Comparative analysis between different volumetric methods on measuring intracranial hemorrhage incorporating roundness index.

Intracranial hematoma (ICH) volume is considered a predictor of clinical outcome and mortality rate in ICH patients with traumatic brain injury (TBI). The ABC/2 method for ICH volume is the standard method used to date, however, its level of accuracy has been questioned in some studies. This study compared the performance of the ABC/2 method with planimetry and truncated pyramidal methods to highlight the potential of the planimetry method applied with automatic segmentation for evaluation of epidural hematoma (EDH) and intraparenchymal hematoma (IPH) volume. Six different phantoms were designed to evaluate the accuracy of volume estimation methods. 221 hematoma regions extracted from CT scans of 125 patients with head injury were also used to analyze the efficiency. The roundness index was utilized for the quantification of the ellipsoid-like shape. Regions of EDH and IPH on the CT scans were annotated by radiologists. The estimation errors for each method were statistically analyzed and compared. In addition, the relationship between the errors and roundness index was examined. The planimetry method showed the lowest relative error on phantom data. In the case of the CT scan data, the truncated pyramidal method resulted in the underestimation of the volumes of EDH and IPH. Meanwhile, the ABC/2, through principal component analysis (PCA) in the two-dimensional and PCA in the three-dimensional methods, resulted in a significant overestimation. In addition, both these approaches produced relative errors that showed a correlation with the roundness indexes for IPH. In comparison to other methods, the planimetry method had the lowest level of error with regards to calculation of the volume and it was also independent of the hematoma shape. The planimetry method, therefore, has the potential to serve as a useful tool for the assessment of ICH volume in TBI patients by using a deep learning system.

A comparison of performance between a deep learning model with residents for localization and classification of intracranial hemorrhage.

Intracranial hemorrhage (ICH) from traumatic brain injury (TBI) requires prompt radiological investigation and recognition by physicians. Computed tomography (CT) scanning is the investigation of choice for TBI and has become increasingly utilized under the shortage of trained radiology personnel. It is anticipated that deep learning models will be a promising solution for the generation of timely and accurate radiology reports. Our study examines the diagnostic performance of a deep learning model and compares the performance of that with detection, localization and classification of traumatic ICHs involving radiology, emergency medicine, and neurosurgery residents. Our results demonstrate that the high level of accuracy achieved by the deep learning model, (0.89), outperforms the residents with regard to sensitivity (0.82) but still lacks behind in specificity (0.90). Overall, our study suggests that the deep learning model may serve as a potential screening tool aiding the interpretation of head CT scans among traumatic brain injury patients.

Benefits of Combined MRI Sequences in Meningioma Consistency Prediction: A Prospective Study of 287 Consecutive Patients.

Objective Consistency of meningiomas is one of the most important factors affecting the completeness of removal and major risks of meningioma surgery. This study used preoperative magnetic resonance imaging (MRI) sequences in single and in combination to predict meningioma consistency. Methods The prospective study included 287 intracranial meningiomas operated on by five attending neurosurgeons at Chiang Mai University Hospital from July 2012 through June 2020. The intraoperative consistency was categorized in four grades according to the method of surgical removal and intensity of ultrasonic aspirator, then correlated with preoperative tumor signal intensity pattern on MRI including T1-weighted image, T2-weighted image (T2WI), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted image (DWI), which were described as hypointensity, isointensity, and hyperintensity signals which were blindly interpreted by one neuroradiologist. Results Among 287 patients, 29 were male and 258 female. The ages ranged from 22 to 83 years. A total of 189 tumors were situated in the supratentorial space and 98 were in the middle fossa and infratentorial locations. Note that 125 tumors were found to be of soft consistency (grades 1, 2) and 162 tumors of hard consistency (grades 3, 4). Hyperintensity signals on T2WI, FLAIR, and DWI were significantly associated with soft consistency of meningiomas (relative risk [RR] 2.02, 95% confidence interval [CI] 1.35-3.03, p = 0.001, RR 2.19, 95% CI 1.43-3.35, p < 0.001, and RR 1.47, 95% CI 1.02-2.11, p = 0.037, respectively). Further, chance to be soft consistency significantly increased when two and three hyperintensity signals were combined (RR 2.75, 95% CI 1.62-4.65, p ≤ 0.001, RR 2.79, 95% CI 1.58-4.93, p < 0.001, respectively). Hypointensity signals on T2WI, FLAIR, and DWI were significantly associated with hard consistency of meningiomas (RR 1.82, 95% CI 1.18-2.81, p = 0.007, RR 1.80, 95% CI 1.15-2.83, p = 0.010, RR 1.67, 95% CI 1.07-2.59, p = 0.023, respectively) and chance to be hard consistency significantly increased when three hypointensity signals were combined (RR 1.82, 95% CI 1.11-2.97, p = 0.017). Conclusion T2WI, FLAIR, and DWI hyperintensity signals of the meningiomas was solely significantly associated with soft consistency and predictive value significantly increased when two and three hyperintensity signals were combined. Each of hypointensity signals on T2WI, FLAIR, and DWI was significantly associated with hard consistency of tumors and tendency to be hard consistency significantly increased when hypointensity was found in all three sequences.

Concerns of Home Isolating COVID-19 Patients While Receiving Care via Telemedicine during the Pandemic in the Northern Thailand: A Qualitative Study on Text Messaging.

As there were strict limits on contact between health professionals and patients during the COVID-19 pandemic, telemedicine increased in importance with regard to improving the provision of health care and became the preferred method of care. This study aims to determine the topics of concern expressed by individuals with COVID-19 receiving care at home via teleconsultation. The qualitative study was conducted using secondary data of chat messages from 213 COVID-19 patients who had consented to online consultation with the health care team. The messages were sent during the home isolation period, which was between 29th October and 20th December 2021. Thematic analysis was used to analyze the data. All patients had consented to the use of their data. A small majority of the patients were female (58.69%). The average age was 32.26 ± 16.92 years. A total of 475 questions were generated by 150 patients during the isolation period. Nearly thirty percent (29.58%) never asked any questions. From the analysis, the questions could be divided into three themes including: (1) complex care system; (2) uncertainty about self-care and treatment plan with regard to lack of knowledges and skills; and (3) concern about recovery and returning to the community after COVID-19 infection. In conclusion, there were enquiries about many aspects of medical care during home isolation, detailed answers from professionals were useful for the self-care of patients and to provide guidance for their future health behavior. The importance of the service being user friendly and accessible to all became increasingly evident.

Influence of clivo-axial angle on outcome after foramen magnum decompression in adult symptomatic Chiari type 1 malformation.

OBJECTIVE: A significant number of patients with Chiari type 1 malformation (CM1) have abnormal clivo-axial angle (CXA) without other radiographic indicators of basilar invagination or craniovertebral junction (CVJ) instability. This study aimed to investigate whether abnormal CXA alone influences postoperative outcomes among patients who underwent foramen magnum decompression (FMD). METHODS: A total of 44 adult patients with symptomatic CM1 undergoing FMD without CVJ fixation were enrolled. Preoperative clinical characteristics and radiographic measurement include the CXA as well as the radiographic indicators of basilar invagination and instability were recorded. The univariate and multivariate binary logistic regression tests were used to identify the potential prognostic factors for favorable outcomes. RESULTS: Eighteen patients (41%) and 26 patients (59%) were divided into unfavorable and favorable outcome groups, respectively. Baseline demographic and imaging characteristics were similar between the two patient groups. The mean CXA was 132.3 ± 15.8 and 145 ± 13.6 degrees in the unfavorable and favorable groups, respectively (P = 0.091). In the favorable outcome group, the proportion of patients with CXA > 135 degrees was significantly higher than that of the unfavorable outcome group (77% vs. 44%; P = 0.05). The CXA > 135 degrees was found to be the only independent predictor associated with favorable outcomes (adjusted risk ratio 2.16; 95% CI 1.01-4.76; P = 0.047). CONCLUSION: The preoperative CXA of greater than 135 degrees was identified as a prognostic factor associated with a favorable outcome at one-year follow-up after FMD among adult patients with symptomatic CM1 without basilar invagination or CVJ instability. This factor should be incorporated into preoperative considerations.

Comparison of the Surgical Outcomes of Cranioplasty Using Titanium, Customized Polymethylmethacrylate, and Liquid Polymethylmethacrylate in Maharaj Nakhon Chiang Mai Hospital, Thailand.

ABSTRACT: Cranioplasty is a standard procedure used to restore skull defects after craniectomy. Many different materials are used in cranioplasty. The study aim was to compare the surgical outcomes of cranioplasty using different materials: liquid polymethylmethacrylate (PMMA), customized PMMA, and titanium. The authors retrospectively reviewed the outcomes of cranioplasty performed from 2016 to 2021. Data collection included patient characteristics and complications, including postoperative infection, hematoma, implant exposure, and subgaleal cerebrospinal fluid collection. Eighty-five patients received cranioplasty with different materials: titanium, 14; customized PMMA, 31; and liquid PMMA, 40. There were no significant differences in the basic patient characteristics among the 3 cranioplasty groups except for lower age in the customized PMMA group. There were no significant differences between superficial and deep infections, implant exposure, postoperative hematoma, or seizure. However, subgaleal cerebrospinal fluid collection was more common in the liquid PMMA group than in the customized PMMA group ( P = 0.02). This study showed that good outcomes were achieved by cranioplasty performed with different materials (titanium, customized PMMA, and liquid PMMA).

Potential roles of vagus nerve stimulation on traumatic brain injury: Evidence from in vivo and clinical studies.

Traumatic Brain Injury (TBI) is a one of the leading causes of death and disability worldwide. The consequences of TBI can be divided into two stages: 1) the immediate neuronal destruction during the initial trauma, resulting in the primary brain injury and pathophysiologic sequelae, and 2) the secondary brain injury, encompassing mitochondrial dysfunction, inflammation, cellular excitotoxicity, oxidative stress, and cortical edema, resulting in increased intracranial pressure (ICP) with exacerbated brain damage. Although the pathophysiology in TBI has been thoroughly investigated, the effectivity of therapeutic approaches for TBI is still lacking. Vagus nerve stimulation (VNS) has been used for treating medical refractory epilepsy and chronic drug-resistant depression. Several previous studies also demonstrated that VNS has beneficial effects for TBI in animal models and patients. The neuroprotective effects of VNS on TBI are possibly explained through several mechanisms, including a noradrenergic mechanism, anti-inflammatory effects, regulation of neurotransmitters, and attenuation of blood brain barrier breakdown, and brain edema. The aims of this review are to summarize and discuss the current evidence pertinent to the effect of VNS on both primary and secondary brain injury following TBI from both in vivo and clinical studies.

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.

The Alterations in Mitochondrial Dynamics Following Cerebral Ischemia/Reperfusion Injury.

Cerebral ischemia results in a poor oxygen supply and cerebral infarction. Reperfusion to the ischemic area is the best therapeutic approach. Although reperfusion after ischemia has beneficial effects, it also causes ischemia/reperfusion (I/R) injury. Increases in oxidative stress, mitochondrial dysfunction, and cell death in the brain, resulting in brain infarction, have also been observed following cerebral I/R injury. Mitochondria are dynamic organelles, including mitochondrial fusion and fission. Both processes are essential for mitochondrial homeostasis and cell survival. Several studies demonstrated that an imbalance in mitochondrial dynamics after cerebral ischemia, with or without reperfusion injury, plays an important role in the regulation of cell survival and infarct area size. Mitochondrial dysmorphology/dysfunction and inflammatory processes also occur after cerebral ischemia. Knowledge surrounding the mechanisms involved in the imbalance in mitochondrial dynamics following cerebral ischemia with or without reperfusion injury would help in the prevention or treatment of the adverse effects of cerebral injury. Therefore, this review aims to summarize and discuss the roles of mitochondrial dynamics, mitochondrial function, and inflammatory processes in cerebral ischemia with or without reperfusion injury from in vitro and in vivo studies. Any contradictory findings are incorporated and discussed.

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.

Age as a prognostic factor of 30-day mortality in hemorrhagic stroke patients: A Thai large tertiary care referral center.

OBJECTIVE: The aim of the present study was to identify incidences and prognostic factors for 30-day mortality of hemorrhagic strokes (HS) and divide them into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). METHODS: This retrospective cohort study was conducted using medical records of patients who underwent surgery due to HS, between January 2013 and April 2017, at Chiang Mai University Hospital, a large tertiary referral center, in Northern Thailand. 30-day mortality was followed after surgery. Prognostic factors included patients' characteristics, and clinical date related to early death, were determined. Data analysis was performed using Cox's proportional hazards model. RESULTS: 460 patients were enrolled. The 30-day mortality rate was 8.8% and 12.3%, in ICH and SAH patients, respectively. Multivariable analyses demonstrated that the prognostic factors of early mortality in ICH patients were age 65-70 years (Adjusted HR 3.10 (95%CI 1.14-8.41)), >70 years (Adj.HR 2.64 (95%CI 1.09-6.36)) and hypertension (HT) (Adj.HR 2.98 (95%CI 1.25-7.12)). In SAH patients, prognostic factors were HT (Adj.HR 7.32 (95%CI 2.12-25.29)), and atrial fibrillation (AF) (Adj.HR 5.48 (95% CI 1.57-19.09)). CONCLUSIONS: Ages over 65 years and HT were an important predictor of 30-day mortality in a subgroup of ICH patients, whereas HT and AF were significant prognostic factors in SAH. To reduce early death, management for stroke cases needed to take into account the specifics for older age patients with HT, and AF.

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.

Delirium after a traumatic brain injury: predictors and symptom patterns.

BACKGROUND: Delirium in traumatic brain injury (TBI) is common, may be predictable, and has a multifaceted symptom complex. This study aimed to examine: 1) the sum score of Glasgow Coma Scale (GCS) and if its component scores could predict delirium in TBI patients, and 2) the prominent symptoms and their courses over the first days after TBI. METHODS: TBI patients were recruited from neurosurgical ward inpatients. All participants were hospitalized within 24 hours after their TBI. Apart from the sum score of GCS, which was obtained at the emergency department (ED), the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria for delirium were applied daily. The severity of delirium symptoms was assessed daily using the Delirium Rating Scale - Revised-98 (DRS-R-98). RESULTS: The participants were 54 TBI patients with a mean GCS score of 12.7 (standard deviation [SD] =2.9). A total of 25 patients (46.3%) met the diagnosis of delirium and had a mean age of 36.7 years (SD =14.8). Compared with 29 non-delirious patients, 25 delirious patients had a significantly lower mean GCS score (P=0.04), especially a significantly lower verbal component score (P=0.03). Among 18 delirious patients, four symptoms of the DRS-R-98 cognitive domain (orientation, attention, long-term memory, and visuospatial ability) were moderate symptoms (score ≥2) at the first day of admission. After follow-up, three cognitive (orientation, attention, and visuospatial ability) and two noncognitive symptoms (lability of affect and motor agitation) rapidly resolved. CONCLUSION: Almost half of patients with mild to moderate head injuries may develop delirium in the first 4 days after TBI. Those having a low GCS score, especially the verbal component score, at the ED were likely to have delirium in this period. Most cognitive domains of delirium described in the DRS-R-98 were prominent within the first 4 days of TBI with delirium. Three cognitive and two noncognitive symptoms of delirium decreased significantly.

Bevacizumab is superior to Temozolomide in causing mitochondrial dysfunction in human brain tumors.

OBJECTIVE: Current chemotherapy treatments available for treating high-grade brain tumors, Temozolomide (TMZ) or Bevacizumab (BEV), not only have specific anti-tumor mechanisms, but also have an effect on mitochondria. However, effects of both drugs on mitochondria isolated from human brain tumors have not been thoroughly investigated. This study determined the direct effects of TMZ and BEV as well as the neurotoxic condition (calcium overload), on the function of mitochondria and compared these effects on mitochondria isolated from low- and high-grade human brain tumors. METHODS: Mitochondria were isolated from either low- or high-grade human primary brain tumors. Calcium overload conditions (100 or 200 µM), TMZ (300 µM), and BEV (2 mg/mL) were applied to isolated mitochondria from low- and high-grade brain tumors. Following the treatment, mitochondrial function, including reactive oxygen species production, membrane potential changes, and swelling, were determined. The mitochondrial morphology was also examined. RESULTS: In calcium overload conditions, mitochondrial dysfunction was only found to have occurred in low-grade tumors. In TMZ and BEV treatment, BEV, rather than TMZ, caused greater membrane depolarization and mitochondrial swelling in both grades of brain tumors. CONCLUSIONS: TMZ and BEV can directly cause the dysfunction of mitochondria isolated from human brain tumors. However, BEV has a greater ability to disturb mitochondrial function in mitochondria isolated from human brain tumors than either TMZ or calcium overload conditions.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting).

BACKGROUND: Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009. OBJECTIVES: To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS: Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials. MAIN RESULTS: We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS: This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

The result of surgical treatment in patients with cerebral aneurysms in Maharaj Nakorn Chiang Mai Hospital: a report of 225 cases.

OBJECTIVE: Evaluate the result of intracranial aneurysm surgery in Maharaj Nakorn Chiang Mai Hospital. MATERIAL AND METHOD: A retrospective study ofpatients who underwent surgery for intracranial aneurysms between 2003 and 2007. The patients'age, gender, signs and symptoms, CT brain findings, Subarachnoid hemorrhage (SAH), World Federation of Neurosurgical Society grading (WFNS), and aneurysm location were studied and correlated with outcome after surgery. RESULTS: Two hundred twenty five patients ofintracranial aneurysm were operated on between 2003 and 2007. Two hundred nine patients (92%) had anterior circulation aneurysms and 18 (8%) had posterior circulation aneurysms. The outcome, as evaluated by Glasgow Outcome Scale (GOS), showed good recovery and moderate disability patients (142, 62.9%) were classified as favorable outcome group whereas patients with severe disability, vegetative state, and dead (83, 36.9%) were classified as unfavorable outcome. According to WFNS grading, the patients with unruptured aneurysm and WFNS grade 1-2 had favorable outcome in 116 patients (78.37%) and unfavorable outcome in 32 patients (21.62%). Whereas the patients with WFNS grade 3-5 had favorable outcome in 32 patients (33.76%) and unfavorable outcome in 51 patients (66.23%). CONCLUSION: This study of 225 cases revealed 142 cases with favorable outcome and 83 cases with unfavorable outcome. Factors that affected the outcome were WFNS grading and age.

Local versus general anaesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be reduced by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004 and 2008. OBJECTIVES: To determine whether carotid endarterectomy under local anaesthetic: (1) reduces the risk of perioperative stroke and death compared with general anaesthetic; (2) reduces the complication rate (other than stroke) following carotid endarterectomy; and (3) is acceptable to patients and surgeons. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (September 2013), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and Index to Scientific and Technical Proceedings (ISTP) (1980 to September 2013). We also handsearched relevant journals, and searched the reference lists of articles identified. SELECTION CRITERIA: Randomised trials comparing the use of local anaesthetic to general anaesthetic for carotid endarterectomy were considered for inclusion. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial quality and extracted data. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, stroke or death, myocardial infarction, local haemorrhage, cranial nerve injuries, and shunted arteries. MAIN RESULTS: We included 14 randomised trials involving 4596 operations, of which 3526 were from the single largest trial (GALA). In general, reporting of methodology in the included studies was poor. All studies were unable to blind patients and surgical teams to randomised treatment allocation and for most studies the blinding of outcome assessors was unclear. There was no statistically significant difference in the incidence of stroke within 30 days of surgery between the local anaesthesia group and the general anaesthesia group. The incidence of strokes in the local anaesthesia group was 3.2% compared to 3.5% in the general anaesthesia group (Peto OR 0.92, 95% CI 0.67 to 1.28). There was no statistically significant difference in the proportion of patients who had a stroke or died within 30 days of surgery. In the local anaesthesia group 3.6% of patients had a stroke or died compared to 4.2% of patients in the general anaesthesia group (Peto OR 0.85, 95% CI 0.63 to 1.16). There was a non-significant trend towards lower operative mortality with local anaesthetic. In the local anaesthesia group 0.9% of patients died within 30 days of surgery compared to 1.5% of patients in the general anaesthesia group (Peto OR 0.62, 95% CI 0.36 to 1.07). However, neither the GALA trial or the pooled analysis were adequately powered to reliably detect an effect on mortality. AUTHORS' CONCLUSIONS: The proportion of patients who had a stroke or died within 30 days of surgery did not differ significantly between the two types of anaesthetic techniques used during carotid endarterectomy. This systematic review provides evidence to suggest that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.

Silicone injected cadaveric head for neurosurgical dissection: Prepared from defrosted cadaver.

BACKGROUND: Most reports of cadaveric specimen preparation for neurosurgical dissection describe methods using fresh cadavers. Our cultural limitations prevent us from obtaining fresh cadaveric heads. OBJECTIVE: To study and report on an alternative method of preparation of head specimens for neurosurgical dissection using defrosted cadavers. MATERIALS AND METHODS: Twenty-four head specimens were procured through the Department of Anatomy, received by donation three to seven days after funeral activity. The specimens were sectioned through the neck, and preserved by refrigeration at a temperature of -10°C for a period of one week to three months prior to preparation. The process began with defrosting the frozen head specimens for 48 hours in a refrigerator, in which the temperature was controlled within the range of -2° to -8°C. The great vessels were identified and cannulated. These were then irrigated with tap water until clear, following which colored silicone was injected. The specimens were preserved in 95% ethyl alcohol, and were assessed for quality one week after the preparation process. They were then re-assessed at monthly intervals for 12 months. RESULTS: When compared with specimens prepared from fresh cadavers, our method provided similar quality specimens for dissection. The scalp and muscles of all specimens remained soft. The vasculature was good, and the colored silicone made identification easy. The brain tissues were soft and easily retracted, and still in good condition for dissection after a long preparation period (12 months). CONCLUSION: The head specimens prepared with this method were of good quality for dissection, and were comparable in quality to those prepared from fresh cadavers as in published methods. We were thus able to provide a suitable substitute to fresh head specimens in situations where access to fresh cadavers is unavailable.

Factors influencing the outcome of decompressive craniectomy used in the treatment of severe traumatic brain injury.

OBJECTIVE: To evaluate risk factors that influences the outcome of decompressive craniectomy (DC) in severe traumatic brain injury patients. MATERIAL AND METHOD: The authors' retrospective review of data collected from 826 severe traumatic brain injury patients admitted to the Chiang Mai University Hospital between January 1, 2006 and December 31, 2008. During this period, 159 of 826 patients (19.25%) underwent DC and the craniectomy size was not smaller than a fronto-temporo-parietal or a bifrontal bone flap. Data collected included demographics, pre- and post-operative Glasgow coma scores (GCS), timing of surgery, complications, and Glasgow outcome score (GOS) at discharge and six months after surgery. At our institution, patients are managed using the Brain Trauma Foundation guidelines. RESULTS: One hundred fifty nine patients were identified, 130 (81.76%) male and 29 (18.23%) female. One hundred twenty two patients were operated within the first 24 hours after admission. Overall mortality rate was 44.65%. The survival group was younger (30.73 years vs. 43.46 years, p < 0.001) and had a higher pre-craniectomy GCS (6 vs. 5, p = 0.002). Of the 88 survivors, favorable outcome was achieved in 21 patients (13.20%) at discharge and increased to 38 patients (23.89%) at six months after surgery. Those with favorable outcome were younger (25.43 years vs. 38.35 years, p = 0.001) and had a higher pre-craniectomy GCS (p = 0.013). CONCLUSION: Younger age group patients and higher pre-operative GCS are two factors that influence the outcome of DC. Early decompressive craniectomy in patients with higher GCS may result in better functional outcomes.