Sanguansin Ratanalert

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.

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.

Prognosis of severe head injury: an experience in Thailand.

This study of 300 patients with severe head injury evaluated the clinical predictors determined after admission and associated with significant increase of poor outcome. The overall poor outcome was 58%. Logistic regression showed that age, status of basal cisterns on initial CT, Glasgow Coma Scale score (GCS) at 24 h after injury and electrolyte derangement occurring during admission strongly correlated with the outcome. A probability diagram of the outcome determined at 24 h after injury from the combination of the significant predictive factors provides a basis for determining the interventions to the appropriate target population. Intracranial pressure monitors with sophisticated devices may not be suitable for a developing country. Allocation of resources toward development of adequate intensive care beds and well-trained staff combined with serial CT imaging may be an alternative approach for the improvement of the outcome of severe head injury.

The impacts and outcomes of implementing head injury guidelines: clinical experience in Thailand

Objective: To describe the impact of implementing clinical practice guidelines (CPG) for head injury in a trauma referral system in Songkla province, Thailand. Methods: The CPG was developed by a local multidisciplinary team and implemented using multi-faceted methods. The outcome of patients with head injury from three community hospitals and a university hospital (Songklanagarind Hospital) was reported in terms of “talk and deteriorate” patients and a “poor” outcome for patients with severe head injury. Changes to clinical practice were observed where the guidelines were implemented. Results: 1000 patients with head injury were enrolled from 1st August 2005 to 15th January 2006. The incidence of “talk and deteriorate” patients was 10.5% and a poor outcome was noted in 35.5% of patients with severe head injury, similar to the results of a previous study in Songklanagarind Hospital (p>0.05). Following implementation of the guidelines, 19.8% of patients underwent CT scanning with similar outcomes for alert patients with and without basal skull fracture (p>0.05). The clinician—nurse relationship also improved and there was closer collaboration between hospitals. Short observation in community hospitals for repeat neurological examination may be an appropriate strategy for management of some patients with minor head injury. Conclusions: Local ownership, an appropriate implementation strategy and working as a multidisciplinary team are key factors for success in implementing the CPG. Basal skull fracture may not be an absolute criterion for CT imaging of the head. Further initiatives will be developed in response to the incidence of “talk and deteriorate” patients.

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.

Social attitudes toward shaving for cranial neurosurgery.

Unshaved cranial neurological surgery has been successfully performed at Songklanagarind Hospital. However, within the Buddhist community, shaving is one of the traditional procedures for cleanliness and purification, and the unshaved method may have a cultural effect on social beliefs. Knowledge of social attitudes toward shaving or not shaving for cranial neurological surgery has implications for informed consent process prior to cranial operation. The attitudes of shaving were surveyed in the communities of Songkhla Province where Songklanagarind Hospital is situated. Of 1128 respondents, the female to male ratio was 3:2, their age was mostly under 40 years old and 91% were Buddhist. Sixty per cent of the respondents were in favour of shaving. After knowing the equivalent result of surgery either by shaved or unshaved method, the group favouring unshaved cranial surgery increased from 12 to 37%. Statistical analysis, through ordinal and multinomial logit, identified the young age, female and more educated who needed to socialize, and frequently meet many people were the groups who preferred or were ready to change their choice to the unshaved method. The neurosurgeon should give an advice to the patient not only the indications and results of surgery, but also a choice of shaved or unshaved cranial neurological surgery.

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.

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.