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Background and purpose: Midline shift is a life-threatening complication of acute large artery occlusion (LAO). The value of superficial middle cerebral vein (SMCV) for predicting midline shift is currently unclear for patients with acute LAO. Methods: Consecutive acute LAO (middle cerebral artery M1 ± intracranial internal carotid artery) patients between March 2018 and May 2019 were included. Absent filling of ipsilateral cortical vein (marked as SMCV–) was defined as no contrast filling into the vein across the whole venous phase of four-dimensional computed tomography (CT) angiography derived from CT perfusion in the ischemic hemisphere. Results: In the total of 81 patients, 31 (38.4%) were identified as SMCV–. SMCV– independently predicted midline shift, with sensitivity of 87.5% and specificity of 82.5%. Receiver operating characteristic analysis showed that including SMCV– as a predictor in addition to baseline ischemic core volume significantly increased the area under the curve in predicting midline shift (SMCV– with baseline ischemic core volume vs. baseline ischemic core volume: AUC = 0.903 vs. 0.841, Z = 2.451, P = 0.014). Conclusion: In acute LAO patients, the presence of SMCV– was a sensitive and specific imaging marker for midline shift. SMCV– had supplementary value to baseline ischemic core volume in predicting midline shift. [ABSTRACT FROM AUTHOR]

The recurrence rate of chronic subdural hematoma (CSDH) has been reported to range from 2.3 to 33%. As bridging veins are composed of abundant collagen bundles and bone matrix, we aimed to investigate the possible associations between skull Hounsfield unit (HU) values and the recurrence of CSDH. We retrospectively enrolled patients with CSDH who underwent burr hole surgery. The HU values of the frontal skull were measured on brain CT scans. The cumulative hazard for recurrence was estimated according to predictive factors. To identify the independent predictors associated with the recurrence of CSDH, hazard ratios (HRs) were estimated using multivariate Cox regression analysis. A total of 208 consecutive patients who underwent burr hole trephination for CSDH over a 7-years period at a single institution were enrolled in this study. We found that age, greater midline shift (≥10.5 mm), lower skull HU (<769.5), and diabetes were independent predictors for the recurrence of CSDH (HR 1.06, 95% confidence interval [CI] 1.00–1.12, p = 0.042; HR 5.37, 95% CI 1.48–19.46, p = 0.010; HR 6.71, 95% CI 1.84–24.45, p = 0.004; and HR 3.30, 95% CI 1.05–10.43, p = 0.042, respectively). A relationship between possible low bone mineral density (BMD) and CSDH recurrence was observed. In addition, age, greater preoperative midline shift, and diabetes were also identified as predictive factors for recurrence. We expect that our findings may facilitate our understanding of the possible association between CSDH and BMD. [ABSTRACT FROM AUTHOR]

Background and Purpose: Although outcome in intracerebral hemorrhage (ICH) patients is generally not improved by surgical intervention, the use of minimally invasive surgery (MIS) has shown promising results. However, vitamin K antagonist (VKA)-related ICH patients are underrepresented in surgical treatment trials. We therefore assessed the safety and efficacy of a bedside MIS approach including local application of urokinase in VKA-related ICH. Methods: Patients with a VKA-related ICH > 20 ml who received bedside hematoma evacuation treatment (n = 21) at the University Medical Center Freiburg were retrospectively included for analysis and compared to a historical control group (n = 35) selected from an institutional database (University Medical Center Erlangen) according to identical inclusion criteria. Propensity score matching was performed to obtain comparable cohorts. The evolution of hematoma and peri-hemorrhagic edema (PHE) volumes, midline shift, and the occurrence of adverse events were analyzed. Furthermore, we assessed the modified Rankin Scale and NIHSS scores recorded at discharge. Results: Propensity score matching resulted in 16 patients per group with well-balanced characteristics. Median ICH volume at admission was 45.7 (IQR: 24.2–56.7) ml in the control group and 48.4 (IQR: 28.7–59.6) ml in the treatment group (p = 0.327). ICH volume at day 7 was less pronounced in the treatment group [MIS: 23.2 ml (IQR: 15.8–32.3) vs. control: 43.2 ml (IQR: 27.5–52.4); p = 0.013], as was the increase in midline shift up to day 7 [MIS: −3.75 mM (IQR: −4.25 to −2) vs. control: 1 mM (IQR: 0–2); p < 0.001]. No group differences were observed in PHE volume on day 7 [MIS: 42.4 ml (IQR: 25.0–72.3) vs. control: 31.0 ml (IQR: 18.8–53.8); p = 0.274] or mRS at discharge [MIS: 5 (IQR: 4–5) and 5 (IQR: 4–5); p = 0.949]. No hematoma expansion was observed. The catheter had to be replaced in 1 patient (6%). Conclusions: Bedside catheter-based hematoma evacuation followed by local thrombolysis with urokinase appears to be feasible and safe in cases of large VKA-related ICH. Further studies that assess the functional outcome associated with this technique are warranted. Clinical Trial Registration: DRKS00007908 (German Clinical Trial Register; www.drks.de) [ABSTRACT FROM AUTHOR]

Objectives: Lateral displacement and impaired cerebral autoregulation are associated with worse outcomes following acute brain injury, but their effect on long-term clinical outcomes remains unclear. We assessed the relationship between lateral displacement, disturbances to cerebral autoregulation, and clinical outcomes in acutely comatose patients.Design: Retrospective analysis of prospectively collected data.Setting: Neurocritical care unit of the Johns Hopkins Hospital.Patients: Acutely comatose patients (Glasgow Coma Score ≤ 8).Interventions: None.Measurements and Main Results: Cerebral oximetry index, derived from near-infrared spectroscopy multimodal monitoring, was used to evaluate cerebral autoregulation. Associations between lateral brain displacement, global cerebral autoregulation, and interhemispheric cerebral autoregulation asymmetry were assessed using mixed random effects models with random intercept. Patients were grouped by functional outcome, determined by the modified Rankin Scale. Associations between outcome group, lateral displacement, and cerebral oximetry index were assessed using multivariate linear regression. Increasing lateral brain displacement was associated with worsening global cerebral autoregulation (p = 0.01 septum; p = 0.05 pineal) and cerebral autoregulation asymmetry (both p < 0.001). Maximum lateral displacement during the first 3 days of coma was significantly different between functional outcome groups at hospital discharge (p = 0.019 pineal; p = 0.008 septum), 3 months (p = 0.026; p = 0.007), 6 months (p = 0.018; p = 0.010), and 12 months (p = 0.022; p = 0.012). Global cerebral oximetry index was associated with functional outcomes at 3 months (p = 0.019) and 6 months (p = 0.013).Conclusions: During the first 3 days of acute coma, increasing lateral brain displacement is associated with worsening global cerebral autoregulation and cerebral autoregulation asymmetry, and poor long-term clinical outcomes in acutely comatose patients. The impact of acute interventions on outcome needs to be explored. [ABSTRACT FROM AUTHOR]

Background: Drain insertion following chronic subdural haematoma (CSDH) evacuation reduces recurrence and improves outcomes. The mechanism of this improvement is uncertain. We assessed whether drains result in improved postoperative imaging, and which radiological factors are associated with recurrence and functional outcome. Methods: A multi-centre, prospective cohort study of CSDH patients was performed between May 2013 and January 2014. Patients aged > 16 years undergoing burr hole evacuation of primary CSDH with pre- and postoperative imaging were included in this subgroup analysis. Baseline and clinical details were collected. Pre- and postoperative maximal subdural width and midline shift (MLS) along with clot density were recorded. Primary outcomes comprised mRS at discharge and symptomatic recurrence requiring re-drainage. Comparisons were made using multiple logistic regression. Results: Three hundred nineteen patients were identified for inclusion. Two hundred seventy-two of 319 (85%) patients underwent drain insertion at the time of surgery versus 45/319 (14%) who did not. Twenty-nine of 272 patients who underwent drain insertion experienced recurrence (10.9%) versus 9 of 45 patients without drain insertion (20.5%; p = 0.07). Overall change in median subdural width was significantly greater in the drain versus 'no drain' groups (11 mm versus 6 mm, p < 0.01). Overall change in median midline shift (MLS) was also significantly greater in the drain group (4 mm versus 3 mm, p < 0.01). On multivariate analysis, change in maximal width and MLS were significant predictors of recurrence, although only the former remained a significant predictor for functional outcome. Conclusions: The use of subdural drains results in significantly improved postoperative imaging in burr hole evacuation of CSDH, thus providing radiological corroboration for their recommended use. [ABSTRACT FROM AUTHOR]

The state of research on the topic of visual midline shift syndrome following a cerebrovascular accident is unknown. A scoping review was conducted using the search terms of 'visual midline shift' (or equivalent) and 'cerebrovascular accident' (or equivalent). Articles were selected from eight academic and one grey literature database, and went through two levels of review, as per Arksey and O'Malley, before being deemed acceptable for inclusion. Of the 931 abstracts reviewed, 27 articles met the criteria for inclusion. Data extracted from the selected articles included terminology and definition, symptoms, underlying pathophysiology, duration, assessment method, and management of visual midline shift syndrome following cerebrovascular accident. There is agreement on the existence of a midline shift following a cerebrovascular accident resulting in poor posture and imbalance. Much uncertainty exists in the literature regarding terminology, underlying pathophysiology, assessment method and management of this condition. Further research is required. [ABSTRACT FROM AUTHOR]

Purpose: To introduced our experience with progressive extra-axial hematoma (EAH) in the original frontotemporoparietal (FTP) site after contralateral decompressive surgery (CDS) in traumatic brain injury patients and discuss the risk factors associated with this dangerous situation.Methods: This retrospective study was conducted on 941 patients with moderate or severe TBI treated in Daping Hospital, Army Medical University, Chongqing, China in a period over 5 years (2013-2017). Only patients with bilateral lesion, the contralateral side being the dominant lesion, and decompressive surgery on the contralateral side conducted firstly were included. Patients were exclude if (1) they underwent bilateral decompression or neurosurgery at the original location firstly; (2) although surgery was performed first on the contralateral side, surgery was done again at the contralateral side due to re-bleeding or complications; (3) patients younger than 18 years or older than 80 years; and (4) patients with other significant organ injury or severe disorder or those with abnormal coagulation profiles. Clinical and radiographic variables reviewed were demographic data, trauma mechanisms, neurological condition assessed by Glasgow coma scale (GCS) score at admission, pupil size and reactivity, use of mannitol, time interval from trauma to surgery, Rotterdam CT classification, type and volume of EAH, presence of a skull fracture overlying the EAH, status of basal cistern, size of midline shift, associated brain lesions and types, etc. Patients were followed-up for at least 6 months and the outcome was graded by Glasgow outcome scale (GOS) score as favorable (scores of 4-5) and unfavorable (scores of 1-3). Student's t-test was adopted for quantitative variables while Pearson Chi-squared test or Fisher's exact test for categorical variables. Multivariate logistic regression analysis was also applied to estimate the significance of risk factors.Results: Initially 186 patients (19.8%) with original impact locations at the FTP site and underwent surgery were selected. Among them, 66 met the inclusion and exclusion criteria. But only 50 patients were included because the data of the other 16 patients were incomplete. Progressive EAH developed at the original FTP site in 11 patients after the treatment of, with an incidence of 22%. Therefore the other 39 patients were classified as the control group. Multivariate logistic regression analysis showed that both the volume of the original hematoma and the absence of an apparent midline shift were significant predictors of hematoma progression after decompressive surgery. Patients with fracture at the original impact site had a higher incidence of progressive EAH after CDS, however this factor was not an important predictor in the multivariate model. We also found that patients with progressive EAH had a similar favorable outcome with control group.Conclusion: Progressive EAH is correlated with several variables, such as hematoma volumes ≥10 mL at the original impact location and the absence of an apparent midline shift (<5 mm). Although progressive EAH is devastating, timely diagnosis with computed tomography scans and immediate evacuation of the progressive hematoma can yield a favorable result. [ABSTRACT FROM AUTHOR]

Postoperative seizures are potential complications of chronic subdural hematoma (cSDH). Knowledge of risk factors may help to identify patients that may benefit from antiepileptic prophylaxis. A total of 101 patients (mean age, 70.1 ± 32.1 years) with surgical evacuation of cSDH were enrolled. We retrospectively collected patient characteristics, hematoma specifics, and procedural aspects and evaluated their impact on postoperative seizures within a 14-day follow-up period by means of bivariate logistic regression analysis. Postoperative seizures occurred in 14 patients (13.9%). At discharge, the mean Markwalder grading scale score was 1.1 ± 1.1 and 0.5 ± 0.8 in patients with and without seizures, respectively (P = 0.04). In the univariate analysis, preoperative midline shift (8.3 vs. 4.5 mm, P = 0.045), open craniotomy (85.7% vs. 55.2%, P = 0.031), and membranectomy (57.1% vs. 20.7%, P = 0.004) were significantly associated with postoperative seizures, respectively. In the multivariate analysis, preoperative midline shift (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01–1.26; P = 0.029) and membranectomy (OR, 3.9; 95% CI, 1.0–15.0; P = 0.048) remained as independent risk factors for seizures. Perioperative antiepileptic prophylaxis may be recommended in patients with preoperative midline shift. Membranectomy may not be routinely applied during surgery. [ABSTRACT FROM AUTHOR]

Abstract In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.

Mechanical compression is a common abnormality of brain tumors that has been shown to be responsible for the severe neurological defects of brain cancer patients representing a negative prognostic factor. Indeed, it is of note that patients that undergo resection exhibited higher survival rates than those subjected to biopsy only, suggesting that compressive forces generated during brain tumor growth play a key role in tumor progression. Despite the importance of mechanical compression in brain tumors, there is a lack of studies examining its direct effects on brain cancer cells and the mechanisms involved. In the present study, we used two brain cancer cell lines with distinct metastatic potential, the less aggressive H4 and the highly aggressive A172 cell lines, in order to study the effect of compression on their proliferative and migratory ability. Specifically, we used multicellular tumor spheroids (MCS) embedded in agarose matrix to show that compression strongly impaired their growth. Using mathematical modeling, we estimated the levels of compressive stress generated during the growth of brain MCS and then we applied the respective stress levels on brain cancer cell monolayers using our previously established transmembrane pressure device. By performing a scratch assay, we found that compression strongly induced the migration of the less aggressive H4 cells, while a less pronounced effect was observed for A172 cells. Analysis of the gene expression profile of both cell lines revealed that GDF15 and small GTPases are strongly regulated by mechanical compression, while GDF15 was further shown to be necessary for cells to migrate under compression. Through a phospho-proteomic screening, we further found that compressive stimulus is transmitted through the MEK1/Erk1 signaling pathway, which is also necessary for the migration of brain cancer cells. Finally, our results gave the first indication that GDF15 could regulate and being regulated by MEK1/Erk1 signaling pathway in order to facilitate the compression-induced brain cancer cell migration, rendering them along with small GTPases as potential targets for future anti-metastatic therapeutic innovations to treat brain tumors.

Chronic subdural haematoma represents a major problem in the neurosurgical field concerning population both under and above 75 years old. It is not only a matter of prevalence or pure statistics but it embodies true understanding of how the pathology affects older patients, their life expectancy and quality when reliable factors are implied such as comorbidities, relation with the moment of surgery, the existence of anticoagulation therapy, and many more. We target these challenges in a study on 232 cases of treated chronic subdural haematomas with impact on two major categories - those under and above 75 years old in the Neurosurgery Department, County Hospital “Pius Branzeu” Timisoara, Romania.

Mechanical compression is a common abnormality of brain tumors that has been shown to be responsible for the severe neurological defects of brain cancer patients representing a negative prognostic factor. Indeed, it is of note that patients that undergo resection exhibited higher survival rates than those subjected to biopsy only, suggesting that compressive forces generated during brain tumor growth play a key role in tumor progression. Despite the importance of mechanical compression in brain tumors, there is a lack of studies examining its direct effects on brain cancer cells and the mechanisms involved. In the present study, we used two brain cancer cell lines with distinct metastatic potential, the less aggressive H4 and the highly aggressive A172 cell lines, in order to study the effect of compression on their proliferative and migratory ability. Specifically, we used multicellular tumor spheroids (MCS) embedded in agarose matrix to show that compression strongly impaired their growth. Using mathematical modeling, we estimated the levels of compressive stress generated during the growth of brain MCS and then we applied the respective stress levels on brain cancer cell monolayers using our previously established transmembrane pressure device. By performing a scratch assay, we found that compression strongly induced the migration of the less aggressive H4 cells, while a less pronounced effect was observed for A172 cells. Analysis of the gene expression profile of both cell lines revealed that GDF15 and small GTPases are strongly regulated by mechanical compression, while GDF15 was further shown to be necessary for cells to migrate under compression. Through a phospho-proteomic screening, we further found that compressive stimulus is transmitted through the MEK1/Erk1 signaling pathway, which is also necessary for the migration of brain cancer cells. Finally, our results gave the first indication that GDF15 could regulate and being regulated by MEK1/Erk1 signaling pathway in order to facilitate the compression-induced brain cancer cell migration, rendering them along with small GTPases as potential targets for future anti-metastatic therapeutic innovations to treat brain tumors. [ABSTRACT FROM AUTHOR]

Transcranial Doppler is a bedside procedure that measures linear cerebral blood flow velocity (CBFV) and the pulsatility index through the intracranial circulation. Transcranial color-coded duplex Doppler (TCCD) provides both CBFV and B-mode functions. In this review they are both referred to as brain ultrasound TCCD. Brain ultrasound can be applied in various environments, including out-of-hospital, emergency room, surgery, intensive care, and ward settings. The most common neurologic disease processes evaluated with TCCD are subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke. However, TCCD also is used outside the neuroenvironment for diseases such as sickle cell anemia or for cerebral hemodynamic assessment during the cardiovascular perioperative period. In these applications, TCCD can be used for the detection of cerebral vessel occlusion, estimation of cerebrovascular reactivity, right-to-left cardiac shunts, noninvasive estimation of cerebral perfusion and intracranial pressure, optic nerve sheath diameter, midline shift, hydrocephalus, and the presence of foreign objects. Finally, TCCD has a high accuracy in confirming total cerebral circulatory arrest and has been used as an ancillary test to support clinical diagnosis of brain death. Other indications for TCCD include assessment of collateral blood flow and embolization during carotid endarterectomy, assessment of patterns and extent of collateral circulation in severe stenosis or occlusion, assessment of patent foramen ovale/paradoxical embolism, assessment of arteriovenous malformations and studying their supply arteries and flow patterns, assessment of noncardiac right-to-left shunts, assessment of severe stenosis in the arteries of the circle of Willis, and assessment of vertebral artery dissection. [ABSTRACT FROM AUTHOR]

Background: Pupillary dysfunction is recognized as a sign of acute neurological deterioration due to worsening mass effect in patients with hemispheric strokes. Recent neuroimaging studies suggest that horizontal displacement of brain structures may be more important than vertical displacement in explaining these pupillary findings. Pupillometers allow objective and standardized evaluation of the pupillary light reflex. We hypothesized that pupillary data (Neurological Pupil index [NPi] and constriction velocity [CV]) obtained with a hand-held pupilometer, correlate with horizontal intracranial midline shift in patients with ischemic and hemorrhagic strokes.Methods: The ENDPANIC registry is a prospective database of pupillometer readings in neurological patients. There were 134 patients in the database with an acute ischemic stroke or intracerebral hemorrhage who had at least 2 neurologic imaging studies (CT or MRI) and pupillometer assessments performed within 6 hours of the imaging. Horizontal shift of the septum pellucidum (SPS) was measured in 293 images. We computed the correlation between SPS and the following pupillary variables: size, NPi, CV (left, right, and left-right difference), followed by a regression model to control for confounders.Results: There were 94 patients (70.1%) with an ischemic stroke and 40 patients (29.9%) had an intracerebral hemorrhage. After controlling for age, race, and gender, there was a significant correlation between the SPS and NPi (left [P < .001], right [P < .001]), CV (left [P < .005], right [P < .001]) pupillary asymmetry (absolute difference between right and left; P < .05), but not between SPS and pupillary size (left or right). There was a significant correlation between the NPi and CV for the right pupil when there was a right-to-left SPS (P < .001 and P < .05, respectively), but none between the NPi and CV for the left pupil and left-to-right SPS.Conclusions: In patients with ischemic and hemorrhagic strokes, there is a significant correlation between SPS and the NPi, CV and pupillary asymmetry, but not with pupillary size. [ABSTRACT FROM AUTHOR]

Aim: This study aims to evaluate the esthetic prevalence of upper dental midline deviation in female patients reported in our hospital. Background: Midline deviations are a common and persistent problem that all orthodontists must face. The esthetic perception of dental professionals does not always match the opinion of the patients and this different view implies that more research would help to better understand the perception and esthetic effects of certain smile characteristics. A proper understanding of the etiology and the contribution of the components in midline discrepancy is very essential in proper diagnosis and treatment planning. Materials and Methods: A total of 50 female participants who had never undergone any orthodontic treatment with the age range of 18-50 years were selected randomly and a frontal view with smiling full photographs were taken to evaluate the midline shift. The facial and maxillary midline is observed to determine whether they coincide or not up to certain millimeter. The facial midline is examined by marking the point at glabella, nasion, and pogonion. Results: The majority of the female population have the coincident facial midline and dental midline which is 69% to be exact. Therefore, the remaining 31% of the population has no coincidence with 21% dental midline shift to the right and 10% dental midline shift to the left. Conclusion: The dental midline and facial midline for the majority of the female population are coincided with each other. However, 31% of female population had no coincidence of dental midline with facial midline. This helps to outline the treatment plan and define which procedures should be performed during the final stage of orthodontic treatment. [ABSTRACT FROM AUTHOR]

Objective: The present study was undertaken to evaluate the prevalence of malocclusion and its association with deleterious oral habits in school going children in Sakaka region of Saudi Arabia. Materials and Methods: A cross-sectional study was designed that included school children of 9 to 11 years, enrolled in primary schools in Sakaka. Children with craniofacial anomalies (clefts and syndromes) and those who underwent or had a history of orthodontic treatment were excluded from the study. Data were collected using a questionnaire and orthodontic examination chart. Results: This study revealed that 46% of the examined children had normal occlusion. Deleterious oral habits which are deemed to be the greatest culprits in the causation of occlusal discrepancies were found to be prevalent in 79.2% of the children evaluated in the study. The highest prevalence was seen for thumb sucking, which was common in more than 70% of the subjects and the lowest prevalence was for nail biting which was common in only 9% of the subjects. The habit of mouth breathing was seen among 21% of study population. The various orthodontic variables that were evaluated in this study included maxillary and mandibular crowding and spacing, midline shift, openbite and crossbite. Conclusion: The variables that were most strongly associated with the presence of oral habit were malocclusion and mandibular spacing although the number of subjects with oral habits displayed more occurrence of all the variables that were under consideration. Midline shift and maxillary and mandibular crowding, illustrated in this study were higher compared to those obtained from other developing countries [ABSTRACT FROM AUTHOR]

Objective To determine the prevalence and risk factors of hypopituitarism in patients with traumatic brain injury(TBI) . Methods The clinical data of 198 TBI patients were retrospectively analyzed. The patients were divided into hypopituitarism group and non-hypopituitarism group, and the related clinical indicators were compared between 2 groups. Results Forty two patients were diagnosed with hypopituitarism, while 156 patients were diagnosed with normal pituitary function. Univariate analysis showed that GCS score at admission, intracranial pressure ( ;,, 20 mmHg), midline shift ( ;,, 5 mm), length of ICU stay, skull base fracture and total length hospital stay were associated with hypopituitarism. Logistic regression analysis showed that intracranial pressure;,, 20 mmHg (OR = 3. 495, P = 0. 022), midline shift ;;. 5 mm ( OR = 6. 882,P = 0. 003 ) and GCS score ~ 8 (OR = 2. 482, P = 0. 039 ) were independent risk factors for posttraumatic hypopituitarism. Conclusions The incidence of hypopituitarism after TBI is high. Intracranial pressure ;e:2O mmHg, midline shift ;e:5 mm and GCS score ~ 8 were independent risk factors for posttraumatic hypopituitarism. Routine pituitary function evaluation and hormone replacement therapy are indicated for this group of patients. [ABSTRACT FROM AUTHOR]

Spontaneous intracranial hypotension (SIH) is a syndrome in which hypovolemia of the cerebrospinal fluid (CSF) results in various symptoms. Although its prognosis is usually benign, cases with a rapid neurologic deterioration resulting in an altered mental status have been reported. One of the characteristic radiographic findings in such cases is the presence of bilateral accumulation of subdural fluid (hematoma/hygroma). When SIH-related subdural hematoma is present only unilaterally with a concomitant midline shift, making an accurate diagnosis may be challenging, and inadvertent hematoma evacuation may result in further neurologic deterioration. We report a 58-year-old woman with an altered mental status who had visited a local hospital and in whom a brain CT showed a unilateral subdural hematoma with a marked midline shift. She was referred to our department because of her neurologic deterioration after hematoma evacuation. A CT myelography revealed a massive CSF leakage in the entire thoracic epidural space. She made a full neurologic recovery following blood patch therapy. Our case is unique and educational because the suspicion for SIH as an underlying cause of subdural hematoma is warranted in nongeriatric patients not only with bilateral but also unilateral lesions. An immediate search for CSF leakage may be important in cases with failed hematoma evacuation surgery.

Objective: The objective of this study was to investigate potential correlations between skull density and the progression of chronic subdural hematoma (CSDH)., Methods: Patients with unilateral CSDH were retrospectively enrolled between January 2018 and December 2022. Demographic and clinical characteristics, as well as hematoma and skull density (Hounsfield unit, Hu), were collected and analyzed., Results: The study enrolled 830 patients with unilateral CSDH until the resolution of the CDSH or progressed with surgical treatment. Of the total, 488 patients (58.80%) necessitated surgical treatment. The study identified a significant correlation between the progression of CSDH and three variables: minimum skull density (MiSD), maximum skull density (MaSD), and skull density difference (SDD) ( p  < 0.001). Additionally, in the multivariable regression analysis, MiSD, MaSD, and SDD were independent predictors of CSDH progression. The MiSD + SDD model exhibited an accuracy of 0.88, as determined by the area under the receiver operating characteristic curve, with a sensitivity of 0.77 and specificity of 0.88. The model's accuracy was validated through additional analysis., Conclusion: The findings suggest a significant correlation between skull density and the CSDH progression., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yang, Chen, Yao, Zhang, Zhang, Fang, Wu and Hu.)

Objective: The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients., Methods: This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS., Results: A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model., Conclusion: Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Chen, Yang, Han, Wu, Li, Xu, Sun, Gao, Huang, Parsons and Lin.)

Chronic subdural haematoma represents a major problem in the neurosurgical field concerning population both under and above 75 years old. It is not only a matter of prevalence or pure statistics but it embodies true understanding of how the pathology affects older patients, their life expectancy and quality when reliable factors are implied such as comorbidities, relation with the moment of surgery, the existence of anticoagulation therapy, and many more. We target these challenges in a study on 232 cases of treated chronic subdural haematomas with impact on two major categories -those under and above 75 years old in the Neurosurgery Department, County Hospital "Pius Branzeu" Timisoara, Romania. [ABSTRACT FROM AUTHOR]

Background: This study aims to determine the relationship between pupillary reactivity, midline shift and basal cistern effacement on brain computed tomography (CT) in moderate-to-severe traumatic brain injury (TBI). All are important diagnostic and prognostic measures, but their relationship is unclear.Methods: A total of 204 patients with moderate-to-severe TBI, documented pupillary reactivity, and archived neuroimaging were included. Extent of midline shift and basal cistern effacement were extracted from admission brain CT. Mean midline shift was calculated for each ordinal category of pupillary reactivity and basal cistern effacement. Sequential Chi-square analysis was used to calculate a threshold midline shift for pupillary abnormalities and basal cistern effacement. Univariable and multiple logistic regression analyses were performed.Results: Pupils were bilaterally reactive in 163 patients, unilaterally reactive in 24, and bilaterally unreactive in 17, with mean midline shift (mm) of 1.96, 3.75, and 2.56, respectively (p = 0.14). Basal cisterns were normal in 118 patients, compressed in 45, and absent in 41, with mean midline shift (mm) of 0.64, 2.97, and 5.93, respectively (p < 0.001). Sequential Chi-square analysis identified a threshold for abnormal pupils at a midline shift of 7-7.25 mm (p = 0.032), compressed basal cisterns at 2 mm (p < 0.001), and completely effaced basal cisterns at 7.5 mm (p < 0.001). Logistic regression revealed no association between midline shift and pupillary reactivity. With effaced basal cisterns, the odds ratio for normal pupils was 0.22 (95% CI 0.08-0.56; p = 0.0016) and for at least one unreactive pupil was 0.061 (95% CI 0.012-0.24; p < 0.001). Basal cistern effacement strongly predicted midline shift (OR 1.27; 95% CI 1.17-1.40; p < 0.001).Conclusions: Basal cistern effacement alone is associated with pupillary reactivity and is closely associated with midline shift. It may represent a uniquely useful neuroimaging marker to guide intervention in traumatic brain injury. [ABSTRACT FROM AUTHOR]

Head injury is the major cause of death in young adult population worldwide with associated high morbidity. The objective of this study is to find out the outcome and factors affecting the outcome in isolated traumatic acute subdural hematoma. All patients with isolated acute subdural hematoma presenting within 24 hours of trauma and admitted over a period of 1 year were included in this study. Patient was classified according to Glasgow Coma Scale(GCS) after resuscitation in the emergency department. The outcome of the patient was recorded according to the Glasgow Outcome Scale at the time of discharge and at 3 months after the trauma in follow-up. Statistical analysis was performed to find the correlation between GCS, pupillary changes and radiological finding in the form of midline shift and hematoma volume to dichotomized outcome. Out of 38 patients enrolled in the study, 33 patients had favorable outcome. Surgery was performed in 12 patients out of whom 4 patients had unfavorable outcome. GCS score, papillary changes, midline shift and hematoma volume were found to have significant association with the outcome in isolated traumatic acute subdural hematoma. Clinical parameters and radiological parameters can gauge the outcome in isolated traumatic brain injury. [ABSTRACT FROM AUTHOR]

This study aims to clarify some variables associated with an improved outcome in acute and chronic subdural hematomas with major midline shifts (extreme subdural hematomas). A retrospective review of 814 patients, who were admitted to a Level 1 trauma center with the diagnosis of subdural hematoma, was performed. Out of those patients 77 were included in the overall statistical analysis. Both groups were assessed in regard to 33 different variables, including mechanism of injury (spontaneous, fall, other trauma), time of injury, presence of prior brain lesion (e.g. stroke, tumor), coagulation profile at the time of admission, etc. The Glasgow Coma Scale at the time of admission, Glasgow Outcome Scale at discharge, the amount of brain displacement, and the presence of hydrocephalus, herniation, or new infarcts were also recorded. Additionally, 8 radiographic variables were evaluated using computed tomography investigation to assess the degree of shift and location of extra-axial fluid collections as well as the degree of midline shift following therapeutic intervention and at the time of discharge. The study included 26 patients with acute subdural hematoma and 51 patients with chronic subdural hematoma. In patients with acute subdural hematoma and extreme midline shift, unfavorable outcomes were significantly associated with coagulopathy, delayed intervention and failure to achieve reduction of midline shift to <10 mm during the hospital stay. In patients with chronic subdural hematoma and extreme midline shift, unfavorable outcome is associated with lower Glasgow Coma Scale at the time of admission, midline shifts ≥20 mm and failure to reduce midline shift to less than 10 mm during the hospitalization. The ratio of reduction in midline shift measured at discharge was statistically higher with the usage of a drain (p=0.027). Finally, mechanism of injury did not show any statistically significant effect on treatment outcomes. A relatively small group of patients with major extra-axial fluid collections was reviewed showing the possibility of a good recovery among a substantial patient cohort. Thus, cases of large subdural effusions with massive shifts are not necessarily associated with bad outcomes and a substantial subgroup of patients will have favorable recovery when appropriately treated. [ABSTRACT FROM AUTHOR]

Rapid spontaneous resolution of traumatic acute subdural haematomas (ASDH) can occur but is rare. We present an 88-year-old female who presents with a large left acute subdural haematoma (ASDH) measuring 18 mm in thickness with midline shift of 10.7 mm. We managed her conservatively based upon good consciousness level and absent neurological deficits. Repeat computed tomography (CT) the following day demonstrated near complete resolution of the ASDH and midline shift regression; a further CT confirmed resolution. Most patients with large ASDH require surgical evacuation; however, in rare cases, they can resolve spontaneously with extreme rapidity. Conservative management can be a valid option in carefully selected cases. [ABSTRACT FROM AUTHOR]

Background: Midline shift (MLS) has been associated with unfavorable outcome in patients with intracerebral hemorrhage (ICH). However, the optimal criteria to define the MLS measurements that indicate future outcome in ICH patients are absent, and the quantitative threshold of MLS that differentiates favorable and poor clinical outcome should be further explored.Methods: We enrolled patients with ICH who underwent admission computed tomography (CT) within 6 h after onset of symptoms. We assessed MLS at several locations, including the pineal gland, septum pellucidum, and cerebral falx. MLS(max) was defined as the maximum midline shift among these locations. Functional outcomes were assessed with the Modified Rankin Scale (mRS) at 3 months. We performed multivariate logistic regression analysis to investigate the MLS locations for predicting poor outcome. ROC curve analysis was used to establish whether MLS values were predictive of 90-day poor outcome.Results: In 199 patients with ICH, 78 (39.2%) patients had poor functional outcome at 3-month follow-up. Pineal gland shift, septum pellucidum shift, cerebral falx shift, and MLS(max) all showed a significant difference between poor outcome and favorable outcome (p < 0.001). After adjustment for age, baseline Glasgow Coma Scale score, ICH location, time to initial CT, baseline ICH volume, and intraventricular hemorrhage, the MLS(max) was independently associated with poor outcome (p = 0.032). MLS(max) > 4 mm (our proposed optimal threshold) was more likely to have poorer outcomes than those without (p < 0.001).Conclusions: MLS(max) can be a good independent predictor of clinical outcome, and MLS(max) > 4 mm is an optimal threshold associated with poor outcome in patients with ICH. [ABSTRACT FROM AUTHOR]

Intracerebral haemorrhage (ICH) may lead to intractable elevation of intracranial pressure (ICP), which may lead to decompressive craniectomy (DC). In this setting, surgical evacuation of ICH is controversially discussed. We therefore analysed radiological and clinical parameters to investigate the influence of additional haematoma evacuation to DC in patients with ICH. Forty-four patients suffering from spontaneous, hypertensive ICH between August 2007 and February 2016 underwent DC with and without ICH evacuation at the author’s institution. Patients were stratified into two groups (DC without ICH evacuation versus DC with ICH evacuation). Patient characteristics, clinical and radiological findings were assessed and retrospectively analysed. Fifteen (34%) patients underwent DC with additional ICH evacuation and 29 (66%) underwent DC without ICH evacuation. Mean ICH volume was 60 ± 38 ml with no significant difference between both groups (p = 0.8). Midline shift (MLS) reduction after DC did not significantly differ between both groups (p = 0.4). Overall, 13 patients (30%) achieved a favourable outcome. DC can be performed in cases of spontaneous supratentorial ICH and pathological elevated ICP despite best medical treatment. However, additional ICH evacuation does not seem to be beneficial according to the present study and may therefore be omitted. [ABSTRACT FROM AUTHOR]