Multi-Technique Management of Chronic Subdural Hematoma in a Single Patient: A Case Report

Background: Chronic Subdural Hematoma (cSDH) is one of the most everyday neurosurgical conditions. Unfortunately, there is no defined gold standard technique in managing cSDH, as studies show mixed results with no consensus on the superiority of a particular method. This lack of uniformity in the treatment of cSDH makes the management choice dependent on the clinical symptomatology, surgeon’s preference, and recurrence after a prior intervention. Different management approaches are available, ranging from novel medical therapy, e.g., steroids, etizolam, tranexamic acid, angiotensin-converting enzymes inhibitors (ACEIs), to minimally invasive techniques, e.g., endovascular middle meningeal artery (MMA) embolization and endoscopic treatment, to more invasive surgical approaches, e.g., twist drill craniostomy, burr hole craniostomy, and craniotomy. A component network meta-analysis by Jack et al. showed a 10.8% recurrence rate (95% CI 10.2-11.5) across 418 studies involving different management techniques. The use of a post-operative drain and MMA embolization reduced recurrence, while the risk of morbidity was equivalent across surgical treatments. We aim to present the multi-technique management approaches required to achieve clinical and radiological resolution in a cSDH patient. The Case: We report the clinical course and management of a 47-year-old male with no history of trauma who presented with sudden onset of severe headaches and brain computed tomography scan finding of bilateral cSDH. He required multiple treatment techniques, starting with bilateral twist drill craniostomies and Jackson-Pratt drain insertion with the resolution of the right collection and recurrence of the left collection. He further required the placement of two left burr hole craniostomies for drainage. However, the collection recurred. He then proceeded to have a left middle meningeal artery embolization and a left craniotomy before a clinical and radiological resolution was achieved. Conclusion: The management of cSDH is still an art and not a cookbook. Familiarity of clinicians with multiple techniques and selection based on clinical judgment is essential for improved outcomes. Appropriate patient selection for the right technique will depend on accumulating data from clinical practice and its analysis.

Abstract P430: Inflammatory Survival Gene Expression Patterns Differentiate Favorable and Unfavorable Outcomes Following Surgical Intervention in Intracerebral Hemorrhage

Background and Aims: Surgical management of intracerebral (ICH) remains controversial due to unclear benefit. In this study, we analyzed temporal changes in expression of proinflammatory and anti-inflammatory survival genes to discern the molecular differences between favorable and unfavorable outcomes after surgery.

Methods: Venous blood collected in Paxgene Blood RNA from ICH patients before surgery at ‘early’ (Day 0-2) and at ‘delayed’ (Day 3-5) timepoints. Extracted total RNA was used for real-time Taqman PCR analysis for anti-inflammatory, survival genes superoxide dismutase 1(SOD1), COX-2, IL-10, peroxisome proliferator activated receptor gamma (PPARG), TGF-B1, and IL-10. The pro-inflammatory genes included arginase-1 (ARG1), TNF, IL-1B, monocyte/macrophage activity markers (CD36, CD163) and NF-kB members (NFKB1, NFKB2, RELA, RELB, REL, NFKBIA). Relative fold changes were determined after normalizing to GAPDH. 90-day Modified Rankin Score (mRS) were collected and classified as favorable, mRS 0-3 (n=4) and unfavorable, mRS 4-6 (n=8). Statistical analysis was carried out by Welch’s ANOVA test (p<0.05).

Results: Mean age was 56.25yrs (SD 19.7). ICH location was 10 deep nuclei (thalamus or basal ganglia), 1 cerebellum, and 1 lobar. ICH volume was lower in the mRS 0-3 group (24.15ml SD21.2 vs 35.8ml SD 31.7 p=0.68). All patients had a decompressive hemicraniectomy and 7 included hematoma evacuation. Overall, the NFkB family gene expression was increased at ‘delayed’ relative to the early time points in both groups. However, RELB expression was significantly higher at the early time point of mRS 0-3 compared to mRS 4-6 group. Expression of ARG1, SOD1, COX2, IL-1B, IL-10, TGF-B1, PPARG and CD36 increased significantly at the delayed compared to the early time point. In the unfavorable outcome group (mRS 4-6), TNF expression increased significantly at the delayed timepoints compared to mRS 0-3 which was unchanged.

Conclusions: The studied genes were highly expressed and differed significantly between time points. TNF was significantly expressed at the delayed time point in the mRS 4-6 group but unchanged in the mRS 0-3 group. Further studies will explore the role of TNF and related genes in patient selection and outcomes for surgical management of ICH.

Measurement of radiation attenuation parameters of modified defatted soy flour-soy protein isolate-based mangrove wood particleboards to be used for CT phantom production

For the first time, Rhizophora spp. (Rh. spp.) particleboard phantoms were developed using defatted soy flour (DSF) and soy protein isolate (SPI) modified by sodium hydroxide and itaconic acid polyamidoamine-epichlorohydrin (IA-PAE) adhesive. The microstructural characterization and X-ray diffraction patterns of the material revealed that the modified DSF and SPI adhesives became more compact and homogeneous when NaOH/IA-PAE was added, which prevented damage by moisture. It was confirmed that the composite is crystalline with (101), (002), and (004) orientations. Phantoms made of this material were scanned with X-ray computed tomography (CT) typically used for abdominal examinations with varying energies corresponding to 80, 120, and 135 kVp, to determine CT numbers, electron densities, and density distribution profiles. The radiation attenuation parameters were found to be not significantly different from those of water (XCOM) with p values [Formula: see text] 0.05 for DSF and SPI. The DSF- and SPI-based particleboard phantoms showed CT numbers close to those of water at the three X-ray CT energies. In addition, electron density and density distribution profiles of DSF-SPI-Rh. spp. particleboard phantoms with 15 wt% IA-PAE content were even closer to those of water and other commercial phantom materials at the three X-ray CT energies. It is concluded that DSF-SPI with NaOH/IA-PAE added can be used as a potential adhesive in Rh. spp. particleboard phantoms for radiation dosimetry.

Decompressive hemicraniectomy in the management of subcortical spontaneous intracerebral hemorrhage

BACKGROUND

The benefit of decompressive hemicraniectomy in patients with malignant acute ischemic stroke is well established, however its role in supratentorial intracerebral hemorrhages is unclear and evolving. Prior studies combined cortical and subcortical hemorrhages in their analysis despite their different natural history. Subcortical hematoma is associated with worse outcomes due to mechanical compression of subcortical structures. We describe outcomes of a matched comparison of patients with spontaneous subcortical hemorrhage managed with hemicraniectomy versus medical management alone.

METHODS

Using our "Get-with-the-guideline stroke" database, patients with spontaneous subcortical hematoma managed with hemicraniectomy were identified. Using age, gender, and hematoma volume (categorized as 0-30, 30-60, >60ml), patients managed with hemicraniectomy were matched with medical management alone. Outcomes included hospital length of stay, discharge disposition, and Glasgow outcome score.

RESULTS

Eight patients with subcortical hematoma managed with hemicraniectomy were matched with 22 medically managed patients. Other than use of antithrombotics, clinical characteristics did not differ between groups. On comparing outcomes, hospital length of stay in the hemicraniectomy group (26.5 vs 12.5 days p = 0.006) was significantly longer. Discharge disposition did not differ between groups (75% vs 36.4% p = 0.101). Despite a higher frequency of Glasgow outcome score ≥ 3 at 90 days amongst hemicraniectomy cases, there was no significant difference between groups (71.3% vs 54.5% p = 0.535).

CONCLUSION

Hemicraniectomy for subcortical hematoma was associated with a prolonged hospital stay. Despite improving survival and favorable discharge disposition, there was no statistically significant difference between groups. Further studies on the benefit of hemicraniectomy in subcortical hematoma are needed.

Abstract TP334: Admission Neutrophilia is Not a Predictor of Hematoma Expansion in Deep Nuclei or Lobar Supratentorial Intracerebral Hemorrhage

Background and Purpose: Hematoma expansion of intracerebral hemorrhages (ICH) is associated with poor patient outcomes. However, the true mechanism remains unclear. Previous studies have investigated the role of admission leukocytosis and neutrophilia in predicting poor outcomes in patients admitted with ICH. In these studies, deep and lobar ICH, which have different pathophysiologies, were not distinguished. In our study, we aim to investigate the value of admission neutrophilia (AN) in predicting hematoma expansion in patients with deep ICH and lobar ICH.

Methods: We performed a retrospective review of a prospective database of patients admitted with ICH between November 1, 2012 and March 31, 2016. We included patients with ICH confirmed by CT imaging admitted for a minimum of 24 hours. Patients were excluded if etiologies included trauma, primary or metastatic brain tumors, evidence of hemorrhagic conversion from ischemic stroke, and vascular malformations. In addition to demographic and clinical data, we collected data on primary ICH location and volume, volume after 24 hours, and admission leukocyte and neutrophil counts. We defined AN as a neutrophil count >7.7 K/μL. Hematoma expansion was defined as an increase of >30% on the 24 hour repeat imaging. Basal ganglia and thalamic ICH were classified as deep ICH.

Results: Of the 573 patients admitted with ICH, 432 who met inclusion criteria were included for our analysis. 153 (41.3%) had deep ICH and 217 (58.6%) had lobar ICH. The presence of AN was significantly different between deep vs lobar ICH (47.7% vs 27.6% p=0.0001). Among these patients, larger initial hematoma volume was found in lobar ICH as compared with deep ICH (67.2ml (SD 51.0) vs 44.6ml (SD 50.5) p=0.003). However, the frequency of hematoma expansion was not significantly different between groups (12.3% vs 15.2% p=0.87). On multivariate analysis, AN was not an independent predictor of hematoma expansion in deep, lobar or both groups combined.

Conclusion: Contrary to previous reports, AN is not an independent predictor of hematoma expansion. This suggests that the pathophysiological process leading to hematoma expansion is likely multifactorial.

Analysis of Surfactants by Thin-Layer Chromatography: A Review

Thin-layer chromatographic analysis of surfactants is presented in this review. Various chromatographic systems useful for the identification, separation and quantification of surfactants are reported. New approaches in thin-layer chromatography enable analysts to separate and determine surfactants in complex mixtures (in various environmental samples). Thin-layer chromatographic methods are mainly used for the separation of surfactants either in the separation of different classes or separation of different groups within the same class.

Polyhydroxyalkanoate biosynthesis and simplified polymer recovery by a novel moderately halophilic bacterium isolated from hypersaline microbial mats

AIMS

Halophilic micro-organisms have received much interest because of their potential biotechnological applications, among which is the capability of some strains to synthesize polyhydroxyalkanoates (PHA). Halomonas sp. SK5, which was isolated from hypersaline microbial mats, accumulated intracellular granules of poly(3-hydroxybutyrate) [P(3HB)] in modified accumulation medium supplemented with 10% (w/v) salinity and 3% (w/v) glucose.

METHODS AND RESULTS

A cell density of approximately 3.0 g l(-1) was attained in this culture which yielded 48 wt% P(3HB). The bacterial strain was also capable of synthesizing poly(3-hydroxybutyrate-co-3-hydroxyvalerate) [P(3HB-co-3HV)] when cofed with relevant precursors. Feeding with sodium valerate (0.7 mol l(-1) carbon) at various time intervals within 36 h resulted in 3HV molar fractions ranging from 6 up to 54 mol%. Oil palm trunk sap (OPTS) and seawater as the carbon source and culture medium respectively facilitated a significant accumulation of P(3HB). Simplified downstream processing based on osmotic lysis in the presence of alkali/detergent for both dry and wet biomass resulted in approximately 90-100% recovery of polymers with purity as high as 90%. Weight-average molecular weight (M(w) ) of the polymers recovered was in the range of 1-2 × 10(6) .

CONCLUSIONS

Halomonas sp. SK5 was able to synthesize P(3HB) homopolymer as well as P(3HB-co-3HV) copolymer from various carbon sources.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first time a comprehensive study of both production and downstream processing is reported for Halomonas spp.

A novel agricultural waste adsorbent for the removal of lead (II) ions from aqueous solutions

The present study explores the ability of modified soda lignin (MSL) extracted from oil palm empty fruit bunches (EFB) in removing lead (II) ions from aqueous solutions. The effect of contact time, point zero charge (pH(pzc)) and pH of the solution, initial metal ion concentration and adsorbent dosage on the removal process were investigated. Furthermore, the MSL is characterized by SEM, XRF, FT-IR and surface area analysis. Equilibrium adsorption isotherms and kinetics were investigated. The experimental data were analyzed by the Langmuir, Freundlich and Temkin models of adsorption. The kinetic data obtained at different initial concentrations were analyzed using pseudo-first-order and pseudo-second-order models. The results provide strong evidence to support the hypothesis of adsorption mechanism.

High-resolution in vivo diffusion tensor imaging of the injured cat spinal cord using self-navigated, interleaved, variable-density spiral acquisition (SNAILS-DTI)

Diffusion tensor magnetic resonance imaging (DTI) is useful for studying the microstructural changes in the spinal cord following traumatic injury; however, image quality is generally poor due to the small size of the spinal cord, physiological motion and susceptibility artifacts. Self-navigated, interleaved, variable-density spiral diffusion tensor imaging (SNAILS-DTI) is a distinctive pulse sequence that bypasses many of the challenges associated with DTI of the spinal cord, particularly if imaging gradient hardware is of conventional quality. In the current study, we have demonstrated the feasibility of implementing SNAILS-DTI on a clinical 3.0-T MR scanner and examined the effect of navigator filter parameters on image quality and reconstruction time. Results demonstrate high-quality, high-resolution (546 μm×546 μm) in vivo DTI images of the cat spinal cord after traumatic spinal cord injury.

An assay for selection of sera with circulating Toxoplasma gondii antigens

We have developed an ELISA that employs monoclonal anti-Toxoplasma SAG1 (p30) as the capture antibody to detect T. gondii circulating antigens in patients' serum samples. Using serum spiked with Toxoplasma soluble and with SAG1 recombinant proteins, the detection limits were 31.25 ng/mL and 62.50 ng/mL, respectively. We obtained positive results in 28% (21/75) and 11% (23/206) of probable active and chronic toxoplasmosis serum samples, respectively. Western blot analysis on pooled antigen-positive serum samples showed antigenic bands of molecular weights 25 and 75 kDa from sera of probable active infection and five antigenic bands ranging in size from 26 to 33 kDa from chronic infection sera. This assay would be useful as an initial serum selection step in developing a Toxoplasma antigen detection test and for characterization studies.

Adsorption of copper (II), chromium (III), nickel (II) and lead (II) ions from aqueous solutions by meranti sawdust

The present study proposed the use of meranti sawdust in the removal of Cu(II), Cr(III), Ni(II) and Pb(II) ions from synthetic aqueous solutions. Batch adsorption studies showed that meranti sawdust was able to adsorb Cu(II), Cr(III), Ni(II) and Pb(II) ions from aqueous solutions in the concentration range 1-200mg/L. The adsorption was favoured with maximum adsorption at pH 6, whereas the adsorption starts at pH 1 for all metal ions. The effects of contact time, initial concentration of metal ions, adsorbent dosage and temperature have been reported. The applicability of Langmuir, Freundlich, and Dubinin-Radushkevich (D-R) isotherm was tried for the system to completely understand the adsorption isotherm processes. The adsorption kinetics tested with pseudo-first-order and pseudo-second-order models yielded high R(2) values from 0.850 to 0.932 and from 0.991 to 0.999, respectively. The meranti sawdust was found to be cost effective and has good efficiency to remove these toxic metal ions from aqueous solution.

Scavenging behaviour of meranti sawdust in the removal of methylene blue from aqueous solution

Meranti (Philippine mahogany) sawdust, an inexpensive material, showed strong scavenging behaviour through adsorption for the removal of methylene blue (MB) from aqueous solution. Batch studies were performed to evaluate and optimize the effects of various parameters such as contact time, pH, initial dye concentrations and adsorbent dosage. Langmuir, Freundlich and Temkin isotherms were used to analyze the equilibrium data at different temperatures. The experimental data fitted well with the Langmuir adsorption isotherm, indicating thereby the mono layer adsorption of the dye. The monolayer sorption capacity of meranti sawdust for MB was found to be 120.48, 117.64, 149.25 and 158.73 mg/g at 30, 40, 50 and 60 degrees C, respectively. Thermodynamic calculations showed that the MB adsorption process is endothermic and spontaneous in nature. Kinetic studies showed that the adsorption followed a pseudo-second-order kinetic model. The results indicated that the meranti sawdust could be an alternative material in place of more costly adsorbents used for dye removal.

Seroprevalence of toxoplasmosis among migrant workers from different Asian countries working in Malaysia

A serologic study of Toxoplasma antibodies among 501 foreign migrant workers in Malaysia was conducted in a plantation and detention camp. The highest prevalence rate of 46.2% was among Nepalese workers. Statistical analysis indicated the IgG positivity rate among local residents was significantly higher than the migrants studied (p < 0.05). The IgM positivity rate showed no significant difference between the two groups (p > 0.05). No significant difference in the prevalence rate was noted between the migrants and the local workers when grouped by agricultural and non-agricultural occupations (p > 0.05). The continuous introduction of these infections may influence the epidemiology and further compromise efforts in control and prevention. It is therefore important to monitor of non-notifiable diseases.

Evaluation of shear strength of oil treated laminated bamboo

Studies were carried out on heat treatment of bamboo species Gigantochloa scortechinii Gamble using palm oil. The samples were laminated and glued. The adhesion results showed that the delamination of glue line increased as the temperature and duration of oil heat treatment increased. Maximum load and shear strength of the glue line reduced as the heat treatment become more severe. It was found that the palm oil used as the heating medium penetrated in some parts of the cell wall as well as in the cell lumen of the bamboo.

Some of the properties of flame retardant medium density fiberboard made from rubberwood and recycled containers containing aluminum trihydroxide

The flame retardancy of medium density fiberboard (MDF) made from mixture of rubberwood fibers and recycled old corrugated containers was studied. Aluminum trihydroxide (ATH) was used as a fire retardant additive and mixed with the fibers to manufacture experimental MDF panels using wet process. Phenol formaldehyde (PF) resin in liquid, 2% based on oven dry weight of fibers, was used along with 0%, 10%, 15% and 20% of ATH. The flame retardant test was done using the limiting oxygen index (LOI) test. The other properties investigated include internal bond strength, thickness swelling and water absorption. The results showed that ATH loading increased as the LOI of MDF increased. This demonstrated that ATH could improved the fire retardant property of MDF at sufficient loading. An increase in concentration of ATH showed an increase in the IB values of MDF made without resin. MDF panels made without resin showed a progressive increase in internal bond as the composition of recycled old corrugated containers fiber increased. Addition of resin improved internal bond strength and reduced thickness swelling, and water absorption. Thickness swelling of panel increased as the composition of recycled old corrugated containers fiber increased. Scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDAX) showed that there is indication of ATH and resin filling the void space in between fibers.

Experimental strategies to promote functional recovery after peripheral nerve injuries

The capacity of Schwann cells (SCs) in the peripheral nervous system to support axonal regeneration, in contrast to the oligodendrocytes in the central nervous system, has led to the misconception that peripheral nerve regeneration always restores function. Here, we consider how prolonged periods of time that injured neurons remain without targets during axonal regeneration (chronic axotomy) and that SCs in the distal nerve stumps remain chronically denervated (chronic denervation) progressively reduce the number of motoneurons that regenerate their axons. We demonstrate the effectiveness of low-dose, brain-derived neurotrophic and glial-derived neurotrophic factors to counteract the effects of chronic axotomy in promoting axonal regeneration. High-dose brain-derived neurotrophic factor (BDNF) on the other hand, acting through the p75 receptor, inhibits axonal regeneration and may be a factor in stopping regenerating axons from forming neuromuscular connections in skeletal muscle. The immunophilin, FK506, is also effective in promoting axonal regeneration after chronic axotomy. Chronic denervation of SCs (>1 month) severely deters axonal regeneration, although the few motor axons that do regenerate to reinnervate muscles become myelinated and form enlarged motor units in the reinnervated muscles. We found that in vitro incubation of chronically denervated SCs with transforming growth factor-beta re-established their growth-supportive phenotype in vivo, consistent with the idea that the interaction between invading macrophages and denervated SCs during Wallerian degeneration is essential to sustain axonal regeneration by promoting the growth-supportive SC phenotype. Finally, we consider the effectiveness of a brief period of 20 Hz electrical stimulation in promoting the regeneration of axons across the surgical gap after nerve repair.

Epidemiological screening of lymphatic filariasis among immigrants using dipstick colloidal dye immunoassay

We have recently reported that a dipstick colloidal dye immunoassay (DIA) that detect parasite antigens in human serum is sensitive and specific for the diagnosis of active infection of lymphatic filariasis. Rabbit polyclonal antibodies (RbBmCAg) labelled with a commercial dye, palanil navy blue was used to detect filarial antigenemia among Indonesian and Bangladeshi immigrant workers (N= 630) at oil palm estates at Hulu Trengganu District, Peninsular Malaysia. Microfilaremia with Brugia malayi were detected in 51 (8.10 %) individuals, of which 42 (6.67 %) were among the Indonesians and 9 (1.98 %) among the Bangladeshis. Microfilaremia with Wuchereria bancrofti were detected in 33 (5.24 %) individuals of which 15 (2.38 %) were among the Indonesians and 18 (2.86 %) among the Bangladeshis workers. The DIA detected 96 (15.24 %) antigenemic cases which comprise of all the microfilaremic cases and 15 (2.38 %) amicrofilaremic cases. The amicrofilaremic cases with filarial antigenemia consisted of 9 (1. 43 %) Indonesians and 6 (0.95%) Bangladeshis. We have used 6 ul of the RbBmCAg and diluted (1:10) patients' sera per dipstick which make the DIA reagent conservative. The DIA is a rapid test and can be read in approximate 2 hours.. Additionally, coloured dots developed in the DIA can be qualitatively assessed visually for intensity. The DIA does not require sophisticated equipment or radioactivity, and therefore suitable for field application.