Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?

Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.

Nonaneurysmal nonperimesencephalic subarachnoid hemorrhage: is it a benign entity?

BACKGROUND: Although the clinical profile of patients with PMN SAH is well documented, there are scarce data available for patients with nonaneurysmal n-PMN SAH. In the present study, the clinical characteristics of patients with n-PMN SAH were analyzed and compared with those of PMN SAH and aneurysmal SAH. METHODS: Patients with spontaneous SAH, in whom the initial DSA or 3-dimensional CTA result was normal, underwent another investigation (CTA/DSA). If the results of both of these were negative, a second DSA was done after 4 to 6 weeks. Patients in whom even the second DSA failed to reveal an aneurysm or any other vascular abnormality were labeled as nonaneurysmal SAH. Within this group, 2 different types were identified: PMN SAH and n-PMN SAH. RESULTS: There were 61 patients in whom the results of the first DSA and CTA were both negative. In 2 of these patients, an aneurysm was demonstrated at a second DSA. Seven patients died before a second DSA could be done. After excluding these, there were 18 patients with PMN SAH and 34 with n-PMN SAH. There was no mortality in these patients; and at a mean follow-up of 1.8 years, all patients with PMN SAH and 94.1% of patients with n-PMN SAH had a good outcome. Associated comorbid illnesses were more frequent in patients with PMN SAH and n-PMN SAH as compared with the aneurysmal SAH patients. CONCLUSIONS: Once an aneurysm is definitely excluded, patients with n-PMN SAH have a good outcome, and like PMN SAH, have a benign clinical course. However, a second DSA is mandatory to avoid missing an aneurysm or any other vascular lesion.

Giant dumbbell foramen magnum neurinomas presenting as posterior neck masses: single-stage removal by posterior midline approach.

Two patients with giant dumbbell foramen magnum neurinomas are reported. The intradural component was located anterior to the cervicomedullary junction while the extradural and extraspinal portion of the tumor had grown large enough to present as a neck swelling. In both patients total surgical removal was achieved by a single-stage posterior midline approach. Both patients had complete neurological recovery.

Giant calvarial hyperostosis with biparasagittal en plaque meningioma.

We report a patient with an uncommon presentation in the form of massive bilateral calvarial hyperostosis with bi-parasagittal en plaque meningioma. The tumour was removed by bilateral fronto-parieto-occipital craniotomies. The patient was subjected to post operative radiotherapy to reduce the chances of recurrance. The management of such a case is a surgical challenge.

Distal anterior cerebral artery aneurysms: bifrontal basal anterior interhemispheric approach.

BACKGROUND: Distal anterior cerebral artery (DACA) aneurysms are uncommon. Most authors have reported technical difficulties during surgery for these aneurysms, and a variety of surgical approaches have been advocated. METHODS: Over a period of 5 years (1999-2003), 67 patients with DACA aneurysms were operated. Twenty-eight of these were operated on through the bifrontal basal anterior interhemispheric approach. Of the 28 patients, 68% were in poor clinical grade (Hunt and Hess grade III-V) and 89.3% had a Fisher grade III and IV on computed tomography scan. A surgical trajectory about 2 to 3 cm superior to the anterior cranial fossa floor led directly to the aneurysm. Proximal control was achieved before aneurysm dissection and parallel clipping. RESULTS: Good outcome (Glasgow Outcome Scale V and IV) was seen in 57.19 of the patients, 14.3% had a poor outcome, and 28.6% died. The cause of death in most patients was found to be a poor clinical grade, postoperative infarct, or presence of multiple aneurysms. CONCLUSIONS: The advantages of the bifrontal basal anterior interhemispheric approach were the following: (a) It provided the shortest and a direct trajectory to the aneurysm. (b) Proximal control of the parent A(2) vessels could be easily achieved. (c) Release of cerebrospinal fluid from basal cisterns could be done, if necessary. (d) There was a minimal distortion of or traction over the aneurysm.

Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients.

BACKGROUND: Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA. MATERIALS AND METHODS: Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI. RESULTS: Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function. CONCLUSION: Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.

Safety and efficacy of sildenafil citrate in reversal of cerebral vasospasm: A feasibility study.

OBJECTIVE: Cerebral vasospasm is the commonest cause for mortality and morbidity in patients following clipping of a ruptured aneurysm. Selective phosphodiesterase (PDE) inhibitor like sildenafil acts as a vasodilator. The objective of this study was to evaluate the safety and feasibility of oral sildenafil citrate in patients with symptomatic refractory vasospasm. METHODS: A total of 832 patients with aneurysmal subarachnoid bleed were operated in 4 years. Two hundred and seventy-three patients had vasospasm. Of these, 72 patients had refractory cerebral vasospasm. Vasospasm was defined as refractory when institution of "HHH" failed to reverse the transcranial Doppler (TCD) values even after 24 hours. Computed tomography (CT) scan showed no infarct, hematoma, or hydrocephalus, and the serum electrolytes were within normal limits. They received 100-150 mg of sildenafil every 4 hours. Response was evaluated by 2-hourly TCD. RESULTS: Eight patients had sustained (TCD values normal for >48 hours) and four had temporary relief in vasospasm, as suggested. Four patients developed complications significant enough to terminate the therapy. CONCLUSIONS: Sildenafil citrate may be effective in patients with refractory symptomatic vasospasm. It calls upon the pharmacologists and scientists to discover newer supraselective PDE inhibitors, specific to PDE receptors in brain vessels.

A report of two 'traumatic encephaloceles'; an unrecognized entity.

PURPOSE: An unusual complication following severe head trauma in two infants is described. METHOD: 'Acute traumatic encephalocele' or 'extracalvarial herniation' is presented as an entity, different from 'growing skull fracture'. RESULTS: The acuteness of presentation and non-progressive calvarial fracture aperture, along with increasing size of herniated contents is the hall-mark of such pathology. CONCLUSION: Repair of dural defect with a patch after excision of gliosed brain provides satisfactory outcome.

Tuberculosis of the craniovertebral junction: is surgery necessary?

OBJECTIVE: Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. METHODS: A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978-1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987-1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999-2004), all patients (n = 16) in all stages (Stages I-III) have been managed without surgery by a rigid external immobilization. RESULTS: Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. CONCLUSION: The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.