Primary Dural Acute Lymphoblastic Leukaemia/Lymphoma Masquerading Meningioma: Report of a Case and Review of Literature.

Acute lymphoblastic leukaemia/lymphoma (ALL) is a systemic disease which primarily involves bone marrow or lymphoid organs. Extranodal presentation of ALL is uncommon, and ALL presenting as a dural mass is exceedingly rare. Here we present a case of primary dural B-cell ALL which was preoperatively diagnosed as meningioma on clinico-radiological grounds. A 27-year-old female patient presented with left hemicranial headache for one month's duration along with progressive vision loss of in both eye and altered behaviour. Contrast enhanced magnetic resonance imaging (CE-MRI) suggest dural based mass with dural tail sign. Histopathological examination of the resected specimen revealed B-cell ALL. Further systemic investigations didn't suggest any peripheral blood, bone marrow or lymph node involvement. To the best of our knowledge, only two cases of primary dural ALL have been reported in the literature so far. This report highlights the diagnostic difficulty in extramedullary precursor lymphoid neoplasm.

Morphology of intra tumoral cystic vestibular schwannoma and their response to gammaknife radiosurgery.

BACKGROUND: Cystic vestibular schwannoma (CVS) traditionally considered as poor responder to gammaknife radiosurgery (GKRS). Their longterm radiobiological behavior is less known. Here we discuss 38 cases with intra tumoral cyst CVS primarily treated with GKRS. Tumor morphology was assessed to understand their response to GKRS. METHODS: Total 38 patients(21 male and 17 female with median age of 41.7 years) of CVS treated with GKRS were retrospectively analysed. Tumors were divided as predominantly (greater than50% of total tumor volume) cystic or solid. They were subclassified as type 1 (predominantly cystic CVS, single cyst), type 2 (predominantly solid CVS, single cysts), type 3 (multicystic CVS). The entire cyst was incorporated for radiosurgery. The results were compared with volume matched control of 58 solid tumors(SVS). RESULT: The median tumor volume of CVS was 5.8 cc. The median tumor volume reduction was 44.5 % at a median follow-up of 68.5 months (30-110 months). Median tumor volume reduction was 68.5 %, 34.0%, 11.0.%, 30.5% at a median follow up of 52.5months, 66 months, 78.6 months, 96.5 months for type 1 CVS, type 2 CVS, type 3 CVS and SVS respectively. One patient with multicystic CVS showed increased tumor volume and expired after 9 months of surgery.The tumor volume reduction in type 1CVS was statistically significant as compared to type 3 CVS and SVS. However the tumor volume reduction among other groups did not differ significantly. CONCLUSION: Intra tumoral cystic components respond better to gammaknife radiosurgery in CVS. Tumor with single cyst respond better than multicystic vestibular schwannoma.

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.

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.).

Factors Affecting Time to Emergence From General Anesthesia Following Clipping of Ruptured Aneurysms: A Prospective Observational Study.

INTRODUCTION: Early emergence from anesthesia is valuable, especially among neurosurgical patients for postoperative neurological evaluation and appropriate interventions. However, the factors affecting the emergence in patients undergoing clipping of ruptured aneurysms have not been studied. MATERIALS AND METHODS: This was a prospective observational study on patients of aneurysmal subarachnoid hemorrhage with World Federation of Neurological Surgeons (WFNS) Grades I to III, undergoing surgical clipping. All relevant preoperative and intraoperative details were collected and analyzed to assess the factors affecting emergence time. RESULTS: A total of 67 patients with a median age of 46 years were included in the study. The number of patients with Fisher Grades I, II, III, and IV was 6, 20, 25, and 16, respectively. The median time to emergence was 17 minutes (interquartile range 10-240 minutes). On univariate analysis, the factors that were found to have a significant relationship with time to emergence were preoperative Glasgow Coma Score (GCS; P = 0.02), WFNS grade (P = 0.005, temporary clipping time (P = 0.03), and the temperature at the end of surgery (P < 0.001) In the multivariate analysis using generalized linear model, preinduction GCS (P < 0.001), patient's temperature at the end of surgery (P < 0.001), and temporary clipping time (P = 0.01) had a significant impact on the emergence time, independent of age, American Society of Anesthesiologists grade, Fisher grade, duration of anesthesia and of each other, with GCS and temperature having the maximum impact. ROC curve for temperature had a cutoff value at 35.3°C with an 83% probability of awakening beyond 15 minutes if the temperature decreased below 35.3°C. CONCLUSION: The preinduction GCS, the temperature of patients at the end of surgery, and the duration of temporary clipping have a significant independent impact on the time to emergence from neurosurgical anesthesia, in the order of the strength of the association.

Perioperative cardiovascular changes in patients with traumatic brain injury: A prospective observational study.

BACKGROUND: Traumatic brain injury (TBI) is an acutely stressful condition. Stress and conglomeration of various factors predispose to the involvement of other organ systems. The stress response from TBI has been associated with cardiovascular complications reflecting as repolarization abnormalities on electrocardiogram (ECG) to systolic dysfunction on echocardiography. However, the perioperative cardiac functions in patients with TBI have not been evaluated. METHODS: We conducted a prospective observational study in 60 consecutive adult patients of either sex between the age of 10 and 70 years with an isolated head injury who were taken up for decompressive craniectomy as per institutional protocol. ECG and transthoracic echocardiography was carried out preoperatively and then postoperatively within 24-48 h. RESULTS: The mean age of our study population was 39 + 13 years with a median Glasgow coma score of 11. A majority (73%) of our patients suffered moderate TBI. Preoperatively, ECG changes were seen in 48.33% of patients. Postoperatively, ECG changes declined and were seen only in 13.33% of the total patients. Similarly, echocardiography demonstrated preoperative systolic dysfunction in 13.33% of the total study population. Later, it was found that systolic function significantly improved in all the patients after surgery. CONCLUSION: Cardiac dysfunction occurs frequently following TBI. Even patients with mild TBI had preoperative systolic dysfunction on echocardiography. Surgical intervention in the form of hematoma evacuation and decompression was associated with significant regression of both ECG and echocardiographic changes.

Primary Hypofractionated Gamma Knife Radiosurgery for Giant Cavernous Sinus Hemangiomas.

Cavernous sinus hemangioma (CSH) are notoriously difficult to excise because of their location, propensity for profuse bleeding during surgery, and relationship to complex neurovascular structures. Radiosurgery offers an alternative treatment modality in cases of small and medium-sized CSH. However, no reports are available in the world literature detailing gamma knife radiosurgery (GKRS) in large (3-4 cm) and giant (>4 cm) CSH. Two patients with giant CSH (Tumor volume was 72.2 and 99.8 cm3, respectively) were treated with frame-based fractionated GKRS (5 Gy × 5 #). The treatment was done with Leksell Perfexion with frame in situ and interfraction interval of 24 h. The tumor was engulfing the optic apparatus, and chiasma could not be separated delineated. The patients were followed at 3 months interval with clinic-radiologic evaluation. Following GKRS, both patients showed remarkable clinical improvement in presenting complaints of headache and visual deterioration. Sixth nerve paresis recovered completely in case no. 1. Significant reduction in tumor volumes (85.1 and 75.6% respectively) was noticed in both the patients at 6 months follow-up radiology. Transient alopecia was noted in case 1 at 3 months follow-up that completely resolved by the 6 months. There was no complication till the last follow-up of 9 months. We report the first account of five fraction frame-based hypo fractionated GKRS for giant CSH. At an interval as short as 3 months, giant CSH shows remarkable clinical improvement. Primary hypofractionated GKRS may be considered an alternative effective modality in these difficult lesions with a favorable safety profile.

Role of gamma knife radiosurgery in the management of intracranial gliomas.

Gamma knife for gliomas is a relatively obscure treatment modality with few reports and small series available on the same. An extensive search of English Language literature yields no comprehensive reviews of the same. We here, attempt to review the available literature on gamma knife for all types of gliomas: Low grade, High grade, recurrent, and also for pediatric populations. We used keywords such as "Gamma Knife Glioma," "Stereotactic Radiosurgery Glioma," "Gamma Knife," "Adjuvant therapy Glioma" "Recurrent Glioma" on PubMed search engine, and articles were selected with respect to their use of gamma Knife for Gliomas and outcome for the same. These were then analyzed and salient findings were elucidated. This was combined with National Comprehensive Cancer Network guidelines for the same and also included our own initial experience with these tumors. Gamma-knife improved long term survival and quality of life in patients with low grade gliomas. In pediatric low grade gliomas, it may be considered as a treatment modality with a marginal dose of 12-14 Gy, especially in eloquent structures such as brain stem glioma, anterior optic pathway hypothalamic glioma. However, in newly diagnosed high-grade glioma gamma knife radiosurgery (GKRS) is not recommended because of a lack of definitive evidence in tumor control and quality of life. GKRS may find its role in palliative care of recurrent gliomas irrespective of type and grade. Inspite of growing experience with GKRS for gliomas, there is no Level I evidence in support of GKRS, hence better designed randomized controlled trials with long term outcomes are warranted. Although this modality is not a "one size fits all' therapy, it has its moments when chosen correctly and applied wisely. Gliomas being the most common tumors operated in any neurosurgical setting, knowledge about this modality and its application is essential and useful.

"Slow and Steady" Infiltrates the Brain: An Autopsy Report of Lymphomatosis Cerebri.

Primary central nervous system lymphomas (PCNSL) usually present as single or multiple lesions with mass effect involving the cerebral hemispheres or basal ganglia. An extremely rare pattern of involvement termed "Lymphomatosis cerebri" (LC) presents as diffuse, non-enhancing infiltrative lesions without mass effect. We describe the clinical, radiological, and autopsy findings of one such rare example with a patient presenting with a short history of fever, memory loss, and progressive cognitive decline. Because of subtle yet rapidly progressive clinical symptoms and overlapping neuroimaging features, the diagnosis of LC is challenging with wide ranging differential diagnoses. The dilemma in diagnosing such lesions can lead to delay in diagnosis and institution of appropriate management. Thus, knowledge about its imaging and morphological features is very critical for correct categorization and to avoid potential misdiagnosis of this often-missed disease.

Predominance of M2 macrophages in gliomas leads to the suppression of local and systemic immunity.

Glioblastoma is a highly prevalent and aggressive form of primary brain tumor. It represents approximately 56% of all the newly diagnosed gliomas. Macrophages are one of the major constituents of tumor-infiltrating immune cells in the human gliomas. The role of immunosuppressive macrophages is very well documented in correlation with the poor prognosis of patients suffering from breast, prostate, bladder and cervical cancers. The current study highlights the correlation between the tumor-associated macrophage phenotypes and glioma progression. We observed an increase in the pool of M2 macrophages in high-grade gliomas, as confirmed by their CD68 and CD163 double-positive phenotype. In contrast, less M1 macrophages were noticed in high-grade gliomas, as evidenced by the down-regulation in the expression of CCL3 marker. In addition, we observed that higher gene expression ratio of CD163/CCL3 is associated with glioma progression. The Kaplan-Meier survival plots indicate that glioma patients with lower expression of M2c marker (CD163), and higher expression of M1 marker (CCL3) had better survival. Furthermore, we examined the systemic immune response in the peripheral blood and noted a predominance of M2 macrophages, myeloid-derived suppressor cells and PD-1+ CD4 T cells in glioma patients. Thus, the study indicates a high gene expression ratio of CD163/CCL3 in high-grade gliomas as compared to low-grade gliomas and significantly elevated frequency of M2 macrophages and PD-1+ CD4 T cells in the blood of tumor patients. These parameters could be used as an indicator of the early diagnosis and prognosis of the disease.

Impact of self-instruction manual-based training of family caregivers of neurosurgery patients on their knowledge and care practices - A randomized controlled trial.

BACKGROUND: Family caregivers of operated neurosurgery patients function as informal extensions of the health system. But they are untrained and unprepared for their new role. It has been felt that their problems related to care provision can be resolved by appropriate training. AIM: This study aimed to compare the impact of self-instruction manual-based training of family caregivers of operated neurosurgery patients on their knowledge regarding care provision and care practices. SETTING: Tertiary care hospital setting located in North India. DESIGN: Randomized controlled trial. MATERIALS AND METHODS: A randomized controlled trial was done among the operated neurosurgery patients and their caregiver dyads (n = 90). They were randomly allocated to receive either self-instruction manual and one-to-one training (TP1) or self-instruction manual only (TP2). Block randomization method was used. Sequentially numbered sealed envelope was used for allocation concealment. Monthly follow-up was done for 3 months. The primary outcome measure was knowledge gain of the caregivers. STATISTICAL ANALYSIS USED: Chi-square test, Student's t-test, paired t-test, repeated measures analysis of variance, and Bonferroni's correction were used. RESULTS: The attrition rate was 15.5%. Intention-to-treat analysis was followed. Caregivers in the TP1 group had significant knowledge gain (95% confidence interval of mean difference 9.4-14.5, P < 0.05). The number of caregivers who had followed correct caregiving practices was significantly more in the TP1 group. CONCLUSION: Training of caregivers by providing information along with one-to-one training is an effective strategy for improving the knowledge and skills of caregivers regarding care provision of the operated neurosurgery patients.

Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?

Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.

TLR-3 Stimulation Skews M2 Macrophages to M1 Through IFN-αß Signaling and Restricts Tumor Progression.

During tumor progression, macrophages shift their protective M1-phenotype to pro-tumorigenic M2-subtype. Therefore, conversion of M2 to M1 phenotype may be a potential therapeutic intervention. TLRs are important pathogen recognition receptors expressed by cells of the immune system. Recently, a crucial role of TLR-3 has been suggested in cancer. Consequently, in the current study, we defined the role of TLR-3 in the reversion of M2-macrophages to M1. We analyzed the role of TLR-3 stimulation for skewing M2-macrophages to M1 at mRNA and protein level through qRT-PCR, flow cytometry, western blotting, and ELISA. The effectiveness of TLR-3L stimulation to revert M2-macrophages to M1 was evaluated in the murine tumor model. To determine the role of IFN-αß signaling in vitro and in vivo, we used Ifnar1-/- macrophages and anti-IFN-αß antibodies, respectively. We observed upregulation of M1-specific markers MHC-II and costimulatory molecules like CD86, CD80, and CD40 on M2-macrophages upon TLR-3 stimulation. In contrast, reduced expression of M2-indicators CD206, Tim-3, and pro-inflammatory cytokines was noticed. The administration of TLR-3L in the murine tumor reverted the M2-macrophages to M1-phenotype and regressed the tumor growth. The mechanism deciphered for macrophage reversion and controlling the tumor growth is dependent on IFN-αß signaling pathway. The results indicate that the signaling through TLR-3 is important in protection against tumors by skewing M2-macrophages to protective M1-subtype.

Comparison of Two Intervention Strategies on Prevention of Bedsores among the Bedridden Patients: A Quasi Experimental Community-based Trial.

BACKGROUND: More than 80% of bedridden patients develop bedsores in home care settings. Training of informal caregivers can significantly affect the quality of care to these patients. OBJECTIVE: The objective of this study is to compare the effectiveness of two caregiver training strategies on prevention of bedsores among bedridden patients. METHODS: The study was carried out in Chandigarh. The study center was at PGIMER, Chandigarh. Seventy-eight bedridden patients being taken care in their homes were identified. These were randomly allocated into two groups. Group A received Prevention Package I, i.e., self-instruction Manual (SIM), training, and counseling. Group B received Prevention Package 2, i.e., only SIM. All these patients were followed up periodically for 1 year. During each follow-up, patients were observed for bedsore development. Braden scale was used to assess the risk factors of bedsores. Katz scale was used to evaluate the level of functional dependence of patients. Descriptive statistics was used to analyze the data. RESULTS: The percentage reduction of number of patients at risk of bedsore development as per various domains of Braden Scale was more in Group A as compared to Group B on each successive visit. There was 100% improvement in mobility level in the patients who were totally dependent in both the groups. However, in moderately dependant patients, the improvement in mobility level was more (87%) in Group A as compared to Group B (75%). All the caregivers complied fully with instructions postintervention. CONCLUSION: Training of caregivers for the prevention of bedsores among the bedridden patients was effective in improving the practices of the caregivers and also in reducing the risk factors of bedsores. One-to-one training with SIM distribution yielded better results than the use of only SIM.

Evaluation of the Effect of Aneurysmal Clipping on Electrocardiography and Echocardiographic Changes in Patients With Subarachnoid Hemorrhage: A Prospective Observational Study.

BACKGROUND: Electrocardiographic (ECG) and echocardiographic changes that are subsequent to aneurysmal subarachnoid hemorrhage (a-SAH) are commonly observed with a prevalence varying from 27% to 100% and 13% to 18%, respectively. There are sparse data in the literature about the pattern of ECG and echocardiographic changes in patients with SAH after clipping of the aneurysm. Hence, we observed the effect of aneurysmal clipping on ECG and echocardiographic changes during the first week after surgery, and the impact of these changes on outcome at the end of 1 year. MATERIALS AND METHODS: This prospective, observational study was conducted in 100 consecutive patients with a-SAH undergoing clipping of ruptured aneurysm. ECG and echocardiographic changes were recorded preoperatively and every day after surgery until 7 days. Outcome was evaluated using the Glasgow outcome scale at the end of 1 year. RESULTS: Of 100 patients, 75 had ECG changes and 17 had echocardiographic changes preoperatively. The ECG changes observed were QTc prolongation, conduction defects, ST-wave and T-wave abnormalities, tachyarrhythmias, and bradyarrhythmias. The echocardiography changes included global hypokinesia and regional wall motion abnormalities. Both echocardiographic and ECG changes showed significant recovery on the first postoperative day. Patients presenting with both echocardiographic and ECG changes were found to require higher ionotropic support to maintain the desired blood pressure, and were associated with poor outcome (Glasgow outcome scale, 1 to 2) at 1 year after surgery. There was no association of ECG and echocardiographic changes with mortality (both in-hospital or at 1 year). CONCLUSIONS: The ECG changes, such as QTc prolongation, bradycardia, conduction abnormality, and echocardiographic changes, recover on postoperative day-1, in most of the cases after clipping. Patients with combined ECG and echocardiographic changes tend to have poor neurological outcome at the end of 1 year.

Comprehension and compliance with the discharge advice and quality of life at home among the postoperative neurosurgery patients discharged from PGIMER, Chandigarh, India.

PROBLEM STATEMENT: Neurosurgical patients require special care not only in the hospital but also after their discharge from the hospital. Comprehension and compliance to the instructions given by the doctors/nurses at the time of discharge is important in home care of these patients. Many such patients suffer from various co-morbidities. Variable periods of convalescence affect health-related quality of life in these patients. PURPOSE OF THE STUDY: To determine the degree of compliance of neurosurgery patients and their family caregivers with the discharge advice given by the consultantsTo evaluate the quality of life of these patientsTo know the problems faced by these patients at home. MATERIALS AND METHODS: This cross-sectional interview-based descriptive study was conducted in 2010 in Chandigarh. These patients were visited at their home. A scale was evolved to evaluate comprehension and compliance to the advice given at the time of discharge, according to the criteria developed by Clark et al. Lawton Brody instrumental activity of daily life and Spitzer quality of life index were used to assess patients' quality of life after the operation. Verbatim responses were recorded for the purpose of qualitative research. RESULTS: Overall, 58 patients and their caregivers were interviewed at home. Mean age of the patients was 38.9 years. Out of 37 patients, 35 showed good comprehension and 33 patients had a good compliance with the instructions given for medication. The condition of 74.1% patients improved after the operation. Depression was reported in 31% of the patients. Many (36.2%) patients had to quit their job due to the disease. Almost half (47.4%) of the patients were independent in daily activities of their life while being evaluated on Barthel activity of daily life index. CONCLUSION AND RECOMMENDATIONS: It is in the long term that the true complexity and impact of operations become apparent. After operation, such patients are likely to have a range of physical, emotional, cognitive, behavioral, and social problems, which may result in difficulties for both patients and their family caregivers. Provision of mechanism of prioritized follow-up care to the operated bedridden neurosurgery patients should be made.

Surgical Management of Moderate Sized Spontaneous Cerebellar Hematomas: Role of Intracranial Pressure Monitoring.

AIM: Acute onset spontaneous cerebellar hematoma (SCH) is a neurosurgical emergency with unpredictable natural history and outcome. Specific guidelines are available for management of small ( < 2.5 cm) and large sized (4.0 cm < ) SCH. But, literature is sparse for treatment of moderate sized SCH (2.5-4.0 cm). MATERIAL AND METHODS: In a retrospective analysis of 32 patients, with moderate sized acute SCH, external ventricular drainage (EVD) tube was inserted for evaluation of ICP and evacuation of cerebrospinal fluid. All patients with ICP > 25 mmHg underwent emergency SCH evacuation. Postoperatively, EVD was continued for 48-72 hours for ICP monitoring. Patients showing no improvement or persistent ventriculomegaly underwent ventriculoperitoneal shunt (VPS) insertion for the management of hydrocephalus. RESULTS: 29/32 patients needed operative intervention either in the form of hematoma evacuation or shunt placement. 10 patients improved to GOS 5 and 7 to GOS 4. Overall mortality was 25% (n=8). Despite SCH evacuation, none of the patients with ICP > 40 mmHg experienced good outcome (p < 0.0001). CONCLUSION: 47% of patients with moderate sized SCH need surgical evacuation. EVD insertion not only helps in ICP management but also includes the ability to gradually decompress ventricular system by varying the outflow pressure. Apart from radiologic findings, ICP measurement should be a guideline in management decisions.

Prospective comparison of simple suturing and elevation debridement in compound depressed fractures with no significant mass effect.

BACKGROUND: Compound depressed fractures have conventionally been managed surgically with elevation and debridement to avoid infection, especially when there is dural penetration, nonetheless with little evidence. This study was to prospectively compare outcomes after simple suturing and elevation debridement in patients with compound depressed fractures. METHODS: Patients of compound depressed fracture with GCS of five or more, no serious systemic injury, and no significant mass effect were prospectively studied for various factors in relation to infection, hospital stay, survival, and late post-traumatic seizures. Univariate and multivariate analyses were performed using SPSS21. RESULTS: Of the total 232 patients with complete clinico-radiological and follow-up data, 183 underwent simple cleansing and suturing, and 49 underwent surgical elevation debridement. The surgical group at baseline had significantly lower GCS, greater dural violation, and brain matter herniation compared to the conservative arm. Univariate analysis showed simple suturing group to have significantly shorter hospital stay (2.4 vs. 10.3 days) (p < 0.001), lesser infection among survivors (4 vs. 21 %) (p = 0.001), and greater 'survival with no infection' (85 vs. 69 %) (p = 0.01). Multivariate analysis adjusting for age, sex, GCS, dural penetration, and surgical intervention confirmed significantly shorter hospital stay (p < 0.001) and lesser infection among survivors (p = 0.02) in the simple suturing group. Overall, there was no benefit offered by surgical debridement. Simple suturing had a better outcome in most subgroups, except in those with brain matter herniation and GCS 5-8, which showed non-significant benefit with surgical intervention. CONCLUSIONS: Simple suturing seems to be an equally good option in patients with compound depressed fracture with no significant mass effect or brain matter herniation.

Profile of patients with head injury among vehicular accidents: an experience from a tertiary care centre of India.

BACKGROUND: Pattern of injuries among drivers, pillion riders and co-passengers of two and four-wheeler vehicles need to be separately evaluated and addressed. MATERIALS AND METHODS: A prospective study was conducted on 1545 patients (1314 males and 231 females) between 01 April, 2011 to 31 December, 2011, to evaluate the profile of head injury patients due to road traffic accidents, admitted in Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Proper subset of cases and controls with or without helmet, seat belt and history of alcohol intake were compared. Data was analyzed to evaluate the incidence, severity, pattern of head injury and outcome of the patients. RESULTS: Male drivers of two-wheeler vehicular accidents (71.4%) were most commonly injured. Among helmeted patients, only 4.8% sustained severe head injuries compared to 23.7% of un-helmeted patients. Only full coverage helmets were effective in preventing head injury. Among helmeted patients with a proper chinstrap, 2.6% suffered critical injuries compared to 14% of non-strapped ones. In 142 patients, helmet was at position after the crash and only 0.7% of these sustained severe head injuries. Drunk driving was noticed among 19% and 6% of two- and four-wheeler vehicular occupants, respectively. Only 7.5% of the four-wheel vehicular occupants were wearing seat belt at the time of accident. CONCLUSIONS: Injury profile of two- and four-wheeler vehicular accident victims is entirely different. A ready supply of affordable helmets of appropriate quality and strict legislation for safety constraints is the need of the hour for road safety.