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.

Practice variation in the conservative and surgical treatment of chronic subdural hematoma.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a condition that is frequently seen in the neurological and neurosurgical practice. Surgical treatment is overall preferred; however, conservative treatment is also an option. Both surgical and conservative treatment of CSDH vary across neurosurgeons. The aim of the present study was to evaluate different treatment strategies for CSDH among neurosurgeons in different countries. MATERIAL AND METHODS: We designed a survey that was sent to neurosurgeons affiliated with the Congress of Neurological Surgeons.The questions were related to the conservative and surgical treatment methods of CSDH. Furthermore, we also included questions related to post-operative care. RESULTS: 443 neurosurgeons completed the survey. 46.2 % of the respondents sometimes use dexamethasone as monotherapy. Overall, 26.2 % estimated dexamethasone to have a high efficacy on CSDH. A Glasgow Coma Score lower than 12 was considered to be the most important indication for surgery by 57.8 %. Double burr hole is the preferred surgical technique by 48.1 % of the respondents. One day after surgery, 69.3 % routinely orders a CT-scan. CONCLUSIONS: The majority of the neurosurgeons worldwide remains reluctant in the use of conservative treatment methods in the management of CSDH. Further research is needed to assess the effectivity and side-effects of these conservative methods.

Treatment of scalp defects with a combination of trephination and platelet-rich plasma.

In cases of complete scalp loss where the calvarium is exposed and reconstruction cannot be achieved using replantation, or local or far flaps, using trephination to create holes to the depth of the spongeous layer followed by grafting once granulation has covered all defects is an important reconstruction alternative. However, growth of the granulation after trephination and waiting for the entire defect to be covered is a slow process. Since the introduction of platelet-rich plasma (PRP), several researchers have investigated the efficacy of different bone healing and grafting procedures. We present a case with full-thickness partial scalp defect in which we support the development of granulation through holes drilled to the spongeous layer by trephination with PRP.

Factors affecting mortality after traumatic brain injury in a resource-poor setting.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of long-term disability and economic loss to society. The aim of this study was to assess the factors affecting mortality after TBI in a resource-poor setting. METHODS: Chart review was performed for randomly selected patients who presented with TBI between 2013 and 2017 at St Mary's Hospital, Lacor, northern Uganda. Data collected included demographic details, time from injury to presentation, and vital signs on arrival. In-hospital management and mortality were recorded. Severe head injury was defined as a Glasgow Coma Scale score below 9. RESULTS: A total of 194 patient charts were reviewed. Median age at time of injury was 27 (i.q.r. 2-68) years. The majority of patients were male (M : F ratio 4·9 : 1). Some 30·9 per cent of patients had severe head injury, and an associated skull fracture was observed in 8·8 per cent. Treatment was mainly conservative in 94·8 per cent of patients; three patients (1·5 per cent) had burr-holes, four (2·1 per cent) had a craniotomy, and three (1·5 per cent) had skull fracture elevation. The mortality rate was 33·0 per cent; 46 (72 per cent) of the 64 patients who died had severe head injury. Of the ten surgically treated patients, seven died, including all three patients who had a burr-hole. In multivariable analysis, factors associated with mortality were mean arterial pressure (P = 0·012), referral status (P = 0·001), respiratory distress (P = 0·040), severe head injury (P = 0·011) and pupil reactivity (P = 0·011). CONCLUSION: TBI in a resource-poor setting remains a major challenge and affects mainly young males. Decisions concerning surgical intervention are compromised by the lack of both CT and intracranial pressure monitoring, with consequent poor outcomes.

ANTECEDENTES: La lesión cerebral traumática (traumatic brain injury, TBI) es un insulto al cerebro causado por una fuerza física externa que produce un estado de conciencia disminuido o alterado, lo que resulta en un deterioro de las capacidades cognitivas o del funcionamiento físico. Es una causa importante de discapacidad a largo plazo y pérdida económica para la sociedad. El objetivo de este estudio fue evaluar los factores que afectan a la mortalidad después de una TBI en un entorno de escasos recursos. MÉTODOS: Se realizó la revisión de historias clínicas de pacientes seleccionados al azar que habían presentado una TBI entre 2013 y 2017 en el Hospital St. Mary's, un hospital privado sin ánimo de lucro ubicado en el distrito de Gulu, Lacor, en el norte de Uganda. Se recogieron datos de las características demográficas, intervalo de tiempo entre la lesión y la atención médica, y signos vitales a la llegada al hospital. Se registró también el manejo hospitalario y la mortalidad. El traumatismo craneal grave se definió como aquel con una escala de coma de Glasgow (Glasgow Coma Scale, GCS) por debajo de 9. RESULTADOS: Se revisaron 194 historias clínicas de pacientes. La mediana de edad en el momento del traumatismo fue de 27 (rango intercuartílico de 2 a 68) años. La mayoría eran varones con una relación varón:mujer de 4,9:1. En el 38,1% de los casos los traumatismos craneales fueron calificados como graves y se observó una fractura de cráneo asociada en el 8,8% de los pacientes. Los tratamientos ofrecidos fueron principalmente conservadores en el 94,9%; tres pacientes (1,6%) precisaron trépanos, en cuatro pacientes (2,1%) se realizó una craneotomía y otros tres pacientes (1,6%) precisaron elevación de una fractura craneal con hundimiento. La mortalidad fue del 33,0%; El 71,9% de ellos tenían un traumatismo craneal grave. Entre los pacientes tratados quirúrgicamente, siete (70%) murieron, incluidos los tres pacientes en los que se realizó un trépano. Los factores asociados con la mortalidad en el análisis multivariable fueron la presión arterial media (P < 0,05), el estado en el traslado (P < 0,05), la dificultad respiratoria (P = 0,040), el traumatismo craneal grave (P = 0,012) y la reactividad pupilar (P = 0,011). CONCLUSIÓN: El TBI en un entorno con pocos cursos continúa siendo un desafío importante, afectando principalmente a varones jóvenes. Las decisiones relativas a la intervención quirúrgica y el momento de su práctica están seriamente comprometidas por la falta de disponibilidad de tomografía computarizada (TAC) y monitorización de la presión intracraneal, lo que conlleva unos pobres resultados.

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.

Association between volume of surgery for acute hemorrhagic stroke and mortality.

This study aimed to investigate the association between volume of surgery and mortality in relation to interventions for acute hemorrhagic stroke, namely craniotomy and trephination.We obtained data on acute hemorrhagic stroke patients for a 5-year period (2009-2013) from the Health Insurance Review and Assessment Service. Hospitals were classified into 3 categories according to volume of surgery (low, medium, high). To avoid intentionally setting a cutoff, we placed the hospitals in order from those with high volume of surgery to those with low volume of surgery and divided them into 3 groups (tertile) according to the number of patients. The covariates were age, sex, hemorrhagic stroke site, type of health insurance, intensive care unit admission, history of hypertension, and Charlson comorbidity index. Multiple logistic regression analysis was performed with statistical significance set at 5%.A total of 41,917 patients who underwent craniotomy (n = 20,982) or trephination (n = 20,935) for acute hemorrhagic stroke were analyzed according to hemorrhage site (subarachnoid and others). The results showed that mortality from acute hemorrhagic stroke decreased with increasing volume of surgery. For subarachnoid hemorrhage, the odds ratios of the medium- and high-volume surgery groups were significantly lower (0.74 and 0.59, respectively) for mortality within 7 days of admission, and were also significantly lower (0.78 and 0.68) for mortality within 30 days of admission than that of the low-volume surgery group. The results for other hemorrhage sites were similar. The association between mortality and volume of surgery was more evident in the craniotomy group. Although this study was limited to a single country (South Korea), it partially addressed the shortcomings of previous studies by analyzing a nationwide database and examining all types of hemorrhagic strokes.

Trepanation and enlarged parietal foramen on skulls from the Loyalty Islands (Melanesia).

The goal of this study is a comprehensive examination of openings discovered on two skulls in the collection of skeletal remains from the Loyalty Islands (Melanesia). The skull No. 1524 displayed an evidence of successful trepanation, and the skull No. 7985 revealed openings that were reminiscent of a trepanation, however, we are inclined to believe that in the latter case we are dealing with a rare genetic anomaly - enlarged parietal foramen.

[Development of Endothelial Cell Density after Penetrating Keratoplasty in Patients with Fuchs Dystrophy or Keratoconus - Comparison of Excimer Laser and Mechanical Trephination]. / Entwicklung der Endothelzelldichte nach perforierender Keratoplastik bei Patienten mit Fuchs-Dystrophie oder Keratokonus ­ Vergleich von Excimer-Laser- und mechanischer Trepanation.

Purpose The aim of this retrospective study was to compare the development of endothelial cell density (ECD) after penetrating keratoplasty (PKP) in patients with Fuchs dystrophy (FD), keratoconus (KC) or "other diagnoses" (OD), depending on the type of trephination. Patients and Methods In 104 eyes with Fuchs dystrophy, keratoconus or "other diagnoses", the ECD after PKP using either excimer laser (EXC) or mechanical trephination (MECH) was registered after 1.5, 6, 12, 18 and 24 months. With linear and exponential regression models, the endothelial cell loss (ECL) was determined as absolute and percentage cell loss per year. Results For the entire group of patients, ECD was significantly higher after EXC-PKP during the full range of follow-up (except 6 months). With a linear regression model, there was no significant difference in the absolute ECL per year (p = 0.084), but with an exponential regression model, there was a significant difference in the percentage ECL per year (p = 0.021) in favour of EXC trephination. For keratoconus (n = 33), except for the 24-month-follow-up (p = 0.035), ECD was not significantly different on the basis of EXC vs. MECH. With a linear regression model, there was a significant difference in the absolute ECL per year (p = 0.015) in favour of EXC-trephination, but with an exponential regression model there was no significant difference in the percentage ECL per year (p = 0.088) between the two types of threphination. In patients with FUCHS (n = 35) - except for the 6-week-follow-up (p = 0.024) - ECD was not significantly different for EXC vs. MECH. With linear/exponential regression model, the ECL per year was not significantly different in favour of any type of trephination (p = 0.287/p = 0.121). In patients with OD (n = 36), ECD was not significantly different for EXC vs. MECH. With a linear/exponential regression model, the ECL per year was not significantly different in favour of any type of trephination (p = 0.494/p = 0.787). Conclusion During the first 24 months after PKP, a significantly higher ECD and a significantly lower percentage of ECL per year was observed after EXC trephination for the entire group of patients. For the different diagnostic groups KC, FD and OD, no significant difference in ECD or ECL loss was noticed over a range of follow-up intervals. This may most likely be attributed to the small number of patients in the three subgroups.

A novel concept for smart trepanation.

Trepanation of the skull is a common procedure in craniofacial and neurosurgical interventions, allowing access to the innermost cranial structures. Despite a careful advancement, injury of the dura mater represents a frequent complication during these cranial openings. The technology of computer-assisted surgery offers different support systems such as navigated tools and surgical robots. This article presents a novel technical approach toward an image- and sensor-based synergistic control of the cutting depth of a manually guided soft-tissue-preserving saw. Feasibility studies in a laboratory setup modeling relevant skull tissue parameters demonstrate that errors due to computed tomography or magnetic resonance image segmentation and registration, optical tracking, and mechanical tolerances of up to 2.5 mm, imminent to many computer-assisted surgery systems, can be compensated for by the cutting tool characteristics without damaging the dura. In conclusion, the feasibility of a computer-controlled trepanation system providing a safer and efficient trepanation has been demonstrated. Injuries of the dura mater can be avoided, and the bone cutting gap can be reduced to 0.5 mm with potential benefits for the reintegration of the bone flap.

Subdural hematomas and emergency management in infancy and childhood: a single institution's experience.

OBJECTIVE: We aimed to identify the incidence, clinical features, management, and outcome of subdural hematomas (SHs) in infancy and childhood. METHODS: Twenty-one children younger than 11 years with SH were analyzed. Clinical features and possible child abuse were considered in each case. RESULTS: Eight children experienced minor injuries due to hitting of solid items on their head. Five of these children also had coagulation disorders. Three of the children suffered from child abuse, only one of the children had head trauma due to car accident. Nine of the patients experienced SH due to fall down. Nine patients have acute SH, 7 had subacute SH, 4 had chronic SH, and 1 had acute and subacute SH together. Clinical presentation varied greatly. Most of them presented with vomiting and seizure. The outcome patterns were different among the patients. Deep coma on admission was associated with an unfavorable outcome. CONCLUSIONS: Subdural hematoma is common in infancy and childhood and carries a poor prognosis. Most of the cases are due to head trauma, coagulation disorders, and child abuse. We believe that clinical investigation of such children should be carried out in a multidisciplinary approach with the collaboration of pediatricians, social workers, and neurosurgeons.

Reversible monoparesis following decompressive hemicraniectomy for traumatic brain injury.

OBJECT: The "syndrome of the trephined" is an uncommon and poorly understood disorder of delayed neurological deficit following craniectomy. From the authors' extensive experience with decompressive hemicraniectomy for traumatic brain injury (TBI), they have encountered a number of patients who developed delayed motor deficits, also called "motor trephine syndrome," and reversal of the weakness following cranioplasty repair. The authors set out to study motor function systematically in this patient population to define the incidence, contributing factors, and outcome of patients with motor trephine syndrome. METHODS: The authors evaluated patient demographics, injury characteristics, detailed motor examinations, and CT scans in 38 patients with long-term follow-up after decompressive hemicraniectomy for TBI. RESULTS: Ten patients (26%) experienced delayed contralateral upper-extremity weakness, beginning 4.9 +/- 0.4 months (mean +/- standard error) after decompressive hemicraniectomy. Motor deficits improved markedly within 72 hours of cranioplasty repair, and all patients recovered full motor function. The CT perfusion scans, performed in 2 patients, demonstrated improvements in cerebral blood flow commensurate with resolution of cerebrospinal fluid flow disturbances on CT scanning and return of motor strength. Comparisons between 10 patients with and 20 patients (53%) without delayed motor deficits identified 3 factors--ipsilateral contusions, abnormal cerebrospinal fluid circulation, and longer intervals to cranioplasty repair--to be strongly associated with delayed, reversible monoparesis following decompressive hemicraniectomy. CONCLUSIONS: Delayed, reversible monoparesis, also called motor trephine syndrome, is common following decompressive hemicraniectomy for TBI. The results of this study suggest that close follow-up of motor strength with early cranioplasty repair may prevent delayed motor complications of decompressive hemicraniectomy.

Secondary insults and outcomes in patients with hypertensive basal ganglia hemorrhage.

This study was designed to monitor secondary insults and their impact on outcomes of patients with hypertensive basal ganglia hemorrhage (HBGH). One hundred and twelve patients with HBGH (male 73, female 39) of age 42 +/- 8 years (range from 38 to 57 years) were studied. Operations included craniotomy or trephination drainage with urokinase thrombolysis. Conventional therapies were also given to the patients including the administration of mannitol, crystalloid and colloid solution. In the meantime, blood pressure (MAP), temperature (T) and SaO2 and other parameters were recorded in the intensive care unit. The ICP values were recorded, and the early clinical outcome was assessed upon discharge according to Glasgow Outcome Scale. Cerebral Perfusion Pressure was calculated as CPP = MAP-MICP. Outcomes in the group without secondary insults were better than that in the group with secondary insults (P < 0.01). No unfavorable outcomes were found in the 59 cases managed by ultra-early surgery whereas 36.1% of the cases operated after 6 hours of onset had unfavorable outcomes. It is concluded that the high incident rate of secondary insults in HICH patients influences outcome. Ultra-early surgery may also contribute to improved quality of survival.