Quantitative Assessment of Brain Expansion After Evacuation of Chronic Subdural Hematoma as a Predictor of Recurrence.

BACKGROUND: A lack of brain expansion is considered a risk factor for recurrence after evacuation of a chronic subdural hematoma (CSDH). To the best of our knowledge, no studies have reported on objective measurement of brain expansion after evacuation of a CSDH. METHODS: We performed a retrospective analysis of prospectively collected data of patients undergoing 2 burr hole evacuation of a CSDH. We measured the depth of the brain surface from the frontal burr hole dural opening after hematoma evacuation using a specially devised measuring tool. Other predictors analyzed for recurrence of hematoma were age, gender, a history of hypertension, the use of anticoagulant and/or antiplatelet agents, Glasgow coma scale score at presentation, unilateral or bilateral hematoma, computed tomography appearance, and hematoma thickness. RESULTS: Among 88 patients who underwent hematoma evacuation, 3 (3.4%) underwent surgery for recurrence. The significant factors associated with recurrence were the presence of bilateral hematoma (P = 0.001), hematoma width >2.3 cm (P = 0.04), gradation type of hematoma on the computed tomography scan (P = 0.03), and the depth of the brain after hematoma evacuation (P = 0.02). The brain expanded less in those with recurrence, with a mean depth of the brain of 18 ± 6 mm versus 7.27 ± 7.8 mm in those without recurrence. CONCLUSIONS: Evacuation of a CSDH through 2 burr holes, along with copious irrigation and bed rest for 3 days, resulted in a very low recurrence rate without the use of a drain. A lack of brain expansion might be a predictor of recurrence. To the best of our knowledge, this is the first study to quantitatively measure the depth of the brain at surgery in patients undergoing surgery for CSDH.

Intraoperative point-of-care assessment of an inflammatory biomarker in chronic subdural hematomas: Technical note.

OBJECTIVE: Inflammatory processes have been associated with the development and recurrence of chronic subdural hematomas (cSDH). Elevated levels of presepsin, a truncated N-terminal fragment of soluble CD14, occur in various inflammatory conditions of bacterial and non-bacterial origin. Here we report on our initial experiences with the intraoperative point-of-care (POC) assessment of presepsin in patients treated for cSDH. PATIENTS AND METHODS: The POC analyser Pathfast® was used in 21 patients treated for cSDH at our institution. Prior to surgery, levels of C-reactive protein (CRP) and white blood cells (WBC) were assessed. After burr hole trephination and dura incision, samples of subdural fluid and whole blood were collected and immediately assessed with the POC analyser. Values of presepin were compared between samples of the subdural compartment and whole blood. RESULTS: Presepsin levels were assessed within 13 min in all patients and no technical difficulties occurred. Compared to the reported normal range values of presepsin (55-184 pg/mL), mean levels of presepsin in samples of the subdural compartiment was increased more than 5-fold (821 ±â€¯110.1 pg/mL). Furthermore, mean presepsin values in samples of the subdural compartiment were significantly higher than in samples of whole blood (154.8 ±â€¯19.2 pg/mL; p < 0.0001). CONCLUSION: POC assessment of the inflammatory biomarker presepsin is feasible within minutes during surgical treatment of cSDH. Corresponding to previous studies, presepsin levels were highly elevated in the subdural fluid, indicating processes of inflammation. Whether results of intraoperative POC assessment of inflammatory biomarkers is associated with outcome parameters in patients treated for cSDH has to be addressed in further studies. In our view, there is a role for this promising technique in improving future treatment strategies in respective patients.

Computed tomographic assessment of a new nonsurgical sinus trephination technique using a medical bone marrow drill.

The objective of this study was to determine the feasibility of trephination of the frontal sinus and injection of antifungal cream using a medical bone marrow drill in dogs. Results were compared with frontal sinus trephination using a standard surgical technique. Bilateral trephination of the frontal sinuses was carried out in the heads of 11 cadavers using a medical bone marrow drill and a surgical bone chuck. The time taken to carry out the procedure using both techniques was compared. Before and after injection of antifungal cream into the frontal sinuses, computed-tomography (CT) scanning was done to assess for iatrogenic trauma and to determine the degree to which the sinuses were filled with each technique and evaluate the diffusion of the cream into the nasal cavity of each dog. The mean volume of the sinuses was 8.8 mL (3.1 to 14.3 mL). Trephination, flushing, and injecting of antifungal cream were significantly faster using the medical technique. There was no significant difference in the mean filling of the frontal sinuses between the medical (82.7%) and the surgical (82.4%) technique (P-value = 0.3). Filling of the nasal cavity was classified as very good in 6/11 cases, with evidence of trauma caused by the surgical trephination technique in 1 head. Findings suggest that use of the medical bone marrow drill is highly feasible for frontal sinus trephination. Injection of antifungal cream into the frontal sinuses using the bone marrow needle resulted in good diffusion into the ipsilateral nasal cavity and could be used to treat aspergillosis when debridement or sinusoscopy is not deemed necessary.

L'objectif de cette étude est d'évaluer l'utilisation d'une perceuse de moelle osseuse pour la trépanation du sinus frontal et l'injection de crème antifungique chez le chien. Les résultats sont comparés à la trépanation du sinus par une technique chirurgicale classique. Les sinus frontaux de 11 têtes de cadavres de chiens ont été trépanés, en utilisant une perceuse pour moelle osseuse ou un trépan chirurgical. La durée de la procédure avec chaque technique est comparée. Les sinus frontaux sont examinés par tomodensitométrie avant et après injection de crème antifungique, afin de noter de potentielles lésions iatrogéniques, d'évaluer le degré de remplissage du sinus frontal pour chaque technique, et d'apprécier la diffusion de la crème dans les cavité nasales pour chaque chien. Le volume moyen des sinus était de 8,8 ml (3,1 à 14,3 ml). La trépanation, le flush et l'injection de crème antifungique étaient significativement plus rapide avec la perceuse médicale. Il n'y avait pas de différence significative entre le remplissage moyen des sinus par la technique médicale (82,7 %) ou chirurgicale (82,4 %) (P = 0,3). Le remplissage des cavités nasales était qualifié de très bon dans 6 cas sur 11. Une lésion iatrogénique fut constatée dans un cas, avec la technique chirurgicale. Ces résultats semblent montrer qu'une perceuse médicale pour moelle osseuse est facilement utilisable pour trépaner le sinus frontal chez le chien. L'injection de crème dans le sinus frontal par le trocart de la perceuse pour moelle osseuse permet un bon remplissage de la cavité nasale ipsilatérale, et pourrait donc être utilisée dans le cadre du traitement de l'aspergillose canine, dans les cas où un débridement du sinus n'est pas nécessaire.(Traduit par Docteur Serge Messier).

[Cranial trepanation in primitive cultures]. / La trepanación craneal en las culturas primitivas.

A review is presented on cranial trepanations performed by primitive cultures. The scientific interest in this topic began after the discovery in 1965 by Ephraim G. Squier of a pre-Columbian trepanated skull, and studied by Paul Broca in Paris. Pseudotrepanation and other types of cranial manipulation are reviewed. The techniques, technology, and instruments for every type of trepanation are well known. There are a surprisingly high percentage of cases showing signs of post-trepanation survival. Indications for trepanation are speculative, perhaps magic. Although trepanation in primitive cultures is widespread around the world, and throughout time, the main fields of interest are the Neolithic Period in Europe, the pre-Columbian Period in Andean South America, and some contemporaneous Pacific and African tribes. This particular trepanation procedure has no relationship with modern Neurosurgery, or with trepanations with therapeutic purposes performed since the Greco-Roman period in Europe, and afterwards around the world.

Protótipo para realização de cranioplastia de baixo custo / Prototype for cranioplasty low cost in postoperative decompressive craniotomy

Objetivo: O presente trabalho propõe uma técnica para realização de cranioplastia com metilmetacrilato em formas pré-moldadas e esterilizadas visando evitar cranioplastia com prototipagem pré-moldada.Método: Conforme rotina apresentada, o flap ósseo realizado para craniotomia descompressiva é armazenado em recipientes com formol e enviado para o serviço de patologia do hospital. Quando realizamos a cranioplastia, utilizamos o flap ósseo armazenado para realização dos moldes que serão utilizados na cranioplastia. Resultado: O resultado estético é muito bom e os índices de complicação e infecção são baixos. Conclusão: Apresenta resultados estéticos semelhantes aos casos de prototipagemcom baixo custo na confecção.

Objective: This paper proposes a technique for cranioplasty with methyl methacrylate and molded into shapes pre-sterilized to avoid aiming cranioplasty with pre molded prototyping. Method: As presented routine bone flap performed to decompressive craniectomy is stored in containers with formalin and sent to the pathology service of the hospital. When we performed the cranioplasty, we used the bone flap stored for realization of molds that will be used in cranioplasty. Result: The aesthetic result is very good and the rates of complication and infection are lo

Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age.

OBJECT: Decompressive surgery can be life saving after malignant cerebral infarction. However, severe residual disability occurs in a significant number of surviving patients. Most discussion about the benefits of surgery is based on studies performed in patients who are < or = 60 years of age. Less is known about the benefits of the procedure in the elderly population. The authors undertook a review of the literature on decompressive craniectomy for malignant cerebral infarction and compared the mortality and outcome data published in patients older and younger than 60 years of age. The authors discuss their analysis, with specific reference to the limitations of the studies analyzed, the outcome measures used, and the special considerations required when discussing stroke recovery in the elderly. METHODS: Studies on decompressive craniectomy for malignant middle cerebral artery infarction reported in the English literature were analyzed. A cutoff point for age of > 60 or < or = 60 years was set, and the study population was segregated. No studies specifically analyzed patients > 60 years old. A total of 19 studies was identified, 10 of which included patients who were > 60 years of age. A comparison between the 2 age groups was made within the 10 studies and also among all the patients in the 19 studies. Mortality rates and outcome scores were assessed for each study, and a Barthel Index (BI) score of < 60 or a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. Rates were compared using the Fisher exact test, and p values < 0.05 were considered statistically significant. RESULTS: Nineteen studies were found, which included 273 patients undergoing decompressive craniectomy for malignant cerebral infarcts. Ten of these studies included 73 patients (26.7%) who were > 60 years of age. The mean follow-up times ranged from 5.75 to 12.3 months in the > 60-years group and 4.2 to 28 months in the < or = 60-years group. The mortality rate was significantly higher, at 51.3% in the > 60-years group (37 of 72 patients) compared with 20.8% (41 of 197 patients) in the < or = 60-years group (p < 0.0001). Similarly, patients who survived in the > 60-years group had significantly higher rates of poor outcomes, at 81.8% (27 of 33), compared with 33.1% (47 of 142) in the < or = 60-year-old group (p < 0.0001). The BI was the most commonly used primary outcome measure (15 out of 19 studies), followed by the mRS score, which was used in 4 studies. CONCLUSIONS: The mortality rate and functional outcome, as measured by the BI and mRS, were significantly worse in patients > 60 years of age following decompressive craniectomy for malignant infarction. Age is an important factor to consider in patient selection for surgery. However, cautious interpretation of the results is required because the outcome scores that were used only measure physical disability, whereas other factors, including psychosocial, financial, and caregiver burden, should be considered in addition to age alone.

[Neurological paleopathology in the pre-Columbine cultures of the coast and the Andean plateau (II). The history of cranial trepanations]. / Paleopatología neurológica en las culturas precolombinas de la costa y el altiplano andino (II). Historia de las trepanaciones craneales.

INTRODUCTION AND AIMS: Trepanation is one of the earliest examples of a surgical procedure being carried out by human beings and was performed from the Neolithic period onwards in a large number of primitive cultures throughout the five continents. Trepanation and cranial deformation were both common in the pre-Columbine cultures. The aim of this work was to study the trepanations carried out by the ancient Paraca, Nazca, Huari, Tiahuanaco and Inca cultures. To do so, we conducted a field study involving visits to archaeological remains and anthropological museums on the Andean plateau and the Peruvian coast. DEVELOPMENT: In the pre-Columbine cultures, trepanation was performed on both men and women for therapeutic purposes (depressed fractures, epilepsy, vascular headaches and those associated to artificial cranial deformations) and as a ritual. Signs of trepanation have been found in 5% of skulls and 80% of these show evidence of the 'patient' having survived such an intervention. Some of them have several holes in different stages of healing. The trephining procedure involved the use of obsidian knives with wooden handles and tumis, which were ceremonial knives that were used to cut the scalp. Gold and silver cranioplasty plates have also been found in some skulls. CONCLUSIONS: Cranial trepanation was very successful despite the rudimentary methods and instruments employed to perform it.