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.

Antero posterior elongation of midbrain in traumatic brain injury- significant sign yet a mistaken entity.

BACKGROUND: Antero posterior elongation of the midbrain is observed occasionally in severe traumatic brain injury and generally implies a bad outcome. The objective of the study was to document midbrain elongation and identify the implications of this finding. METHODS: This prospective study included 100 patients with traumatic intracranial haematoma of more than 20 cc in volume. Key measurements were taken in the midbrain and pontine regions and the status of perimesencephalic basal cisterns was noted. All the predictors were analyzed for the outcome. RESULTS: In twenty-nine patients the distorted midbrain appeared to be elongated in the antero posterior direction on visual inspection of CT head images. However, on statistical analysis, it was made out that there is no demonstrable anteroposterior lengthening of the midbrain. The factors influencing the appearance and outcome were discussed. CONCLUSIONS: Although not a true sign, the finding of the elongated appearance of the midbrain in traumatic brain injury still holds significance as a predictor of mortality. Hence, this finding should alert neurosurgeons or intensivists to expedite the administration of suitable interventions in a salvageable patient.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma.

OBJECTIVE: Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score. METHODS: Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome. RESULTS: Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels. CONCLUSIONS: The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.

Chronic Subdural Hematoma: A Questionnaire Survey of Management Practice in India and Review of Literature.

OBJECTIVE: To identify the current management modalities practiced by neurosurgeons in India for chronic subdural hematoma. METHODS: A questionnaire was prepared for the survey and sent via e-mail to neurosurgeons. It covered the following aspects of managing chronic subdural hematoma: 1) demographic and institutional details; 2) choice of surgical procedure; 3) surgical adjutants such as placing a subdural drain; 4) pre- and postoperative care; and 5) recurrences and management. Responses obtained were entered in a SPSS data sheet and analyzed. RESULTS: Response rate of the survey was 9.3%. The majority of neurosurgeons (75%) preferred to do burr whole drainage for primary chronic subdural hematoma and also for recurrences. Only one third of routinely placed a subdural drain. Considerable practice variations exist for medical and perioperative management. CONCLUSIONS: Bedside twist drill drainage, which is effective and less costly than operative room procedures, has not gained popularity in practice. The present survey points towards the importance of making management guidelines for this common neurosurgical entity.

Primary pyogenic spinal epidural abscess: How late is too late and how bad is too bad? - A study on surgical outcome after delayed presentation.

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.