Brain Herniation Research Articles

Case Report: Cerebral Edema and Tonsillar Herniation Leading to Brain Death After Cocaine Use in a Patient with End-Stage Renal Disease

The effect of cocaine use on the cerebral vasculature is well understood, with potential for ischemic or hemorrhagic stroke. The risk of adverse effects can be prolonged and amplified in patients with renal dysfunction and uremia. Uremia-induced osmotic gradients and upregulation of aquaporin channels along with cocaine-induced blood-brain barrier degradation may act synergistically. We present the first known case of a non-compliant dialysis patient who suffers cerebral edema, tonsillar herniation, and brain death following cocaine use. A 32-year-old female with end-stage renal disease presented with shortness of breath and flu-like symptoms for one week and was alert and oriented with no neurologic deficits. The patient had missed her last 5 dialysis treatments and labs revealed hyperkalemia and uremia. Urine drug screen was positive for cocaine, opiates, and tetrahydrocannabinol (THC). Following dialysis and metabolic correction, she developed an irregular respiratory pattern and stridor and received neck computed tomography (CT). The patient became unresponsive with dilated and nonreactive pupils. CT revealed absent intraluminal carotid and vertebral artery flow at the skull base, cerebellar tonsil herniation, and anoxic brain injury. Vital signs were maintained, and cerebral edema was managed with 45-degree head-of-bed elevation and mannitol. Following cerebral edema treatment, the patient had preserved respiratory drive, fixed and dilated pupils, no corneal reflex, no cough or gag reflex, and negative oculocephalic reflex. Repeat cranial CT angiography revealed bilateral hemispheric edema, basal subarachnoid hemorrhage, and confirmed absent intracranial blood flow. Brain death was diagnosed with a radioisotope cerebral blood flow study. The use of cocaine in patients with renal dysfunction may increase the risk of cerebral edema and tonsillar herniation due to synergistic physiologic effects. Physicians should be aware of this interaction to allow for preventative measures.

Acute dural venous sinus thrombosis in a child with idiopathic steroid-dependent nephrotic syndrome: a case report

Nephrotic syndrome (NS) is a hypercoagulable state in which children are at risk of venous thromboembolism. A higher risk has been reported in children with steroid-resistant NS than in those with steroid-sensitive NS. The mortality rate of cerebral venous sinus thrombosis (CVST) is approximately 10% and generally results from cerebral herniation in the acute phase and an underlying disorder in the chronic phase. Our patient initially manifested as a child with massive proteinuria and generalized edema. He was treated with albumin replacement and diuretics, angiotensin-converting enzyme inhibitor, and deflazacort. Non-contrast computed tomography showed areas of hyperattenuation in the superior sagittal sinus when he complained of severe headache and vomiting. Subsequent magnetic resonance imaging revealed empty delta signs in the superior sagittal, lateral transverse, and sigmoid sinuses, suggesting acute CVST. Immediate anticoagulation therapy was started with unfractionated heparin, antithrombin III replacement, and continuous antiproteinuric treatment. The current report describes a life-threatening CVST in a child with steroid-dependent NS, initially diagnosed by contrast non-enhanced computed tomography and subsequently confirmed by contrast-enhanced magnetic resonance imaging, followed by magnetic resonance venography for recanalization, addressing successful treatment.

Clinical Findings And Visual Pathway Disorders Due To Tumor, What MRI can be Found?

The 10th most common cause of mortality for both men and women is brain and other nervous system cancer. These tumors can cause serious ocular signs and symptoms as well as neurologic complications due to increased intracranial pressure, cranial nerve disturbances, or brain compression. CT and MRI are the modalities most commonly used to evaluate visual disturbances around the visual pathway. MRI is the preferred imaging modality for evaluating tumors because it does not use X-rays but uses a magnetic field, producing clearer images

661: ROLE OF DECOMPRESSIVE HEMICRANIECTOMY IN PEDIATRIC MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION

Introduction: Malignant conversion of cerebral infarct leading to cerebral herniation is well described in adults. There is a lack of sufficient literature on malignant infarction in children. We report a rare case of middle cerebral artery infarct (MCAI) in a teenage girl with initial improvement (honeymoon period), followed by progression to malignant MCAI (MMCAI), requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement at discharge and at 4-month follow-up. Description: A 14-year-old previously healthy female presented with loss of consciousness for 45 minutes followed by right side weakness. Her MRI of the brain showed acute infarct without hemorrhage involving the territory of the left MCA requiring PICU management. The initial diagnostic workup was suggestive of idiopathic MCAI. She had right-sided hemiplegia, and National Institute of Health Stroke Scale (NIHSS) score of 19. On hospital day 3, she showed improvement with NIHSS changing from 19 to 15. On the evening of hospital day 5, she developed progressively worsening headaches, emesis, and loss of consciousness. CT head demonstrated malignant cerebral edema, midline shift and uncal and sub-falcine herniation. She was intubated and taken emergently to the operating room for a left-sided DHC. She was then managed in the PICU with neuroprotective strategies, aggressive management of her elevated intracranial pressure, and goal-directed management of her cerebral perfusion pressure. She subsequently improved with successful extubation on hospital day 21 and discharge on hospital day 66. At a 4-month follow-up in the neurosurgery clinic, she was alert, interactive, verbal with slow speech, able to identify simple objects, lift right shoulder, and extend the right lower extremity. Discussion: Our case described above is a unique report of DHC in a pediatric patient who had rare MMCAI with a positive outcome. The additional feature of our case worth reporting was the initial honeymoon period before malignant conversion. This rare presentation highlights the importance of monitoring the neurological status in a patient with an MCAI for progression to life-threatening malignant MCAI. This case report also highlights the importance of consideration of DHC for a favorable outcome of MMCAI.

Decompressive craniectomy: Comparative analysis between surgical time and better prognosis.

Malignant ischemic stroke is characterized by the involvement of 2/3 of the area of the middle cerebral artery, associated with cerebral edema, intracranial hypertension (ICH) and cerebral herniation, generating high morbidity and mortality. Over the years, several therapies have been studied in an attempt to reverse or reduce the damage caused by this vascular disorder, including decompressive craniectomy (DC), a surgical technique reserved for cases that evolve with refractory ICH. This study seeks to perform a comparative analysis on the effectiveness of decompressive craniectomy using four randomized clinical trials and the results found in the retrospective study conducted in a neurosurgical reference center between 2010 and 2018. The total sample consisted of 263 patients, among which 118 were randomized and 145 were part of the retrospective study. The outcome was analyzed based on the modified Rankin Scale (mRS) for 6 and 12 months. The mean time to perform the DC was 28.4 h in the randomized trials, with the late approach (> 24 h) associated with unfavorable outcomes (mRS between 4 and 6). Compared to the aforementioned studies, the study by Bem Junior et al. shows that a surgical approach in < 12 h had a better outcome, with 70% of the patients treated early classified as mRS 2 and 3 at the end of 12 months (1). Decompressive craniectomy is currently the most effective measure to control refractory ICH in cases of malignant ischemic stroke, and the most appropriate approach before surgery is essential for a better prognosis for patients.

The assessment of risk factors for brainstem injuries and supratentorial brain injuries in patients with traumatic brain injury

Traumatic brain injury (TBI) is an important cause of death with a significant worldwide percentage. In the United States, there are approximately 2.8 million TBIs yearly with 250,000 hospitalized patients and 50,000 TBI-related deaths. Every year, there are one million hospitalizations in the European Union, resulting in more than 50,000 deaths, most of which occur due to road traffic accidents. Needless to say, these estimations varied based on the different sources of data. The patient’s outcome is determined by the context of the trauma, the type of lesion, as well as other factors. The aim of the study was to assess variables associated with brainstem injury and supra-tentorial brain injury in patients with TBI. This cohort included 70 consecutive TBI-related deaths from the Institute of Legal Medicine Cluj-Napoca. There was a significant difference in brainstem contusion (haemorrhage contusion) in patients younger than 60. According to the computed tomography (CT) data, brain contusion and laceration were observed in association with brainstem contusion in a significant percentage of TBI-related deaths (p=0.016). Neither the meningo-cerebral blood collections nor the intraparenchymal hematomas had a significant occurrence with brainstem contusion. The diffuse axonal injuries were detected on a CT scan in a significant number of cases with brainstem contusion (p=0.011). The mass effect with brain herniation in the posterior fossa was associated with the occurrence of brainstem contusion, possibly as an extensive process (p=0.041). Analyzing the histopathological data, we observed the significant presence of intracranial haemorrhage in association with a hemorrhagic contusion in the brainstem (p=0.004), but not with meningeal haemorrhage. The poor neurological assessment evaluated by GCS was not an independent variable in relation to this brainstem lesion. That was probably caused by the complexity of the TBI. We did not include this variable in a multivariate analysis considering the poor outcome for all patients

547: CEREBRAL EDEMA IN MOG ANTIBODY DISEASE TREATED WITH INVASIVE MULTIMODAL NEUROMONITORING

Introduction: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a neuroinflammatory disorder with a range of clinical phenotypes. MOGAD is typically steroid-responsive, with more refractory cases receiving intravenous immunoglobulin (IVIG) or plasmapheresis. Invasive multimodal neuromonitoring provides real-time measurements of intracranial pressure (ICP) and brain tissue oxygenation (PbtO2) and may be accomplished via insertion of an intraparenchymal probe, also known as a “bolt”. It is becoming an important strategy in the management of patients with traumatic brain injury but is less well described in other acute neurological conditions associated with increased ICP. We describe a case of MOGAD in a child that presented as life-threatening cerebral edema, in which invasive multimodal neuromonitoring with ICP- and PbtO2-directed therapy was employed. This child ultimately survived with some persistent neurological deficits but with normal mood and affect and the ability to eat, drink, and ambulate independently. Description: A 7-year old boy presented with headaches, nausea and somnolence and was found to have increased ICP of unclear etiology. He then progressed to develop exam findings consistent with herniation. He received emergent medical therapies including hypertonic (3%) saline, hyperventilation, and sedation. A bolt was placed for invasive neuromonitoring, which guided treatment based on real-time measurements of ICP and PbtO2. Workup for the etiology of his severe cerebral edema revealed serum MOG antibodies. He received immunomodulatory therapies including steroids, plasmapheresis, and tocilizumab. He was discharged two months later with expressive and receptive aphasia and mild gait imbalance, but with recovered bowel and bladder continence, independent ambulation, and the ability to eat, drink, and interact socially with a normal mood and affect. Discussion: We describe a child who presented with cerebral edema and herniation due to MOGAD. He was managed with invasive multimodal neuromonitoring in addition to standard immunomodulatory treatments and had a favorable outcome. While further data is needed, invasive multimodal neuromonitoring may have utility as an adjunct to standard therapy in children with MOGAD and severe cerebral edema.

Assessment of magnitude and spectrum of cardiovascular disease admissions and outcomes in Saint Paul Hospital Millennium Medical College, Addis Ababa: A retrospective study.

Cardiovascular diseases(CVD) remain the leading cause of death in the world and over 80% of all cardiovascular-related deaths occur in low and middle income countries. Ethiopia is in epidemiologic transition from predominantly infectious diseases to non-communicable diseases and the CVD is a major public health challenge. The aim of this study was to assess the magnitude and spectrum of cardiovascular admission and its outcomes among medical patients admitted to both Medical Ward and ICU of St. Paul Teaching Hospital from 1st of Jan 2020 to 1st of Jan 2021. Out of 1,165 annual medical admissions, the prevalence of cardiovascular diseases(CVD) was 30.3%. About 60%(212) of patients had advanced congestive heart failure of diverse causes. Hypertensive heart disease (HHD) was the next predominant diagnosis (41%(146)), and also the leading cause of cardiac diseases followed by rheumatic valvular heart disease(RVHD) (18%(64)) and Ischemic heart disease (IHD) (12.2%(43)), respectively. Yong age, rural residence and female sex were associated with RVHD(p = 0.001). Stroke also accounted for 20%(70) of CVD admission (hemorrhagic stroke-17% Vs Ischemic stroke-83%). Hypertension was the predominate risk factor for CVD and present in 46.7%(168) of patients. The mean hospital stay was 12days and in-hospital mortality rate was 24.3% with septic shock being the commonest immediate cause of death followed by fatal arrhythmia, brain herniation, and massive PTE. Cardiovascular diseases were common in the study area causing significant morbidity and mortality. Therefore, comprehensive approach is imperative to timely screen for cardiovascular risk reduction, disease control and complication prevention. Strategies should also be designed to increase public awareness regarding the cardiovascular risk reduction, drug adherence, and possible complications.

Machine-learning-based risk stratification for probability of dying in patients with basal ganglia hemorrhage

To confirm whether machine learning algorithms (MLA) can achieve an effective risk stratification of dying within 7 days after basal ganglia hemorrhage (BGH). We collected patients with BGH admitted to Sichuan Provincial People’s Hospital between August 2005 and August 2021. We developed standard ML-supervised models and fusion models to assess the prognostic risk of patients with BGH and compared them with the classical logistic regression model. We also use the SHAP algorithm to provide clinical interpretability. 1383 patients with BGH were included and divided into the conservative treatment group (CTG) and surgical treatment group (STG). In CTG, the Stack model has the highest sensitivity (78.5%). In STG, Weight-Stack model achieves 58.6% sensitivity and 85.1% specificity, and XGBoost achieves 61.4% sensitivity and 82.4% specificity. The SHAP algorithm shows that the predicted preferred characteristics of the CTG are consciousness, hemorrhage volume, prehospital time, break into ventricles, brain herniation, intraoperative blood loss, and hsCRP were also added to the STG. XGBoost, Stack, and Weight-Stack models combined with easily available clinical data enable risk stratification of BGH patients with high performance. These ML classifiers could assist clinicians and families to identify risk states timely when emergency admission and offer medical care and nursing information.

Carotid Artery Stenting for Patients With Carotid Stenosis and Contralateral Carotid Artery Occlusion: A 12-Year Experience

Carotid artery stenting (CAS) has emerged as a potential alternative for treating patients with extracranial cerebrovascular diseases. Contralateral carotid artery occlusion (CCO) occurs in approximately 2.3% to 25% of patients with carotid artery stenosis. However, the association of a CCO with long-term outcomes after CAS remains unclear. Here, we aimed to evaluate the perioperative and long-term recovery and safety of patients with CCO after receiving CAS. We retrospectively collected the data of patients with CCO treated with CAS between 2010 and 2021. The primary endpoint was a nonfatal major stroke. The secondary endpoints included cerebral hemorrhage, nonfatal myocardial infarction (MI), restenosis, acute renal insufficiency, stent-related complications, and death. Long-term outcomes were analyzed by Kaplan-Meier survival analysis using the following variables: symptomatic carotid stenosis, age, stent type, collateral flow status, and post-dilation. Seventy-one consecutive patients with CCO who underwent CAS were included in the study. Of these, 61 patients (86%) were followed up for 9-134 months, with an average of 63.3 ± 30.4 months. In the perioperative period, 2 patients (2.8%) experienced stroke, and 1 patient (1.4%) died due to cerebral hemorrhage combined with cerebral hernia. During follow-up, 2 patients (3.3%) developed stroke at 4 and 6 months each after CAS, and 6 patients (9.8%) died (2 patients died due to MI, and 4 patients died due to either severe liver failure, car accident, cervical fracture, or unknown cause. Kaplan-Meier survival analysis showed that symptomatic carotid stenosis, age, stent type, and post-dilation were not associated with long-term stroke (P＜0.05). The inadequate collateral flow group showed a higher stroke rate than the control group (P = 0.009). CAS is a safe and effective therapy for patients with CCO. Inadequate collateral flow is associated with a higher long-term rate of stroke. Our findings revealed that symptomatic carotid stenosis, age, stent type, and post-dilation had no significant effect on outcome events after CAS.

A Rapidly Fatal Case of Anti-GFAP Receptor Encephalitis Due to Acute Brain Edema and Herniation

Objective Glial fibrillary acidic protein antibody (GFAP) is a newly recognized biomarker for an immunotherapy responsive autoimmune meningo-encephalomyelitis with a wide variety of clinical presentations. We report the second GFAP antibody positive case in a young man who died despite appropriate and aggressive immunomodulatory treatment. Background 29 year old previously healthy male with childhood immune disorder presented with 3 week history of acute progressive worsening headaches, bloody emesis, nausea, blurry vision and generalized weakness. Exam was significant for downbeating nystagmus, limb ataxia and tremor and later progressing into inattention, confusion, urinary retention, asymmetric pupils, hyprreflexia and lack of motor or sensory response. Lumbar puncture revealed lymphocytic pleocytosis with elevated protein and opening pressure of 36 cm H20. MRI demonstrated areas of restricted diffusions symmetrically involving white matter of the corpus callosum, middle cerebellar peduncle, cerebellar white matter bilaterally as well as within the pons centrally. Patient was started on intravenous immunogammaglobulin (IVIG) and pulse corticosteroids along with broad spectrum antimicrobial therapy. After an initial apparent response to treatment, repeat head CT showed Diffuse Sulci effacement. Shortly after, He rapidly decompensated with clinical findings indicating brainstem herniation, cardiac arrest and brain death was diagnosed. CSF studies subsequently were reported as positive for GFAP antibodies. An autopsy reported the cause of death as cerebellar tonsillar herniation secondary to diffuse cerebral edema. all sections showed perivascular inflammation and gliosis. Design/Methods NA. Results NA. Conclusions This reported case of anti-GFAP meningo-encephalomyelitis is unusual for the rapid onset of cerebral edema and rapid progression to herniation and brain death occurring only 4 weeks after symptom onset. While this may be a rare complication of Anti GFAP encephalitis, clinicians should be vigilant for acutely increased intracranial pressure in patients with clinical findings of encephalitis in general.

COT-15 PATHOLOGICAL ANALYSIS OF MALIGNANT GLIOMA IN THE END STAGE

Abstract Background Malignant gliomas have an extremely high rate of recurrence and brain invasion despite standard treatment, ultimately leading to tumor death. Tumor death is generally thought to be caused by brain herniation due to mass effect, as confirmed by studies of malignant glioma brain autopsies performed in the 1960s and 1980s. However, there have been few studies of brain autopsies of malignant gliomas after the introduction of chemotherapy with temozolomide, and the pathological characteristics of the end stage of the disease have not been clarified in recent years. In this study, we report the clinical and pathological characteristics of the end stages of malignant glioma cases treated at our hospital from the initial treatment to the confirmation of death. Methods 10 cases of malignant glioma that were treated from initial treatment to pathological autopsy at our hospital from 2007 to 2018 were included in this study. We analyzed the pathology, neuroradiological changes, and clinical course of these cases at the end stage. Results The mean age of the 10 patients was 59 (15-77) years, and the median overall survival was 16.5 months. The primary tumor sites were 2 frontal lobes, 3 parietal lobes, 3 temporal lobes, 1 cerebellum, and 1 multiple lesions. The direct cause of death in all cases was neurological death due to tumor progression. Gross findings of pathological autopsy specimens showed that tumor excision sites were cavitated or recurrent, but mass effect was poor and there were few cases of brain herniation. On the other hand, microscopic findings showed infiltration of tumor cells into the brain stem through the brain parenchyma. Conclusion This study suggests that tumor invasion into the brainstem is involved as a cause of tumor death. It is possible that the new treatment may change the recurrence pattern or alter the morphology of glioma cells.

Ultrasound-guided cerebral resuscitation in patients with severe traumatic brain Injury.

Traumatic brain injury (TBI) is a worldwide public health concern given its significant morbidity and mortality, years of potential life lost, reduced quality of life and elevated healthcare costs. The primary injury occurs at the moment of impact, but secondary injuries might develop as a result of brain hemodynamic abnormalities, hypoxia, and hypotension. The cerebral edema and hemorrhage of the injured tissues causes a decrease in cerebral perfusion pressure (CPP), which leads to higher risk of cerebral ischemia, herniation and death. In this setting, our role as physicians is to minimize damage by the optimization of the CPP and therefore to reduce mortality and improve neurological outcomes. Performing a transcranial doppler ultrasound (TCD) allows to estimate cerebral blood flow velocities and identify states of low flow and high resistance. We propose to include TCD as an initial assessment and further monitoring tool for resuscitation guidance in patients with severe TBI. We present an Ultrasound-Guided Cardio-cerebral Resuscitation (UGCeR) protocol in Patients with Severe TBI.

Using Magnetic Resonance Imaging During Childbirth to Demonstrate Fetal Head Moldability and Brain Compression: Prospective Cohort Study.

Childbirth is a physiological process with significant medical risk, given that neurological impairment due to the birthing process can occur at any time. Improvements in risk assessment and anticipatory interventions are constantly needed; however, the birthing process is difficult to assess using simple imaging technology because the maternal bony pelvis and fetal skeleton interfere with visualizing the soft tissues. Magnetic resonance imaging (MRI) is a noninvasive technique with no ionizing radiation that can monitor the biomechanics of the birthing process. However, the effective use of this modality requires teamwork and the implementation of the appropriate safeguards to achieve appropriate safety levels. This study describes a clinically effective and safe method to perform real-time MRI during the birthing process. We reported the experience of our team as part of the IMAGINAITRE study protocol (France), which aimed to better understand the biomechanics of childbirth. A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1-Tesla open-field MRI. Of these 27 patients, 7 (26%) subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head moldability and brain compression. All 7 observed babies showed a sugarloaf skull deformity and brain compression at the middle strait. The fetus showing the greatest degree of molding and brain shape deformation weighed 4525 g and was born spontaneously but also presented with a low Apgar score. In this case, observable brain shape deformation demonstrated that brain compression had occurred, and it was not necessarily well tolerated by the fetus. Depending on fetal head moldability, these observations suggest that cephalopelvic disproportion can result in either obstructed labor or major fetal head molding with brain compression. This study suggests the presence of skull moldability as a confounding factor explaining why MRI, even with the best precision to measure radiological landmarks, fails to accurately predict the modality of childbirth. This introduces the fetal head compliance criterion as a way to better understand cephalopelvic disproportion mechanisms in obstetrics. MRI might be the best imaging technology by which to explore all combined aspects of cephalopelvic disproportion and achieve a better understanding of the underlying mechanisms of fetal head molding and moldability.

A RARE CASE OF MIDDLECEREBRAL ARTERYSTROKERESULTING FROM ADISTANT PENETRATINGCHEST TRAUMA

This case report analyses the occurrance of an exceedingly rare and unpredictable complication of remote penetrating chest trauma with arterial injury , which is embolic stroke , leading to a particular combination of hemorrhagic shock hemodynamic profile altering the cerebral autoregulation , with malignant middle cerebral artery stroke in a young patient , causing intracranial hypertension resulting in subfalcine herniation , and compromising the penumbral zone and the chances of survival , and rendering most of the conventional stroke teatments contra indicated or not useful , our purpose is to raise into awareness this type of complication in order to establish efficient salvatory treatments without delay.

Magnetic resonance based morphometric analysis of the tentorial notch.

The study of the tentorial notch can improve the understanding of brain injury mechanisms. Tentorial morphology has been analysed primarily in cadaveric studies. However, the postmortem effect can cause variability in the measurements. The objective was to evaluate the morphometry of the tentorial notch and the third cranial nerve on living subjects using magnetic resonance imaging (MRI). A retrospective cross-sectional study was performed. Using consecutive cases, 60 MRI scans were analysed for tentorial notch morphology. Maximum notch width (MNW), notch length (NL), interpedunculoclival (IC) distance, apicotectal (AT) distance, third cranial nerve (CN-III) distance, and inter- CN-III angle, were obtained. For the classification of the tentorial notch quartile distribution technique for MNW, NL, AT distance, and IC distance were used. According to the quartile of the MNW, patients were stratified into narrow, midrange, and wide groups. Using the NL quartile groups, they were also classified as short, midrange, and long. With these, the tentorial notch could be classified into eight types. Statistical differences between genders in the MNW and inter-CN-III angle were found, as well as a strong positive correlation between NL and AT distance, and between right and left CN-III distances. There were differences between the cadaveric samples and living subjects in the CN-III distances. This difference could be explained by the dehydration of brain volume in the postmortem process which may cause nerve elongation. Morphometry of the tentorial notch and its neurovascular relations allows a better understanding of the mechanisms of brain herniation.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma.

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course. We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed. The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome. rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

Solitary intraventricular tumors in dogs and cats treated with radiotherapy alone or combined with ventriculoperitoneal shunts: A retrospective descriptive case series.

Intraventricular tumors are rare, optimal treatment is not defined. Symptomatic patients often exhibit life-threatening hydrocephalus. With several months time-to-effect after radiotherapy (RT), increased intracranial pressure is concerning. This increase in pressure can be overcome by ventriculoperitoneal shunting (VPS). Retrospective evaluation of outcome and complications in dogs and cats with intracranial tumors treated with either RT or VPS/RT. Twelve client-owned cats and dogs. Dogs and cats with symptomatic intraventricular tumors treated with definitive-intent RT or VPS/RT were included in a retrospective, descriptive case series. Complications, tumor volume evolution, time-to-progression, and survival time were determined. Twelve animals were included: 1 cat and 5 dogs treated with single-modality RT and 4 cats and 2 dogs treated with VPS/RT. Neurological worsening seen in 4/6 animals during single-modality RT and 2/6 died during RT (suspected brain herniation). All dogs with VPS normalized clinically by the end of RT or earlier. Complications occurred in 4/6 animals, all but 1 were successfully managed surgically. Imaging follow-up in 8 animals surviving RT showed a marked decrease in tumor volume. Median survival time was 162 days (95% confidence interval [CI]: 16; infinity) for animals treated with RT and 1103 days (95%CI: 752; infinity) for animals treated with VPS/RT. Median time-to-progression was 71 days (95%CI: 7; infinity) and 895 days (95%CI: 704; infinity) for each group, respectively. Two dogs died because of intraventricular metastasis 427 and 461 days after single-modality RT. Ventriculoperitoneal shunting led to rapid normalization of neurological signs and RT had a measurable effect on tumor volume. Combination of VPS/RT seems to be beneficial.

Fetal Open Surgery for Occipital Encephalocele: First Experience in a Tertiary Public Hospital in Brazil

AbstractOccipital encephalocele is a rare neural tube defect characterized by an opening in the occipital bone, resulting in herniation of meninges and brain tissue. Current treatment consists of surgical repair in the postnatal period. The main objective of intrauterine surgery for encephalocele is to decrease/stop the progression of the brain herniation and reversal of microcephaly, contributing to better perinatal outcomes. We reported the first experience of a fetal open surgery for occipital encephalocele in a Brazilian Public Health Service. The surgery took place with gestational age of 27 + 2 weeks of pregnancy. Careful dissection was performed between the skin and the dura that herniated through the bone defect, and the redundant tissue was removed and the dura was opened for access to neural tissue. Cesarean section was indicated prematurely at 34 + 4 weeks due to significant thinning of the myometrial wall with risk of uterine rupture. The newborn was discharged from the neonatal intensive care unit at 21 days after delivery and from the hospital at 30 days in good conditions. Fetal open surgery for encephalocele is still an experimental therapy with maternal–fetal risks; however, the postnatal follow-up is critical for the assessment of the real benefits of this surgery.

Prognostic factors of prolonged disorder of consciousness after stroke: A single centre retrospective study

BackgroundStroke is a common disease in neurology, which often causes prolonged disorder of consciousness (pDOC) and brings a heavy burden to the patient's family and society. This study aims to explore the epidemiological factors of pDOC after stroke and the factors affecting the outcome of consciousness. MethodThe patients that admitted in Tianjin Huanhu Hospital from January 2019 to December 2021 and met the inclusion criteria were selected. Descriptive statistics was initially performed on the relevant factors of the stroke group, and statistical analysis was subsequently performed. Finally, to judge the sensitivity and specificity of the significant factors to the prediction of outcome, the receiver operating characteristic (ROC) curve of the participants was used. ResultThe statistical results showed that the location of brain injury (λ2 = 7.550, P = 0.023), cerebral hernia (λ2 = 7.534, P = 0.006), and Glasgow Coma Scale (GCS) score at onset (t = −2.479, P = 0.017) were statistically significant indicators in the improvement of consciousness in patients with pDOC after stroke. The ROC curve showed that the sensitivity and specificity of predicting the outcome of brain injury site (area under the curve [AUC] = 0.766, 95% confidence interval [CI]: 0.708–0.824) were 0.50 and 0.90, respectively, and that of cerebral hernia (AUC = 0.663, 95% CI: 0.594–0.732) were 0.73 and 0.60, respectively. The GCS score (AUC = 0.660, 95% CI: 0.596–0.724) predicted the outcome with sensitivity and specificity of 0.35 and 0.92, respectively. ConclusionThe incidence rate of pDOC after stroke in men was higher than that in women, and the improvement rate in the consciousness level was significantly higher than that of ischemic–hypoxic encephalopathy. However, the improvement rate of the consciousness level in patients with pDOC after stroke was not related to age and gender. Cerebral hernia occurred at the time of onset, stroke occurred in the brainstem, and the low GCS score at the time of onset was significantly associated with the poor prognosis of consciousness level.