Mohsin Qadeer

Cranioplasty after decompressive craniectomy: An institutional audit and analysis of factors related to complications

Background: Although a relatively simple procedure, cranioplasties have been associated with high complication rates. Keeping this in perspective, we aimed to determine the factors associated with immediate and long-term complications of cranioplasties at our institution. Methods: A retrospective review of patient records was carried out for patients having undergone reconstructive cranioplasties at our institution during the last 10 years (2001-2010). All case notes, records, and investigations were reviewed and the data were recorded in a predesigned questionnaire. Complications were recorded along with existing comorbids and measures taken for their prevention and management. Univariate and multivariate logistic regression analysis was performed to determine possible predictors of complications. Results: A total of 96 patients with a mean age of 33 + 15 years were included in the study. Of the sample, 76% (n = 73) had no comorbids. The leading primary pathology was blunt traumatic brain injuries in 46% (n = 44), followed by cerebrovascular incidents in 24% (n = 23), penetrating traumatic brain injuries in 12% (n = 11), and tumors in 10% (n = 10) of cases, with 41% (n = 39) of patients requiring multiple craniotomies. In a mean follow-up of 386 ± 615 days, complications were noted in 36.5% (n = 35) of the patients. Twenty six percent of patients (n = 25) had minor complications which included breakthrough seizures (15.6%, n = 15), subgaleal collections (3.1%, n = 3), and superficial wound infections (3.1%, n = 3), whereas major complications (10.4% n = 10) included hydrocephalus (3.1%, n = 3), transient neurological deficits (3.1%, n = 3), and osteomyelitis (2.1%, n = 2). Univariate and multivariate analysis revealed External Ventricular Drain (EVD) placement and parietal flaps to be associated with complications. This could be explained by the fact that the patients requiring EVD usually have relatively severe head injuries, increasing the possibility of hydrocephalus. Conclusion: We have found a higher risk of complications of cranioplasty in patients who had EVD placement and removal prior to their constructive surgery. We however did not find any association between risks of complications in any other studied variable. We also did not find any association between intraoperative placement of subgaleal drains and postoperative risk of subgaleal fluid collections. Overall, our results are comparable with other reported series on cranioplasties.

Safety of untreated autologous cranioplasty after extracorporeal storage at -26 degrees Celsius.

Abstract Background. Given the improved survival of patients requiring decompressive craniectomies, the frequency of subsequent cranioplasties are on the rise. The most feared complication of autologous cranioplasty is infection and one method for reducing the rate of infection, is to store the bone flaps at subnormal temperatures. However, to date there is no defined temperature for flap storage and temperature ranges from − 18 to − 83°C have been described in literature. Considering our limited resources it has been the practice at our center to store bone flaps at − 26°C. In this study, we have retrospectively reviewed our practice and have audited this choice of temperature with respect to the frequency of infections. Methods. A retrospective review was conducted for all cranioplasties performed at our center between January 2001 to March 2011, using autologous bone which was cryopreserved according to institutional protocol. During this period the operative and cryopreservation protocol remained the same. All patient records including charts, notes and laboratory findings were reviewed with a specific focus to identify infections. Results. Of the 88 patients included in the study, only 3 (3.40%) patients were found to show signs of infection. Of these, two patients had superficial surgical site infections which resolved with oral antibiotics (Co-Amoxiclav 1 gm BD for 7 days). However the third patient developed deep surgical site infection requiring re-exploration and washout. All three patients had complete resolution of infection with preservation of autologous bone. Conclusion. Despite our method of keeping the bone flap in freezer at − 26°C we have reported an acceptable rate of infection and raised the notion whether there is a justification for sophisticated and costly equipment for bone flap preservation, especially in resource depleted setups.

Predicting outcomes of decompressive craniectomy: use of Rotterdam Computed Tomography Classification and Marshall Classification

Abstract Background Data on the evaluation of the Rotterdam Computed Tomography Classification (RCTS) as a predictor of outcomes in patients undergoing decompressive craniectomy (DC) for trauma is limited and lacks clarity. Objective To explore the role of RCTS in predicting unfavourable outcomes, including mortality in patients undergoing DC for head trauma. Methods This was an observational cohort study conducted from 1 January 2009 to 31 March 2013. CT scans of adults with head trauma prior to emergency DC were scored according to RCTS. A receiver operating characteristic curve analysis was performed to identify the optimal cut-off RCTS for predicting unfavourable outcomes [Glasgow outcome scale (GOS) = 1–3]. Binary logistic regression analysis was performed to evaluate the relationship between RCTS and unfavourable outcomes including mortality. Results One hundred ninety-seven patients (mean age: 31.4 ± 18.7 years) were included in the study. Mean Glasgow coma score at presentation was 8.1 ± 3.6. RCTS was negatively correlated with GOS (r = −0.370; p < 0.001). The area under the curve was 0.687 (95% CI: 0.595–0.779; p < 0.001) and 0.666 (95% CI: 0.589–0.742; p < 0.001) for mortality and unfavourable outcomes, respectively. RCTS independently predicted both mortality (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.792, 95% CI: 1.235–6.311) and other unfavourable outcomes (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.063, 95% CI: 1.056–4.031). Conclusion RCTS is an independent predictor of unfavourable outcomes and mortality among patients undergoing emergency DC.

Surgically treated spinal metastases: Do prognostic scores have a role?

Background: The outcome for patients with metastatic disease in spine is difficult to predict. Multiple scoring systems were utilized in this study to determine their effectiveness in predicting long-term prognoses. Methods: A retrospective analysis of surgically treated patients of spinal metastasis was performed between 2005 and 2016. Data were collected prospectively during which 8 patients were lost to follow-up. Ultimately, data from 63 patients were reviewed. Treatment and prognoses were analyzed utilizing various scoring systems including the SINS, the Tomita, the modified Tokouhashi and Bauer scores. Results: Records of 63 patients, averaging 54 years of age, were analyzed. The Tomita score was applied in 44 patients, a modified Bauer score was studied in 49 patients, while SINS and modified Tokouhashi scores were calculated in all 63 patients. The hazard ratios for the Tomita score were 1, 0.030, 0.622, and 0.272, respectively. The hazard ratios for the modified Bauer scores were 1, 4.663, and 1.622, respectively. The Tokouhashi ratios were 1, 1.656, and 0.501, respectively. Of interest, the Tomita scores provided the highest statistical significance (P = 0.000) followed by the Bauer (P = 0.002) and Tokuhashi scores (P = 0.003). Notably, the SINS score showed no significant correlation in predicting patient survival. Conclusion: For evaluating the metastatic spine disease, this study evaluated the prognostic efficacy of four widely used scores: the Tomita, score, the modified Tokouhashi and Bauer scores, and the SINS scores. The Tomita scores provided the highest statistical significance, followed by the Bauer, and Tokuhashi scores, while the SINS score showed no significant correlation in predicting patient survival.

Use of enteral levetiracetam for prophylaxis of early post traumatic seizures

AIM Traumatic brain injury is one of the leading causes of mortality and morbidity worldwide. The role of prophylactic anti-epileptic drugs has been established. Phenytoin used traditionally for this purpose carries a burden of adverse reactions and cumbersome need of monitoring and maintaining levels in serum. Therefore, as the evidence on levetiracetam, emerged part of neurosurgery section started using this drug for seizure prophylaxis after early loading with phenytoin. So we decided to assess the use of enteral levetiracetam in prophylaxis of early post-traumatic seizures. MATERIAL AND METHODS This was a retrospective cohort study done at the department of neurosurgery of Aga Khan University in Karachi from July 2010 to March 2011. Charts of patients who were started on levetiracetam enterally were reviewed and followed for occurrence of clinical seizures within one week of trauma. The results were then compared to the group of patients treated prophylactically with phenytoin alone over the same time period. RESULTS The study included 50 patients in each group. Both groups were comparable in terms of demographics and baseline characteristics. However, 2 patients in each group suffered from clinical seizures with a non-significant p value. CONCLUSION Enteral levetiracetam after initial phenytoin loading is a viable option in the armamentarium of anti-epileptic drugs. Further larger prospective studies are required to improve the evidence.

Confusing presentation of chaetomium brain abscess.

Abstract We put forth the case of a young immunocompetent female who presented with fever and left basal ganglia bleed secondary to vasculitis. After 2 weeks of prednisolone therapy, she continued to deteriorate. MRI scan revealed enhancement of previous hematoma, pus was aspirated surgically and fungal culture grew Chaetomium.

Fuzzy prediction of complications in craniopathy

Decompressive craniectomy is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand. It is a life-saving procedure used in the treatment of medically refractory intracranial hypertension, most commonly in the setting of trauma or cerebral infarction. Essentially, any increase in the volume of the contents of the skull is first treated to be contained. If such treatments fail, then the related part of the skull is removed through surgery and the increase of volume is allowed to happen until the pathology subsides and the brain returns to its normal relaxed state. After which the defect is repaired by a procedure called Cranioplasty in which case the left-out bone is placed back and joined onto the skull. This procedure is extremely risky but is becoming very popular due to clinical successes. The determination of risk of complications at the stage of bone-replacement can be a very useful information for the doctor as well as the patient since it can determine the post-surgical treatment, care, and patient-management procedures. In this paper, we have proposed a very systematic algorithmic approach to determine this using Fuzzy Inference System. The system inputs many qualitative as well as numerical inputs and determines the risk as one of the clsses of complications; Severe, Minor, Least/None.