Dharmendra Ganesan

Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: a randomised controlled trial

BACKGROUND Chronic subdural haematoma causes serious morbidity and mortality. It recurs after surgical evacuation in 5-30% of patients. Drains might reduce recurrence but are not used routinely. Our aim was to investigate the effect of drains on recurrence rates and clinical outcomes. METHODS We did a randomised controlled trial at one UK centre between November, 2004, and November, 2007. 269 patients aged 18 years and older with a chronic subdural haematoma for burr-hole drainage were assessed for eligibility. 108 were randomly assigned by block randomisation to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing redrainage. The trial was stopped early because of a significant benefit in reduction of recurrence. Analyses were done on an intention-to-treat basis. This study is registered with the International Standard Randomised Controlled Trial Register (ISRCTN 97314294). FINDINGS Recurrence occurred in ten of 108 (9.3%) people with a drain, and 26 of 107 (24%) without (p=0.003; 95% CI 0.14-0.70). At 6 months mortality was nine of 105 (8.6%) and 19 of 105 (18.1%), respectively (p=0.042; 95% CI 0.1-0.99). Medical and surgical complications were much the same between the study groups. INTERPRETATION Use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months. FUNDING Academy of Medical Sciences, Health Foundation, and NIHR Biomedical Research Centre (Neurosciences Theme).

Diffusion tensor imaging parameters in mild traumatic brain injury and its correlation with early neuropsychological impairment: A longitudinal study

Abstract We explored the prognostic value of diffusion tensor imaging (DTI) parameters of selected white matter (WM) tracts in predicting neuropsychological outcome, both at baseline and 6 months later, among well-characterized patients diagnosed with mild traumatic brain injury (mTBI). Sixty-one patients with mTBI (mean age=27.08; standard deviation [SD], 8.55) underwent scanning at an average of 10 h (SD, 4.26) post-trauma along with assessment of their neuropsychological performance at an average of 4.35 h (SD, 7.08) upon full Glasgow Coma Scale recovery. Results were then compared to 19 healthy control participants (mean age=29.05; SD, 5.84), both in the acute stage and 6 months post-trauma. DTI and neuropsychological measures between acute and chronic phases were compared, and significant differences emerged. Specifically, chronic-phase fractional anisotropy and radial diffusivity values showed significant group differences in the corona radiata, anterior limb of internal capsule, cingulum, superior longitudinal fasciculus, optic radiation, and genu of corpus callosum. Findings also demonstrated associations between DTI indices and neuropsychological outcome across two time points. Our results provide new evidence for the use of DTI as an imaging biomarker and indicator of WM damage occurring in the context of mTBI, and they underscore the dynamic nature of brain injury and possible biological basis of chronic neurocognitive alterations.

Concomitant injuries and its influence on functional outcome after traumatic brain injury.

Abstract Purpose: This study aims to describe the presence and severity of extracranial concomitant injuries in traumatic brain injury (TBI) patients and to ascertain their effect on long-term functional outcome. Method: A retrospective cohort study was performed in a single-center recruiting patients with first episode of TBI. The types and severity of extracranial concomitant injuries were documented for patients who fulfilled the inclusion criteria. Injuries with Abbreviated Injury Scale (AIS) grade 3–6 were considered to be high grade. A cross-sectional functional assessment was conducted at 18 months post-injury using Glasgow Outcome Scale. Results: A total of 100 patients were included in the analysis. Extracranial concomitant injuries were seen in 78% of the patients. Three commonest injuries were facial (44%), lower extremity (20%) and upper extremity (12%) injuries. Among the AIS grade ≥ 3, injury involving the chest was most common (41%). Presence of extracranial concomitant injuries AIS grade ≥ 3 was significantly associated with disability in TBI patients at 18 months (OR 12.74, 95% CI 2.39–67.95, p = 0.003). Conclusion: Presence of extracranial concomitant injuries was high. In TBI survivors, extracranial concomitant injuries AIS grade ≥ 3 influenced the long-term functional outcome at 18 months, causing moderate and severe disabilities. Implications for Rehabilitation Concomitant injuries should be suspected in patients with traumatic brain injury, especially in a high-speed trauma mechanisms as the incidence can be as high as 78% as in this study and may interfere with the long term rehabilitation and outcome. This study shows that severe extra cranial concomitant injuries are associated with a poor long term functional outcome even in the mild traumatic brain injury patients and therefore need to be addressed early in the rehabilitation of this group of patients. Early diagnosis and management of severe concomitant injuries is warranted and may improve the functional gains in the long term after traumatic brain injury.

Prospective study of outcomes in lumbar discectomy

Establishing standardized methods to assess outcome is needed to measure the effectiveness of surgery in relieving symptoms and improving quality of life. We prospectively studied 203 patients undergoing primary lumbar discectomy. Data was collected before surgery, at 3 months postoperatively and at long-term follow-up (12 – 60 months, median 24) using both disease-specific (visual analogue scores, Roland – Morris disability scales, and Hospital Anxiety and Depression scales) and generic (SF-36) instruments. Continued significant symptomatic benefit was observed to long-term assessment and the health gains in this patient group compared favourably with other elective surgical procedures. We have used this data to validate the SF-36 for use in this context and we recommend that SF36 should be used as a sole measure of outcome in routine practice, as well as in future studies.

Video clip transfer of radiological images using a mobile telephone in emergency neurosurgical consultations (3G multi-media messaging service)

Abstract Background. The purpose of this study was to validate and assess the accuracy and usefulness of sending short video clips in 3gp file format of an entire scan series of patients, using mobile telephones running on 3G-MMS technology, to enable consultation between junior doctors in a neurosurgical unit and the consultants on-call after office hours. Method. A total of 56 consecutive patients with acute neurosurgical problems requiring urgent after-hours consultation during a 6-month period, prospectively had their images recorded and transmitted using the above method. The response to the diagnosis and the management plan by two neurosurgeons (who were not on site) based on the images viewed on a mobile telephone were reviewed by an independent observer and scored. In addition to this, a radiologist reviewed the original images directly on the hospitals Patients Archiving and Communication System (PACS) and this was compared with the neurosurgeons’ response. Results. Both neurosurgeons involved in this study were in complete agreement with their diagnosis. The radiologist disagreed with the diagnosis in only one patient, giving a kappa coefficient of 0.88, indicating an almost perfect agreement. Conclusion. The use of mobile telephones to transmit MPEG video clips of radiological images is very advantageous for carrying out emergency consultations in neurosurgery. The images accurately reflect the pathology in question, thereby reducing the incidence of medical errors from incorrect diagnosis, which otherwise may just depend on a verbal description.

Stent placement for management of a small parasagittal meningioma. Technical note.

The patient in this report had a parasagittal meningioma with an intrasinus extension that presented with features of benign intracranial hypertension and no focal neurological deficit or seizure. The meningioma was managed with a combination of endovascular stent placement and radiotherapy. The authors describe the investigation and technical aspects of stent placement for the stenosed sinus. Good symptomatic relief in the patient was achieved.

A minimally invasive endoscopic transnasal approach to the craniovertebral junction in the paediatric population.

A 13-year-old male with Type 1 Chiari malformation presented with progressive limb weakness for 2 months. He had a high stepping, unsteady gait with grade 4/5 motor strength in all extremities and increased reflexes. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated Arnold–Chiari malformation type I with basilar invagination, worsening syringomyelia and tonsillar herniation (Fig. 1a). There was no evidence of hydrocephalus. He underwent an occipitocervical instrumentation and fusion followed by endoscopic transnasal odontoidectomy in the same operative setting.

Missense Mutation of Brain Derived Neurotrophic Factor (BDNF) Alters Neurocognitive Performance in Patients with Mild Traumatic Brain Injury: A Longitudinal Study.

The predictability of neurocognitive outcomes in patients with traumatic brain injury is not straightforward. The extent and nature of recovery in patients with mild traumatic brain injury (mTBI) are usually heterogeneous and not substantially explained by the commonly known demographic and injury-related prognostic factors despite having sustained similar injuries or injury severity. Hence, this study evaluated the effects and association of the Brain Derived Neurotrophic Factor (BDNF) missense mutations in relation to neurocognitive performance among patients with mTBI. 48 patients with mTBI were prospectively recruited and MRI scans of the brain were performed within an average 10.1 (SD 4.2) hours post trauma with assessment of their neuropsychological performance post full Glasgow Coma Scale (GCS) recovery. Neurocognitive assessments were repeated again at 6 months follow-up. The paired t-test, Cohen’s d effect size and repeated measure ANOVA were performed to delineate statistically significant differences between the groups [wildtype G allele (Val homozygotes) vs. minor A allele (Met carriers)] and their neuropsychological performance across the time point (T1 = baseline/ admission vs. T2 = 6th month follow-up). Minor A allele carriers in this study generally performed more poorly on neuropsychological testing in comparison wildtype G allele group at both time points. Significant mean differences were observed among the wildtype group in the domains of memory (M = -11.44, SD = 10.0, p = .01, d = 1.22), executive function (M = -11.56, SD = 11.7, p = .02, d = 1.05) and overall performance (M = -6.89 SD = 5.3, p = .00, d = 1.39), while the minor A allele carriers showed significant mean differences in the domains of attention (M = -11.0, SD = 13.1, p = .00, d = .86) and overall cognitive performance (M = -5.25, SD = 8.1, p = .01, d = .66).The minor A allele carriers in comparison to the wildtype G allele group, showed considerably lower scores at admission and remained impaired in most domains across the timepoints, although delayed signs of recovery were noted to be significant in the domains attention and overall cognition. In conclusion, the current study has demonstrated the role of the BDNF rs6265 Val66Met polymorphism in influencing specific neurocognitive outcomes in patients with mTBI. Findings were more detrimentally profound among Met allele carriers.

Infratentorial benign cystic meningioma mimicking a hemangioblastoma radiologically and a pilocytic astrocytoma intraoperatively: a case report

IntroductionCystic meningiomas are rare variants of meningiomas; they can pose a radiological diagnostic dilemma.Case presentationWe present a rare case of a 30-year-old Chinese woman with a histopathological diagnosis of infratentorial cystic meningioma (World Health Organization Grade 1) in which the features in imaging modalities were suggestive of a hemangioblastoma. Intraoperatively, however, the gross macroscopic features were more in keeping with a pilocytic astrocytoma.ConclusionIn benign cystic meningiomas, particularly the infratentorial variety, radiological findings utilizing the various imaging modalities and intraoperative impressions may not be reflective of or in keeping with the final histopathological diagnosis.

A Rare Orbital Complication of Eye Exodeviation With Limited Abduction During Monobloc Le Fort III Distraction Osteogenesis

Monobloc Le Fort III distraction osteogenesis allows superior skeletal advancement in treating severe syndromic craniosynostosis. We report a rare orbital complication in a 3-year-old boy with Crouzon syndrome who developed right-eye exodeviation with limited abduction during the intradistraction period following this surgery. Images from a computed tomography scan confirmed direct impingement of the distracted right lateral orbital wall to the lateral rectus muscle. The impingement was surgically relieved via lateral orbital wall osteotomy. Ten months postdistraction, a review showed normal eye movement. A lateral orbital osteotomy cut for a monobloc Le Fort III distraction should be designed near the rim to prevent this complication.