A prospective study of early versus late craniectomy after traumatic brain injury.

BACKGROUND: Decompressive craniectomy is an important method for managing traumatic brain injury (TBI). At present, controversies about this procedure exist, especially about the optimum operative time for patients with TBI. METHODS: A prospective study was performed at the First Affiliated Hospital, College of Medicine, Zhejiang University. From January 2008 to December 2009, 25 patients who underwent early decompressive craniectomy were included in the study group, and 19 patients who underwent "late" decompressive craniectomy as a second-tier therapy for intracranial hypertension were included as a comparison group. RESULTS: The 30-day mortality after the operation was 16% in the study group. The overall mortality rate was 20% at the 6-month follow-up. A total of 52% of the patients (13 patients) had good outcomes, and 7 patients remained in a severely disabled or vegetative state. In the comparison group, 4 patients died, and 12 had good outcomes at the 6-month follow-up. The remaining 3 patients had poor outcomes. The study group was well matched with the comparison group. However, the outcomes in the study group were not better than those in the comparison group, as evaluated by the 6-month GOS score. CONCLUSION: Early decompressive craniectomy as a first-tier therapy for intracranial hypertension did not improve patient outcome when compared with "late" decompressive craniectomy for managing TBI.

Sella turcica anatomy by three-dimensional computed tomography for an endonasal transsphenoidal approach to pituitary adenoma.

BACKGROUND: The aim of this study was to identify the anatomic landmarks of sella turcica on the surface of the head, and to investigate the feasibility of studying sella turcica anatomy individually by three-dimensional computed tomography (3D-CT) before an endonasal transsphenoidal operation. PATIENTS AND METHODS: The three-dimensional anatomic structures of the heads of 49 patients were studied by 3D-CT using image reconstruction with surgical clip image registration. The tip of the nose and the apex of the ear helix were used as surface markers on the head, and the locations of the sphenoid sinus and sellar floor with respect to a line defined by these 2 markers were investigated. Using an endonasal transsphenoidal approach with a surgical trajectory guided by the nose tip-ear apex line and 3D-CT anatomic images of the sella turcica, 12 patients with pituitary adenoma were treated surgically. RESULTS: The nose tip-ear apex line passed through the sphenoid sinus in 100% of the cases and through the sellar floor in 41.4% of the cases. The mean distance from the sellar floor clivus point perpendicularly to the nose tip-ear apex line was 3.5±2.0 mm. The 3D-CT imaging clearly showed the configuration of the sphenoid sinus, bone septum, optic protuberance, carotid protuberance and the sellar floor. 12 pituitary adenomas were resected totally. CONCLUSION: The nose tip-ear apex line provides a precise, simple, and practical tool for orienting the sphenoid sinus, sellar floor and surgical trajectory of the endonasal transsphenoidal approach. 3D-CT images more clearly and intuitively display the sella turcica anatomy. Preoperative 3D-CT increases the surgeon's confidence in endonasal transsphenoidal operations and should be routinely performed in patients with pituitary adenomas.

Solitary intracerebral chondroma without meningeal attachment: a case report with review of the literature.

Intracranial chondromas are rare, benign cartilaginous tumours that account for < 0.3% of primary intracranial tumours. They usually originate from the basal synchondrosis and are extradural though, extremely rarely, they can be intracerebral. Here the case of a 45-year old female is presented with a solitary intracerebral chondroma located in the right frontal lobe with no meningeal attachment. The epidemiology, aetiology, clinical behaviour, radiological features, histological features and treatment of the case are discussed with a review of previous cases reported in the literature.

Isolated primary non-Hodgkin's lymphoma of the thoracic spine: a case report with a review of the literature.

A case of isolated primary non-Hodgkin's lymphoma of the spine is presented along with a review of previous cases reported in the literature. An 80-year old immunocompetent man was admitted with progressive numbness and weakness of both lower extremities of 2 weeks' duration. Magnetic resonance imaging (MRI) of the cervicothoracic spine revealed an extradural spinal mass at the T1 - T3 level, with invasion into the T3 vertebral body. The lesion was at first thought to be a metastatic tumour. Because of the manifestations of compression, the patient underwent laminectomy and posterior decompression. Histopathological examination revealed diffuse large B-cell non-Hodgkin's lymphoma. All other investigations (including computed tomography of the chest and abdomen, bone scan, peripheral blood examination and tumour marker examination) were negative for occult disease. This case demonstrates that neurosurgeons should be aware of the occurrence of isolated primary spinal lymphoma, which should be included in the differential diagnosis of metastatic tumours.

Shunt implantation in a special sub-group of post-traumatic hydrocephalus--patients have normal intracranial pressure without clinical representations of hydrocephalus.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a frequent complication secondary to traumatic brain injury (TBI) and controversy remains over whether to perform a shunt placement for patients with normal pressure hydrocephalus when the patient is too injured to display symptoms or has atypical symptoms. METHOD: A hospital-based retrospective study was performed in patients who developed normal pressure hydrocephalus, without atypical symptoms, from January 2004 to June 2007. Information regarding patients' demographics, TBI, hydrocephalus and outcome was collected. RESULTS: A total of 31 patients were involved in this study. At the 12-month follow-up, 20 patients (64.5%) showed clear improvement. Among the 10 patients who developed PTH after decompressive craniectomy, cranioplasty was performed after shunt implantation and clinical improvement was observed in nine patients. Additionally, in this series, the patients' age and the severity of hydrocephalus, assessed by CT imaging before shunt placement, significantly correlated with improvement. CONCLUSION: Although the effect was not definitively established, many patients in the sub-group of PTH patients described here would benefit from shunt placement, especially when they simultaneously have large cranial defects after surgical decompression and underwent cranioplasties after shunt placement. Additionally, younger patients and those with less severe hydrocephalus before shunt placement may expect a better outcome after shunt placement.

Spontaneous rapid resolution of acute subdural hematoma after head trauma: is it truly rare? Case report and relevant review of the literature.

BACKGROUND: Spontaneous rapid resolution of acute subdural hematoma (ASDH) is a rare phenomenon for this severe insult after head trauma. CASE REPORT: We present a 22-year-old patient who developed ASDH with a moderate midline shift and compression of lateral ventricle after a truncal collision but without a direct beat on the head. Conservative management was performed under close monitoring because of unexpected improvement of clinical signs and symptoms. Unexpectedly, the ASDH resolved spontaneously within 13 h after the trauma, and he was discharged 1 week later without any neurological deficit. In addition, similar cases reported in literature were reviewed. CONCLUSION: Because most of the patients developing ASDH underwent emergent surgical intervention, the incidence of this phenomenon may be underestimated. Although emergent surgical removal remains the first choice for the treatment of ASDH, conservative management with careful monitoring may also work out in selected patients who show neurologic and radiologic improvements.

Contralateral subdural effusion secondary to decompressive craniectomy performed in patients with severe traumatic brain injury: incidence, clinical presentations, treatment and outcome.

OBJECTIVE: This study was performed to better understand postoperative contralateral subdural effusion, an uncommon but serious complication secondary to decompressive craniectomy in patients with head trauma. SUBJECTS AND METHODS: Data from medical records of 169 patients who underwent decompressive craniectomy after head trauma between 2003 and 2006 were collected. The data included demographics, clinical presentations, treatment and outcome. RESULTS: Of the 169 patients, 11 (6.5%) had contralateral subdural effusion. On the average, this complication was found 14 days after decompressive craniectomy. Of the 11 patients, conservative treatment was effective in 7 with a gradual resolution which lasted 52.7 days on average. The effusion in the remaining 4 patients led to progressive deterioration of clinical presentation, and surgical intervention was necessary: subduroperitoneal shunting in 3 cases and burr hole drainage in the remaining 1 case. CONCLUSIONS: Our findings confirmed that postoperative contralateral subdural effusion was not an uncommon complication secondary to decompressive craniectomy. Most contralateral subdural effusions resolved spontaneously after conservative management, but surgical management may be necessary if the patients develop deteriorating clinical manifestations or the subdural effusion has an apparent mass effect.

Supratentorial Brain AVM Embolization with Onyx-18 and Post-Embolization Management. A Single-Center Experience.

SUMMARY: Onyx is increasingly used in endovascular therapy of intracranial arteriovenous malformations (AVMs). However, the embolic effect and post-embolization management are still under discussion. We report our experience in the treatment of supratentorial brain arteriovenous malformations (SBAVMs) with Onyx and discuss post-embolic management. From June 2006 to July 2008, 20 patients with SBAVM were embolized with Onyx. There were 14 men and six women ranging from 14 to 64 years of age (mean 38.3 years). Initial symptoms included spontaneous hemorrhage (n=12), headaches (n=4), seizure (n=3) and incidentally disclosed after head trauma (n=1). After the endovascular procedure, all had subsequent treatment (follow-up angiogram, stereotactic radiosurgery or microsurgery) according to the obliteration degree. At angiography, seven patients (35%, 7/20) were completely obliterated (over 95% closure) after embolization while one suffered a small subarachnoid hemorrhage without permanent clinical sequelae. Four patients (20%, 4/20) were subtotally obliterated (over 80% closure), one patient who suffered severe cerebral edema after embolization underwent decompressive craniectomy, two patients had additional radiosurgery and one patient had follow-up angiogram. Nine patients (45%, 9/20) were partially obliterated (20-80% closure), five patients had additional surgery, two patients had additional radiosurgery and two patients had follow-up angiogram (one patient had intraventricular hemorrhage three months after embolization). Of all 20 AVMs, an average of 2.2 ml Onyx was used per patient and average volume reduction was 80% (range, 30%-99%). Onyx is suitable for embolization of SBAVMs because of its diffuse controllable properties. We suggest clinical follow-up after complete obliteration, additional radiosurgery or angiographic follow-up after subtotal obliteration and additional surgery after partially obliteration. More cases with long-term follow-up are needed to evaluate the long-term prognosis of our post-embolization management.

Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases.

BACKGROUND: Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications. METHODS: From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed. FINDINGS: Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications. CONCLUSIONS: The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

Treatment of intracerebral glioblastomas with G422 tumour cell vaccine in a mouse model.

The aim of this study was to develop a tumour vaccine with the ability to induce and expand higher affinity cytotoxic T lymphocytes and stimulate an effective antitumour immune response. The hypothesis tested was that G422 glioblastoma cells modified with B7-1 and interferon (IFN)-gamma genes could serve as a tumour vaccine. It was found that therapeutic subcutaneous immunizations with this tumour vaccine significantly induced a cytotoxic T-cell response and prolonged the survival of female Kuming mice with intracerebral G422 tumour isografts. The data collectively suggested that G422 glioblastoma cells genetically modified with B7-1 and IFN-gamma genes could serve as a tumour vaccine.

Cranioplasty for patients developing large cranial defects combined with post-traumatic hydrocephalus after head trauma.

BACKGROUND: Large cranial defects combined with hydrocephalus after decompressive craniectomy are a common, harsh reality among patients with head trauma. Typically, a shunt is first used to relieve the hydrocephalus. However, subsequently the patients may develop a severe sinking scalp flap over the skull defect before cranioplasty, which would make the procedure difficult. METHODS: This problem was overcome by temporarily adjusting the shunt pressure using a programmable ventriculoperitoneal shunt tube, which allowed expansion of the depressed scalp flap and facilitated the subsequent cranioplasty. This study describes two patients who were treated for this problem after severe head trauma. RESULTS: When performing a titanium mesh cranioplasty after a shunt, this new method facilitated the separation of the scalp from the underlying muscle or dura and obliterated the dead space between the titanium mesh and the underlying tissue. Both patients had satisfactory outcomes without complications. CONCLUSIONS: This method is easy and safe and it facilitates the cranioplasty, reducing the potential complications, including intracranial haematoma, effusions and infection, and thereby improving the patient outcome.