Validation of the Elderly Traumatic Brain Injury Score: Observational Case Control Study.

BACKGROUND: Traumatic brain injury (TBI) poses a particular health risk for the elderly. The recently developed elderly TBI (eTBI) score combines the prognostic information of the risk factors characteristic of the geriatric population. We aimed to determine its validity and reliability on an independent sample. METHODS: We present a retrospective analysis of 506 consecutive patients after TBI aged ≥65 years. The previously described nomogram and the eTBI score were used. The primary outcome measure was mortality or vegetative state at 30 days after hospital admission. RESULTS: Mortality or vegetative state rate was 21.3%. The nomogram and eTBI Score showed similar predictive performance with accuracy of 83.8% (95% confidence interval 80.2%-87%) and 84.4% (95% confidence interval 80.8%-87.6%), respectively. On the basis of the Youden index and C4.5 algorithm, we divided patients according to the 3-tier pattern into low-, high-, and medium-risk groups. The outcome prediction in the first 2 groups was correct in 93.1% (survival in the low-risk group) and 94.4% (mortality in the high-risk group). Patients included in the medium-risk group usually required surgical treatment (85.3%) and were characterized by increased mortality or vegetative state (55%). Among patients with eTBI ≥5 (n = 221), there was no difference in outcome between those treated conservatively and surgically. CONCLUSIONS: This is the first study confirming the validity of the eTBI Score and its close association with outcome of geriatric population after TBI. The novel 3-tier risk stratification scheme was applicable to both conservatively and surgically treated patients.

Prophylactic use of dural tenting sutures in elective craniotomies in adults-is it necessary? A study protocol for a multicentre, investigator- and participant-blinded randomised, parallel-group, non-inferiority trial.

BACKGROUND: In the early days of neurosurgery, extradural haemorrhages (EDHs) contributed to a high mortality rate after craniotomies. Almost a century ago, Walter Dandy reported dural tenting sutures as an effective way to prevent postoperative EDH. Over time, his technique gained in popularity and significance to finally become a neurosurgical standard. Yet, several retrospective reports and one prospective report have questioned the ongoing need for dural tenting sutures. Dandy's explanation that the haemostasis observed under hypotensive conditions is deceiving and eventually causes EDH may be obsolete. Today, proper intra- and postoperative care, including maintenance of normovolemia and normotension and the use of modern haemostatic agents, may be sufficient for effective haemostasis. Thus, there is a fundamental need to evaluate the necessity of dural tenting sutures in a solid, unbiased, evidence-based manner. METHODS: This study is designed as a randomised, multicentre, double-blinded, controlled interventional trial with 1:1 allocation. About one half of the participants will undergo craniotomy without dural tenting sutures and will be considered an intervention group. The other half will undergo craniotomy with these sutures. Both groups will be followed clinically and radiologically. The primary outcome is reoperation due to extradural haematoma. Secondary outcomes aim to evaluate the impact of dural tenting sutures on mortality, readmission risk, postoperative headaches, size of extradural collection, cerebrospinal fluid leak risk and the presence of any new neurological deficit. The study protocol follows the SPIRIT 2013 statement. DISCUSSION: It is possible that many neurosurgeons around the globe are tenting the dura in elective craniotomies which brings no benefit and only extends the operation. Unfortunately, there is not enough data to support or reject this technique in modern neurosurgery. This is the first study that may produce strong, evidence-based recommendations on using dural tenting sutures. TRIAL REGISTRATION, ETHICS AND DISSEMINATION: The Bioethics Committee of the Medical University of Warsaw approved the study protocol (KB/106/2018). The trial is registered at http://www.clinicaltrials.gov ( NCT03658941 ) on September 6, 2018. The findings of this trial will be submitted to a peer-reviewed neurosurgical journal. Abstracts will be submitted to relevant national and international conferences. TRIAL STATUS: Protocol version and date: version 1.5, 14.01.2020 First recruitment: September 7, 2018 Estimated recruitment completion: September 1, 2021.

Inflammatory Myofibroblastic Tumor of Spinal Canal: Brief Case Report.

We describe a case of an intradural extramedullary inflammatory myofibroblastic tumor of the cervical spine. A 56-year-old woman presented with progressive neck pain, radiating to the right scapula, without any neurologic deficit. Magnetic resonance imaging showed an intradural extramedullary tumor with a dural tail sign, located at the C3-T1 segment with homogeneous contrast enhancement. The patient was operated on for a suspected meningioma. Pathologic examination showed fibrosis and inflammation with infiltration of B and T lymphocytes accompanied by plasmocytes, macrophages, and myofibroblast oocytes. We present the clinical course and review of the literature.

Predicting Outcome and Conservative Treatment Failure in Patients with Skull Fracture after Traumatic Brain Injury: A Retrospective Cohort Study.

OBJECTIVE: Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide. The prognostic value of skull fracture (SF) remains to be clearly defined. To evaluate the need for neurosurgical intervention and determine the risk factors of conservative treatment failure (CTF), we retrieved from the hospital database the records of patients with SF after TBI. METHODS: We analyzed 146 consecutive patients (mean age: 49.8 ± 17.5 years) treated at the department of neurosurgery in a 5-year period. Clinical data, radiologic reports, and laboratory results were evaluated retrospectively. RESULTS: A total of 63% of patients were treated conservatively, 21.9% were operated on immediately, and 15.1% experienced CTF. Overall, 73.3% had a favorable outcome; the mortality rate was 13%. Intracranial bleeding occurred in 96.6% of cases, basilar SF in 61%, and cerebrospinal fluid (CSF) leak in 2.8%. The independent risk factors for outcome were Glasgow Coma Scale (GCS) score, age, and platelet count (PCT). The independent risk factors for CTF were epidural hematoma, subdural hematoma, mass effect, edema, international normalized ratio, PCT, mean platelet volume, and CSF leakage. The consensus decision tree algorithm used at the accident and emergency department indicated patients with no need for neurosurgical intervention with an accuracy of 91.7%, sensitivity of 88.9%, and featured the importance of mass effect, GCS, and epidural hematoma. CONCLUSIONS: Tests included in the complete blood count appeared useful for predicting the course in patients with SF, although the most important factors were age and neurologic status, as well as radiologic findings. Our decision tree requires further validation before it can be used in everyday practice.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System.

BACKGROUND: Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization. METHODS: To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection. RESULTS: The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 109 cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics. CONCLUSIONS: The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

Necessity of dural tenting sutures in modern neurosurgery: protocol for a systematic review.

INTRODUCTION: The ongoing need for dural tenting sutures in a contemporary neurosurgical practice has been questioned in the literature for over two decades. In the past, these sutures were supposed to prevent blood collecting in the potential space between the skull and the dura by elevating the latter. Theoretically, with modern haemostasis and proper postoperative care, this technique should not be necessary and the surgery time can be shortened. Unfortunately, there is no evidence-based proof to either support or reject this hypothesis. METHODS AND ANALYSIS: The systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and The Cochrane Handbook for Systematic Reviews of Interventions. Eight electronic databases of peer-reviewed journals will be searched, as well as other sources. Eligible articles will be assessed against inclusion criteria. The intervention is not tenting the dura and this will be compared with the usual dural tenting sutures. Where possible, 'summary of findings' tables will be generated. ETHICS AND DISSEMINATION: Ethical committee approval is not required for a systematic review protocol. Findings will be presented at international neurosurgical conferences and published in a peer-reviewed medical journal. PROSPERO REGISTRATION NUMBER: CRD42018097089.

Diagnostic value of lateral ventricle ratio: a retrospective case-control study of 112 acute subdural hematomas after non-severe traumatic brain injury.

PRIMARY OBJECTIVE: To evaluate correlation between the lateral ventricle ratio (LVR) and the risk of conservative treatment failure (CTF) among patients with acute subdural hematoma (ASDH) after non-severe traumatic brain injury (TBI), we retrieved from the hospital database and performed a retrospective analysis of 1339 cases with TBI treated during the 2008-2016 period. METHODS AND PROCEDURES: 112 patients with ASDH, GCS≥ 9 and initial conservative treatment were enrolled. They were divided according to the final treatment method applied (surgical or conservative). Clinical and radiological data was evaluated. We used ROC curve analysis and multivariate logistic regression model to identify risk factors of CTF. MAIN OUTCOMES AND RESULTS: LVR higher than 1.48 calculated on admission CT scans was the strongest predictor of CTF, with sensitivity of 78.9% and specificity of 93.5% (AUC: 0.774-0.994). LVR, prolonged prothrombin time and coexisting traumatic subarachnoid hemorrhage were independent risk factors. CONCLUSIONS: Despite limitations, study results support the view that patients after non-severe TBI with ASDH and with lateral ventricle asymmetry, defined as LVR> 1.48, require surgical treatment. LVR seems to be indirect, but still the closest method to quantify intracranial compliance. Thus, in the selected group of patients without clinical symptoms of critically diminished compensatory reserve, LVR could indicate those who need a surgical decompression.

Value of oxyneurography, based on near infrared spectroscopy, in the diagnosis of carpal tunnel syndrome in comparison to provocative clinical diagnostic tests and nerve conduction studies.

OBJECTIVE: Evaluation of the diagnostic utility of the oxyneurography (ONG) in diagnosing carpal tunnel syndrome (CTS). METHODS: ONG examination of the median nerve was performed in 260 patients. The results were compared with nerve conduction studies and clinical provocative tests. RESULTS: ONG index greater than or equal to 62% was found in 95.18% of the patients with no or minimal Nerve Conduction Study (NCS) changes (1-2 according to the Padua classification) but only in 1.69% of the patients with advanced NCS changes (Padua 3-6). The sensitivity and specificity of the ONG study i.e. 95.18% and 98.31%, respectively, were compared with standard clinical tests: Tinel sign (61.45% and 14.69%), Phalen test (34.94% and 45.20%), reverse Phalen test (81.93% and 34.46%) and carpal compression test (91.57% and 72.32%). CONCLUSIONS: ONG index lower than 62% was indicative of CTS. ONG has higher sensitivity and specificity then other clinical tests and it is an accurate and reliable method for the diagnosis of CTS. SIGNIFICANCE: Oxyneurography is a non-invasive, fast and safe study which may play role in the diagnosis of carpal tunnel syndrome.

Reorganization of language centers in patients with brain tumors located in eloquent speech areas - A pre- and postoperative preliminary fMRI study.

INTRODUCTION: The aim of this study was to determine in pre- and postsurgical fMRI studies the rearrangement of the Broca's and Wernicke's areas and the lateralization index for these areas in patients with brain tumors located near speech centers. Impact of the surgical treatment on the brain plasticity was evaluated. MATERIALS AND METHODS: Pre- and postoperative fMRI examinations were performed in 10 patients with low grade glial, left-sided brain tumors located close to the Broca's (5 patients) or Wernicke's area (5 patients). BOLD signal was recorded in regions of interest: Broca's and Wernicke's areas, and their anatomic right-sided homologues. RESULTS: In the preoperative fMRI study the left Broca's area was activated in all cases. The right Broca's area was activated in all the patients with no speech disorders. In the postoperative fMRI the activation of both Broca's areas increased in two cases. In other two cases activation of one of the Broca's area increased along with the decrease in the contralateral hemisphere. In all patients with temporal lobe tumors, the right Wernicke's area was activated in the pre- and postsurgical fMRI. After the operation, in two patients with speech disorder, the activation of both Broca's areas decreased and the activation of one of the Wernicke's areas increased. CONCLUSIONS: In the cases of tumors localized near the left Broca's area, a transfer of the function to the healthy hemisphere seems to take place. Resection of tumors located near Broca's or Wernicke's areas may lead to relocation of the brain language centers.

Anatomical anomalies of the V3 segment of the vertebral artery in the Polish population.

PURPOSE: The aim of this study is to evaluate the incidence of the anatomical anomalies of the V3 segment of the vertebral artery in the Polish population. There is conflicting evidence on the incidence of these anomalies: Asian-based studies show high incidence of 10 %, whereas the North American study identifies these anomalies in less than 1 % of patients. METHODS: 1800 computed tomography angiographies (CTA) obtained at the Barlicki University Hospital in Lodz, Poland, were reviewed retrospectively. RESULTS: All the patients were Caucasians. There were 968 males and 832 females. The mean age of the patients was 58. CTAs were obtained for the following reasons: stroke 1312, trauma 25, vascular/aneurysm 216, and intracranial haemorrhage 247. Vertebral artery hypoplasia was present in 360 cases (20 %). Persistent intersegmental artery (type I anomaly) was not found in any study. Fenestration of the V3 vertebral artery (type II) was recognized in three angiograms (0.16 %). Vertebral artery ending up as posterior inferior cerebellar artery (type III anomaly) was seen in 11 patients (0.61 %). CONCLUSIONS: Very low incidence of V3 segment anomalies does not justify in our opinion routine vascular imaging in patients undergoing posterior cervical instrumented procedures.

Glioblastoma multiforme and meningioma in the same patient - a case report.

We describe a case of a 64-year-old female who presented with concurrent left parietal glioblastoma multiforme and left occipital parasagittal meningioma. Both lesions were excised during the operation. There was no clinical evidence of phacomatosis. Aetiological and clinical aspects of the phenomenon are discussed.

[Role of proteoglycans and glycosaminoglycans in the intervertebral disc degeneration]. / Rola glikozaminoglikanów i proteoglikanów w procesie degeneracji krazków miedzykregowych.

Proteoglycans and glycosaminoglycans are the main components of the extracellular matrix of the nucleus pulposus. Intervertebral disc degeneration due to aging and excessive mechanical loads results in adverse quantitative and structural changes to the macromolecules. Metalloproteinases induced by inflammatory mediators play a key role in degrading proteoglycans. Progressive matrix breakdown decreases water content in the disc. Dehydration compromises disc cells function and impairs resistance to compression. Biochemical changes may result in disc prolapse. Modifying the metabolism of proteoglycans and glycosaminoglycans might be an effective therapeutic strategy.

[Supplementation of cranial defects by an autologous bone flap stored in the abdominal wall]. / Uzupelnianie ubytków kosci pokrywy czaszki autologicznym platem kostnym przechowywanym w powlokach brzucha.

BACKGROUND AND PURPOSE: The aim of this paper is to present an alternative method of cranioplasty with the use of an autologous cranial bone flap stored between primary and restorative surgery in the subcutaneous pocket in the lateral hypogastric region. MATERIAL AND METHODS: Between January 1999 and April 2002, in the Department of Neurosurgery of Medical University of Lódz we performed 36 procedures of the bone flap implantation into the abdominal subcutaneous fat tissue. These procedures followed craniectomy, mainly in cases of acute subdural hematomas and ruptured intracranial aneurysms. RESULTS: After storage, the bone flap was reimplanted in 28 patients. The mean time between operations was 14 days (range 8-53 days). In the cranioplasty group we had only one infection of the bone flap. Among patients excluded from the bone flap restoration we observed one inflammatory complication in the abdominal wall and one subcutaneous hematoma requiring evacuation. CONCLUSIONS: In our opinion, the presented method of the cranial defect's supplementation may be competitive to procedures utilizing synthetic prostheses in the population of patients for whom reimplantation of the bone flap will be expected in 2-3 months after the primary operation. Advantages of the procedure are: the autologous bone graft, the excellent cosmetic effect, low costs of the procedure and low rate of inflammatory complications.