Nakornchai Phuenpathom

Outcome and outcome prediction in acute subdural hematoma

This study is based on a series of 109 consecutive head injured patients with the CT scan diagnosis of acute subdural hematoma. The overall outcome was assessed at 6 months after injury using the Glasgow Outcome Scale. By logistic regression analysis a small set of clinical features (the best sum Glasgow Coma Scale score within 24 h after admission, and pupillary inequality) was revealed as significant prognostic features. The method described allows bedside predictions in individual future cases.

Nonshaved cranial neurosurgery.

BACKGROUND Preoperative shaving for cranial neurosurgical procedures is still recommended in textbooks. There are reports demonstrating the success of nonshaved surgery. The objective of this study was to compare the surgical infection rate of cranial neurosurgical procedures with two different scalp preparations: shaved or nonshaved. METHODS Clinical trials of nonshaved scalp preparation were performed in non-emergency cranial neurosurgical procedures at Songklanagarind Hospital from August 1994 to December 1996. Patients were entered in the nonshaved group using the following exclusion criteria: immunocompromised host, presence of infectious diseases, surgery with foreign material insertion, multiple operations within 1 month, and presence of traumatic wound around the operative site. Patients who survived less than 1 month after surgery were excluded except in cases where death resulted from intracranial infection. RESULTS During the 29-month period, 225 of 1,244 cranial neurosurgical procedures were selected for study. Ages ranged from 4 to 86 years. Brain tumors were encountered in 57%. In the nonshaved group, there were 89 procedures (80 cases), compared with 136 procedures (123 cases) in the shaved group. Surgical infection rates were 3.37% and 5.88%, respectively (p>0.05). CONCLUSIONS Nonshaved scalp preparation is recommended for nonemergency cranial neurosurgical procedures.

Traumatic occipitoatlantal dislocation

BACKGROUND Traumatic occipitoatlantal dislocation (OAD) is a severe ligamentous injury resulting in instantaneous death or severe neurological deficit. However, survivors of OAD, both short and long term, have been increasingly reported; this may be because of improved prehospital care, more rapid transportation, a high index of suspicion, and new radiological techniques. METHODS The medical records and film of three patients who had traumatic OAD were retrospectively reviewed. Diagnosis was made by lateral cervical spine radiography, computed tomography (CT), or magnetic resonance imaging (MRI). Treatment consisted of early respiratory support and subsequent posterior surgical fusion. RESULTS The three survivors of traumatic OAD represent 3.1% of all cervical spine injuries in our service. Two were children and the other was a 64-year-old man, all of whom suffered from severe neurological deficits. Lateral cervical spine radiographs led to the diagnosis of OAD. Two were longitudinal, and one was anterior. Two patients died within 2 weeks after injury. The remaining patient, who had anterior OAD, survived longer, which allowed posterior fusion with a U-shape Steinman pin and wiring to be performed. However, she died 5 months after injury because of septicemia. CONCLUSION Early recognition and treatment may improve the outcome of this injury. Treatment consists of early respiratory support and subsequent surgical fusion.

ICP threshold in CPP management of severe head injury patients

BACKGROUND Elevated intracranial pressure (ICP) is significantly associated with high mortality rate in severe head injury (SHI) patients. However, there is no absolute agreement regarding the level at which ICP must be treated. The objective of this study was to compare the outcomes of severe head injury patients treated by setting the ICP threshold at >or=20 mm Hg or >or=25 mm Hg. METHODS Treatment protocol in this study consisted of therapeutic maneuvers designed to maximize cerebral profusion pressure (CPP) and control ICP. Twenty-seven patients with severe head injury and intracranial hypertension (ICP >or=20 mm Hg) were enrolled and fourteen cases were allocated to the group of ICP threshold >or=25 mm Hg. Six-month clinical outcomes were evaluated using the Glasgow Outcome Score (GOS). RESULTS There were no statistically significant differences in clinical parameters between the groups. Logistic regression identified the presence of basal cisterns on the initial computed tomography (CT) scan as a significant predictor of good outcome. ICP threshold did not influence outcome. CONCLUSIONS This study supported a recommended ICP threshold of 20 to 25 mm Hg in SHI management. However, in cases with an absence of basal cisterns on initial CT scan, the probability of good outcome may be higher using an ICP threshold of >or=20 mm Hg.

Management of head injury patients who talked and deteriorated

Of 203 patients with severe head injuries admitted from January 1986 to May 1989 at Songklanagarind Hospital, 32 cases who initially talked prior to deteriorating to a Glasgow Coma Scale score of 7 or less within 48 hours after injury were identified. Many variables were analyzed to ascertain what might be responsible for the differences in outcome. The Glasgow Coma Scale score before neurosurgical intervention was identified, using the logistic regression model, as a significant prognostic predictor. Mortality rate was 40.6%, with two patients left in a vegetative state. Surgically correctable intracranial mass lesions occurred in 29 cases. The most important factors in salvaging these patients are rapid diagnosis and immediate surgical decompression before irreversible brain damage sets in.

The changing pattern of head injury in Thailand

OBJECTIVE To determine whether patterns of head injury are changing with time. MATERIALS AND METHODS A total of 3194 and 4217 consecutive trauma patients who attended the emergency room in 1985-86 and 1996 respectively were studied with respect to age, sex, cause of injury, injury severity, pathology, and outcome. RESULTS The number of patients with head injury in 1996 nearly doubled (1224/4,217:29.03%) when compared to the 1985-86 study (504/3, 194; 15.78%). This was due to an increase in the outpatient subgroup (1009/1224). The admitted patients with head injury showed a pattern of less severe injury. Severe head injury decreased from 12.4 to 7. 9%. However, acute subdural haematoma and diffuse brain injury increased from 12.2% and 9% to 32% and 16.8% respectively. The mortality rate of admitted patients increased statistically significantly from 14.4% to 21.8% between the 1985-86 and 1996 studies. CONCLUSIONS This comparative study showed attend toward less severe injury. This may be due to multiple factors. The predominant factor may be the compulsory use of motorcycle helmets. The limitation of this study was that it utilised tertiary hospital based data only. Tertiary hospital receive more and serious head injured patients from surrounding provincial hospitals this may be the major cause of the increased the mortality rate.

Multiple, primary brain tumors with diverse origins and different localizations: Case series and review of the literature

Background: Multiple, primary brain tumors with different histological types occurring in the same patient are extremely rare. Several hypotheses have been proposed, and the pathophysiology of coexisting tumors has long been debated; however, due to low incidence, standard practices for this scenario are still inconclusive. Case Description: The authors describe 6 cases of coexisting tumors. By conducting a literature research focused on the computed tomography (CT) era and patients without prior radiation or phakomatosis. Sixty-five such reported cases were identified. In addition, the authors summarize their experience in 6 patients including histopathological features, chronological presentations, outcomes, mortality, and management from their series as well as from previous cases from the reported literature. Conclusion: The coexistence of multiple, primary brain tumors is an interesting condition. Surgical management remains the major treatment; malignant histology has a poor prognostic factor.

Impact of road traffic injury to pediatric traumatic brain injury in Southern Thailand

Background: Motor vehicle is a major transportation in Southern Thailand as the result of road traffic injury and death. Consequently, severe disability and mortality in pediatric traumatic brain injury (TBI) were observed from traffic accident, particularly motorcycle accident. To identify the risk of intracranial injury in children, the association of treatment outcome with various factors including mechanisms of injury, clinical characteristics, and intracranial pathology can be assessed. Materials and Methods: This was a retrospective study conducted on children, who were younger than 15 years old with TBI and were enrolled from 2004 to 2015. Several clinically relevant issues were reviewed and statistically analyzed. Results: A total of 948 casualties were enrolled. Compared with falling down, the motorcycle accident was significantly associated with intracranial injury (odds ratio 1.73, 95% confidence interval [CI] 1.08–2.76). Other factors associated with intracranial injury were hemiparesis (odds ratio 5.69, 95% CI 1.44–22.36), positive of basal skull fracture signs (odds ratio 15.66, 95% CI 3.44-71.28), and fixed reaction to light of both pupils (odds ratio 5.74, 95% CI 1.71–19.23). Mortality found in thirty cases (3.2%). Furthermore, the risk of death correlated with motorcycle accident (P = 0.02) and severe head injury (P < 0.001). Neurosurgical intervention was not associated with outcome, but severe head injury, hemorrhagic shock, epidural, and subdural hematoma were impact factors. Conclusion: The findings demonstrate road traffic injury, especially motorcycle accident leading to brain injury and death. Prevention program is a necessary key to decrease mortality and disability in pediatric TBI.