Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

Outcome of 1939 traumatic brain injury patients from road traffic accidents: Findings from specialist medical reports in a low to middle income country (LMIC)

OBJECTIVE

Road traffic accident (RTA) is the major cause of traumatic brain injury (TBI) in developing countries and affects mostly young adult population. This research aimed to describe the factors predicting functional outcome after TBI caused by RTA in a Malaysian setting.

METHODS

This was a retrospective cross-sectional study conducted on specialist medical reports written from 2009 to 2019, involving patients who survived after TBI from RTA. The functional outcome was assessed using the Glasgow Outcome Scale-Extended (GOSE). Factors associated with good outcome were analysed via logistic regression analysis. Multivariate logistic regression analysis was used to derive the best fitting Prediction Model and split-sample cross-validation was performed to develop a prediction model.

RESULTS

A total of 1939 reports were evaluated. The mean age of the study participants was 32.4 ± 13.7 years. Most patients were male, less than 40, and with average post RTA of two years. Good outcome (GOSE score 7 & 8) was reported in 30.3% of the patients. Factors significantly affecting functional outcome include age, gender, ethnicity, marital status, education level, severity of brain injury, neurosurgical intervention, ICU admission, presence of inpatient complications, cognitive impairment, post-traumatic headache, post traumatic seizures, presence of significant behavioural issue; and residence post discharge (p<0.05). After adjusting for confounding factors, prediction model identified age less than 40, mild TBI, absence of post traumatic seizure, absence of behaviour issue, absence of cognitive impairment and independent living post TBI as significant predictors of good functional outcome post trauma. Discrimination of the model was acceptable (C-statistic, 0.67; p<0.001, 95% CI: 0.62-0.73).

CONCLUSION

Good functional outcome following TBI due to RTA in this study population is comparable to other low to middle income countries but lower than high income countries. Factors influencing outcome such as seizure, cognitive and behavioural issues, and independent living post injury should be addressed early to achieve favourable long-term outcomes.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Supratentorial cerebrospinal fluid diversion using image-guided trigonal ventriculostomy during retrosigmoid craniotomy for cerebellopontine angle tumors

Background

Cerebellar contusion, swelling and herniation is frequently encoutered upon durotomy in patients undergoing retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors, despite using standard methods to obtain adequate cerebellar relaxation.

Objective

The aim of this study is to report an alternative cerebrospinal fluid (CSF)-diversion method using image-guided ipsilateral trigonal ventriculostomy.

Methods

Single-center retro- and prospective cohort study of n = 62 patients undergoing above-mentioned technique. Prior durotomy, CSF-diversion was performed to the point where the posterior fossa dura was visibly pulsatile. Outcome assessment consisted of the surgeon's intra- and postoperative clinical observations, and postoperative radiological imaging.

Results

Fifty-two out of n = 62 (84%) cases were eligible for analysis. The surgeons consistently reported successful ventricular puncture and a pulsatile dura prior durotomy without cerebellar contusion, swelling or herniation through the dural incision in n = 51/52 (98%) cases. Forty-nine out of n = 52 (94%) catheters were placed correctly within the first attempt, with the majority of catheter tips (n = 50, 96%) located intraventricularly (grade 1 or 2). In n = 4/52 (8%) patients, postoperative imaging revealed evidence of a ventriculostomy-related hemorrhage (VRH) associated with an intracerebral hemorrhage [n = 2/52 (4%)] or an isolated intraventricular hemorrhage [n = 2/52 (4%)]. However, these hemorrhagic complications were not associated with neurological symptoms, surgical interventions or postoperative hydrocephalus. None of the evaluated patients demonstrated radiological signs of upward transtentorial herniation.

Conclusion

The method described above efficiently allows CSF-diversion prior durotomy to reduce cerebellar pressure during retrosigmoid approach for CPA tumors. However, there is an inherent risk of subclinical supratentorial hemorrhagic complications.

Equitable Access to State-of-the-Art Medical Technology-a Malaysian Mini-Public-Private Partnership Case Study

BACKGROUND

The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini-public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries.

METHODS

A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return.

RESULTS

CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015-2019, 37,724 patients used the Centre's facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19.

CONCLUSIONS

Focused, small-scale mini-public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.

Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives

Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury.

Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base.

Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones.

Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.

Employment status after traumatic brain injury and the effect of concomitant injuries on return to work

PURPOSE

This study aims to describe the employment status and pattern among survivors of traumatic brain injury after motor vehicle accidents, and to explore the effects of demographic, injury variables and concomitant injuries on the employment status .

METHOD

A retrospective analyses of 370 medical reports written for patients who sustained traumatic brain injury from motor vehicle accidents was conducted. To establish the employment pattern, the pre-injury employment history was compared to the latest employment status documented. Types and severity of concomitant injuries were rated according to Abbreviated Injury Scale criteria. All significant variables were further analyzed using logistic regression to explore predictors of employment.

RESULTS

Up to 87% of the patients sustained concomitant injuries, with more than two-thirds (72%) scoring ≤ 2 on the Abbreviated Injury Scale. One hundred and eighty-two patients (49.2%) successfully returned to work. Among those who returned to work, 34% returned to former employment with pre-injury job description. Severity of traumatic brain injury, length of acute hospital stay, ambulation status and cognitive status were found to be significant predictive factors for employment status post traumatic brain injury. Presence of concomitant extremity injuries was found to influence the employment pattern among traumatic brain injury survivors.

CONCLUSION

The return to work rate was somewhat low and was not influenced by presence of concomitant injuries. .

Consensus statement from the international consensus meeting on post-traumatic cranioplasty

Background

Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach.

Methods

The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP.

Results

The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations.

Conclusions

This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Telemedicine via Smart Glasses in Critical Care of the Neurosurgical Patient-COVID-19 Pandemic Preparedness and Response in Neurosurgery

Objective

The coronavirus disease 2019 pandemic poses major risks to health care workers in neurocritical care. Recommendations are in place to limit medical personnel attending to the neurosurgical patient as a protective measure and to conserve personal protective equipment. However, the complexity of the neurosurgical patient proves to be a challenge and an opportunity for innovation. The goal of our study was to determine if telemedicine delivered through smart glasses was feasible and effective in an alternative method of conducting ward round on neurocritical care patients during the pandemic.

Methods

A random pair of neurosurgery resident and specialist conducted consecutive virtual and physical ward rounds on neurocritical patients. A virtual ward round was first conducted remotely by a specialist who received real-time audiovisual information from a resident wearing smart glasses integrated with telemedicine. Subsequently, a physical ward round was performed together by the resident and specialist on the same patient. The management plans of both ward rounds were compared, and the intrarater reliability was measured. On study completion a qualitative survey was performed.

Results

Ten paired ward rounds were performed on 103 neurocritical care patients with excellent overall intrarater reliability. Nine out of 10 showed good to excellent internal consistency, and 1 showed acceptable internal consistency. Qualitative analysis indicated wide user acceptance and high satisfaction rate with the alternative method.

Conclusions

Virtual ward rounds using telemedicine via smart glasses on neurosurgical patients in critical care were feasible, effective, and widely accepted as an alternative to physical ward rounds during the coronavirus disease 2019 pandemic.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement

BACKGROUND

Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

METHODS

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

RESULTS

The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

CONCLUSIONS

In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Frequency and Causes of Line of Sight Issues During Neurosurgical Procedures Using Optical Image-Guided Systems

BACKGROUND

Navigation (image guidance) is an essential tool in modern neurosurgery, and most surgeons use an optical tracking system. Although the technology is accurate and reliable, one often is confronted by line of sight issues that interrupt the flow of an operation. There has been feedback on the matter, but the actual problem has not been accurately quantified, therefore making this the primary aim of this study. It is particularly important given that robotic technology is gradually making its way into neurosurgery and most of these devices depend on optical navigation when procedures are being conducted.

METHODS

In this study, the frequency and causes of line of sight issues is assessed using recordings of Navigation probe locations and its synchronised video recordings.

RESULTS

The mentioned experiment conducted for a series of 15 neurosurgical operations. This issue occured in all these surgeries except one. Maximum duration of issue presisting reached up to 56% of the navigation usage time.

CONCLUSIONS

The arrangment of staff and equipment is a key factor in avoiding this issue.

Endoscopic Transsphenoidal Resection of Craniopharyngioma

Objectives  To demonstrate, step-by-step, the technique and efficacy of endoscopic transsphenoidal approach in resection of a suprasellar craniopharyngioma.

Design  The video shows a step-by-step approach to the resection, covering the exposure, access, resection, and confirmation of resection and reconstruction.

Setting  The surgery was performed in the University of Malaya Medical Centre, a tertiary referral center in the capital of Malaysia.

Participants  Surgery was performed jointly by Professor Prepageran from the department of otorhinolaryngology and Professor Vicknes Waran from the division of neurosurgery. Both surgeons are from the University of Malaya. Video compilation, editing, and voice narration was done by Dr. Kong Yew Liew.

Main Outcome Measures  Completeness of resection and avoidance of intra- and postoperative complications.

Results  Based on intraoperative views and MRI findings, the tumor was completely resected with the patient suffering only transient diabetes insipidus.

Conclusion  Central suprasellar tumors can be removed completely via an endoscopic transsphenoidal approach with minimal morbidity to the patient.

The link to the video can be found at: https://youtu.be/ZNIHfk12cYg .

Neuropsychological Outcomes in Patients with Complicated Versus Uncomplicated Mild Traumatic Brain Injury: 6-Month Follow-Up

OBJECTIVE

To compare the extent of persistent neuropsychological impairment in patients with complicated mild traumatic brain injury (mTBI) and those with uncomplicated mTBI.

METHODS

Sixty-one patients with mTBI (Glasgow Coma Scale score 13-15) were recruited prospectively, categorized according to baseline computed tomography findings, and subjected to neuropsychological assessment at initial admission (n = 61) as well as at a 6-month follow-up (n = 30). The paired t test, Cohen's d effect size calculation, and repeated-measures analysis of variance were used to establish the differences between the 2 groups in terms of neuropsychological performance.

RESULTS

A trend toward poorer neuropsychological performance among the patients with complicated mTBI was observed during admission; however, performance in this group improved over time. In contrast, the uncomplicated mTBI group showed slower recovery, especially in tasks of memory, visuospatial processing, and executive functions, at follow-up.

CONCLUSIONS

Our findings suggest that despite the broad umbrella designation of mTBI, the current classification schemes of injury severity for mild neurotrauma should be revisited. They also raise questions about the clinical relevance of both traumatic focal lesions and the absence of visible traumatic lesions on brain imaging studies in patients with milder forms of head trauma.

Missense Mutation of Brain Derived Neurotrophic Factor (BDNF) Alters Neurocognitive Performance in Patients with Mild Traumatic Brain Injury: A Longitudinal Study

The predictability of neurocognitive outcomes in patients with traumatic brain injury is not straightforward. The extent and nature of recovery in patients with mild traumatic brain injury (mTBI) are usually heterogeneous and not substantially explained by the commonly known demographic and injury-related prognostic factors despite having sustained similar injuries or injury severity. Hence, this study evaluated the effects and association of the Brain Derived Neurotrophic Factor (BDNF) missense mutations in relation to neurocognitive performance among patients with mTBI. 48 patients with mTBI were prospectively recruited and MRI scans of the brain were performed within an average 10.1 (SD 4.2) hours post trauma with assessment of their neuropsychological performance post full Glasgow Coma Scale (GCS) recovery. Neurocognitive assessments were repeated again at 6 months follow-up. The paired t-test, Cohen's d effect size and repeated measure ANOVA were performed to delineate statistically significant differences between the groups [wildtype G allele (Val homozygotes) vs. minor A allele (Met carriers)] and their neuropsychological performance across the time point (T1 = baseline/ admission vs. T2 = 6th month follow-up). Minor A allele carriers in this study generally performed more poorly on neuropsychological testing in comparison wildtype G allele group at both time points. Significant mean differences were observed among the wildtype group in the domains of memory (M = -11.44, SD = 10.0, p = .01, d = 1.22), executive function (M = -11.56, SD = 11.7, p = .02, d = 1.05) and overall performance (M = -6.89 SD = 5.3, p = .00, d = 1.39), while the minor A allele carriers showed significant mean differences in the domains of attention (M = -11.0, SD = 13.1, p = .00, d = .86) and overall cognitive performance (M = -5.25, SD = 8.1, p = .01, d = .66).The minor A allele carriers in comparison to the wildtype G allele group, showed considerably lower scores at admission and remained impaired in most domains across the timepoints, although delayed signs of recovery were noted to be significant in the domains attention and overall cognition. In conclusion, the current study has demonstrated the role of the BDNF rs6265 Val66Met polymorphism in influencing specific neurocognitive outcomes in patients with mTBI. Findings were more detrimentally profound among Met allele carriers.

A Cost-Effective Delivery System for FloSeal During Endoscopic and Microscopic Brain Surgery

OBJECTIVE

To share our experience with a new delivery system for the flowable hemostatic matrix, FloSeal, in endoscopic and microscopic skull base surgery.

METHODS

We prospectively analyzed the use of FloSeal with a hemostatic delivery system in transnasal endoscopic and microscopic skull base procedures performed at the authors' institution from January 1, 2015, to June 30, 2015. In all cases the number of aliquots was noted for the entire operation, and the total number of FloSeal ampules of 5 mL was also recorded.

RESULTS

Our device allowed controlled application of small amounts (0.5-1 mL) of FloSeal to the site of bleeding. This controlled application resulted not only in increased visibility during its application, but it also reduced the amount of FloSeal required during the procedure. We were able to use 5-10 applications per 5-mL ampule of FloSeal within an individual procedure. No procedure required more than one 5-mL ampule of FloSeal. Therefore, the use of our device results in a reduction of costs. Prior to the use of our device, we were often only able to use 1 vial of 5 ml of material for 1 or 2 applications, especially in transnasal endoscopic procedures when working along a deep corridor.

CONCLUSIONS

Our results indicate that our delivery device of FlowSeal can effectively control hemostasis by applying small amounts of FlowSeal to the site of bleeding. This results in increased visibility during hemostasis and a reduction of cost.

Integrated Anterior, Central, and Posterior Skull Base Unit - A New Perspective

The skull base is one of the most complex anatomical regions and forms the floor of the cranial cavity. Skull base surgery involves open, microscopic, and endoscopic approaches to the anterior, middle, or posterior cranial fossa. A multispecialty team approach is essential in treating patients with skull base lesions. Traditionally, rhinologists are involved in providing access to anterior skull base lesions while otologists are involved in the treatment of lesions of the posterior skull base. This is the case in most skull base centers today. In this article, we share a new perspective of an integrated skull base unit where a team of otolaryngologists and neurosurgeons treat anterior, middle, and posterior skull base pathologies. The rationale for this approach is that most technical skills required in skull base surgery are interchangeable and apply whether an endoscopic or microscopic approach is used. We show how the different skills apply to the different approaches and share our experience with an integrated skull base unit.

Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis

PURPOSE

Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN.

METHODS

A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed.

RESULTS

Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence.

CONCLUSION

Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.

Diffusion Tensor Imaging Parameters in Mild Traumatic Brain Injury and Its Correlation with Early Neuropsychological Impairment: A Longitudinal Study

We explored the prognostic value of diffusion tensor imaging (DTI) parameters of selected white matter (WM) tracts in predicting neuropsychological outcome, both at baseline and 6 months later, among well-characterized patients diagnosed with mild traumatic brain injury (mTBI). Sixty-one patients with mTBI (mean age=27.08; standard deviation [SD], 8.55) underwent scanning at an average of 10 h (SD, 4.26) post-trauma along with assessment of their neuropsychological performance at an average of 4.35 h (SD, 7.08) upon full Glasgow Coma Scale recovery. Results were then compared to 19 healthy control participants (mean age=29.05; SD, 5.84), both in the acute stage and 6 months post-trauma. DTI and neuropsychological measures between acute and chronic phases were compared, and significant differences emerged. Specifically, chronic-phase fractional anisotropy and radial diffusivity values showed significant group differences in the corona radiata, anterior limb of internal capsule, cingulum, superior longitudinal fasciculus, optic radiation, and genu of corpus callosum. Findings also demonstrated associations between DTI indices and neuropsychological outcome across two time points. Our results provide new evidence for the use of DTI as an imaging biomarker and indicator of WM damage occurring in the context of mTBI, and they underscore the dynamic nature of brain injury and possible biological basis of chronic neurocognitive alterations.

Endoscopic transnasal approach to anterior and middle cranial base lesions

We present our experience in managing pathologies involving the anterior and middle cranial base using an endoscopic transnasal approach, highlighting the surgical technique, indications, and complications. The different types of endoscopic approaches used include the transtuberculum/transplanum, transcribiform, transsellar, and cavernous sinus approaches. The common indications include repair of cerebrospinal fluid leaks (both spontaneous and post traumatic) and excision of pituitary adenomas, meningiomas, craniopharyngiomas, esthesioneuroblastomas, and other malignancies of the anterior cranial base. Careful reconstruction is performed with the multilayer technique utilizing fat, fascia lata, and fibrin sealant. The endoscopic transnasal approach, coupled with the present-day sophisticated neuronavigation systems, allows access to lesions in the midline extending from the cribriform plate to the craniovertebral junction. However, preoperative planning and careful selection of cases with evaluation of each case on an individual basis with regard to the lateral extension of the lesion are imperative.

Endoscopic skull base training using 3D printed models with pre-existing pathology

Endoscopic base of skull surgery has been growing in acceptance in the recent past due to improvements in visualisation and micro instrumentation as well as the surgical maturing of early endoscopic skull base practitioners. Unfortunately, these demanding procedures have a steep learning curve. A physical simulation that is able to reproduce the complex anatomy of the anterior skull base provides very useful means of learning the necessary skills in a safe and effective environment. This paper aims to assess the ease of learning endoscopic skull base exposure and drilling techniques using an anatomically accurate physical model with a pre-existing pathology (i.e., basilar invagination) created from actual patient data. Five models of a patient with platy-basia and basilar invagination were created from the original MRI and CT imaging data of a patient. The models were used as part of a training workshop for ENT surgeons with varying degrees of experience in endoscopic base of skull surgery, from trainees to experienced consultants. The surgeons were given a list of key steps to achieve in exposing and drilling the skull base using the simulation model. They were then asked to list the level of difficulty of learning these steps using the model. The participants found the models suitable for learning registration, navigation and skull base drilling techniques. All participants also found the deep structures to be accurately represented spatially as confirmed by the navigation system. These models allow structured simulation to be conducted in a workshop environment where surgeons and trainees can practice to perform complex procedures in a controlled fashion under the supervision of experts.

Injecting realism in surgical training-initial simulation experience with custom 3D models

The traditionally accepted form of training is direct supervision by an expert; however, modern trends in medicine have made this progressively more difficult to achieve. A 3-dimensional printer makes it possible to convert patients imaging data into accurate models, thus allowing the possibility to reproduce models with pathology. This enables a large number of trainees to be trained simultaneously using realistic models simulating actual neurosurgical procedures. The aim of this study was to assess the usefulness of these models in training surgeons to perform standard procedures that require complex techniques and equipment.

METHODS

Multiple models of the head of a patient with a deep-seated small thalamic lesion were created based on his computed tomography and magnetic resonance imaging data. A workshop was conducted using these models of the head as a teaching tool. The surgical trainees were assessed for successful performance of the procedure as well as the duration of time and number of attempts taken to learn them.

FINDINGS

All surgical candidates were able to learn the basics of the surgical procedure taught in the workshop. The number of attempts and time taken reflected the seniority and previous experience of each candidate.

DISCUSSION

Surgical trainees need multiple attempts to learn essential procedures. The use of these models for surgical-training simulation allows trainees to practice these procedures repetitively in a safe environment until they can master it. This would theoretically shorten the learning curve while standardizing teaching and assessment techniques of these trainees.

Utility of multimaterial 3D printers in creating models with pathological entities to enhance the training experience of neurosurgeons

The advent of multimaterial 3D printers allows the creation of neurosurgical models of a more realistic nature, mimicking real tissues. The authors used the latest generation of 3D printer to create a model, with an inbuilt pathological entity, of varying consistency and density. Using this model the authors were able to take trainees through the basic steps, from navigation and planning of skin flap to performing initial steps in a craniotomy and simple tumor excision. As the technology advances, models of this nature may be able to supplement the training of neurosurgeons in a simulated operating theater environment, thus improving the training experience.

Neuronavigation with the universal probe to access intracranial targets

INTRODUCTION

The universal probe is a tool devised to allow navigation-directed biopsies and drainage procedures to be performed in a simple manner using a single hardware and software.

AIM

To assess the efficacy and safety of the universal probe.

RESULTS

We used the universal probe in a total of 17 patients for 10 biopsies and 8 drainage procedures. We were able to achieve our set objectives in all 18 procedures. We did not encounter any complications using this device.

CONCLUSION

The universal probe enabled a variety of navigation-based procedures to be carried out using only a single software and hardware.

Intrasellar pituitary mucocele: diagnostic dilemma

Isolated intrasellar pituitary mucocele following transsphenoidal sinus surgery is extremely rare. The clinical features resemble a pituitary tumor, therefore careful radiological interpretation is crucial to reach the correct diagnosis. We report a case of intrasellar mucocele who had transsphenoidal sinus surgery performed 15 years prior.

The creation and verification of cranial models using three-dimensional rapid prototyping technology in field of transnasal sphenoid endoscopy

BACKGROUND

Surgical navigation systems have been used increasingly in guiding complex ear, nose, and throat surgery. Although these are helpful, they are only beneficial intraoperatively; thus, the novice surgeon will not have the preoperative training or exposure that can be vital in complex procedures. In addition, there is a lack of reliable models to give surgeons hands-on training in performing such procedures.

METHODS

A technique using an industrial rapid prototyping process by three-dimensional (3D) printing was developed, from which accurate spatial models of the nasal cavity, paranasal sinuses (sphenoid sinus in particular), and intrasellar/pituitary pathology were produced, according to the parameters of an individual patient. Image-guided surgical (IGS) techniques on two different platforms were used during endoscopic transsphenoidal surgery to test and validate the anatomical accuracy of the sinus models by comparing the models with radiological images of the patient on IGS.

RESULTS

It was possible to register, validate, and navigate accurately on these models using commonly available navigation stations, matching accurately the anatomy of the model to the IGS images.

CONCLUSION

These 3D models can be reliably used for teaching/training and preoperative planning purposes.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

The utilization of cranial models created using rapid prototyping techniques in the development of models for navigation training

INTRODUCTION

Navigation in neurosurgery has expanded rapidly; however, suitable models to train end users to use the myriad software and hardware that come with these systems are lacking. Utilizing three-dimensional (3D) industrial rapid prototyping processes, we have been able to create models using actual computed tomography (CT) data from patients with pathology and use these models to simulate a variety of commonly performed neurosurgical procedures with navigation systems.

AIM

To assess the possibility of utilizing models created from CT scan dataset obtained from patients with cranial pathology to simulate common neurosurgical procedures using navigation systems.

METHODOLOGY

Three patients with pathology were selected (hydrocephalus, right frontal cortical lesion, and midline clival meningioma). CT scan data following an image-guidance surgery protocol in DIACOM format and a Rapid Prototyping Machine were taken to create the necessary printed model with the corresponding pathology embedded. The ability in registration, planning, and navigation of two navigation systems using a variety of software and hardware provided by these platforms was assessed.

RESULTS

We were able to register all models accurately using both navigation systems and perform the necessary simulations as planned.

CONCLUSION

Models with pathology utilizing 3D rapid prototyping techniques accurately reflect data of actual patients and can be used in the simulation of neurosurgical operations using navigation systems.

Genetic polymorphisms of EGF 5'-UTR and NAT2 857G/A associated with glioma in a case control study of Malaysian patients

Studies of genetic mutations that have been used in predicting glioma prognosis have revealed a complex relationship between clinical and genetic factors. Epidermal growth factor (EGF) and the NAT2 gene play a central role in carcinogenesis. An adenine (A) to guanine (G) single nucleotide polymorphism at position 61 in the 5'-untranslated region (5'-UTR) of the EGF gene has been found to be associated with levels of EGF production, and the mutations in the NAT2 gene have been postulated as a risk factor for cancer. We investigated EGF and the NAT2 gene in 13 glioma tissue samples and 12 normal controls. In the EGF 5'-UTR 61G polymorphism, the heterozygote GA was the most common genotype in the glioma patients. In the NAT2 polymorphism at nucleotide position 857G/A, the G allele and the GG genotype were the most prevalent forms in both the glioma and normal samples. We did not find any homozygous AA genotypes in the glioma patients. Based on this preliminary evidence, the EGF 5'-UTR at position 61 and the NAT2 SNP at position 857 polymorphisms are associated with increased risk for glioma.

A new expandable cannula system for endoscopic evacuation of intraparenchymal hemorrhages

The authors describe a newly developed expandable cannula to enable a more efficient use of an endoscope in removing intraparenchymal spontaneous hypertensive intracerebral hematomas. The cannula is introduced like a conventional brain cannula, using neuronavigation techniques to reach the targeted hematoma accurately, and, once deployed, conventional microsurgical techniques are used under direct endoscopic visualization. This method was used in 6 patients, and, based on the results of intraoperative intracranial pressure monitoring and postoperative CT scanning, the authors were able to achieve good hematoma removal. They found that by using the expandable cannula, efficient endoscopic surgery in the brain parenchyma was possible.

Surgical management of large acoustic neuromas: a review

Acoutic neuromas operated at UMMC from 2001 to 2006 were retrospectively reviewed. There were a total of 27 cases. All tumors were large, measuring more than 2 cm. Hearing loss was the most common presenting symptom (63%), followed by headache (52%), dysequilibrium (30%), facial numbness (30%), tinnitus (26%) and gait disturbances (15%). Eleven (41%) of patients had hydrocephalus at the time of presentation, for which a shunt procedure was required. The translabrynthine (TL) approach was used for 12 patients and the retrosigmoid (RS) with or without presigmoid clearance for the remaining 15. Major complications included one mortality and three cerebrovascular accidents (CVA's). The one-year facial nerve outcome was good to acceptable in 62% (House-Brackmann Grade I - IV) of patients. A literature review of current management of acoustic neuromas is presented.

Cerebrospinal fluid otorrhoea from an abnormal communication between the internal auditory meatus and the medial wall of the tympanic cavity

Patients who have had middle-ear or mastoid surgery are at an increased risk of developing cerebrospinal fluid (CSF) otorrhoea. The CSF leak is usually from defects in the tegmen or posterior cranial fossa. We present a patient with CSF otorrhoea following a modified radical mastoidectomy seven years ago. There was an unusual communication between the internal auditory meatus (IAM) and the middle ear. Radiologic imaging like the MRI is useful in identifying the site of leak.

Minimally invasive image-guided removal of retrobulbar intraconal foreign body

Surgical approaches are becoming increasingly minimally invasive, without compromising either safety or ease. Penetrating ocular foreign bodies has traditionally been approached either by intraocular or supraorbital access. We successfully attempted a minimally invasive approach to remove a retrobulbar foreign body under computer-assisted image guidance in a 19-year-old man involved in an industrial mishap.

Pneumocephalus: an uncommon finding in trauma

Pneumocephalus (Intracranial aerocele), defined as intracranial air, is an uncommon complication in head injury patients. It can present immediately following head trauma or be delayed for many days before clinical symptoms occur. We present two cases of extensive pneumocephalus after trauma. The diagnosis was made by computed tomography (CT). When pneumocephalus is suspected, CT can play a vital role in determining the precise location of the gas collection, its relationship to the basal skull fracture site or air sinuses and the amount of mass effect on the brain.

Bilateral temporal bone xanthoma. Case report

Xanthoma formation is frequently seen over the subcutaneous tissue of extensor surfaces and tendons that have received minor trauma or friction in patients with hypercholesterolemia. However, temporal bone xanthomas with intracranial extension are uncommon. To the best of the authors' knowledge, this is the second report in the literature in which bilateral extension of a xanthoma is described. Xanthomas of the temporal bone are benign lesions, and complete or even partial removal is effective. The predisposing cause of the lesion should also be treated.

Primary intracerebral haemorrhage in Malaysia: in-hospital mortality and outcome in patients from a hospital based registry

Primary intracerebral haemorrhage (ICH) results in significant morbidity and mortality among patients. There is a paucity of epidemiological data on this condition in Malaysia. The purpose of this hospital based study was to define the clinical profile in patients with primary spontaneous intracerebral haemorrhage at University of Malaya Medical Centre (UMMC) and to determine the mortality rate of intracerebral haemorrhage at the time of discharge, the prognostic factors and one year outcome of this cohort of patients. Sixty-six patients were admitted at the Neurosurgical unit of University of Malaya Medical Centre for a period of 13 months from March 2002 to March 2003. Fifty percent of the subjects were female. The mean age was 61.6 +/- 16.7 years. Among our patients with intracerebral haemorrhage, the common risk factors were: hypertension (80.3%), diabetes mellitus (25.7%) and smoking (27.2%). Common presenting features for our series were: weakness (61.8%), LOC (58.5%), headache (56.3%) and speech disturbances (45.3%). On neuroimaging, the lesions were seen in basal ganglia/thalamus (45.1%), lobar (32.9%), brainstem (13.4%) and cerebelli (8.5%). The overall 30 days mortality rate for intracerebral haemorrhage (ICH) was 43.9%. The important predictors of for mortality were the GCS score on admission (p < 0.0001), haematoma volume > 30 mls (p < 0.0001), evidence of intraventricular extension (p = 0.011) and ICH score (p < 0.0001). At one year follow up, 48.5% (n = 32) were dead, 33.3% (n = 11) obtained good recovery, 36.4% (n = 12) moderate disability, 18.2% (n = 6) severe disability and 3% remain vegetative state. The overall mortality rate for our series of patients with primary intracerebral haemorrhage is quite similar to previously published epidemiological studies. ICH scoring is useful in the prognostication.

Importance of intra-operative imaging for sphenoid sinus disease

INTRODUCTION

Sphenoid sinus mucoceles comprise 1-2 per cent of paranasal sinus mucoceles. Endoscopic marsupialisation is currently the treatment of choice.

CASE REPORT

We present a patient with a sphenoid mucocele whose sphenoid sinus cavity appeared normal on endoscopy due to a horizontal plate of accessory septa, below the sphenoid ostia. The mucocele was in the inferior portion of the sinus below the septa, expanding the sinus inferiorly.

CONCLUSION

Intra-operative imaging was essential in the successful management of this patient's condition. Although endoscopy offers direct visualisation, endoscopic surgeons must be aware of the anatomical variations in this region. Intra-operative imaging modalities such as image guidance systems and image intensifiers are often vital for safe surgery.

A randomized trial of synthetic patch versus direct primary closure in carotid endarterectomy

OBJECTIVE

To define whether or not direct microscopic closure with or without the use of a vascular patch is advantageous in terms of clinical outcome and late vessel occlusion rates after microsurgical carotid endarterectomy.

METHODS

Three hundred thirty-eight elective carotid endarterectomies in 315 patients were randomized to direct arteriotomy or closure with a polyester collagen-coated vascular patch. Ten procedures did not follow the randomization process because of technical difficulties and were excluded. Vessel patency (duplex ultrasound) and outcome were assessed during and immediately after surgery and at 4 and 12 months after surgery.

RESULTS

Four-month ultrasound assessment (n = 321) identified five occluded vessels: two in the patch group (n = 149) and three in the direct closure group (n = 172). Six patients in the patch group had died or were significantly disabled at 4 months, compared with five in the direct closure group. At the 12-month assessment (n = 313), eight vessels had occluded: five from the patched group (n = 146) and three from the direct closure group (n = 167). Eight patients in the patch group had died or were significantly disabled, compared with four in the direct closure group. No statistically significant difference between the two groups in terms of vessel occlusion, morbidity, or mortality was seen (P > 0.1).

CONCLUSION

No difference in vessel patency and clinical outcome has been identified after microscopic patch angioplasty and direct arteriotomy repair. The authors conclude that there is no benefit from the routine use of patch angioplasty in microscopic carotid endarterectomy.

Neurocysticercosis an uncommon intra-cerebral infection in Malaysia

Neurocysticercosis, infection of the central nervous system (CNS) by larvae of the pork tapeworm Taenia solium, is the commonest neuroparasitic infection in humans. However in countries as in Malaysia it poses a diagnostic problem as the disease in not seen amongst the local population; however with the arrival of immigrant workers, a number of cases have recently been diagnosed. There were 3 cases of neurocysticercosis reported in our centre over the last 5 years.

Melioidosis presenting as spinal epidural abscess

Central nervous system melioidosis is an unusual infection in humans. This article reports a case of melioidosis presenting as an acute spinal epidural abscess. A discussion of this case and its management together with a brief review of melioidosis of the central nervous system is presented.

Rupture of the lateral ventricle secondary to a fourth ventricle tumour resulting in an indirect nontraumatic cerebrospinal fluid fistula

We present a rare indirect nontraumatic cerebrospinal fluid (CSF) fistula secondary to a fourth ventricle ependymoma. The fistula resulted from rupture of the left temporal horn, distant from the tumour. The fistula was well demonstrated by MRI. High-resolution CT demonstrated a defect in the roof of the sphenoid sinus, but no leakage of CSF was seen on CT cisternography.

Multimodality monitoring and the diagnosis of traumatic caroticocavernous fistula following head injury

Increases in jugular bulb saturations (SjO2) following head injury are usually due to hyperaemia. Less commonly this may be due to the development of an arteriovenous fistula. We describe how SjO2 monitoring can be used in conjunction with transcranial Doppler ultrasound to make the distinction between these two conditions, which require distinct therapies. Multimodality monitoring in acute injury provides information regarding underlying pathophysiology and permits individualization of therapy.

Assessing outcome in lumbar disc surgery using patient completed measures

Measuring outcome after spinal surgery is difficult. The objective of this study was to assess the use of four measures in establishing outcome in patients undergoing lumbar discectomy. Forty-six consecutive patients who had undergone two operations for lumbar disc prolapse and 54 patients who had undergone one operation for the same condition over the same period were identified. The SF-36 questionnaire was used to assess general health. The Roland-Morris questionnaire and a simple modification of the Roland-Morris questionnaire were used to assess back and leg related disability, respectively. Analogue pain scales were used to measure back pain and sciatica. The SF-36 scores revealed significantly worse health status in the two operation compared with the one operation patients and in all patients compared with the normal population. Using the Roland-Morris and the leg disability questionnaires, patients who had undergone two operations reported significantly worse disability (Roland-Morris, 53%, poor outcome) than those who had undergone one operation (Roland-Morris, 19%, poor outcome). There was significantly greater back disability than leg disability in both groups of patients and this was confirmed by the analogue pain scales. In patients who had undergone two operations, 25% classified their back pain as very bad or unbearable, and 22.5% described very bad or unbearable leg pain. For the one operation patients these figures were 9.5 and 2.4%, respectively. The results demonstrate that both generic and condition specific patient completed measures have the potential to detect differences in outcome between patients who have undergone either one or two lumbar disc operations. The study provides support for the use of these patient completed measures in assessing outcome in lumbar disc surgery.