Neuroprotective Effects Of Coenzyme Q 10 And Ozone Therapy On Experimental Traumatic Spinal Cord Injuries In Rats

OBJECTIVE

This study investigates the neuroprotective effects and functional recovery potential of Coenzyme Q10 (CoQ10) and ozone therapy in spinal cord injury (SCI).

MATERIAL AND METHODS

In this study, 40 female Sprague-Dawley rats were divided into five groups of eight. Surgical procedures induced spinal cord trauma in all groups, except the control group. The ozone group received 0.7 mg/kg rectal ozone daily for seven days, starting one hour post-spinal cord trauma. The CoQ10 group was administered 120 mg/kg CoQ10 orally once daily for seven days, beginning 24 hours prior to trauma. The CoQ10 + ozone group received both treatments. Examinations included a modified Tarlov scale and inclined plane test on days 1, 3, 5, and 7. Malondialdehyde (MDA) analysis was conducted on serum samples, and assessments of caspase-3, Bcl-2, and Bax levels were performed on tissue samples. Additionally, a comprehensive examination analyzed histopathological and ultrastructural changes.

RESULT

After SCI, there was a statistically significant increase in serum MDA, tissue caspase-3, and Bax levels (MDA p<0.001, caspase-3 p<0.001, Bax p=0.003). In the CoQ10 + ozone group, serum MDA (p=0.002), tissue caspase-3 (p=0.001), and Bax (p=0.030) levels were significantly lower compared to the trauma group. Tissue Bcl-2 levels were also significantly higher (p=0.019). The combined treatment group demonstrated improved histopathological, ultrastructural, and neurological outcomes.

CONCLUSION

This study shows that CoQ10 + ozone therapy in traumatic SCI demonstrates neuroprotective effects via antioxidant and antiapoptotic mechanisms. The positive effects on functional recovery are supported by data from biochemical, histopathological, ultrastructural, and neurological examinations.

Clinical Significance of Pneumocephalus in Pediatric Mild Traumatic Brain Injury

OBJECTIVES

Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head computed tomography scan, a considerable portion of the cases have intracranial imaging abnormalities on computed tomography scan. Whereas other intracranial pathological findings have been extensively studied, little is known about the clinical significance of pneumocephalus in pediatric mTBI.

METHODS

We retrospectively identified pediatric mTBI patients with pneumocephalus using the institutional database of a large regional trauma referral center. Outcome measures were defined as clinically important TBI (ciTBI), hospitalization, intensive care unit (ICU) admission, and neurosurgical intervention. Comparisons were made between pneumocephalus and control (isolated linear fracture) groups as well as between isolated (only linear fracture and pneumocephalus) and nonisolated pneumocephalus (pneumocephalus and TBI) groups.

RESULTS

Among 3524 pediatric mTBI cases, 43 cases had pneumocephalus (1.2%). Twenty-one cases (48.8%) had isolated pneumocephalus. The pneumocephalus group had higher rates of ciTBI, hospital admission, ICU admission, and neurosurgery when compared with the isolated linear fracture (control) group. The isolated pneumocephalus group had fewer ciTBI (21.1% vs 70%, P = 0.002), fewer hospitalization (23.8% vs 81.8%, P < 0.001), but similar ICU admission rates (4.8% vs 22.7%, P = 0.089) and length of hospital stay (4.0 ± 2.7 vs 3.6 ± 2.4 days, P = 0.798) in comparison to the nonisolated pneumocephalus group. None of the patients in the isolated group had neurosurgery whereas 2 patients in the nonisolated pneumocephalus group underwent surgery. Multivariable analysis revealed pneumocephalus as an independent predictor of ciTBI and hospital admission, but not ICU admission or neurosurgical intervention.

CONCLUSION

Pneumocephalus is associated with increased rates of hospitalization and ciTBI, but not ICU admission, unfavorable outcome, or neurosurgical intervention in pediatric mTBI. Although usually spontaneously resolving pathology, it may occasionally be linked with complications such as cerebrospinal fluid leakage, meningitis, and tension pneumocephalus. Therefore, careful evaluation, close observation, and early detection of complications may prevent adverse outcomes.

A Novel Decision-Support Tool (IniCT Score) for Repeat Head Computed Tomography in Pediatric Mild Traumatic Brain Injury

BACKGROUND

The necessity of computed tomography (CT) has been questioned in pediatric mild traumatic brain injury (mTBI) because of concerns related to radiation exposure. Distinguishing patients with lower and higher risk of clinically important TBI (ciTBI) is paramount to the optimal management of these patients.

OBJECTIVE

This study aimed to analyze the imaging predictors of ciTBI and develop an algorithm to identify patients at low and high risk for ciTBI to inform clinical decision making using a large single-center cohort of pediatric patients with mTBI.

METHODS

We retrospectively identified pediatric patients with mTBI with repeat CT within 48 hours of injury using an institutional database.

RESULTS

Among 3867 pediatric patients, 219 patients with mTBI with repeat CT were included. Thirty-eight had ciTBI (17%), 16 (7%) required intensive care unit admission, and 6 (3%) underwent surgery. Median time interval between initial and repeat CT was 7 hours (range, 4-10). Clinical worsening and radiologic progression were evident in 36 (16%) and 24 (11%) patients, respectively. Multivariate analysis showed that 5 pathologic findings (depressed skull fracture, pneumocephalus, epidural hematoma, subdural hematoma, and contusion) on initial CT and radiologic progression on repeat CT were independent predictors of ciTBI. A new scoring system based on these 5 factors on initial CT (IniCT [Initial CT scoring system] score) had excellent discrimination for ciTBI, need for intensive care unit admission, and neurosurgery (area under the curve >0.8).

CONCLUSIONS

The IniCT scoring system can successfully differentiate low-risk and high-risk patients based on initial CT scan. Zero score can eliminate the need for a routine repeat CT, whereas scores ≥2 should prompt serial neurologic examinations and/or repeat CT depending on the clinical situation.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Resection of an anterolateral mesencephalic cavernoma via transsylvian/transuncal approach in a child

This video demonstrates the resection of an anterolateral mesencephalic cavernous malformation (CM) through a transsylvian/transuncal approach. A 10-year-old girl presented with progressive headache and left-sided spastic hemiparesis. Neuroimaging revealed a 20-mm CM located in the right anterolateral midbrain/cerebral peduncle. After orbitozygomatic craniotomy and wide sylvian fissure opening, the oculomotor nerve was dissected and separated from the temporal lobe. Partial resection of the uncus allowed access to the CM through the oculomotor-tentorial triangle. The CM was excised in a piecemeal fashion. Postoperative imaging confirmed the gross-total resection. The patient had no additional neurological deficits postoperatively. Her left hemiparesis almost completely resolved at the 12-month follow-up.

The video can be found here: https://youtu.be/Jb_EaWbn5LU.

Active Rebleeding of a Ruptured Middle Cerebral Artery Aneurysm During Diagnostic Catheter Angiography

Rebleeding of cerebral aneurysms has been previously reported during diagnostic angiography. However, capturing the exact moment of active rebleeding of a cerebral aneurysm during angiography is extremely rare. Here, a case of a rebleeding middle cerebral artery aneurysm during diagnostic digital subtraction angiography (DSA) was illustrated, accompanied with a video demonstration of the incident which is the only one in the literature. During the acquisition of lateral projection DSA images, active extravasation of the contrast medium was witnessed, indicating rebleeding. Simultaneously, there was a sudden rise in arterial blood pressure and an episode of bradycardia. The procedure was terminated immediately and the patient was transferred to the intensive care unit for extraventricular drainage and stabilization of vital signs. Unfortunately, the patient was lost.