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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.).
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Craneotomía , Craniectomía Descompresiva , Hematoma Subdural Agudo , Humanos , Craneotomía/efectos adversos , Craneotomía/métodos , Craniectomía Descompresiva/efectos adversos , Craniectomía Descompresiva/métodos , Escala de Consecuencias de Glasgow , Hematoma Subdural Agudo/cirugía , Calidad de Vida , Estudios Retrospectivos , Cráneo/cirugía , Resultado del Tratamiento , Colgajos Quirúrgicos/cirugíaRESUMEN
Ventricular involvement in central nervous system tuberculosis can be in the form of tuberculous ependymitis, intraventricular tuberculoma, intraventricular tuberculous abscess, choroid plexitis and choroid plexus tuberculoma. Only a few cases of choroid plexus tuberculomas have been described and even more rare is the description of the role of endoscopy in management of intraventricular tuberculomas. We report a 33-year-old patient while on treatment for tubercular meningitis who developed a left side choroid plexus lesion with loculated temporal horn. To confirm the diagnosis, endoscopic biopsy of the lesion was carried out. The final histopathology was tuberculoma. Intraventricular tuberculomas are usually associated with recalcitrant lesions, probably due to the poor drug levels within the CSF or as an indirect effect of immune resistance and biopsy becomes important to rule out other possibilities.
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Plexo Coroideo/cirugía , Endoscopía , Tuberculoma Intracraneal/diagnóstico , Tuberculoma Intracraneal/tratamiento farmacológico , Adulto , Antituberculosos/uso terapéutico , Biopsia con Aguja/métodos , Humanos , Masculino , Tuberculoma Intracraneal/diagnóstico por imagenRESUMEN
Spinal epidural abscess is a rare clinical entity with considerable morbidity. Even with prompt diagnosis and treatment, many patients are left with persistent residual neurological deficits. The present study details the outcome in 23 patients of primary pyogenic spinal epidural abscess, addressing the outcome following late presentation at a neurological facility. At presentation only 2 patients had relatively preserved neurological status. Eleven patients were paraplegic. All the patients underwent laminectomy and evacuation of abscess. A good functional outcome was observed in almost half of the patients, and there was a significant reduction in the number of the patients with severe disability. Factors influencing the outcome are described in this study.
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Absceso Epidural/cirugía , Espacio Epidural/cirugía , Adolescente , Adulto , Femenino , Humanos , Laminectomía/métodos , Imagen por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Compresión de la Médula Espinal/cirugía , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/cirugía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
There are only a few case reports comprising exclusively of os omovertebrale. Here, we discuss various types, varied clinical presentations, associated abnormalities, and management strategies of this abnormality. We retrospectively analyzed three patients with os omovertebrale and their clinical presentation, and also reviewed the limited available literature. Patients were evaluated clinically and radiologically to diagnose this abnormality as well as the associated abnormalities. Two patients were operated for neurological deficits attributed to this deformity. It is quite common to miss this abnormality when it is of osseocartilaginous or fibrous type, especially when it is asymptomatic and not associated with Sprengel's scapula. By analyzing our patients and other reported cases, we have proposed a classification system. In addition, we discuss varied clinical presentations and their practical application. Os omovertebrale is a rare abnormality. It should be kept in mind and managed when encountered in clinical practice. The classification and clinicoradiological correlations described here can be useful to individualize management issues.
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Escápula/anomalías , Humanos , Estudios RetrospectivosRESUMEN
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.
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Neuroma , Traumatismos de los Nervios Periféricos , Animales , Ratas , Adhesivo de Tejido de Fibrina/uso terapéutico , Traumatismos de los Nervios Periféricos/cirugía , Estudios Prospectivos , Suturas , Inflamación , Anastomosis Quirúrgica , Nervio Ciático/cirugíaRESUMEN
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.
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Lesiones Traumáticas del Encéfalo , Craniectomía Descompresiva , Lesiones Traumáticas del Encéfalo/cirugía , Craneotomía , Estudios de Factibilidad , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: A number of pharmacological agents have been tried to circumvent the problem of delayed cerebral ischemia (DCI) with ozagrel sodium being one such agent aimed at the prevention of DCI. Ozagrel is an inhibitor of thromboxane synthetase. It has anti-platelet aggregation action and it dilates vessels. Ozagrel was not available outside Japan till recently. It is available now in India and we had the opportunity to use it among patients with aneurysmal subarachnoid hemorrhage (SAH). AIMS: To analyse the results of ozagrel administration for patients with aneurysmal SAH. SETTINGS AND DESIGN: Tertiary care neurosurgical center. MATERIALS AND METHODS: Retrospective analysis of the outcomes of patients who received ozagrel after microsurgical cllipping of aneurysm and comparison with a control grpup who received treatment as usual. STATISTICAL ANALYSIS: The t-test (two-tailed), Chi-square test, and Mann-Whitney U-test asymptomatic significance (two-tailed), were used respectively for continuous, categorical, and ordinal variables. The significance was determined at P = 0.05 level. RESULTS: A total of 106 patients underwent surgical clipping of their ruptured intracranial aneurysms over a period of 22 months. Forty two (39.6%) patients received ozagrel, and 62 (60.4%) received the standard treatment. Ozagrel was started at a median of one [interquartile range (IQR) 0.75] day after the surgery, and was given for a median of five (IQR 5) days after the surgery. There was no difference in age, postictal days, World Federation Neurosurgical Society grade, Fisher grade, and the size of ruptured aneurysm in patients who received ozagrel compared to the patients who did not receive ozagrel. Of the 42 patients who received ozagrel, 30 patients (71.4%) had preoperative angiographic vasospasm which improved after the administration of ozagrel. Fifteen (35.5%) patients who received ozagrel developed delayed cerebral ischemia compared to only 11 (17.2%) patients who did not receive ozagrel. Thirty-six (85.7%) patients who received ozagrel had favorable outcome at discharge compared to 52 (81.3%) patients who did not receive ozagrel. No adverse event was observed with ozagrel therapy. At 3-month follow-up, 37 patients (88.1%) who received ozagrel had favorable outcomes against 53 patients (82.8%) who did not receive ozagrel. CONCLUSION: Ozagrel may be a useful drug in the armamentarium to treat vasospasm after aneurysmal SAH. A future multicenter large cohort study may validate the findings of our study.
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Fibrinolíticos/uso terapéutico , Metacrilatos/uso terapéutico , Procedimientos Neuroquirúrgicos/efectos adversos , Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/tratamiento farmacológico , Anciano , Isquemia Encefálica/etiología , Isquemia Encefálica/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Periodo Posoperatorio , Estudios Retrospectivos , Hemorragia Subaracnoidea/cirugía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos , Vasoespasmo Intracraneal/etiologíaRESUMEN
INTRODUCTION: Cervical laminectomy is a very well-known posterior decompressive procedure for cervical compressive myelopathy (CCM). Our objective is to evaluate the functional effect of posterior decompressive laminectomy for poor grade CCM. METHODS: This study was an observational retrospective study carried out on patients with poor-grade CCM who underwent decompressive laminectomy from January 2010 to December 2015. Patients with Nurick Grades 4 and 5 (walking with support or bedbound) were included in the study. Clinical data and radiological information were collected from medical records, and objective scales were applied to compare the surgical outcome between preoperative score and postoperative score. RESULTS: A total of 69 patients who underwent decompressive laminectomy for poor grade CCM were included. The mean age was 54.9 years, and the male-to-female ratio was 5.3:1. Ossified posterior longitudinal ligament comprised 52.6% cases. The follow-up data of at least 6 months' duration after surgery was available for 57 (82.6%) cases. On comparing with preoperative Nurick grade at follow-up, 40 of the 57 patients (70.2%) were found to have improvement following surgery by at least one grade. The remaining 17 (29.8%) had either remained the same or had deteriorated further. The mean preoperative modified Japanese Orthopedic Association score was 8.4 ± 2.8, and the mean follow-up score was 11.8±0.3 (P = 0.0001). On multivariate analysis, the number of levels of laminectomy, postoperative deterioration, and anesthesia grade were predictors of outcome. CONCLUSION: Decompressive laminectomy for poor grade myelopathy is effective in improving functional outcome.
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Anterior communicating artery aneurysm rarely presents with symptoms of compression of anterior visual pathways. We report a case of 65 years old man, who had complete loss of vision in right eye and temporal hemianopsia in left eye due to giant anterior communicating artery aneurysm.
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CONTEXT: Experience with elderly pedestrian neurotrauma at a major neurotrauma tertiary center. AIMS: To highlight the specific injuries and outcome of the elderly pedestrian neurotrauma patients within the city of Bangalore and its surrounding districts. SETTINGS AND DESIGN: A retrospective study consisting of demographic data, clinical findings, radiological details, and outcomes. MATERIALS AND METHODS: A study was conducted at the casualty services, in which 143 consecutive elderly pedestrian (age >60 years) head injury victims were studied from June to September 2009. The records from the hospital mortuary were analyzed from 2007 to 2009. An analysis of 77 elderly patients who died as a pedestrian in accidents during this period was performed. STATISTICAL ANALYSIS USED: SPSS 15. RESULTS: The elderly pedestrians constituted 27% (143/529) of all pedestrian traumas. Two wheelers were the most common accident vehicle (56.6%, 81/143). Most of the injuries (38.5%, 55/143) occurred during peak traffic hours, that is, 4 pm to 9 pm. Majority sustained moderate to severe head injury (61%, 87/143). More than three-fourths of patients required a computed tomography (CT) scan (77%, 110/143), in which there was a higher frequency of contusion (31.5%, 45/143), and subdural hemorrhage (23.1%, 33/143). Most of the injured (43.3%, 13/30) underwent surgery for intracranial hematoma. The mortality rate was 22.8% (8/35). Nearly one-fourth of conducted postmortems among pedestrians belonged to the elderly age group (77/326, 23.6%). CONCLUSIONS: Elderly pedestrian neurotrauma patients sustain a more severe injury as evident by poorer Glasgow Coma Score (GCS) scores and CT scan findings, and hence have a higher mortality rate.