In subarachnoid hemorrhage following traumatic brain injury (TBI), the high intracisternal pressure drives the cerebrospinal fluid into the brain parenchyma, causing cerebral edema. Basal cisternostomy involves opening the basal cisterns to atmospheric pressure and draining cerebrospinal fluid in an attempt to reverse the edema. We describe a case of basal cisternostomy combined with decompressive craniectomy. A 35-year-old man with severe TBI following a road vehicle accident presented with acute subdural hematoma, Glasgow coma scale score of 6, fixed pupils and no corneal response. Opening of the basal cisterns and placement of a temporary cisternal drain led to immediate relaxation of the brain. The patient had a Glasgow coma scale score of 15 on postoperative day 6 and was discharged on day 10. We think basal cisternostomy is a feasible and effective procedure that should be considered in the management of TBI.
Adult ; Brain ; Brain Edema ; Brain Injuries, Traumatic/surgery* ; Decompressive Craniectomy/methods* ; Glasgow Coma Scale ; Humans ; Male ; Treatment Outcome

OBJECTIVE: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. METHODS: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. RESULTS: The mean age of patients was 71.6 years (range, 38–90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. CONCLUSION: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.
Alcoholism ; Craniotomy ; Drainage ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Headache ; Hematoma ; Hematoma, Subdural, Acute ; Hematoma, Subdural, Chronic ; Hemorrhage ; Humans ; Methods ; Trephining ; Urokinase-Type Plasminogen Activator

OBJECTIVE: To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI).METHODS: We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.RESULTS: Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p < ;0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.CONCLUSION: We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.
Brain Injuries ; Classification ; Cohort Studies ; Coma ; Emergency Service, Hospital ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Humans ; Intensive Care Units ; Korea ; Mortality ; Retrospective Studies ; Trauma Centers

OBJECTIVE: Assessing the severity of injury and predicting outcomes are essential in traumatic brain injury (TBI). However, the respiratory rate and Glasgow Coma Scale (GCS) of the Revised Trauma Score (RTS) are difficult to use in the prehospital setting. This investigation aimed to develop a new prehospital trauma score for TBI (NTS-TBI) to predict mortality and disability.METHODS: We used a nationwide trauma database on severe trauma cases transported by fire departments across Korea in 2013 and 2015. NTS-TBI model 1 used systolic blood pressure < 90 mmHg, peripheral capillary oxygen saturation < 90% measured via pulse oximeter, and motor component of GCS. Model 2 comprised variables of model 1 and age >65 years. We assessed discriminative power via area under the curve (AUC) value for in-hospital mortality and disability defined according to the Glasgow Outcome Scale with scores of 2 or 3. We then compared AUC values of NTS-TBI with those of RTS.RESULTS: In total, 3,642 patients were enrolled. AUC values of NTS-TBI models 1 and 2 for mortality were 0.833 (95% confidence interval [CI], 0.815 to 0.852) and 0.852 (95% CI, 0.835 to 0.869), respectively, while AUC values for disability were 0.772 (95% CI, 0.749 to 0.796) and 0.784 (95% CI, 0.761 to 0.807), respectively. AUC values of NTS-TBI model 2 for mortality and disability were higher than those of RTS (0.819 and 0.761, respectively) (P < 0.01).CONCLUSION: Our NTS-TBI model using systolic blood pressure, motor component of GCS, oxygen saturation, and age was feasible for prehospital care and showed outstanding discriminative power for mortality.
Anoxia ; Area Under Curve ; Blood Pressure ; Brain Injuries ; Capillaries ; Fires ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Hospital Mortality ; Humans ; Hypotension ; Korea ; Mortality ; Observational Study ; Oxygen ; Quality Improvement ; Respiratory Rate

OBJECTIVE: To investigate the clinical effect of modified Graeb criteria score and Glasgow coma score (GCS) in individualized treatment of intraventricular hemorrhage. METHODS: 113 patients with intraventricular hemorrhage admitted to the department of neurosurgery of Second Affiliated Hospital of Guangxi Medical University from June 2014 to February 2018 were enrolled, and they were divided into 13-15, 9-12, and 3-8 groups according to GCS score at admission, and modified Graeb criteria score was classified as grade I, II and III at the same time. In GCS 9-12 and 3-8 groups, patients with modified Graeb criteria score grade III were treated with bilateral extra ventricular drainage, patients with modified Graeb criteria score grade II were treated with bilateral extra ventricular drainage or lumbar cistern drainage (GCS 9-12 group was more prior to lumbar cistern drainage, 3-8 group was given priority to extra ventricular drainage), and patients with modified Graeb criteria score grade I were treated conservatively. In GCS 13-15 group, bilateral extra ventricular cerebral drainage or lumbar cistern drainage was performed if the modified Graeb criteria score grade was III, lumbar cistern drainage or conservative treatment was performed if the modified Graeb criteria score grade was II, and conservative treatment was performed if the modified Graeb criteria score grade was I. The changes in GCS score at 1 month after individualized treatment and the favourable prognosis rate at 6 months after treatment were observed [favourable prognosis was defined as Glasgow outcome score (GOS) IV-V] as well as the basic clearance time of intraventricular hematomas, and the occurrence of complications such as intracranial infection, pulmonary infection and hydrocephalus were recorded. RESULTS: 113 patients with intraventricular hemorrhage were enrolled in the final analysis, including 39 patients in GCS 13-15 group, 27 in 9-12 group, and 47 in 3-8 group; 21 patients with the first grade of modified Graeb criteria score, 42 with the second grade and 50 with the third grade. At 1 month after individualized treatment, the GCS scores in GCS 13-15 and 9-12 groups were significantly higher than those at admission (14.8±0.2 vs. 13.7±0.8, 13.1±1.7 vs. 10.7±1.1, both P < 0.05). When comparing the GCS score of the same patient at admission with that of 1 month after treatment, the GCS scores of the three groups were significantly improved, indicating that the consciousness of patients with different coma levels at admission had been significantly improved after individualized treatment. The basic clearance time of intracerebroventricular hematomas in patients with the second grade of modified Graeb criteria score was (7.0±2.8) days, in patients with the third grade was (6.1±2.0) days. At 6 months after individualized treatment, among 113 patients, GOS score was grade I in 7 patients (6.2%), grade II in 13 patients (11.5%), grade III in 28 patients (24.8%), grade IV in 27 patients (23.9%), and grade V in 38 patients (33.6%), with the favourable prognosis rate of 57.5% (65/113). Among 113 patients, intracranial infection occurred in 5 patients (4.4%), pulmonary infection in 22 patients (19.5%), hydrocephalus in 2 patients (1.8%) and rebleeding in 4 patients (3.5%). In 83 patients with lumbar cistern drainage, 1 patient had post-drainage infection (1.2%), 3 patients had plugging (3.6%), 6 patients had accidental drop of drainage tube (7.2%), and none of them had occipital macroforamen hernia after drainage. Seven of the 113 patients died including 2 patients died of cerebral hernia caused by rebleeding, 5 patients died of severe pneumonia or automatic discharge from hospital. CONCLUSIONS The combination of modified Graeb criteria score and GCS score can individualize treatment for patients with intraventricular hemorrhage and effectively improve the prognosis of patients with intraventricular hemorrhage.
Cerebral Hemorrhage ; China ; Glasgow Coma Scale ; Humans ; Hydrocephalus ; Prognosis ; Retrospective Studies ; Treatment Outcome

OBJECTIVE: Minimally invasive techniques such as stereotactic aspiration have been regarded as promising alternative methods to replace craniotomy in the treatment of intracerebral hemorrhage (ICH). The aim of this study was to identify the optimal timing of stereotactic aspiration and analyze the factors affecting the clinical outcome. MATERIALS AND METHODS: This retrospective study included 81 patients who underwent stereotactic aspiration for spontaneous supratentorial ICH at single institution. Volume of hematoma was calculated based on computed tomography scan at admission, just before aspiration, immediately after aspiration, and after continuous drainage. The neurologic outcome was compared with Glasgow outcome scale (GOS) score. RESULTS: The mean volume ratio of residual hematoma was 59.5% and 17.6% immediately after aspiration and after continuous drainage for an average of 2.3 days, respectively. Delayed aspiration group showed significantly lower residual volume ratio immediately after aspiration. However, there was no significant difference in the residual volume ratio after continuous drainage. The favorable outcome of 1-month GOS 4 or 5 was significantly better in the group with delayed aspiration after more than 7 days (p = 0.029), despite no significant difference in postoperative 6-months GOS score. A factor which has significant correlation with postoperative 6-months favorable outcome was the final hematoma volume ratio after drainage (p = 0.028). CONCLUSION: There is no difference in final residual volume of hematoma or 6-months neurologic outcome according to the surgical timing of hematoma aspiration. The only factor affecting the postoperative 6-months
Cerebral Hemorrhage* ; Craniotomy ; Drainage ; Glasgow Outcome Scale ; Hematoma ; Humans ; Minimally Invasive Surgical Procedures ; Residual Volume ; Retrospective Studies ; Stereotaxic Techniques

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of stent-assisted coil embolization using only a glycoprotein IIb/IIIa inhibitor (tirofiban). MATERIALS AND METHODS: We retrospectively reviewed patients with a subarachnoid hemorrhage due to ruptured wide-necked intracranial aneurysms who were treated by stent-assisted coil embolization. In all patients, the glycoprotein IIb/IIIa inhibitor tirofiban was administered just before stent deployment. Electronic medical records for these patients were reviewed for peri-procedural complications and extra-ventricular drainage catheter related hemorrhage, as well as Glasgow outcome scale (GOS) at discharge, 3 months, and 6 months follow-up were recorded. RESULTS: Fifty-one aneurysms in 50 patients were treated. The mean patient age was 64.9 years. Eighteen patients (36%) received a World Federation of Neurosurgical Societies grade of 4 or 5. The mean aneurysm size was 9.48 mm and mean dome-to-neck ratio was 1.06. No intraoperative aneurysm ruptures occurred, although five (10%) episodes of asymptomatic stent thrombosis did occur. Three patients experienced a delayed thrombo-embolic event and two a delayed hemorrhagic event. Immediate radiologic assessment indicated a complete occlusion in 29 patients, a residual neck in 19, and a residual sac in 3. Four patients (8%) died. Sixteen patients (32%) experienced a poor GOS (< 4). Two aneurysms were recanalized during the follow-up period (mean, 19 months for clinical and 18 months for angiographic follow-up). CONCLUSION: Treatment of ruptured wide-necked intracranial aneurysms via stent-assisted coil embolization with a glycoprotein IIb/IIIa inhibitor alone was found to be relatively safe and efficient.
Aneurysm* ; Catheters ; Drainage ; Electronic Health Records ; Embolization, Therapeutic* ; Endovascular Procedures ; Follow-Up Studies ; Glasgow Outcome Scale ; Glycoproteins* ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Neck ; Platelet Aggregation Inhibitors ; Retrospective Studies ; Rupture ; Stents ; Subarachnoid Hemorrhage ; Thrombosis

OBJECTIVE: Despite recent advances in medicine, no significant improvement has been achieved in therapeutic outcomes for severe traumatic brain injury (TBI). In the treatment of severe multiple traumas, accurate judgment and prompt action corresponding to rapid pathophysiological changes are required. Therefore, we developed the “All-in-One” therapeutic strategy for severe TBI. In this report, we present the therapeutic concept and discuss its efficacy and limitations. METHODS: From April 2007 to December 2015, 439 patients diagnosed as having traumatic intracranial injuries were treated at our institution. Among them, 158 patients were treated surgically. The “All-in-One” therapeutic strategy was adopted to enforce all selectable treatments for these patients at the initial stages. The outline of this strategy is as follows: first, prompt trepanation surgery in the emergency room (ER); second, extensive decompression craniotomy (DC) in the operating room (OR); and finally, combined mild hypothermia and moderate barbiturate (H-B) therapy for 3 to 5 days. We performed these approaches on a regular basis rather than stepwise rule. If necessary, internal ecompression surgery and external ventricular drainage were performed in cases in which intracranial pressure could not be controlled. RESULTS: Trepanation surgery in the ER was performed in 97 cases; among these cases, 46 had hematoma removal surgery and also underwent DC in the OR. Craniotomy was not enforced unless the consciousness level and pupil findings did not improve after previous treatments. H-B therapy was administered in 56 cases. Internal decompression surgery, including evacuation of traumatic intracerebral hematoma, was additionally performed in 12 cases. Three months after injury, the Glasgow Outcome Scale (GOS) score yielded the following results: good recovery in 25 cases (16%), mild disability in 28 (18%), severe disability in 33 (21%), persistent vegetative state in 9 (6%), and death in 63 (40%). Furthermore, 27 (36%) of the 76 most severe patients who had an abnormal response of bilateral eye pupils were life-saving. Because many cases of a GOS score of ≤5 are included in this study, this result must be satisfactory. CONCLUSION: This therapeutic strategy without any lose in the appropriate treatment timing can improve the outcomes of the most severe TBI cases. We think that the breakthrough in the treatment of severe TBI will depend on the shift in the treatment policy.
Brain Injuries* ; Consciousness ; Craniotomy ; Decompression ; Drainage ; Emergency Service, Hospital ; Glasgow Outcome Scale ; Hematoma ; Humans ; Hypothermia ; Intracranial Pressure ; Judgment ; Multiple Trauma ; Operating Rooms ; Persistent Vegetative State ; Pupil ; Trephining

OBJECTIVE: This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC). METHODS: A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance < 20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively. RESULTS: The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p < 0.001; operation time: 125.92 vs. 144.83 min, p < 0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups. CONCLUSION: We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.
Adult ; Anesthesia ; Brain ; Brain Injuries* ; Decompressive Craniectomy* ; Female ; Glasgow Outcome Scale ; Hematoma ; Humans ; Intensive Care Units ; Male ; Medical Records ; Retrospective Studies ; Superior Sagittal Sinus* ; Trauma Centers*

OBJECTIVE: The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction.METHODS: From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score < 11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia.RESULTS: The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045).CONCLUSION: This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.
Arrhythmias, Cardiac ; Brain Edema ; Cerebral Infarction ; Glasgow Coma Scale ; Hemorrhage ; Humans ; Hypotension ; Hypothermia ; Infarction ; Infarction, Middle Cerebral Artery ; Logistic Models ; Middle Cerebral Artery ; Mortality ; National Institutes of Health (U.S.) ; Pneumonia ; Postoperative Care ; Prognosis ; Retrospective Studies ; Sepsis ; Stroke ; Treatment Outcome