Background and purposeThe pathogenesis of brain injury after intracerebral hemorrhage is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue.In recent years, there has been a greater research interest into the various inflammatory biomarkers and growth factors that are secreted during intracerebral hemorrhage. The biomarkers investigated in this study are tumor necrosis factor alpha (TNF alpha), C-reactive protein (CRP), homocysteine (Hcy), and vascular endothelial growth factor (VEGF). The aim of this study was to further investigate the effects of these biomarkers in predicting the acute severity outcome of intracerebral hemorrhage (ICH).MethodsWe conducted a retrospective chart review of patients with spontaneous ICH with TNF alpha, CRP, VEGF, and Hcy levels drawn on admission. Forty-two patients with spontaneous ICH with at least one of the above labs were included in the study. Primary outcomes included death, Glasgow Coma Scale (GCS) on admission, early neurologic decline (END), and hemorrhage size. Secondary outcomes included GCS on discharge, ICH score, functional outcome risk stratification scale of intracerebral hemorrhage (FUNC score), change in hemorrhage size, need for surgical intervention, and length of intensive care unit (ICU) stay.ResultsForty-two patients with spontaneous intracerebral hemorrhage (ICH) were analyzed, 12 patients (28.5%) required surgical intervention, and four patients (9.5%) died. Only low VEGF serum values were found to predict mortality. TNF alpha, CRP, Hcy, and VEGF levels in our patients with ICH were not found to predict early neurologic decline and were not correlated with GCS on admission, initial hemorrhage size, change in hemorrhage size, need for surgical intervention, ICH score, FUNC score, midline shift, and length of ICU stay. CRP and Hcy were elevated in 58% and 31% of patients tested, respectively. GCS on admission and ICH score were significantly associated with mortality.ConclusionAfter careful statistical review of the data obtained from this patient population, only low VEGF values were found to be a significant predictor of mortality. However, elevated CRP and Hcy levels were associated with a non-significant trend in hemorrhage size and mortality suggesting that CRP and Hcy-lowering therapies may decrease hemorrhagic stroke risk and severity.

We studied the interictal EEG of 50 epileptic patients (28 males, 22 females) who had parenchymal neurocysticercosis, diagnosed by CAT/MRI of the brain, positive immunological reaction for cysticercosis in cerebral spinal fluid or both. Age ranged from 5 to 61 years old; the mean age of onset was 24.2 +/- 12.2 years. Thirty-six patients had generalized seizures, 13 partial seizures with secondarily generalized seizures, and 1 had complex partial seizures. Twenty-two patients had parenchymal calcifications (inactive form); 21 had parenchymal cysts (active form) and 7 had both. EEG was abnormal in 14 patients (28%): 8 had focal slowing, 3 had focal sharp or spike activity, and 3 had both. The EEG was normal in patients with inactive forms of neurocysticercosis. The EEG was abnormal in 50% of patients with active and mixed forms of neurocystercosis and in 48% of patients with active form only. We conclude that the active forms of neurocysticercosis should be suspected when the EEG is found to be abnormal. In additional, EEG abnormality does not depend on the number of lesions, but rather on location and viability of the cysts, and on host response.

In contmdistinction to the widespread use of imaging ultrasound in exmnining many other l'egions of the body, ultrasonography of the centralnervow; system has been seriously limited because high· frequency ultrasound dues not readily penetrate the bon y covering of this organ system. The difl'iculty in using ultrasound to visualize lm1in and spinal cord structm·es is a paradox in the history of medical ultr:•sonogmphy hecause much of the interest in the early days of this field of diagnostic imaging was in the central nervous system. ~lore than 30 years ago, French et a!. used A-mode s<:anning to localize il subcortical brain tumor in an e:\+ cised postmortem specimen. U! Advances in central nervous system ultrasonography have been made, however, in applic.ltions in which the skull or vertebral bodies have not impeded the pasage of ultrasound waves. There have been three pl'incipal areas of such applkations: postoperative scanning through craniectomy portals, : l .~ imaging through the fontanels of infants,5·6 and intraoperative ultrasonography.Operative use of imaging ultrasound for brain disease was first employed in the 1960s. ' :' "-II However, the A-mode scanning available then presented problems of interpretation which prevented widespread applkation of this dia~nostic tool. ~lore recent adnmces in ultrasound technology, particularly the development of high-resolution real-time B-mode scanners, have eliminated manv of the em~ lier difHculties in operative imaf,ting. This IHL'i re· suited in u renewed trial of ultrasonic scanning in various types of operations on the hrain 1 :2 -:H and spinal cord. ~. 2l iAs part of a pro~ra m to assess the utility of op· erative ultrasonography in a number of surgical dis· ciplines. we employed ultrasound imaging during brain and spinal cord surgery. \Ve have reviewed our experience of spedfic applications in terms of the impact of ultrasonography on management during opemtion. From this analysis we have de· termined the situations in which ultrasonograph~· during neurosurgery can be most helpful. This analvsis has enabled us to establish criteria for the most productive use of ultrasound during brain and spinal cord surgery and is the basis of this report. METHODSOperative ultrasonography during neurosurgical procedures was performed with real-time B-mode instruments employing mechanically driven sectorscanning transducers. High Stoy. Philips, and Dia-155

Introduction: Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality among young adults. The clinical outcome may also be difficult to predict. We aim to identify the factors predictive of favorable and unfavorable clinical outcomes for youthful patients with severe TBI who have the option of surgical craniotomy or surgical craniectomy.Methods: A retrospective review at a single Level II trauma center was conducted, identifying patients aged 18 to 30 years with isolated severe TBI with a mass-occupying lesion requiring emergent (< 6 hours from time of arrival) surgical decompression. Glasgow Coma Scale (GCS) score on arrival, type of surgery performed, mechanism of injury, length of hospital stay, Glasgow Outcome Score (GOS), mortality, and radiographic findings were recorded. A favorable outcome was a GOS of four or five at 30 days post operation, while an unfavorable outcome was GOS of 1 to 3.Results: Fifty patients were included in the final analysis. Closed head injuries (skull and dura intact), effacement of basal cisterns, disproportional midline shift (MLS), and GCS 3-5 on arrival all correlated with statistically significant higher rate of mortality and poor 30-day functional outcome. All mortalities (6/50 patients) were positive for each of these findings.Conclusions: Closed head injuries, the presenting GCS 3-5, the presence of MLS disproportional to the space occupying lesion (SOL), and effacement of basal cisterns on the initial computed tomography of the head all correlated with unfavorable 30-day outcome. Future prospective studies investigating a larger cohort may provide further insight into patients suffering from severe TBI.

No abstract

Background: Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission. Methods: Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18–90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors. Results: A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD 6.0 mm + Marshall score 3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP 20 mmHg during hospitalization. Conclusion: Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

Open Access Original Article

IntroductionIncidental durotomy (ID) is a well-known complication in spine surgery. Surveys have not identified a consensus for repair method among neurosurgeons. IDs may lead to complications such as cerebrospinal fluid (CSF) fistula, which may predispose patients to infection, additional procedures, increased length of stay and morbidity. This study aims to compare durotomy repair methods with clinical outcomes.MethodsThe neurosurgery database at a single institution, Arrowhead Regional Medical Center, was screened for all patients who underwent thoracic and lumbar spine surgery from 2007-2017. Retrospective chart review of operative reports identified patients with an ID. Data collection included: length of stay, infection, additional procedures, time lying flat, CSF fistula formation (primary endpoint) with analysis using t-tests.ResultsA total of 384 patients underwent initial analysis. Of the 384 patients, 25 had an incidental durotomy based on operative reports. Four patients were excluded from this subset: two were repaired with muscle graft (low N), two were excluded for unclear repair method. The remaining 21 were stratified into two groups, those repaired directly with suture with or without adjunct (N=9) and those repaired indirectly with sealant (N=12). No patients developed a CSF fistula. The indirect group had a length of stay of six days, while the direct group had a length of stay of four days, p=0.184. Two of the nine patients in the direct group and two of the twelve patients in the indirect group developed an infection, p=0.586.ConclusionNo patients developed CSF fistulas. Secondary endpoints of length of stay and infection rate did not differ. This study was unable to determine if direct versus indirect repair was a more effective repair method for ID. It is possible that if an incidental durotomy is identified and repaired with a water-tight seal, the repair method does not affect the outcome. It is up to the surgeon to individualize repair based on ability and circumstances.