Risk factors of deterioration in patients of head injury with non-operative management on first neurosurgical consultation

Objectives

In most of the emergency trauma intensive care units (ICUs) of India, neurosurgical opinion is sought for patients presenting with head trauma after earliest possible resuscitation to determine the further line of management. This study aimed to identify common risk factors, leading to neurological deterioration in conservatively managed patients of traumatic brain injury (TBI).

Materials and Methods

This retrospective study analyzed patients admitted with acute TBI and traumatic intracranial hematoma under emergency trauma care ICU who did not require neurosurgical operation within 48 h of trauma. The recorded data were analyzed to determine the predictors of neurological deterioration using univariate and binary logistic regression analysis in SPSS-16 software.

Results

Medical records of consecutive 275 patients of acute TBI presenting to the emergency department were studied. One hundred and ninety-three patients were afflicted with mild TBI (70.18%), 49 patients had moderate TBI (17.81%), and 33 had severe TBI (12%). In the outcome, 74.54% of patients were discharged, and operative decision was made on 6.18% of patients and 19.27% died. Severe TBI is the independent predictor of neurological deterioration during their stay in ICU. Progressive hemorrhagic injury (PHI) showed neurological deterioration in 86.5% of patients. Systemic inflammatory response syndrome (SIRS) was present in 93.5% of patients who had deteriorated neurologically. Dyselectrolytemia was the biochemical derangements seen in 24.36% of cases.

Conclusion

This study revealed severe TBI, PHI, and SIRS to be strong and independent risk factors of neurological deterioration.

Guillain-Barre Syndrome as Presenting Feature in a Patient with Systemic Lupus Erythematosus

Guillain-Barré syndrome. GBS as initial manifestation of lupus is exceedingly rare and has been reported in a few cases in the literature. We report here a 35 year old woman who presented with 10 day history of progressive muscle weakness and paraesthesias in all four limbs. She was diagnosed as SLE with renal involvement and was treated with steroids and cyclophosphamide.

Ruptured Posterior Circulation Aneurysms with Bilateral Internal Carotid Artery Occlusion: Surgical Nuance

Background:

Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease.

Methods:

A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity.

Results:

Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients.

Conclusions:

Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.

Mesenteric Vasculitis in a Case of Systemic Lupus Erythematosus

We present a case of mesentric vasculitis with systemic lupus erythematosus who relapsed after high dose steroids but achieved subsequent remission after starting pulse cyclophosphamide therapy. 38 years old female who had earlier polyserositis and cerebral venous thrombosis was admitted with provisional diagnosis of SLE and developed acute abdominal pain during hospital stay. She was diagnosed as mesenteric vasculitis and initially responded to pulse methylprednisolone. However, she had relapse which subsequently responded to pulse cyclophosphamide and steroids. During the ward course she also developed acute thyroiditis and was diagnosed to have class IV lupus nephritis on renal biopsy.

A case report of hemophagocytic lymphohistiocytosis (HLH)

Hemophagocytic lymphohistiocytosis (HLH), is an uncommon, life-threatening hyperinflammatory syndrome caused by severe hypercytokinemia with excessive activation of lymphocytes and macrophages due to a highly stimulated but ineffective immune process. We report a case of Hemophagocytic Lymphohistiocytosis in a 15 year old boy presenting with fever, lymphadenopathy and pancytopenia due to infection caused by Klebsiella Pneumoniae and Acinetobacter.

Spinal angiolipoma manifesting with apoplexy

We report a 58-year-old man presenting with acute paraplegia. MRI showed a haematoma within a well-defined epidural lesion at C7-D1. Intraoperatively, organised epidural haematoma surrounded by tumour tissue was found. The final histopathology report was angiolipoma. The patient had dramatic recovery. Angiolipomas should be considered in the differential diagnosis of acute paraplegia when imaging shows well-circumscribed haematoma.

Primary amenorrhea due to empty sella: an underestimated entity

We report a 16-year-old girl who had stunted growth and primary amenorrhea presenting with headache and vomiting. MRI of brain showed posterior fossa dermoid cyst with hydrocephalus and empty sella. Growth hormone (GH), Leutinizing hormone (LH) and Follicular stimulating hormone (FSH) were grossly reduced on endocrinological work-up. She underwent suboccipital midline craniectomy and complete excision of dermoid cyst .She had no additional deficit after the surgery. She had menarche six months after the surgery and developed adequate secondary sexual characters, however her height remains subnormal at follow-up after 2 years as compared to age matched controls. We briefly review the radiological features, pathogenesis and outcome of this underestimated entity.

Adiposis dolorosa of scalp presenting with severe headache: an unusual case

A 46-year-old female, known case of adiposis dolorosa since adolescence, noticed painful thickening of scalp in bilateral parieto-occipital areas and vertex 1 year back. Six weeks prior to the presentation to our service, she developed severe occipital headache refractory to drug treatment. She improved after bilateral greater occipital nerve blocks. She was subjected to bilateral greater occipital chemical neurolysis which has given her complete pain relief.

Chronic intradiploic hematoma in patients with coagulopathy

Intradiploic hematomas occur rarely. They have been reported in patients with and without coagulation disorders. The presentation of intradiploic hematomas varies depending on their location and the severity of the coagulopathy. We describe a patient with a huge hemicranial chronic intradiploic hematoma. Surgery involved opening the thinned outer table and evacuation of a jelly-like material and an organized clot, leaving behind the inner table. The rarity of this disease, possible pathogenesis and related surgical aspects are discussed.