Third Ventricle Volume Predicts Functional Outcome in Chronic Subdural Hematoma.

OBJECTIVES: There is a lack of evidence demonstrating the utility of computed tomography (CT) to predict chronic subdural hematoma (CSDH) clinical outcomes. We aim to analyze the role of tomographic volumetric analysis in patients with CSDH. METHODS: We performed a retrospective study of patients undergoing burr-hole craniostomy (BHC) for CSDH over five years at a tertiary care center. Degree of midline shift, radiographic density, subdural hematoma volume, acute blood volume, and third ventricle (3VV) and fourth ventricle (4VV) volume were estimated using semiautomatic segmentation of preoperative CT. Postoperative functional outcome was measured by two endpoints: National Institute of Health Stroke Scale (NIHSS) at discharge and short-term modified Rankin Scale (mRS) at 6-week follow-up. Univariate and multivariate analyses were performed using nonparametric tests. Discriminative capacity and optimal thresholds of independent variables were calculated by means of receiving-operative curves (ROC). RESULTS: A total of 79 patients were included for analysis with a median age of 78.5 years. Greater preoperative 3VV independently correlated with poor discharge NIHSS (p = .01) and short-term mRS (p = .03). A cutoff value of 0.545 mL demonstrated the highest sensitivity (77.1%) and specificity (88.8%) with an odds ratio for an mRS functional dependence of 9.29 (p = .001). CONCLUSIONS: Greater preoperative tomographic 3VV independently prognosticates poor discharge NIHSS and 6-week mRS. A threshold 3VV of 0.545 mL can be used to identify patients at higher risk of being dependent at first protocolized follow-up.

Role of the patient comorbidity in the recurrence of chronic subdural hematomas.

Chronic subdural hematoma (CSDH) is an old blood collection between the cortical surface and the dura. Recurrence of CSDH after surgical evacuation occurs in up to a quarter of patients. The association between patient premorbid status and the rate of recurrence is not well known, and some previous results are contradictory. We aim to determine the impact of patient comorbidities in the risk of recurrence after surgical evacuation of CSDH. Retrospective data of a single institution's surgically evacuated CSDH cases followed up for at least 6 months were analyzed, and univariate and multivariate analyses were performed to identify the relationships between recurrence of CSDH and factors such as age, gender, CSDH thickness, neurological impairment at admission (NIHSS score), location of the CSDH (unilateral vs bilateral), Charlson Comorbidity Index (CCI), prothrombin time (PT), hemoglobin levels, and platelet count. A total of 90 patients (71 men and 19 women), aged 41-100 years (mean age, 76.4 ± 11.2 years), were included. CSDH recurred in 17 patients (18.9%). A higher CCI correlated with higher scores in the NIHSS. In the univariate analysis, recurrence was associated with a higher CCI (2.39 vs 1.22, p = 0.002), higher NIHSS scores (6.5 vs 4, p = 0.034), and lower PT levels (9.9 vs 13.4, p = 0.007). In multivariate analysis, only PT and CCI demonstrated to be independent risk factors for CSDH recurrence after surgical evacuation (p = 0.033 and p = 0.024, respectively). Patients with more comorbidities have a higher risk of developing recurrent CSDH. CCI provides a simple way of predicting recurrence in patients with CSDH and should be incorporated into decision-making processes, when counseling patients.

Prognostic Value of Age and Early Magnetic Resonance Imaging in Patients with Cervical Subaxial Spinal Cord Injuries.

BACKGROUND AND OBJECTIVE: The predictive role of a patient's age in spinal cord injury (SCI) is still unclear given the coexistence of potential confounding factors, whether clinical or radiological. Thus, it is the aim of this work to assess the prognostic role of a patient's age against initial radiological features in a traumatic cervical SCI population. METHODS: Clinical and radiological data from patients with acute traumatic cervical SCI and a first MRI performed within 48 h of trauma were retrospectively reviewed. Patients were dichotomized according to the length intramedullary lesion, and associations between age and other clinical or radiological prognostic variables were analyzed. The receiver-operating characteristic (ROC) curve was used to test the discriminative capacity of the patient age to predict neurological and functional outcomes. Poor functional outcome was defined as a Walking Index Spinal Cord Injury score <1 and poor neurological outcome as the lack of neurological improvement between admission and follow up. RESULTS: 134 patients fulfilled the inclusion criteria and were analyzed. The mean age was 43 years, with a male/female ratio of 4:1. polytrauma and soft tissue injuries were inversely proportional to patient age (P < 0.001). A critical value of 55-year-old was established as a threshold for determining poor functional and neurological outcomes. Across the group of patients with minor intramedullary lesions, older age was correlated with poor functional and neurological outcomes (P < 0.001 and P = 0.04, respectively). CONCLUSIONS: Patient age is an important prognostic factor in patients with traumatic cervical SCI. Fifty-five years is the critical cutoff associated with poor prognostic outcome.

Spinal Cord Injury Without Radiological Abnormalities and the importance of Magnetic Resonance.

Comment on:  Bonfanti L, Donelli V, Lunian M et al. Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review. Acta Biomed 2018; 89: 593-598.

Factors predicting outcome of surgical treatment of spontaneous spinal hematomas: a retrospective cohort study in four tertiary reference centers.

BACKGROUND: Spontaneous spinal extradural hematoma (SSEH) is a rare but disabling disorder. Most of the previous assumptions regarding the factors that contribute to poor neurological recovery from SSEH are based on small case samples or conditions with similar clinical presentations but different physiopathologies. Our goal was to find the most relevant prognostic factors for neurological recovery in patients suffering SSEH treated with surgical evacuation. METHODS: From a retrospective database of 29 surgical patients with SSEH, several clinical and radiological variables were recorded. These variables were compared between patients with good and poor neurological recovery, considering good as an improvement by at least one point in the ASIA Scale. RESULTS: Among the patients included, morbidity and mortality rate was 6.9% and 3.4%, respectively, with a mean follow-up of 7.1 months. Neurological full recovery was experienced by 33% of the patients included, and 86% of individuals had an improvement in their neurological condition at last follow-up. Lesser intramedullary lesions were significantly associated with greater chances of improvement in ASIA Scale at discharge and at follow-up. Surgical decompression within the first 24 hours of onset of symptoms were correlated with better neurological outcomes at follow-up. CONCLUSIONS: MRI is a powerful tool to predict the neurological outcome in SSEH patients, and it should be considered as an another resource to better know the patients with greater chances of having neurological recovery, especially in cases where the neurological examination is not reliable at the initial exam.

The "Brain Stress Timing" phenomenon and other misinterpretations of randomized clinical trial on aneurysmal subarachnoid hemorrhage.

Clipping and coiling are currently the two alternatives in treatment of ruptured cerebral aneurysms. In spite of some meritorious analysis, further discussion is helpful to understand the actual state of art. Retreatment and rebleeding rates clearly favors clipping, although short-term functional outcome seems to be beneficial for clipping, while this different is not such if we perform the comparison at a longer follow up. Long-term follow ups and cost analysis are mandatory to have a clear view of the current picture in treatment of subarachnoid hemorrhage. Treatment strategy should be made by a multi-disciplinary team in accredited centers with proficient experience in both techniques.

Acute Deafness: A Rare Complication of Shunting.

BACKGROUND: Mild hearing loss following shunting has been described; however, severe auditory impairment associated with ventriculoperitoneal (VP) shunt is an uncommon, rarely reported phenomenon. Treatment options and pathophysiologic considerations are discussed in this case report. CASE DESCRIPTION: A 27-year-old man who was treated for an eighth cranial nerve schwannoma with complete resection and a VP shunt 10 years previously presented to the emergency department with acute severe hearing loss and headache. Imaging showed diminished size of the ventricles and dural contrast enhancement. The previous shunt was replaced with a programmable antisiphoning VP shunt. The patient's hearing and headache improved 48 hours later, as demonstrated in serial audiograms. CONCLUSIONS: Hearing loss is an underestimated complication of shunting that in some cases may progress to severe impairment and deafness. Patients with a VP shunt who experience hearing loss should undergo further evaluation and possibly adjustment of shunt settings.

Spontaneous Tension Pneumocephalus: A Rare Complication of Shunting.

BACKGROUND: Spontaneous tension pneumocephalus (STP) is a rare but serious complication derived from shunting procedures. Few cases have been published with purely intraventricular location. Treatment options and physiopathology considerations are discussed in this case report. CASE DESCRIPTION: A 75-year-old woman with a 15-year-old lumboperitoneal (LP) shunt insertion was treated with a ventriculoperitoneal shunt for her normotensive hydrocephalus. Two months later she was brought to the emergency room showing symptoms of lethargy and confusion. A helicoidal computed tomography (CT) scan revealed a bone defect in the floor of the right temporal fossa. The patient underwent a temporal craniotomy for closing the bone and dural defect, and the LP shunt was removed, at which point her condition improved. CONCLUSIONS: A high-resolution CT scan of the skull base is useful to localize the point where the air enters into the intracranial cavity in STP cases. Coexistent or preceding otologic symptoms might direct the suspicion toward an otogenic origin. Shunt removal, or adjusting the opening pressure, if feasible, is recommended. Otherwise, dural repair and covering of the bone defect have acceptable rates of success and should be performed before any other more aggressive techniques to avoid the risk of hearing loss.