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Neurotrauma without neurosurgeons?

Simpson D

Aust N Z J Surg, 1994 Aug;64(8):525-6.
PMID: 8048887
Matched MeSH terms: Craniocerebral Trauma/surgery*
Post traumatic cerebral oedema in severe head injury is related to intracranial pressure and cerebral perfusion pressure but not to cerebral compliance

Nujaimin U, Saufi A, Rahman AG, Badrisyah I, Sani S, Zamzuri I, et al.

Asian J Surg, 2009 Jul;32(3):157-62.
PMID: 19656755

This was a prospective cohort study, carried out in the Neuro Intensive Care Unit, Department of Neurosciences, Hospital Universiti Sains Malaysia, Kubang Kerian Kelantan. The study was approved by the local ethics committee and was conducted between November 2005 and September 2007 with a total of 30 patients included in the study. In our study, univariate analysis showed a statistically significant relationship between mean intracranial pressure (ICP) as well as cerebral perfusion pressure (CPP) with both states of basal cistern and the degree of diffuse injury and oedema based on the Marshall classification system. The ICP was higher while CPP and compliance were lower whenever the basal cisterns were effaced in cases of cerebral oedema with Marshall III and IV. In comparison, the study revealed lower ICP, higher mean CPP and better mean cerebral compliance if the basal cisterns were opened or the post operative CT brain scan showed Marshall I and II. These findings suggested the surgical evacuation of clots to reduce the mass volume and restoration of brain anatomy may reduce vascular engorgement and cerebral oedema, therefore preventing intracranial hypertension, and improving cerebral perfusion pressure and cerebral compliance. Nevertheless the study did not find any significant relationship between midline shifts and mean ICP, CPP or cerebral compliance even though lower ICP, higher CPP and compliance were frequently observed when the midline shift was less than 0.5 cm. As the majority of our patients had multiple and diffuse brain injuries, the absence of midline shift did not necessarily mean lower ICP as the pathology was bilateral and even when after excluding the multiple lesions, the result remained insignificant. We assumed that the CT brain scan obtained after evacuation of the mass lesion to assess the state basal cistern and classify the diffuse oedema may prognosticate the intracranial pressure and cerebral perfusion pressure thus assisting in the acute post operative management of severely head injured patients. Hence post operative CT brain scans may be done to verify the ICP and CPP readings postoperatively. Subsequently, withdrawal of sedation for neurological assessment after surgery could be done if the CT brain scan showed an opened basal cistern and Marshall I and II coupled with ICP of less than 20 mmHg.

Matched MeSH terms: Craniocerebral Trauma/surgery*
Severe head injury management in a general surgical department

Visvanathan R

Aust N Z J Surg, 1994 Aug;64(8):527-9.
PMID: 8048888

Sixty-nine severely head-injured patients treated by general surgeons over a 28 month period with admission Glasgow Coma Scale motor scores of 3 to 8 were reviewed retrospectively. Fifty-one patients were comatose on admission with periods from injury to admission exceeding 4 h in 34 patients who were referred from peripheral hospitals. Forty patients with acute intracranial bleeding underwent emergency decompressive surgery with 13 good recoveries and 18 deaths; good recoveries were observed in 11 of 20 patients with extradural haemorrhages, one out of eight patients with subdural haemorrhages, and one of 12 patients with intracerebral and/or combined haemorrhages. Twenty-nine patients with no evidence of acute mass lesions were treated medically with sedation, mechanical ventilation and mannitol infusion for cerebral decompression with seven good recoveries and 16 deaths. There were 15 good outcomes in 40 patients with admission motor scores of 6, 7 or 8 and five good outcomes in 29 patients with scores of 3, 4 or 5. A good outcome of 29% in the study may be improved by (i) better neurosurgical training of surgical and nursing staff; (ii) provision of technologically advanced diagnostic and treatment modalities; (iii) an efficient referral system; and (iv) provision of effective long-term rehabilitation.

Matched MeSH terms: Craniocerebral Trauma/surgery*
The estimated cost of surgically managed isolated traumatic head injury secondary to road traffic accidents

You X, Liew BS, Rosman AK, Dcsn, Musa KI, Idris Z

Neurosurg Focus, 2018 05;44(5):E7.
PMID: 29712526 DOI: 10.3171/2018.1.FOCUS17796

OBJECTIVE Traumatic brain injury due to road traffic accidents occurs mainly in the younger age group in which injury-related disability leads to long-term impact on employment and economic and social consequences across the lifespan. This study was designed to assign a monetary cost (in Malaysian ringgits [RM]) to the treatment of patients with surgically treated isolated traumatic head injury as determined up to 1 year after injury. METHODS Relevant resource items used were identified and valued using the direct measurement of costs method, cost accounting methods, standard unit costs method, fees, charges and/or market prices method. These values were then tabulated to generate the total costs for each patient, via a combination of macro-costing and micro-costing methods. Malaysian currency values were converted to US dollars according to the average conversion rate for the period from January to May 2016: RM1 = US$0.2452. RESULTS This costing study analyzed data from 49 patients. The estimated cost for the 1st year of care for all patients was RM1,471,919.80 (US$360,914.735), with a mean (± SD) cost per case of RM30,039.18 ± 22,986.25 or $7365.61 ± $5636.23. The mean cost of care per case was RM11,041.35 ± 10,936.88 or $2707.34 ± $2681.72 for mild head injury, RM32,550.00 ± 20,998.76 or $7981.26 ± $5148.90 for moderate head injury, and RM36,917.86 ± 23,697.34 or $9052.26 ± $5810.59 for severe head injury. Severe head injury (p = 0.001), sustaining 2 or more intracranial pathologies (p = 0.01), having a poor Glasgow Outcome Scale (GOS) score (GOS score 1-3) (p = 0.02), requiring a tracheostomy (p < 0.001), and contracting pneumonia (p < 0.001) were significantly associated with higher cost. Logistic regression analysis revealed that cost of care increased by RM591.60 or $145.06 per year increment of age (β = RM591.60, p = 0.05). CONCLUSIONS The mean cost of treatment for traumatic head injury is high compared to the per capita income of RM37,900 in 2016. The cost values generated in this study provide baseline cost estimates that the authors hope will be used as a guide to determine where adequate funding should be allocated to provide timely and appropriate delivery of care.

Matched MeSH terms: Craniocerebral Trauma/surgery*
Fulltext Neurosurgical Services in the Northern Zone of Sarawak in Malaysia: The Way Forward Amid the COVID-19 Pandemic

Low PH, Mangat MS, Liew DNS, Wong ASH

World Neurosurg, 2020 12;144:e710-e713.
PMID: 32949798 DOI: 10.1016/j.wneu.2020.09.045

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has set a huge challenge to the delivery of neurosurgical services, including the transfer of patients. We aimed to share our strategy in handling neurosurgical emergencies at a remote center in Borneo island. Our objectives included discussing the logistic and geographic challenges faced during the COVID-19 pandemic.
METHODS: Miri General Hospital is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the health care workers involved was determined.
RESULTS: During the initial 6 weeks of the Movement Control Order in Malaysia, there were 50 urgent neurosurgical consultations. Twenty patients (40%) required emergency surgery or intervention. There were 9 vascular (45%), 5 trauma (25%), 4 tumor (20%), and 2 hydrocephalus cases (10%). Eighteen patients were operated at Miri General Hospital, among whom 17 (94.4%) survived. Ninety percent of anticipated transfers were avoided. None of the medical staff acquired COVID-19.
CONCLUSIONS: This framework allowed timely intervention for neurosurgical emergencies (within a safe limit), minimized transfer, and enabled uninterrupted neurosurgical services at a remote center with difficult access to neurosurgical care during a pandemic.

Matched MeSH terms: Craniocerebral Trauma/surgery*
Superior long term functional and scar outcome of Meek micrografting compared to conventional split thickness skin grafting in the management of burns

Lee SZ, Halim AS

Burns, 2019 09;45(6):1386-1400.
PMID: 31054957 DOI: 10.1016/j.burns.2019.04.011

INTRODUCTION: Autologous skin grafting is the mainstay of treatment in burn patients. Extensive full thickness burns remains a challenge to the burns surgeon due to the lack of autologous skin donor sites. The conventional split thickness skin grafting (SSG) and the Meek micrografting (Meek) technique are part of the armamentarium of the burns surgeon to curtail the challenge of paucity of donor sites. With advances in burn care, mortality rates of burn patients have reduced. As a result, with more patients surviving acute burn, there is a paradigm shift of research towards assessment of functional outcomes and quality of life of the burn survivors. As there is lack of research regarding the functional outcome of the Meek technique, this study was designed to examine the long term functional outcome of the Meek technique and SSG in burns.
METHOD: A cross-sectional study was conducted in Hospital Universiti Sains Malaysia to assess patients with burns between 10 to 40% total body surface area (TBSA) and with at least one year after injury. The Burn Specific Health Score-brief (BSHS-B) was utilized to compare the functional outcome whilst the Vancouver Scar Scale (VSS) was used for comparison on the scar outcome of the two skin grafting techniques.
RESULTS: Forty three patients (Meek,15; SSG,28) were included. The mean current age (years old) of Meek and SSG was 24.7 (range, 7-75) and 25.9 (range, 7-65) respectively. The mean TBSA (%) of the Meek group was 26.7 (range, 13-40) while that of the SSG group was 16.1 (range, 10-32). A simplified domain structure was used for the BSHS-B questionnaire. The work and sexuality subscale were analyzed separately due to missing data. There mean scores of affect and relations was higher in Meek compared to SSG (Meek, 3.86; SSG, 3.75; p > 0.05). Function domain was also better in Meek compared to SSG (Meek, 3.88; SSG, 3.73; p > 0.05). The Meek group displayed superior scar outcome compared to SSG as evidenced by the statistically significant difference in score for the pigmentation, pliability, height and total VSS score.
CONCLUSION: The Meek group showed more favorable BSHS-B scores compared to the SSG group. The scar outcome of the Meek technique is significantly superior to SSG. Therefore, the Meek technique is superior in the management of burns because the long term scar and functional outcome of this technique is better compared to conventional SSG.

Matched MeSH terms: Craniocerebral Trauma/surgery
Retained haemodialysis-catheter guidewire in the head and neck: a multidisciplinary team approach

Xiao Hong C, Abd Wahab S, Azman M

BMJ Case Rep, 2020 Oct 27;13(10).
PMID: 33109696 DOI: 10.1136/bcr-2020-236484

Penetrating foreign body in the head and neck can be catastrophic from injury to the constellation of vascular and neural structures in the neck. Early recognition and prompt surgical intervention is imperative to save lives. Herein, we present an unusual case of iatrogenic foreign body-a coiled guidewire embedded in the deep neck space. The complications, radiological investigation and multidisciplinary surgical management are further discussed.

Matched MeSH terms: Craniocerebral Trauma/surgery
Preliminary report on spiegelberg pre and post-operative monitoring of severe head-injured patients who received decompressive craniectomy

Abdullah J, Zamzuri I, Awang S, Sayuthi S, Ghani A, Tahir A, et al.

Acta Neurochir. Suppl., 2005;95:311-4.
PMID: 16463872

The monitoring of craniospinal compliance is uncommonly used clinically despite it's value. The Spiegelberg compliance monitor calculates intracranial compliance (C = deltaV/deltaP) from a moving average of small ICP perturbations (deltaP) resulting from a sequence of up to 200 pulses of added volume (deltaV = 0.1 ml, total V = 0.2 ml) made into a double lumen intraventricular balloon catheter. The objective of this study was thus to determine the effectiveness of the decompressive craniectomy done on the worst brain site with regard to compliance (Cl), pressure volume index (PVI), jugular oximetry (SjVo2), autoregulation abnormalties, brain tissue oxygen (TiO2) and cerebral blood flow (CBF). This is a prospective cohort study of 17 patients who were enrolled after consent and approval of the ethics committee between the beginning of the year 2001 and end of the year 2002. For pre and post assessment on compliance and PVI, all 12 patients who survived were reported to become normal after decompressive craniectomy. There is no significant association between pre and post craniectomy assessment in jugular oxymetry (p > 0.05), autoregulation (p > 0.05), intracranial brain oxymetry (p = 0.125) and cerebral blood flow (p = 0.375). Compliance and PVI improved dramatically in all alive patients who received decompressive craniectomy. Compliance and PVI monitoring may be crucial in improving the outcome of severe head injured patients after decompressive craniectomy.

Matched MeSH terms: Craniocerebral Trauma/surgery*