A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage.

CONTEXT: Spontaneous intracerebral haemorrhage (ICH) accounts for 4-14% of all strokes and has a high mortality rate of 30-50% during the first month. Management of large hematomas is controversial, with some advocating medical management while others favoring surgical evacuation. AIM: This study was undertaken to compare the outcome of patients with a spontaneous supratentorial intracerebral hemorrhage (SSICH) managed with or without surgical evacuation. SETTINGS AND DESIGN: Four hundred and eighty-two SSICH patients admitted from September 2013 to August 2015 were evaluated based on the inclusion and exclusion criteria. MATERIALS AND METHODS: Among a total of 61 patients with Glasgow Coma Scale (GCS) of 4-14 and hematoma volume of> 30 ml, 27 were randomized to receive medical management (MM) alone and the remaining 34 were randomized to combined surgical as well as medical management (SM). Primary and secondary outcomes were mortality and dependency at 3 months, respectively. STATISTICAL ANALYSIS USED: Student's t-test and X2 test were used for univariate analysis, and logistic regression analysis was employed for multiple variables. RESULTS: On univariate analysis, mortality was significantly lower in the SM group (n = 21,61.8%) compared to the MM group (n = 23,85.2%) (P = 0.043); however, the groups showed no significant difference in dependency at 3 months. Further subgroup analysis showed that a hematoma volume of 30-60 ml, a deeply located hematoma, associated intraventricular hemorrhage, and a Glasgow Coma Scale (GCS) of 4-8 had a significantly lesser mortality in the SM group (P < 0.05). On multivariate analysis, a significant association was found between the mortality and the treatment arm (P = 0.006). CONCLUSIONS: In patients with SSICH, mortality was found to be significantly associated with the treatment arm and the results were in favour of SM among the patients presenting with GCS 4-8, hematoma volume 31-60 ml, midline shift of more than 5 mm, and intraventricular extension of the hematoma.

Craniofacial Trauma in Pediatric Patients Following Winnowing Blade Injury-review of Literature.

In developing countries, during the harvest season, winnower blade injuries occur very frequently in children and results in lifelong disability. Nine children were managed during 1 month, all resulting due to winnower blade induced craniofacial trauma. PubMed search for "fan blade injury" showed two case series and three case reports. In our study, 88% had compound depressed fracture; brain matter leak in 56%, cerebrospinal fluid (CSF) leak alone in 22%. 66.7% had injury involving the frontal bone. Two patients had eye injury with visual loss. Seven underwent debridement craniectomy, five augmentation duroplasty and three contusectomy. All had vegetable material, sand particles. Complications in 66.6% with two cases of CSF leak settled with lumbar drain, one case of CSF otorrohea, 22.2% of wound infection, 44.4% wound dehiscence requiring redebridement and suturing in five patients. Two patients had postoperative seizures, two patients had hemiparesis both improved. Two low Glasgow Coma Scale remained so on postoperative period. One case of subdural empyema needed debridement and duroplasty with glue. No mortality noted. These findings were consistent with previous reports. Follow-up at 1.5 months showed good functional recovery. Early surgery debridement, steps to minimize postoperative infections, identifying putative risk factors early in the management are the principles of a successful treatment regimen.

Retrograde Partial Migration of Ventriculoperitoneal Shunt with Chamber: Review of Causative Factors and Its Prevention.

Distal migration of shunt is a very common occurrence. Proximal migration of shunt is rare and possible pathophysiological mechanisms to explain this unusual complication is rarely attempted. A 5-month-old child shunted for posttraumatic hydrocephalus presented 1.5 years later with raised intracranial pressure and seizures. Imaging showed subdural hygroma, partial intracranial migration of shunt/chamber. On endoscopy, choroid plexus was adherent to shunt tip and some pericranial tissue was found in the anchoring suture (intraventricularly displaced). Shunt was retrieved endoscopically and diversion established by endoscopic third ventriculostomy with symptoms free follow-up. Host-related and surgical factors have been postulated. Tug-of-war effect on the anchoring suture and collapsing cortex are the possible mechanisms that explain proximal migration in our case. Three-point fixation of the chamber to pericranium, small burr hole with a smaller durotomy, can prevent shunt migration. Proximal shunt migrations should be dealt with endoscopy so as to avoid complications.