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Objectives: Ischemic edema is associated with worse clinical outcomes, especially in large infarcts. Computed tomography (CT)–based densitometry allows direct quantification of absolute edema volume (EV), which challenges indirect biomarkers like midline shift (MLS). We compared EV and MLS as imaging biomarkers of ischemic edema and predictors of malignant infarction (MI) and very poor clinical outcome (VPCO) in early follow-up CT of patients with large infarcts. Materials and methods: Patients with anterior circulation stroke, large vessel occlusion, and Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5 were included. VPCO was defined as modified Rankin scale (mRS) ≥ 5 at discharge. MLS and EV were quantified at admission and in follow-up CT 24 h after admission. Correlation was analyzed between MLS, EV, and total infarct volume (TIV). Multivariable logistic regression and receiver operating characteristics curve analyses were performed to compare MLS and EV as predictors of MI and VPCO. Results: Seventy patients (median TIV 110 mL) were analyzed. EV showed strong correlation to TIV (r = 0.91, p < 0.001) and good diagnostic accuracy to classify MI (EV AUC 0.74 [95%CI 0.61–0.88] vs. MLS AUC 0.82 [95%CI 0.71–0.94]; p = 0.48) and VPCO (EV AUC 0.72 [95%CI 0.60–0.84] vs. MLS AUC 0.69 [95%CI 0.57–0.81]; p = 0.5) with no significant difference compared to MLS, which did not correlate with TIV < 110 mL (r = 0.17, p = 0.33). Conclusion: EV might serve as an imaging biomarker of ischemic edema in future studies, as it is applicable to infarcts of all volumes and predicts MI and VPCO in patients with large infarcts with the same accuracy as MLS. Clinical relevance statement: Utilization of edema volume instead of midline shift as an edema parameter would allow differentiation of patients with large and small infarcts based on the extent of edema, with possible advantages in the prediction of treatment effects, complications, and outcome. Key Points: • CT densitometry–based absolute edema volume challenges midline shift as current gold standard measure of ischemic edema. • Edema volume predicts malignant infarction and poor clinical outcome in patients with large infarcts with similar accuracy compared to MLS irrespective of the lesion extent. • Edema volume might serve as a reliable quantitative imaging biomarker of ischemic edema in acute stroke triage independent of lesion size. [ABSTRACT FROM AUTHOR]

Introduction: Decompressive craniectomy [DC] is one of the leading armaments to lower refractory intracranial pressure. Post-DC hydrocephalus [PDCH] occurs in 11.9–36% of patients undergoing DCs for TBIs. Various theories have been given regarding pathophysiological mechanism of PDCH but remain dubious. Risk factors predicting PDCH still under research. Exact timeline regarding developmental process of PDCH remains undefined. Method: This retrospective study was conducted on 422 patients who underwent DCs in our tertiary care trauma center over the period of one year. 60 patients out of 422 who developed PDCH were analyzed with respect to demographic variables and preoperative and postoperative risk factors. A total of 20 randomly selected patients, who underwent DCs but did not develop hydrocephalus, were selected and compared with patients who developed PDCH. Outcome analysis was done by dichotomizing the groups into independent and dependent groups. Results: Among 422 patients undergoing DC, 14.21%[n = 60] developed PDCH. Younger [34.2 y vs 43.3 y, p = 0.0004] male age group was predominant in our study. Age [p = 0.021, multivariate analysis] and midline shift [p = 0.008, multivariate analysis] were significant preoperative predicting risk factors for PDCH. Interhemispheric hygroma [p = 0.031], brain bulge [ p = 0.008], and blood in postoperative scan [p = 0.029] were significant postoperative risk factors. Lower GCS score at admission [p = 0.0003], postoperative day 10 and at the time of establishment of PDCH were significantly predicted surgery to hydrocephalus time. Midline shift [p = 0.007] and thickness of interhemispheric hygroma [p = 0.021] were associated with poor outcome in patients with PDCH. Conclusion: Younger age group and presence of midline shift are significant preoperative predictors of PDCH. Blood in postoperative scan, interhemispheric hygroma and brain bulge in postoperative period are significant predictors for PDCH. Deterioration in GCS score in postoperative period following DC should be taken as high index of suspicion for developing PDCH. [ABSTRACT FROM AUTHOR]

Background: Neuro Intensive Care Unit (Neuro-ICU) handles neurological emergencies that involve intracranial (IC) hemorrhages. It can be challenging to manage elevated intracranial pressure (ICP) and midline shift (MLS), as they requires constant monitoring and frequent imaging. Trans-cranial Color Coded Sonography (TCCS), a bedside monitoring tool, may be helpful in monitoring MLS under such conditions. Objectives: To correlate MLS of the third ventricle in the brain measured by TCCS with CT midline shift. Method: A prospective observational study was conducted on patients with IC bleed who were mechanically ventilated and had a head CT done to rule out MLS. Within an hour of doing a CT brain, TCCS-MLS was identified. Data was collected and analyzed. Results: A total of fifty patients studied, the MLS (mean ±SD) was 5.3mm ± 3.1 mm using TCCS and 6.7±4.4 mm using CT brain. The calculated midline shift between TCCS and CT brain demonstrated a Pearson's correlation of 0.78 (P5mm MLS on CT scan with a sensitivity of 95% and specificity of 90%. Conclusions: This study suggests that TCCS could serve as an alternative bedside monitoring tool in patients whose transportation is risky, in predicting the transcranial MLS >5mm with reasonable accuracy.

Abstract Introduction Decompressive craniectomy [DC] is one of the leading armaments to lower refractory intracranial pressure. Post-DC hydrocephalus [PDCH] occurs in 11.9–36% of patients undergoing DCs for TBIs. Various theories have been given regarding pathophysiological mechanism of PDCH but remain dubious. Risk factors predicting PDCH still under research. Exact timeline regarding developmental process of PDCH remains undefined. Method This retrospective study was conducted on 422 patients who underwent DCs in our tertiary care trauma center over the period of one year. 60 patients out of 422 who developed PDCH were analyzed with respect to demographic variables and preoperative and postoperative risk factors. A total of 20 randomly selected patients, who underwent DCs but did not develop hydrocephalus, were selected and compared with patients who developed PDCH. Outcome analysis was done by dichotomizing the groups into independent and dependent groups. Results Among 422 patients undergoing DC, 14.21%[n = 60] developed PDCH. Younger [34.2 y vs 43.3 y, p = 0.0004] male age group was predominant in our study. Age [p = 0.021, multivariate analysis] and midline shift [p = 0.008, multivariate analysis] were significant preoperative predicting risk factors for PDCH. Interhemispheric hygroma [p = 0.031], brain bulge [ p = 0.008], and blood in postoperative scan [p = 0.029] were significant postoperative risk factors. Lower GCS score at admission [p = 0.0003], postoperative day 10 and at the time of establishment of PDCH were significantly predicted surgery to hydrocephalus time. Midline shift [p = 0.007] and thickness of interhemispheric hygroma [p = 0.021] were associated with poor outcome in patients with PDCH. Conclusion Younger age group and presence of midline shift are significant preoperative predictors of PDCH. Blood in postoperative scan, interhemispheric hygroma and brain bulge in postoperative period are significant predictors for PDCH. Deterioration in GCS score in postoperative period following DC should be taken as high index of suspicion for developing PDCH.

Introduction: The dental midline is a vital element in smile design. The maxillary and mandibular central incisors midline should ideally be positioned coinciding with each other, Incorrect placement of midlines would lead to instability in dental composition. The dental literature fails to disclose the data as to how nature positions the midline of anterior teeth. Aim: To evaluate the relation between the midlines of maxillary and mandibular dental arches in the dentate population using standardised digital photographs. Materials and Methods: This in-vitro cross-sectional study was carried out in the Department of Prosthodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India between June 2021 to December 2022. A total of 155 dentate subjects (102 females and 53 males) of this demographic area, all within the age group 18-45 years of age were selected for present study. Full-face standardised photographs of the subject’s frontal profile of occluding teeth in a retracted mouth were captured with a Digital Camera (Nikon D3200 DSLR). The collected samples of intraoral images were analysed in image analysing software (Digimiser version 6.0). Lines were constructed in the software to record the maxillary midline and mandibular midline to assess the coincidence or deviation between them. Direct measurements were also obtained within these constructed lines to record the distance of deviation. Direction (right/left) and distance of deviation were recorded. The collected data were subjected to appropriate statistical testing. The statistical analysis was done using the Chi-square test, t-test, etc., and performed in the statistical software International Bussiness Machine (IBM) Statisical Packages of Social Sciences (SPSS) statistics version 25 (Armonk, USA). Results: The mandibular midline did not coincide with the maxillary midline in 134 (86%) of the tested population and within both genders and showed a significant (p-value-0.00) deviation of 1.88 mm after application of the t-test. Although 78 (50%) deviations were towards the left-side and 56 (36%) toward the right-side of the maxillary midline within both genders, the results were statistically insignificant with the Chi-square test. Conclusion: Mandibular and maxillary dental midline fails to coincide in more than four-fifths of the subjects.

Introduction: The dental midline is a vital element in smile design. The maxillary and mandibular central incisors midline should ideally be positioned coinciding with each other, Incorrect placement of midlines would lead to instability in dental composition. The dental literature fails to disclose the data as to how nature positions the midline of anterior teeth. Aim: To evaluate the relation between the midlines of maxillary and mandibular dental arches in the dentate population using standardised digital photographs. Materials and Methods: This in-vitro cross-sectional study was carried out in the Department of Prosthodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India between June 2021 to December 2022. A total of 155 dentate subjects (102 females and 53 males) of this demographic area, all within the age group 18-45 years of age were selected for present study. Full-face standardised photographs of the subject’s frontal profile of occluding teeth in a retracted mouth were captured with a Digital Camera (Nikon D3200 DSLR). The collected samples of intraoral images were analysed in image analysing software (Digimiser version 6.0). Lines were constructed in the software to record the maxillary midline and mandibular midline to assess the coincidence or deviation between them. Direct measurements were also obtained within these constructed lines to record the distance of deviation. Direction (right/left) and distance of deviation were recorded. The collected data were subjected to appropriate statistical testing. The statistical analysis was done using the Chi-square test, t-test, etc., and performed in the statistical software International Bussiness Machine (IBM) Statisical Packages of Social Sciences (SPSS) statistics version 25 (Armonk, USA). Results: The mandibular midline did not coincide with the maxillary midline in 134 (86%) of the tested population and within both genders and showed a significant (p-value-0.00) deviation of 1.88 mm after application of the t-test. Although 78 (50%) deviations were towards the left-side and 56 (36%) toward the right-side of the maxillary midline within both genders, the results were statistically insignificant with the Chi-square test. Conclusion: Mandibular and maxillary dental midline fails to coincide in more than four-fifths of the subjects. [ABSTRACT FROM AUTHOR]

Objectives: Midline shift (MLS) is a critical indicator of the severity of brain trauma and is even suggestive of changes in intracranial pressure. At present, radiologists have to manually measure the MLS using laborious techniques. Automatic detection of MLS using artificial intelligence can be a cuttingedge solution for emergency health-care personnel to help in prompt diagnosis and treatment. In this study, we sought to determine the accuracy and the prognostic value of our screening tool that automatically detects MLS on computed tomography (CT) images in patients with traumatic brain injuries (TBIs). Materials and Methods: The study enrolled TBI cases, who presented at the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi. Institutional ethics committee permission was taken before starting the study. The data collection was carried out for over nine months, i.e., from January 2020 to September 2020. The data collection included head CT scans, patient demographics, clinical details as well as radiologist's reports. The radiologist's reports were considered the "gold standard" for evaluating the MLS. A deep learning-based three dimensional (3D) convolutional neural network (CNN) model was developed using 176 head CT scans. Results: The developed 3D CNN model was trained using 156 scans and was tested on 20 head CTs to determine the accuracy and sensitivity of the model. The screening tool was correctly able to detect 7/10 MLS cases and 4/10 non-MLS cases. The model showed an accuracy of 55% with high specificity (70%) and moderate sensitivity of 40%. Conclusion: An automated solution for screening the MLS can prove useful for neurosurgeons. The results are strong evidence that 3D CNN can assist clinicians in screening MLS cases in an emergency setting. [ABSTRACT FROM AUTHOR]

Introduction: Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. The aim of this retrospective study is to predict the indicators of mortality after DC. Methods: 30 cases in S.G.M.H, getting admitted through SOPD, casualty or transferred from other department diagnosed as severe Traumatic Brain Injury during the period of study were included in the study. Severity was defined according to Glasgow Comal Scale at admission. Patients with moderate to severe head injury requiring decompressive craniectomy considered for this trail, entry will be determined using the above inclusion and exclusion criteria after resuscitation, and data was entered in proforma. Result: Age >55Years undergoing Primary decompression Craniotomy had 100% Mortality. Males constituted of about 83.33% of the studied cases as large number of males were admitted due to RTA(Road Traffic Accidents). In Mechanism of injury-RTA contributed for the maximum number of deaths (61.11%). Multiple seizure episodes show higher Mortality rate of 93.33%. LOC > 6hrs show higher Mortality rate of 88.88%. Cohort with ENT Bleed + had a mortality rate of 66.66% while the other cohort had mortality of 33.33%. Severe Head injury with GCS < 8 had the highest mortality of 90.90% when compared to that of Moderate (63.63%) and Mild (12.5%) head injury. Mortality is highest in cohort with B/L Dilated Pupils on admission-88.88%. Mortality is highest in cohort with B/L Non reactive Pupils on admission-91.66%. Patients admitted wit Contusion had a mortality of 75% while that of SDH is 73.33%. Mortality is 100% in cohort of patients admitted with Midline shift =10mm. Mortality is about 85.7% in Cohort of IntraOp Hypotension while it is 33.33% in cohort without IntraOp Hypotension. It showed a significant statistical relation. Mortality among Cohort with PostOp GCS at 24Hrs with GCS=8 is 92.30% and that of PostOp GCS > 8 is 35.29%.Cohort of patients with Preop Hyperglycaemia had a mortality of 75%. Highest mortality is seen in patients with time lapse of >72hrs between trauma and surgery which is 80%. Conclusion:In patients undergoing primary DC after traumatic brain injury, the predictors of mortality include Age =70years, LOC > 6hrs, Multiple Seizure Episodes, ENT Bleed, Severe Head Injury(GCS=8), Bilateral unreactive pupils, B/L Dilated Pupils, Contusion & Subdural hemorrhage, Midline shift =10mm, Diagnosis of Contusion & SDH, intraoperative hypotension, Time Lapse of > 72hrs. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) often results in midline shift (MLS) that is a critical indicator of the severity and prognosis of head injuries. Automated analysis of MLS from head computed tomography (CT) scans using artificial intelligence (AI) techniques has gained much attention in the past decade and has shown promise in improving diagnostic efficiency and accuracy. This review aims to summarize the current state of research on AI-based approaches for MLS analysis in TBI cases, identify the methodologies employed, evaluate the performance of the algorithms, and draw conclusions regarding their potential clinical applicability. A comprehensive literature search was conducted, identifying 15 distinctive publications. The identified articles were analyzed for their focus on MLS detection and quantification using AI techniques, including their choice of AI algorithms, dataset characteristics, and methodology. The reviewed articles covered various aspects related to MLS detection and quantification, employing deep neural networks trained on two-dimensional or three-dimensional CT imaging datasets. The dataset sizes ranged from 11 patients' CT scans to 25,000 CT images. The performance of the AI algorithms exhibited variations in accuracy, sensitivity, and specificity, with sensitivity ranging from 70 to 100%, and specificity ranging from 73 to 97.4%. AI-based approaches utilizing deep neural networks have demonstrated potential in the automated detection and quantification of MLS in TBI cases. However, different researchers have used different techniques; hence, critical comparison is difficult. Further research and standardization of evaluation protocols are needed to establish the reliability and generalizability of these AI algorithms for MLS detection and quantification in clinical practice. The findings highlight the importance of AI techniques in improving MLS diagnosis and guiding clinical decision-making in TBI management. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. Aims and Objectives: To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Materials and Methods: Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. Results: A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Conclusion: Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients. [ABSTRACT FROM AUTHOR]

This study harnessed machine learning to forecast postoperative mortality (POM) and postoperative pneumonia (PPN) among surgical traumatic brain injury (TBI) patients. Our analysis centered on the following key variables: Glasgow Coma Scale (GCS), midline brain shift (MSB), and time from injury to emergency room arrival (TIE). Additionally, we introduced innovative clustered variables to enhance predictive accuracy and risk assessment. Exploring data from 617 patients spanning 2012 to 2022, we observed that 22.9% encountered postoperative mortality, while 30.0% faced postoperative pneumonia (PPN). Sensitivity for POM and PPN prediction, before incorporating clustering, was in the ranges of 0.43–0.82 (POM) and 0.54–0.76 (PPN). Following clustering, sensitivity values were 0.47–0.76 (POM) and 0.61–0.77 (PPN). Accuracy was in the ranges of 0.67–0.76 (POM) and 0.70–0.81 (PPN) prior to clustering and 0.42–0.73 (POM) and 0.55–0.73 (PPN) after clustering. Clusters characterized by low GCS, small MSB, and short TIE exhibited a 3.2-fold higher POM risk compared to clusters with high GCS, small MSB, and short TIE. In summary, leveraging clustered variables offers a novel avenue for predicting POM and PPN in TBI patients. Assessing the amalgamated impact of GCS, MSB, and TIE characteristics provides valuable insights for clinical decision making. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives. To assess characteristic data of patients hospitalized due to subacute subdural hematomas (SSDHs) and chronic subdural hematomas (CSDHs) and to evaluate radiological findings and establish predictors of hematoma recurrence of SSDHs and CSDHs patient populations. Methods. 149 patients with SSDHs and CSDHs who underwent surgery at Kaunas Clinics Neurosurgery Department from 2020 to 2021 were analyzed. Based on recurrence rate, patients were divided into different subtypes based on computer tomography (CT) imaging. Descriptive analysis, hypothesis testing and correlation matrix were performed using Excel spreadsheet and R programming language with the significance at p-value < 0.05. Results. Out of 149 patients, SSDHs and CSDHs were observed in 89 males (59.6%) and 60 (40.3%) females. Mean of the patients age was 71.1±15 years. Dichotomizing results based on recurrence (cut-off value of 25%), 2 groups were made: 1) low reoperation rate –hypodense sedimented (10%), isodense (21.6%), hypodense (22.2%); 2) high reoperation rate – hypodense bridging (26.7%), hypodense trabecular (27.8%), hypodense with acute bleeding (28.6%), hypodense laminar (30%), isodense with acute bleeding (33.3%). Conclusion. It is concluded that based on 25% reoperation rate high-recurrence and low-recurrence chronic subdural hematomas groups were similar in all terms apart from the hematoma thickness (mm), which leads to a fact that radiological appearance of higher recurrence hematomas should be carefully taken into consideration. [ABSTRACT FROM AUTHOR]

Background and Purpose: Volumetric and densitometric biomarkers have been proposed to better quantify cerebral edema after stroke, but their relative performance has not been rigorously evaluated. Methods: Patients with large vessel occlusion stroke from three institutions were analyzed. An automated pipeline extracted brain, cerebrospinal fluid (CSF), and infarct volumes from serial CTs. Several biomarkers were measured: change in global CSF volume from baseline (ΔCSF); ratio of CSF volumes between hemispheres (CSF ratio); and relative density of infarct region compared with mirrored contralateral region (net water uptake [NWU]). These were compared to radiographic standards, midline shift and relative hemispheric volume (RHV) and malignant edema, defined as deterioration resulting in need for osmotic therapy, decompressive surgery, or death. Results: We analyzed 255 patients with 210 baseline CTs, 255 24‐hour CTs, and 81 72‐hour CTs. Of these, 35 (14%) developed malignant edema and 63 (27%) midline shift. CSF metrics could be calculated for 310 (92%), while NWU could only be obtained from 193 (57%). Peak midline shift was correlated with baseline CSF ratio (ρ = –.22) and with CSF ratio and ΔCSF at 24 hours (ρ = –.55/.63) and 72 hours (ρ = –.66/.69), but not with NWU (ρ =.15/.25). Similarly, CSF ratio was correlated with RHV (ρ = –.69/–.78), while NWU was not. Adjusting for age, National Institutes of Health Stroke Scale, tissue plasminogen activator treatment, and Alberta Stroke Program Early CT Score, CSF ratio (odds ratio [OR]: 1.95 per 0.1, 95% confidence interval [CI]: 1.52‐2.59) and ΔCSF at 24 hours (OR: 1.87 per 10%, 95% CI: 1.47‐2.49) were associated with malignant edema. Conclusion: CSF volumetric biomarkers can be automatically measured from almost all routine CTs and correlate better with standard edema endpoints than net water uptake. [ABSTRACT FROM AUTHOR]

The aim of our study was to investigate the effect of the burr hole width on the postoperative chronic subdural hematoma (CSH) thickness and midline shift radiologically. The medical records of 92 patients who had undergone surgery after a diagnosis of CSH between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computed tomography (CT) scans were reviewed, and the thickness of the hematoma and midline shift and the diameters of 2 burr holes opened were measured and recorded. The correlation between the burr hole diameter width and CSH thickness on postoperative CT scans and the improvement in midline shift were investigated statistically. When the CT scans performed on the first postoperative day and first postoperative month were examined, we found that the preoperative hematoma thickness and midline shift were significantly reduced postoperatively (P < 0.001). A positive significant correlation was found between the improvement in the midline shift, posterior burr hole diameter, and anteroposterior burr hole arithmetic mean (P < 0.001 and P = 0.029, respectively). Having examined the current surgical techniques in the treatment of CSH, we found that an increase in the burr hole craniostomy width, especially the posterior burr hole craniostomy width, contributed to the improvement in the midline shift. [ABSTRACT FROM AUTHOR]

The purpose of this study was to find a suitable model to evaluate the relationship between temperature and intracerebral hemorrhage (ICH) and explore the effects of cold spells and heat waves on the clinicopathological parameters of ICH patients.

Background: Large vessel occlusion (LVO) stroke research is limited regarding high-risk patient groups for complications including cerebral edema. Large, well-phenotyped cohorts hold potential insights, but identifying cohorts and manually extracting outcomes is impractical. Natural language processing (NLP) software has previously extracted stroke characteristics from radiology reports, but there has not been an integrated extraction of both LVO classification and acute stroke outcomes. Methods: We constructed a rules-based NLP pipeline that extracted presence/location of arterial occlusion and core/penumbral volumes from multimodal CT reports, along with presence of edema and midline shift on follow-up CTs. The algorithm flagged inconsistent reports for manual adjudication. We validated performance over two cohorts and analyzed the associations between NLP-extracted variables and clinical edema outcomes. Results: The algorithm identified occlusions in the development (n=577) and test cohorts (n=442) with 94% and 85% recall, increasing to 97% and 93% after review of flagged reports. It could distinguish proximal ICA/M1 from distal occlusions with 96% recall and correctly extracted 98% of core/penumbral volumes. NLP recall was 93% and 86% for identifying edema and midline shift from follow-up reports of 213 patients with ICA/MCA occlusions. NLP-extracted radiographic edema captured 89% of those who developed clinical cerebral edema, which was more likely in those with NLP-identified proximal vs distal occlusions and associated with significantly higher core/penumbral volumes. Conclusion: A rules-based NLP pipeline can accurately identify and phenotype an LVO cohort, yielding clinical associations with stroke research implications.

Purpose: To determine the association between optic nerve sheath diameter (ONSD) and outcome in patients with traumatic brain injury (TBI) who undergo hematoma removal (HR). Methods: This study was a retrospective analysis of data from a single center between 2016 and 2021. Adult patients with TBI who underwent HR within 24 h after admission were included in this study. Preoperative and postoperative ONSD of the surgical side and the mean ONSD of both sides were measured for analysis. The primary outcome was mortality at 30 days. Receiver operating characteristic curve analysis was performed to calculate the area under the curve (AUC) and 95% confidence interval (CI) for 30 days mortality. Results: Sixty-one patients were enrolled in the study. Among them, 48 (78.7%) survived for 30 days after admission. The AUC and 95% CI of the postoperative mean ONSD on both sides and postoperative/preoperative mean of the ONSD ratio on both sides were 0.884 [0.734–0.955] and 0.875 [0.751–0.942], respectively. The postoperative mean of both ONSDs of 6.0 mm had high accuracy as a cut-off value with a sensitivity of 85%, specificity of 83%, positive likelihood ratio (LR) of 5.0, and negative LR- of 0.18. Conclusion: This study demonstrated that postoperative ONSD and the postoperative/preoperative ONSD ratio were associated with postoperative outcome in patients with TBI who underwent HR. [ABSTRACT FROM AUTHOR]

Background: Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non–invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics. Methods: We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm³. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications. Results: Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07). Conclusion: We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain. [ABSTRACT FROM AUTHOR]

Background: The methodology of measuring chronic subdural hematoma (cSDH) extent and its effect on intracranial structures is relevant for patient classification and outcome measurements and affects the external validity of cSDH studies. With embolization of the middle meningeal artery (MMA) as a possible treatment of cSDHs, the topic has gained substantial interest. We sought to summarize the heterogeneity of radiologic measurements, specifically in the evaluation of cSDHs based on literature review. Methods: In this review, we identified and described the most common radiological methodologies for measurements of cSDH thickness, cSDH volume and of midline shift. Conclusion: There are numerous published methods on how to evaluate cSDH thickness, cSDH volume and midline shift but no common standard. The definition of measurement methods and reporting standards for MMA embolization in cSDH patients and their validation needs to be addressed. [ABSTRACT FROM AUTHOR]

BackgroundMidline shift (MLS) is troublesome problem that may occur in patients with a large infarct core (LIC) and may be related to the baseline infarct core volume. The purpose of this study was to explore the relationship between baseline infarct core volume and early MLS presence.Materials and methodsPatients with acute intracranial large artery occlusion and a pretreatment relative cerebral blood flow (rCBF) 40 ml based on an rCBF < 15% showed good predictive value for early MLS occurrence.

Background: Subacute subdural hematoma (SDH) is a common pathology most frequently affecting older patients and may be treated operatively through burr holes versus craniotomy or minimally invasively with bedside twist drill craniostomy. Less invasive intervention is favored when possible given a frequently comorbid population. The subdural evacuation port system (SEPS) is a popular treatment option that warrants investigation and reporting of its use and outcomes. Methods: A retrospective review of consecutive patients undergoing SEPS drain placement for chronic or mixed density SDH between 2010 and 2021 was conducted. Outcomes of SDH recurrence, need for operating room procedure after SEPS placement, discharge disposition other than home, and modified Rankin Scale score

Background: In addition to heart disease, ECG also changes in non-heart disease, which due to its similarity, can lead to misdiagnosis of heart disease in patients. ECG changes in brain lesions such as ischemic and hemorrhagic strokes, brain traumas, etc. and have been studied in many articles, but the effects of brain midline shift on ECG changes have not been studied. In this study, we want to examine these changes. Methods: This is a prospective cross-sectional descriptive study. Patients with brain tumors who were referred to Al-Zahra and Kashani hospitals in Isfahan from April 2019 to March 2021 were selected. Patients with a history of heart disease, patients receiving medications that cause ECG changes, patients with ECG changes due to noncardiac and cerebral causes, and individuals under 15 years of age were not included in the study. Patients whose ECG changes were due to electrolyte disturbances or acute heart problems were also excluded from the study. After obtaining informed consent from patients, a CT scan or brain MRI was taken and patients were divided into two groups with and without midline shift. Then the ECG was taken and ECG changes (T wave, ST segment, QTc Interval, QRS prolongation) were compared in two groups of brain tumors with and without midline shift. Results: 136 patients were included in the study. Of these, 69 patients were in the without midline shift group and 67 patients were in the midline shift group. In the midline shift group, 3% of patients had ST segment changes and 23.9% had T wave changes, which were 1.4% and 10.1% in the without midline shift group, respectively. The mean QTc Interval in the two groups without and with midline shift was 338.26 (4 28.438) and 388.66 (37.855), respectively, and the mean QRS in the without midline shift group was 86.09 (88.9.88) ms and in the midline shift group was 94.63 (±12.83) ms. Conclusion: Brain midline shifts can cause QRS widening, QTc interval prolongation, and T-wave changes in patients' ECGs. [ABSTRACT FROM AUTHOR]

Currently, the treatment of spontaneous intracerebral hemorrhage (sICH) is limiting, especially in patients with midline shift and supratentorial hemorrhage. Here, we investigated the clinical value of minimally invasive surgery (MIS) in patients with midline shift and supratentorial sICH by observing the consciousness state, midline shift, and short-term mortality. A total of 124 supratentorial sICH patients with midline shift, hematoma volume >30 mL and <150 mL were included in this study. Based on treatment methods, the enrolled patients were divided into minimally invasive surgical (MIS) (group 1, n = 61) and conservative (group 2, n = 63) treatment groups. Measurements of midline shift and state of consciousness using the Glasgow Coma Scale (GCS) score were performed on day 2 following treatment. Additionally, mortality, adverse events, and neurologic recovery (modified Rankin Scale score) in each group were observed after 1 month. On postoperative day 2, the recovery rates of midline shift and consciousness state in group 1 patients were 59.02% and 50.82%, respectively, significantly higher than group 2, 26.98% and 25.40% (P < 0.01). By comparing death, adverse events, and neurologic function recovery of the 2 groups within 1 month postoperative, we observed a significantly lower fatality rate in group 1 (16.39%; 10 cases) than group 2 (33.33%; 21 cases) (P < 0.05). No significant difference of the adverse event rates was observed between groups 1 and 2 (19.67% [12 cases] vs. 19.05% [12 cases]). In addition, neurologic function recovery also had no significant difference between the 2 groups (P > 0.05). MIS could reduce early-stage midline shift, improve consciousness state and reduce short-term mortality in patients with supratentorial sICH. [ABSTRACT FROM AUTHOR]

In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016–March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1–3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi <3 was highly predictive of unfavourable outcome, with highest specificity (100% (90–100)) at day 3 (sensitivity 24% (15–35), negative predictive value 36% (34–39)). The addition of NPi, from day 1 following ABI to age and cerebral CT scan, provided the best prognostic performance (AUROC curve 0.85 vs. 0.78 without NPi, p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information. [ABSTRACT FROM AUTHOR]

A midline shift (MLS) is an important clinical indicator for intracranial hemorrhage. In this study, we proposed a robust, fully automatic neural network-based model for the detection of MLS and compared it with MLSs drawn by clinicians; we also evaluated the clinical applications of the fully automatic model. We recruited 300 consecutive non-contrast CT scans consisting of 7269 slices in this study. Six different types of hemorrhage were included. The automatic detection of MLS was based on modified Keypoint R-CNN with keypoint detection followed by training on the ResNet-FPN-50 backbone. The results were further compared with manually drawn outcomes and manually defined keypoint calculations. Clinical parameters, including Glasgow coma scale (GCS), Glasgow outcome scale (GOS), and 30-day mortality, were also analyzed. The mean absolute error for the automatic detection of an MLS was 0.936 mm compared with the ground truth. The interclass correlation was 0.9899 between the automatic method and MLS drawn by different clinicians. There was high sensitivity and specificity in the detection of MLS at 2 mm (91.7%, 80%) and 5 mm (87.5%, 96.7%) and MLSs greater than 10 mm (85.7%, 97.7%). MLS showed a significant association with initial poor GCS and GCS on day 7 and was inversely correlated with poor 30-day GOS (p < 0.001). In conclusion, automatic detection and calculation of MLS can provide an accurate, robust method for MLS measurement that is clinically comparable to the manually drawn method. [ABSTRACT FROM AUTHOR]

Background Acute subdural hematomas commonly require emergent surgical decompression by craniotomy. There is currently limited research on alternative surgical strategies in the elderly population. This study investigates delayed surgical intervention for stable patients with low-energy trauma presenting with acute subdural hematomas. Methodology In this retrospective chart review, 45 patients over the age of 55 presenting with acute subdural hematomas with a Glasgow Coma Scale score greater than or equal to 13 in the setting of low-energy trauma were selected. Additionally, included patients had a maximal hematoma thickness of >10 mm and/or a midline shift size of >5 mm per the current Brain Trauma Foundations guidelines for surgical intervention of subdural hematomas. The study was performed at a large tertiary care center, with records being examined from 1995 to 2020. Comparison groups were immediate craniotomy (within 24 hours) or delayed burr hole (minimum of 48 hours passing since the initial presentation). Primary outcomes included minor complications, major complications, any complications, and any complications with mortality excluded. There was no significant difference in mortality between the two cohorts. Results The immediate craniotomy group consisted of 16 patients, while the delayed burr hole group consisted of 29 patients. The results demonstrated a statistically significant increase in the incidence of any complication including mortality (relative risk (RR) = 3.17, 95% confidence interval (CI) = 1.71-5.88, p < 0.0001), major complications (RR = 2.33, 95% CI = 1.07-5.07, p = 0.031), and minor complications (RR = 2.42, 95% CI = 1.02-5.74, p = 0.041) in the immediate craniotomy group compared to the delayed burr hole group. Conclusions Our study demonstrates the decreased risk of major and minor complications for delayed burr hole evacuation in stable patients >55 years old presenting with low-energy trauma and subdural hematoma. The results suggest that for this population of patients, it appears to be beneficial to delay surgery if the patient's clinical situation allows., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Virginia Commonwealth University Institutional Review Board issued approval HM20019735. This study was approved by the Virginia Commonwealth University Institutional Review Board. All patient data pertinent to the manuscript was de-identified in compliance with the IRB and HIPAA. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Graham et al.)

Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal. [ABSTRACT FROM AUTHOR]

Objectives: There is limited data on upfront middle meningeal artery (MMA) embolization in the context of significant midline shift (MLS) (greater than 5mm) for the treatment of chronic subdural hematomas (cSDH). This study reports the temporal changes following MMA embolization as an upfront treatment of cSDH in patients with or without MLS and either mild, no symptoms or mild and stable neurological deficits. Methods: A retrospective series of patients with a cSDH from a single institution in the United States between 2018-2020 was conducted. Eligible patients were treated with upfront MMA embolization. Results: 27 upfront MMA embolization procedures in 23 patients were included. Twelve patients had MLS of 5 millimeters or more (52%). The median maximal thickness at diagnosis was 18 mm [11-22]. The mean distance of MLS was 5 mm ±4. There were no procedural complications. The overall rescue surgery rate was 15%. A single rescue surgery secondary to an increase in hematoma thickness was required (4%). The temporal changes for both hematoma and MLS showed gradual improvement between 2 weeks and 4 weeks post-procedure. The average time-to-resolution of MLS was 46 days in patients with less than 5 mm MLS and 51 days in those with 5 mm or more. Conclusion: Upfront MMA embolization for cSDH with a thickness up to 25 mm provides adequate symptom relief, stabilization and/or progressive resorption of the cSDH during follow-up in carefully selected asymptomatic or mildly symptomatic patients even in the presence of a MLS greater than 5 mm. [ABSTRACT FROM AUTHOR]

The impact of midline shift (MLS) on long-term survival and progression in glioblastoma (GBM) is unknown. The objective of this study was to analyze the influence of mass effect on survival and progression with consideration of the patient demographics, tumor morphology, operative techniques, molecular pathology, and postoperative treatment. One hundred ninety-eight patients with GBM were analyzed retrospectively. Both MLS groups (< or ≥ 10 mm) were compared with regard to survival, progression-free survival (PFS), and postoperative course of Karnofsky Performance Status (KPS). A two-sided Fisher exact test showed no statistically significant differences in the confounders between the low- and high-MLS groups. The median survival was 18.0 months (95% confidence interval (CI) = 15.3–20.7) in the low-MLS group (n = 173) and 9.0 months (95% CI = 4.8–13.2) in the high-MLS group (n = 25) (p = 0.045). In the high-MLS group, 59.1% (13/22) with an initially high MLS had a KPS of less than 70% after 3 months, whereas 20.5% of the low-MLS group had a KPS of less than 70% (p < 0.001). Binary logistic regression analysis including the O-6-methylguanine-DNA methyltransferase (MGMT) status, extent of resection, baseline KPS, and MIB-I index showed low MLS as the only predictor for survival at 12 months (p = 0.046, odds ratio (OR) = 2.70, 95% CI = 1.0–7.2). Median PFS was 6.0 months in the high-MLS group and 9.0 months in the low-MLS group (log-rank test; p = 0.08). An initial midline shift of 10 mm or greater seems to be an imaging characteristic that independently predicts the survival in glioblastoma. [ABSTRACT FROM AUTHOR]

The amount of midline shift (MLS) considered safe for middle meningeal artery embolization (MMAE) in patients with chronic subdural hematoma (CSDH) has not been established. Whether MMAE could be used as upfront treatment for unilateral large CSDH patients with significant MLS (>1 cm) has not been reported.To investigate the efficacy and safety of MMAE in unilateral large CSDH patients with MLS > 1 cm.Eleven carefully selected CSDH patients with mild or moderate symptoms and significant MLS > 1 cm from 1 May 2021 to 31 August 2022 were included in the study. All patients were treated with MMAE using polyvinyl alcohol (PVA) particles. Outcomes were assessed clinically and with interval imaging studies at follow-up.All 19 MMAs (unilateral embolization in three patients and bilateral embolization in eight patients) were successfully embolized. All 11 patients were followed for subsequent months, and there was no recurrence and enlargement of CSDH. Procedural adverse events, mortality, or complications were not observed. The average time to achieve a 50% reduction in MLS was approximately four weeks, while it took approximately eight weeks to achieve a 50% reduction in maximal volume. All 11 patients showed improvement in their neurological symptoms at three days post-operation, including four hemiplegic patients.MMAE may demonstrate safety in carefully selected CSDH patients with significant midline shift (MLS > 1 cm), particularly in those who are not suitable for surgery, thus providing a potential alternative approach. [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, papillary 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.

A number of treatment approaches have been advocated for persistent visual complaints following mild traumatic brain injury. These include devices such as binasal occlusion, yoked prisms, vertical prisms, and filters, as well as vestibular training. We discuss the rationale and the evidence for each of these approaches. Binasal occlusion has been advocated for visual motion sensitivity, but it is not clear why this should help, and there is no good evidence for its symptomatic efficacy. Base-in prisms can help manage convergence insufficiency, but there are few data on their efficacy. Midline shift is an unproven concept, and while the yoked prisms advocated for its treatment may have some effect on egocentric neglect, their use in mild traumatic brain injury is more questionable. A wide variety of posttraumatic symptoms have been attributed to vertical heterophoria, but this is an unproven concept and there are no controlled data on the use of vertical prisms for mild traumatic brain injury symptoms. Filters could plausibly ameliorate light intolerance but studies are lacking. Better evidence is emerging for the effects of vestibular therapy, with a few randomized controlled trials that included blinded assessments and appropriate statistical analyses. Without more substantial evidence, the use of many of these techniques cannot be recommended and should be regarded as unproven and in some cases implausible. • Binasal occlusion is used for visual motion sensitivity but with weak rationale and evidence. • There is no proof that yoked prisms have a clinically significant effect on balance. • The few retrospective reports on vertical heterphoria syndrome are marred by circular reasoning. • Filters may relieve symptoms for photophobia but efficacy and long-term effects are unknown. • Controlled trials of vestibular therapy suggest some efficacy on speed and degree of recovery. [ABSTRACT FROM AUTHOR]

In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016–March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1–3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information.

A midline shift (MLS) is an important clinical indicator for intracranial hemorrhage. In this study, we proposed a robust, fully automatic neural network-based model for the detection of MLS and compared it with MLSs drawn by clinicians; we also evaluated the clinical applications of the fully automatic model. We recruited 300 consecutive non-contrast CT scans consisting of 7269 slices in this study. Six different types of hemorrhage were included. The automatic detection of MLS was based on modified Keypoint R-CNN with keypoint detection followed by training on the ResNet-FPN-50 backbone. The results were further compared with manually drawn outcomes and manually defined keypoint calculations. Clinical parameters, including Glasgow coma scale (GCS), Glasgow outcome scale (GOS), and 30-day mortality, were also analyzed. The mean absolute error for the automatic detection of an MLS was 0.936 mm compared with the ground truth. The interclass correlation was 0.9899 between the automatic method and MLS drawn by different clinicians. There was high sensitivity and specificity in the detection of MLS at 2 mm (91.7%, 80%) and 5 mm (87.5%, 96.7%) and MLSs greater than 10 mm (85.7%, 97.7%). MLS showed a significant association with initial poor GCS and GCS on day 7 and was inversely correlated with poor 30-day GOS (p < 0.001). In conclusion, automatic detection and calculation of MLS can provide an accurate, robust method for MLS measurement that is clinically comparable to the manually drawn method.

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.

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 (

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)

Supernumerary tooth represents a developmental anomaly that consists in duplication of tooth in the normal series. The presence of a supernumerary tooth may result in the appearance of aesthetic or functional problems in the dento-maxillary system. A girl, 11 years old, with upper midline shift following a supernumerary teeth and severe upper crowding was successfully treated after extraction of supernumerary tooth and four first bicuspids. Stages of diagnosis and treatment have been described in detail. In order to obtain good treatment results it was necessary to use an asymmetrical orthodontic mechanic. In this case report, the diagnostic workflow and current treatment concepts was presented and critically discussed.