Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury.

INTRODUCTION: Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. METHODS: A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. RESULTS: 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively (P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). CONCLUSION: Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly.

INTRODUCTION: Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS: A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS: There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION: Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Assessing the Cost Burden of Pediatric Neurosurgery in Kaduna, Nigeria.

BACKGROUND: Few studies have evaluated the cost burden borne by neurosurgical patients in the developing world and their potential implications for efficient and effective delivery of care. This study aims to assess the cost associated with obtaining pediatric neurosurgical care in a hospital in Kaduna. METHODS: All patients younger than 15 years who had a neurosurgical operation from July to December 2019 were included in the study. The characteristics of the patients were obtained using a proforma while the cost data were retrieved from the accounts unit of the hospital. The direct cost was obtained from the billing records of the hospital. Indirect cost was obtained using a questionnaire. The data obtained were analyzed using SPSS version 25 for Windows. RESULTS: A total of 27 patients were included in the study with a mean age of 7.2 years and a standard deviation of 4.95 years. The 2 most common procedures done were craniotomy for trauma and ventriculoperitoneal shunt insertion for hydrocephalus. The mean total cost of a neurosurgical procedure was $895.99. Intensive care unit length of stay was found to have a significant influence on the direct cost. The cost of surgery and investigation were the main contributors to the total cost of care with a mean of $618.3 and a standard deviation of $248.67. CONCLUSIONS: The mean cost of pediatric neurosurgical procedures in our setting is $895.99, which is 40.18% of our gross domestic product per capita. The main drivers of cost are the cost of operation, investigations, and intensive care unit length of stay.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Surgical Procedures, Complications, and Postoperative Outcomes.

BACKGROUND: Traumatic brain injury (TBI) is an important cause of trauma-related mortality and morbidity in Ethiopia. There are significant resource limitations along the entire continuum of care, and little is known about the neurosurgical activity and patient outcomes. METHODS: All surgically treated TBI patients at the 4 teaching hospitals in Addis Ababa, Ethiopia were prospectively registered from October 2012 to December 2016. Data registration included surgical procedures, complications, reoperations, discharge outcomes, and mortality. RESULTS: A total of 1087 patients were included. The most common procedures were elevation of depressed skull fractures (49.5%) and craniotomies (47.9%). Epidural hematoma was the most frequent indication for a craniotomy (74.7%). Most (77.7%) patients were operated within 24 hours of admission. The median hospital stay for depressed skull fracture operations or craniotomies was 4 days. Decompressive craniectomy was only done in 10 patients. Postoperative complications were seen in 17% of patients, and only 3% were reoperated. Cerebrospinal fluid leak was the most common complication (7.9%). The overall mortality was 8.2%. Diagnosis, admission Glasgow Coma Scale (GCS) score, surgical procedure, and complications were significant predictors of discharge GCS score (P < 0.01). Age, admission GCS score, and length of hospital stay were significantly associated with mortality (P ≤ 0.005). CONCLUSIONS: The injury panorama, surgical activity, and outcome are significantly influenced by patient selection due to deficits within both prehospital and hospital care. Still, the neurosurgical services benefit a large number of patients in the greater Addis region and are qualitatively comparable with reports from high-income countries.

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.

BACKGROUND: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. METHODS: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). RESULTS: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSION: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. LEVEL OF EVIDENCE: Epidemiological, level III; Care management/Therapeutic level III.

Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review.

BACKGROUND: Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH. METHODS: A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes. RESULTS: Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults. CONCLUSIONS: Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.

Predictors of re-operation in the setting of non-acute subdural hematomas: A 12-year single center retrospective study.

Non-acute subdural hematomas (naSDH) may recur after surgical treatment. A second operation affects the quality of life and functional outcome of the patients, and lengthens hospital stay. We aim to identify the predictors of reoperation as the healthcare system in the US is moving towards patient-centered care. This retrospective study included patients treated surgically with burr-holes or mini-craniotomy for non-acute subdural hematoma between February 2006-June 2018. Univariate and multiple logistic regression models were performed. 23 (12.0%) patients had reoperation. Controlling for all the factors, postoperative acute blood in the operative bed was the strongest predictor of recurrence of naSDH (OR = 37.93, 95% CI: 5.35-268.87, p < 0.001). Those undergoing a mini-craniotomy were over six times as likely to experience a recurrent SDH compared to those operated on via burr holes (OR = 6.34, 95% CI: 1.21-33.08, p = 0.029). Finally, patients with a past medical history of thrombocytopenia were nearly six times as likely to experience a recurrence of SDH (OR = 5.80, 95% CI: 1.20-28.10, p = 0.029). Postoperative hematoma thickness showed a trend toward significance such that thicker hematomas were associated with an increased likelihood of experiencing a recurrent SDH. In conclusion, we found that operative technique, thrombocytopenia and the presence of postoperative hemorrhage are significant predictors for reoperation. Given the current interest in endovascular embolization for SDH, understanding these risk factors may aid in determining indications for such adjunctive treatment.

Optimization of Intracranial Germinoma Treatment: Radiotherapy Alone with Reduced Volume and Dose.

PURPOSE: We investigated optimal management for intracranial germinoma, including target volume and dose of radiation therapy (RT) and the combination of RT and chemotherapy (CTx). METHODS AND MATERIALS: We retrospectively evaluated 213 patients with intracranial germinoma treated between 1971 and 2017. Treatment policies changed as diagnostic techniques and clinical experience improved. In the 1980s, trial RT and tumor marker study were performed, and craniospinal irradiation was performed to treat patients with presumed germinoma. CTx was introduced in 1991, and RT volume was reduced in patients showing a complete response. In 2012, the policy was changed to a "reduced volume/dose RT alone" approach, involving a smaller target volume (the whole ventricle/whole brain for localized disease) without CTx. RT doses were gradually reduced to 36 Gy for primary tumors and 18 Gy for neuraxis. RESULTS: The median age was 16 years. In total, 118 and 95 patients had pathologically proven and presumed germinoma, respectively, and 151 and 62 patients had localized and multifocal or metastatic diseases, respectively. With a median follow-up of 141 months, the 10-year disease-free and overall survival rates were 91.6% and 95.6%, respectively. Recurrence rates were similar for patients receiving RT-only (9 of 137, 6.6%) and those receiving CTx + RT (4 of 73, 5.5%); all patients receiving CTx-only experienced recurrences (3 of 3, 100%). Rates were the highest in the focal RT group (10 of 29, 34.5%) but were relatively low in the whole ventricle/whole brain RT (3 of 51, 5.9%) and craniospinal irradiation groups (0 of 130, 0%). Infield failure occurred in 3 patients. Fourteen patients died of recurrence (n = 4), secondary malignancy (n = 4), CTx-related toxicity (n = 2), and others (n = 4). Among the 33 patients who received "reduced volume/dose RT alone" treatment, 2 (6.1%) experienced recurrence in the spinal cord and biopsy tract, respectively. CONCLUSIONS: The additional benefit of CTx in the treatment of intracranial germinoma seems minimal. An RT-only approach with reduced target volume and dose seems reasonable.

Long-Term Growth following Trigonocephaly Repairs: Are Overcorrections Necessary?

BACKGROUND: Does bifrontal width change with growth following trigonocephaly corrections? Postoperative long-term growth was assessed, along with the impacts of phenotypic severity, surgical timing, and operative technique, to determine how wide to surgically set bifrontal width. METHODS: A retrospective review of all trigonocephaly repairs was performed. Exclusion criteria included syndromic conditions, incomplete records, and follow-up under 1 year. Anthropometric measurements taken through completion of growth were evaluated and compared to sex- and age-matched normal standards for Z score conversion. RESULTS: Of 370 consecutive patients undergoing repairs, 95 had sufficient anthropometric data. The mean surgical age was 10.8 months (range, 2 months to 7 years) and mean follow-up was 54.3 months (range, 12 months to 17.8 years). Sequential measurements revealed progressive increases in bifrontal width. However, following conversion to Z scores, the initial overcorrection (mean overcorrection, 8.7 mm; mean Z score, +2.3) steadily diminished to an undercorrection (mean measurement, -5.5 mm; mean Z score, -1.1). Compared to treatment at an older age (10 to 12 months), repairs performed in those younger than 8 months showed worse growth (p = 0.004). Those more severely affected (lowest bifrontal Z scores) had growth similar to that of those more mildly impacted. Only two patients (2.1 percent) underwent secondary procedures for recurrences. No correlation was found between anthropologic measurements and observers' severity assessments. CONCLUSIONS: Subnormal bifrontal growth occurs following trigonocephaly corrections, especially with earlier corrections. Repairs performed at approximately 11 months of age had to be overcorrected by approximately 1.5 cm to produce a normal bifrontal width at maturity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cranial burr holes in the emergency department: to drill or not to drill?

The practice of trepanning (referred to today as a craniotomy) dates back to the Neolithic period. Reasons for drilling a hole through the skull evolved from releasing evil spirits and curing insanity to practical management of head injuries in ancient Greece and Rome. Today, craniotomy or drilling a burr hole through the skull is very much the purview of the neurosurgeon. Yet one could argue that the procedure itself is more 'bone surgery' than 'brain surgery'. Nevertheless, despite the fact that head injury is a common presentation at district general hospitals and traumatic extra-axial haemorrhages are encountered often, the straightforward skillset required to drill a burr hole as a pretransfer, temporising, life-saving measure is seldom taught and has never gained traction. What we advocate in this article is the adaptation and novel application of an old, tried and tested technique in new hands. The critical pathophysiological turning point of any expanding extra-axial haemorrhage is the inflection point on the volume/Intracranial pressure (ICP) curve beyond which compensation is impossible. The subsequent rising ICP initiates a predictable continuum of clinical signs signalling progressive herniation. There are few emergencies as time-critical as a patient with an isolated, expanding extradural haemorrhage embarking on a trajectory of rostrocaudal deterioration and inevitable death. In many cases, the tragedy is compounded by the knowledge that such a patient probably has a healthy underlying brain, often evidenced by a lucid period after trauma. Our emergency department is attached to a small 300-bed District General Hospital (DGH) on the rural North West coast of Ireland. We are 262 km distant by road from a national neurosciences department that can, at best, be reached in 2 hours and 30 min. Quality improvement review of years of dismal outcomes in patients such as those described earlier with potentially remediable pathology prompted research and development of the skillset we are now able to offer, an old technique in new hands.

Reoperations after surgery for acute subdural hematoma: reasons, risk factors, and effects.

PURPOSE: To analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome. METHODS: Among adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery-trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied. RESULTS: Of 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients. CONCLUSIONS: Reoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

Risk Factors for Urinary Tract Infection or Pneumonia After Admission for Traumatic Subdural Hematoma at a Level I Trauma Center: Large Single-Institution Series.

BACKGROUND: The development of infections such as urinary tract infections (UTIs) or pneumonia after a traumatic subdural hematoma (tSDH) can worsen patient outcomes and increase healthcare costs. We herein identify clinical parameters that influence the risk of infections after tSDH. METHODS: This single-institution retrospective cohort study examined the incidence and risk factors for UTI and pneumonia among tSDH patients from 1990 to 2015. Multivariate logistic regression assessed the impact of various demographic and clinical variables on these outcomes. RESULTS: 3024 patients with tSDHs were identified (73.1% male); Of those, 208 (6.9%) experienced a UTI and 434 (14.4%) experienced pneumonia. Of the 559 patients (18.5%) who underwent a craniotomy and/or craniectomy for evacuation of a tSDH, 62 (11.1%) experienced a UTI and 222 (39.7%) experienced pneumonia. Risk factors for both pneumonia and UTI included length of stay (LOS) ≥7 days (odds ratio [OR] = 6.0, P < 0.001; OR = 11.2, P < 0.001), intensive care unit LOS ≥7 days (OR = 8.1, P < 0.001; OR = 1.7, P = 0.012), and mechanical ventilation ≥14 days (OR = 3.4, P < 0.001; OR = 1.8, P = 0.007). Craniotomy/craniectomy increased the risk of pneumonia (OR = 1.4, P = 0.019) but not UTI. Glasgow Coma Scale (GCS) ≥13 was associated with a decreased pneumonia risk (OR = 0.5, P = 0.003), and male gender (OR = 0.5, P < 0.001) and age <60 (OR = 0.6, P < 0.001) were associated with a decreased UTI risk. CONCLUSIONS: Patients with prolonged hospitalizations and/or intensive care unit stays were more likely to experience UTIs and pneumonia. Male gender and younger age were protective against UTI, and higher GCS was protective against pneumonia. These data may aid the identification and treatment of at-risk populations after admission for a tSDH.

Undertriaged trauma patients: Who are we missing?

BACKGROUND: Trauma team activation (TTA) criteria, set by the American College of Surgeons Committee on Trauma, are used to identify patients prehospital who are at highest risk for severe injury and mobilize the optimal resources. Patients are undertriaged if they are severely injured (Injury Severity Score, ≥16) but do not meet TTA criteria. This study examined the epidemiology and injury patterns of undertriaged patients and potential clinical effects. METHODS: All patients presenting to our Level I trauma center (June 1, 2017 to May 31, 2018) were screened for inclusion using modified TTA criteria (mTTA), that is, age over 70 years added to the standard American College of Surgeons Committee on Trauma TTA criteria. Demographics, injury/clinical data, and outcomes of undertriaged patients were analyzed. Undertriaged patients were further subcategorized as "high-risk" if they expired or required emergent intervention. RESULTS: 233 undertriaged patients were identified from 1423 routine trauma consults (16%). Mean Injury Severity Score was 20 (range, 16-43). Most undertriage occurred following blunt trauma (n = 224, 96%), especially motor vehicle collisions (n = 66, 28%) and auto versus pedestrian collisions (n = 57, 24%). Thirty-two (14%) patients were identified as high-risk undertriaged patients: 16 (50%) required emergency surgery (mainly craniectomy; n = 10, 63%), 5 (16%) required angioembolization, and 14 patients (44%) died. In this high-risk group, the cause of death was almost exclusively traumatic brain injury (TBI) (n = 13, 93%). Of the patients who died of TBI, the majority had a depressed Glasgow Coma Scale score on presentation to the ED (<11) (n = 10, 77%) despite not meeting field criteria for TTA. CONCLUSION: Using mTTA criteria, undertriage rates are relatively low, particularly after penetrating trauma. However, there is a high-risk population that is not captured, among whom mortality and need for emergent intervention are high. Most undertriage deaths are secondary to severe TBI. Despite not qualifying for highest-level activation, patients with head trauma and Glasgow Coma Scale score less than 11 on admission are at high-risk for adverse outcomes and additional resource mobilization should be considered. LEVEL OF EVIDENCE: Care Management, level IV.

Association of Angiotensin-Converting Enzyme Inhibitors with Increased Mortality Among Patients with Isolated Severe Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is associated with one-third of all deaths from trauma. Preinjury exposure to cardiovascular drugs may affect TBI outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) exacerbate brain cell damage and worsen functional outcomes in the laboratory setting. ß-blockers (BBs), however, appear to be associated with reduced mortality among patients with isolated TBI. OBJECTIVE: Examine the association between preinjury ACEI and BB use and clinical outcome among patients with isolated TBI. METHODS: A retrospective cohort study of patients age ≥ 40 years admitted to an academic level 1 trauma center with isolated TBI between January 2010 and December 2014 was performed. Isolated TBI was defined as a head Abbreviated Injury Scale (AIS) score ≥ 3, with chest, abdomen, and extremity AIS scores ≤ 2. Preinjury medication use was determined through chart review. All patients with concurrent BB use were initially excluded. In-hospital mortality was the primary measured outcome. RESULTS: Over the 5-year study period, 600 patients were identified with isolated TBI who were naive to BB use. There was significantly higher mortality (P = .04) among patients who received ACEI before injury (10 of 96; 10%) than among those who did not (25 of 504; 5%). A multivariate stepwise logistic regression analysis revealed a threefold increased risk of mortality in the ACEI cohort (P < .001), which was even greater than the twofold increased risk of mortality associated with an Injury Severity Score ≥ 16. A second analysis that included patients who received preinjury BBs (n = 98) demonstrated slightly reduced mortality in the ACEI cohort with only a twofold increased risk in multivariate analysis (P = .05). CONCLUSIONS: Preinjury exposure to ACEIs is associated with an increase in mortality among patients with isolated TBI. This effect is ameliorated in patients who receive BBs, which provides evidence that this class of medications may provide a protective benefit.

Cranioplasty Using Polymethylmethacrylate Cement Following Retrosigmoid Craniectomy Decreases the Rate of Cerebrospinal Fluid Leak and Pseudomeningocele.

OBJECTIVE: Cerebrospinal fluid (CSF) leak frequently occurs after retrosigmoid craniectomy. The present study investigated the effects of cranioplasty using polymethylmethacrylate (PMMA) cement to reduce the incidence of CSF leak following retrosigmoid craniectomy as compared with the autologous bone flap combined with titanium plates. METHODS: Two hundred forty-three patients underwent surgeries via retrosigmoid approach for microvascular decompression or tumor resection. Of these, 107 patients underwent craniotomy, and incomplete cranioplasty was performed with autologous bone flap fixed with titanium plates, while 136 patients underwent craniectomy and complete cranioplasty was performed with PMMA cement. Variables including the incidence of CSF leak, pseudomeningocele formation, wound infection, rejection reaction were compared retrospectively based on the clinical data between the 2 groups. RESULTS: In the autologous bone group, 9 patients had postoperative CSF leaks, and 11 patients had pseudomeningoceles, while 3 CSF leaks and 2 pseudomeningoceles were found in the PMMA group. Statistical analysis showed that PMMA significantly decreased the incidence of postoperative CSF leaks (P = 0.03) and pseudomeningocele formation (P = 0.002). Wound infections were observed in 2 and 1 patients between the autologous bone and PMMA group, respectively, which did not differ significantly (P = 0.58). None of the patients in both groups developed a rejection reaction of artificial materials. CONCLUSIONS: Complete cranioplasty with PMMA cement following retrosigmoid craniectomy could decrease the incidence of CSF leak and pseudomeningocele formation as compared with the autologous bone flap combined with titanium plates. Thus, PMMA cement is preferable for bone reconstruction with excellent biocompatibility and without increasing the rate of wound infection.

State of the Union in Open Neurovascular Training.

BACKGROUND: The evolution of minimally invasive endovascular approaches and training paradigms has reduced open neurovascular case exposure for neurosurgical residents. There are no published estimates of open neurovascular case volumes during residency or Committee on Advanced Subspecialty Training (CAST) accredited fellowships. METHODS: Case volumes from residency programs submitting data for CAST accredited fellowship applications were collected and analyzed. The study period covered the academic years of 2013-2016. Case index volumes were calculated to provide an estimate of total volume of cases each trainee participated in a given year. The case index volume was defined as the total volume of cases per year divided by the total training complement. RESULTS: Over the study period, institutional data from 46 programs were available. Of those programs, 9 programs had CAST accredited open cerebrovascular fellowships. Across all 46 programs, the median number of vascular cases was 246 (interquartile range [IQR]: 148-340), whereas the median number of open vascular cases was 105 (IQR: 67-152). The median number of open aneurysm cases among programs with CAST cerebrovascular fellowships was 80 (IQR: 54-103) and among programs without CAST cerebrovascular fellowships was 34 (IQR: 24-63). The median open aneurysm case index volume for trainees at programs with and without CAST cerebrovascular fellowships was 23 (IQR: 14-29) and 19 (IQR: 11-24). CONCLUSIONS: Strong neurovascular training can be obtained through dedication and planning. Completion of a CAST accredited cerebrovascular fellowship will often more than double aneurysm case exposure of trainees.

Neurosurgical Oncology in Vietnam.

BACKGROUND: In conjunction with Vietnam's unparalleled economic growth over the past 20 years, our scope of neurosurgical interventions has considerably diversified throughout this time period. METHODS: Although still appreciably limited, healthcare resources and infrastructure have expanded and shifted the focus within neurosurgery at Ho Chi Minh City's Cho Ray Hospital from head trauma (which remains highly prevalent) to an equal proportion of elective cases for vascular lesions, tumors, and degenerative spine disease. Arguably the most significant progress throughout the new millennium has been achieved in the realm of neurosurgical oncology. RESULTS: About 1000 craniotomies are performed annually for brain tumors at our institution, most of which are for lower-grade lesions that result in excellent surgical outcomes. We continue to strive to improve the standard of care for patients with malignant brain tumors, as the first multidisciplinary neuro-oncology care team was founded recently in 2016. CONCLUSIONS: This article is the first in the English neurosurgical literature to report on the current state and outcomes of neuro-oncology in Vietnam, as we highlight our experiences in caring for patients with brain tumors at Cho Ray Hospital.

Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis.

BACKGROUND: Early tracheostomy has been associated with shorter hospital stay and fewer complications in adult trauma patients. Guidelines for tracheostomy have not been established for children with severe traumatic brain injury (TBI). The purpose of this study was to (1) define nationwide trends in time to extubation and time to tracheostomy and (2) determine if early tracheostomy is associated with decreased length of stay and fewer complications in children with severe TBI. METHODS: Records of children (<15 years) with severe TBI (head Abbreviated Injury Severity [AIS] score ≥3) who were mechanically ventilated (>48 hours) were obtained from the National Trauma Data Bank (2007-2015). Outcomes after early (≤14 days) and late (≥15 days) tracheostomy placement were compared using 1:1 propensity score matching to control for potential confounding by indication. Propensity scores were calculated based on age, race, pulse, blood pressure, Glasgow Coma Scale motor score, injury mechanism, associated injury Abbreviated Injury Severity scores, TBI subtype, craniotomy, and intracranial pressure monitor placement. RESULTS: Among 6,101 children with severe TBI, 5,740 (94%) were extubated or died without tracheostomy, 95% of the time within 18 days. Tracheostomy was performed in 361 children (6%) at a median [interquartile range] of 15 [10, 22] days. Using propensity score matching, we compared 121 matched pairs with early or late tracheostomy. Early tracheostomy was associated with fewer ventilator days (14 [9, 19] vs. 25 [19, 35]), intensive care unit days (19 [14, 25] vs. 31 [24, 43]), and hospital days (26 [19, 41] vs. 39 [31, 54], all p < 0.05). Pneumonia (24% vs. 41%), venous thromboembolism (3% vs. 13%), and decubitus ulcer (4% vs. 13%) occurred less frequently with early tracheostomy (p < 0.05). CONCLUSIONS: Early tracheostomy is associated with shorter hospital stay and fewer complications among children with severe TBI. Extubation without tracheostomy is rare beyond 18 days after injury. LEVEL OF EVIDENCE: Prognostic and epidemiological, retrospective comparative study, level III.

Visual Complications of Pediatric Posterior Fossa Tumors: Analysis of Outcomes.

OBJECTIVE: Visual abnormalities are common among children with posterior fossa tumors, resulting from disruption of ocular afferent and efferent systems due to the tumor or surgery. This study describes the visual complications and outcomes associated with these tumors. METHODS: Clinical and radiographic data of patients who underwent index surgery for resection of posterior fossa tumor from 2007 to 2016 were reviewed. Descriptive statistics, univariate, and multivariate regression were performed to assess factors contributing to visual acuity and postoperative strabismus. RESULTS: There were 182 patients who underwent posterior fossa craniotomy for neoplasm were included. Ophthalmologic symptoms were the fourth most common presenting complaint; initial ophthalmologic examination was abnormal in 40% of patients. Evaluation of visual acuity demonstrated a good outcome in 88% of patients following treatment. The most common postoperative oculomotor finding was esotropia (29%) which resolved spontaneously in more than half of patients. A good outcome was obtained in all patients who underwent surgery for esotropia. Hypertropia was noted in 14% of the cohort and less than half resolved spontaneously; less than half undergoing strabismus surgery for hypertropia had a good outcome. Multivariate analysis confirmed the association between cerebellar mutism and postoperative esotropia and hypertropia. Clinically significant pathological nystagmus was seen in 8% of the cohort. CONCLUSIONS: Our results indicate a good visual outcome in the majority of pediatric patients undergoing resection of posterior fossa tumors. Ophthalmologic complications should be appropriately evaluated and addressed to allow for the best possible vision to survivors of posterior fossa tumors.

Meningioma Surgery-Are We Making Progress?

BACKGROUND: To study improvements in outcomes after surgery for intracranial meningiomas. METHODS: We performed a longitudinal observational study comparing 1469 patients operated on for intracranial meningioma in 4 consecutive time frames (1990-1994, 1995-1999, 2000-2004, and 2005-2010). RESULTS: Median age at surgery was 58.3 years. Median follow-up was 7 years. Patients in later periods were older than in the earlier ones (odds ratio [OR], 1.19 [1.09-1.32]; P < 0.0005), indicating a trend toward operating on more elderly patients. Before 2000, 42%, 32%, 6%, 19%, and 0.3% achieved Simpson grade (SG) I, II, III, IV, and V, respectively, whereas the SG rates were 35%, 37%, 4%, 23%, and 0.9% after 2000 (OR, 1.18 [1.06-1.30]; P < 0.005). The perioperative mortality (OR, 0.65 [0.46-0.91]; P < 0.05) and worsened neurologic outcome rate (OR, 0.70 [0.60-0.83]; P < 0.0001) were significantly lower in later decades, but the 4 surgical periods were similar regarding postoperative infections and hematomas. Retreatment-free survival (RFS) and overall survival (OS) increased significantly over the 4 time frames (P < 0.05 and P < 0.0001, respectively). Multivariate analysis confirmed the improvement of surgical radicality, neurologic outcome, perioperative mortality, OS, and RFS. CONCLUSIONS: Meningioma surgery as well as patient population changed over the 2 decades considered in this study. We observed higher rates of gross total resection in the later period and the perioperative outcomes improved or were unchanged, which signifies better long-term outcomes, RFS, and OS.