Search Results (97)

Introduction: Traumatic brain injury (TBI) is a leading cause of morbidity worldwide, with the Glasgow Coma Scale (GCS) serving as a tool to measure injury severity. This study aimed to investigate the relationship between GCS admission scores and various socio-demographic, clinical, injury-related, and hospital-related variables in patients with TBI across two tertiary care centers in Eastern Europe, a region that remains underrepresented in the literature. Methods: A retrospective observational study was conducted using data from 119 TBI patients admitted between March 2020 and June 2023 at Cluj County Emergency Hospital (Romania) and Saint Vincent Hospital (Poland). GCS scores were analyzed as both categorical and continuous variables. Statistical analyses included Wilcoxon and Kruskal–Wallis tests for group comparisons and Spearman correlations for continuous variables. Results: Most patients included suffered a mild TBI (GCS score between 13 and 15). There were significant associations between GCS scores and post-traumatic amnesia (p < 0.05), discharge status (p < 0.01), discharge destination (p < 0.01), and education level (p < 0.01). GCS scores at admission were linked to survival, absence of post-traumatic amnesia, higher education levels, and home discharge. No significant differences observed across sex, residence, employment status, injury type, cause, or mechanism of injury. A weak but significant negative correlation was observed between GCS and length of hospital stay (rho = −0.229, p > 0.05), while age showed a non-significant correlation. Conclusions: The GCS score at admission is significantly associated with various clinical and socio-demographic outcomes in TBI patients, supporting the utility of the GCS score as a prognostic tool. The predominance of mild cases and the absence of radiological data, such as cerebral contusions or epidural or subdural hematomas, limit the generalizability of the findings. Further studies with larger samples and comprehensive imaging data are necessary to validate these findings. Full article

The elderly population in Japan was 29.3% in 2024, the highest in the world, making medical care for elderly patients an urgent social issue. There are challenges in providing care for elderly patients with head injury, since the buffering effect of the expansion of the subdural space due to brain atrophy masks the neurological symptoms caused by a hematoma, making detection difficult. However, brain damage can be detected with high sensitivity and specificity using blood D-dimer as a biomarker without the need for head computed tomography (CT). Also, about 30% of elderly patients with traumatic brain injury (TBI) are taking antithrombotic drugs, and the effects of these drugs on TBI may include an increase in intracranial hematomas and an increased risk of deterioration. Reversal therapy is used as a countermeasure to prevent hematoma expansion, but this requires the administration of a reversal agent early after injury and before hematoma expansion. In decompression surgery, the use of a mini-craniotomy with neuroendoscopic assistance under local anesthesia can reduce invasiveness, and this method significantly reduces intraoperative bleeding and operation times compared to a major craniotomy. These innovations have improved mortality for TBI in elderly patients, but there is still a need for improvements in functional outcomes. Full article

Background and Clinical Significance: Fulminant pulmonary embolism (PE) leading to an out-of-hospital cardiac arrest (OHCA) is associated with a high mortality rate and cardiopulmonary resuscitation (CPR) frequently failing to achieve return of spontaneous circulation (ROSC). Extracorporeal CPR (eCPR) has emerged as a potential life-saving intervention. Case Presentation: A 66-year-old woman suffered an OHCA due to massive PE, presenting with pulseless electrical activity (PEA). After 90 min of pre- and in-hospital CPR without sustained ROSC, venoarterial extracorporeal membrane oxygenation (va-ECMO) was initiated as eCPR upon arrival at the hospital. Even after implantation of the va-ECMO, there was initially a pronounced acidosis (pH 6.9) with a high elevated lactate level (>30 mmol/L); these factors, together with the prolonged low-flow period, indicated a poor prognosis. Further diagnostic tests revealed intracranial hemorrhage (subdural hematoma), and systemic lysis was not possible. With persistent right heart failure, surgical thrombectomy was performed during hospitalization. Intensive multidisciplinary management finally led to successful therapy and weaning from mechanical ventilation, as well as to complete neurological recovery (CPC-Score 1-2). Conclusions: This case illustrates that eCPR can facilitate survival with good favorable neurological outcomes despite initially poor prognostic predictors. It underscores the importance of refining patient selection criteria and optimizing management strategies for eCPR in refractory cardiac arrest secondary to PE. Full article

Background/Objectives: Venous thromboembolism (VTE) is a preventable cause of morbidity in the neurocritical ill patient population. There is ongoing debate regarding the optimal timing and choice of pharmacologic thromboprophylaxis (PTP) and how these decisions relate to balancing the risk of bleeding complications with the development of VTE. Our review assesses the available data to provide un updated perspective to clinicians. Methods: A literature search was performed in December 2024 in PubMed and EMBASE. We focused on the timing of PTP initiation and the comparison of enoxaparin (ENX) with unfractionated heparin (UFH) in patients with traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), spinal or spinal cord injury (SCI), or requirement for neurosurgical intervention. Results: We included 90 articles spanning a total of 669,725 patients with injuries of interest within neurocritical care. The existing data largely signaled a benefit of early administration (<24–72 h) of PTP in VTE prevention, though some studies suggested increased risks of complications. Data to inform a preference for PTP agent was less robust, though a signal of benefit for enoxaparin is suggested for subsets of patients with acute brain injury such as TBI. The data quality is limited by the large body of retrospective studies, the heterogeneity of study populations, outcome definitions, study methodologies, and the lack of detailed reporting of relevant factors. Conclusions: Our review provides an updated assessment of the available data on PTP timing and choice in neurocritically ill patients with hemorrhages or surgical need, with a practice-focused overview for clinicians balancing VTE risk with bleeding risk. The data suggest that in most circumstances, early PTP appears safe and indicated, and that low-molecular weight heparin (LMWH) can be considered over UFH in certain subsets of patients. Still, data gaps and conflicting results highlight the need for patient-specific decision making and indicate that more robust research is warranted to inform optimal clinical practice. Full article

Background and Importance: Chronic subdural hematoma (cSDH) is a common and complex neurosurgical problem, particularly in elderly patients. Revision surgery for chronic subdural hematoma can be challenging, particularly in cases with inhomogeneous, firm consistency and extensive adhesions. Clinical Presentation: In this article, we present our endless-loop craniotomy technique, which offers a novel approach to address these challenges by performing the wide, curved exposure of the subdural space utilizing the already-present burr hole. This technique allows for a wide, unobstructed view of the subdural space, enabling the access and evacuation of this chronic and often adhesive subdural hematoma. Conclusion: We believe that endless-loop craniotomy is a valuable addition to the neurosurgeon’s armamentarium for managing complex cases of revision surgery in chronic subdural hematomas. Full article

Background: Chronic subdural hematoma (CSDH) is a common condition in older adults with rising rates of incidence. While burr hole drainage remains the standard treatment, it is associated with significant recurrence and complications. This study assesses MMA embolization with Squid, both as a standalone procedure and as an adjunct to surgery. Methods: Our prospective registry included 101 patients with 134 CSDH cases treated at two tertiary care centers from December 2020 to January 2024. Patients were divided into two groups: embolization alone and embolization combined with surgery. Demographic, clinical, radiological, and procedural data were collected. Follow-up imaging was conducted at 1, 3, and 6 months. Treatment failure was defined as rescue surgery, hematoma thickness ≥ 10 mm, midline shift > 3 mm at 6 months, or procedure-related death. Results: Fifty-two patients (51.5%) underwent combined treatment, and forty-nine (48.5%) received embolization alone. Most were men (68.3%) and the median age was 82 years. Combined-treatment patients had larger hematomas and more symptoms. Procedures were performed under general anesthesia in 72.3% of patients, with radial and femoral access used equally frequently, and 32.7% underwent bilateral embolization. Patients’ hematoma thickness in follow-up imaging showed a significant decrease (p = 0.000), reaching a median of 0 mm at six months, with no significant difference between groups. Complications occurred in 5.9%, and treatment failure in 4%. Mortality was higher in the embolization-only group, likely reflecting greater rates of comorbidities. Conclusions: This study supports the use of MMA embolization with Squid as a safe and effective treatment for CSDH. Comparable procedural and radiological outcomes in both groups suggest embolization alone may suffice in select patients, offering a less invasive alternative. Full article

Background/Objectives: Nonacute subdural hematomas (naSDHs) are a prevalent intracranial pathology, particularly in older people, due to increased brain atrophy, fall risk, and anticoagulant use. This study examines the impact of frailty on the surgical outcomes of craniotomy for naSDH over 20 years. Methods: Data from the Nationwide Inpatient Sample (NIS) from 2000 to 2021 were analyzed, including 251,597 patients who underwent cranial decompression for naSDH. Patients were selected using specific ICD codes. Frailty was calculated using the modified frailty index (mFI-5 and mFI-11) and the Charlson Comorbidity Index (CCI). Outcomes were compared using descriptive statistics and multivariable regression models. Results: 251,597 patients underwent craniotomy, with a mean age of 69.2 years. The cohort exhibited significant comorbid conditions, reflected in a mean Charlson Comorbidity Index (CCI) of 3.8, and a high frailty prevalence, with 23.49% of patients classified as frail and 20.14% as severely frail. The CCI demonstrated the highest predictive value for adverse outcomes, with an area under the curve (AUC) of 0.6346 for mortality and 0.6804 for complications. Frailty indices (mFI-5 and mFI-11) were also strongly associated with increased mortality (p < 0.001), complications (p < 0.001), and extended length of stay (p < 0.001). Age was not a significant predictor of outcomes. Conclusions: This study highlights the moderate impact of frailty on surgical outcomes for naSDH. Full article

Background: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, particularly among elderly patients. Middle meningeal artery (MMA) embolization has emerged as a minimally invasive adjunctive treatment aimed at reducing recurrence. However, its comparative efficacy and safety remain under investigation. Methods: In this systematic review and meta-analysis, randomized-controlled clinical trial (RCT) data evaluating MMA embolization combined with best medical therapy (BMT) versus BMT alone in adult patients with symptomatic cSDH were pooled. The primary efficacy outcome was recurrence or progression of hematoma at follow-up. Secondary efficacy outcomes included good functional outcome [modified Rankin Scale (mRS) score ≤ 2], independent ambulation (mRS score ≤ 3), and hematoma thickness at follow-up. The primary safety outcome was all-cause mortality. Procedure-related complications were assessed as a secondary safety outcome. Results: Six RCTs were included, comprising 760 patients treated with MMA embolization and 788 patients treated with BMT alone. MMA embolization significantly reduced recurrence compared to BMT alone (RR: 0.50; 95% CI: 0.37–0.69; six studies; I² = 0%; number-needed-to-treat = 13). No significant differences were observed in good functional outcome (RR: 1.01; 95% CI: 0.97–1.05; three studies; I² = 0%), independent ambulation (RR: 1.01; 95% CI: 0.99–1.04; three studies; I² = 0%), or hematoma thickness at follow-up (SMD: −0.1; 95% CI: −0.3 to 0; four studies; I² = 42%). All-cause mortality was similar between the two groups (RR: 1.01; 95% CI: 0.42–2.40; five studies; I² = 44%). The pooled rate of procedure-related adverse events in the MMA embolization-group was 1% (95% CI: 0–3%; two studies; I² = 35%). Conclusions: MMA embolization significantly reduced cSDH recurrence when used as an adjunct to BMT. However, it did not demonstrate a significant impact on functional outcomes or mortality in this meta-analysis. Further research is needed to identify patient subgroups that benefit most from MMA embolization and to evaluate its impact on cognitive function and quality of life using longer follow-up periods. Full article

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical condition that usually occurs in the elderly. Surgical evacuation of the hematoma with burr holes is considered the standard of care for the treatment of patients with CSDH. However, a high risk of recurrence, up to 34%, after hematoma evacuation has been reported, while the risk factors linked with recurrence have not been studied in depth. In the present study, we set out to identify risk factors of recurrence in patients surgically treated for CSDH. Methods: We retrospectively studied patients with symptomatic CSDH who were treated surgically in our institute during a five-year period. All the patients were treated by single or double burr hole drainage. The data for this study were extracted by the pre-operative and post-operative CT scan of each patient. These data include the sex, the midline shift, the width, and the presence of acute clots and subdural air collection post-operatively. A univariate analysis was performed. A receiver operating characteristic (ROC) analysis was utilized to detect the hematoma’s width more efficiently, differentiating patients that developed recurrence. Results: A total of 222 patients were included in this study. Recurrence occurred in 20 (9.0%) patients. The univariate analysis showed that the presence of acute clots post-operatively are significant factors related with recurrence (OR = 4.01, CI 95% 1.55–10.33, and p = 0.002). There was no significant relationship between the recurrence rate and the hematoma’s width, sex, the midline shifts pre-operatively or post-operatively, the subdural space, and air collection post-operatively. Conclusions: The presence of acute clots in the post-operative CT scan is a potential, previously unexplored, risk factor associated with the recurrence of CSDH. Full article

Background: Acute subdural hematoma (aSDH) is associated with a high risk of epilepsy, a complication linked to poor outcomes. Craniotomy is a known risk factor, with an epilepsy incidence of approximately 25%. This study evaluated radiomic features from preoperative CT scans to predict epilepsy risk in aSDH patients undergoing craniotomy. Methods: A retrospective analysis of 178 adult aSDH patients treated between 2016 and 2022 identified 64 patients meeting inclusion criteria. Radiomic features (e.g., Feret diameter, elongation, flatness, surface area, and volume) from preoperative CT scans within 24 h of surgery were analyzed alongside clinical factors, including cardiac comorbidities, pupillary response, SOFA score, age, and anticoagulation status. Results: Of the 64 patients, 18 (28%) developed generalized seizures. Univariate analysis showed significant associations with Feret diameter (p = 0.045), elongation (p = 0.005), cardiac comorbidities (p = 0.017), and SOFA score (p = 0.036). ROC analysis showed excellent discriminatory ability for elongation (AUC = 0.82). Multivariate analysis identified elongation as an independent predictor (p = 0.003); elongation ≥ 1.45 increased seizure risk 7.78-fold (OR = 7.778; 95% CI = 1.969–30.723). Conclusions: Radiomic features, particularly elongation, may help predict epilepsy risk in aSDH patients undergoing craniotomy. Prospective validation is needed. Full article

Background and Objective: The study’s aim is to identify a subgroup of patients who would benefit from primary decompressive craniectomy (pDC) after acute subdural hematoma (aSDH) evacuation. Materials and Methods: A retrospective analysis of 290 patients undergoing aSDH evacuation between 2016 and 2021 was conducted. Osteoplastic craniotomy (OC) was performed in 213 cases (73.4%), whereas 77 individuals underwent pDC. Preoperative characteristics, such as age, initial GCS score, hematoma thickness, midline shift, and cisternal effacement score (CES), were used to predict outcome at discharge by the Glasgow Outcome Scale (GOS). Results: Older age, lower initial GCS, and higher CES preoperatively were independently associated with lower GOS scores at discharge. Age and degree of cisternal compression remained significant predictors of GOS score in the pDC subgroup. Survivors who underwent pDC were younger in comparison to deceased individuals receiving OC (mean age 55.43 ± 14.58 vs. 72.28 ± 14.63, p < 0.001). Patients who achieved favorable outcomes after pDC were significantly younger compared to those who had poor outcomes after OC (mean age 49.20 ± 12.05 vs. 72.28 ± 14.32, p < 0.001). Conclusions: Younger patients (<55 years old) with initial GCS scores of 4–6, midline shifts of 1 to 2 cm, subdural hematoma thickness of 1 to 2.5 cm, and CES in a range of 7–12 may benefit from pDC as it could potentially improve survival and functional outcomes after aSDH evacuation. Full article

Background/Objectives: Childhood hemophilia, a hereditary bleeding disorder predominantly affecting males, arises due to gene mutations encoding clotting factors VIII or IX. Intracranial hemorrhage represents a significant and life-threatening complication in pediatric patients with hemophilia. The incidence of intracranial hemorrhage in children with hemophilia, although relatively low, is notably higher compared to the general pediatric population. Methods: In this study, the objective is to examine patients with hemophilia who have experienced intracranial hemorrhage retrospectively. This study is a multicenter, retrospective analysis using data from three tertiary care centers in a provincial city in Turkey. Data were obtained from the participants’ hospital records. The presence of inhibitors against FVIII in the participants and the prophylaxis used against them were included in the analysis. Trauma history was queried, with types of traumas examined, including traffic accidents, falls, and a traumatic vaginal delivery. The duration and causes of complaints among the participants were investigated. The causes of complaints were categorized as fever, hematoma, convulsions, loss of consciousness, and hemiparesis. The participants’ Physical Examination Findings were classified as fever, hematoma, and loss of consciousness. The duration of hospital stays was evaluated. The hemorrhage location was classified into five groups: parenchymal, subdural, scalp, subarachnoid, and multiple hemorrhagic foci. The recurrence of bleeding, the need for transfusion, surgical intervention, and mortality were also examined. Results: A significant difference was identified between the participants’ survival rates and age variables, as well as transfusion in <36 months. A total of 9 participants had spontaneous intracranial bleeding, 2 experienced cranial trauma as a result of traffic accidents, and 25 participants were exposed to head trauma due to falls. Of the remaining individuals, one suffered head trauma from a severe impact, and one had cranial trauma following a traumatic vaginal delivery. Fourteen participants required transfusion, and three underwent surgical intervention. Conclusions: According to the results of the statistical analyses, the variables Factor Level, Physical Examination Findings, Transfusion, Recurrent Bleeding, Inhibitor, and Prophylaxis were found to affect survival significantly. No significant relationship was determined between the other analyzed variables and survival. During our study, five of the participants examined died. Accordingly, the mortality rate identified in our study is 13.1%. Full article

Background/Objectives: Traumatic acute subdural hematoma (aSDH) often requires surgical intervention, such as craniotomy, to relieve mass lesions and pressure. The extent of hematoma evacuation significantly impacts patient outcomes. This study utilizes 3D Slicer software to analyse post-craniotomy hematoma volume changes and evaluate their prognostic significance in aSDH patients. Methods: Among 178 adult patients diagnosed with aSDH from January 2015 to December 2022, 64 underwent hematoma evacuation via craniotomy. Initial scans were performed within 24 h of trauma, followed by routine postoperative scans to assess residual hematoma. We conducted radiomic analysis of preoperative and postoperative volumes, surface area, Feret diameter, sphericity, flatness, and elongation. Clinical parameters, including SOFA score, APACHE score, pupillary response, comorbidities, age, anticoagulation status, and preoperative haematocrit and haemoglobin levels, were also evaluated. Results: Changes in Δ surface area significantly correlated with 30-day outcomes (p = 0.03) and showed moderate predictive accuracy (AUC = 0.65). Patients with a Δ surface area > 30,090 mm² experienced poorer outcomes (OR = 6.66, p = 0.02). Significant features included preoperative surface area (p = 0.009), Feret diameter (p = 0.0012). In multivariate analysis, only the Feret diameter remained significant (p = 0.01). Conclusions: Postoperative Δ surface area is, among other variables, a strong predictor of 30-day outcomes, while in multivariate analysis, preoperative Feret diameter remains the only independent predictor. Radiomic analysis with 3D Slicer may enhance prognostic accuracy and inform tailored therapeutic strategies. Full article

Traumatic brain injury (TBI) remains one of the leading causes of death. Because of the individual nature of the trauma (brain, circumstances and forces), humans experience individual TBIs. This makes it difficult to generalise therapies. Clinical management issues such as whether intracranial pressure (ICP), cerebral perfusion pressure (CPP) or decompressive craniectomy improve patient outcome remain partly unanswered. Experimental drug approaches for the treatment of secondary brain injury (SBI) have not found clinical application. The complex, cellular and molecular pathways of SBI remain incompletely understood, and there are insufficient experimental (animal) models that reflect the pathophysiology of human TBI to develop translational therapeutic approaches. Therefore, we investigated different injury patterns after acute subdural hematoma (ASDH) as TBI in a post-hoc approach to assess the impact on SBI in a long-term, human-sized porcine TBI animal model. Post-mortem brain tissue analysis, after ASDH, bilateral ICP, CPP, cerebral oxygenation and temperature monitoring, and biomarker analysis were performed. Extracerebral, intraparenchymal–extraventricular and intraventricular blood, combined with brainstem and basal ganglia injury, influenced the experiment and its outcome. Basal ganglia injury affects the duration of the experiment. Recognition of these different injury patterns is important for translational interpretation of results in this animal model of SBI after TBI. Full article

Background: Post-hemicraniectomy patients often need extended intensive care treatment. While computed tomography (CT) is considered the gold standard for regular imaging, its frequent use could be linked to adverse clinical outcomes. This study aimed to assess bedside transcranial ultrasound (TUS) to capture intracranial anatomical structures and pathologies. Methods: We analyzed 19 patients treated in our neurosurgical ICU from 1 January 2023 to 1 February 2024. Six physicians from our unit (three residents and three attending physicians) conducted a retrospective evaluation. A total of 158 sessions, including multiple freeze frames and video footage, were analyzed, including 7 imaging categories, using a Likert scale. Subsequently, correlation between CT and TUS was evaluated for midline (ML) shift, subdural space, lateral ventricular width (LVW), and extent of intracerebral hematoma using the Pearson’s correlation coefficient (r). Results: TUS was performed on average on 8.32/19.53 days (mean inpatient stay). It provided the lowest Likert scores for the imaging categories ventricular system, midline, subdural space, intraventricular catheter placement, and cortical gyration. Residents reported slightly inferior assessability, resulting in higher scores on the Likert scale (0.02–0.93 mean difference compared with attending physicians). A high correlation was shown in terms of ML shift, LVW, and intracerebral hematomas. No relevant correlation was shown in subdural space. Conclusions: TUS is a safe, cost-, and time-efficient method, potentially gaining relevance for imaging post-hemicraniectomy patients. In our setting, the method seemed effective in depicting intraventricular catheter placement, hydrocephalus, ML shift, and space-occupying lesions. Further improvement in image quality could potentially reduce the overall number of indicated CT scans. Full article