Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: a pooled analysis of two randomized controlled trials

BACKGROUND

Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy.

METHODS

We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression.

RESULTS

Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75).

CONCLUSIONS

DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life.

CLINICAL TRIAL REGISTRATION

The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.

The effect of patient age on the degree of midline shift caused by chronic subdural hematomas: a volumetric analysis

OBJECTIVE

Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH.

METHODS

The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis.

RESULTS

Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001).

CONCLUSIONS

For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.

Evaluation of the frequency of tentorial hypoplasia and accompanying gyral herniation using MRI

Purpose The cerebellar tentorium, the second-largest dural reflection in the brain, separates supratentorial and infratentorial structures. This study aimed to determine the frequency of tentorial hypoplasia (TH) and gyral herniation and their relationship with clinical findings. Methods The standard brain MRIs were examined retrospectively. The presence of TH and laterality were investigated. If hypoplasia was accompanied by a gyrus extending inferior to the line where the tentorium should be located, this was recorded as tentorial hypoplasia-herniated gyrus (TH-HG), while the cases with hypoplasia alone were noted as isolated TH. It was also determined which gyrus or gyri were herniated. The clinical findings of the patients were obtained, and the correlation between HG was explored. Results Standard brain MRIs of the 2051 patients were evaluated. Two hundred ten patients were excluded from the study due to different intracranial disorders, and 1841 patients, 739 (40.1%) males, and 1102 (59.9%) females, were included. Isolated TH or TH-HG was present in 56 patients, resulting in a prevalence of 3.04%. Of the patients with TH or TH-HG, 15 were men, and 41 were women. TH and TH-HG were significantly more common in women (p=0.038). TH-HG was unilateral in 22 (39.2%) patients and bilateral in 21 (37.5%). Left TH was found in 11 (19.6%) patients, left TH-HG in 29 (51.7%), right TH in eight (14.2%), and left TH-HG in 35 (62.5%). Conclusion Hypoplasia of the tentorium is a rare and unknown anomaly that can be easily diagnosed using MRI, and different gyral herniations may accompany TH.

Secondary hyperperfusion injury following surgical evacuation for acute isolated epidural hematoma with concurrent cerebral herniation

Objective

Hemispherical cerebral swelling or even encephalocele after head trauma is a common complication and has been well elucidated previously. However, few studies have focused on the secondary brain hemorrhage or edema occurring regionally but not hemispherically in the cerebral parenchyma just underneath the surgically evacuated hematoma during or at a very early stage post-surgery.

Methods

In order to explore the characteristics, hemodynamic mechanisms, and optimized treatment of a novel peri-operative complication in patients with isolated acute epidural hematoma (EDH), clinical data of 157 patients with acute-isolated EDH who underwent surgical intervention were reviewed retrospectively. Risk factors including demographic characteristics, admission Glasgow Coma Score, preoperative hemorrhagic shock, anatomical location, and morphological parameters of epidural hematoma, as well as the extent and duration of cerebral herniation on physical examination and radiographic evaluation were considered.

Results

It suggested that secondary intracerebral hemorrhage or edema was determined in 12 of 157 patients within 6 h after surgical hematoma evacuation. It was featured by remarkable, regional hyperperfusion on the computed tomography (CT) perfusion images and associated with a relatively poor neurological prognosis. In addition to concurrent cerebral herniation, which was found to be a prerequisite for the development of this novel complication, multivariate logistic regression further showed four independent risk factors contributing to this type of secondary hyperperfusion injury: cerebral herniation that lasted longer than 2 h, hematomas that were located in the non-temporal region, hematomas that were thicker than 40 mm, and hematomas occurring in pediatric and elderly patients.

Conclusion

Secondary brain hemorrhage or edema occurring within an early perioperative period of hematoma-evacuation craniotomy for acute-isolated EDH is a rarely described hyperperfusion injury. Because it plays an important prognostic influence on patients' neurological recovery, optimized treatment should be given to block or reduce the consequent secondary brain injuries.

Magnetic resonance based morphometric analysis of the tentorial notch

BACKGROUND

The study of the tentorial notch can improve the understanding of brain injury mechanisms. Tentorial morphology has been analysed primarily in cadaveric studies. However, the postmortem effect can cause variability in the measurements. The objective was to evaluate the morphometry of the tentorial notch and the third cranial nerve on living subjects using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

A retrospective cross-sectional study was performed. Using consecutive cases, 60 MRI scans were analysed for tentorial notch morphology. Maximum notch width (MNW), notch length (NL), interpedunculoclival (IC) distance, apicotectal (AT) distance, third cranial nerve (CN-III) distance, and inter- CN-III angle, were obtained. For the classification of the tentorial notch quartile distribution technique for MNW, NL, AT distance, and IC distance were used.

RESULTS

According to the quartile of the MNW, patients were stratified into narrow, midrange, and wide groups. Using the NL quartile groups, they were also classified as short, midrange, and long. With these, the tentorial notch could be classified into eight types. Statistical differences between genders in the MNW and inter-CN-III angle were found, as well as a strong positive correlation between NL and AT distance, and between right and left CN-III distances.

CONCLUSIONS

There were differences between the cadaveric samples and living subjects in the CN-III distances. This difference could be explained by the dehydration of brain volume in the postmortem process which may cause nerve elongation. Morphometry of the tentorial notch and its neurovascular relations allows a better understanding of the mechanisms of brain herniation.

Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

Are bilaterally fixed and dilated pupils the kiss of death in patients with transtentorial herniation? Systematic review and pooled analysis

OBJECTIVE

Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery.

METHODS

Systematic review of MEDLINE, EMBASE, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to PRISMA methodology. Individual patient data were extracted, pooled, and analyzed.

RESULTS

Twenty-two studies totaling 503 patients were included. Study designs were: prospective cohort (n=1), retrospective cohort (n=15), case report (n=6). Nearly two-thirds of patients (67.7%) were male. Mean age was 41 years (range 3-82). Median preoperative Glasgow coma score (GCS) was 3 (range 3-6). Nearly two-thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. Mean follow-up was 7 months (range 1-40). Two-thirds (67%) died. Among survivors, 50.5% had severe disability (GOS 2-3), while 49.5% had good outcome (GOS 4-5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, GCS, and time to surgery could not be determined.

CONCLUSION

The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space-occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted.

Retrospective evaluation of the relationship between admission variables and brain herniation in dogs (2010-2019): 54 cases

OBJECTIVE

To document the admission systolic blood pressure (SBP), heart rate (HR), and modified Glasgow coma scale (MGCS) score in dogs with and without brain herniation and to determine their relationship with brain herniation.

DESIGN

Retrospective study between 2010 and 2019.

SETTING

University veterinary teaching hospital.

ANIMALS

Fifty-four client-owned dogs with brain herniation and 40 client-owned dogs as a control group, as determined on magnetic resonance imaging.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

SBP, HR, MGCS score, and outcome were extracted from medical records. MGCS score was retrospectively calculated based on initial neurological examination in dogs with adequate available information. Dogs with brain herniation had a significantly higher SBP (P = 0.0078), greater SBP-HR difference (P = 0.0006), and lower MGCS score (P < 0.0001) compared to control dogs. A cutoff value of an SBP ≥ 178 mm Hg, SBP-HR ≥ 60, and MGCS score ≤ 14 each provides a specificity of 90%-98%. A combination of an SBP > 140 mm Hg and HR < 80/min provided 24% sensitivity and 100% specificity to diagnose dogs with brain herniation (P < 0.0001).

CONCLUSIONS

A high SBP, a greater difference between SBP and HR, a combination of higher SBP and lower HR, and a low MGCS score were associated with brain herniation in dogs presenting with neurological signs upon admission. Early recognition of these abnormalities may help veterinarians to suspect brain herniation and determine timely treatment.

Computed Tomography Based Score of Early Ischemic Changes Predicts Malignant Infarction

Background and Purpose: Identification of ischemic stroke patients at high risk of developing life-threatening malignant infarction at an early stage is critical to consider more rigorous monitoring and further therapeutic measures. We hypothesized that a score consisting of simple measurements of visually evident ischemic changes in non-enhanced CT (NEMMI score) predicts malignant middle cerebral artery (MCA) infarctions (MMI) with similar diagnostic power compared to other baseline clinical and imaging parameters. Methods: One hundred and nine patients with acute proximal MCA occlusion were included. Fifteen (13.8%) patients developed MMI. NEMMI score was defined using the sum of the maximum diameter (anterior-posterior plus medio-lateral) of the hypoattenuated lesion in baseline-CT multiplied by a hypoattenuation factor (3-point visual grading in non-enhanced CT, no/subtle/clear hypoattenuation = 1/2/3). Receiver operating characteristic (ROC) curve analysis and multivariable logistic regression analysis were used to calculate the predictive values of the NEMMI score, baseline clinical and other imaging parameters. Results: The median NEMMI score at baseline was 13.6 (IQR: 11.6-31.1) for MMI patients, and 7.7 (IQR: 3.9-11.2) for patients with non-malignant infarctions (p < 0.0001). Based on ROC curve analysis, a NEMMI score >10.5 identified MMI with good discriminative power (AUC: 0.84, sensitivity/specificity: 93.3/70.7%), which was higher compared to age (AUC: 0.76), NIHSS (AUC: 0.61), or ischemic core volume (AUC: 0.80). In multivariable logistic regression analysis, NEMMI score was significantly and independently associated with MMI (OR: 1.33, 95%CI: 1.13-1.56, p < 0.001), adjusted for recanalization status. Conclusion: The NEMMI score is a quick and simple rating tool of early ischemic changes on CT and could serve as an important surrogate marker for developing malignant edema. Its diagnostic accuracy was similar to CTP and clinical parameters.

Tissue damage in herniated brain parenchyma into giant arachnoid granulations: demonstration with high resolution MRI

BACKGROUND

Brain herniation (BH) into arachnoid granulation has been remarkable in recent years.

PURPOSE

To evaluate the damage in herniated parenchyma into the giant arachnoid granulation (GAG) and to investigate the clinical-demographic importance of this damage.

MATERIAL AND METHODS

Patients with BH into GAG were retrospectively included in the study. Each of the patients had at least one high-resolution 3D magnetic resonance imaging (MRI) sequence. The arachnoid granulation dimensions, locations, and origin of herniated parenchyma were evaluated by two experienced radiologists. The demographic and symptomatic features of the patients were recorded from the hospital database.

RESULTS

A total of 27 patients (21 females, 6 males; age range 6-71 years; mean age 41.3 years) were found to contain BH into GAG. It was most commonly seen in the transverse sinus (67%); the origin was most common in the cerebellar parenchyma (56%). Abnormal signal and morphology were detected in herniated parenchyma in 11 (47%) patients, atrophy in six, and atrophy and gliosis in five. The most common complaints were headache (47%), while other frequent symptoms were vertigo (15%) and blurred vision (11%). There was a statistically significant positive correlation between frequency of damage in herniated brain parenchyma and the maximal size of GAG (P<0.05).

CONCLUSION

In patients with BH into GAG, parenchymal damage may be associated with various symptoms, such as headache and vertigo, although they have not been statistically proven. It is important to carefully evaluate hernia tissue, as the risk of tissue damage may increase in larger GAGs.

Rapid Cerebral Edema and Herniation in a 65-Year-Old Man With Balamuthia Mandrillaris

This case describes a 65-year-old man with hepatocellular carcinoma as well as other medical comorbidities who developed rapidly progressive cerebral edema, nonconvulsive status epilepticus, and ultimately died. Postmortem examination revealed massive cerebral edema, widespread parenchymal necrosis, herniation, hemorrhage, and cerebral amebiasis. The causative agent was identified by the Center for Disease Control as Balamuthia mandrillaris.

Transverse sinus stenting for treatment of papilloedema secondary to a large brain herniation into a dural venous sinus with associated tectal plate lesion: Case report and literature review

Brain herniation into a dural venous sinus is a rare entity of unknown clinical significance without a clear relationship to raised intracranial pressure. There are yet to be detailed reports of interventional neuroradiology procedures involving sinus stenting across brain herniations. The authors of this paper present the first case of a stent placed across a large brain herniation into the transverse sinus in a patient with a tectal plate lesion and features of chronically raised intracranial pressure. This case demonstrates objective resolution of papilloedema and venous sinus pressure gradient at six months without complication.

Temporal encephalocele into transverse sinus in an adult with partial seizures: MRI evaluation of a rare site of brain herniation

Herniation of brain parenchyma outside its normal enclosure (also known as encephalocele) has long been known to occur at certain classic sites and is classified accordingly. With widespread use of modern neuroimaging, the previously unknown atypical and rare sites of encephalocele have now been identified. Brain herniation into a dural venous sinus is one such recently described entity with case reports extending only upto the earlier part of this decade. With no definite clinical symptomatology, imaging is crucial to diagnose this lesion accurately and differentiate it from the more familiar entity in this region of the brain, the arachnoid granulations. Also known as occult encephalocele, focal brain herniation into dural venous sinus has few specific imaging features and characteristic sites. We report a case of a 21-year-old man with partial seizures in whom MRI of the brain revealed focal herniation of the normal temporal lobe parenchyma into the left transverse sinus and discuss the key imaging features and pathophysiology of this entity.

Role, Effectiveness, and Outcome of Decompressive Craniectomy for Cerebral Venous and Dural Sinus Thrombosis (CVST): Is Surgery Really an Option?

Cerebral venous and dural sinus thrombosis (CVST) is predominantly a disease of young people. It accounts for 0.5% of all strokes, and patients usually have good outcomes. However, a minority of patients may present with elevated intracranial pressure characteristics in a serious illness type and may die from brain herniation if not treated promptly. Decompressive craniectomy (DC) is the only treatment modality that can prevent death in such cases of imminent brain herniation. Unfortunately, due to the condition's rarity and ethical concerns, randomized controlled trials are not available. This review assessed the available literature on cerebral venous and dural sinus thrombosis in different age groups and decompressive craniectomy in cerebral venous and dural sinus thrombosis. It revealed that decompressive surgery is extremely effective when done early and for the correct indications with patients achieving excellent functional outcomes post-surgery. Decompressive surgery is recommended in rapidly deteriorating patients with computed tomography (CT) scan evidence of basal cisterns effacement, a mass effect from haemorrhage and/or infarction, and significant midline shift.

Surgical treatment of rostrotentorial meningioma complicated by foraminal herniation in the cat

OBJECTIVES

This study was performed to evaluate retrospectively the clinical signs, complications and postoperative outcomes of feline intracranial meningioma (IM) with concurrent cingulate, transtentorial and foramen magnum herniations.

METHODS

The medical records and MRI scans of cats with IM and cerebral herniation were reviewed. Cases involving concurrent cingulate, transtentorial and foramen magnum herniations were included. Owners were contacted to obtain long-term follow-up information.

RESULTS

Seven cats (four castrated males and three spayed females) met the inclusion criteria. Median age was 13.0 years (range 9.9-16.1 years) and median duration of clinical signs was 35 days (range 21-163 days). The clinical signs of cats with cerebral herniation included visual impairment (n = 5 [71.4%]), ataxia (n = 4 [57.1%]), impaired consciousness (n = 2 [28.6%]), head pressing (n = 2 [28.6%]), paresis (n = 1 [14.3%]), torticollis (n = 1 [14.3%]) and personality changes (n = 1 [14.3%]). Median tumour volume, cranial cavity volume and tumour volume:intracranial volume ratio before surgery were 3.37 cm³ (range 3.23-11.5 cm³), 32.6 cm³ (range 29.8-78.3 cm³) and 10.4% (range 5.3-35.3%), respectively. Median overall tumour excision rate was 90.6%. Preoperative intracranial pressure (ICP) ranged from 15 to 32 mmHg (median 29 mmHg). In all cases, the ICP dropped to 0 mmHg immediately after tumour removal. No adjuvant therapy was required after surgery. The median survival period was 612 days (range 55-1453 days).

CONCLUSIONS AND RELEVANCE

The results of this study indicate that surgical treatment of rostrotentorial IM is effective and allows prolonged survival, even in cats with concurrent cingulate, transtentorial and foramen magnum herniations.

Extreme Intracranial Hypotension With Brain Herniation Treated With Repeat Bolus Intrathecal Infusions

Intracranial hypotension (IH) is a relatively common condition associated with low cerebrospinal (CSF) pressure. The most typical symptom is orthostatic headache, although neurological deficits and changes in the level of consciousness, such as encephalopathy, stupor, and coma, may also occur. Uncomplicated CSF hypotension headaches generally resolve with rest, hydration, and analgesia. However, persistent cases may require an epidural blood patch (EBP) for resolution. Our report presents the case of a 50-year-old male with a history of intravenous (IV) drug abuse, positive for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) antibodies, who was admitted for new-onset headache and brain magnetic resonance imaging (MRI) findings suggesting CSF hypotension. The patient subsequently developed altered mental status with agonizing respirations, prompting intubation and admission to the intensive care unit (ICU) with neurosurgery consult. The initial exam revealed fixed and dilated pupils, suggestive of severe IH with brain herniation and the decision was made to proceed with an emergent intrathecal infusion with intraparenchymal intracranial pressure (ICP) monitoring, combined with EBP. A substantial clinical improvement was noted following the procedure. Within 45 minutes, the patient's mental status improved to normal and pupillary dilation and areflexia were no longer observed. While the procedure may need to be repeated in cases of late deterioration, this report provides evidence that intrathecal bolus saline infusion with simultaneous ICP monitoring may be considered an effective measure to treat extreme cases of IH with associated brain herniation. If performed in a timely fashion, improvement of ICP numbers, and clinical resolution can be quite rapid.

[Brain tissue relaxation in craniotomy: a modern view of the perennial problem]

Intraoperative relaxation of brain tissue is one of the important factors affecting the quality and successful outcome of neurosurgical interventions. Despite many clinical studies on the problem of brain bulging, many issues remain not fully resolved. First of all, these are safety aspects of the preventive and therapeutic use of various strategies to fight this phenomenon, development of indications for introduction of hyperosmotic solutions, and use of hyperventilation or lifting of the head end of the operating table.

Risk factors for corticosteroid insufficiency during the sub-acute phase of acute traumatic brain injury

Hypothalamic-pituitary-adrenal axis dysfunction may lead to the occurrence of critical illness-related corticosteroid insufficiency. Critical illness-related corticosteroid insufficiency can easily occur after traumatic brain injury, but few studies have examined this occurrence. A multicenter, prospective, cohort study was performed to evaluate the function of the hypothalamic-pituitary-adrenal axis and the incidence of critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. One hundred and forty patients with acute traumatic brain injury were enrolled from the neurosurgical departments of three tertiary-level hospitals in China, and the critical illness-related corticosteroid insufficiency incidence, critical-illness-related corticosteroid insufficiency-related risk factors, complications, and 28-day mortality among these patients was recorded. Critical illness-related corticosteroid insufficiency was diagnosed in patients with plasma total cortisol levels less than 10 μg/dL (275.9 nM) on post-injury day 4 or when serum cortisol was insufficiently suppressed (less than 50%) during a dexamethasone suppression test on post-injury day 5. The results demonstrated that critical illness-related corticosteroid insufficiency occurred during the sub-acute phase of traumatic brain injury in 5.6% of patients with mild injury, 22.5% of patients with moderate injury, and 52.2% of patients with severe injury. Traumatic brain injury-induced critical illness-related corticosteroid insufficiency was strongly correlated to injury severity during the sub-acute stage of traumatic brain injury. Traumatic brain injury patients with critical illness-related corticosteroid insufficiency frequently presented with hemorrhagic cerebral contusions, diffuse axonal injury, brain herniation, and hypotension. Differences in the incidence of hospital-acquired pneumonia, gastrointestinal bleeding, and 28-day mortality were observed between patients with and without critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. Hypotension, brain-injury severity, and the types of traumatic brain injury were independent risk factors for traumatic brain injury-induced critical illness-related corticosteroid insufficiency. These findings indicate that critical illness-related corticosteroid insufficiency is common during the sub-acute phase of traumatic brain injury and is strongly associated with poor prognosis. The dexamethasone suppression test is a practical assay for the evaluation of hypothalamic-pituitary-adrenal axis function and for the diagnosis of critical illness-related corticosteroid insufficiency in patients with traumatic brain injury, especially those with hypotension, hemorrhagic cerebral contusions, diffuse axonal injury, and brain herniation. Sub-acute infection of acute traumatic brain injury may be an important factor associated with the occurrence and development of critical illness-related corticosteroid insufficiency. This study protocol was approved by the Ethics Committee of General Hospital of Tianjin Medical University, China in December 2011 (approval No. 201189).

Incomplete Cushing's reflex in extracorporeal membrane oxygenation

We report a case of intracranial hypertension presenting with bradycardia as the only component of Cushing's triad in a patient on extracorporeal membrane oxygenation. A 41-year-old woman with recurrent driveline infections of HeartMate-II had sternotomy and debridement that was complicated by right ventricular failure requiring veno-arterial extracorporeal membrane oxygenation. Patient was comatose and acute onset of bradycardia occurred without any change in blood pressure or respiration. Computed tomography of brain demonstrated an uncal herniation from diffuse cerebral edema. Acute onset of bradycardia in comatose patients may be the sole component of Cushing's triad in laminar flow circulatory support.

Autopsy in dengue encephalitis: An analysis of three cases

Dengue viral infection with unusual presentations has been described in literature, but autopsy is rarely done and is only limited to some cases, based on the literature review. Here, we present the autopsy findings in three cases of dengue encephalitis. All the three patients clinically presented with signs of meningoencephalitis and were positive for dengue non-structural (NS) 1 antigen (Ag) in the serum and cerebrospinal fluid. The postmortem findings revealed cerebral edema, inflammation, hemorrhage, and microinfarcts in all the three cases with herniation of the brain in one case. Sub-massive hepatocellular necrosis was seen in one case. The renal findings included hemorrhage into the Bowman's capsule with red cell cast in two of three cases. The pulmonary findings included a diffuse destruction of the alveoli and hemorrhage into the alveolar spaces in all the three cases.

Gastrointestinal Hemorrhage is Associated with Mortality after Acute Ischemic Stroke

OBJECTIVE

Gastrointestinal (GI) hemorrhage is serious during the acute phase and is reported to be related to an increased risk of death during the acute phase of acute ischemic stroke in particular. Our study was designed to investigate the relationship between GI hemorrhage and the mortality of acute ischemic stroke, assessing the influence of cerebrovascular risk factors, brain herniation and oral anticoagulation on the onset of GI hemorrhage. The identified risk factors for the occurrence of GI hemorrhage help to elucidate their respective roles in the mortality of acute ischemic stroke.

METHODS

A total of 15993 consecutive patients with acute ischemic stroke, including 216 cases and 15777 controls, were enrolled in the study from October 2010 to December 2018. Basic clinical and examination data were collected at the time of study enrollment. GI hemorrhage was diagnosed according to the presence of clinical features and endoscopy. Chi-square test and multiple logistic regressions were conducted to explore the associations between the GI hemorrhage occurrence and known risk factors. Kaplan-Meier was used to assess the influence of GI hemorrhage on the age of mortality of acute ischemic stroke.

RESULTS

GI hemorrhage cases among patients with acute ischemic stroke accounted for 1.35%. Male patients with ischemic stroke were more likely to have GI hemorrhage than their female counterparts (odds ratio (OR): 1.79; P = 0.000). Patients with atrial fibrillation (AF) had a higher incidence of GI hemorrhage than their counterparts without AF (3.03% vs. 1.20%; P < 0.05). Use of oral anticoagulants was related to increased risk for GI hemorrhage (OR: 1.96; P = 0.00). After adjusting for age and sex, both AF and oral anticoagulant use maintained associations with increased risk for GI hemorrhage (2.59-times and 2.02-times risk respectively; P = 0.00). Patients with hyperlipidemia had a lower incidence of GI hemorrhage than their counterparts without hyperlipidemia (0.62% vs. 1.60%; P < 0.05). Hyperlipidemia was associated with a reduced risk of GI hemorrhage (OR: 0.38, 95% confidence interval (CI): 0.25-0.58; P = 0.00), even after adjusting for age and sex (OR: 0.41; P = 0.00). Patients with brain herniation had a 6.54-times increased risk for GI hemorrhage (P = 0.00). GI hemorrhage was associated with 10.98-fold risk for mortality of acute ischemic stroke (P = 0.00). There was an interaction between GI hemorrhage and brain herniation and increased 26.91-fold risk for the mortality after acute ischemic stroke (P = 0.00).

CONCLUSION

AF, oral anticoagulant use, brain herniation and male sex increase GI hemorrhage risk, while hyperlipidemia reduces risk. GI hemorrhage itself increases the risk for mortality of acute ischemic stroke. The interaction between GI hemorrhage and brain herniation increased the risk for the mortality after acute ischemic stroke.

Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis

OBJECTIVELumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall.METHODSIncluded were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared.RESULTSBrain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004).CONCLUSIONSBrain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Recurrence of atretic parietal cephalocele in adult: a case report and review of literature

Common presentation of atretic parietal cephalocele is mostly seen in infants and young children. It is a palpable midline parietal soft tissue mass which is thought to represent involuted true cephalocele (meningocele or encephalocele) connected to dura mater via a fibrous stalk. Atretic parietal cephalocele is associated with increased incidence of intracranial anomalies.. Parietal cephaloceles comprise about 1% of all cerebrospinal congenital malformations and 10% of cephaloceles. We report here the case of an atretic parietal cephalocele with no associated brain malformations in adult.

Brain and Optic Chiasm Herniation into Sella after Pituitary Tumor Apoplexy

Brain and optic chiasm herniation has been rarely reported following dopamine agonist treatment for large prolactinomas. We report a case of brain and optical chiasm herniation, secondary to an empty sella due to apoplexy of a prolactinoma, and we focus on the specific presentation of this case. A 32-year-old female presented to a neurologist complaining of headaches. Her past medical history was significant for acute vision loss in both eyes accompanied by right third nerve palsy when she was 16 years old. She does not recall any endocrine or imaging evaluation at that time and she had spontaneous partial recovery of left eye vision within 3 months, with permanent blindness of right eye. She did not return to any follow-up until her neurologist consultation. Brain magnetic resonance imaging (MRI) revealed herniation of frontal lobe and optic chiasm into the pituitary sella, as well as a pituitary hypointense lesion measuring 5 mm × 5 mm after gadolinium injection. Prolactin levels were 206 ng/ml (4.79-23.3 ng/ml). Repeated prolactin was 258 ng/ml (4.79-23.3 ng/ml). She was started on bromocriptine 2.5 mg/day. Prolactin levels and menstrual cycles normalized. A repeat brain MRI performed 5 months later showed disappearance of pituitary mass, with no changes in brain and chiasmal herniation. To our knowledge, this is the first reported case of brain associated with chiasm herniation secondary to pituitary apoplexy of a prolactinoma. In conclusion, this case highlights that frontal lobe herniation in combination with optic chiasm herniation can be a complication of pituitary tumor apoplexy. Long-term surveillance of patients with pituitary apoplexy is warranted to detect delayed complications.

Analysis of Fulminant Cerebral Edema in Acute Pediatric Encephalitis

BACKGROUND

Acute pediatric encephalitis with fulminant cerebral edema can rapidly become fatal or result in devastating neurological sequelae.

METHODS

All cases coded with the discharge diagnosis of acute encephalitis between January 2000 and December 2010 were reviewed. Of the 1038 children with acute pediatric encephalitis, 25 were enrolled in our study with ages ranging from 5 months to 16 years.

RESULTS

The major neurological symptoms included an altered level of consciousness (72%), vomiting (60%), and headache (48%). The onset of neurological symptoms to signs of brain herniation ranged from 0 days to 9 days. Nineteen (76%) patients had a seizure 24-48 hours prior to showing signs of fulminant cerebral edema, and 12 (48%) patients developed status epilepticus. Sixteen patients died, and no survivors returned to baseline. Risk factors for seizures and status epilepticus were compared between the fulminant cerebral edema group (n = 25, 19 seizures, including 12 status epilepticus) and control group (nonfulminant cerebral edema) (n = 1013, 444 seizures, including 141 status epilepticus; p = 0.001 for seizures and p < 0.001 for status epilepticus).

CONCLUSION

Our findings indicate that preceding seizures and status epilepticus are significant risk factors for fulminant cerebral edema in children with acute encephalitis.

"Spontaneous" CSF Fistula due to Transtegmental Brain Herniation in Combination with Signs of Increased Intracranial Pressure and Petrous Bone Hyperpneumatization: An Illustrative Case Report

Background and Importance Transtegmental brain herniation into the petrous bone is a rare cause of rhinoliquorrhea. Our case presents a combination of several typical clinical and imaging findings illustrating the ongoing etiologic discussion of such cerebrospinal fluid (CSF) fistulas.

Clinical Presentation A 53-year-old man presented with nasal discharge after a strong effort to suppress coughing. Imaging revealed a transtegmental herniation of parts of the inferior temporal gyrus into the petrous bone and in addition a combination of signs of chronically increased intracranial pressure and a hyperpneumatization of the petrous bone. The fistula was closed by a middle cranial fossa approach.

Conclusion The case illustrates the two main predisposing factors for development of petrous bone CSF fistulas: increased intracranial pressure and thinning of the tegmental roof due to extensive development of air cells. Because the CSF leakage repair does not change the underlying cause, patients have to be informed about the possibility of developing increased intracranial pressure and recurrences of brain herniations at other sites.

A report of two paediatric cases

SUMMARY - 'Idiopathic' herniation of the brain is a rare entity previously reported in 13 cases. It may be incidentally encountered in neuroimaging studies acquired for various clinical indications. We herein describe two cases of idiopathic brain herniation that were incidentally diagnosed. A 12-year-old boy presented with a six-month history of daytime sleepiness and sudden spells of sleep. Herniation of the left inferior temporal gyrus was revealed in MRI acquired with the suspicion of epilepsy. His overnight polysomnogram and multiple sleep latency tests were compatible with the diagnosis of narcolepsy. The other case, a two-year-old girl, was transferred from an outside hospital due to partial seizures with the fever. Herniation of the precuneal gyrus was encountered in MRI acquired after controlling her seizures with the initiation of phenytoin. The brain herniations of both patients were considered to be inconsistent with their medical conditions, so that they were symptom-free with only medical treatment for following three and six months, respectively. This is a rare presentation of idiopathic brain herniation as an incidental finding that accompanied narcolepsy and epilepsy. Awareness of this entity would avoid excessive surgical and medical treatments.

Idiopathic temporal bone encephalocele

Meningoencephaloceles are herniations of brain tissue through dehiscences of the skull base. These skull defects are either acquired (otologic infection, trauma, surgery, neoplasia) or spontaneous. Spontaneous temporal bone meningoencephaloceles are quite rare conditions, usually congenital in origin presenting during childhood, and only occasionally idiopathic presenting during adulthood. We present a case of temporal bone meningoencephalocele of adult onset. The patient was treated with exploratory mastoidectomy, amputation of the herniated cele and closure of the defect with temporalis fascia and an inferiorly based pedicled muscular flap. No reconstruction of the bony defect was performed, as the layered closure was considered adequate. Twelve months' follow-up revealed no relapse of the condition or postoperative complications.