Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009.

INTRODUCTION: Trauma is one of the leading causes of morbidity and mortality in the world and in India. OBJECTIVE: To describe 1) selected epidemiological and clinical characteristics of persons with traumatic brain injury (TBI) who died within 24 h after admission to the emergency departments (EDs) of two medical facilities in rural India and 2) the methods used to transport these patients from the locale of the injury incident to the study sites. MATERIALS AND METHODS: Medical records of all injured patients regardless of age or sex who died within 24 h after admission to both EDs during January 31, 2007 through December 31, 2009 were reviewed and abstracted. Demographic variables and information on prehospital care, time and mechanism of injury, mode of transport to EDs, and primary hospital resuscitation were abstracted and analyzed. RESULTS: Of the 113 injured patients in this study, 42 had TBI and died within 24 h of ED admission. All of these TBI patients were transported to the ED by relatives or bystanders in non-ambulance vehicles. Most of the patients with TBI (78.5%) were 21-50-years-old; and overall 90.0% were males. Persons working near or along busy roads struck by vehicles accounted for 80.9% of all TBI cases. Severe TBIs were present in 97.6% of the patients; of these, 92.8% had a Glasgow Coma Scale (GCS) score of 3 on arrival. Other concurrent injuries included superficial lacerations (85.7%), facial injuries (57.1%), and upper (35.7%) and lower (30.9%) extremity fractures. Common lesions recognized on computed tomography (CT) scan were acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%); in 21.4% of cases, the CT scan were reported normal. CONCLUSION: Most of the TBI patients who died within 24 h after admission to EDs in this study were not transported to EDs in emergency medical vehicles; most were of working age (ages 20-50 years); were male; and were day laborers working on busy interstate roads where they were hit by vehicles.

Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from a rural set-up of a developing country.

BACKGROUND: Neurosurgical patients including patients with severe head injury are at risk of developing respiratory complications. These can adversely affect the outcome and can result in poor survival. Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head, facial and multisystem organ trauma. AIMS: To know the indications for performing early tracheostomy and its outcome. SETTINGS AND DESIGN: Retrospective data analysis. MATERIALS AND METHODS: The present study is a retrospective analysis of all patients who were admitted with the diagnosis of head injury between January 2007 and December 2009 and underwent tracheostomy at a rural tertiary care trauma center of Central India. RESULTS: During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14-75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. Tracheostomy was performed in 30 patients with severe head injury, 9 patients with moderate head injury and in only one case of mild head injury as the patient had multiple facial injuries compromising the airway. CONCLUSIONS: Neurocritical care is a relatively new field in India, and the facilities for critical neurosurgical patients are available only in a very few tertiary care centers mainly serving the urban areas. In the present study, we discuss our limited experience with tracheostomy in patients with head injury while facing the challenge of limited resources.

Cervical intramedullary epidermoid cyst with liquid contents.

Intramedullary spinal epidermoid cysts are benign ectopic embryological growths with reported incidence of less than 1% of intramedullary tumors. In this case we report an unusual cervical intramedullary epidermid with liquid contents. A 40-year-old patient presented with progressive weakness of all four limbs of four months duration, bowel and bladder disturbances of two days duration, pain and paresthesias in all four limbs. Magnetic resonance imaging (MRI) revealed a well defined intramedullary lesion extending from C2-C3 level with widening of the cord. The lesion was hypointense on T1W images, hyperintense on T2W and fluid attenuation and inversion recovery images with thin rim of enhancement after contrast administration. Histopathological examination of the excised specimen revealed epidermal lining and keratinous material features of an epidermoid cyst. As in present case, rarely epidermoid cyst can have clear contents, and an MRI finding can closely mimic the features of arachnoid cyst, findings not classical and is different than described in literature.

Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country.

INTRODUCTION: Traumatic brain injuries (TBI) are steadily increasing and are a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. In the present study, we describe our experience of resource utilization in the management of TBI in a critical care unit (CCU) from a rural setup. MATERIALS AND METHODS: All consecutive patients who were admitted from January 2007 to December 2009 in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome. RESULTS: The total duration (days) of hospital stay was 8.96±6.16 days and a median of 8 days, and CCU stay was 3.77±6.34 days with a median of 2 days. No deaths occurred with mild head injury. A total of 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, odds ratio (OR) 1.032 [95% confidence interval (CI) 0.351-3.03], so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954-1.00). The severity of head injury (mild, moderate, and severe) and CCU stay parameters had significant difference with risk of death [OR, 3.22 (95% CI, 2.49-4.16) and OR, 2.50 (95% CI, 1.9-3.2)]. CONCLUSIONS: Apparently it seems possible to use the existing health care structures in rural areas to improve trauma care. It becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, there is a need to compare with the reference group to further support the evidence.

Metastatic lung cancer presenting with jugular foramen syndrome in a case of von Recklinghausens disease.

Metastatic carcinomas from a distant primary malignancy involving the temporal bone particularly the jugular foramen are rare tumors. A 57-year-old gentleman had multiple gradually increasing swellings over the body since many years. For last two years, he noticed enlargement of the swelling in left calf and rapidly enlarging painful new swelling over the left chest wall in back for last one year. He had recent involvement of left seventh, eighth and lower cranial nerves. CT scan showed an extensive lesion in left jugular foramen region with bone destruction. The patient underwent decompression of the left jugular foramen mass lesion. The tumor was extremely vascular and a partial decompression could only be performed. Although there was relief in the headache but the neurological deficits were persisting. Histopathology of the tumor showed features of metastatic small ling cancer. In the present case, there was presence of long standing multiple swelling all over the body and the patient had painful enlargement that he perceived as an ongoing process of the von Recklinghausen's disease and made a delay in seeking the medical advice resulting in a well advanced disease and with poor prognosis.

Extensive supratentorial hemorrhages following posterior fossa meningioma surgery.

Remote supratentorial hematoma soon after posterior fossa surgery for the removal of a space-occupying lesion is a rare but dramatic and dreaded complication, carrying significant morbidity and mortality. A 47-year-old woman presented with headache of 1-year duration that worsened over last 2 months, progressive ataxia of 2 months' duration, blurring and diminution of vision of 2 months' duration and forgetfulness of 2 months' duration. Fundus showed bilateral papille dema, and visual acuity was 6/9 in both eyes. She had left-sided cerebellar signs. There were no focal motor or sensory neurological deficits. MRI brain with contrast showed a large posterior fossa tumor with obstructive hydrocephalus. The patient underwent left paramedian suboccipital craniectomy in prone position with left side up. In the immediate postoperative period, the patient did no recover from anesthesia and was persistently drowsy. Immediate repeat CT scan showed diffuse subarachnoid hemorrhage spread all over the bilateral cerebral hemispheres with diffuse cerebral edema. The patient recovered with conservative management without deficits. This case stresses the importance of early postoperative CT scan and optimal management of the hemorrhage for good outcome.

Cystic hemangioblastoma of the brainstem.

Hemangioblastomas are very highly vascular neoplasm with benign characteristics and; in comparison to cerebellar hemangioblastoma; cases of cystic hemangioblastoma of the brain stem are rare with only a few case reports available in the literature. We report the case of a 43-year-old-female with cystic hemagioblastoma of the brainstem managed successfully and review the relevant literature.

A giant occipital encephalocele.

Giant occipital encephaloceles are rare lesions. Because of their enormous size they pose a surgical challenge. Herein we report a four months old female baby who presented with progressively increasing swelling over the occipital region. This swelling was present since birth. Surgery was planned to reduce the size of the swelling as well as its contents. The redundant sac was excised and reduced sufficiently enough to accommodate the healthy looking brain tissue. In contrast to the previous case reports where the neonates had poor prognosis, this infant did well postoperatively.