Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage.

INTRODUCTION: Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes. METHOD: Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis. RESULTS: During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15. CONCLUSION: Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Middle cerebral artery infarction, A rare complication of intracranial cryptococcoma in an immunocompetent patient: A case report and literature review.

Background: This report presents the first case of intracranial cryptococcoma arising from the right frontal lobe causing right middle cerebral artery infarction. Intracranial cryptococcomas usually occur in the cerebral parenchyma, basal ganglia, cerebellum, pons, thalamus, and choroid plexus; they may mimic intracranial tumors, but seldom cause infarction. Of the 15 cases of pathology-confirmed intracranial cryptococcomas in the literature, no case has been complicated by middle cerebral artery (MCA) infarction. Here, we discuss a case of intracranial cryptococcoma with an ipsilateral middle cerebral artery infarction. Case Description: A 40-year-old man was referred to our emergency room due to progressive headaches and acute left hemiplegia. The patient was a construction worker with no history of avian contact, recent travel, or human immunodeficiency virus (HIV) infection. Brain computed tomography (CT) showed an intra-axial mass, and subsequent magnetic resonance imaging (MRI) delineated a large mass of 53 mm in the right middle frontal lobe and a small lesion of 18 mm in the right caudate head, with marginal enhancement and central necrosis. A neurosurgeon was consulted in view of the intracranial lesion, and the patient underwent en-bloc excision of the solid mass. The pathology report later identified a Cryptococcus infection rather than malignancy. The patient underwent 4 weeks of postoperative treatment with amphotericin B plus flucytosine; he then received subsequent oral antifungal treatment for 6 months, and had neurologic sequelae that manifested as left side hemiplegia. Conclusion: Diagnosis of fungal infections in the CNS remains challenging. This is especially true of Cryptococcus CNS infections that present as a space-occupying lesion in an immunocompetent patient. A Cryptococcus infection should be considered in the differential diagnoses in patients with brain mass lesions, as this infection can be misdiagnosed as a brain tumor.

Ticagrelor versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms.

BACKGROUND: Dual antiplatelet therapy is widely used for stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs) to prevent thromboembolic events (TEs). Compared to clopidogrel associated with aspirin, knowledge of the safety and efficacy of ticagrelor is lacking in large studies to date. METHODS: A retrospective cohort study was conducted from January 2016 to December 2018 with at least one year of follow-up in a single institution and systemic review. RESULTS: Altogether, 153 patients with UIA receiving SACE were separated into two groups: 113 patients receiving clopidogrel plus aspirin and 40 patients receiving ticagrelor plus aspirin. Acute in-stent thrombotic events were noted in two patients in the clopidogrel group (1.77%) and none in the ticagrelor group (0%). Additionally, one patient (0.88%) in the clopidogrel group had an early ischemic stroke (<3 months). Delayed ischemic stroke was noted in 6 patients (5.31%) in the clopidogrel group and 3 patients (7.50%) in the ticagrelor group. There were no major hemorrhagic events in either group. The two groups showed no significant differences with regard to ischemic stroke or hemorrhagic stroke. CONCLUSION: Compared to the clopidogrel based regimen, ticagrelor can also reduce TEs without increasing bleeding tendency for SACE of UIAs. Ticagrelor combined with low-dose aspirin is a safe and effective alternative option for SACE.