No abstract

Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34-79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p = 0.407). High admission GCS (p = 0.0032), younger age (p = 0.0023), smaller hematoma volume (p = 0.044), subcortical hematoma location (p = 0.041), absent or minimal preoperative (p = 0.0068), and postoperative (p = 0.0031) midline shift as well as absent intraventricular extension of the hematoma (p = 0.036) contributed significantly to a better outcome. Selected patients' subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p = 0.0015) and from 50 to less than 70 (p = 0.00619) as well as immediate preoperative GCS from 6 to 8 (p = 0.000436) and from 9 to 12 (p = 0.00774). At 6 months' follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p = 0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.

Epidermoid cysts are benign slowly growing tumors commonly involving the cerebellopontine angle (CPA). The aim of this study was to analyze the surgical limitations, surgical strategies, complications, and outcome of resection of these lesions. The clinical data and outcome of 32 cases operated for CPA epidermoid between 2007 and 2015 were retrospectively analyzed. The mean follow-up period was 42.6 months, and all patients were followed up at least for a whole year. There were 15 males and 17 females. The median age was 37.6 years. Headache and cranial nerves dysfunction were the most common presenting symptoms. Surgery was performed in all patients using the standard lateral suboccipital retrosigmoid approach. In three cases, microvascular decompression of an arterial loop was performed in addition to tumor excision. Total resection was accomplished in 19 out of 32 cases (59.4%), subtotal resection in 7 cases (21.9%), and only partial excision was achieved in 6 cases (18.7%). There was no recurrence or regrowth of residual tumor during the follow-up period. We had a single postoperative mortality due to postoperative pneumonia and septic shock. New cranial nerves deficits occurred in 15.6% of cases but were transient in most of them. The favorable outcome of total resection of CPA epidermoids should always be weighed against the critical risks that accompany it especially in the presence of tight adhesions to vital neurovascular structures. The retrosigmoid approach is suitable for the resection of these tumors even if they were large in size.

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Acute intracranial subdural hematoma (ASDH) is commonly associated with a grave prognosis citing a high incidence of morbidity and mortality. The parameters to decide on surgical evacuation of the hematoma are sometimes controversial. In this study, we theorized that the ratio between maximal hematoma thickness and midline shift would be varied by associated intrinsic brain pathology emanating from the trauma and would thus objectively evaluates the prognosis in ASDH. The records of patients diagnosed with ASDH who were submitted to surgical evacuation through a craniotomy were revised. Data collected included basic demographic data, preoperative general and neurological examinations, and radiological findings. The maximal thickness of the hematoma (H) on the preoperative CT brain was divided by the midline shift at the same level (MS) formulating the H/MS ratio. Postoperative data obtained included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), and follow-up period. Sixty-seven eligible patients were included in the study, of which 53 (79.1%) patients were males. Mean age was 34 years. The H/MS ratio ranged from 0.69 to 1.8 with a mean of 0.93. Age above 50 years (P = 0.0218), admission GCS of less than 6 (0.0482), and H/MS ratio of 0.79 or less (P = 0.00435) were negative prognostic factors and correlated with a low postoperative GCS and GOS. H/MS ratio is a useful prognostic tool in patients diagnosed with ASDH and can be added to the armamentarium of data to improve the management decision in this cohort of patients.