Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis.

PURPOSE: We aimed to assess the long-term neurological outcomes and the functionality and QoL in patients undergoing decompressive craniectomy for severe traumatic brain injury, respectively. MATERIALS AND METHODS: Among the 120 patients who underwent decompressive craniectomy for severe TBI between 2002 and 2007, 101 were included based on the inclusion criteria. Long-term follow-up results (minimum 3 years) were available for 22 patients. The outcomes were assessed using the Glasgow Outcome Scale (GOS) and the functionality and HRQoL were assessed using the Short Form-36 (SF-36) (v2) and Quality of Life After Brain Injury (QoLIBRI) questionnaires. RESULTS: Among the patients with severe TBI, 62 (61.4%) died and 39 (38.6%) were discharged to either home or a physical therapy facility. Eleven of the thirty-nine patients could not be reached and were excluded from the final analysis. The mean GOS of the remaining 28 patients was 4.14 ± 0.8 after 6.46 ± 1.64 years of follow-up. The HRQoL was assessed in 22 of the 28 patients. The HRQoL scores were lower in patients with TBI than in healthy controls. Furthermore, there was a significant difference in the HRQoL scores in patients with improved GOS scores than in those with unimproved GOS scores. CONCLUSIONS: Health-related outcome scores could help clinicians understand the requirements of survivors of severe TBI to create a realistic rehabilitation target for them. QoLIBRI served as a good way of communication in these subjects.

Caregiver Burden and Quality of Life of Caregivers for Patients with Parkinson's Disease Treated with Deep Brain Stimulation.

Objective: This study aimed to identify caregiver burden (CB) and contributing factors to CB for Parkinson's disease (PD) patients under Subthalamic Nucleus Deep Brain Stimulation (STN-DBS) treatment, and investigation the factors, affecting the caregivers' quality of life (QoL). Methods: Twenty-four PD patients under STN-DBS treatment and their caregivers participated in this study. Unified Parkinson's Disease Rating Scale (UPDRS) was applied for the clinical assessment of the patients. Beck Depression Inventory-II (BDI), Hospital Anxiety and Depression Scale (HADS), and Minnesota Impulse Control Disorders Interview (MIDI) were used to screen for neuropsychiatric symptoms of the patients. CB was evaluated with the Caregivers Burden Inventory (CBI) and the Burden Scale for Family Caregivers (BSFC-s). The health-related QoL of caregivers was assessed with the Short Form Survey-36 (SF-36). Results: Mean total CBI and BSFC-s scores of caregivers were 32.53 ± 19.71 and 11.66 ± 8.86, respectively. Nineteen caregivers defined moderate or severe caregiver burden according to BSFC-s. Both CBI and BSFC-s scores were significantly associated with UPDRS-part-1 scores, but not with the age and gender of both the patients and their caregivers, disease duration, PDQ39, BDI, HADS, LARS scores, and scores of patients for other UPDRS parts. The presence of impulse control behaviors (ICBs) significantly increased the total CBI score and total BSFC-s (P < 0.01). The caregivers' total and all domain scores of SF-36 were significantly affected by higher CBI and BSFC-s scores. Conclusions: The CB of the patients under STN-DBS treatment was severe. Non-motor symptoms, particularly impulsivity, significantly increased CB and worsened the caregivers' mental and physical health.

Neuropsychiatric Effects of Bilateral Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: Results at the 12-Month Follow-up.

Introduction: It is aimed to report the effects of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) on motor symptoms, neuropsychiatric symptoms, and quality of life in Parkinson's Disease (PD) patients. Methods: The results of 22 patients with PD, who had undergone bilateral STN-DBS, were analyzed. The Unified Parkinson's Disease Rating Scale (UPDRS) was applied to assess the patients' clinical characteristics before surgery and 6-, and 12-month follow-up after surgery. The quality of life of the patients was evaluated with the Parkinson's Disease Questionnaire (PDQ-39). Neuropsychological tests including Minnesota Impulse Control Disorders Interview (MIDI), Beck Depression Inventory-II (BDI), Hospital Anxiety and Depression Scale (HADS), Lille Apathy Rating Scale (LARS), and Mini-Mental State Examination (MMSE) were also routinely performed at baseline and 6 months and 12 months after surgery. Results: The mean age of patients was 57.3±8.8 years. Fourteen patients (63.6%) were male. Significant improvements were seen in UPDRS-part-II, UPDRS-part-III UPDRS-part-IV, and PDQ-39 in the follow-ups after the surgery. No significant change was observed in 6- and 12-month follow-up visits for BDI, HADS, MMSE, and LARS, compared to baseline. A depressive episode, requiring antidepressant treatment was recorded in four (18.1%) patients. Before DBS surgery, eight patients had at least one current impulse control behaviors (ICBs). Among these eight patients; ICBs disappeared in one patient, did not change in two patients, and worsened in five patients after STN-DBS treatment. Conclusion: In patients with a history of psychiatric disease, bilateral STN-DBS treatment may aggravate psychiatric symptoms such as depression, and ICBs.

Surgical-Related and Hardware-Related Adverse Effects of Deep Brain Stimulation: A Retrospective Single-Center Analysis.

AIM: To review both the surgical-related, and hardware-related adverse effects of deep brain stimulation (DBS) in a single center over the last five years. MATERIAL AND METHODS: All patients who underwent DBS electrode implantation at the Akdeniz University Hospital during the last five years participated in this study. Demographic information (sex, age, diagnosis, the duration between diagnosis and surgery, comorbid disease) and the date of surgery were collected from an electronic medical database. The adverse effects of DBS were classified into two: surgery-related and hardware-related effects, which were further subdivided based on whether they occurred intraoperatively, in the early postoperative stage, or over a long period time. RESULTS: A database of 47 patients with 90 DBS electrode implants was analyzed in the study. The median age at the time of surgery of all patients was 54 years (range 11-75). Comorbid diseases were recorded in 16 (34%) patients. Out of the total, 33 patients (70.2%) had no adverse effects related to DBS. Surgical-related adverse effects were observed in five patients and of these, one haD an asymptomatic intracerebral hemorrhage (ICH), one had symptomatic ICH, one had both a seizure intraoperatively and an asymptomatic subdural hematoma whereas the other two had non-infectious peri-electrode edema. Hardware-related adverse effects were recorded in nine patients (19.1%). We recorded infections in six (12.7%) patients, erosion without infection in two (4.2%), and both lead fracture and lead malposition in one patient. All long-lasting adverse effects were hardware-related and recorded in eight (19%) patients. CONCLUSION: DBS has been a well-established treatment for movement disorders but is associated with an increased risk of some adverse events which have been analyzed in this study.

Multiple spinal cavernous malformations in Klippel-Trenaunay-Weber syndrome.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare, congenital vascular disorder characterized by cutaneous haemangiomas, venous varicosities, and hypertrophy of the osseous and soft tissue. Various vascular anomalies of the central nervous system have been described in this syndrome. Two previous associations between KTWS and spinal cord cavernous malformations have been reported in the English literature. In this report, we present a patient in whom multiple cavernous malformations located in the conus medullaris region and cauda equina were associated with KTWS. General physical examination as well as neuroradiological and operative findings are described.

Effects of decompressive surgery in patients with severe traumatic brain injury and bilateral non-reactive dilated pupils.

BACKGROUND: We investigated Glasgow Coma Scale (GCS) scores, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes, and long-term clinical outcomes in patients with severe traumatic brain injury (STBI) associated with bilateral non-reactive dilated pupils (BNDP) who underwent decompressive surgery (DS). METHODS: The study group consisted of 28 patients (11 females, 17 males) with BNDP from among 147 patients who underwent DS due to STBI in our department. RESULTS: The mean GCS score was 4.96±1.20 at admission and 4 preoperatively. Mean ICP in non-surviving patients after DS was higher (p<0.05). ICP decrease after DS was also higher in surviving patients than in non-surviving patients (p<0.05). The overall mortality rate was 61.02%. A GCS motor score >2 at admission was associated with lower mortality (p<0.05). Four of the surviving patients (14.28%) had a functional outcome (Glasgow Outcome Score: 4 and 5) at one year after hospital discharge. CONCLUSION: Outcome in patients with BNDP after STBI may not always be fatal or poor. Rapid DS may increase the chance of functional survival, especially in patients with admission GCS score of 6 or 7.

Sutural diastasis caused by pseudotumor cerebri.

The diagnosis of pseudotumor cerebri is based on the triad of: (1) papilloedema, (2) elevated intracranial pressure with a normal cerebrospinal constituency and (3) normal central nervous system imaging studies. However, the diagnosis of pseudotumor cerebri is not always straightforward. We report a 19-year-old morbidly obese girl who developed pseudotumor cerebri associated with sutural diastasis of the cranium based on the direct radiographies. Following a ventriculo-peritoneal shunt operation, we demonstrated the closing and perisuturally sclerosis on all major cranial sutures. A careful examination of direct radiographies might be critical for diagnosis of pseudotumor cerebri. Prompt recognition, evaluation, and treatment are needed to prevent permanent visual loss.

Outcomes of intrathecal baclofen (ITB) therapy in spacticity.

AIM: Spasticity is associated with various neurological conditions. Intrathecal baclofen (ITB) is one of the popular treatments for severe spasticity. In this paper we present our experience in treating 30 patients with both spinal and supraspinal spasticity with chronic infusion of Baclofen to evaluate the long term efficacy of this treatment on spasticity, disability and pain, and to evaluate the side effects of intrathecal Baclofen. MATERIAL AND METHODS: The medical records of 30 patients who underwent baclofen pump placement from 2000 to 2010 under Department of Neurosurgery at the University of Akdeniz at Antalya/Turkey, were reviewed. All study subjects had diffuse chronic, severe, and generalized spasticity (Ashworth score ≥ 3), and had shown inadequate response to various oral antispastic drugs including baclofen. All patients were evaluated by means of the Ashworth score, spasm frequency, Barthel index, Rankin scales and VAS. RESULTS: Spasticity and spasm frequency and pain scores were clinically and statistically decreased in all patients. CONCLUSION: ITB therapy increases the quality of lifestyle and functional independence by reducing not only cerebral but also spinal related spasticity in appropriately selected cases.

Effect of early bilateral decompressive craniectomy on outcome for severe traumatic brain injury.

AIM: Debate continues as to whether decompressive craniectomy (DC) is an effective treatment for severe traumatic brain injury (STBI). DC is mostly used as a second tier treatment option. The aim of this study was determined whether early bilateral DC is effective as a first tier treatment option in patients with STBI. MATERIAL AND METHODS: The study compared two groups. Group 1 comprised 36 STBI patients for whom control of intracranial pressure (ICP) was not achieved with conservative treatment methods according to radiological and neurological findings. These patients underwent bilateral or unilateral DC as a second tier treatment. Group 2 comprised 40 STBI patients who underwent early bilateral DC as a first tier treatment. RESULTS: Group 2 patients had a mean better outcome than Group 1 patients especially for patients with a GCS 6-8. Postoperative ICP was lower in Group 2 patients than Group 1 patients. CONCLUSION: This study indicates that early bilateral DC can be effective for controlling ICP in STBI patients. It is likely the favorable outcome results for Group 2 patients reflects the relatively short time between trauma and surgery. Therefore, these data indicate early bilateral DC can be considered as a first tier treatment in STBI patients.

Spontaneous resolution of a large chronic subdural hematoma: a case report and review of the literature.

Spontaneous resolution of a chronic subdural hematoma has been reported rarely in the literature. We present herein the case of a 35-year-old patient with spontaneous resolution of a large chronic subdural hematoma, the volume of which was measured as approximately 76.5 ml on magnetic resonance imaging. No pathology was determined on neurological examination. Neither cerebral angiography nor EEG showed any abnormality. We discuss the possible relation between mechanisms of physio-pathogenesis and spontaneous resolution of chronic subdural hematomas, and also present the patient characteristics together with the other literature data.

Modified experimental mild traumatic brain injury model.

BACKGROUND: Experimental models of traumatic brain injury (TBI), using a variety of techniques and species, have been devised with the aim of producing repeatable lesions resembling those found in head injuries. There are various TBI models mentioned in the literature. In experimental head trauma models, emphasis has been placed on the severe head injuries. There are only a few models developed to study mild traumatic brain injury (MTBI). In fact, MTBI is as important a problem as severe head injuries for neurosurgeons. METHODS: Fifty-six male Sprague-Dawley rats were subjected to MTBI with a weight-drop device, which was described by Marmarou et al. The said model was used in its original form as well as in modified forms by employing different weights dropped from the same height. Animals were divided into four groups of 14 rats as follows: Group I (n=14), head injury was induced using 450 g-1 m weight-height impact; Group II (n=14), head injury was induced using 350 g-l m weight-height impact; Group III (n=14), head injury was induced using 300 g-1 m weight-height impact; Group IV (n=14), control group, no injury was applied. Animals were evaluated neurologically, physiologically, electrophysiologically, and histopathologically. RESULTS: Group I and II animals (450 and 350 g-1m weight-height impact, respectively) showed the symptoms of severe head injury, whereas Group III animals (300 g-l m) showed more MTBI symptoms. CONCLUSION: We recommend the application of the modified MTBI model used for group III (300 g-l m weight-height impact) as the most appropriate and the simplest model for future MTBI studies.

Role of decompressive surgery in the management of severe head injuries: prognostic factors and patient selection.

Decompressive surgery or craniectomy (DC) is a treatment option, which should be considered when the intracranial pressure (ICP) cannot be treated by conservative methods. The purpose of this study was to evaluate the benefits of decompressive craniectomy in patients with intractable posttraumatic intracranial hypertension and to evaluate the patient selection criteria for this management protocol. In this study, 100 patients with severe head injuries were involved. All patients were treated according to the European Brain Injury Consortium (EBIC) guidelines for severe head injuries and were assessed based on individual initial Glasgow Coma Scores (GCS), age, Glasgow Outcome Score (GOS), presence of systemic injury, changes in ICP, presence of mass lesion and the right timing for DC. All patients presented with a GCS of 8 or below. Based on their initial GCS, the patients were divided in two groups of 60 (group I with GCS 4-5) and 40 (group II with GCS 6-8) in each, respectively. Prognosis was evaluated according to the (GOS). After treatment with DC, 84 of the patients (84%) showed unfavorable and 16 (16%) showed favorable outcomes. In group I, 58 patients (96.6%) showed unfavorable and two (3.4%) showed favorable outcomes. In group II, 26 (65%) patients showed unfavorable and 14 (25%) showed favorable outcomes. The importance of initial GCS and age in patient outcomes were statistically significant. The presence of systemic injuries or mass lesions in outcomes were not statistically significant. Based on our findings, we conclude that patients with Glasgow Coma Scores of 6-8 are the best candidates for DC treatment.

Hydrocephalus after intraventricular hemorrhage in preterm and low-birth weight infants: analysis of associated risk factors for ventriculoperitoneal shunting.

BACKGROUND: Intraventricular hemorrhage and posthemorrhagic hydrocephalus are common causes of neonatal morbidity and mortality among preterm and low-birth weight infants (PT-LBWIs). Clinical management of posthemorrhagic hydrocephalus (PHH) is difficult and not well standardized. In this study, we aimed to determine the incidence of hydrocephalus after intraventricular hemorrhage (IVH) and the associated risk factors for ventriculoperitoneal (V-P) shunting in PT-LBWIs. We also aimed to identify the medical-care practices for these babies. METHODS: We reviewed the medical records of 42 babies with IVH diagnosed by cranial ultrasonography (classification of Papile et al, J Pediatr 1978;92:529-34). We compared 11 babies who required a V-P shunt with the 31 control subjects who did not require a V-P shunt or who died before discharge with respect to risk factors involved in V-P shunting. Maternal, perinatal, and neonatal risk factors, and therapies for IVH and PHH were studied as the V-P shunt-associated risk factors. RESULTS: The mean gestational age studied was 28.9 +/- 2.7 weeks, and the mean birth weight was 1164 +/- 391 g. This study revealed an incidence of 26% of PHH in PT-LBWIs with IVH. The most important risk factor for V-P shunt was found to be the severity of IVH (P < .05). Late gestational age and the time of IVH were found to be significant as well (P < .05). The length of hospitalization was found to be longer in patients with V-P shunt (P < .05). Therapies used for IVH and/or PHH were not significant as a risk factor for V-P shunt. In addition, the mortality rate was found to be 38% for all patients with IVH. CONCLUSION: Intraventricular hemorrhage in PT-LBWIs remains a significant problem, particularly when it is associated with PHH leading to long-term neurological impairment and decreased survival rate.

Comparison of serum and cerebrospinal fluid protein S-100b levels after severe head injury and their prognostic importance.

BACKGROUND: This study aimed to compare serum and cerebrospinal fluid (CSF) S-100b protein levels after a severe head injury. The changes in serum S-100b and CSF S-100b concentrations were investigated as indicators of brain damage for patients suffering from severe head injuries. METHODS: The sample included 48 patients with Glasgow Coma Scale scores of 8 or below who had been admitted to the authors' emergency service soon after their severe head injury occurred. Both blood and CSF samples were taken within 1 to 11 hours after admission, then 24, 48, and 72 hours after the injury. Samples of CSF were taken using a ventricular catheter. The outcome was evaluated 6 to 9 months after hospital discharge using the Glasgow Outcome Scale. RESULTS: The overall mean serum S-100b concentration was 3.5 +/- 6.4 among the patients with unfavorable outcomes and 1.3 +/- 2.5 among those with favorable outcomes. These results were not statistically significant (p > 0.05). The overall mean CSF S-100b concentration was 62.2 +/- 21.8 among the patients with unfavorable outcomes and 21.8 +/- 17.7 among those with favorable outcomes. These results, however, were statistically significant (p < 0.05). CONCLUSION: The results show that CSF S-100b levels clearly are superior to serum S-100b levels for predicting outcome after severe head injury.

Visceral Kaposi's sarcoma with intracranial metastasis: a rare complication of renal transplantation.

The incidence of Kaposi's sarcoma (KS) has increased in solid organ transplantation recipients. This type of KS tends to be aggressive, involving lymph nodes, mucosa and visceral organs in about half of patients, sometimes in the absence of skin lesions. Brain involvement of KS has rarely been reported. A 16-yr-old Turkish boy underwent renal transplantation from his mother. The immunosuppressive regimen included prednisolone, cyclosporin A and azathioprine. Fourteen months later the azathioprine was changed to cyclophosphamide (3 mg/kg/day) because of the development of a nephrotic syndrome. After 12 weeks, the cyclophosphamide was changed to mycophenolate mofetil (MMF) to control the nephrotic syndrome. At this time his serum creatinine level rose to 2.1 mg/dL. Polyclonal or monoclonal antibodies were never given. Multiple intra-abdominal lymphadenopathy was detected on abdominal tomography at the 32nd month after renal transplantation. Kaposi's sarcoma was diagnosed via laparotomy and biopsy. He had a generalized tonic and clonic seizure and contrast enhanced cranial tomography showed two intracranial masses which had an abundant vascular component which caused a mild shift. One of the masses was removed via a burr-hole with the aim of diagnosis and treatment of the shift. A pathologic examination of the intracranial lesion was also reported as Kaposi's sarcoma. Herpes virus-8 DNA was detected by PCR in the intracranial lesion.