Morphometric evaluation of traumatic axonal injury and the correlation with post-traumatic cerebral atrophy and functional outcome

Introduction Imaging plays a crucial role in the diagnosis, prognosis and follow-up of traumatic brain injury. Whereas computed tomography plays a pivotal role in the acute setting, magnetic resonance imaging is best suited to detect the true extent of traumatic brain injury, and more specifically diffuse axonal injury. Post-traumatic brain atrophy is a well-known complication of traumatic brain injury. Purpose This study investigated the correlation between diffuse axonal injury detected with fluid-attenuated inversion recovery and susceptibility-weighted imaging magnetic resonance imaging, post-traumatic brain atrophy and functional outcome (Glasgow outcome scale – extended). Materials and methods Twenty patients with a closed head injury and diffuse axonal injury detected with fluid-attenuated inversion recovery and susceptibility-weighted imaging were included. The total volumes of the diffuse axonal injury fluid-attenuated inversion recovery lesions were determined for each subject’s initial (<14 days) and follow-up magnetic resonance scan (average: day 303 ± 83 standard deviation). The different brain volumes were automatically quantified using a validated and both US Food and Drug Administration-cleared and CE-marked machine learning algorithm (icobrain). The number of susceptibility-weighted imaging lesions and functional outcome scores (Glasgow outcome scale – extended) were retrieved from the Collaborative European NeuroTrauma Effectiveness Research Traumatic Brain Injury dataset. Results The volumetric fluid-attenuated inversion recovery diffuse axonal injury lesion load showed a significant inverse correlation with functional outcome (Glasgow outcome scale – extended) ( r = −0.57; P = 0.0094) and white matter volume change ( r = −0.50; P = 0.027). In addition, white matter volume change correlated significantly with the Glasgow outcome scale – extended score ( P = 0.0072; r = 0.58). Moreover, there was a strong inverse correlation between longitudinal fluid-attenuated inversion recovery lesion volume change and whole brain volume change ( r = −0.63; P = 0.0028). No significant correlation existed between the number of diffuse axonal injury susceptibility-weighted imaging lesions, brain atrophy and functional outcome. Conclusions Volumetric analysis of diffuse axonal injury on fluid-attenuated inversion recovery imaging and automated brain atrophy calculation are potentially useful tools in the clinical management and follow-up of traumatic brain injury patients with diffuse axonal injury.

The relationship between modified Graeb score and intraventricular hematoma volume with Glasgow outcome scale and modified Rankin scale in intraventricular hemorrhage of brain: a comparative study

Background: Intraventricular hemorrhage (IVH) is an acute neurosurgical condition. The aim of this study was to identify the relationship between modified Graeb score (mGS) and intraventricular hematoma volume with Glasgow outcome scale (GOS) and modified Rankin scale (mRS).Methods: This is a Quasi-experimental study conducted in the department of neurosurgery, Chittagong Medical College Hospital, Chittagong, Bangladesh during the period from 24 July 2018 to 23 July 2019. After a detailed history and clinical examination, 150 patients were selected for this study. The study participants were divided into two major groups- external ventricular drainage (EVD) and conservative; both groups consisted of 44 patients. Written informed consent were taken from the participants. Data were analyzed using statistical package for the social sciences (SPSS) software.Results: Overall mean age was around 60 years with an age range from 15-85 years. More than three fourth of the patients in both groups were from the age group of >50 years (73.83%). There were no differences between EVD and conservative groups regarding medical comorbidities. Most prevalent comorbidity among the patients of both groups’ hypertension, followed by diabetes and previous ischemic stroke. Overall the most frequent symptoms in the studied patients were vomiting, followed by loss of consciousness, headache and convulsion. There were no significant differences between the two groups regarding presenting symptoms. The mean Glasgow coma scale (GCS) score level was significantly lower in the patients with EVD than their counterpart from 1st post-operative day to 8th post-operative day. However, within-group comparison shows that the GCS score was significantly increased from 1st day to 8th day in both groups of patients.Conclusions: These findings can be used to identify patients in whom an EVD may provide measurable outcomes benefit with respect to patient mortality and help guide neurosurgical decision-making in particular patient subgroups with acute IVH.

Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial

Background Hypothermia is neuroprotective in some ischemia–reperfusion injuries. Ischemia–reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia–reperfusion injury and improve global neurologic outcome. Methods This international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels. Results Independent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups. Conclusions This trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups.

Transcortical approaches to large intraventricular tumors: a prospective case series of 20 patients

Background Large intraventricular tumors (IVTs) impose technical and surgical challenges, due to their enormous sizes, mass effect, vast extensions, and vascularity. Objective The authors aim at presenting their results, clinical outcomes, and the surgical strategies in the management of large IVTs through transcortical approaches. Methods A prospective trial was conducted at the Main Hospital of Alexandria University, Egypt, between August 2018 and October 2020 on 20 patients harboring IVTs larger than 5 cm or bilaterally represented. The variables evaluated included the extent of resection, postoperative neurological deficits, blood loss, surgical approaches, intraoperative challenges, complications, adjuvant therapies, Glasgow Outcome Scale, hydrocephalus, and cerebrospinal fluid (CSF) diversion. Results The study included 20 cases (9 males and 11 females). Mean age at diagnosis was 16.1 years (range 1–45). Mean follow-up was 12 months (range 9–26). Primary tumor locations were ventricular body, atrium, temporal horn, and frontal horn in 11, 5, 3, and 1 cases, respectively. Main pathologies were central neurocytomas (7 patients/35%), ependymomas (3 patients/15%), and subependymal giant cell astrocytoma (SEGA) (3 patients/15%). Excision was gross total (n = 19) and near-total (n = 1). Significant intraoperative bleeding (n = 6). Postoperative minor intraventricular hemorrhage (n = 6), subdural collections (n = 8), hydrocephalus (n = 9), memory affection (n = 4), and motor deficits (n = 4). Postoperative Glasgow Outcome Scale of 5/5 (n = 20), no mortalities were recorded. preoperative seizures (n = 7), new onset postoperative seizures (n = 2). Conclusion Surgical approaches to large tumors of the lateral ventricles should be tailored to the variability of tumor locations, dimensions, extensions, and the individual morbid anatomy, in addition to the surgeon’s experience and preferences. Trans-cortical approaches can provide safe surgical corridors to tackle these challenging subtypes of IVTs with good clinical outcomes, tumor resectability rates, and seizure control.

Neurobehavioral Changes: An under looked aspect of Head Injury

Background: Different types of behavioral changes are seen in head injury patients, and these changes are directly or indirectly related to daily activities. Major alterations of personality after head injury are generally seen in the patients with severe head injury. However, disturbing post-concussional symptoms like headache, dizziness and memory problems generally persists for few months even in the less severely injured ones. Materials and methods: Objective: To analyze the neurobehavioral changes in adult head injured patients. Study design: Prospective analytical study. Sampling technique: Non - probability consecutive sampling. Site of study: National Institute of Neurological and Allied Sciences, Bansbari, Nepal. Inclusion Criteria: All head injured patients above the age of 16 years. Exclusion Criteria: Extended Glasgow Outcome Scale of less than 3 at 6 months follow up. Data Collection and Analysis: All patients above the age of 16 years with head injury who got admitted were enrolled in the study. Parameters like age, gender, mode of injury, GCS at presentation were recorded. Extended Glasgow Outcome Scale along with Neurobehavioral rating was evaluated at 6 months. Then neurobehavioral rating scale was obtained by direct interview. Data analysis was done using SPSS v.20. Results: Total number patients were 76 among which 71% were below 40 years of age and majorities (87%) were males. Neurobehavioral categories like abnormal intentional behavior, lowered emotional state, heightened emotional state, arousal state and language had significant association with GCS at presentation and EGOS at 6 months. Similarly, age had significant association with language, where there was absent to mild language difficulty in patients below 40 years of age. Likewise, language difficulty, lower emotional state and abnormal intentional behavior were significantly associated with gender, as it was mild to severe in 30% of the female population who had sustained head injury. Conclusion: Several neurobehavioral characters seem to be present in the various categories of the head injured patients in different ratios. Language problems seems to be less in the younger patients below the age of 40 years; although, few neurobehavioral parameters seems to affects the females more common compared to male counterparts. Also, family disruption and its extent of severity was significantly related to the severity of head injury.

CORRELATION OF RADIOLOGICAL FINDINGS WITH SHORT-TERM CLINICAL OUTCOME IN PATIENTS OF TRAUMATIC BRAIN INJURY AT A PUBLIC HOSPITAL IN NORTH INDIA.

BACKGROUND: Traumatic brain injury is dened as an aggression to the brain caused by an external physical force producing a state of diminished or altered consciousness leading to decreased cognitive abilities and physical functioning. The Glasgow Outcome Scale (GOS) is a general measure widely used in TBI management and surgery outcome studies. The Rotterdam Computed Tomography (CT) score of traumatic brain injury is a relatively recently described classication aimed at improving prognostic evaluation of patients admitted with acute traumatic brain injuries. OBJECTIVE: Aim of our study is to correlate the severity of traumatic brain injury using CT Rotterdam criterion with clinical outcome at 3 months using Glasgow Outcome Scale (GOS). MATERIAL AND METHODS: This was a hospital based observational study conducted in Department of radiology from May 2020 to February 2021. All patients with history of traumatic brain injury who underwent NCCT in department were contacted telephonically 3 months after the date of CT scan and a verbal questionnaire in vernacular language was asked telephonically to calculate the nature of their disability after the inciting event of trauma. The CT severity score was then correlated with GOS at 3 months. RESULTS: GOS and CT Rotterdam score are negatively related to each other with a value of -0.284 but are signicantly associated to each other with p value of 0.009 thereby indicating that the patients with a higher modied Rotterdam score demonstrated poorer recovery 3 months after the traumatic insult in form of lower Glasgow outcome score. CONCLUSION: Use of CT based Rotterdam criteria in routine reporting is critical in the initial evaluation and can also predict the prognosis of patients with TBI.

Effectiveness comparisons of drug therapies for postoperative aneurysmal subarachnoid hemorrhage patients: network meta‑analysis and systematic review

Objective To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis. Methods Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies. Results From the 493 of initial citation screening, forty-four RCTs (n = 10,626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR = 3.35,95%CI = 1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA = 87.29%, 95%CrI 0.07–0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR = 1.61, 95%CI 1.01,2.57) and cilostazol (OR = 3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. Conclusions Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively.

Prediction of Glasgow Outcome Scale after Barbiturate Coma Therapy in patients suffering from Refractory Intracranial Hypertension after Brain Tumour Surgery: Incorporating Ensemble approach into automated Machine Learning

Ensemble approach is incorporated into Automated machine learning to predict Glasgow outcome scale and In-hospital mortality in patients receiving Barbiturate coma therapy for refractory intracranial hypertension post Brain tumour surgery.

Clipping of unruptured cerebral aneurysms

Summary Background The incidence of aneurysms is steadily increasing in older patients due to the aging population. This study compared radiological parameters as well as clinical outcomes between patients younger than 65 years and those over 65 years of age, with special respect to individual treatment options. Methods Retrospective data were obtained for patients with cerebral aneurysms at a single academic institution within a 7-year period. Data reviewed included admission protocols, patient charts, operating reports as well as outpatient clinic charts. Aneurysmal characteristics as well as surgical outcome were compared between older patients, defined as patients older than 65 years of age, and a control group of patients younger than 65 years of age. To evaluate and compare individual clinical characteristics various scores including the Hunt and Hess score, the Fisher score, and the Glasgow outcome scale were used. Results A total of 347 patients were included in the final analysis. The control group included 290 patients, while 57 patients were in the older patient group. Neither the Hunt and Hess scores nor Fisher scores were significantly correlated to patient age. The Glasgow outcome scale was significantly lower in the older group after clipping of ruptured aneurysms (p < 0.000) but not significantly different after clipping of unruptured aneurysms (p = 0.793). Conclusion Postoperative Glasgow outcome scale scores were not significantly different after clipping of unruptured cerebral aneurysms approximately 1 cm in diameter in older patients compared to the younger age group. Therefore, clipping of unruptured cerebral aneurysms may also be a valuable treatment option for older patients.