and 66 females and the mean age of presentation was 64.02 years. The study group included 121 patients (51.1%) who were previously diagnosed with systemic arterial hypertension and 15 patients diagnosed with diabetes mellitus. The most frequent locations of hematoma were basal ganglia (n=127), lobar (n=94), intraventricular hemorrhage (n=69), cerebellar (n=15) and brainstem (n=11). The mean volume of the blood clot on admission was 25.97 ml. surgical evacuation of hematoma and decompression through craniotomy was done in 52 (21.9%) patients. Independent predictors of unfavorable outcomes includes the variables like headache (p=0.007), aphasia (p=0.017), mean GCS score (p=0.00) and motor GCS score (p=0.00); CT finding of intraventricular extension of hemorrhage (p=0.00), midline shift (p=0.00), intracerebral blood volume (p=0.00); and surgery (p=0.007).&#x0D; Conclusion: ICH predominantly affects a younger population in Nepal in comparison to the Western world. The variables include clinical features like headache, aphasia, pupillary size and reaction, mean GCS score and motor GCS score; CT finding of intraventricular extension of hemorrhage, midline shift, intracerebral blood volume; and surgery were the predictors of an unfavorable outcome. On binary logistic regression, the ICH score was the most consistent predictor of unfavorable outcomes in terms of MRS (OR 2.236, p=0.002).

Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing.

Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing.

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

BackgroundThe expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy.Methods/designPatients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury.DiscussionThis study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice.Trial registrationClinicalTrials.govNCT 04261673. Registered on 04 February 2020

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke

ObjectivesStandard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH. Materials and MethodAll costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation. ResultsThe incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57. DiscussionFrom the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Intracranial hematoma following ruptured anterior communicating artery aneurysms: risk factors, outcome, and prognostic factors after management of coiling first

BackgroundTo determine the risk factors for intracranial hematoma (ICH) development following ruptured anterior communicating artery (AcomA) aneurysms and to determine prognostic factors associated with unfavorable outcomes after coiling first.MethodsFrom March...