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Background. The REgistry of Stroke Care Quality (RES-Q) enables to evaluate the quality of care provided to the stroke patients in hospitals and to compare it with the quality in other countries. Objective: to evaluate the quality of inpatient care for patients with stroke in Ukraine. Materials and methods. Since 2017, information about 14,305 patients from 90 hospitals in Ukraine has been entered in the RES-Q. Results. The average age of patients was 68 years. 85.08 % of persons had ischemic stroke, 10.53 % — intracerebral hemorrhage, 1.98 % — subarachnoid hemorrhage, 0.01 % — venous thrombosis, 0.27 % — cryptogenic stroke, 2.13 % — transient ischemic attack. In 19.33 % of patients, cerebral stroke was recurrent. Results. 67.9 % of patients were treated in stroke units, the rest — in intensive care units, wards of general neurology and neurosurgery. Computed tomography, magnetic resonance imaging were performed in 92.1 % of patients. National Institutes of Health Stroke Scale was used to assess the severity of stroke in 88.5 % of individuals (mean score — 9). The dysphagia test was performed in 86.71 % of patients. Recanalization was carried out in 5.94 % of persons with ischemic stroke (thrombolytic therapy — 5.33 %, mechanical thrombectomy — 0.61 %). 0.29 % of patients underwent hemicraniectomy. Removal of intracranial hematoma was performed in 2.7 % of persons with intracerebral hemorrhages. 71.98 % of patients received rehabilitation care. Conclusions. Completing the RES-Q allowed us to assess the quality of treatment on a small number of patients (5 % of the total number of stroke patients for 3 years in Ukraine) and to admit that it required a significant improvement and changes in the care organization., Реестр качества лечения инсульта (REgistry of Stroke Care Quality, RES-Q) позволяет оценить качество оказания помощи больным с инсультом в стационарах и сравнить ее с качеством в других странах. Цель исследования. Оценить качество оказания стационарной помощи больным с мозговым инсультом в Украине. Материалы и методы. С 2017 года в реестр RES-Q внесена информация по 14 305 пациентам из 90 больниц Украины. Средний возраст больных составил 68 лет. 85,08 % больных были с ишемическим инсультом, 10,53 % — с внутримозговыми геморрагиями, 1,98 % — с субарахноидальным кровоизлиянием, 0,01 % — с венозным тромбозом, 0,27 % — с криптогенным инсультом, 2,13 % — с транзиторной ишемической атакой. У 19,33 % пациентов мозговой инсульт был повторным. Результаты. В инсультных отделениях лечилось 67,9 % больных, остальные — в отделениях реанимации, общей неврологии, нейрохирургии. КТ, МРТ проведены 92,1 % больных. Тяжесть инсульта по шкале NIHSS была оценена у 88,5 % больных (средний балл — 9). Тест на дисфагию проведен 86,71 % больных. Реканализация проведена 5,94 % пациентов с ишемическим мозговым инсультом (тромболитическая терапия — 5,33 %, механическая тромбэктомия — 0,61 %). Гемикраниэктомия проведена у 0,29 % пациентов. Удаление интракраниальной гематомы выполнено у 2,7 % пациентов с внутримозговыми геморрагиями. Реабилитационную помощь получили 71,98 % больных. Выводы. Проведение анализа реестра RES-Q позволило на небольшом количестве пациентов (5 % общего числа больных с мозговым инсультом за 3 года в Украине) оценить качество лечения и признать, что оно требует значительного улучшения и изменений в организации помощи больным., Реєстр якості лікування інсульту (REgistry of Stroke Care Quality, RES-Q) дозволяє оцінити якість надання допомоги хворим з інсультом у стаціонарах і порівняти її з якістю в інших країнах. Мета дослідження. Оцінити якість надання стаціонарної допомоги хворим із мозковим інсультом в Україні. Матеріали та методи. З 2017 року до реєстру RES-Q внесено інформацію по 14 305 пацієнтах із 90 лікарень України. Середній вік хворих становив 68 років. 85,08 % хворих було з ішемічним інсультом, 10,53 % — із внутрішньомозковими геморагіями, 1,98 % — із субарахноїдальним крововиливом, 0,01 % — з венозним тромбозом, 0,27 % — з криптогенним інсультом, 2,13 % — із транзиторною ішемічною атакою. У 19,33 % пацієнтів мозковий інсульт був повторним. Результати. В інсультних відділеннях лікувалося 67,9 % хворих, решта — у відділеннях реанімації, загальної неврології, нейрохірургії. КТ, МРТ проведено 92,1 % хворих. Тяжкість інсульту за шкалою NIHSS була оцінена у 88,5 % хворих (середній бал — 9). Тест на дисфагію проведено 86,71 % хворих. Реканалізацію зроблено 5,94 % пацієнтів з ішемічним мозковим інсультом (тромболітична терапія — 5,33 %, механічна тромбектомія — 0,61 %). Гемікраніектомію проведено у 0,29 % пацієнтів. Видалення інтракраніальної гематоми виконано у 2,7 % пацієнтів із внутрішньомозковими геморагіями. Реабілітаційну допомогу отримали 71,98 % хворих. Висновок. Проведення аналізу реєстру RES-Q дозволило на невеликій кількості пацієнтів (5 % від загального числа хворих на мозковий інсульт за 3 роки в Україні) оцінити якість лікування і визнати, що вона вимагає значного поліпшення і змін в організації допомоги хворим.

The 30-day mortality rate of spontaneous cerebral hemorrhage (ICH) is approximately 30-50%. Surgery may improve the prognosis of patients with severe ICH. However, ICH survivors after surgery still face the risks of postoperative intracranial rebleeding (PIB), and clinical tools that accurately predict the risk of PIB occurrence are not available. Therefore, a retrospective study was performed. The population was divided into two groups according to the occurrence of PIB. Univariate and multivariate logistic regression analyses were performed to screen risk factors for PIB. Next, an early PIB risk nomogram prediction model was constructed. In addition, the impact of PIB on the prognosis of ICH was evaluated. In total, 150 ICH patients were continuously enrolled in this study; 21 patients suffered from PIB, and the overall incidence of PIB was 14.0% (21/150). Coronary heart disease history, a lower GCS score, and subarachnoid hemorrhage absence were screened as risk factors for early PIB. The early PIB risk nomogram showed good calibration and discrimination with a concordance index of 0.807 (95% confidence interval (CI), 0.715-0.899), which was confirmed to be 0.788 through bootstrapping validation. In addition, a significant difference in discharged GOS scores (P = 0.043) was observed between the PIB group and the n-PIB group. These results showed that a history of coronary heart disease, a lower GCS score, and absence of subarachnoid hemorrhage were risk factors for early PIB. In addition, the early PIB risk nomogram prediction model exhibits good discrimination and calibration. The occurrence of PIB could reduce the prognosis of ICH patients.

Background Choriocarcinoma is a subtype of gestational trophoblastic disease, gestational trophoblastic neoplasia. Patients with brain metastasis are rare and information on the optimal treatment and patient outcome is limited. In order to improve the prognosis of this disease, accurate and timely treatments are very important for the patient of brain metastasis by choriocarcinoma. Case summary A 17-year-old unmarried girl was misdiagnosed with a cerebral hemangioma with intracranial hemorrhage in a local hospital after presentation with severe head pain. She underwent craniotomy three times for treatment. The pathological results of posterior intracranial hematoma showed choriocarcinoma, and the patient was diagnosed as choriocarcinoma (21 points in stage IV). After uterine artery embolization, etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine chemotherapy for 7 cycles, and whole brain radiotherapy, the patient achieved remission. She has been followed for 2 years with no signs of tumor recurrence. Conclusion For female patients of childbearing age with an intracranial hematoma, the possibility of brain metastasis by choriocarcinoma should be considered. It is necessary to obtain a detailed history, including menstruation, beginning age of first sex, contraception, etc. The level of β-human chorionic gonadotropin should be tested at the beginning, and a stratified treatment should be administered according to the International Federation of Gynecology and Obstetrics staging and World Health Organization prognostic scoring systems.

As one of the main types of secondary craniocerebral injury, the onset, progression, and prognosis of chronic subdural hematoma (CSDH) are closely related to the local inflammation of intracranial hematoma. Atorvastatin is reported to be effective in the conservative treatment of CSDH. This study aimed to clarify whether atorvastatin regulated the inflammatory responses in CSDH by interfering with the function of macrophages. The rat CSDH model was prepared by repeated intracranial blood injection with velocity gradient, and MRI was applied to calculate the intracranial hematoma volume. Changes in rat nerve functions were evaluated by foot-fault and Morris water maze tests. Flow cytometry was applied to detect the number of total macrophages and the percentage of M1 or M2 macrophages. The expression of inflammatory factors was examined by ELISA and western blot. Western bolt was applied to detect the expression of proteins involved in the colony-stimulating factor 1 receptor (CSF-1R) signaling pathway. Our results showed that atorvastatin significantly accelerated the absorption of hematoma and improved the nerve functions of CSDH rats. In addition, atorvastatin treatment effectively suppressed the expression of TNF-α, IL-6, and IL-8 and promoted the expression of IL-10. The total number of macrophages was decreased, and the percentage of M2 macrophages was increased in the intracranial hematoma following atorvastatin treatment. Furthermore, atorvastatin increased the levels of M2-related genes and surface markers in BMDMs stimulated by lipopolysaccharides and IFNγ, and activated the CSF-1R signaling pathway. In conclusion, our study shows that atorvastatin could alleviate the symptoms of CSDH and promote hematoma ablation by polarizing macrophages to M2 type and regulating the inflammatory responses.

Background Microsurgical clipping is effective for treating early rupture hemorrhage in intracranial aneurysm (IA) patients. We aimed to evaluate the therapeutic effects of microsurgical clipping at different time points on IA and to explore prognostic factors. Methods A total of 102 eligible patients were divided into good prognosis group (n = 87) and poor prognosis group (n = 15) according to Glasgow Outcome Scale (GOS) scores at discharge. The effects of microsurgical clipping at different time points (within 24 h, 48 h and 72 h) were compared. The incidence rates of postoperative complications in patients with different Hunt–Hess grades were compared. Prognostic factors were determined by multivariate logistic regression analysis. The nomogram prediction model was established based on independent risk factors and validated. Results The good recovery and success rates of complete aneurysm clipping were significantly higher in patients undergoing surgery within 24 h after rupture. The incidence rate of complications was significantly higher in patients with Hunt–Hess grade IV. Good and poor prognosis groups had significantly different age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and National Institute of Health Stroke Scale (NIHSS) score, as independent risk factors for prognosis. The nomogram model predicted that poor prognosis rate was 14.71%. Conclusion Timing (within 24 h after rupture) microsurgical clipping benefits the prognosis of IA patients. Age, history of hypertension, preoperative intracranial hematoma volume, aneurysm size, preoperative Hunt–Hess grade, later surgery, postoperative complications and NIHSS score are independent risk factors for poor prognosis.

Background: Although most traumatic epidural hematomas are secondary to arterial injuries, particularly rupture of the middle meningeal artery, around 9.7% of cases are associated with dural venous sinus injury, leading to poorer prognosis and greater complications. We report a case of a patient presenting cranial trauma with bone fracture and laceration of the transverse sinus producing epidural hematoma, and discuss the main aspects of this condition. Case description: A 47-year-old man struck by a motorcycle was admitted to the Emergency Room with a score of 15 on the Glasgow Coma Scale, evolving over 5 hours with reduced level of consciousness. A cranial CT scan was performed disclosing right parieto- occipital hyperdensity, consistent with acute epidural hematoma, and a parieto-occipital fracture line crossing the path of the ipsilateral transverse sinus. Parietal craniotomy was performed to drain the hematoma, revealing a venous sinus injury requiring immediate repair. Conclusions: This case and discussion highlight the many details and technical specificities to be taken into account by neurosurgeons when encountering intracranial hematoma caused by traumatic injury of the dural venous sinus, and which are pivotal in determining the efficacy of the treatment approach and prognosis of the patient.

Traumatic brain injury is a common and devastating injury that is the leading cause of neurological disability and death worldwide. Patients with cerebral lobe contusion received conservative treatment because of their mild manifestations, but delayed intracranial hematoma may increase and even become life-threatening. We explored the noninvasive method to predict the prognosis of progression and Glasgow Outcome Scale (GOS) by using a quantitative radiomics approach and statistical analysis. Eighty-eight patients who were pathologically diagnosed were retrospectively studied. The radiomics method developed in this work included image segmentation, feature extraction, and feature selection. The nomograms were established based on statistical analysis and a radiomics method. We conducted a comparative study of hematoma progression and GOS between the clinical factor alone and fusion radiomics features. Nineteen clinical factors, 513 radiomics features, and 116 locational features were considered. Among clinical factors, international normalized ratio, prothrombin time, and fibrinogen were enrolled for hematoma progression. As for GOS, treatment strategy, age, Glasgow Coma Scale score, and blood platelet were associated factors. Eight features for GOS and five features for hematoma progression were filtered by using sparse representation and locality preserving projection-combined method. Four nomograms were constructed. After fusion radiomics features, area under the curve of hematoma progression prediction increased from 0.832 to 0.899, whereas GOS prediction went from 0.794 to 0.844. A radiomic-based model that merges radiomics and clinical features is a noninvasive approach to predict hematoma progression and clinical outcomes of cerebral contusions in traumatic brain injury.

In order to realize the automatic recognition of intracranial hematoma and accurate measurement of hematoma volume in patients with ICH (intracerebral hemorrhage), the FCM algorithm (fuzzy c-means algorithm) was improved in this study, and a new level set segmentation algorithm based on FCM was obtained, FCRLS (fuzzy c-means regularized level set). Then, 120 ICH patients were used as the research objects, and the FCRLS algorithm was evaluated by the recall, precise, and F1-score values to evaluate the effect of intracranial hematoma recognition. The CT images of 48 patients with intracranial hematoma were used as the data set of the FCRLS algorithm. The hematoma was segmented, and the DSC (Dice similarity coefficient) value and running time were used to evaluate the segmentation results of the algorithm. At the same time, the LS (level set) algorithm and the FCM algorithm were introduced for comparison. The results show that the recall value of the FCRLS algorithm is 0.89, the precise value is 0.94, the F1-score value is 0.91, the Dice coefficient is 94.81%, and the running time is 14.48 s. Compared with the LS algorithm and the FCM algorithm, the above five indicators have significant differences ( P < 0.05 ). Hematoma volume measurement found that the average error of FCRLS algorithm from expert measurement results was 5.62%, which was statistically significant compared with LS algorithm and FCM algorithm ( P < 0.05 ). In summary, the FCRLS algorithm can accurately identify the cerebral hematoma area of ICH patients, has an ideal segmentation effect on the hematoma, and can accurately measure the true volume of the hematoma, which is worthy of clinical application.

Background Red blood cell-induced cerebral inflammation and toxicity has been shown to be attenuated by induction of the heme-catalyzing enzyme, hemoxygenase-1 (HO-1), in animal models of subarachnoid hemorrhage (SAH). Although inflammatory mechanisms leading to secondary neuronal injury in SAH are becoming increasingly well understood, markers of cerebral inflammation have so far not been implemented in clinical prediction models of SAH. Methods In this biomarker observational study, HO-1 messenger ribonucleic acid (mRNA) expression levels were determined in cerebrospinal fluid (CSF) and blood of 66 patients with aneurysmal SAH on days 1, 7, and 14 after the SAH event. HO-1 mRNA expression was determined via real time polymerase chain reaction (PCR), and relative expression changes were quantified in comparison with expression levels in nonhemorrhagic control CSF. Subarachnoid blood burden, as well as presence of vasospasm and delayed cerebral ischemia (DCI), were recorded. Short and long-term clinical outcomes were assessed using the Modified Rankin Scale at discharge and 1 year after the SAH event. Results CSF HO-1 expression levels showed a significant increase over the 14-day observation period (p F = 22.53) and correlated with intracranial hematoma burden (ρ = 0.349, p = 0.025). In multivariate analyses, CSF HO-1 expression levels did not reach significance as independent predictors of outcome. Vasospasm on computed tomographic angiography was associated with lower CSF HO-1 expression levels on day 7 after SAH (n = 53, p = 0.010), whereas patients with DCI showed higher CSF HO-1 expression levels on day 14 after SAH (n = 21, p = 0.009). Conclusions HO-1 expression in CSF in patients with SAH follows a distinct temporal induction pattern and is dependent on intracranial hematoma burden. CSF HO-1 expression was unable to predict functional outcome. Associations of early low HO-1 expression with vasospasm and late elevated HO-1 expression with DCI may point to detrimental effects of late HO-1 induction, warranting the need for further investigation in a larger study population.

Purpose The aim of the current study was to investigate the risk factors for post-traumatic epilepsy (PTE) in a large cohort of patients after severe non-penetrating civilian traumatic brain injury (TBI). Methods This was a longitudinal study. All patients with a severe non-penetrating TBI, who were admitted at the neuro-intensive care unit of Shahid Rajaee Trauma Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, Iran, from 2015 until 2019, were studied. Severe TBI was defined as a Glasgow Coma Scale-Motor score below six. Post-traumatic epilepsy was defined as any seizures that occurred after being discharged from the hospital. Results In total, 803 patients with severe non-penetrating TBI were studied; 82 patients (10.2%) reported any late post-traumatic seizures (PTSs). A higher Glasgow outcome scale (extended) at discharge was significantly inversely associated with PTE [Odds Ratio (OR)= 0.76, 95% Confidence Interval (CI): 0.65–0.87; p = 0.0001]. Depressed skull fracture (OR= 1.88, 95% CI: 0.92–3.80; p = 0.081), epi‑dural hematoma (OR= 1.67, 95% CI: 0.93–2.97; p = 0.083), and sub-dural hematoma (OR= 1.64, 95% CI: 0.96–2.78; p = 0.068) were associated with PTE as trends. Conclusion Our study adds to the literature on the risk of PTE after severe non-penetrating civilian TBI. Our large sample size and also the application of a logistic regression analysis model may suggest that other variables (e.g., depressed skull fracture and intracranial hematoma) are indeed associated with the Glasgow outcome scale (extended) at discharge and that is why they lost their significance in the model.

The medical and health industry has successively experienced three stages of digital medical treatment, local area network medical treatment, and internet medical treatment. With the rapid development of technologies such as the Internet of Things, big data, and artificial intelligence, emerging applications and service models have gradually penetrated into all aspects of the medical and health field. At this point, the informatization development process of the medical industry has entered the stage of smart medical treatment. (Smart medical system is a new medical system that improves users’ medical experience and provides users with better services. Due to the cumbersome, complicated, and mechanically rigid environment of the past medical service, there was no uniform standard. In order to create a reliable and open medical service environment, an intelligent medical system came into being.). A diversified technical foundation and smart medical protection, conducive to providing patients with high-quality medical services, are established. This article mainly introduces the analysis of the therapeutic effect of smart medical electronic endoscopic hematoma removal on hypertensive basal ganglia cerebral hemorrhage and aims to inject advanced technology and vitality of smart medical treatment into the treatment of hypertensive basal ganglia cerebral hemorrhage by hematoma removal and help the doctor to treat the patient. This article proposes the research methods of smart medical application in the treatment of hypertensive basal ganglia cerebral hemorrhage with electronic endoscopic hematoma removal, including smart medical overview, intracranial hematoma removal for hypertensive basal ganglia cerebral hemorrhage, and smart medical bioelectric signal classification. The recognition algorithm is used to realize the smart medical application of the electronic endoscopic hematoma removal in the treatment of hypertensive cerebral hemorrhage in the basal ganglia area. The experimental results show that the removal of intracranial hematoma based on smart medicine can effectively improve the removal rate of intracranial hematoma, with a recovery rate of 26.73% and a significant efficiency of 36.49%.

This study aimed to examine the beneficial effects of a novel prophylactic barbiturate therapy, step-down infusion of barbiturates, using thiamylal with normothermia (NOR+sdB), on the poor outcome in the patients with severe traumatic brain injuries (sTBI), in comparison with mild hypothermia (MD-HYPO). From January 2000 to March 2019, 4133 patients with TBI were admitted to our hospital. The inclusion criteria were: a Glasgow coma scale (GCS) score of ≤8 on admission, age between 20 and 80 years, intracranial hematoma requiring surgical evacuation of the hematoma with craniotomy and/or external decompression, and patients who underwent management of body temperature and assessed their outcome at 6-12 months. Finally, 43 patients were included in the MD-HYPO (n = 29) and NOR+sdB (n = 14) groups. sdB was initiated intraoperatively or immediately after the surgical treatment. There were no significant differences in patient characteristics, including age, sex, past medical history, GCS on admission, type of intracranial hematoma, and length of hospitalization between the two groups. Although NOR+sdB could not improve the patient's poor outcome either at discharge from the intensive care unit (ICU) or at 6-12 months after admission, the treatment inhibited composite death at discharge from the ICU. The mean value of the maximum intracranial pressure (ICP) in the NOR+sdB group was

Intracranial hematoma after spinal anesthesia is a rare complication. It generally presents with posture-dependent headache that becomes persistent. We describe the case of patient submitted to spinal anesthesia for cesarean section who presented a non-posture-dependent headache, resistant to clinical treatment, that progressively worsened and with symptoms of intracranial hypertension. The patient had a history of head trauma without symptoms. The CT-scan revealed a chronic bilateral parietal hematoma with a recent bleeding component, treated surgically. We concluded that spinal puncture led to chronic hematoma to rebleed. We have reported the case to draw attention to the importance of investigating atypical headache after spinal anesthesia.

The use of tolvaptan to treat both euvolemic and hypervolemic hyponatremia has rapidly increased in recent years. However, data on its effects on children, especially newborns and infants, are limited. Here, we present a newborn who developed syndrome of inappropriate secretion of antidiuretic hormone following an intracranial hematoma drainage operation who was unresponsive to conventional treatments. The infant was successfully treated with tolvaptan, a competitive inhibitor of the vasopressin V2 receptor.

Spontaneous intracranial hematoma (ICH) is the second leading cause of stroke and has a high risk of postoperative ischemic events (PIEs). But, the evidence on PIEs in ICH patients still lacks. Therefore, a retrospective study was carried out to screen the risk factors for PIEs and construct a visual predictive model. This was a retrospective study whose population were divided into two groups based on the occurrence of PIEs. Univariate logistic regression analysis was used to determine factors associated with PIEs. Multifactorial logistic regression analysis was used to screen risk factors and construct the early PIEs risk nomogram. In addition, impact of PIEs on patient prognosis and surgery related costs was assessed. Out of 122 ICH patients, 24 (19.7%) were diagnosed with PIEs. Coronary heart disease history, ischemic stroke history, regular shaped hematoma and platelet number were identified as risk factors for early PIEs. Early PIEs risk nomogram showed good calibration and discrimination of the data with concordance index of 0.846 (95% confidence interval, 0.747-0.945) which was confirmed to be 0.827 through bootstrapping validation. In addition, there was statistical difference in discharged Glasgow Coma Scale score (P = 0.046) and surgery related costs (p = 0.031) between PIEs group and nPIEs group. These results showed the early PIEs risk nomogram was accurate for prediction risks of PIEs and the occurrence of PIEs affects prognosis of patients, and increases surgery related costs.

Objective: To improve the treatment of young children with traumatic intracranial hematomas by improving the diagnosis and use of minimally invasive surgical methods based on calculations of the intracranial hematoma volume index (VICH). Subjects and Methods: An analysis of the clinical course as well as the surgical treatment of 111 patients was carried out. The patients were under the age of 3, with severe traumatic brain injury, and formation of intracranial hematomas. The children were treated at the Department of Pediatric Neurosurgery of the City Children’s Clinical Hospital No.3 in Omsk, Russia, from 2008 to 2018. Three groups were identified: Group A - children with epidural hematomas (n=30), Group B - children with subdural hematomas (n=43), Group C - children with multiple hematomas (n=38). The volume index of intracranial hematomas (VICH) was calculated, and the surgical tactics were determined based on the value of the VICH. Results: Children with a VICH less than 2% received conservative treatments. Those with a VICH from 2 to 4% were treated with minimally invasive methods (puncture, drainage). Children with VICH above 4% underwent decompressive surgery. Conclusion: The effectiveness of the developed differentiated tactics of treatment of young children with traumatic intracranial hematomas (ICH) is characterized by a decrease in the risk of an unfavourable outcome by 74.2% and mortality by 1.2%.

Background The use of nonsteroidal anti-inflammatory drugs in neurosurgery remains controversial because of potential risk of hematoma formation secondary to platelet dysfunction. This study aimed to investigate the efficacy and safety of diclofenac compared with paracetamol for the management of postcraniotomy pain. Methods In all, 110 adult patients undergoing craniotomy for supratentorial tumors were randomized to receive either intravenous paracetamol (15 mg/kg) or intravenous diclofenac sodium (1.5 mg/kg) 30 minutes before the end of surgery and postoperatively at 12-hour intervals up to 48 hours. The analgesic efficacy of diclofenac and paracetamol was assessed using the Numerical Rating Scale (NRS) score at 12, 24, and 48 hours after surgery. We also examined the need for rescue analgesia, coagulation profiles using a Sonoclot analyzer, and incidence of intracranial hematoma formation. Results At 24 hours postsurgery, NRS scores were lower in group D than in group P; median (interquartile range) and mean rank NRS score in group D was 3.00 (1.0), 43.71, respectively, compared with 3.00 (1.0), 59.29 in group P (P=0.004). Patients in group P received more rescue analgesia than those in group D. Coagulation profiles were similar between groups at 24 hours. Activated clotting time was longer in group D (128.76±12.61 s) than in group P (123.84±09.77 s; P=0.03) at 48 hours, although remained within normal limits in both groups; clot rate and platelet function were similar at 48 hours. There was no difference in the incidence of postoperative tumor bed hematoma. Conclusion Compared with paracetamol, diclofenac sodium provided more effective postoperative analgesia at 24 hours with no evidence of adverse effects on coagulation profiles in patients undergoing craniotomy for supratentorial tumors.

Intracranial cavernoma is a vascular malformation composed of thin-walled vascular vessels. Blood flow in these lesions is much lower than in AVMs and their hemorrhages are usually small. The presentation is often subacute with seizures or focal neurological deficit, which can be confused in pregnant women with pregnancy toxaemia especially if the malformation is bleeding. We report the case of a 35-year-old patient , 30 weeks pregnant , admitted for delivery who presented with acute intracranial hypertension syndrome with obnubilation of consciousness. Emergency brain CT showed a right fronto-parietal intracranial hematoma. MRI with angiographic sequences show a left parietal hematoma without visible arteriovenous malformation. The patient underwent emergency surgery to evacuate her intracranial hematoma, then the patient was transferred to a gynecological unit for emergency fetal extraction. Histo-pathological analysis of the removed fragments showed an intracranial cavernoma appearance. Urgent surgical evacuation is only necessary if the prognosis is vital.

A 6-month-old, previously healthy boy hit the right frontal region of his head against the corner of a plastic toy box. At presentation, a small area with scalp discoloration was noted in the right frontal region. Head computed tomography at the level of discoloration revealed an intracranial hematoma, 5 mm in maximal thickness, below the coronal suture. In addition, there were bony bridges connecting the frontal and parietal bones. Furthermore, a linear crack was found in the diploe of the frontal bone in contact with the coronal suture. Cerebral MRI confirmed linear hyperintensity between the inner tables. We assumed that a kind of ping-pong ball fracture was caused by the head blow, centering on the coronal suture, resulting in rupture of contacting diploic channels and tear of the dura mater, and forming a subdural hematoma. Acute subdural hemorrhage may be caused by an insignificant blow to the coronal suture in infantile patients with underdeveloped cranial bones and sutures, accompanied by subtle external findings.

The study objective is to evaluate the effectiveness of intracranial pressure (ICP) monitoring in patients with severe head injury in a multispecialty hospital. Materials and methods . A retrospective study included 2343 patients who underwent surgical treatment at the N. V. Sklifosovsky Research Institute of Emergency Medicine between 2012 and 2018. Patients admitted in atonic coma, who died in the space of 48 hours after hospitalization, with intracranial hematoma volume >200 cm3, and older than 65 years were excluded. Additionally, results of conservative therapy in 69 patients with severe cerebral contusion were included. ICP monitoring was performed in 249 patients (22.5 % of all patients who underwent surgery with indications for monitoring and no counterindications). A binary logistic regression model included age, sex, type of intracranial injury, depression of consciousness severity at admittance as variables. For treatment outcomes, odds ratio (OR) with 95 % confidence interval and p

Objective: This study is to discuss CT performances and direct surgical strategy as well as therapeutic effect of patients who have rupture hemorrhage of intracranial anterior circulation aneurysm with complications of intracranial hematoma and cerebral hernia. Methods: CT performances and treatment of 14 patients who have rupture hemorrhage of intracranial anterior circulation aneurysm with complications of intracranial hematoma and cerebral hernia in our hospital from March, 2019 to March, 2021 were reviewed. The relationship between hematoma caused by intracranial anterior circulation aneurysm and position of the aneurysm was analyzed. Besides, surgical processing keys were discussed. Results: For all selected patients, intracranial hemorrhage is proved to be caused by rupture of aneurysm. Among them, there are 2 cases of anterior communicating aneurysms, 3 cases of posterior communicating aneurysms, and 9 cases of middle cerebral aneurysms. According to exploration, we found 1 case of multiple aneurysm, which is the combination of a middle cerebral aneurysm (the responsible aneurysm) and ipsilateral posterior communicating aneurysm. There were two cases of intraoperative rupture. In this study, 3 patients died. According to GOS grading at 3 months after the operation, there were 1 case of V-grade (good recovery), 3 cases of IV-grade (self-maintenance), 5 cases of III-grade (severe disabled), 2 cases of II-grade (persistent vegetative state) and 3 cases of I-grade (died). Conclusions: Emergency microsurgical treatment can lower the death rate of cerebral hernia caused by intracranial anterior circulation aneurysm with intracranial hematoma and recover the neurological functions to the maximum extent.

Objective Burr hole trephination is a common treatment for chronic subdural hematoma, intracranial hematoma, and intraventricular hematoma due to its effective drainage of hematoma, minimal invasiveness and short operation time. However, cosmetic complications such as scalp depression can occur. The aim of this study was to evaluate the usefulness of an allogenic acellular dermal matrix (ADM) to prevent scalp depression at the burr hole site. Methods A retrospective analysis was performed with 75 cases in 66 patients who were treated with burr hole trephination from January 2018 to December 2019. These cases divided into 2 groups; based on the method used to cover the burr hole site: Gelfoam packing only (GPO) and ADM. The degree of the scalp depression was measured from the more recent follow-up brain computed tomography scan. Results There was a significant difference in the degree of scalp depression between GPO and ADM groups (p=0.003). No significant correlation between patient's age and the degree of scalp depression (GPO: p=0.419, ADM: p=0.790). There were no wound infection complication in either group. Conclusion ADM is a suitable material to prevent scalp depression after burr hole trephination.

background Intracranial hypotension due to cerebrospinal fluid (CSF) leak is often associated with secondary chronic subdural hematoma (CSDH). Although epidural blood patch (EBP) treatment for the CSF leak site has been reported to result in spontaneous regression of the CSDH in most cases, it is still debatable whether blocking CSF leak first in the patients with intracranial hematoma is always safe. Case Description A 72-year-old woman presented with orthostatic headache after a head injury and was diagnosed with intracranial hypotension. Computed tomography myelography and radioisotope cisternography failed to reveal the CSF leak point. The overflow leak test, a novel diagnostic method for intracranial hypotension, revealed a leakage at the cervical spine. Bilateral CSDHs were also observed by a computed tomography scan of the head. We performed EBP at the cervical spine and anticipated subsequent regression of the CSDH by normalizing intrathecal pressure. However, the patient became delirious the morning after EBP, and an emergency burr hole trepanation was performed. The patient's consciousness fully recovered, and her orthostatic headache improved as well. Conclusions This case presentation demonstrated that in the case of intracranial hypotension with secondary CSDH, performing EBP and waiting for subsequent spontaneous regression of CSDH are not necessarily safe. Immediate burr hole trepanation should be prepared for the subsequent rapid symptomatic change of the CSDH after EBP.

OBJECTIVEThe intracranial hematoma volume in patients with traumatic brain injury is a key parameter for the determination of the management approach and outcome. Apolipoprotein E (APOE) ε4 is reported to be a risk factor for larger hematoma volume, which might contribute to a poor outcome. However, whether APOE ε4 is related to progressive hemorrhagic injury (PHI), a common occurrence in the clinical setting, remains unclear. In this study, the authors aimed to investigate the association between the APOE genotype and occurrence of PHI.METHODSThis prospective study included a cohort of 123 patients with traumatic intracerebral hemorrhage who initially underwent conservative treatment. These patients were assigned to the PHI or non-PHI group according to the follow-up CT scan. A polymerase chain reaction and sequencing method were carried out to determine the APOE genotype. Multivariate logistic regression analysis was applied to identify predictors of PHI.RESULTSThe overall frequency of the alleles was as follows: E2/2, 0%; E2/3, 14.6%; E3/3, 57.8%; E2/4, 2.4%; E3/4, 22.8%; and E4/4, 2.4%. Thirty-four patients carried at least one allele of ε4. In this study 60 patients (48.8%) experienced PHI, and the distribution of the alleles was as follows: E2/2, 0%; E2/3, 5.7%; E3/3, 22.8%; E2/4, 2.4%; E3/4, 16.3%; and E4/4, 1.6%, which was significantly different from that in the non-PHI group (p = 0.008). Additionally, the late operation rate in the PHI group was significantly higher than that in the non-PHI group (24.4% vs 11.4%, p = 0.002). Multivariate logistic regression identified APOE ε4 (OR 5.14, 95% CI 2.40–11.62), an elevated international normalized ratio (OR 3.57, 95% CI 1.61–8.26), and higher glucose level (≥ 10 mmol/L) (OR 3.88, 95% CI 1.54–10.77) as independent risk factors for PHI. Moreover, APOE ε4 was not a risk factor for the coagulopathy and outcome of the patients with traumatic intracerebral hemorrhage.CONCLUSIONSThe presence of APOE ε4, an elevated international normalized ratio, and a higher glucose level (≥ 10 mmol/L) are predictors of PHI. Additionally, APOE ε4 is not associated with traumatic coagulopathy and patient outcome.

Background and Objective Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. Methods We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. Results There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. Conclusions EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Introduction: The fracture of skull is considered as severe injury and have grave prognosis. It is mainly because of complications of the acute head injury affect the brain directly or indirectly. Compound depressed fractures are surgical emergencies and unless treated promptly and properly complications like meningitis, cerebral abscess and osteomyelitis of skull may occur. Objectives: to determine the causes of depressed fracture skull and its complications and also to find out various presentation and severity of depressed skull fracture and effective modality of management. Materials and Methods: A prospective study undertaken at department of surgery in coordination with emergency department. Detailed inquiry was done about history of demographic data, presenting symptoms and other diseases done. General, central nervous system examination, other systems examination and local examination were done thoroughly and documented. Patients were treated according conservatively and operatively as per decision taken by surgeon. Results: Out of total 100 patients, assault (43%) was most common, followed by vehicular accident (41%), fall of patients (15%) and fall of object on the patients (1%). Patients with severe head injury (GCS Conclusion: Conservative management is better in patients with CT scan suggestive of depressed skull fracture nor more than 10 mm and not intracranial hematoma. Patients with depressed skull fracture with more than 10 mm with severe head injury and associate hematoma are better managed operatively. Keywords: Depressed skull fracture, Operative management, Conservative management.

Ultrasonography (US) has been used as a reliable imaging modality, providing real-time information during neurosurgical operations. One recent innovative US technique, superb microvascular imaging (SMI), visualizes small vessels and flow, which are not detected with standard US with doppler. We apply SMI to intraoperative US monitoring in emergency surgery for intracerebral hemorrhage (ICH). Eleven consecutive patients with ICH underwent endoscopic emergency surgery under US monitoring with SMI. After performing a small craniotomy, US images were obtained using SMI, a fusion technique, and a contrast agent technique, with the probe on the brain surface during surgery. Fusion images were obtained with the probe on the head before craniotomy in some patients. Animated US images with SMI could differentiate hematoma containing no vessels from brain tissue, and flow images using SMI and contrast agent techniques clarified the borderlines. Animated fusion images of intraoperative US and preoperative CT provided information on the extent of hematoma and residual hematoma during emergency surgery. We made various fusion CT images showing intracranial hematoma with US probes and decided on the skin incision line before beginning surgery, as if we were using a neuronavigation system. US with SMI, contrast agent, and fusion techniques provide information on the extent of intracranial hematoma and residual hematoma with no vessels and no flow. Monitoring by US and fusion CT images is useful for ICH surgery as a next-generation neuronavigator.

Background Traumatic intracranial hemorrhaging associated with revascularization surgery for moyamoya vasculopathy is a potentially devastating problem that requires meticulous management, including surgery. However, only a few studies on this subject have been reported, and the clinical characteristics are poorly understood. We report a case of successful surgical management for a patient with traumatic intracranial hematoma managed with encephalo-duro-arterio-myo-synangiosis (EDAMS). The purpose of this article is to clarify the specific features of clinical scenarios, hemorrhagic sites, and operative techniques by reviewing all published cases. Case Description A 10-year-old Japanese girl with a history of EDAMS for quasi-moyamoya disease was referred to our institution after minor head trauma. Cranial computed tomography scans revealed a right intracranial hematoma overlying the temporal muscle flap. After admission, hematoma developed, and emergency hematoma evacuation was performed. Venous hemorrhaging from the fascia of the temporal muscle flap was confirmed. Collaterals from indirect bypass were preserved in the surgery. Postoperative diffusion-weighted imaging revealed no ischemic complications. She immediately recovered and returned to her preinjury baseline. Conclusion In moyamoya vasculopathy, intrinsic collaterals or de novo anastomoses from revascularization surgery are easily injured, even with mild head trauma. Furthermore, the administration of antiplatelets agents increases the risk of hematoma development. Sacrifice of collaterals can lead to acute cerebral infarction. During emergency surgery for traumatic intracranial hematoma, a careful surgical strategy is needed to preserve the collateral supply.

Background Level I trauma centers use patient triaging systems to deploy neurosurgical resources and pursue good outcomes; however, data describing the effectiveness these triage systems are lacking. We reviewed the leveling protocol (cases designated urgent and emergent) of a regional Level I trauma center to obtain epidemiologic data about the efficiency of that system and identify areas for improvement. Methods We retrospectively reviewed leveled neurosurgical cases from January 2015 to October 2017, assessing surgery date, neurosurgical procedure, posted surgical urgency level (levels 1–3, with 1 being most urgent), and post-to-room (PTR) time (i.e., the time between initial leveling and admission of the patient to the operating room). Mean PTR times were compared between case types using one-way analysis of variance with post hoc Tukey honestly significant difference analysis. Results Of 1469 cases, 577 (39.3%) were shunt placement or revision, 231 (15.7%) were craniectomy or craniotomy for hematoma, 147 (10.0%) were craniectomy or craniotomy for tumor, and 514 (35.0%) were for other indications. Among level 1 cases, PTR time was lowest for craniotomies to evacuate intracranial hematoma (mean 16.2 minutes) and highest for spinal decompression procedures and wound washouts (mean 36.2 and 42.4 minutes, respectively). Conclusions To our knowledge, this is the first study of variability in PTR timing as a function of surgical urgency or indication. The most common leveled cases were craniectomies or craniotomies to relieve increased intracranial pressure, which were also the most common level 1 cases. Significant variability occurred within each leveling category; thus, further investigation is required.

Increased resource constraints secondary to a smaller medical footprint, prolonged evacuation times, or overwhelming casualty volumes all increase the challenges of effective management of traumatic brain injury (TBI) in the austere environment. Prehospital providers are responsible for the battlefield recognition and initial management of TBI. As such, targeted education is critical to efficient injury recognition, promoting both provider readiness and improved patient outcomes. When austere conditions limit or prevent definitive treatment, a comprehensive understanding of TBI pathophysiology can help inform acute care and enhance prevention of secondary brain injury. Field deployable, noninvasive TBI assessment and monitoring devices are urgently needed and are currently undergoing clinical evaluation. Evidence shows that the assessment, monitoring, and treatment in the first few hours and days after injury should focus on the preservation of cerebral perfusion and oxygenation. For cases where medical management is inadequate (eg, evidence of an enlarging intracranial hematoma), guidelines have been developed for the performance of cranial surgery by nonneurosurgeons. TBI management in the austere environment will continue to be a challenge, but research focused on improving evidence-based monitoring and therapeutic interventions can help to mitigate some of these challenges and improve patient outcomes.

THE AIM OF THE STUDY. was an index creation for both single and multiple acute traumatic intracranial hematomas (ATIH) for objectification of the surgical treatment indications and using multispiral computed tomography (MSCT) and based on up-to-date clinical recommendations.MATERIAL AND METHODS. We performed a retrospective study of 3 groups of patients with ATIH. Group 1 included 19 patients who were treated conservatively and discharged from the hospital without complications (group of conservative treatment). Group 2 included 9 patients who were observed after hospitalization and were treated in a delayed manner surgically due to growth of the intracranial hematoma volume or the patient condition deterioration (group of observation). Group 3 included 18 patients who were operated due urgent indications (group of surgical treatment). For each patient, the acute traumatic hematoma index (ATHI) was calculated by our original formula. It took the ATIH location, volume in milliliters according to the first MSCT, and risk factors significant for poor outcomes into account. After a preliminary assessment of the significance of differences between the studied characters of groups, a discriminant analysis was carried out with determination of the ATHI values in each group.RESULTS AND CONCLUSIONS. The suggested ATHI index has been shown to be effective in assessing single and multiple ATIHs of any location in accordance with current recommendations. The index is an objective (digital) and easy-to-use for determining ATIH surgical treatment indications and statistical treatment. If ATHI is less than 3 points, there are no indications for surgery and the repeated MSCT of the brain is indicated at least 12 hours after the first checkup or if the suspicious clinical sings appear; if ATHI is 3–4, the indications for surgery are relative and the repeated MSCT of the brain is required 6 hours later even if the patient condition is unaltered; the surgery is indicated if ATHI is more than 4 points.Authors declare lack of the conflicts of interests.

Objective: To evaluate the factors affecting the surgical outcome of traumatic intracranial hematoma. Patient and Methods: This study was retrospectively conducted on 60 patients with traumatic intracranial hematoma admitted to the Neurosurgery Department, Al-Azhar University Hospital and underwent surgical management. Results: The age range was 10 - 58 years, mean age was 31.50 years, male-to-female ratio was 3:1. The causative trauma was road traffic accident (45%), direct trauma to the head (30%) and fall from height (FFH) (25%) of all studied patients. Morbidity and/or mortality was reported in 38.3% and unfavorable outcome was significantly associated with longer delay time (time from injury to surgery), increased operative time, long duration of hospital stay and lower Glasgow coma scale at admission and discharge. Otherwise, the unfavorable outcome although increased with old age, there was no significant association. Conclusion: Head trauma is considered as a frequent cause of death and disability. Time consuming to reach the hospital, operative time, length of stay in hospital and Glasgow coma score of the patient on admission and discharge markedly determine the surgical outcome of traumatic intracranial hematoma.

Introduction: This study is done to evaluate the role of different clinical factors in hematoma enlargement, especially severe hypertension during the early phase of spontaneous ICH. Materials and Methods: All patients with spontaneous intracranial hematoma who were of > 18 years in age, presented within 24 hour of onset, were enrolled for this study. Repeat CT scan was done within 24 - 48 hours after 1st scan. Results: 88 patients were enrolled and among them, 11 (12.5%) had >20% enlargement in the size of the hematoma on the second CT. The Mean increase in the size of hematoma was 19.8 11.4 ml (47.3 27.2 %). Progression of symptom after onset and after admission, lower GCS ( from onset to CT the enlargement of the hematoma. Mean systolic BP at admission > 200 mm Hg was present in a higher proportion of patients with hematoma enlargement. Conclusion: The present study showed that patients of spontaneous ICH presenting within 6 hours with higher NIHSS, low GCS (GCS hematoma enlargement. SBP >200 mm of Hg at admission may be a potential risk factor. ( Hematoma enlargement, NIHSS =National Institute Health Stroke Scale score, GCS =Glasgow Coma Scale, MAP=mean arterial pressure) Keywords: ute Health SHematoma enlargement, National Instittroke Scale score, Glasgow Coma Scale

Objectives: To explore the clinical value of minimally invasive aspiration and drainage of intracranial hematoma in the treatment of cerebral hemorrhage. Methods: Seventy-eight patients with cerebral hemorrhage who were treated in the Taian City Central Hospital and the Second Affiliated Hospital of Shandong First Medical University between June 2018 and December 2019 were selected. The patients were randomly numbered and divided into two groups by drawing lots, 39 in each group. The control group was treated with the traditional internal medicine conservative therapy, and the observation group was treated with minimally invasive intracranial hematoma aspiration and drainage. The indexes of the two groups were compared. Results: The efficacy rate of the observation group was significantly higher than that of the control group, and the difference was statistically significant (P

ObjectiveThis study aimed to establish optimal surgical strategies via reviewing the clinical outcomes of various surgical approaches for the pertroclival meningiomas (PCMs).MethodsThis retrospective study enrolled 107 patients with PCMs at the authors’ institution from year 2010 to 2020. Patient demographics, the clinical characteristics, various operative approaches, major morbidity, post-operative cranial nerve deficits and tumor progression or recurrence were analyzed.ResultsThe subtemporal transtentorial approach (STA), the Kawase approach (KA), the retrosigmoid approach (RSA) and the anterior sigmoid approach (ASA), namely the posterior petrosal approach (PPA) were adopted for 17 cases, 22 cases, 31 cases and 34 cases respectively. Total or subtotal resection was achieved in 96 cases (89.7%). The incidence of new-onset and aggravated cranial nerve dysfunction were 13.1% (14/107) and 10.4% (15/144), respectively. Furthermore, 14 cases suffered from intracranial infection, 9 cases had cerebrospinal fluid leakage, and 3 cases sustained intracranial hematoma (1 case underwent second operation). The mean preoperative and postoperative Karnofsky Performance Status (KPS) score was 80 (range 60-100) and 78.6 (range 0-100), but this was not statistically significant (P>0.05). After a mean follow-up of 5.1 years (range 0.3- 10.6 years), tumor progression or recurrence was confirmed in 23 cases. Two cases died from postoperative complications.ConclusionsFor the treatment of PCMs, it is still a challenge to achieve total resection. With elaborate surgical plans and advanced microsurgical skills, most patients with PCMs can be rendered tumor resection with satisfactory extent and functional preservation, despite transient neurological deterioration during early postoperative periods.

Intracranial hemorrhage is a rare but life-threating complication of spinal anesthesia. Herein, we describe such a rare case that was diagnosed as parenchymal intracerebral hemorrhage after spinal anesthesia. We also aim to raise awareness of its diagnosis and treatment.

Background: Saccular aneurysm in the distal segment of the middle cerebral artery (DMCA) occurs very rarely and often represents with a rupture. We report a successful surgical case of a DMCA aneurysm rupture with large cerebral and subarachnoid hemorrhage. Case Description: A 44-year-old female presented a sudden onset headache and coma (the Glasgow Coma Scale was 3). Head computed tomography (CT) revealed a subarachnoid hemorrhage around the right Sylvian fissure and large intracranial hematoma in the right parietal lobe. The CT angiography showed a saccular aneurysm in the peripheral cortical segment of the right angular branch of the right DMCA. We decided to perform a right craniotomy to evacuate hematoma and interrupt the aneurysm. Just after the dural incision, the aneurysm ruptured again. We applied a temporary clip on the artery proximal to the aneurysm before excising it. Conclusion: Aneurysm in DMCA can be treated safely with surgical excision and risk of sudden recurrent hemorrhage needs to be anticipated.

Introduction  Intracranial pressure (ICP) monitoring is a vital element in the diagnosis and management of several neurological disorders, such as head injury, hydrocephalus, subarachnoid hemorrhage, and intracranial hematoma.  The optic nerve sheath is in direct contact with the subarachnoid space. This relationship provides the physiological foundation for using the optic nerve sheath to assess intracranial pressure. Since the optic nerve sheath is loosely attached to the nerve, the subarachnoid space in this region more distensible, and appears bulbous on ultrasound. Dilation of the optic nerve sheath, in contrast to papilloedema, occurs faster, and can be a sign of increased intracranial pressure.  The advancements of ultrasound modalities enabled researchers to enhance optic nerve sheath diameter (ONSD) measurements, with further research that concentrated on determining the best distance behind the globe to measure OSND. According to a 1996 study, ONSD increased by up to 60% at 3 mm behind the globe compared to only 35% at 10 mm. Later studies showed that the measuring should be performed 3 mm behind the globe, since ultrasound contrast is superior at this depth with a linear probe, allowing for reproducibility.

Background and PurposeThe effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients.MethodsThis was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison.ResultsOne hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072).ConclusionIn conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.

Surgical evacuation of intracranial hematoma, including epidural, subdural, intracerebral, and intraventricular hematoma, is recommended in patients with traumatic brain injury (TBI) for prevention of cerebral herniation and possible saving of life. However, preoperative coagulopathy is a major concern for emergent surgery on patients with severe TBI. We reviewed 65 consecutive patients with severe TBI who underwent emergency craniotomy for intracranial hematomas. Univariate analysis showed preoperative pupil abnormality, absence of pupil light reflex, respiratory failure, preoperative thrombocytopenia ( 36 s), low fibrinogen (

Objective Pin-type head frame systems have become a worldwide standard procedure, but they can cause some complications on rare occasions. This study aimed to examine the incidence and associated risk factors of depressed skull fracture and related intracranial hematoma (DSFH) due to the use of head frames in our institute over the past 10 years. Methods This study included 1749 patients who underwent neurosurgical surgeries using pin-type head frames, including the Mayfield (Integra NeuroSciences, Plainsboro, NJ) skull clamp (721 cases) and the Sugita (Mizuho Ikakogyo Co., Ltd., Tokyo, Japan) head frame (1028 cases). We retrospectively reviewed hospital records of our institute to identify cases of DSFH, and documented the type of head frame used, as well as patient characteristics. Results The incidence of DSFH was 0.29% (5 of 1749 cases). All 5 cases had an associated epidural hematoma, with a single case having an additional dural laceration (without subdural damage). All perforation sites, located at the parietal bone near the pterion, occurred by the unilateral horizontal screw of the Sugita head frame. None of the patients experienced postoperative neurological decline. Conclusions Even in the adult population, the DSFH by the pin-type head frame can occur infrequently. Based on our results, we recommend that the following factors should be considered when the pin-type head frame is used for neurosurgical procedures: location of pin application, thickness and fragility of the skull, and adequate control of compressive forces exerted by the head frame.

Introduction: Interdural hematoma (IDH) is an extremely rare hemorrhage between the outer periosteal dura mater and the inner meningeal dura mater. There are 8 cases of convexity IDH reported previously but none of them were acute post traumatic one. We report the case of a patient with an initial diagnosis of acute epidural hematoma (EDH) that was eventually revealed to be an acute convexity IDH.Case report: A 57-year-old man presented to the emergency department with a complaint of falling from 2 meters. Imaging findings revealed an expanding intracranial hematoma with a linear skull fracture extending to sagittal suture, which was mistaken as an EDH. Emergent surgical evacuation was performed; the hematoma was lodged between two dural layers.Discussion: This is the first case of acute convexity IDH following trauma that has been reported. In chronic and sub-acute hematomas MRI scans could be very useful, but in acute cases under emergent circumstances, CT scan cannot make a proper differentiation between an EDH and IDH. IDH should be considered during craniotomy when extradural findings do not explain the CT scan findings. This case showed a linear skull fracture expanding to the sagittal suture, and this can be a possible explanation for IDH formation. Surgical evacuation of the hematoma without inner nor outer layer resection and leaving the outer layer open, to connect the interdural space to epidural space was first described in this report.

OBJECTIVE To enhance students' understanding and imagination and improve teachers' teaching quality through the "Hand As Foot" teaching method. METHODS Teachers explained the hierarchical structure of brain and the location of intracranial hematoma through the "Hand As Foot" teaching method. RESULTS Through the "Hand As Foot" teaching method, students can deeply remember the hierarchical structure of brain and the location of intracranial hematoma. CONCLUSION This novel and unique teaching method makes the interaction between teachers and students stronger and improves the teaching quality.

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

Dislocation of the mandibular condyle into the middle cranial fossa is a rare complication of mandibular trauma due to anatomical and biomechanical factors. Due to the proximity of the mandibular condyle to the middle cranial fossa and middle meningeal artery, there is the risk of serious sequelae in case of trauma. The authors report the case of a 31-year-old female patient, who was beaten up in a family dispute. Computer tomography results demonstrated a basilar skull fracture, pneumocephalus, the dislocation of the mandible into the middle cranial fossa. The patient was hospitalized in the neurosurgical department; anti-edema treatment and antibiotic therapy were prescribed. During the first day, deterioration of the condition presented with rising headache and a gradual suppression of consciousness (GCS 13). The control tomography of the brain revealed negative dynamics in the form of development of intracerebral hemorrhage in the right temporal lobe, subdural hematoma to the right and lateral dislocation of the median structures to the left.The patient was operated in critical situation. Right-sided subtemporal approach and cranial trepanation were performed. There were removed numerous bone fragments of a multi-fragile fracture of the petrous part of the right temporal bone. A reposition of the mandibular condyle was performed by pull-through of the latter from the middle cranial fossa. The intracerebral hemorrhage of the right temporal lobe was removed, and a thorough hemostasis was performed. In addition, skull base reconstruction was performed. Rapid diagnosis and a multidisciplinary approach are needed to minimize complications. The modern opportunities of reconstruction of imaging using the CT method were applied. Treatment options should be individualized in case of suspicion of intracranial hematoma formation., Дислокация головки нижней челюсти в среднюю черепную ямку – редкое осложнение травмы нижней челюсти из-за анатомических и биомеханических факторов. Вследствие близости головки нижней челюсти к средней черепной ямке и менингиальным артериям существует риск серьезных последствий в случае травмы. Описан клинический случай. Пациентка в возрасте 31 год была избита во время семейного спора. По данным спиральной компьютерной томографии головного мозга обнаружен перелом основания черепа, пневмоцефалии, дислокация нижней челюсти в среднюю черепную ямку. Больную госпитализировали в нейрохирургическое отделение. Назначили противоотечную, антибактериальную терапию. В течение первых суток отмечено ухудшение состояния в виде нарастания головной боли и постепенного угнетения сознания до умеренного оглушения (13 баллов по шкале комы Глазго). По данным контрольной томографии головного мозга обнаружена отрицательная динамика в виде появления внутримозгового кровоизлияния в правую височную долю, субдуральной гематомы справа и латеральной дислокации срединных структур влево.Пациентке проведена операция по жизненным показаниям. Выполнены правосторонний подвисочный доступ и костно-пластическая трепанация черепа. Удалены многочисленные осколки многооскольчатого перелома пирамиды правой височной кости. Проведена репозиция головки нижней челюсти путем низведения последней со средней черепной ямки. Удалено внутримозговое кровоизлияние в правой височной доли и выполнен тщательный гемостаз. Дополнительно проведена реконструкция основания черепа аутотканями и Тахокомбом. Для минимизации осложнений необходимы быстрое установление диагноза и мультидисциплинарный подход. Применены современные возможности реконструкции изображения методом спиральной компьютерной томографии. В случае подозрения на формирование внутричерепной гематомы метод лечения выбирают индивидуально., Дислокація головки нижньої щелепи в середню черепну ямку – рідкісне ускладнення травми нижньої щелепи через анатомічні та біомеханічні чинники. Внаслідок близькості головки нижньої щелепи до середньої черепної ямки та менінгіальних артерій існує ризик серйозних наслідків у разі травми. Описано клінічний випадок. Пацієнтку віком 31 рік було побито під час сімейної суперечки. За даними спіральної комп’ютерної томографії головного мозку виявлено перелом основи черепа, пневмоцефалію, дислокацію нижньої щелепи в середню черепну ямку. Хвору госпіталізовано до нейрохірургічного відділення. Призначено протинабрякову, антибактеріальну терапію. Протягом першої доби відзначено погіршення стану у вигляді наростання головного болю та поступового пригнічення свідомості до помірного приглушення (13 балів за шкалою коми Глазго). За даними контрольної томографії головного мозку виявлено негативну динаміку, зокрема появу внутрішньомозкового крововиливу в праву скроневу частку, субдуральну гематому праворуч та латеральну дислокацію серединних структур ліворуч.Пацієнтці проведено операцію за життєвими показаннями. Виконано правобічний підскроневий доступ і кістково-пластичну трепанацію черепа. Видалено численні уламки багатоуламкового перелому піраміди правої скроневої кістки. Проведено репозицію головки нижньої щелепи шляхом зведення донизу останньої із середньої черепної ямки. Видалено внутрішньомозковий крововилив у правій скроневій частці та виконано ретельний гемостаз. Додатково проведено реконструкцію основи черепа автотканинами і Тахокомбом. Для мінімізації ускладнень необхідні швидке встановлення діагнозу та мультидисциплінарний підхід. Застосовано сучасні можливості реконструкції зображення методом спіральної комп’ютерної томографії. У разі підозри щодо формування внутрішньочерепної гематоми метод лікування вибирають індивідуально.

Venous thromboembolism (VTE) is recognized as a factor of morbidity and mortality in trauma patients suffering from severe blunt traumatic brain injury (TBI). The administration of pharmacological prophylaxis is broadly accepted as an effective therapy to prevent VTE events in trauma patients. Regardless of its ascertained efficacy, the risk of hematoma progression complicates the therapy in patients suffering from TBI: therefore, the optimal time to start prophylactic anticoagulation in these patients remains controversial.All primary admissions to our level-1-trauma center between January 2012 and December 2016 were screened for severe blunt TBI with a head Abbreviated Injury Scale (AIS) ≥ 3. Patients who died within the first 24 h were excluded. Basic demographic results, thromboembolic events and progression of the intracranial hematoma were extracted from the patient's records. The patients were categorized into 4 groups according to start of VTE chemoprophylaxis: early ( 24 h after hospitalization), intermediate (24-48 h), late ( 48 h) and no therapy (no prophylactic anticoagulation within the first five days of hospitalization). A total of 292 patients with severe TBI were analyzed (early: n = 93, intermediate: n = 90, late: n = 74, no therapy: n = 35). The overall rate of intracranial bleeding progression was 13.6% after prophylactic anticoagulation was started.No statistically significant differences were found in the frequency of intracranial bleeding progression comparing the different time groups (early 12.9% vs. intermediate 11.1% vs. late 17.6%; adj. p = 0.13). In patients with VTE chemoprophylaxis, no thromboembolic events were recorded. Male gender, age, head AIS and subarachnoidal hemorrhage were identified as independent risk factors associated with intracranial hematoma progression.The early administration of VTE chemoprophylaxis within 24 h after admission in patients with severe TBI did not increase the risk of intracranial bleeding progression.

Background and objective: Treating children with head injuries is one of the most frequent causes of admission to the neurosurgical emergency unit in Erbil city. In many cases, the parents ask whether the presence of a skull fracture in their child indicates any association with intracranial hemorrhage. Most of the previous studies focused on the association between skull fractures and intracranial hematomas in the adult population. We conducted this study to determine if there is a statistically significant association between skull fracture and types of intracranial hemorrhage in children. Methods: A descriptive study was conducted between July 2015 and July 2017 at West Erbil Emergency Hospital. The study sample included children with the head injury whose brain Computerized Tomography (CT)-scan showed intracranial hemorrhage. Data collected using a questionnaire prepared by the researcher. Data were analyzed using descriptive and inferential statistical tests. Results: A total of 201 children met the inclusion criteria; their ages ranged between 2 months and 17 years. Male to female ratio was 121:80. Highest percentages (64.7%) of children were 1-5 years old. The most common (72.63%) cause of head injury was fall from height. The most frequent (48.8%) intracranial hematoma encountered was an epidural hematoma, followed by intracerebral hematoma and subdural hematomas. There was a highly significant (P = 0.001) association between skull fractures and types of intracranial hematomas. Conclusion: In children, skull fracture increases the incidence of intracranial hematoma. Most common intracranial hematomas in order of frequency were an epidural hematoma, intracerebral hematoma, and subdural hematoma. The most common cause of head injury was fall from height. Most patients were males between one and five years old.

Introduction: Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC). Materials and Methods: Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the “ABC/2” technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC. Results: HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00–5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08–8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87–13.13), frontal location (RR: 1.42, 95% CL: 1.08–3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51–10.01, subdural-RR: 2.91, 95% CL: 1.26–6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01–5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789–32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114–0.860). Conclusion: Initial computed tomography scan is a good predictor of high-risk group for HPC.

Background Rupture of cerebral aneurysm is an inevitable complication during embolization, followed by subsequent acute subarachnoid hemorrhage or intracranial hematoma, and results in the aggravation of a patient’s condition. In particular, for patients who have had a ruptured aneurysm, urgent treatment strategies are required during operation. The most common hemostatic methods seen in clinical practices are as follows: after lowering the blood pressure, we continue to embolize the aneurysms with detachable coils as soon as possible or inject with Glubran/Onyx embolization liquids, as well as use a balloon catheter to temporarily block the blood supply. If the conditions are permissible, a balloon guiding catheter may even be used to restrict the proximal blood flow. At times, due to limitations of these methods, neurosurgeons are requested to perform craniotomy to treat the hemostasis. However, the delayed transition often leads to rapid deterioration of the patient’s condition and even death due to cerebral hernia. Case description We herein presented two cases of ruptured cerebral aneurysms to provide an alternative method for hemostasis and to save the lives of patients as much as possible. In an extremely urgent situation (conventional treatment is ineffective), we successfully saved the patient’s life by injecting lyophilizing thrombin powder (LTP) solution into the aneurysmal sac and the parent artery through a microcatheter. Conclusions To our knowledge, this is the first report of successful hemostasis during coil embolization of ruptured cerebral aneurysm with LTP. Further prospective studies are needed to confirm the safety and efficacy of LTP in cerebrovascular interventional therapy.