High In-Hospital Mortality Incidence Rate and Its Predictors in Patients with Intracranial Hemorrhage Undergoing Endotracheal Intubation

(1) Background: The goal of this study was to determine the incidence of in-hospital mortality and to investigate its predictors in patients with a primary intracranial hemorrhage (ICH) undergoing endotracheal intubation. (2) Methods: This retrospective study, between July 2018 to July 2019, recruited patients who were diagnosed with a primary ICH and who were intubated during treatment in our institution. The outcome variable was in-hospital mortality, known as 30-day mortality, in patients with ICH undergoing endotracheal intubation. Multivariable analyses were performed to identify the prediction of in-hospital mortality. (3) Results: A total of 180 patients with ICH undergoing endotracheal intubation were included, with a mean (SD) age of 62.64 (13.82) years. A total of 73.33% were female, and 71.11% of the patients were indicated for intubation due to neurological reasons. The in-hospital mortality rate, following endotracheal intubation, was 58.33%. In a reduced model using a stepwise backward selection strategy with p values < 0.2, independent predictors of in-hospital mortality were brain herniations on cranial CT scans (OR: 10.268, 95% CI: 2.749–38.344), lower Glasgow coma scale (CGS) scores before intubation (OR: 0.614, 95% CI: 0.482–0.782), and the loss of the vertical oculocephalic reflex before intubation (OR: 6.288, 95% CI: 2.473–15.985). Conclusions: The in-hospital mortality rate was comparable to that in the early evidence, but was significantly higher compared to recent reports. We infer that brain herniations on cranial CT imaging, lower CGS scores before intubation, and the loss of the vertical oculocephalic reflex before intubation could be used to approximately predict in-hospital mortality in patients with primary ICH undergoing endotracheal intubation. These considerations can help guide clinical decisions and community stroke discussions.

Case Report: Fatal Neurotoxicity Following Resmethrin Poisoning in a Child

Resmethrin, a type I pyrethroid insecticide, can activate sodium channels, causing neurotoxicity in both mammals and insects. Possible routes of poisoning include inhalation, dermal contact and ingestion. There are no specific symptoms for resmethrin poisoning. Until now, no antidote has been available for resmethrin. Resmethrin poisoning is rarely reported in children. Here, we report a fatal case of resmethrin poisoning that might have been caused by accidental ingestion by a 26-month-old child. He presented with neurotoxic symptoms that included vomiting, recurrent seizures, and coma. The cranial CT showed extensive lesions of low intensity in the bilateral white matter, thalamus, brainstem, and cerebellum. Lumbar punctures showed increased intracranial pressure (ICP &gt; 25 mmHg). Cerebrospinal fluid (CSF) tests revealed that protein was elevated to 289.2 mg/dL without pleocytosis. Resmethrin was detected in his blood by liquid chromatography-mass spectrometry, which confirmed the diagnosis of resmethrin poisoning. The child developed brain stem herniation and then was declared brain dead at the 77th h after admission. Resmethrin poisoning can be fatal, and it requires immediate diagnosis and treatment. Previous studies reported that cranial CT and CSF analyses were all normal in patients with pyrethroid poisoning. This case might extend the knowledge of neuroimaging and CSF analysis in children with resmethrin poisoning.

Comparison of intracranial injury predictability between machine learning algorithms and the nomogram in pediatric traumatic brain injury

OBJECTIVE The overuse of head CT examinations has been much discussed, especially those for minor traumatic brain injury (TBI). In the disruptive era, machine learning (ML) is one of the prediction tools that has been used and applied in various fields of neurosurgery. The objective of this study was to compare the predictive performance between ML and a nomogram, which is the other prediction tool for intracranial injury following cranial CT in children with TBI. METHODS Data from 964 pediatric patients with TBI were randomly divided into a training data set (75%) for hyperparameter tuning and supervised learning from 14 clinical parameters, while the remaining data (25%) were used for validation purposes. Moreover, a nomogram was developed from the training data set with similar parameters. Therefore, models from various ML algorithms and the nomogram were built and deployed via web-based application. RESULTS A random forest classifier (RFC) algorithm established the best performance for predicting intracranial injury following cranial CT of the brain. The area under the receiver operating characteristic curve for the performance of RFC algorithms was 0.80, with 0.34 sensitivity, 0.95 specificity, 0.73 positive predictive value, 0.80 negative predictive value, and 0.79 accuracy. CONCLUSIONS The ML algorithms, particularly the RFC, indicated relatively excellent predictive performance that would have the ability to support physicians in balancing the overuse of head CT scans and reducing the treatment costs of pediatric TBI in general practice.

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

Background We describe and compare the clinical, diagnostic evaluation and outcomes of patients who underwent therapeutic management for pyogenic brain abscess. Methods We retrospectively reviewed adults who presented with pyogenic brain abscess from January 1, 2009 through June 30, 2020. Results 231 patients were identified during the study period. Sixty-one (26.4%) patients received antibiotic therapy alone, and 170 (73.6%) had a combination of antibiotic therapy and surgical intervention. The median age for the medical and combined therapy group was 59 years and 58 years, respectively. Patients who received medical treatment had a higher prevalence of infective endocarditis than those who received combined therapy (6.6% vs. 0.6%; P=0.005). The medical therapy group was more likely to have brain MRI and cranial CT than the patients with combined therapy (75.4% vs. 63.5%; P=0.041). Midline shift (11.5% vs. 31.2%; P=0.002), a single (21% vs. 83%; P=0.001) and greater size (1.4 cm vs. 2.5 cm; P=0.007) brain abscess was significant when comparing medical vs. surgically managed abscess. Stereotactic surgical technique was the preferred diagnostic approach for the medical group (65.6% vs. 46.5%; P=0.010), and excision/craniotomy for the combined group (31.1% vs. 53.5%; P=0.002). Streptococcus viridans group was the predominant organism (32.8% and 25.9%; P=0.30). Compared to those who received combined therapy, patients with medical therapy alone were most likely to receive cephalosporin (72.1% vs. 41.2%; P=&lt; 0.0001), vancomycin (23% vs. 12.4%; P=0.047) and metronidazole (27.9% vs. 14.7%; P=0.022). In both groups, median duration of antimicrobial therapy was 42 days (P=0.12). Patients with medical therapy alone had a higher mortality rate (18% vs. 7.1%; p=0.014) but less neurologic sequelae (21.3% vs. 30.6%; P=0.16) compared with combined therapy. Medical Management. Organism isolated in the medical management group Combined Management. Organism isolated in the combined management group Demographic and Clinical Characteristics of Patients with Brain Abscess who Underwent Therapeutic Management Conclusion Most patients with pyogenic brain abscess had no identified risk factors, and brain MRI and cranial CT were the diagnostic imaging modalities of choice. Compared to those who received medical therapy alone, patients with combined treatment had a single and greater size fluid collection with the presence of midline shift. A prompt combined surgical and medical approach with prolonged antimicrobial therapy can cure the infection. Outcomes of Patients with Bacterial Brain Abscess Radiologic and Surgical Diagnosis of Patient with Brain Abscess who Underwent Therapeutic Management Disclosures John C. O’Horo, Sr., MD, MPH, Bates College and Elsevier Inc (Consultant) M. Rizwan Sohail, MD, Medtronic Inc., Philips, and Aziyo Biologics, Inc (Consultant) M. Rizwan Sohail, MD, Aziyo Biologics (Individual(s) Involved: Self): Consultant; Philips (Individual(s) Involved: Self): Consultant

A Case Report of Mycetoma and Cranial Osteomyelitis by Nocardia nova

Mycetoma is a chronic, localized, slowly progressive, granulomatous infection of the skin that may progress to subcutaneous tissue, muscle and bone. It is an infrequent manifestation of Nocardia infection that predominantly occurs on the lower extremities.A previously healthy, 17-year-old boy presented with a 3-month history of scalp abscesses. On physical examination he had numerous, large left parietal and occipital inflammatory nodules on the scalp covered by alopecic skin and several sinuses discharging a purulent and serosanguinous material. He underwent a CT-scan and an MRI of the skull that revealed signs of cranial osteomyelitis and epidural empyema. Polymerase chain reaction assay of the purulent exudate was performed and identified Nocardia nova. The patient was discharged from the hospital after 8 weeks of antibiotherapy with meropenem and TMP-SMX with clinical, laboratorial and imaging improvement. He completed 12 months of outpatient oral therapy with TMP-SMX, after which cranial CT-scan showed a significant reduction of soft tissue thickening and bone reconstitution, with no relapses after stopping the treatment.The best antibiotic regimen and length of treatment are not established for the management of nocardiosis. This is an unusual and severe presentation of infection by Nocardia nova with extent to the bone and epidural space, with full recovery under standard antibiotic therapy. This case shows that a good outcome may be achieved with prolonged antimicrobial treatment in an immunocompetent patient.

Traumatic infratentorial epidural haematoma: presentation and treatment outcome at the Jos University Teaching Hospital, North Central Nigeria

Background: Traumatic infratentorial epidural haematoma (TIEH), also called posterior fossa epidural haematomas when compared to their supratentorial counterparts, are very rare and their presentation nonspecific, accounting for 0.1-0.3% of all head trauma. Data on TIEH in our environment is very scanty. Our objective was to document the different presentations of TIEH and the outcome of management of these patients in our setting.Methods: This was a retrospective study of consecutive patients with head injury in whom non contrast cranial CT scan showed the presence of an infratentorial epidural haematoma and who presented to the Jos university teaching hospital between January 2012 to December 2020. The patients’ demographics, aetiology, clinical features, CT scan findings and outcome of treatment were extracted from the case folders and analysed using simple proportions.Results: There was a total of seven patients with TIEH out of a total of 308 patients with traumatic epidural haematoma, thus accounting for 2.3% of epidural haematomas in our series. All the TIEH were caused by road traffic collisions, all but one (85.7%) occurred in adults. Six (85.7%) of the patients had occipital skull fractures detected with cranial CT scan or at surgery. Two (28.6%) of the patients were managed non-operatively under close monitoring and did well. Five (71.4%) of the patients were managed surgically. There was one death, giving an overall mortality of (14.3%).Conclusions: TIEH is rare, the presentation is non-specific and early surgical decompression is lifesaving in selected patients.

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients.Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results.Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination.Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.