Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age?

Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.

The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke.

BACKGROUND: Malignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome. METHODS: A cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3. RESULTS: Median age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P = 0.0003) and was associated with a worse outcome (P < 0.0001) after exceeding a cutoff volume of 300 cm3. CONCLUSIONS: Volumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.

Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons.

Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients' wishes, their surrogates' wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon's interest in gathering additional information on the patient's social environment and supposed patient's wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.

"I am not afraid of death"-a survey on preferences concerning neurosurgical interventions among patients over 75 years.

INTRODUCTION: Treatment decisions in elderly patients with traumatic brain injury (TBI) are mainly determined by trauma severity and patient age. The aim of this study was to explore personal preferences of potential patients regarding life-prolonging neurosurgical interventions by interviewing ambulatory, autonomous elderly people. METHODS: One hundred consecutive patients older than 75 years frequenting the outpatient clinic of the Department of Neurosurgery were interviewed about their attitudes regarding the hypothetical case of an 81-year-old patient with TBI and a space-occupying acute subdural hematoma (aSDH) using a 21-point questionnaire. RESULTS: Fifty-one percent of the consulted persons declined life-prolonging surgical measures. If surgery was associated with physical disability, 68% of the people wished no surgery. In case of cognitive impairment after surgery, 91% were against any surgical intervention. The majority feared being a burden to relatives (76%) and becoming unable to master an independent life (75%). Four-fifths of the interviewed patients (82%) were not afraid of death. CONCLUSIONS: The majority of elderly patients only consent to surgical measures if no relevant disabilities are involved and if they can return to their previous life. These findings need consideration in case of life-threatening neurosurgical emergencies as well as in the surgical treatment of elderly patients in general.

Postoperative Thromboembolic Prophylaxis with Low-Molecular-Weight Heparin and Risk of Rebleeding in Patients with Chronic Subdural Hematomas: A Comparative Retrospective Cohort Study.

OBJECTIVE: Early postoperative administration of low-molecular-weight heparin (LMWH) to prevent thromboembolic events in patients with chronic subdural hematoma (CSDH) is controversial. Our goal was to investigate impact of early postoperative LMWH administration on recurrence rate of CSDHs. METHODS: Retrospective review was performed of 136 patients with CSDHs who were operated on during an 18-month period. Early postoperative administration of LMWH was at the discretion of the treating surgeon. This resulted in patients treated (heparin [H] group) or not treated with LMWH (no heparin [NH] group). All patients underwent imaging 4 weeks after surgery or earlier in cases of deterioration. The primary outcome variable was reoperation. Secondary outcomes were reoperation, important residual hematoma (defined as hematoma depth of more than one third of original size), and incidence of thromboembolic complications. Relative risk and absolute risk reduction were calculated. RESULTS: We included 105 patients, 50 (47.6%) in the NH group and 55 (52.4%) in the H group. Nine patients (18%) in the NH group and 6 patients (10.9%) in the H group required secondary surgery (relative risk 0.61, 95% confidence interval 0.23-1.58, P = 0.404, absolute risk reduction 0.07). Eleven patients (22%) in the NH group and 15 patients (27.3%) in the H group presented with important residual hematoma or underwent surgery for hematoma recurrence (relative risk 1.24, 95% confidence interval 0.63-2.44, P = 0.532, absolute risk reduction -0.05). CONCLUSIONS: Our data provide preliminary evidence that early postoperative administration of LWMH does not increase risk of clinically relevant recurrence of CSDHs.

Reconstruction of large cranial defects with poly-methyl-methacrylate (PMMA) using a rapid prototyping model and a new technique for intraoperative implant modeling.

BACKGROUND: Reconstruction of large cranial defects after craniectomy can be accomplished by free-hand poly-methyl-methacrylate (PMMA) or industrially manufactured implants. The free-hand technique often does not achieve satisfactory cosmetic results but is inexpensive. In an attempt to combine the accuracy of specifically manufactured implants with low cost of PMMA. METHODS: Forty-six consecutive patients with large skull defects after trauma or infection were retrospectively analyzed. The defects were reconstructed using computer-aided design/computer-aided manufacturing (CAD/CAM) techniques. The computer file was imported into a rapid prototyping (RP) machine to produce an acrylonitrile-butadiene-styrene model (ABS) of the patient's bony head. The gas-sterilized model was used as a template for the intraoperative modeling of the PMMA cranioplasty. Thus, not the PMMA implant was generated by CAD/CAM technique but the model of the patients head to easily form a well-fitting implant. Cosmetic outcome was rated on a six-tiered scale by the patients after a minimum follow-up of three months. RESULTS: The mean size of the defect was 74.36cm2. The implants fitted well in all patients. Seven patients had a postoperative complication and underwent reoperation. Mean follow-up period was 41 months (range 2-91 months). Results were excellent in 42, good in three and not satisfactory in one patient. Costs per implant were approximately 550 Euros. CONCLUSION: PMMA implants fabricated in-house by direct molding using a bio-model of the patients bony head are easily produced, fit properly and are inexpensive compared to cranial implants fabricated with other RP or milling techniques.

Opening the Internal Hematoma Membrane Does Not Alter the Recurrence Rate of Chronic Subdural Hematomas: A Prospective Randomized Trial.

BACKGROUND: Factors determining the recurrence of chronic subdural hematomas (CSDHs) are not clear. Whether opening the so-called internal hematoma membrane is useful has not been investigated. OBJECTIVE: To investigate whether splitting the inner hematoma membrane influences the recurrence rate in patients undergoing burr-hole craniotomy for CSDH. METHODS: Fifty-two awake patients undergoing surgery for 57 CSDHs were prospectively randomized to either partial opening of the inner hematoma membrane (group A) or not (group B) after enlarged burr-hole craniotomy and hematoma evacuation. Drainage was left in situ for several days postoperatively. Groups were comparable with regard to demographic, clinical, and imaging variables. Outcome was assessed after 3-6 weeks for the combined outcome variable of reoperation or residual hematoma of one third or more of the original hematoma thickness. RESULTS: Fourteen patients underwent reoperation for clinical deterioration or residual hematoma during follow-up (n = 6 in group A, 21%; n = 8 in group B, 28 %) (P = 0.537). Residual hematoma of ≥ one third not requiring surgery was present in 7 patients in group A (25%) and 10 patients in group B (36%) (P = 0.383). The overall cumulative failure rate (reoperation or hematoma thickness ≥ one third) was 13/28 (46%) in group A and 18/28 in group B (P = 0.178; relative risk, 0.722 [95% confidence interval, 0.445-1.172]; absolute risk reduction -16% [95% confidence interval, -38% to 8%]). CONCLUSIONS: Opening the internal hematoma membrane does not alter the rate of patients requiring revision surgery and the number of patients showing a marked residual hematoma 6 weeks after evacuation of a CSDH.

Remote ischemic preconditioning in the prevention of ischemic brain damage during intracranial aneurysm treatment (RIPAT): study protocol for a randomized controlled trial.

BACKGROUND: The treatment of intracranial aneurysms may be associated with cerebral ischemia. We hypothesize that pre-interventional remote ischemic preconditioning (RIPC) reduces ischemic cerebral tissue damage in patients undergoing elective intracranial aneurysm treatment. METHODS/DESIGN: This study is a single-center, prospective, randomized, double-blind explorative trial. Patients with an unruptured intracranial aneurysm admitted to Innsbruck Medical University Hospital for coiling or clipping will be consecutively randomized to either the intervention group (= RIPC by inflating an upper extremity blood-pressure cuff for 3 x 5 min to 200 mmHg) or the control group after induction of anesthesia. Participants will be randomized 1:1 to either the preconditioning group or the sham group using a random allocation sequence and block randomization. The precalculated sample size is n = 24 per group. The primary endpoint is the area-under-the-curve concentration of serum biomarkers (S100B, NSE, GFAP, MMP9, MBP, and cellular microparticles) in the first five days after treatment. Secondary endpoints are the number and volume of new ischemic lesions in magnetic resonance imaging and clinical outcome evaluated with the National Institutes of Health Stroke Scale, the modified Rankin Scale, and neuropsychological tests at six and twelve months. All outcome variables will be determined by observers blinded to group allocation. This study was approved by the local institutional Ethics Committee (UN5164), version 3.0 of the study protocol, dated 20 October 2013. DISCUSSION: This study uses the elective treatment of intracranial aneurysms as a paradigmatic situation to explore the neuroprotective effects of RIPC. If effects are demonstrable in this pilot trial, a larger, prospective phase III trial will be considered.

Complete removal of vagus nerve stimulator generator and electrodes.

Vagus nerve stimulation has become widely used in the palliative treatment of refractory epilepsy. Removal of a vagus nerve stimulator may be desirable or even necessary due to lack of efficacy, intolerable side effects, signs of infection, or failure of the device. Unless the lead or the helical electrodes are defective, only the generator is explanted and the electrodes are usually left behind for fear of damaging nerve or surrounding structures. The authors review their experience with complete removal of the stimulating electrodes and pacemaker-like generator device in 9 consecutive patients, 3 of whom were children. Using microsurgical techniques, the authors were able to completely remove the stimulator, including electrodes in all patients. All nerves remained morphologically intact. One case of temporary and one of permanent clinically silent ipsilateral vocal cord paresis were observed.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

PURPOSE: Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. METHODS: A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. RESULTS: The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. CONCLUSION: A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.