Neurosurgical Management of Nonmissile Penetrating Cranial Lesions.

OBJECTIVE: The objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up. METHODS: From January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected. RESULTS: Among the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04). CONCLUSIONS: TBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.

Predictors of Outcome in Nontraumatic Spontaneous Acute Spinal Subdural Hematoma: Case Report and Literature Review.

OBJECTIVES: To analyze the clinical presentation and outcome of nontraumatic spontaneous acute spinal subdural hematoma by observing the predictors of outcome. METHODS/RESULTS: This study was based on a case report and systematic review of the international literature. Among the 151 patients, 80 were female and 65 were male (1.25 female/1.0 male). The age distribution ranged from 6 months to 87 years, with a small increase in incidence between the first and second decade of life and a major peak at age 60 years. The difference of proportion of good results between patients with and without established neurologic deficits was: 0.488, 95% confidence interval (95% CI) 0.237-0.648, P = 2.71e-08; coagulopathy was 0.335, 95% CI 0.163-0.508, P = 0.0002; SAH was 0.0539, 95% CI -0.119 to 0.226, P = 0.6529; lumbar puncture/associated diseases was 0.149 95% CI -0.032 to 0.330, P = 0.1171; surgery was 0.0593, 95% CI -0.114 to 0.233, P = 0.5838; and hematoma extension equal or longer than 5 levels was 0.010 95% CI -0.178 to 0.197, P = 1. CONCLUSIONS: Although mortality and morbidity associated with nontraumatic spontaneous acute spinal subdural hematoma has decreased during the last 2 decades, the disease still carries a mortality rate of approximately1.3% and a morbidity (permanent neurologic deficits) rate of 28%. The main factors affecting the outcome are neurologic status at presentation and coagulopathies.

Vasoespasmo cerebral após hemorragia subaracnóidea aneurismática: uma revisão atualizada / Cerebral vasospasm after aneurysmal subarachnoid hemorrhage: an update review

A ruptura de aneurisma intracraniano é a principal causa de hemorragia subaracnóidea (HSA) espontânea. O curso clínicoda HSA aneurismática pode resultar em complicações como ressangramento, hematomas intraventriculares e intracerebrais,hidrocefalia, convulsão e vasoespasmo cerebral. O vasoespasmo cerebral é a complicação médica mais devastadora após a HSAaneurismática e está associada à alta taxa de morbi-mortalidade, mesmo após o tratamento dos aneurismas que originarama mesma por sua ruptura. O presente estudo compreende uma revisão bibliográfica sobre a fisiopatologia do vasoespasmo,aspectos diagnósticos e as formas de prevenção e tratamento.