A randomized controlled trial of nurse-led Brief Focused Intervention for patients with alcohol use-related mild traumatic brain injury in the emergency and casualty services of a tertiary hospital.

Objectives: Driving under the influence of alcohol is one of the leading causes of road traffic accidents in India. Individuals with acute injuries often present to emergency hospital services. Carrying out brief interventions in the emergency can prevent further injury and even progression to severe patterns of drinking. However, there are no known studies from India examining the effectiveness of such interventions in emergency settings. Against this background, the objective of this randomized controlled trial was to evaluate the effectiveness of a nurse-led Brief Focused Intervention (BFI) in comparison with the minimal intervention for patients with mild Traumatic Brain Injury (TBI) reporting to the emergency and casualty services of a tertiary hospital in Bengaluru, South India, who screened positive for alcohol use. Materials and Methods: The BFI comprised a video portraying the effects of alcohol on the brain and muscles and brief advice on how to reduce or avoid alcohol use. Subjects (N = 90) were randomly allocated to two groups: BFI (n = 45) or Minimal Intervention Group (MIG) (n = 45). Standardized tools were used to assess both groups on specific outcomes for up to six months following discharge from the emergency and casualty services. At the end of six months, complete data wasavailable for 73 patients. Results: Participants' (N = 73) mean age was 35 years (standard deviation [SD]-11). Over the six-month follow-up, the BFI group reported significantly lesser quantity of alcohol consumption (Alcohol Use Disorder Identification Test [AUDIT] Score - 5.03, SD 4.09, 95% confidence interval [CI] = 3.70, 6.35) compared to MIG (AUDIT Score - 9.76, SD 2.96, 95% CI = 8.73, 10.80), and fewer alcohol use-related problems in BFI group (Mean - 4.18, SD 3.21, 95% CI = 3.14, 5.22) compared to MIG (Mean - 5.88, SD 2.59, 95% CI = 4.98, 6.79). Results of logistic regression showed that being in MIG as well as baseline hazardous use of alcohol were associated with unfavorable outcomes at the end of six months follow-up. Conclusion: Findings provide the first known evidence from India for the effectiveness of nurse-led BFI in the emergency and casualty services in improving post-discharge outcomes for patients with alcohol use-related mild TBI. While the findings of the study are statistically significant, these findings also have significant clinical relevance, as they have shown that the BFI improved clinical outcomes. Thus, brief interventions should be implemented for these patients whenever possible in the Emergency setting.

Factors That Predict Recurrence Following Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea.

BACKGROUND: The endoscopic approach has gained popularity in cerebrospinal fluid (CSF) rhinorrhea repair with high success rates, yet recurrence is frequent. We analyzed our cases to determine the outcomes of endoscopic repair of CSF rhinorrhea and the effect of several perioperative factors on the success of repair. METHODS: A retrospective review of 50 patients who underwent endoscopic repair of CSF rhinorrhea between January 2013 and July 2023 was performed, collecting details of presentation, surgery, and postoperative period. RESULTS: The most frequent etiology was nontraumatic CSF rhinorrhea (76%), in which the defect was most commonly located at the left cribriform plate, followed by traumatic CSF rhinorrhea (24%), in which sphenoid defects were most frequent. Traumatic CSF rhinorrhea was more common among male patients and was significantly associated with anosmia. Success rate at first repair attempt was 84%. Persistent CSF rhinorrhea was present in 3 patients (6%), and 5 patients (10%) developed recurrence of CSF rhinorrhea. Overall, 7 patients required reoperation, with 100% success rate after the second surgery. The use of 3-layered repair with fat, fascia lata, and mucosal flap was protective against repair failure, whereas bilateral defects and duration of symptoms >1 year were significantly associated with repair failure. The use of lumbar drain did not demonstrate a difference in repair success rate. CONCLUSIONS: Endoscopic repair of CSF rhinorrhea appears to be safe and effective when performed with accurate localization of the site of the lesion and multilayered repair. Potential predictors of recurrence include bilateral and long-standing defects.

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.

BACKGROUND: Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. METHODS: We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS: A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group. CONCLUSIONS: Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).

Is Popularity of Fibrin Glue a Misrepresentation? A Comparative Study with Fibrin Glue and Suture Anastomosis in Rat Sciatic Nerve Injury Analysing Functional, Histological, Electrophysiological Parameters.

Background: Fibrin glue as an adjunct in peripheral nerve injuries has gained recent popularity. Whether fibrosis and inflammatory processes which are the major hindrances in repair reduce with fibrin glue has more of theoretical support than experimental. Methodology: A prospective nerve repair study was conducted between two different species of rats as donor and recipient. Four comparison groups with 40 rats were outlined with or without fibrin glue in immediate post-injury period with fresh or cold preserved grafts were examined based on histological, macroscopic, functional, and electrophysiological criteria. Results: There was suture site granuloma along with neuroma formation and inflammatory reaction and severe epineural inflammation in allografts with immediate suturing (Group A), whereas suture site inflammation and epineural inflammation were negligible in cold preserved allografts with immediate suturing (Group B). Allografts with minimal suturing and glue (Group C) had less severe epineural inflammation with less severe suture site granuloma and neuroma formation as compared to first two groups. Continuity of nerve was partial in later group as compared to other two. In fibrin glue only group (Group D), suture site granuloma and neuroma were absent, with negligible epineural inflammation, but continuity nerve was partial to absent in most of the rats with some showing partial continuity. Functionally, microsuturing with or without glue demonstrated significant difference with better SLR and toe spread (p = 0.042) as compared with only glue. Electrophysiologically, NCV was maximum in Group A and least in Group D at 12 weeks. We report significant difference in CMAP and NCV between microsuturing group vs. only glue group (p < 0.05) and also between microsuturing with glue group vs. only glue group (p < 0.05). Conclusion: There may be more data required with proper standardization for adept usage of fibrin glue. Though our results have shown partial success, it nonetheless highlights the lack of sufficient data for widespread glue usage.

A comparative study between preoperative and postoperative conventional autonomic functions in congenital craniovertebral junction anomalies.

Background: Autonomic nervous system (ANS) is invariably affected by craniovertebral junction (CVJ) anomalies. The usual presentation is sudden after trivial trauma. When symptomatic, most of this autonomic dysfunction is clearly elicited clinically with bedside tests. Nonetheless, ANS functionality in relatively less symptomatic or asymptomatic patients is not known as no studies exist. Methodology: We performed a longitudinal prospective study of 40 less symptomatic patients who underwent surgery with conventional autonomic function tests (AFT) in pre- and post-operative periods. Correlation of its association with such anomalies is studied. Results: All 40 had both pre- and post-operative clinical follow-up, pre-operative AFT, whereas only 22 patients had follow-up AFT. The mean age for the group was 32 years and male: female ratio was 2.3:1. Mean Nurick's grade was 1.8, whereas Barthel's index was 83.75%. Clinical improvement was seen in almost 98% at follow-up. Orthostatic test showed a significant association with Nurick's grade. Barthel's index was significantly associated with degree of compression. The mean follow-up was 17.4 months. Most conventional AFTs were significantly decreased in the preoperative period (P ≤ 0.01). Both parasympathetic and sympathetic tone improved on follow-up with better improvement later. Overall clinical involvement of ANS was seen in 22.5% whereas subclinical involvement in the form of AFT impairment was seen in 100%. Conclusion: There is a definite involvement of subclinical ANS in all patients of CVJ anomalies irrespective of their symptomatology. Knowing the extent of involvement in the preoperative period can help prognosticate, prioritize regarding surgery as well as correlate with the extent of improvement.

Traumatic brain injury during COVID-19 pandemic-time-series analysis of a natural experiment.

OBJECTIVES: This study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using Google community mobility and alcohol sales data. DESIGN: A retrospective time-series analysis. SETTING: Emergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care. PARTICIPANTS: Daily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail. RESULTS: An optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ2=130, df=1, p<0.001). Two principal components of community mobility, alcohol sales and weekday explain the change in the number of TBI cases (pseudo R2=58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period. CONCLUSIONS: Decongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.

Vertebral artery dissection in acute cervical spine trauma.

Objective: The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST). Methods: A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD. Results: Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified. Conclusion: There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

Six-year longitudinal prospective comparative study between preoperative and postoperative heart rate variability indices in congenital craniovertebral junction anomalies.

Background: Craniovertebral junction (CVJ) anomalies involve mosaic interaction of multifaceted neurovascular and bony elements. Most of them present late in the course of illness usually as acute presentations following trivial trauma. Knowing subclinical autonomic dysfunction in such anomalies when managed medically can not only indicate progression but also provide en route to early intervention for better outcomes, especially in relatively asymptomatic patients. Materials and Methods: We conducted a 6-year longitudinal prospective study including 40 consecutive patients of CVJ anomalies with clinical, radiological, and heart rate variability (HRV) parameters and found their correlation in preoperative and follow-up period. Results: Twenty-eight patients were male and the rest were female. The mean age was 32 years with the least age being 8 years and maximum age being 75 years old. Mean Nurick's grade and Barthel's index were 1.8 and 83.75, respectively. 38% had severe-to-moderate compression. The mean follow-up was 17.4 months. Both sympathetic and parasympathetic oscillator HRV indices were significantly affected in the preoperative period (P ≤ 0.001) with no association with Nurick's grade or degree of compression although there was association with grade of Barthel's index. Poincare plots showed "fan," "complex," or "torpedo" patterns in 36 patients. Forty patients had both preoperative and follow-up clinical grade whereas 22 patients HRV tests in the above periods. None of the HRV indices showed significant improvement at follow-up. Nonetheless both sympathetic and parasympathetic did improve at follow-up with sympathetic tone registering better scores. Poincare plots showed improvement toward "comet" patterns in all patients. Conclusion: HRV indices not only help in prognosticating but may also help in predicting outcomes.

When the Bone Flap Expands Like Bellows of Accordion: Feasibility Study Using Novel Technique of Expansile (Hinge) Craniotomy for Severe Traumatic Brain Injury.

BACKGROUND: Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty. OBJECTIVE: To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC. MATERIALS AND METHODS: A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year. RESULTS AND CONCLUSIONS: Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

Consumption of spine by tuberculosis in the era of directly observed treatment, short-course and genomic diagnosis.

BACKGROUND: Extra Pulmonary Tuberculosis (EPTB) is a significant health problem in both developing and developed countries. Spinal tuberculosis (STB) is one of the significant forms of EPTB lacking epidemiological data. The present study was conducted to study the clinical, radiological, microbiological and histopathological features, treatment and outcome of Spinal tuberculosis. METHODS: This study was conducted for a duration of 19 years, from 2000 to 2018 at the department of Neuromicrobiology, NIMHANS, Bengaluru. It comprised of 252 patients with STB. All patients were diagnosed with the clinical features and confirmed by radiological, microbiological and histopathological findings. RESULTS: Results were tabulated and statistically studied. The most common age group is 30-40 years with male preponderance. Most patients presented with motor paraplegia/para paresis (99.6%). Thoracic spine was the most common vertebra affected (47.62%). The commonest imaging feature is soft tissue collection (81.74%). Most common histopathological feature was necrotising granulomatous inflammation (65.87%). Microbiology reports showed growth of Mycobacterium tuberculosis (MTB) in 29.76%, Ziehl Neelsen (ZN) smear showed acid fast bacilli (AFB) in 25.79%. Anti tubercular drugs and surgery were advised in 55.55% patients and only anti TB drugs for 39.28%. The entire course of anti tubercular treatment (ATT) was completed in 60.71% and 4.76% were defaulters. CONCLUSION: Spinal tuberculosis is a global disease, timely diagnosis with clinical, imaging, microbiological, histopathological features and complete course of anti-tubercular treatment along with symptomatic treatment appears to be safe and effective.

The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

INTRODUCTION: Severe acute respiratory syndrome, coronavirus 2 (SARS-COV 2) has inexplicably and irreversibly changed the way of neurosurgery practice. There has been a substantial reduction in neurosurgical operations during the period of lockdown. The lockdown might be the most effective measure to curtail viral transmission. Once we return to the normalization of the lifestyle, there will be a backlog of unoperated pending cases along with the possibility of further spread of the coronavirus. METHODS: We reviewed the available literature and protocols for neurosurgical practice in different geographic locations. We drafted a consensus statement based on the literature and protocols suggested by the World Health Organization (WHO) and various professional societies to prevent the spread of SARS-COV2 while streamlining the neurosurgical practice. RESULTS: The consensus statement suggests the patient triage, workflow, resource distribution, and operational efficacy for care providers at different stages of management. The priority is set at personal protection while ensuring patients' safety, timely management, and capacity building. We performed a detailed subsection analysis for the management of trauma and set up for COVID-free hospitals for simultaneous management of routine neurosurgical indications. In this time of medicolegal upheaval, special consent from the patients should be taken in view of the chances of delay in management and the added risk of corona infection. The consensus statements are applicable to neurosurgical setups of all capacities. CONCLUSION: Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion. These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers both.

Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature.

Background Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators. Materials and Methods We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis. Results A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)-PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA-PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up. Conclusion Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

Hinge/floating craniotomy as an alternative technique for cerebral decompression: a scoping review.

Hinge craniotomy (HC) is a technique that allows for a degree of decompression whilst retaining the bone flap in situ, in a 'floating' or 'hinged' fashion. This provides expansion potential for ensuing cerebral oedema whilst obviating the need for cranioplasty in the future. The exact indications, technique and outcomes of this procedure have yet to be determined, but it is likely that HC provides an alternative technique to decompressive craniectomy (DC) in certain contexts. The primary objective was to collate and describe the current evidence base for HC, including perioperative parameters, functional outcomes and complications. The secondary objective was to identify current nomenclature, operative technique and operative decision-making. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Fifteen studies totalling 283 patients (mean age 45.1 and M:F 199:46) were included. There were 12 different terms for HC. The survival rate of the cohort was 74.6% (n = 211). Nine patients (3.2%) required subsequent formal DC. Six studies compared HC to DC following traumatic brain injury (TBI) and stroke, finding at least equivalent control of intracranial pressure (ICP). These studies also reported reduced rates of complications, including infection, in HC compared to DC. We have described the current evidence base of HC. There is no evidence of substantially worse outcomes compared to DC, although no randomised trials were identified. Eventually, a randomised trial will be useful to determine if HC should be offered as first-line treatment when indicated.

Craniovertebral Junction Arachnoiditis: An Unusual Sequelae to Tuberculous Meningitis.

Adhesive arachnoiditis at the craniovertebral junction should be suspected in patients with a history of meningitis having delayed onset gradually progressive tetra paresis. Patients can present after an asymptomatic interval of 2 to 20 years. Cardiac gated cine magnetic resonance imaging is useful for its diagnosis. Posterior fossa decompression with upper cervical laminectomy and adhesiolysis appears to be a reasonable treatment for the same. We illustrate two patients who presented to us with gradually progressive spastic tetra paresis; both had prior history of cured tuberculous meningitis.

Intracranial fungal granuloma: a single-institute study of 90 cases over 18 years.

OBJECTIVE: Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now. METHODS: In this retrospective study, all cases of IFG surgically treated in the years 2001-2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status. RESULTS: A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1-79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06-48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3-144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up. CONCLUSIONS: A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis.

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions.

Cosmetic Outcome of Cranioplasty After Decompressive Craniectomy-An Overlooked Aspect.

BACKGROUND: Cranioplasty (CP) is an obligatory surgery after decompressive craniectomy (DC). The primary objective is to protect the brain from external injury and prevent syndrome of trephined. In a government hospital, such cases pose a significant burden to a trauma center. Because of this reason, cosmetic outcome is never taken into account for the CP. We present results of CP performed at our hospital. METHODS: This is a retrospective review of the cases of CP performed over the past 3 years at our hospital. The cosmetic outcome was divided into 3 grades: 1-good symmetrical, 2-irregularities, 2a-elevated and 2b depressed, and 3-bad cosmetic outcome requiring reoperation. RESULTS: A total of 133 patients with acute brain injury underwent CP during the study period. The outcome was good in 74 (55.6%) and bad, requiring reoperation, in 2 (1.5%) cases. Various types of the CP materials like autologous bone flap, titanium mesh, and customized titanium plates were used. Methods of fixation were threads or miniplates and screws. In univariate analysis, cerebral venous thrombosis as an indication for DC, use of autologous bone flap, and fixation with thread were associated with poor outcome. However, in multivariate analysis only the method of implant fixation was associated with poor outcome. It was found that if screws and plates are used for fixation of bone flap, the chances of bad outcome are reduced by 74.6%. CONCLUSIONS: The cosmetic outcome is overlooked for CP. The bone flap fixation has to be rigid for a good outcome.