Validation of a New Clinico-Radiological Grading for Compound Head Injury: Implications on the Prognosis and the Need for Surgical Intervention

Systematic review exploring the effect of therapeutic hypothermia on patients with intracranial hypertension

Background:

Intracranial hypertension is found in patients with various neurological and neurosurgical conditions such as subarachnoid hemorrhage (more than 50% of the patients have intracranial pressure > 20 mmHg at some point during their hospital stay), traumatic brain injury, and stroke. Various modalities are used to control intracranial hypertension, therapeutic hypothermia is one of them. This systematic review aims to assess the efficacy of therapeutic hypothermia in controlling intracranial hypertension in an adult patient.

Methods:

A systematic review of the literature published between one patient 1990 and 2020 was conducted. Four databases were searched including CINAHL, PubMed, the Cochrane Library, and EMBASE using keywords traumatic brain injury, intracranial pressure, randomized and controlled trials, and the effect of therapeutic hypothermia on intracranial hypertension.

Results:

All of the studies included in this review were randomized controlled trials. Most of the studies provided their sample demographics. Sample sizes ranged from 14 to 501. Of the 12 studies, five of them were from the United Kingdom, three of them were from China, two from North America, one from India, and one from Japan.

Conclusion:

Treating intracranial hypertension with therapeutic hypothermia may be beneficial according to a few studies but it is also associated with many adverse effects. Both the groups suffered from adverse events which were higher in the hypothermic group. However, these adverse events can be managed in any health-care setting. To treat the patients with therapeutic hypothermia, one (the managing team) should be competent enough to manage the adverse effects.

Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An Exploratory Survey

BACKGROUND

Chronic tension type headache (CTTH) is one of the common cause of hospital visits among adolescents and adults. Chronic tension type headache produces pain, sleep disturbances, and disability among patients leading to a poor quality of life. Knowledge pattern of headache and various associated factors will aid appropriate management.

AIMS

To identify the headache dimensions and their various influencing factors among patients of chronic tension-type headache.

METHODS

Using consecutive sampling techniques, 169 patients with chronic tension-type headache were recruited in this cross-sectional survey. Approval was obtained from the Institute's Ethics Committee. The Wong-Baker Foundation Pain intensity scale was used to assess the pain severity.

RESULTS

A pain severity score of 6 out of 10 was reported by 56% of the patients, and the mean pain score reported by the patients was 6.62 ± 1.16. The mean weekly headache frequency was 4.95 ± 0.38, and the mean daily headache duration was 8.68 ± 1.68 hours. Significantly more patients who are married, patients who had a duration of illness less than two years, and patients who were treated with only analgesics reported higher headache severity. Higher headache frequency was reported by significantly more patients who were male, married, from a nuclear family, educated, unskilled laborers or employed, urban inhabitants, or only on analgesics, or had illness duration less than two years. Headache duration was significantly higher in patients who were unskilled laborers or only on analgesics, or had illness duration less than two years.

CONCLUSIONS

Patients with chronic tension-type headache experience moderate to high severity of headache, along with substantial duration and frequency, an outcome that was associated with various lifestyle-related factors that can result in stress. Lifestyle modification and nonpharmacological management are thus essential to reduce the severity, frequency, and duration of headache in patients with a chronic tension-type headache and medication overuse.

Diagnostic and predictive value of white blood cell count, erythrocyte sedimentation rate, and coagulation tests in patients with blunt head trauma

Introduction: Head trauma is the third leading cause of death and one of the most common causes of referral to the emergency department. Prognosis in these patients identifies individuals at higher risk and provides them with faster and more complete treatment, so it is of particular importance. The aim of this study is to evaluate the diagnostic and predictive value of white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and coagulation tests in the outcome of patients with blunt head trauma. Methods: In this retrospective study, 91 patients referred to the emergency department of Imam Reza hospital of Tabriz, with a complaint of DAI type of blunt head trauma, were enrolled in a complete and sequential study during the first six months of the year 2017. The patientswere divided into two groups according to good or poor prognosis and their association with leukocytosis status and other paraclinical factors at the baseline. Results: The final outcome in high consciousness group was 13.3% need for intubation,26.7% need for surgery, 50% improvement without complications, and 10% mortality. In the low consciousness group, 16.7% required intubation, 20.0% required surgery, 10% had no complications, and 53.3% experienced mortality. The significance level of the chi-squaretest was 0.001. Independent t test results showed that the WBC and ESR values in the lowconsciousness group were significantly higher than the high consciousness group. But the international normalized ratio (INR) in the high consciousness group was significantly higher than the low consciousness group (P<0.05). Conclusion: There is a significant relationship between severity of injury and leukocytosis, ESRelevation, and related coagulopathy after major trauma.

Cognitive Impairments After Clipping of Ruptured Anterior Circulation Aneurysms

BACKGROUND

The cognitive impairments after treatment of ruptured aneurysms have often been underestimated. This study sought to assess their prevalence and analyze various associated factors.

METHODS

Patients who were operated on for ruptured anterior circulation aneurysms and discharged with a Glasgow Outcome Scale score of 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual, and overall memory), verbal fluency (phonemic and category fluency), and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS version 21.

RESULTS

A total of 87 patients were included in our study. Phonemic fluency was the most affected, noted in 66% of patients. Although 56% had some memory-related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory, respectively. Patients operated on for anterior cerebral artery (ACA) aneurysms had significantly greater impairments in recent (34% vs. 8%) and remote memory (43% vs. 28%) compared with the rest, both in univariate (P = 0.01 and 0.002, respectively) and multivariate analyses (P = 0.01 and 0.03, respectively). ACA-related aneurysms also had significantly greater independent impairments in phonemic fluency (P = 0.04), compared with others. The clinical grade had a significant independent impact only on remote memory (P = 0.01).

CONCLUSIONS

Cognitive impairments are frequent after treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater after treatment of ACA-related aneurysms, compared with others, independent of other factors.

Quality of Life Among Children Who Had Undergone Ventriculoperitoneal Shunt Surgery

BACKGROUND

Ventriculoperitoneal (VP) shunting is the most common neurosurgical treatment for hydrocephalus. In spite of significant developments in the technology and design of shunt systems, shunt surgery is still associated with morbidity.

AIM

To identify the problems faced by children on VP shunt and assess their quality of life (QOL).

SETTING AND DESIGN

A cross-sectional exploratory study.

MATERIALS AND METHODS

A total of 31 children on VP shunt were selected through consecutive sampling technique, and hydrocephalus outcome questionnaire was used to collect the data, with the converted metric score ranging from 0 to 1. Hydrocephalus due to stroke, hemorrhage, and malignant tumors was excluded.

RESULTS

The mean age of patients was 11.51 ± 4.26 years. Headache and generalized pain were the common problems experienced (42%). The mean score of QOL was 0.67 ± 0.21. Among the three domains, cognitive domain was the most affected. Among the clinicoradiological factors, multiple surgeries (P = 0.02) had the most significant impact on QOL.

CONCLUSION

Children who underwent VP shunt face various health-related problems in different domains and low QOL. Although cognitive domain was the most affected, multiple surgeries had the most significant impact on QOL. Appropriately focused interventions and holistic management are essential to improve the QOL of children undergoing VP shunt.

Independent impact of plasma homocysteine levels on neurological outcome following head injury

Homocysteine (tHcy) has been hardly studied among patients with head injury. This study was to evaluate whether there is any independent impact of tHcy levels on neurological outcome following head injury in a multivariate model. Patients admitted within 24 h of injury were included in the study, along with 20 age- and gender-matched controls. Plasma levels of tHcy were measured at admission using direct immunoassay. All the variables were analyzed with respect to tHcy levels and outcome according to Glasgow Outcome Score (GOS) at 3 months. Univariate and multivariate analyses were performed using SPSS 21. There were a total of 72 patients in the study. tHcy levels were significantly higher after head injury (mean 24.03[SD ± 16.0] μmol/L), compared to matched controls (mean 16.62 [SD ± 10.4] μmol/L) (p = 0.05). Patients with severe head injury, acute SDH, or diffuse higher radiological grades had greater levels of tHcy compared to others. There was a significant relationship between tHcy level and neurological outcome. tHcy levels were significantly higher in patients who had unfavorable GOS (mean 36.22[±25.3] μmol/L), compared to those with favorable GOS (mean 22.71[±14.3] μmol/L) (P = 0.03). In multivariate analysis, tHcy level (adj. odds ratio [OR] 1.17, P = 0.05) and Glasgow Coma Scale (adj. OR 5.17, P = 0.01) had significant association with neurological outcome at 3 months independent of age, dietary habit, radiological grading and of each other. tHcy level has significant independent impact on neurological outcome and may be useful as a prognostic marker following head injury.

Prevalence and Trends in the Neuropsychological Burden of Patients having Intracranial Tumors with Respect to Neurosurgical Intervention

BACKGROUND

The burden of neuropsychological symptoms evidenced by behavioral changes among patients with intracranial tumors has not been studied in detail.

PURPOSE

This study was conducted to prospectively assess the neuropsychological symptoms in patients with intracranial tumors undergoing treatment.

METHODS

A longitudinal study was conducted using purposive sampling to assess the neuropsychological symptoms in conscious and consenting patients with intracranial tumors who were availing treatment from a tertiary care center. Neuropsychiatric Inventory Questionnaire (NPI-Q), which identifies 12 behavioral disturbances, was assessed at baseline, and later at 1 month and 6 months after treatment, and scored as symptom severity as well as symptom scores.

RESULTS

Among the 34 patients studied, all had experienced at least one neuropsychological symptom. The commonest neuropsychological symptoms at baseline were anxiety (82%), agitation (75%), irritability (74%), depression (74%), and sleep disturbances (70%). The neuropsychiatric symptom and severity scores were 5.84 (SD ±2.7) and 11.8 (±7.1) at baseline, which reduced significantly to 4.3 (±3.1) and 5.6 (±3.2) at 1 month, and further to 2.3 (±2.9) and 3.6 (±3.2) at 6 months, respectively. The neuropsychological symptoms persistent at 6 months were anxiety (33%), depression (33%), sleep disturbances (33%), agitation (25%), irritability (25%), and disinhibition (25%).

CONCLUSION

There is substantial neuropsychological burden among patients with intracranial tumors. The severity score improved immediately after surgery, while the symptom score improved gradually. The variable spectrum of improvement in neuropsychological symptoms at 6 months after surgical treatment needs further consideration. Addressing these symptoms should be one of the long-term goals of the neuro-oncology teams.

Impact of Early Leukocytosis and Elevated High-Sensitivity C-Reactive Protein on Delayed Cerebral Ischemia and Neurologic Outcome After Subarachnoid Hemorrhage

BACKGROUND

The role of inflammatory response in the pathophysiology of subarachnoid hemorrhage (SAH) is being increasingly recognized. This study analyzed the impact of cellular and biochemical markers of early inflammatory response to ictus on outcome after SAH.

METHODS

Patients with SAH were prospectively studied for markers of early cellular, biochemical, and cytotoxic inflammatory response, including total leukocyte count (TLC), high-sensitivity C-reactive protein (hs-CRP), and lactate dehydrogenase. The relationship of these markers to delayed cerebral ischemia (DCI), new infarct, and Glasgow Outcome Scale (GOS) score at 3 months was studied.

RESULTS

The study comprised 246 patients. Of patients, 94 who developed DCI had a significantly higher TLC [± SD] (11.2 × 10(3)/mm(3) [± 4.0] vs. 9.4 × 10(3)/mm(3) [± 2.9], P = 0.001) and 62 with new infarct had significantly higher TLC (11.0 × 10(3)/mm(3) [± 3.6] vs. 9.8 × 10(3)/mm(3) [± 3.4], P = 0.05). GOS score had a significant inverse relationship to TLC at admission. The mean TLC [± SD] was 12.7 × 10(3)/mm(3) [± 4.2], 11.7 × 10(3)/mm(3) [± 3.1], 10.2 × 10(3)/mm(3) [± 3.4], and 9.3 × 10(3)/mm(3) [± 2.8] among patients with GOS scores of 1, 3, 4, and 5 (P < 0.001). hs-CRP showed a trend of an inverse relationship to GOS score in univariate analysis. Lactate dehydrogenase had no relationship with any outcome parameter. In multivariate analysis, higher admission TLC had a significant association with DCI (P = 0.01) and poorer GOS score (P < 0.001), and higher hs-CRP had a significant association with poorer GOS score (P = 0.05).

CONCLUSIONS

A leukocytosis response to ictus seems to have a significant independent association with both DCI and poor GOS score, and hs-CRP level had a significant independent association with poor GOS score, indicating preeminence of early cellular response in SAH pathophysiology.