Method: This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months.
Results: Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368).
Conclusion: In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.
Methods: This was a retrospective observational study. A total of 44 consecutive patients who were admitted to Sarawak General Hospital from January 1, 2018, to September 30, 2018, with severe TBI were included. Data were collected from discharge summaries and hospital medical records. Chi-square and t test were used. SPSS was employed.
Results: Of a total of 44 patients with severe TBI, 18 patients (41%) died during the same admission. The mean age of patients was 37.1 years with 93.2% of affected patients being male. 56.9% of patients presented with a Glasgow Coma Scale (GCS) of 6 and less. A large percentage (86.3%) were discharged with a GOSE of less than 7. Older age and low admission GCS (6 and less) were significantly associated with poor GOSE scores on discharge and after 6 months (p < 0.05) on multivariate analysis. Leucocytosis on admission was also associated with poor outcomes where patients with higher total white counts on presentation attaining lower GOSE scores (p < 0.05).
Conclusion: We concluded that leucocytosis was significantly associated with poor outcomes in severe TBI patients in addition to other factors such as advanced age and poor GCS on arrival.
Methods: A prospective cohort study of all patients in Hospital Kuala Lumpur, Malaysia, who presented with the clinical diagnosis of a large MCA infarction within 48 h of onset were subjected to CT brain, and CTP scans on admission and were followed up to determine the development of malignant infarction requiring surgical decompression.
Results: CTP parameters were generally lower in patients with malignant brain infarct (MBI) group compared to the nonMBI group. The largest mean difference between the group was noted in the TTP values (P = 0.005). CTP parameters had a comparable positive predictive value (83%-90%) and high net present value (88-93). CBF with cutoff value of >32.85 of the hemisphere could accurately predict malignant infarctions in 81.4% of cases. The National Institutes of Health Stroke Scale score of more than 13.5 was also found to be able to accurately determine malignant infarct (97.6%). Functional outcome of patients based on Glasgow outcome scale was similar on discharge, however, showed improvement at 6 months during reviewed base on modified Rankin scale (P < 0.001).
Conclusion: CTP parameters should be included in the initial evaluation of patients to predict malignant brain infarction and facilitate surgical treatment of large MCA infarctions.
Key messages: CT perfusion parameters have an important role in predicting malignant brain infarction and should be included in the initial evaluation of patients to facilitate the early identification and surgical treatment of large middle cerebral artery infarctions, to improve patient's prognosis.
METHODOLOGY: A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013-April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0.
RESULTS: A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm(3). The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH.
CONCLUSION: We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.
Methods: A total of 110 severe TBI patients, aged 18-60, who underwent emergency brain surgery were randomised into Group T (TCI) (n = 55) and Group S (sevoflurane) (n = 55). Anaesthesia was maintained in Group T with propofol target plasma concentration of 3-6 μg/mL and in Group S with minimum alveolar concentration (MAC) of sevoflurane 1.0-1.5. Both groups received TCI remifentanil 2-8 ng/mL for analgesia. After the surgery, patients were managed in the intensive care unit and were followed up until discharge for the outcome parameters.
Results: Demographic characteristics were comparable in both groups. Differences in Glasgow Outcome Scale (GOS) score at discharge were not significant between Group T and Group S (P = 0.25): the percentages of mortality (GOS 1) [27.3% versus 16.4%], vegetative and severe disability (GOS 2-3) [29.1% versus 41.8%] and good outcome (GOS 4-5) [43.6% versus 41.8%] were comparable in both groups. There were no significant differences in other outcome parameters.
Conclusion: TCI propofol and sevoflurane anaesthesia were comparable in the outcomes of TBI patients after emergency surgery.
METHODS: Twenty-eight patients with severe TBI (GCS ≤ 8, three patients had initial GCS = 9-10, but rapidly deteriorated to ≤8) were recruited. CSF was collected from admission to day 5 post-injury. TRP, kynurenine (KYN), kynurenic acid (KYNA), QUIN, anthranilic acid (AA) and 3-hydroxyanthranilic acid (3HAA) were measured in CSF. The Glasgow Outcome Scale Extended (GOSE) score was assessed at 6 months post-TBI. Post-mortem brains were obtained from the Australian Neurotrauma Tissue and Fluid Bank and used in qPCR for quantitating expression of KP enzymes (indoleamine 2,3-dioxygenase-1 (IDO1), kynurenase (KYNase), kynurenine amino transferase-II (KAT-II), kynurenine 3-monooxygenase (KMO), 3-hydroxyanthranilic acid oxygenase (3HAO) and quinolinic acid phosphoribosyl transferase (QPRTase) and IDO1 immunohistochemistry.
RESULTS: In CSF, KYN, KYNA and QUIN were elevated whereas TRP, AA and 3HAA remained unchanged. The ratios of QUIN:KYN, QUIN:KYNA, KYNA:KYN and 3HAA:AA revealed that QUIN levels were significantly higher than KYN and KYNA, supporting increased neurotoxicity. Amplified IDO1 and KYNase mRNA expression was demonstrated on post-mortem brains, and enhanced IDO1 protein coincided with overt tissue damage. QUIN levels in CSF were significantly higher in patients with unfavourable outcome and inversely correlated with GOSE scores.
CONCLUSION: TBI induced a striking activation of the KP pathway with sustained increase of QUIN. The exceeding production of QUIN together with increased IDO1 activation and mRNA expression in brain-injured areas suggests that TBI selectively induces a robust stimulation of the neurotoxic branch of the KP pathway. QUIN's detrimental roles are supported by its association to adverse outcome potentially becoming an early prognostic factor post-TBI.