The purpose of this retrospective study is to determine the pattern of cerebrospinal fluid (CSF) rhinorrhoea presenting to our tertiary referral centre in Kuala Lumpur and to assess the clinical outcomes of endonasal endoscopic surgery for repair of anterior skull base fistulas. Sixteen patients were treated between 1998 and 2004. The aetiology of the condition was spontaneous in seven and acquired in nine patients. In the acquired category, three patients had accidental trauma and this was iatrogenic in six patients (five post pituitary surgery), with one post endoscopic sinus surgery (ESS). Imaging included computed tomography (CT) scan and magnetic resonance imaging (MRI). Endoscopic repair is less suited for defects in the frontal sinuses with prominent lateral extension and defects greater than 1.5 cm in diameter involving the skull base. Fascia lata, middle turbinate mucosa, nasal perichondrium and ear fat ('bath plug') were the preferred repair materials in the anterior skull base, whereas fascia lata, cartilage and abdominal fat obliteration was preferentially used in the sphenoid leak repair. Intrathecal sodium flourescein helped to confirm the site of CSF fistula in 81.3 per cent of the patients. Ninety per cent of the patients who underwent 'bath plug' repair were successful. The overall success rate for a primary endoscopic procedure was 87.5 per cent, although in two cases a second endoscopic procedure was required for closure. In the majority of cases endoscopic repair was successful, and this avoids many of the complications associated with craniotomy, particularly in a young population. Therefore it is our preferred option, but an alternative procedure should be utilized should this prove necessary.

Anticonvulsant prophylaxis to minimize the adverse effects of early seizures in head injury should be considered for young children (less than 2 years old) with subdural haematoma and a prolonged duration of coma. Prompt and effective control of recurrent seizures is recommended.

The outcome of 151 children less than 15 years of age and admitted within 24 h of head injury was studied in relation to clinical and computed tomography (CT) scan features. Thirty one (20.5%) had a poor outcome (24 died, 6 were severely disabled at 6 months after injury and 1 was in a persistent vegetative state) while 120 (79.5%) had a good outcome (89 recovered well and 31 were moderately disabled). Factors associated with a poor outcome were Glasgow Coma Scale (GCS) score 24 h following injury, presence of hypoxia on admission and CT scan features of subarachnoid haemorrhage, diffuse axonal injury and brain swelling. GCS scores alone, in the absence of other factors, had limited predictive value. The prognostic value of GCS scores <8 was enhanced two- to fourfold by the presence of hypoxia. The additional presence of the CT scan features mentioned above markedly increased the probability of a poor outcome to >O.8, modified only by the presence of GCS scores > 12. Correct predictions were made in 90.1 % of patients, indicating that it is possible to estimate the severity of a patient’s injury based on a small subset of clinical and radiological criteria that are readily available.

The outcome of 109 patients with severe head injury was studied in relation to clinical and computed tomographic (CT) criteria on admission, after resuscitation. Age, Glasgow Coma Score (GCS) and state of pupils strongly correlated with outcome. The presence of hypothalamic disturbances, hypoxia and hypotension were associated with an adverse outcome. The CT indicators associated with poor outcome were perimesencephalic cistern (PMC) obliteration, subarachnoid haemorrhage, diffuse axonal injury and acute subdural haematoma. The prognostic value of midline shift and mass effect were influenced by concomitant presence of diffuse brain injury. For the subset of patients aged < 20 years, with GCS 6-8 and patent PMC (n = 21), 71.4% correct predictions were made for a good outcome. For the subset of patients aged > 20 years, with GCS 3-5 and partial or complete obliteration of PMC (n = 28), 89.3% correct predictions were made for a poor outcome.

Micrococcus spp. are commensal organisms colonizing the body surfaces of humans. In a few instances these organisms have been reported to colonize ventricular shunts. We report a patient, with no overt evidence of immunosuppression, in whom Micrococcus luteus was responsible for intracranial suppuration at multiple sites.

: Accurate diagnosis can be made on images of acute neurosurgical problems transferred using a conventional camera phone and meaningful decisions can be made on these images. This method of consultation also proved to be highly convenient and cost effective.

The aim of this investigation was to determine the prognostic value of coagulation abnormalities in a defined subset of patients with acute head injury. Prothrombin time, accelerated partial thromboplastin time (APTT), thrombin clotting time, fibrinogen assay, platelet count, fibrin degradation products (FDP) were assayed in 204 patients with acute closed head injury. Their values were graded on a score 0-3 and the sum score for each patient regarded as the disseminated intravascular coagulation (DIC) score. Moderate to severe DIC scores were evident in 38% of the cohort. At least one parameter was abnormal in 71% of patients. The DIC score correlated inversely with the Glasgow coma score (GCS) (p < 0.0001). In the GCS 13-15 subset, FDP scores were significant predictors of poor outcome (p < 0.001). In the GCS 6-12 subset, the APTT score (p < 0.001), and DIC score (p < 0.0001) predicted an adverse outcome. The DIC scores were significantly abnormal in most patients who had a poor outcome, without evidence of adverse predictors on CT. Logistic regression analysis confirmed the independent predictive capacity of APTT, FDP and DIC scores when values for GCS were fixed. Abnormal haemostatic parameters may enhance the predictive ability in subsets of patients with acute head injury defined by clinical or CT predictors.

No abstract