Surgically accessing pathological lesions located within the central nervous system (CNS) frequently requires creating an incision in cosmetic regions of the head and neck. The biggest factors of surgical success typically tend to focus on the middle portion of the surgery, but a vast majority of surgical complications tend to happen towards the end of a case, during closure of the surgical site incisions. One of the most difficult complications for a surgeon to deal with is having to take a patient back to the operating room for wound breakdowns and, even worse, wound or CNS infections, which can negate all the positive outcomes from the surgery itself. In this paper, we discuss the underlying anatomy, pharmacological considerations, surgical techniques and nutritional needs necessary to help facilitate appropriate wound healing. A successful surgery begins with preoperative planning regarding the placement of the surgical incision, being cognizant of cosmetics, and the effects of possible adjuvant radiation therapy on healing incisions. We need to assess patient's medications and past medical history to make sure we can optimise conditions for proper wound reepithelialisation, such as minimizing the amount of steroids and certain antibiotics. Contrary to harmful medications, it is imperative to optimise nutritional intake with adequate supplementation and vitamin intake. The goals of this paper are to reinforce the mechanisms by which surgical wounds can fail, leading to postoperative complications, and to provide surgeons with the reminder and techniques that can help foster a more successful surgical outcome.

Background: Hospital-acquired infections (HAIs) are profound causes of prolonged hospital stay and worse patient outcomes. HAIs pose serious risks, particularly in neurosurgical patients in the intensive care unit, as these patients are seldom able to express symptoms of infection, with only elevated temperatures as the initial symptom. Data from Center for Disease Control (CDC) and the Infectious Disease Society of America (IDSA) have shown that of all HAIs, urinary tract infections (UTIs) have been grossly over-reported, resulting in excessive and unnecessary antibiotic usage.Methods: We conducted a retrospective analysis of 686 adult patients that were evaluated by the neurosurgery service at Arrowhead Regional Medical Center between July 2018 and March 2019. Inclusion criteria were adults greater than 18 years of age with neurosurgical pathology requiring a minimum of one full day admission to the intensive care unit (ICU), and an indwelling urinary catheter. Exclusion criteria were patients under the age of 18, those who did not spend any time in the ICU, or with renal pathologies such as renal failure.Results: We reviewed 686 patients from the neurosurgical census. In total, 146 adult patients with indwelling urinary catheters were selected into the statistical analysis. Most individuals spent an average of 8.91 ± 9.70 days in the ICU and had an indwelling catheter for approximately 8.14 ± 7.95 days. Forty-two out of the 146 individuals were found to have a temperature of 100.4°F or higher. Majority of the patients with an elevated temperature had an infectious source other than urine, such as sputum (22 out of 42, 52.38%), blood (three out of 42, 7.14%) or CSF (one out of 42, 2.38%). We were able to find only two individuals (4.76%) with a positive urine culture and no evidence of other positive cultures or deep vein thrombosis.Conclusions: Our analysis shows evidence to support the newest IDSA guidelines that patients with elevated temperatures should have a clinical workup of all alternative etiologies prior to testing for a urinary source unless the clinical suspicion is high. This will help reduce the rate of unnecessary urine cultures, the over-diagnosis of asymptomatic bacteriuria, and the overuse of antibiotics. Based on our current findings, all potential sources of fever should be ruled out prior to obtaining urinalysis, and catheters should be removed as soon as they are not needed. Urinalysis with reflex to urine culture should be reserved for those cases where there remains a high index of clinical suspicion for a urinary source.

Cerebrospinal fluid (CSF) analysis is a common diagnostic tool used to evaluate diseases of the central nervous system (CNS). We sought to determine whether there is a difference between the composition of CSF sampled from an external ventricular drain (EVD) and lumbar drain (LD) and whether this made a difference in guiding therapeutic decisions. Patients and Methods This study was a retrospective analysis from a single neurosurgery service between the dates of January 2011 and April 2019. A total of 12,134 patients were screened. Inclusion criteria were ages 18-80 and the presence of both an EVD and LD. Exclusion criteria were not having both routes of CSF sampling and the inability to determine which samples originated from which compartment. Results Six patients underwent simultaneous spinal and ventricular routine CSF sampling <24 hours apart and were analyzed for their compositions. There were 42 samples, but only 20 paired EVD-LD samples that could be analyzed. When comparing the EVD and LD sample compositions, there were statistically significant differences in white blood cells (WBCs; p = 0.040), total protein (p = 0.042), and glucose (p = 0.043). Red blood cells (RBCs; p = 0.104) and polymorphonuclear leukocytes (PMN; p = 0.544) were not statistically significant. We found a statistically significant correlation between cranial and spinal CSF WBC (r = 0.944, p < 0.001), protein (r = 0.679, p = 0.001), and glucose (r = 0.805, p < 0.001). We also found that there was a significant correlation between CSF and serum glucose (r = 0.502, p = 0.040). There was no statistically significant correlation between RBCs (r = 0.276, p = 0.252).

Spontaneous intracranial hypotension (SIH) is a pathology characterized by orthostatic headaches, diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI), and low to normal cerebrospinal fluid (CSF) pressures.We present the case of a 46-year-old male with refractory postural headaches, found to have a diffuse CSF leak throughout the cervicothoracic (C1-T12) spine. His neurological status declined rapidly to a Glasgow Coma Scale (GCS) of eight, necessitating bilateral subdural drain placement. Despite an overall brisk neurologic recovery, the patient remained unable to speak for nearly a week after the return of the remainder of his function. This raised the concern for possible cerebellar mutism.We review the multiple modalities used in this patient's treatment and explore possible explanations for the failure of initial therapy. The placement of bilateral subdural drains was a temporizing measure to treat the patient's neurologic decline, but it was likely the epidural blood patch with prolonged bedrest that hastened the patient's recovery. His speech function also returned with time and repeated therapy.

Background and purpose Patients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted. Results All trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI. Conclusion The RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.

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Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039).

IntroductionIt is common to start all patients on chemical prophylaxis for deep vein thrombosis (DVT) in order to decrease the risk of venous thromboembolism (VTE) and the associated adverse effects, including the potential for fatal pulmonary embolism (PE). There is no consensus in the literature on the optimal time to resume chemical DVT prophylaxis in patients who present with intracranial hemorrhage requiring neurosurgical intervention. The practice is variable and practitioner dependent. There can be difficulty in balancing the increased risk of further intracranial hemorrhage versus the benefit of starting DVT prophylaxis to prevent VTE.MethodA retrospective review of patients that had diagnosis of intracranial hemorrhage (ICH) defined as epidural hematoma (EDH), subdural hematoma (SDH), or intra-parenchymal hematoma (IPH), was performed using the neurosurgical census at our institution. The review consisted of adult patients greater than 18 years old with a diagnosis of intracranial hemorrhage. Type of intracranial hemorrhage, method of neurosurgical intervention (whether surgical, bedside procedure, or both), day post-procedure prophylaxis was resumed, and the type of chemical prophylaxis used (subcutaneous heparin (SQH) versus enoxaparin) were recorded. The patient’s sex, Glasgow Coma Scale on presentation and discharge, length of hospital stay, and length of intensive care unit (ICU) stay were also recorded. Patients with previously diagnosed bleeding dyscrasia, previously diagnosed DVT or PE, patients without post-procedure cranial imaging (CT or MRI), and patients without post-procedure duplex ultrasound for DVT screening were excluded. Patients were monitored with head CT for possible expansion of ICH after resumption of therapy. Furthermore, we investigated whether the patient developed an adverse effect such as venous thromboembolism including deep vein thrombosis and/or pulmonary embolism during the post-procedure period when they were not on chemical prophylaxis.ResultsA total of 94 patients were analyzed in our study. Nine (9.6%) had an EDH, seventeen (18.1%) had an IPH, and sixty-eight (72.3%) had a SDH. The three most common procedures were craniectomy (28.7%), craniotomy (34%), and subdural drain placement (28.7%). The most common agent for chemical DVT prophylaxis was SQH in 78% of patients. There was no statistically significant association between type of chemical DVT prophylaxis used with respect to either ICU length of stay or hospital length of stay. Change in GCS (the difference of GCS on presentation versus on discharge) was found to have statistically significant relationship with the use of chemical DVT prophylaxis. Furthermore, patients were found to have no statistically significant association with re-bleed or new hemorrhage upon starting chemical DVT prophylaxis, regardless of the type of ICH.ConclusionThe rates of DVT diagnosis did not seem to be significantly affected by the specific type of chemical prophylaxis that was used. ICU and hospital length of stay were not adversely ...