Background: Polymethyl methacrylate (PMMA) cranioplasty, while widely prevalent, has limitations associated with freehand manual intraoperative molding. PMMA has been superseded by titanium or Polyetheretherketone implants, prefabricated commercially from preoperative CT scans, and boasting superior clinical and cosmetic outcomes. However, such services are extremely inaccessible and unaffordable in the lower-middle-income country (LMIC) settings. The study aims to describe, in detail, the process of making ultra-low-cost patient-specific PMMA cranioplasty implants with minimum resources using open-access software. We report the first such service from the public health-care system within Pakistan, a LMIC. Methods: Using open-source software, preoperative CT heads were used to prefabricate three-dimensional implants. Both implant and cranial defects were printed using polylactic acid (PLA) to assess the implant’s size and fit preoperatively. From the PLA implant, we fashioned a silicon mold that shapes the PMMA implant. Ten patients who underwent cranioplasty using our technique for various cranial defects with at least a 12-month follow-up were retrospectively reviewed. Clinical, cosmetic, and radiological outcomes were objectively assessed. Results: Etiology of injury was trauma (8), malignant MCA infarct (1), and arteriovenous fistula (1). We produced seven frontotemporal-parietal implants, one bifrontal, one frontal, and one frontoparietal. At 1 year, eight patients reported their cosmetic appearance comparable to before the defect. Radiological outcome was classified as “excellent” for eight patients. No postoperative complications were encountered, nor did any implant have to be removed. One patient’s implant involving the orbital ridge had an unsatisfactory cosmetic outcome and required revision surgery. The average cost per implant to the National Health Service was US$40. Conclusion: Prefabricated patient-specific PMMA cranioplasty implants are cost-effective. A single surgeon can fashion them in a limited resource setting and provide personalized medicine with excellent clinical/cosmetic-radiological results. Our method produces patient-specific cranioplasty implants in an otherwise unaffordable LMIC setting.
Background: Chronic myeloid leukemia (CML) is mostly asymptomatic at diagnosis. Intracerebral hemorrhage (ICH), as the first presentation of CML in its chronic phase (CP) has only once been reported in the literature. In addition, CML (CP) patients developing ICH are equally rare, with only eight cases reported. ICH is more commonly associated with CML progressing to its end stage (accelerated phase [AP] and blast crisis [BC]). The pathophysiology of ICH in CML-CP is postulated to be due to leukostasis, unlike in the CML-AP/BC, where thrombocytopenia and coagulopathy are the underlying mechanisms. This case adds to the scarce literature on a rare and challenging complication of ICH in CML-CP, especially as these patients tend to rebleed and management is uncertain. Case Description: A 22-year-old male presented with a 2-week history of headaches and vomiting, associated with a 1-week history of the left-sided weakness. Initial blood work revealed hyperleukocytosis. The patient was investigated for CML with intracranial involvement. During his stay, his Glasgow coma score (GCS) dropped (from 14 to 11), prompting an urgent CT scan which revealed a large resolving ICH with perifocal edema and midline shift. A decompressive hemicraniectomy with expansion duraplasty was performed to alleviate the mass effect and reduce intracranial pressure. Three hours postoperatively, the patient developed an extradural hematoma which needed prompt evacuation. A postoperative CT revealed an improved midline shift, and after 7 days, his GCS improved to 15, and he began oncological treatment. Neurological symptoms were experienced by our patient at presentation with hyperleukocytosis on full blood count, which may implicate leukostasis as an underlying mechanism. Conclusion: Even in the CP, CML patients presenting with mild neurological symptoms should be investigated to exclude intracranial bleeds. As these patients tend to rebleed, they should be conservatively managed unless there is a need to alleviate intracranial pressure.
Objective: To evaluate the prognostic factors affecting functional clinical outcomes in severe traumatic brain injury patients with traumatic mass lesions undergoing decompressive hemicraniectomy (DHC). Materials and Methods: A prospective cohort of 85 patients of severe traumatic brain injury patients with traumatic mass lesions underwent a unilateral decompressive hemicraniectomy. Functional outcomes were assessed using the Glasgow Outcome Score at 28 days, 3 months, and 6 months. Bivariate analysis (chi-squared) was used to identify parameters that resulted in poor outcomes and multiple regression was used to identify independent factors predicting poor outcomes. Results: 85 patients were recruited. Functional outcomes were dichotomised as favourable (Glasgow Outcome Score of 4 – 5) and poor (Glasgow Outcome Score 1-3) and evaluated at 28 days, 3 and 6 months. A total of 59 patients expired (69.4%). Bivariate analysis revealed GCS 3 – 5 at presentation (P = 0.002), midline shift greater than 7.5mm (P < 0.001), the volume of the mass lesion more than 40ml (P = 0.006) resulted in a poor outcome. Age dichotomised to less than or more than 50 years bordered statistical significance (P = 0.063). Only GCS at presentation and midline shift were independent factors that predicted poor outcomes when controlling for covariates. Conclusion: Decompressive hemicraniectomy can be a lifesaving intervention in managing severe traumatic brain injury patients with traumatic mass lesions. However, its use needs to be employed judiciously.
Cardiovascular changes following lumbar spine surgery in a prone position are exceedingly rare. Over the past 20 years, a total of six cases have been published where patients experienced varying degrees of bradycardia, hypotension, and asystole, which could be attributed to intraoperative dural manipulation. As such, there is emerging evidence for a potential neural-mediated spinal-cardiac reflex. The authors report their experience of negative chronotropy during an elective lumbar spine surgery that coincided with dural manipulation and review the available literature. A 34-year-old male presented with a long-standing history of lower back pain recently deteriorating to bilaterally radiating leg pain, with restricted left leg raise, and numbness at the left L5 dermatomal territory. The patient was an athletic police officer with no comorbidities or past medical history. Magnetic resonance imaging lumbosacral spine revealed spinal stenosis most pronounced at L4/L5 and disc bulges at L3/L4 and L5/S1. The patient opted for lumbar decompression surgery. After an unremarkable comprehensive preoperative workup, including cardiac evaluation (electrocardiogram, echocardiogram), the patient was induced general anesthesia in a prone position. A lumbar incision was made from L2 to S1. When the left L4 nerve root was retracted while removing the prolapsed disc at L4/L5, the anesthetist cautioned the surgeon of bradycardia (34 beats per minute [bpm]), and the surgery was immediately stopped. The heart rate improved to 60 bpm within 30 seconds. When the root was later retracted again, a second episode of bradycardia occurred for 4 minutes with heart rate declining to 48 bpm. The surgery was stopped, and after 4 minutes, the anesthetist administered 600 µg of atropine. The heart rate then rose to 73 bpm within 1 minute. Other potential causes for bradycardia were excluded. The total blood loss was estimated to be 100 mL. He remains well at his 6-month follow-up and has returned to work as normal. Akin to previously published cases, each episode of bradycardia coincided with dural manipulation, which may indicate a possible reflex between the spinal dura mater and the cardiovascular system. Such a rare adverse event may occur even in seemingly healthy, young individuals, and anesthetists should caution the operating surgeon of bradycardias to exclude operative manipulation of the dura as the cause. While this phenomenon is only reported in a handful of lumbar spine surgery cases, it provides evidence for a potential spinal-cardiac physiological reflex in the lumbar spine that may be neural mediated and should be investigated further.
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