Sakchai Saeheng

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.

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.

Diagnostic Yield and Complication of Frameless Stereotactic Brain Biopsy

Background: With the advancement of neuronavigation technologies, frameless stereotactic brain biopsy has been developed. Previous studies proved that frameless stereotactic brain biopsy was as effective and safe as frame-based stereotactic brain biopsy. The authors aimed to find the factors associated with diagnostic yield and complication rate of frameless intracranial biopsy. Materials and Methods: Frameless stereotactic brain biopsy procedures, between March 2009 and April 2017, were retrospectively reviewed from medical records including imaging studies. Using logistic regression analysis, various factors were analyzed for association with diagnostic yield and postoperative complications. Results: Eighty-nine frameless stereotactic brain biopsy procedures were performed on 85 patients. The most common pathology was primary central nervous system lymphoma (43.8%), followed by low-grade glioma (15.7%), and high-grade glioma (15%), respectively. The diagnostic yield was 87.6%. Postoperative intracerebral hematoma occurred in 19% of cases; however, it was symptomatic in only one case. The size of the lesion was associated with both diagnostic yield and postoperative intracerebral hematoma complication. Lesions, larger than 3 cm in diameter, were associated with a higher rate of positive biopsy result (P = 0.01). Lesion 3 cm or smaller than 3 cm in diameter, and intraoperative bleeding associated with a higher percentage of postoperative intracerebral hematoma complications (P = 0.01). Conclusions: For frameless stereotactic brain biopsy, the size of the lesion is the essential factor determining diagnostic yield and postoperative intracerebral hematoma complication.

Butterfly tumor of the corpus callosum: Clinical characteristics, diagnosis, and survival analysis

Background: The pathologies implicate the bilateral corpus callosum that builds the butterfly pattern on axial view. These tumors have seldom been investigated for both clinical manifestations and outcome. Objective: The objective of this study was to describe the clinical characteristics and outcomes of the butterfly tumor and to identify the predictive factors associated with survival outcome. Methods: A retrospective study of 50 butterfly tumor was conducted between 2003 and 2016. The clinical characteristics, imaging, and outcome were assessed for the purpose of descriptive analysis. Using the Kaplan–Meier method, the median overall survival of the butterfly tumor was determined. Furthermore, the Cox proportional hazard regression was the estimated hazard ratio for death. Results: Diffuse large B-cell lymphoma was common of butterfly lesions. The mortality rate was 78% and overall median survival time was 16.03 months (95% confidence interval: 14.0–19.8). Using Cox proportional hazards regression, the independent prognostic factors were Karnofsky Performance Status score ≤70, splenium involvement, and butterfly glioblastoma. Conclusions: The butterfly tumor is a poor prognostic disease compared with each histology subgroup. Further molecular investigation is preferable to explore genetic variations associated with these tumors.