Prognostic factors and clinical nomogram predicting survival in high-grade glioma.

BACKGROUND: Genomic-based tools have been used to predict poor prognosis high-grade glioma (HGG). As genetic technologies are not generally available in countries with limited resources, clinical parameters may be still necessary to use in predicting the prognosis of the disease. This study aimed to identify prognostic factors associated with survival of patients with HGG. We also proposed a validated nomogram using clinical parameters to predict the survival of patients with HGG. METHODS: A multicenter retrospective study was conducted in patients who were diagnosed with anaplastic astrocytoma (WHO III) or glioblastoma (WHO IV). Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factor analysis was conducted using Cox proportional hazard regression analysis. Then, we used the significant prognostic factors to develop a nomogram. A split validation of nomogram was performed. Twenty percent of the dataset was used to test the performance of the developed nomogram. RESULTS: Data from 171 patients with HGG were analyzed. Overall median survival was 12 months (interquartile range: 5). Significant independent predictors included frontal HGG (hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.40-0.60), cerebellar HGG (HR: 4.67; 95% CI: 0.93-23.5), (HR: 1.55; 95% CI: 1.03-2.32; reference = total resection), and postoperative radiotherapy (HR: 0.18; 95% CI: 0.10-0.32). The proposed nomogram was validated using nomogram's predicted 1-year mortality rate. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve of our nomogram were 1.0, 0.50, 0.45, 1.0, 0.64, and 0.75, respectively. CONCLUSION: We developed a nomogram for individually predicting the prognosis of HGG. This nomogram had acceptable performances with high sensitivity for predicting 1-year mortality.

Development of clinical decision rules for traumatic intracranial injuries in patients with mild traumatic brain injury in a developing country.

BACKGROUND: The majority of clinical decision rules for prediction of intracranial injury in patients with mild traumatic brain injury (TBI) were developed from high-income countries. The application of these rules in low or middle-income countries, where the primary mechanism of injury was traffic accidents, is questionable. METHODS: We developed two practical decision rules from a secondary analysis of a multicenter, prospective cohort of 1,164 patients with mild TBI who visited the emergency departments from 2013 to 2016. The clinical endpoints were the presence of any intracranial injury on CT scans and the requirement of neurosurgical interventions within seven days of onset. RESULTS: Thirteen predictors were included in both models, which were age ≥60 years, dangerous mechanism of injury, diffuse headache, vomiting >2 episodes, loss of consciousness, posttraumatic amnesia, posttraumatic seizure, history of anticoagulant use, presence of neurological deficits, significant wound at the scalp, signs of skull base fracture, palpable stepping at the skull, and GCS <15 at 2 hours. For the model-based score, the area under the receiver operating characteristic curve (AuROC) was 0.85 (95%CI 0.82, 0.87) for positive CT results and 0.87 (95%CI 0.83, 0.91) for requirement of neurosurgical intervention. For the clinical-based score, the AuROC for positive CT results and requirement of neurosurgical intervention was 0.82 (95%CI 0.79, 0.85) and 0.84 (95%CI 0.80, 0.88), respectively. CONCLUSIONS: The models delivered good calibration and excellent discrimination both in the development and internal validation cohort. These rules can be used as assisting tools in risk stratification of patients with mild TBI to be sent for CT scans or admitted for clinical observation.

Prognostic Factors and Nomogram Predicting Survival in Diffuse Astrocytoma.

Background Prognosis of low-grade glioma are currently determined by genetic markers that are limited in some countries. This study aimed to use clinical parameters to develop a nomogram to predict survival of patients with diffuse astrocytoma (DA) which is the most common type of low-grade glioma. Materials and Methods Retrospective data of adult patients with DA from three university hospitals in Thailand were analyzed. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Cox's regression analyses were performed to determine associated factors. Significant associated factors from the Cox regression model were subsequently used to develop a nomogram for survival prediction. Performance of the nomogram was then tested for its accuracy. Results There were 64 patients with DA with a median age of 39.5 (interquartile range [IQR] = 20.2) years. Mean follow-up time of patients was 42 months (standard deviation [SD] = 34.3). After adjusted for three significant factors associated with survival were age ≥60 years (hazard ratio [HR] = 5.8; 95% confidence interval [CI]: 2.09-15.91), motor response score of Glasgow coma scale < 6 (HR = 75.5; 95% CI: 4.15-1,369.4), and biopsy (HR = 0.45; 95% CI: 0.21-0.92). To predict 1-year mortality, sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve our nomogram was 1.0, 0.50, 0.45, 1.0, 0.64, and 0.75, respectively. Conclusions This study provided a nomogram predicting prognosis of DA. The nomogram showed an acceptable performance for predicting 1-year mortality.

Predictive Risk Factors for Early Seizures in Traumatic Brain Injury.

Background Early posttraumatic seizure (PTS) is a significant cause of unfavorable outcomes in traumatic brain injury (TBI). This study was aimed to investigate the incidence and determine a predictive model for early PTS. Materials and Methods A prospective cohort study of 484 TBI patients was conducted. All patients were evaluated for seizure activities within 7 days after the injury. Risk factors for early PTS were identified using univariate analysis. The candidate risk factors with p < 0.1 were selected into multivariable logistic regression analysis to identify predictors of early PTS. The fitting model and the power of discrimination with the area under the receiver operating characteristic (AUROC) curve were demonstrated. The nomogram for prediction of early PTS was developed for individuals. Results There were 27 patients (5.6%) with early PTS in this study. The final model illustrated chronic alcohol use (odds ratio [OR]: 4.06, 95% confidence interval [CI]: 1.64-10.07), epidural hematoma (OR: 3.98, 95% CI: 1.70-9.33), and Glasgow Coma Scale score 3-8 (OR: 3.78, 95% CI: 1.53-9.35) as predictors of early PTS. The AUROC curve was 0.77 (95% CI: 0.66-0.87). Conclusions The significant predictors for early PTS were chronic alcohol use, epidural hematoma, and severe TBI. Our nomogram was considered as a reliable source for prediction.

Clinical indicators for traumatic intracranial findings in mild traumatic brain injury patients.

BACKGROUND: Mild traumatic brain injury (MTBI), accounting for 80% of traumatic brain injury, is one of the most common conditions seen in emergency departments. Clinical parameters to predict intracranial lesions vary among guidelines. This study intended to find clinical parameters that can predict traumatic intracranial lesions in the setting of a middle-income country. METHODS: Data from mild head injury patients admitted to the emergency department from two large hospitals in Chiang Mai, Thailand, were prospectively collected from 2013 to 2014. The primary outcome was identifying clinically-important traumatic brain injury (ciTBI), and the secondary outcome was the neurosurgical procedure performed. Ten clinical findings and six predicting factors were analyzed using univariable and multivariable analysis. RESULTS: Among 1164 patients, ciTBI was identified in 244 cases (21.0%). The neurosurgical operation was performed in 57 cases (4.9%). Multivariable analysis showed factors for ciTBI were a diffuse headache, neurological deficits, signs of skull base fracture, Glasgow Coma Scale Score <13-14 after 2 h of observation, wound at the scalp, palpable skull fracture, dangerous mechanism, and vomiting 2 times or more. Loss of consciousness, amnesia, intoxication, and age were not predictors for ciTBI. CONCLUSION: We found eight indicators to associate with ciTBI after MTBI which can be used to develop further clinical guidelines for computed tomography scans.

Multiple, Primary Brain Tumors with Diverse Origins and Different Localizations: Case Series and Review of the Literature.

BACKGROUND: Multiple, primary brain tumors with different histological types occurring in the same patient are extremely rare. Several hypotheses have been proposed, and the pathophysiology of coexisting tumors has long been debated; however, due to low incidence, standard practices for this scenario are still inconclusive. CASE DESCRIPTION: The authors describe 6 cases of coexisting tumors. By conducting a literature research focused on the computed tomography (CT) era and patients without prior radiation or phakomatosis. Sixty-five such reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature. CONCLUSION: The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor.

Survival and Prognostic Factors in Pediatric Patients with Medulloblastoma in Southern Thailand.

BACKGROUND: The current prognosis of medulloblastoma in children is better because of technological advancements and improvements in treatment strategies and genetic investigations. However, there is a lack of studies that focus on medulloblastoma in Thailand. The aims of our study were to conduct a survival analysis and to identify the prognostic factors of pediatric medulloblastoma. MATERIALS AND METHODS: Fifty-five children, with medulloblastoma, were eligible for analysis between 1991 and 2015. We retrospectively reviewed both the clinical and the histological data. Survival curves were constructed using the Kaplan-Meier method. For comparisons of dichotomous factors, between groups, the log-rank test was used to determine survival. The Cox proportional hazard regression model was used to identify the univariate and multivariate survival predictors. RESULTS: The mortality rate was 49.1% in this study. The median follow-up time was 68.8 months (range: 1-294 months). The 5-year overall survival rate and median survival time were 53.8% (95% CI 38.7-66.7) and 80 months (95% CI 23-230), respectively. Univariate analysis revealed children <3 years of age, hemispheric tumor location, high risk according to risk stratification, and patients who did not receive radiation therapy affected the prognosis. In multivariable analysis, hemispheric tumors (hazard ratio [HR] 2.54 [95% CI 1.11-5.80]; P = 0.01)and high risk groups (HR 3.86 [95% CI 1.28-11.60]; P = 0.01) influenced death. Finally, using conditional inference trees, the study showed that hemispheric tumor locations are truly aggressive in behavior, whereas risk stratification is associated with the prognosis of midline tumors. CONCLUSIONS: Hemispheric medulloblastoma and high-risk groups according to risk stratification were associated with poor prognosis.

Butterfly Tumor of the Corpus Callosum: Clinical Characteristics, Diagnosis, and Survival Analysis.

BACKGROUND: The pathologies implicate the bilateral corpus callosum that builds the butterfly pattern on axial view. These tumors have seldom been investigated for both clinical manifestations and outcome. OBJECTIVE: The objective of this study was to describe the clinical characteristics and outcomes of the butterfly tumor and to identify the predictive factors associated with survival outcome. METHODS: A retrospective study of 50 butterfly tumor was conducted between 2003 and 2016. The clinical characteristics, imaging, and outcome were assessed for the purpose of descriptive analysis. Using the Kaplan-Meier method, the median overall survival of the butterfly tumor was determined. Furthermore, the Cox proportional hazard regression was the estimated hazard ratio for death. RESULTS: Diffuse large B-cell lymphoma was common of butterfly lesions. The mortality rate was 78% and overall median survival time was 16.03 months (95% confidence interval: 14.0-19.8). Using Cox proportional hazards regression, the independent prognostic factors were Karnofsky Performance Status score ≤70, splenium involvement, and butterfly glioblastoma. CONCLUSIONS: The butterfly tumor is a poor prognostic disease compared with each histology subgroup. Further molecular investigation is preferable to explore genetic variations associated with these tumors.

The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand.

OBJECTIVE: To describe the impact of implementing clinical practice guidelines (CPG) for head injury in a trauma referral system in Songkla province, Thailand. METHODS: The CPG was developed by a local multidisciplinary team and implemented using multi-faceted methods. The outcome of patients with head injury from three community hospitals and a university hospital (Songklanagarind Hospital) was reported in terms of "talk and deteriorate" patients and a "poor" outcome for patients with severe head injury. Changes to clinical practice were observed where the guidelines were implemented. RESULTS: 1000 patients with head injury were enrolled from 1st August 2005 to 15th January 2006. The incidence of "talk and deteriorate" patients was 10.5% and a poor outcome was noted in 35.5% of patients with severe head injury, similar to the results of a previous study in Songklanagarind Hospital (p>0.05). Following implementation of the guidelines, 19.8% of patients underwent CT scanning with similar outcomes for alert patients with and without basal skull fracture (p>0.05). The clinician-nurse relationship also improved and there was closer collaboration between hospitals. Short observation in community hospitals for repeat neurological examination may be an appropriate strategy for management of some patients with minor head injury. CONCLUSIONS: Local ownership, an appropriate implementation strategy and working as a multidisciplinary team are key factors for success in implementing the CPG. Basal skull fracture may not be an absolute criterion for CT imaging of the head. Further initiatives will be developed in response to the incidence of "talk and deteriorate" patients.

Non-shaved ventriculoperitoneal shunt in Thailand.

The objective of this study was to determine whether non-shaved patients undergoing ventriculoperitoneal shunt operations would experience a significantly increased shunt infection rate as compared to shaved patients. Clinical trials of non-shaved scalp preparation were performed in ventriculoperitoneal shunt procedures at Songklanagarind Hospital from January 1994 to December 1999. Exclusion criteria were poor scalp condition, previous shunt procedures and immunocompromised hosts. Statistical analysis using univariate, multivariate and logistic regression was used. One hundred and nineteen patients were included in the study. Thirty-six cases were in the non-shaved group. Thirty-eight of 119 cases were less than one year of age and congenital hydrocephalus was the most common problem. The only notable risk factor for shunt infection was an operation lasting more than 59 min. The shunt infection rate in the non-shaved and shaved groups was 6.25% and 14.94%, respectively (p>0.05). In conclusion, leaving the hair intact for ventriculoperitoneal shunt surgery is safe and not associated with increased risk of shunt infection. The non-shaved method may encourage quicker restoration of the patients' self-image and facilitate their early return to normal life.

ICP threshold in CPP management of severe head injury patients.

BACKGROUND: Elevated intracranial pressure (ICP) is significantly associated with high mortality rate in severe head injury (SHI) patients. However, there is no absolute agreement regarding the level at which ICP must be treated. The objective of this study was to compare the outcomes of severe head injury patients treated by setting the ICP threshold at >or=20 mm Hg or >or=25 mm Hg. METHODS: Treatment protocol in this study consisted of therapeutic maneuvers designed to maximize cerebral profusion pressure (CPP) and control ICP. Twenty-seven patients with severe head injury and intracranial hypertension (ICP >or=20 mm Hg) were enrolled and fourteen cases were allocated to the group of ICP threshold >or=25 mm Hg. Six-month clinical outcomes were evaluated using the Glasgow Outcome Score (GOS). RESULTS: There were no statistically significant differences in clinical parameters between the groups. Logistic regression identified the presence of basal cisterns on the initial computed tomography (CT) scan as a significant predictor of good outcome. ICP threshold did not influence outcome. CONCLUSIONS: This study supported a recommended ICP threshold of 20 to 25 mm Hg in SHI management. However, in cases with an absence of basal cisterns on initial CT scan, the probability of good outcome may be higher using an ICP threshold of >or=20 mm Hg.

Talked and deteriorated head injury patients: how many poor outcomes can be avoided?

The objective of this study was to assess the effectiveness of head injury management on the incidence and outcome of talked and deteriorated patients. Of 337 severe head injury patients admitted to Songklanagarind Hospital during 1994 to 1997, 30 were identified as 'talked and deteriorated'. Most deterioration was due to intracranial haematomas. The incidence (8.9%) and poor outcome (40%) were lower than those from a previous study in 1990 (incidence 15.8% and poor outcome 50%). The poor outcome in this group should not be more than 10%, which may be achieved by appropriate practice guidelines combined with a multidisciplinary team approach in caring for head injury patients, and the collaboration of hospitals within a regional trauma system.