Effect of Kencur (Kaempferia galanga L.) Ethanolic Extract Treatment on Cerebral Caspase-3 Expression in Traumatic Brain Injury Rat Models.

Background: Traumatic brain injury is one of the most common forms of trauma and causes significant morbidity and mortality. Kencur (Kaempferia galanga L.) ethanolic extract is known to contain substances that could theoretically inhibit unfavourable cellular processes, including oxidative stress and inflammation. This research aimed to study Kencur's anti-apoptosis activity through the inhibition of caspase-3. Methods: This is a true experimental post-test-only group design study, using male Wistar rats (Ratus novergicus) with weight-drop-induced traumatic brain injury. The subjects in this study were divided into four groups: two Control groups (Groups A and B) and two Therapy groups (Groups C and D). Groups C and D differed in the dose of Kencur ethanolic extract administered (600 mg/kgBW/day and 1,200 mg/kgBW/day, respectively). The Therapy groups were then subdivided into those receiving therapy for 24 h (C-24 and D-24) and those receiving therapy for 48 h (C-48 and D-48). Caspase-3 expression in brain tissue was evaluated at the end of the therapy using immunohistochemistry. All groups were subjected to a Kruskal-Wallis comparison test and the investigation continued with a Mann-Whitney U test to compare the two groups. Results: In traumatic brain injury rat models treated with Kaempferia galanga L. ethanolic extract at doses of 1,200 mg/kgBW/day within 48 h of therapy (D-48) compared to those who were not treated, there was a significant change in the cerebral expression of caspase-3 (P = 0.016). There was also a significant difference between the two doses of intervention (C-24 at 600 mg/kgBW/day and D-48 at 1,200 mg/kgBW/day; P = 0.016). Conclusion: With a minimum of 48 h of treatment split into two doses, Kencur (Kaempferia galanga L.) ethanolic extract can decrease caspase-3 expression in rats with traumatic brain injury.

Diagnosis and Prevalence (1975-2010) of Sudden Death due to Atlantoaxial Subluxation in Cervical Rheumatoid Arthritis: A Literature Review.

Rheumatoid arthritis (RA), a chronic inflammatory disease primarily affecting synovial joints and tendons, can potentially impact various organs within the body. One notable complication associated with RA is upper cervical spine instability, medically termed atlantoaxial subluxation (AAS). This condition can lead to adverse consequences, including chronic myelopathy and acute mechanical compression of the medulla oblongata, with the potential for sudden death. While AAS may often remain asymptomatic, some nonspecific symptoms, such as neck pain, have been documented. Severe atlantoaxial subluxation can trigger more distinct symptoms, including delayed occipital pain attributed to the compression of the exiting C2 nerve root. Recent studies have elucidated a spectrum of symptoms preceding sudden death, encompassing vertigo, dizziness, convulsions, dysphagia, disorientation, and seizures. Remarkably, some cases have reported sudden death occurring during sleep. Historical data reveal a fluctuating incidence of this phenomenon, with eleven cases reported between 1969 and 1975 and six cases documented between 1990 and 2010. Notably, one of the most prevalent causes of sudden mortality in individuals with RA is the acute mechanical damage inflicted upon the medulla oblongata due to atlantoaxial subluxation.

Comparison of outcomes between clipping and endovascular coiling in anterior choroidal artery aneurysm: a systematic review.

SAH (subarachnoid hemorrhage) caused by aneurysm rupture has the greatest mortality rate, with nearly 50% of patients unable to survive beyond 1 month after the attack. Anterior choroidal artery (AChA) aneurysms are one of the most difficult to treat among the numerous types of aneurysms. Until now, some neurosurgeons employed shearing while others employed coiling. In this trial, researchers will compare surgical clipping and endovascular coiling treatments for anterior choroidal artery aneurysms in terms of mortality, rebleeding, retreatment, and post-procedure outcomes. Using the PubMed electronic database, the Cochrane library, the Medline Database, the Directory of Open Access Journals, and EBSCHOHOST, a systematic review compared surgical clipping and endovascular coiling in all cases of choroidal artery aneurysm. There were 17 studies that met the eligibility requirements, with a total of 1486 patients divided into groups that underwent clipping (1106) or endovascular coiling (380). The mortality rate for clipping is 1.8%, while the mortality rate for endovascular coiling is 2.34%. Rebleeding occurs in 0% of patients undergoing endovascular coiling and 0.73% of patients undergoing clipping. Retreatment of clipping was 0.27%, while endovascular coiling was 3.42%. Post-complication procedures occurred in 11.12% of patients undergoing endovascular clipping and 15.78% of patients undergoing endovascular coiling. The intervention technique of clipping has a reduced rate of mortality, reoperation, and post-operative complications. Endovascular coiling results in a reduced rate of rebleeding than clipping.

Traumatic brain injury in pregnancy: A systematic review of epidemiology, management, and outcome.

OBJECTIVE: Traumatic brain injury (TBI) during pregnancy is an extremely rare condition in our neurosurgical emergency practices. Studies on the epidemiology and management of TBI in pregnancy are limited to case reports or serial case reports. There is no specific guidelines of management of TBI in pregnancy yet. METHODS: The authors performed a structured search of all published articles on TBI in pregnancy from 1990 to 2020. We restricted search for papers in English and Bahasa. RESULTS: The literature search yielded 22 articles with total 43 patients. We distinguished C-section based on its timing according to the neurosurgical treatment into primary (simultaneous or prior to neurosurgery) and secondary group (delayed C-section). The mean GOS value in primary C-section is better compared to secondary C-section in severe TBI group (3.57 ± 1.47 vs 3.0 ± 1.27, respectively) consistently in the moderate TBI group (4.33 ± 1.11 vs 3.62 ± 1.47, respectively). The fetal death rate in primary C-section is lower compared to secondary C-section in severe TBI group (14.2 % vs 33.3 %, respectively), contrary, in moderate TBI group (16.7 % vs 12.5 %, respectively). CONCLUSIONS: Care of pregnant patients with TBI often requires multidisciplinary approach to optimize treatment strategy on a case-by-case basis in light of prior experience across different center. We propose management guideline for head injury in pregnancy.

Second Footprint of Reports from Low- and Low- to Middle-Income Countries in the Neurosurgical Data: A Study from 2018-2020 Compared with Data from 2015-2017.

OBJECTIVE: In 2019, we highlighted the disparities in scientific production between high-income countries (HICs) and low- to middle-income countries (LMICs) by emphasizing how scientific research was underrepresented in the latter. The present study aimed to investigate research productivity in neurosurgery of low-income countries (LICs) and LMICs for the years 2018-2020 and to compare it with the results of our previous study for 2015-2017. METHODS: We performed a retrospective bibliometric analysis using PubMed and Scopus databases to record all the reports published in 2018-2020 by investigators affiliated with neurosurgical departments in LICs and LMICs. The attribution of the study to LMICs was based on the presence of either the first author or the majority of authors. RESULTS: Our systematic search identified 486 studies reported by LICs and LMICs for full text examination in 12 journals. These articles represent 4.9% of all published neurosurgical articles, compared with 4.5% in the 2015-2017 study. India remained the country with the highest contribution, with a 17.1% increase in reports. Other countries, such as Nigeria and Philippines, also show an increased percentage of reports (from 0.9% to 3.7% and from 0.6% to 2.1%, respectively). CONCLUSIONS: There is growing consensus in the neurosurgical scientific community that the dissemination and analysis of epidemiologic and clinical data from developing countries can provide guidelines and practical suggestions worldwide. However, our study shows that the number of neurosurgical articles published by low-income countries in 2018-2020 remained at approximately 5% of the total, resulting in a negative impact on the process of globalization.

The uncommon delayed neurological deficit in posterior fossa chronic epidural hematoma: A case report.

BACKGROUND: Chronic epidural hematoma (CEDH) is uncommon and therefore, less well characterized. The incidence of CEDH ranges from 3.9 % to 30 % of all epidural hematomas. Posterior fossa epidural hematomas represent a rare clinical entity. It has been reported in only 4-7 % of all extradural hematomas. This rare condition may present with rapid clinical deterioration by quick increase in size that may cause brain stem compression. This study aims to provide a case of chronic epidural hematoma with uncommon sign of delayed neurological deficits, specifically in the posterior fossa region. CASE PRESENTATION: We report a case of a 34-years-old male with left upper and lower extremities weakness for 3 days before admission. The patient had a history of falling from a height of approximately 3 m about 3 weeks ago. Craniotomy epidural hematoma evacuation was performed on the patient. CONCLUSION: Chronic epidural hematoma is uncommon and therefore, less well characterized. The results of surgical care of symptomatic chronic posterior fossa EDH are often excellent. Early diagnosis and emergent evacuation provide better outcome.

Lumbar disc herniation in a 15-year-old girl: A case report.

INTRODUCTION: Lumbar disc herniation (LDH) is uncommon in the pediatric population. The lumbar spine biodynamics and architecture change with age, with adults being more susceptible to LDH than children. When conservative treatment fails for pediatric LDH, surgery may be considered. We described an unusual instance of pediatric lumbar disc herniation that was successfully treated with microdiscectomy. CASE PRESENTATION: A 15-year-old patient presented with back discomfort and pain in her left leg that had been deteriorating for over 4 years. Conservative treatment with nonsteroidal anti-inflammatory medications and piriformis injection is ineffective. An MRI of her lumbosacral spine revealed that the left L4 root was compressed by a disc herniation at the L4/L5 level. A microdiscectomy was performed on the patient. Within 48 h of surgery, the patient was released home with significant alleviation in sciatic discomfort. DISCUSSION: In the pathogenesis of LDH, trauma and a sedentary lifestyle are important factors. Back pain and radiating pain are typical LDH symptoms. If conservative treatment does not result in a positive outcome, the microdiscectomy procedure is the surgical approach of choice. Long-term outcomes have demonstrated the efficacy and safety of this procedure. CONCLUSION: Every child who presents with back pain or radiculopathy should undergo a thorough evaluation for LDH especially if they have a high body mass index (BMI) or a history of trauma. Careful patient selection and preoperative evaluation result in extremely excellent surgery outcomes in pediatric LDH.

One-stage anterior approach for long-segment subaxial cervical spondylitis tuberculosis: A case report.

BACKGROUND: Spondylitis TB on cervical region is a rare disease, that may lead to severe neurological complications. The anterior approach is considered as a gold standard for cervical spine tuberculosis. Available studies and literature have not precisely mentioned on how many levels are acceptable for this disease and still up for discussion. CASE PRESENTATION: A 45-year-old Asian male was brought from a rural hospital to our outpatient clinic with progressive weakness of all extremities for 3 months. Cervical x-ray and MRI showed three-levels of vertebral body destruction, suggesting a cervical spondylitis TB. Patient had debridement, corpectomy on C4, 5, 6, fusion with cage, and anterior plating from C3 to Th1 in a one-stage anterior approach. Immediately after the surgery, the patient had no complaints of pain, and he was able to walk on his own. One year follow-up after the surgery, no residual neurological impairment is detected and had no limitation in daily activities. Cervical x-ray and MRI showed good ossification and improvement of lordotic curvature. CONCLUSION: Treatment of cervical spondylitis TB which involved three-levels of vertebrae using one-stage anterior approach provides a good rate of deformity correction along with clinical improvement and long-term well-being of the patient.

The Effect of ACTH(4-10) PRO8-GLY9-PRO10 Administration on the Expression of IL-6 and IL-8 in Sprague Dawley Mice with Spinal Cord Injury.

Background Spinal cord injury (SCI) is a significant cause of morbidity since it results in the inflammation process which leads to necrosis or apoptosis. Inflammatory response to the tissue damage increases IL-6 and IL-8 levels. ACTH4 - 10Pro8-Gly9-Pro10 is a peptide community that has been shown to have a beneficial effect on minimizing the morbidity and increasing the recovery time. Methods This study is a true experimental laboratory research with a totally randomized method. The subjects were animal models with light and extreme compression of spinal cord, respectively. Results The administration of ACTH 4-10 in mild SCI in the 3-hour observation group did not show a significant difference in IL-6 expression compared with the 6-hour observation group. The administration of ACTH 4-10 in severe SCI showed a significantly lower expression level of IL-6 in the 3-hour observation group compared with the 6-hour one. The administration of ACTH 4-10 in severe SCI led to a significantly lower IL-8 expression in the 3-hour observation group compared with the 6-hour one. However, there was no significant difference in IL-8 expression in the group receiving ACTH 4-10 in 3 hours observation compared with that in 6 hours observation. Conclusion The administration of ACTH4-10Pro8-Gly9-Pro10 can reduce the expression of IL-6 and IL-8 at 3-hour and 6-hour observation after mild and severe SCI in animal models. Future research works are recommended.

Apparent Diffusion Coefficient Values and Dynamic Contrast-Enhanced Magnetic Resonance Perfusion are Potential Predictors for Grading Meningiomas.

Purpose: Distinguishing between high-grade and low-grade meningiomas might be difficult but has high clinical value in deciding precise treatment and prognostic factors. Magnetic resonance imaging (MRI) using apparent diffusion coefficient (ADC) values and dynamic contrast enhancement (DCE) may have a significant role in capturing such complexities. Methods: Data from our hospital database on meningioma patients from January 2020 to December 2021 were obtained. The MRI results of all patients were evaluated for mean ADC value and DCE parameters, including time-signal intensity curves (TIC), maximum signal intensity (SImax), time to maximum signal intensity (Tmax), maximum contrast enhancement ratio (MCER), and slope. Results: In this retrospective analysis, 33 individuals were included. Twenty-eight (84.8%) patients were pathologically diagnosed with low-grade meningioma and five (15.2%) patients with high-grade meningioma. There is a crossover between high- and low-grade meningiomas in conventional MRI. Tumor size, location, shape, necrotic/cystic changes, peritumoral edema, and enhancement patterns did not differ substantially between groups (p = 0.39, 0.23, 0.28, 0.57, 0.56, and 0.33, respectively). The mean ADC and Tmax values of high-grade meningiomas were substantially lower than those of low-grade meningiomas (p = 0.002 and 0.02, respectively). An optimal cut-off of 0.87 × 10-3 mm2s-1 for the mean ADC value (area under the curve [AUC] = 0.94, sensitivity = 80%, specificity = 92.8%) and 42 s for Tmax (AUC = 0.84, sensitivity = 80%, specificity = 89.3%) was suggested. High-grade meningiomas had significantly higher TIC, SImax, MCER, and slope than low-grade meningiomas (p = 0.004, < 0.001, 0.01, and 0.001, respectively). Type IV TIC had a sensitivity of 80% and specificity of 89.3% in distinguishing high-grade meningiomas from low-grade meningiomas. Optimal cut-offs of 940.2 for SImax (AUC = 0.98, sensitivity = 80%, specificity = 96.4%), 245% for MCER (AUC = 0.94, sensitivity = 80%, specificity = 85.7%), and 5% per second for slope (AUC = 0.97, sensitivity = 80%, specificity = 96.4%) were estimated. Conclusion: The ADC value and DCE-MRI parameters (TIC, SImax, Tmax, MCER, and slope) are potential predictors for separating high-grade from low-grade meningiomas.

The change of serum and CSF BDNF level as a prognosis predictor in traumatic brain injury cases: A systematic review.

Background: Mortality predictions following traumatic brain injury (TBI) may be improved by including genetic risk in addition to traditional prognostic variables. One promising target is the gene coding for brain-derived neurotrophic factor (BDNF), a ubiquitous neurotrophin important for neuronal survival and neurogenesis. Methods: A total of seven publications pertaining to BDNF in the study of traumatic head injury were included and reviewed. The majority of patients were male, that is, 483 (83.85%) patients, compared to 93 (16.15%) female patients. The median length of follow-up was 6 months (3 days-12 months). Measurement of the patient's initial condition was carried out by measuring the initial GCS of the patient at the time of admission across the five studies being 6.5. The median CSF BDNF levels in the unfavorable group being 0.2365 (0.19-0.3119) ng/ml, from favorable group which was 0.20585 (0.17-0.5526) ng/ml. The median serum BDNF level in the unfavorable group being 3.9058 (0.6142-13.0) ng/ml, from favorable group which was 4.3 (0.6174-23.3) ng/ml. Results: Six studies reported on the sex distribution of patients, the majority of patients were male, that is, 483 (83.85%) patients, compared to 93 (16.15%) female patients. Six studies reported the number of patients per outcome group. The comparison of the number of patients in the two groups was quite balanced with the number of patients in the good group as many as 269 patients (55.5%) and the number of patients in the unfavorable group as many as 216 patients (44.5%). Measurement of the patient's initial condition was carried out by measuring the patient's initial GCS at the time of admission. It was reported in five studies, with the overall mean baseline GCS across five studies being 6.5 (3.2-8.8). Measurement of patient outcome was carried out by several methods, two studies used Glasgow Outcome Scale, Glasgow Outcome Scale Extended was used in two studies, and five studies used survival as a patient outcome measure. The patient's BDNF level was measured in CSF and/or serum. A total of four studies measuring BDNF CSF levels and serum BDNF levels. Measurement of BDNF levels in TBI patients conducted on patients in seven literatures showed that there were differences in the trend of BDNF levels from CSF sources and serum sources. Measurement of CSF BDNF levels CSF BDNF levels was reported in two of the seven literatures, with the median CSF BDNF level in the unfavorable group being 0.2365 (0.19-0.3119) ng/ml. CSF BDNF levels were higher than the median in the preferred group, which was 0.20585 (0.17-0.5526) ng/ml. The results of the analysis from three other literatures stated that there was a tendency for lower CSF BDNF levels in the preferred group. Serum BDNF levels were reported in two of the seven literatures, with the median serum BDNF level in the unfavorable group being 3.9058 (0.6142-13.0) ng/ml. This serum BDNF level was lower than the median in the preferred group, which was 4.3 (0.6174-23.3) ng/ml. The results of the analysis of four literatures reporting serum BDNF stated that there was a tendency for lower serum BDNF levels in the poor group. A risk assessment of bias for each study was performed using ROBINS-I because all included studies were non-RCT studies. Overall the results of the risk of bias analysis were good, with the greatest risk of confounding bias and outcome bias. Conclusion: Serum BDNF levels were found to be lower in the unfavorable group than in the favorable group. This is associated with an increase in autonomic function as well as a breakdown of the blood-brain barrier which causes a decrease in serum BDNF levels. Conversely, CSF BDNF levels were found to be higher in the unfavorable group than in the favorable group. This is associated with an increase in the breakdown of the blood-brain barrier which facilitates the transfer of serum BDNF to the brain, leading to an increase in CSF BDNF levels.

Novel Silicone Rubber and Polyvinyl Alcohol (PVA) Compound as Nucleus Pulposus Replacement in Intervertebral Disc Herniation Surgery.

AIM: To identify a novel material with biomechanical properties identical to the nucleus pulposus in the lumbar vertebrae of goats for use in intervertebral disc herniation surgery. MATERIAL AND METHODS: In this laboratory-based experimental study, the silicone rubber material test group consisted of sample compositions 35PVA65SR, 30PVA70SR, and 40PVA60SR. Axial compression mechanical tests were conducted to assess the biomechanical properties of the resulting material in terms of stress, strain, load, and displacement. RESULTS: The mechanical compression test results revealed that the stress (MPa) and strain (%) values of the 40PVA60SR material were closest to the control group (p=1.00) with a load of 684 N in each group. The value of material displacement (mm) for 40PVA60SR was also the closest to control (p=1.00) with a loading of 684 N. CONCLUSION: The new material presents biomechanical properties closest to human nucleus pulposus and is promising in nucleus pulposus replacement therapy. Further clinical research is needed to evaluate other biomechanical properties and the bioavailability of the novel material.

Clinical outcome and safety of stem cell therapy for ischemic stroke: A systematic review and meta-analysis.

Background: Several reports on stem cell administration have emerged proving it to be an ideal therapeutic approach for improving neurological functions in ischemic stroke patients. However, some studies also show disappointing results, with some reporting no statistically significant improvements among several different parameters. Several challenges also arise relating to safety and nonscientific aspects, such as ethics. Methods: We performed a systematic review and meta-analysis to evaluate the effect of stem cell therapy on the clinical outcomes of ischemic stroke patients. A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Scopus, and Cochrane databases. Articles were selected systematically based on the PRISMA protocol and reviewed completely. A total of 19 publications pertaining to stem cell therapy on the ischemic route were included and reviewed. Efficacy outcomes were measured with the National Institutes of Health Stroke Scale, modified Rankin Scale, or Barthel Index. Results: The results of the meta-analysis indicate that the efficacy outcomes suggest favorable results after stem cell therapy, although not all study results are statistically significant. Stem cell therapy in stroke cases showed a better outcome than standard conservative therapy alone, although our analysis shows that many factors can influence this outcome, and significant effects can only be seen after several months. Conclusion: The results of this study show promising and satisfying efficacy and a relatively low rate of serious adverse events.

Multiple spinal intramedullary cavernous angiomas with bleeding episode mimicking an intramedullary tumor.

Intramedullary cavernous angioma is a rare vascular malformation compared to cerebral cavernous malformation. The incidence of cavernous angioma is about 3 - 5% of all central nervous system lesions, 5 - 12% of all spinal vascular lesions, and 1% of all intramedullary lesions in pediatric patients. Although intramedullary cavernous angioma has the same histological picture as cerebral cavernous angioma, the natural history, and surgical approach are different from cerebral cavernous angioma. Due to its location in the eloquent area of the spinal medulla, a slight change in the size of the lesion can affect the neurological function of the patient. We describe a case of an intramedullary cavernous angioma with hemosiderin post bleeding, located in the cervical cord which was initially misdiagnosed as hemorrhagic ependymoma. On whole spine MR imaging we also found an intramedullary cavernous angioma in the lower thoracal cord at the T12 level with mild hemorrhage. Abdominal MRI showed cavernous angiomas in both kidneys. The patient underwent surgical treatment with removal of the lesion in the cervical cord and T12 level, with histopathologic findings consistent with cavernous angioma. No malignancy was detected. Post-surgery, the symptoms gradually improved. Symptomatic intramedullary cavernous angioma tends to bleed repeatedly and being unstable. Early diagnosis and surgical treatment can prevent rebleeding and more severe symptoms.

Periosteum-induced ossification effect in skull defect through interleukin-8 and NF-κB pathway: An experimental study with Oryctolagus cuniculus rabbits.

Background: The purpose of this study was to analyze the response of inflammatory cytokines interleukin-8 (IL-8) and NF-κB to the closure of skull defect with periosteum as a scaffolding material in bone healing used after surgery. Methods: Thirty Oryctolagus cuniculus rabbits underwent a craniotomy to create a 20 mm diameter round defect in the parietal bones. The parietal bones were returned to its place and stabilized by an internal plate fixation. The defects were either left empty or implanted with periosteum. At 6 weeks, the specimens were euthanized and examined. Results: Histological examination showed a more well-developed formation of woven bone in the periosteum group. Immunohistochemical examinations showed that the use of periosteum in the closure of skull defects reduced the NF-κB and IL-8 response which affected the ossification process. Conclusion: The experiment showed that the use of periosteum was linked with IL-8 and NF-κB downregulation toward ossification effects at any point throughout the trial. Periosteum usage might be beneficial as a scaffolding material in bone healing for autograft cranioplasty in animal model and could be applied to clinical practice.

Surgical treatment approach of cervicothoracic junction spinal tuberculosis in pediatric: A case report.

INTRODUCTION AND IMPORTANCE: The cervicothoracic junction is prone to infection by tuberculosis bacteria, which leads to spinal instability. Meanwhile, cervicothoracic junction spinal tuberculosis is a disease that affects the C7 to T3 vertebral, and it accounts for 5% of all spinal tuberculosis cases. Surgical procedures of treating this disease vary, and the most commonly used method is the combined anterior and posterior approach. This case report presents the disease with uncommon location in pediatric, which is rarely reported, and performed with the single-stage posterior approach to treat the patient, which showed a good clinical and radiological result. CASE PRESENTATION: A 15-years old girl with one-month history of progressive inferior paraplegia (within a month, her muscle strength went from score 5 to 0) initially complained of neck pain, gradual weakness of the lower extremities, and hypoesthesia below T4. The spine's MRI also showed a tuberculous spondylitis in the T1 to T3 vertebral and a huge paravertebral abscess at the C5 to T3 level. Subsequently, an adequate decompression, debridement, maintenance and reinforcement of stability as well as deformity correction were carried out using the single-stage posterior approach. CONCLUSIONS: The cervicothoracic junction spinal tuberculosis with huge paravertebral abscess makes surgical procedures difficult, specifically in pediatric patients. However, the single stage posterior approach produced a better clinical and radiological result with a short operation time. The selection of appropriate surgical approach management with good perioperative planning as well as effective medical management improved the patient's condition.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study.

BACKGROUND: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. METHODS: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. FINDINGS: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). INTERPRETATION: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. FUNDING: National Institute for Health Research Global Health Research Group.

Comparison of half-molar sodium lactate and mannitol to treat brain edema in severe traumatic brain injury: A systematic review.

PURPOSE: Hypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP). METHODS: This study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were "half-molar sodium lactate", "mannitol", "cerebral edema or brain swelling", and "severe traumatic brain injury". The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3. RESULTS: From 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09). CONCLUSION: Half-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.

Algorithm of Traumatic Brain Injury in Pregnancy (Perspective on Neurosurgery).

BACKGROUND: The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources. CASE SERIES: A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition. DISCUSSION: We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment. CONCLUSION: The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.

Long Completely Cystic Sciatic Schwannoma: A Rare Case.

Schwannomas are the most common peripheral nerve sheath tumors. Benign schwannomas with malignant transformation are rarely reported. Most common schwannomas occur in the head and neck region. Sciatic schwannomas are rare, as are completely cystic schwannomas. Sciatic nerve schwannomas represent less than 1% of all schwannomas. Benign tumors in the sciatic nerve consist of 60% neurofibromas and 38% schwannomas. In general, a schwannoma induces chronic symptoms. It can be misleading, sometimes mimicking degenerative spinal pathology due to disc herniation. Schwannoma involving the sciatic nerve can be asymptomatic or may present with sciatica or neurological deficits. Most schwannomas are solid or heterogeneous tumors, and completely cystic schwannomas are rare. The differential diagnoses of nondiscogenic sciatica include lumbar disc herniation, tumor, abscess, hematoma, facet syndrome, lumbar instability, sacroiliitis, piriformis syndrome, and sciatic neuritis. We report a rare case of a long completely cystic sciatic schwannoma in the left foraminal L5-S1 zone extending to the left ischial groove with chronic sciatica that was diagnosed radiologically with a combination of conventional MRI and MR neurography and confirmed histopathologically by surgical resection. The patient previously had conservative therapy, but the complaints were not reduced. Nonsurgical therapy is considered the first choice, and surgical therapy is indicated in cases that do not respond to conservative therapy, with recurrent cysts, severe pain, or neurological deficits.