Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Significant Reduction in External Ventricular Drain-Related Infections After Introducing a Novel Bundle Protocol: A Before and After Trial

BACKGROUND

External ventricular drain (EVD)-related infection (ERI) is a serious complication in neurosurgical patients. The estimated ERI rates range from 5 to 20 cases per 1,000 EVD catheter days. The pathophysiology of ERI is similar to central line-associated bloodstream infections (CLABSIs) stemming from skin-derived bacterial colonization. The use of bundle management can reduce CLABSI rates. Due to the pathogenic similarities between infections related to the two devices, we developed and evaluated the effectiveness of an ERI-bundle protocol based on CLABSI bundles.

METHODS

From November 2016 to November 2021, we conducted a study to evaluate the effectiveness of an ERI-bundle protocol. This study adopted a before-and-after trial, comparing the ERI rates for the 2 years before and 3 years after the introduction of the newly developed ERI-bundle protocol. We also analyzed the contributing factors to ERI using logistic regression analysis.

RESULTS

A total of 183 patients with 2,381 days of catheter use were analyzed. The ERI rate decreased significantly after the ERI-bundle protocol from 16.7% (14 of 84; 14.35 per 1,000 catheter days) to 4.0% (4 of 99; 3.21 per 1,000 catheter days) (P = 0.004).

CONCLUSION

Introduction of the ERI-bundle protocol was very effective in reducing ERI.

Protein Requirement Changes According to the Treatment Application in Neurocritical Patients

Objective

Exploring protein requirements for critically ill patients has become prominent. On the other hand, considering the significant impact of coma therapy and targeted temperature management (TTM) on the brain as well as systemic metabolisms, protein requirements may plausibly be changed by treatment application. However, there is currently no research on protein requirements following the application of these treatments. Therefore, the aim of this study is to elucidate changes in patients' protein requirements during the application of TTM and coma therapy.

Methods

This study is a retrospective analysis of prospectively collected data from March 2019 to May 2022. Among the patients admitted to the intensive care unit, those receiving coma therapy and TTM were included. The patient's treatment period was divided into two phases (Phase 1: application and maintenance of coma therapy and TTM; Phase 2: tapering and cessation of treatment). In assessing protein requirements, the Urine Urea Nitrogen (UUN) method was employed to estimate the nitrogen balance, offering insight into protein utilization within the body. The patient's protein requirement for each phase was defined as the amount of protein required to achieve a nitrogen balance within ±5, based on the 24-hour collection of UUN. Changes in protein requirements between phases were analyzed.

Results

Out of 195 patients, 107 patients with a total of 214 UUN values were included. The mean protein requirement for the entire treatment period was 1.84 ± 0.62 g/kg/day, which is higher than the generally recommended protein supply of 1.2 g/kg/day. As the treatment was tapered, there was a statistically significant increase in the protein requirement from 1.49 ± 0.42 to 2.18 ± 0.60 in phase 2 (p < 0.001).

Conclusion

Our study revealed a total average protein requirement of 1.84 ± 0.62g during the treatment period, which falls within the upper range of the preexisting guidelines. Nevertheless, a notable deviation emerged when analyzing the treatment application period separately. Hence, it is recommended to incorporate considerations for the type and timing of treatment, extending beyond the current guideline, which solely accounts for the 'severity by disease.

Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons

Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons.

Deep Sedation in Traumatic Brain Injury Patients

Traumatic brain injury (TBI) is one of the leading causes of mortality and disability in adults. In cases of severe TBI, preventing secondary brain injury by managing intracranial hypertension during the acute phase is a critical treatment challenge. Among surgical and medical interventions to control intracranial pressure (ICP), deep sedation can provide comfort to patients and directly control ICP by regulating cerebral metabolism. However, insufficient sedation does not achieve the intended treatment goals, and excessive sedation can lead to fatal sedative-related complications. Therefore, it is important to continuously monitor and titrate sedatives by measuring the appropriate depth of sedation. In this review, we discuss the effectiveness of deep sedation, techniques to monitor the depth of sedation, and the clinical use of recommended sedatives, barbiturates, and propofol in TBI.

Optimizing Mannitol Use in Managing Increased Intracranial Pressure: A Comprehensive Review of Recent Research and Clinical Experiences

Mannitol, derived from mannose sugar, is crucial in treating patients with elevated intracranial pressure (ICP). Its dehydrating properties at the cellular and tissue levels increase plasma osmotic pressure, which is studied for its potential to reduce ICP through osmotic diuresis. While clinical guidelines support mannitol use in these cases, the best approach for its application continues to be debated. Important aspects needing further investigation include: 1) bolus administration versus continuous infusion, 2) ICP-based dosing versus scheduled bolus, 3) identifying the optimal infusion rate, 4) determining the appropriate dosage, 5) establishing fluid replacement plans for urinary loss, and 6) selecting monitoring techniques and thresholds to assess effectiveness and ensure safety. Due to the lack of adequate high-quality prospective research data, a comprehensive review of recent studies and clinical trials is crucial. This assessment aims to bridge the knowledge gap, improve understanding of effective mannitol use in elevated ICP patients, and provide insights for future research. In conclusion, this review aspires to contribute to the ongoing discourse on mannitol application. By integrating the latest findings, this review will offer valuable insights into the function of mannitol in decreasing ICP, thereby informing better therapeutic approaches and enhancing patient outcomes.

Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management

Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.

Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review

Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.

The surgical outcomes following transsphenoidal surgery for Rathke cleft cysts: Comparison of the surgical approaches at a single institution

The aim of the present study is to retrospectively analyze the surgical outcomes and complications of microscopic and endoscopic transsphenoidal surgery in the management of Rathke cleft cysts (RCCs) at a single institution. A total of 38 patients were enrolled in this study. All patients were diagnosed with RCCs, which were confirmed histopathologically. Endocrine function, radiological, and clinical outcomes were evaluated following surgery. This cohort study consisted of 16 male and 22 female patients. The median age was 48 years (range, 21-72). The median clinical follow-up duration was 57 months (range, 3-187). Twenty-five patients underwent microscopic transsphenoidal surgery and 13 patients underwent endoscopic surgery. The cysts were located within the intrasellar area in 18 (47.4%) patients, and extended to the suprasellar area in 20 (52.6%) patients. The radiological characteristics were similar in the microscope and endoscope groups, except mass volume (1.40 vs 0.65 mm3; P = .003) and peripheral rim enhancement (P = .036). After surgery, 30 (78.9%) of the 38 patients had no residual cysts. There was no significant difference in outcomes between both groups (76.0% vs 84.6%; P = .689). Four (10.5%) patients experienced cyst recurrence in only the microscope group. Twenty-four of the 25 patients who presented with headache showed improvement after surgery. Four patients with visual field defects recovered after surgery. Among the 8 patients with hormonal deficiencies, hormone levels normalized in 5 patients, did not change in 2 patients and worsened in 1 patient. New hormonal deficiencies occurred in 3 patients. Microscopic or endoscopic transsphenoidal surgery for RCCs is a safe and effective treatment option. Complete aspiration of the cyst contents with wide fenestration and wall biopsy, regardless of the surgical approach used, is usually a sufficient treatment for RCCs.

The outcomes of surgical treatment via transsphenoidal approach for patients with nonfunctioning pituitary adenoma: a single institution's experience

BACKGROUND

Nonfunctioning pituitary adenoma is a primary benign brain neoplasm and the transsphenoidal approach is known for a safe and effective first-line surgical treatment for pituitary tumours. The aim of this study was to retrospectively analyse the outcomes of the transsphenoidal approach for nonfunctioning pituitary adenomas treated at a single institute.

METHODS

A total of 181 patients who underwent transsphenoidal approach with nonfunctioning pituitary adenoma at a single institute from March 1998 to November 2018 were included in this study. Ninety-six (53.0%) men and 85 (47.0%) women aged 21-79 years were included. The median outpatient follow-up duration was 58 months, and the median magnetic resonance imaging follow-up duration was 54 months. We assessed the surgical and clinical outcomes, complications, hormonal outcomes and recurrence tendency.

RESULTS

The overall total resection rate of a transsphenoidal approach for nonfunctioning pituitary adenoma was 84.0%. Visual impairment was improved after surgery in 115 (93.5%) of 123 patients. Of the 80 patients who complained of preoperative endocrine dysfunction, 62 (77.5%) patients recovered normal postoperative endocrine function. Diabetes insipidus, which occurred in 22 (12.2%) patients, was the most common complication. A total of 21 (11.6%) patients showed recurrence on average 57.6 months after surgery. The average recurrence period after surgery was 96.3 months in the total resection group of 6 patients and 42.1 months in the subtotal resection group of 15 patients. In multivariate analysis, the extent of resection was identified as a significant predictor of tumour recurrence with a hazard ratio of 6.093 and a p-value of 0.002.

CONCLUSIONS

It is meaningful to report long-term surgical results within a single institution, and through this, it was reconfirmed that transsphenoidal approach is an effective and safe treatment for nonfunctioning pituitary adenoma. Long-term follow-up is required due to the possibility of recurrence. In addition, performing total resection during surgery helps to lower the risk of recurrence.KEY MESSAGESTranssphenoidal approach is an effective and safe treatment modality for pituitary adenoma.Complete resection is a significant predictor for the recurrence of pituitary adenomaLong-term follow-up is necessary for the treatment of nonfunctioning pituitary adenomas.

Real-Time Evaluation of Cerebral Autoregulation Based on Near-Infrared Spectroscopy to Predict Clinical Outcome after Bypass Surgery in Moyamoya Disease

Impaired cerebral autoregulation (CA) can cause negative outcomes in neurological conditions. Real-time CA monitoring can predict and thereby help prevent postoperative complications for neurosurgery patients, especially those suffering from moyamoya disease (MMD). We applied the concept of moving average to the correlation between mean arterial blood pressure (MBP) and cerebral oxygen saturation (SCO2) to monitor CA in real time, revealing optimal window size for the moving average. The experiment was conducted with 68 surgical vital-sign records containing MBP and SCO2. To evaluate CA, the cerebral oximetry index (COx) and coherence obtained from transfer function analysis (TFA) were calculated and compared between patients with postoperative infarction and those who without. For real-time monitoring, the moving average was applied to COx and coherence to determine the differences between groups, and the optimal moving-average window size was identified. The average COx and coherence within the very-low-frequency (VLF) range (0.02-0.07 Hz) during the entire surgery were significantly different between the groups (COx: AUROC = 0.78, p = 0.003; coherence: AUROC = 0.69, p = 0.029). For the case of real-time monitoring, COx showed a reasonable performance (AUROC > 0.74) with moving-average window sizes larger than 30 minutes. Coherence showed an AUROC > 0.7 for time windows of up to 60 minutes; however, for windows larger than this threshold, the performance became unstable. With an appropriate window size, COx showed stable performance as a predictor of postoperative infarction in MMD patients.

Clinical Characteristics and Current Managements for Patients with Chronic Subdural Hematoma : A Retrospective Multicenter Pilot Study in the Republic of Korea

Objective

Chronic subdural hematoma (CSDH) is a common disease in neurosurgical departments, but optimal perioperative management guidelines have not yet been established. We aimed to assess the current clinical management and outcomes for CSDH patients and identify prognostic factors for CSDH recurrence.

Methods

We enrolled a total of 293 consecutive patients with CSDH who underwent burr hole craniostomy at seven institutions in 2018. Clinical and surgery-related characteristics and surgical outcomes were analyzed. The cohort included 208 men and 85 women.

Results

The median patient age was 75 years. Antithrombotic agents were prescribed to 105 patients. History of head trauma was identified in 59% of patients. Two hundred twenty-seven of 293 patients (77.5%) had unilateral hematoma and 46.1% had a homogenous hematoma type. About 70% of patients underwent surgery under general anesthesia, and 74.7% underwent a single burr hole craniostomy surgery. Recurrence requiring surgery was observed in 17 of 293 patients (5.8%), with a median of 32 days to recurrence. The postoperative complication rate was 4.1%. In multivariate analysis, factors associated with CSDH recurrence were separated hematoma type (odds ratio, 3.906; p=0.017) and patient who underwent surgery under general anesthesia had less recurrence (odds ratio, 0.277; p=0.017).

Conclusion

This is the first retrospective multicenter generalized cohort pilot study in the Republic of Korea as a first step towards the development of Korean clinical practice guidelines for CSDH. The type of hematoma and anesthesia was associated with CSDH recurrence. Although the detailed surgical method differs depending on the institution, the surgical treatment of CSDH was effective. Further studies may establish appropriate management guidelines to minimize CSDH recurrence.

Multiple brain abscesses presented with monoparesis in a patient with lung abscess mimicking lung cancer

Multiple brain abscesses associated with the lung mass require differential diagnosis from cancerous diseases. Here, we report a rare case of multiple brain abscesses originating from a lung abscess. A 65-year-old man presented with a 2-day history of motor weakness during antibiotic treatment for pneumonia. Brain magnetic resonance imaging (MRI) revealed multiple enhanced lesions of various sizes in the whole brain. Diffusion-weighted MRI showed high signal intensity in several lesions, and magnetic resonance (MR) spectroscopy showed reduced N-acetyl-aspartate (NAA) and high lactate-lipid complex levels. Positron emission tomography/computed tomography revealed a hypermetabolic mass-like lesion (size: 5 × 3 cm) in the right lower lobe. The patient was diagnosed with organizing pneumonia by bronchoscopy and was successfully treated with empirical antibiotics for multiple brain abscesses and lung abscesses. If new neurological deficits occur during the treatment of inflammatory diseases such as pneumonia, the possibility of brain abscesses and cancerous conditions should be considered. Appropriate diagnosis and antibiotic treatment should be performed to ensure favorable outcomes.

Extremely delayed solitary cerebral metastasis in patient with T1N0M0 renal cell carcinoma after radical nephrectomy: Case report and literature review

RATIONALE

Although renal cell carcinoma (RCC) is one of the common origins of brain metastasis, few cases of extremely delayed brain metastasis from RCC, more than 10 years after nephrectomy, have been reported. We present a rare case of extremely delayed brain metastasis from RCC, also performed a literature review to increase knowledge of the characteristics for extremely delayed brain metastasis from RCC.

PATIENT CONCERNS

A 72-year-old man presented with right-sided hemiplegia and dysarthria. The patient had a history of radical nephrectomy for RCC with stage T1N0M0 15 years earlier.

DIAGNOSIS

Magnetic resonance imaging with contrast revealed a 2-cm sized non-homogenous enhanced mass in the left frontal lobe with peritumoral edema. The pathological examination after surgery reported metastatic clear cell RCC.

INTERVENTIONS

A craniotomy for removal of the mass was performed at the time of diagnosis. Stereotactic radiosurgery was performed for the tumor bed 3 weeks after craniotomy, and then, chemotherapy was started 2 months after the SRS.

OUTCOMES

Metastasis progressed to multiple organs 6 months after the craniotomy. The patient chose a hospice and no longer visited the hospital.

LESSONS

In cases with a history of nephrectomy for RCC, long period follow-up is necessary for monitoring RCC brain metastasis and pathologic diagnosis should be confirmed.

Calvarial Tuberculosis Presenting with Skin Defect in an Elderly Patient

BACKGROUND

Tuberculosis is a common disease; however, the prevalence of calvarial tuberculosis is very rare. Most cases of calvarial tuberculosis occur in young patients. We report a rare case of calvarial tuberculosis in an elderly patient.

CASE DESCRIPTION

An 89-year-old woman presented with a forehead skin defect. Radiologic imaging showed bony erosion 20 × 10 mm in size with adjacent dural enhancement in the left frontal bone. The patient underwent surgical treatment. Pathology revealed chronic granulomatous inflammation with caseous necrosis, consistent with tuberculosis. Antituberculous medications were prescribed for 6 months.

CONCLUSIONS

A careful assessment should be performed to obtain an appropriate diagnosis in cases of osteolytic lesions of the skull.