Surgical Management of Posterior Fossa Mass Lesions

Importance of repeated computed tomography on pediatric traumatic acute posterior fossa subdural hematoma: A case study

Traumatic acute posterior fossa subdural hematoma (PFSDH) is a rare and potentially fatal condition in which the progressed hematoma compresses the brainstem or causes secondary hydrocephalus. Hence, vigilant monitoring of clinical and radiological findings is crucial to detect the typical sudden deterioration, which can occur in the early stages. However, managing pediatric PFSDHs poses additional challenges due to risks associated with radiation exposure from repeat computed tomography (CT) examinations, potentially impeding crucial diagnostic insights. Here, we present a rare pediatric case of fatal acute traumatic PFSDH. Despite undergoing a timely initial CT scan that indicated the presence of PFSDH, the patient experienced sudden deterioration 15 h later and eventually died. No follow-up CT examinations were conducted during this critical period. This case underscores the challenges in managing pediatric PFSDHs, particularly concerning the benefits of repeated CT examinations in initially stable patients.

Automated volumetric evaluation of intracranial compartments and cerebrospinal fluid distribution on emergency trauma head CT scans to quantify mass effect

Background

Intracranial space is divided into three compartments by the falx cerebri and tentorium cerebelli. We assessed whether cerebrospinal fluid (CSF) distribution evaluated by a specifically developed deep-learning neural network (DLNN) could assist in quantifying mass effect.

Methods

Head trauma CT scans from a high-volume emergency department between 2018 and 2020 were retrospectively analyzed. Manual segmentations of intracranial compartments and CSF served as the ground truth to develop a DLNN model to automate the segmentation process. Dice Similarity Coefficient (DSC) was used to evaluate the segmentation performance. Supratentorial CSF Ratio was calculated by dividing the volume of CSF on the side with reduced CSF reserve by the volume of CSF on the opposite side.

Results

Two hundred and seventy-four patients (mean age, 61 years ± 18.6) after traumatic brain injury (TBI) who had an emergency head CT scan were included. The average DSC for training and validation datasets were respectively: 0.782 and 0.765. Lower DSC were observed in the segmentation of CSF, respectively 0.589, 0.615, and 0.572 for the right supratentorial, left supratentorial, and infratentorial CSF regions in the training dataset, and slightly lower values in the validation dataset, respectively 0.567, 0.574, and 0.556. Twenty-two patients (8%) had midline shift exceeding 5 mm, and 24 (8.8%) presented with high/mixed density lesion exceeding >25 ml. Fifty-five patients (20.1%) exhibited mass effect requiring neurosurgical treatment. They had lower supratentorial CSF volume and lower Supratentorial CSF Ratio (both p < 0.001). A Supratentorial CSF Ratio below 60% had a sensitivity of 74.5% and specificity of 87.7% (AUC 0.88, 95%CI 0.82-0.94) in identifying patients that require neurosurgical treatment for mass effect. On the other hand, patients with CSF constituting 10-20% of the intracranial space, with 80-90% of CSF specifically in the supratentorial compartment, and whose Supratentorial CSF Ratio exceeded 80% had minimal risk.

Conclusion

CSF distribution may be presented as quantifiable ratios that help to predict surgery in patients after TBI. Automated segmentation of intracranial compartments using the DLNN model demonstrates a potential of artificial intelligence in quantifying mass effect. Further validation of the described method is necessary to confirm its efficacy in triaging patients and identifying those who require neurosurgical treatment.

Axial Convex-Shaped Hematoma was Associated with Poor Curative Effect of Surgical Treatment for Traumatic Posterior Fossa Epidural Hematoma in Children

BACKGROUND

Posterior fossa epidural hematoma (PFEDH) is rare which accounts for just 4-12.9% of all EDH cases. Since its frequently subtle and nonspecific clinical presentation, CT scan has great importance for early diagnosis and treatment of PFEDH. However, indications for surgery depending on the findings of CT image are still controversial.

METHODS

We retrospectively analyzed 40 pediatric cases of PFEDH. Their baseline characteristic, clinical presentation, imaging findings and outcomes were collected and analyzed. The ellipsoid volume equation X × Y × Z/2 was used to measure the hematoma volume. The Glasgow Outcome Scale (GOS) was used to assess the neurologic functional outcome.

RESULTS

A total of 40 pediatric PFEH patients were included with 8 patients having poor outcome and 32 patients having a relatively good prognosis. GCS score showed a significant difference between good and poor outcome groups (p < 0.001). Y value on CT image was significantly bigger in poor outcome group than good outcome group (p < 0.01). Similar results were got in X/Z value (p < 0.05) and Y/Z value (p < 0.01) which reflected the shape of hematoma. A predictive model with Y + X/Z showed the largest area under the ROC curve with a sensitivity of 75.0% and specificity of 93.7%.

CONCLUSIONS

GCS score at admission was closely related to the prognosis of the pediatric patients with PFEDH. The morphometry of PFEDH has a crucial role in judging the prognosis. Axial convex-shaped hematoma was associated with poor curative effect of surgical treatment.

Simple wound closure compared with surgery for civilian cranial gunshot wounds

OBJECTIVE

A carefully selected subset of civilian cranial gunshot wound (CGSW) patients may be treated with simple wound closure (SWC) as a proactive therapy, but the appropriate clinical scenario for using this strategy is unknown. The aim of this study was to compare SWC and surgery patients in terms of their neurological outcomes and complications, including infections, seizures, and reoperations.

METHODS

This was a single-center, retrospective review of the prospectively maintained institutional traumatic brain injury and trauma registries. Included were adults who sustained an acute CGSW defined as suspected or confirmed dural penetration. Excluded were nonfirearm penetrating injuries, patients with an initial Glasgow Coma Scale (GCS) score of 3, patients with an initial GCS score of 4 and nonreactive pupils, and patients who died within 48 hours of presentation.

RESULTS

A total of 67 patients were included; 17 (25.4%) were treated with SWC and 50 (74.6%) were treated with surgery. The SWC group had a lower incidence of radiographic mass effect (3/17 [17.6%] SWC vs 31/50 [62%] surgery; absolute difference 44.4, 95% CI -71.9 to 16.8; p = 0.002) and lower incidence of involvement of the frontal sinus (0/17 [0%] SWC vs 14/50 [28%] surgery; absolute difference 28, 95% CI -50.4 to 5.6; p = 0.01). There were no differences in the frequency of Glasgow Outcome Scale-Extended scores ≥ 5 between the SWC and surgery groups at 30 days (4/11 [36.4%] SWC vs 12/35 [34.3%] surgery; OR 1.1, 95% CI 0.3-4.5; p > 0.99), 60 days (2/7 [28.6%] SWC vs 8/26 [30.8%] surgery; OR 0.9, 95% CI 0.3-3.4; p > 0.99), and 90 days (3/8 [37.5%] SWC vs 12/26 [46.2%] surgery; OR 0.7, 95% CI 0.1-3.6; p > 0.99). There were no differences in the incidence of infections (1/17 [5.9%] SWC vs 6/50 [12%] surgery; OR 0.5, 95% CI 0.1-4.1; p = 0.67), CSF fistulas (2/11 [11.6%] SWC vs 3/50 [6%] surgery; OR 2.1, 95% CI 0.3-13.7; p = 0.60), seizures (3/17 [17.6%] SWC vs 9/50 [18%] surgery; OR 1, 95% CI 0.2-4.1; p > 0.99), and reoperations (3/17 [17.6%] SWC vs 4/50 [8%] surgery; OR 2.5, 95% CI 0.5-12.4; p = 0.36) between the SWC and surgery groups.

CONCLUSIONS

There were important clinically relevant differences between the SWC and surgery groups. SWC can be considered a safe and efficacious proactive therapy in a carefully selected subset of civilian CGSW patients.

A Machine Learning-Based Prognostic Model for the Prediction of Early Death After Traumatic Brain Injury: Comparison with the Corticosteroid Randomization After Significant Head Injury (CRASH) Model

BACKGROUND

Machine learning (ML) has been used to predict the outcomes of traumatic brain injury. However, few studies have reported the use of ML models to predict early death. This study aimed to develop ML models for early death prediction and to compare performance with the corticosteroid randomization after significant head injury (CRASH) model.

METHODS

We retrospectively reviewed traumatic brain injury patients between February 2017 and August 2021. The patients were randomly assigned to a training set and a test set. Predictive variables included clinical findings, laboratory values, and computed tomography findings. The ML models (random forest, support vector machine [SVM], logistic regression) were developed with the training set. The CRASH model is a prognostic model that was developed based on 10,008 patients included in the CRASH trial. The ML and CRASH models were applied to the test set to evaluate the performance.

RESULTS

A total of 423 patients were included; 317 and 106 patients were randomly assigned to the training and test sets, respectively. The area under the curve was highest in the SVM (0.952, 95% confidence interval = 0.906-0.990) and lowest in the CRASH model (0.942, 95% confidence interval = 0.886-0.999). There were no significant differences between the area under the curves of the ML and CRASH models (P = 0.899 for random forest vs. the CRASH model, P = 0.760 for SVM vs. the CRASH model, P = 0.806 for logistic regression vs. the CRASH model).

CONCLUSIONS

The ML models may have comparable performances compared to the CRASH model despite being developed with a smaller sample size.

The Surgical Intervention for Traumatic Injury Scale: A Clinical Tool for Traumatic Brain Injury

Introduction

There is no widely used method for communicating the possible need for surgical intervention in patients with traumatic brain injury (TBI). This study describes a scoring system designed to communicate the potential need for surgical decompression in TBI patients. The scoring system, named the Surgical Intervention for Traumatic Injury (SITI), was designed to be objective and easy to use.

Methods

The SITI scale uses radiographic and clinical findings, including the Glasgow Coma Scale Score, pupil examination, and findings noted on computed tomography. To examine the scale, we used the patient database for the Progesterone for the Treatment of Traumatic Brain Injury III (ProTECT III) trial, and retrospectively applied the SITI scale to these patients.

Results

Of the 871 patients reviewed, 164 (18.8%) underwent craniotomy or craniectomy, and 707 (81.2%) were treated nonoperatively. The mean SITI score was 5.1 for patients who underwent surgery and 2.5 for patients treated nonoperatively (P<0.001). The area under the receiver operating characteristic curve was 0.887.

Conclusion

The SITI scale was designed to be a simple, objective, clinical decision tool regarding the potential need for surgical decompression after TBI. Application of the SITI scale to the ProTECT III database demonstrated that a score of 3 or more was well associated with a perceived need for surgical decompression. These results further demonstrate the potential utility of the SITI scale in clinical practice.

Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature

OBJECTIVE

Epidural haematoma (EDH) most commonly occurs in the supratentorial area, particularly in the temporal region, of the brain. Posterior fossa epidural haematoma (PFEDH) is less frequently observed, accounting for only 1.2% to 12.9% of all EDH cases. Because of the non-specific symptoms and the potential for rapid and fatal deterioration in children, an early computed tomography (CT) scanning is necessary for all suspicious cases. The aim of the present study was to share the experience of 48 cases and review the literature concerning PFEDH.

METHODS

A retrospective analysis was conducted for 48 paediatric cases diagnosed with PFEDH and admitted to Yuying Children's Hospital of Wenzhou Medical University from January 2010 to August 2015. The clinical features and outcomes were analyzed and compared with previous literature.

RESULTS

Seventeen patients were surgically treated in this series and 31 patients received non-operative treatment. The outcomes were good in 46 patients, evaluated using the Glasgow outcome score (GOS), while mild disability was observed in one patient, and only one case showed severe disability. There were no cases of mortality in this series.

CONCLUSION

Posterior fossa epidural haematoma is relatively rare compared with supratentorial epidural haematoma. Early and serial CT scans should be performed for all suspicious cases. The criteria for the surgical treatment of paediatric patients with PFEDH were concluded. The overall prognosis was excellent in paediatric patients.

Preliminary guideline- and pathophysiology-based protocols for neurocritical care

Background

Because of the complex pathophysiological processes involved, neurocritical care has been driven by anecdotal experience and physician preferences, which has led to care variation worldwide. Standardization of practice has improved outcomes for many of the critical conditions encountered in the intensive care unit.

Main body

In this review article, we introduce preliminary guideline- and pathophysiology-based protocols for (1) prompt shivering management, (2) traumatic brain injury and intracranial pressure management, (3) neurological prognostication after cardiac arrest, (4) delayed cerebral ischemia after subarachnoid hemorrhage, (5) nonconvulsive status epilepticus, and (6) acute or subacute psychosis and seizure.

Conclusion

These tentative protocols may be useful tools for bedside clinicians who need to provide consistent, standardized care in a dynamic clinical environment. Because most of the contents of presented protocol are not supported by evidence, they should be validated in a prospective controlled study in future. We suggest that these protocols should be regarded as drafts to be tailored to the systems, environments, and clinician preferences in each institution.

Quantitative estimation of a ratio of intracranial cerebrospinal fluid volume to brain volume based on segmentation of CT images in patients with extra-axial hematoma

Background Diminishing volume of intracranial cerebrospinal fluid (CSF) in patients with space-occupying masses have been attributed to unfavorable outcome associated with reduction of cerebral perfusion pressure and subsequent brain ischemia. Objective The objective of this article is to employ a ratio of CSF volume to brain volume for longitudinal assessment of space-volume relationships in patients with extra-axial hematoma and to determine variability of the ratio among patients with different types and stages of hematoma. Patients and methods In our retrospective study, we reviewed 113 patients with surgical extra-axial hematomas. We included 28 patients (age 61.7 +/- 17.7 years; 19 males, nine females) with an acute epidural hematoma (EDH) ( n = 5) and subacute/chronic subdural hematoma (SDH) ( n = 23). We excluded 85 patients, in order, due to acute SDH ( n = 76), concurrent intraparenchymal pathology ( n = 6), and bilateral pathology ( n = 3). Noncontrast CT images of the head were obtained using a CT scanner (2004 GE LightSpeed VCT CT system, tube voltage 140 kVp, tube current 310 mA, 5 mm section thickness) preoperatively, postoperatively (3.8 ± 5.8 hours from surgery), and at follow-up clinic visit (48.2 ± 27.7 days after surgery). Each CT scan was loaded into an OsiriX (Pixmeo, Switzerland) workstation to segment pixels based on radiodensity properties measured in Hounsfield units (HU). Based on HU values from -30 to 100, brain, CSF spaces, vascular structures, hematoma, and/or postsurgical fluid were segregated from bony structures, and subsequently hematoma and/or postsurgical fluid were manually selected and removed from the images. The remaining images represented overall brain volume-containing only CSF spaces, vascular structures, and brain parenchyma. Thereafter, the ratio between the total number of voxels representing CSF volume (based on values between 0 and 15 HU) to the total number of voxels representing overall brain volume was calculated. Results CSF/brain volume ratio varied significantly during the course of the disease, being the lowest preoperatively, 0.051 ± 0.032; higher after surgical evacuation of hematoma, 0.067 ± 0.040; and highest at follow-up visit, 0.083 ± 0.040 ( p < 0.01). Using a repeated regression analysis, we found a significant association ( p < 0.01) of the ratio with age (odds ratio, 1.019; 95% CI, 1.009-1.029) and type of hematoma (odds ratio, 0.405; 95% CI, 0.303-0.540). Conclusion CSF/brain volume ratio calculated from CT images has potential to reflect dynamics of intracranial volume changes in patients with space-occupying mass.

Emergency Neurological Life Support: Traumatic Brain Injury

Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis

INTRODUCTION

Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI).

METHODS

We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications.

RESULTS

There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30).

CONCLUSIONS

Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.

Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury

Object

Development of a noninvasive monitor to assess cerebral oxygenation has long been a goal in neurocritical care. The authors evaluated the feasibility and utility of a noninvasive cerebral oxygenation monitor, the CerOx 3110, which uses near-infrared spectroscopy and ultrasound to measure regional cerebral tissue oxygenation in patients with severe traumatic brain injury (TBI), and compared measurements obtained using this device to those obtained using invasive cerebral monitoring.

Methods

Patients with severe TBI admitted to the intensive care unit at Hadassah-Hebrew University Hospital requiring intracranial pressure (ICP) monitoring and advanced neuromonitoring were included in this study. The authors assessed 18 patients with severe TBI using the CerOx monitor and invasive advanced cerebral monitors.

Results

The mean age of the patients was 45.3 ± 23.7 years and the median Glasgow Coma Scale score on admission was 5 (interquartile range 3–7). Eight patients underwent unilateral decompressive hemicraniectomy and 1 patient underwent craniotomy. Sixteen patients underwent insertion of a jugular bulb venous catheter, and 18 patients underwent insertion of a Licox brain tissue oxygen monitor. The authors found a strong correlation (r = 0.60, p < 0.001) between the jugular bulb venous saturation from the venous blood gas and the CerOx measure of regional cerebral tissue saturation on the side ipsilateral to the catheter. A multivariate analysis revealed that among the physiological parameters of mean arterial blood pressure, ICP, brain tissue oxygen tension, and CerOx measurements on the ipsilateral and contralateral sides, only ipsilateral CerOx measurements were significantly correlated to jugular bulb venous saturation (p < 0.001).

Conclusions

Measuring regional cerebral tissue oxygenation with the CerOx monitor in a noninvasive manner is feasible in patients with severe TBI in the neurointensive care unit. The correlation between the CerOx measurements and the jugular bulb venous measurements of oxygen saturation indicate that the CerOx may be able to provide an estimation of cerebral oxygenation status in a noninvasive manner.

Biomarkers for the clinical differential diagnosis in traumatic brain injury--a systematic review

Rapid triage and decision-making in the treatment of traumatic brain injury (TBI) present challenging dilemma in "resource poor" environments such as the battlefield and developing areas of the world. There is an urgent need for additional tools to guide treatment of TBI. The aim of this review is to establish the possible use of diagnostic TBI biomarkers in (1) identifying diffuse and focal brain injury and (2) assess their potential for determining outcome, intracranial pressure (ICP), and responses to therapy. At present, there is insufficient literature to support a role for diagnostic biomarkers in distinguishing focal and diffuse injury or for accurate determination of raised ICP. Presently, neurofilament (NF), S100β, glial fibrillary acidic protein (GFAP), and ubiquitin carboxyl terminal hydrolase-L1 (UCH-L1) seemed to have the best potential as diagnostic biomarkers for distinguishing focal and diffuse injury, whereas C-tau, neuron-specific enolase (NSE), S100β, GFAP, and spectrin breakdown products (SBDPs) appear to be candidates for ICP reflective biomarkers. With the combinations of different pathophysiology related to each biomarker, a multibiomarker analysis seems to be effective and would likely increase diagnostic accuracy. There is limited research focusing on the differential diagnostic properties of biomarkers in TBI. This fact warrants the need for greater efforts to innovate sensitive and reliable biomarkers. We advocate awareness and inclusion of the differentiation of injury type and ICP elevation in further studies with brain injury biomarkers.