Radiological prediction of contralateral extradural haematoma following evacuation of traumatic acute subdural haematoma

OBJECTIVES

To identify radiological predictors of contralateral extradural haematoma (CEDH) in patients undergoing evacuation of acute subdural haematoma (ASDH).

DESIGN

Retrospective case-control study.

SUBJECTS

Patients requiring evacuation of traumatic ASDH via craniotomy/craniectomy with contralateral skull fracture were analysed in two groups: those who developed CEDH postoperatively and those who did not.

MATERIALS AND METHODS

Retrospective analysis of severe traumatic brain injury admissions over 24 months (2017-2019) at a major trauma centre. Pre- and post-operative CT scans were reviewed by a Consultant Neuroradiologist for initial fracture haematoma (FH) and specific contralateral skull fracture features (CLFF) comprising: complex petrous fracture, suture diastasis and fractures involving foramen spinosum or middle meningeal groove (MMG).

RESULTS

35 patients had ASDH evacuation (age: 11-74); 7 with craniotomy, 28 with craniectomy. 9/35 developed CEDH of whom 7 underwent bilateral craniotomy/craniectomy. 8/9 with CEDH had FH, 6/26 of those without CEDH had FH. All patients with CEDH had CLFF. 6/9 had >1 CLFF. CLFF was identified in 9/26 patients without CEDH and only 3/26 non-CEDH had >1 CLFF. Analysis using univariate logistic regression identified statistically significant factors for the development of CEDH which were: younger age, FH on initial CT, increasing number of CLFF and MMG involvement alone. After multivariate analysis, only younger age and FH were significant.

CONCLUSIONS

FH and CLFF on CT enable prediction of CEDH in patients undergoing evacuation of traumatic ASDH. These features raise a high index of suspicion for this complication and may expedite investigation and management for CEDH.

Aneurysm management in patients over 80 years old with good grade subarachnoid haemorrhage

BACKGROUND

An increasing proportion of aneurysmal subarachnoid haemorrhage (aSAH) occurs in older patients, in whom there is widespread variability in treatment rates due to a different balance of risks. Our aim was to compare outcomes of patients over 80 years old with good grade aSAH who underwent treatment of their aneurysm with those who did not.

METHODS

Adult patients with good grade aSAH admitted to tertiary regional neurosciences centres contributing to the UK and Ireland Subarachnoid Haemorrhage Database (UKISAH) and a cohort of consecutive patients admitted from three regional cohorts were included for analysis. Outcomes were functional outcome at discharge, three months and survival at discharge.

RESULTS

In the UKISAH, patients whose aneurysm was treated were more likely to have a favourable outcome at discharge (OR 2.34, CI 1.12-4.91, p = .02), at three months (OR 2.29, CI 1.11-4.76, p = .04), and lower mortality (10% vs. 29%, OR 0.83, CI 0.72-0.94, p < .01). In the regional cohort, a similar pattern was seen, but after correction for frailty and comorbidity there was no difference in survival (HR 0.45, CI 0.12-1.68, p = .24) or favourable outcome at discharge (OR 0.83, CI 0.23-2.94, p = .77) and at three months (OR 1.03, CI 0.25-4.29, p = .99).

CONCLUSIONS

Better early functional outcomes in those undergoing aneurysm treatment appear to be explained by differences in frailty and comorbidity. Therefore, treatment decisions in this patient group are finely balanced with no clear evidence overall of either benefit or harm in this cohort.

A survey of the radiological follow-up of unruptured intracranial aneurysms in the United Kingdom

OBJECTIVE

Unruptured intracranial aneurysms (UIA) are common. For many the treatment risks outweigh their risk of subarachnoid haemorrhage and patients undergo surveillance imaging. There is little data to inform if and how to monitor UIAs resulting in widely varying practices. This study aimed to determine the current practice of unruptured UIA surveillance in the United Kingdom.

METHODS

A questionnaire was designed to address the themes of surveillance protocols for UIA including when surveillance is initiated, how frequently it is performed, and when it is terminated. Additionally, how aneurysm growth is managed and how clinically meaningful growth is defined were explored. The questionnaire was distributed to members of the British Neurovascular Group using probability-based cluster and non-probability purposive sampling methods.

RESULTS

Responses were received from 30 of the 30 (100.0%) adult neurosurgical units in the United Kingdom of which 27 (90.0%) routinely perform surveillance for aneurysm growth. Only four units had a unit policy. The mean patient age up to which a unit would initiate follow-up of a low-risk UIA was 65.4 ± 9.0 years. The time points at which imaging is performed varied widely. There was an even split between whether units use a fixed duration of follow-up or an age threshold for terminating surveillance. Forty percent of units will follow-up patients more than 5 years from diagnosis. The magnitude in the change in size that was felt to constitute growth ranged from 1 to 3mm. No units routinely used vessel wall imaging although 27 had access to 3T MRI capable of performing it.

CONCLUSIONS

There is marked heterogeneity in surveillance practices between units in the United Kingdom. This study will help units better understand their practice relative to their peers and provide a framework forplanning further research on aneurysm growth.

Traumatic Brain Injuries: Comprehensive Management of Complex Clinical Scenarios

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Prognosticating outcome using magnetic resonance imaging in patients with moderate to severe traumatic brain injury: a machine learning approach

INTRODUCTION

Over the last decade advancements in computer processing have enabled the application of machine learning (ML) to complex medical problems. Convolutional neural networks (CNN), a type of ML, have been used to interrogate medical images for variety of purposes. In this study, we aimed to investigate the potential application of CNN in prognosticating patients with traumatic brain injury (TBI).

METHODS

Patients with moderate to severe TBI and evidence of diffuse axonal injury (DAI) were selected retrospectively. A CNN model was developed using a training subgroup and a holdout subgroup was used as a testing dataset. We reported the model characteristics including area under the receiver operating characteristic curve (AUC).

RESULTS

We included a total of 38 patient, of which we generated 725 MRI sections. We developed a CNN model based on a modified AlexNet architecture that interpreted the brain stem injury to generate outcome predictions. The model was able to predict GOS outcomes with a specificity of 0.43 and a sensitivity of 0.997. It showed an AUC of 0.917.

CONCLUSION

The utilization of machine learning MRI analysis for prognosticating patients with TBI is a valued method that require further investigation. This will require multicentre collaboration to generate large datasets.

Venous sinus thrombosis in traumatic brain injury: a major trauma centre experience

BACKGROUND

This study explores the presentation, management and outcomes of traumatic venous sinus thrombosis (VST) and identifies risk factors associated with poor outcomes.

METHODS

This study is a retrospective review of all patients with VST secondary to trauma who presented to a major trauma centre, between April 2015 and January 2020. VST was confirmed by CT venogram and a consultant neuroradiologist.

RESULTS

Forty-six patients were identified (38 male), mean age of 43 (range 12-78) and median follow-up 10.2 months (range 0.7-39.1). Fifty-two percent presented as a severe traumatic brain injury, and all had an associated skull fractures overlying the sinus. Ninety-six percent had cerebral contusions, 96% had an intracranial haematoma, 91% had traumatic subarachnoid haemorrhage (tSAH) and 22% had acute cerebral infarction. Thirty-seven percent of the VSTs were occlusive. Fifty-eight percent had sustained, unprovoked intracranial pressure (ICP) spikes (> 20 mmHg). Fifty percent underwent surgical intervention-20% external ventricular drain and 46% craniotomy/craniectomy. Nine percent were treated with anticoagulation and 4% with antiplatelets, at a median of 13.5 days and 9.5 days post-injury, with no additional complications. Age > 60 was associated with poor outcome (GOS of 3-5) (p = 0.0098). On follow-up CT, 52% of the VSTs remained unchanged, 29% re-canalised, 14% improved and 5% worsened, independent of treatment.

CONCLUSIONS

This study demonstrated a higher incidence of VST in severe TBI and strong associations with skull fractures, cerebral contusions, tSAH, raised ICP and surgical intervention. Management was inconsistent, with no difference in outcome with or without anticoagulation. Larger, prospective cohort studies are needed to better understand this condition and establish evidence-based guidelines.

Improving Neurosurgery Education Using Social Media Case-Based Discussions: A Pilot Study

BACKGROUND

The increasing shift toward a more generalized medical undergraduate curriculum has led to limited exposure to subspecialties, including neurosurgery. The lack of standardized teaching may result in insufficient coverage of core learning outcomes. Social media (SoMe) in medical education are becoming an increasingly accepted and popular way for students to meet learning objectives outside formal medical school teaching. We delivered a series of case-based discussions (CbDs) over SoMe to attempt to meet core learning needs in neurosurgery and determine whether SoMe-based CbDs were an acceptable method of education.

METHODS

Twitter was used as a medium to host 9 CbDs pertaining to common neurosurgical conditions in practice. A sequence of informative and interactive tweets were formulated before live CbDs and tweeted in progressive order. Demographic data and participant feedback were collected.

RESULTS

A total of 277 participants were recorded across 9 CbDs, with 654,584 impressions generated. Feedback responses were received from 135 participants (48.7%). Participants indicated an increase of 77% in their level of knowledge after participating. Of participants, 57% (n = 77) had previous CbD experience as part of traditional medical education, with 62% (n = 84) receiving a form of medical education previously through SoMe. All participants believed that the CbDs objectives were met and would attend future sessions. Of participants, 99% (n = 134) indicated that their expectations were met.

CONCLUSIONS

SoMe has been shown to be a favorable and feasible medium to host live, text-based interactive CbDs. SoMe is a useful tool for teaching undergraduate neurosurgery and is easily translatable to all domains of medicine and surgery.

435 THE IMPACT OF COMPREHENSIVE GERIATRIC ASSESSMENT IN THE OUTCOMES OF OLDER ACUTE NEUROSURGICAL PATIENTS

Introduction

As the population ages, an increasing proportion of the neurosurgical caseload is comprised of older patients. This trend is reinforced by technical advances and anaesthetic considerations within the field, allowing a higher proportion of patients eligible for surgery. Comprehensive geriatric assessment (CGA) is the gold standard clinical approach for evaluating older patients. Peri-operative care of older people (POPS) has provided strong evidence that CGA services can result in fewer post-operative complications. However, this evidence stems largely from trauma and orthopaedic surgery. Currently, there is little evidence of the impact CGA has on older neurosurgical patients. The study aimed to investigate whether CGA for older neurosurgical patients improved outcomes such as thirty-day mortality and length of stay.

Methods

A control group was established by collecting retrospective data for all acute neurosurgical patients over the age of 65. This was then compared with an intervention group who received CGA in the form of regular geriatric consultant reviews. 49 patients were recruited into each group.

Results

Analysis showed that the interventional group had a significantly higher mean age and level of frailty. They also had more confirmed complications with a significant difference in the diagnosis of pneumonia (p = 0.05) and hyponatremia (p = 0.015). Despite this, the thirty-day mortality was lower and average length of stay was on average two days shorter compared to the control group, although this did not reach statistical significance (p = 0.701). The study showed that more patients who received a CGA were discharged home (p = 0.209).

Conclusion

Our findings suggest that CGA input for older neurosurgical patients improves outcomes and should be incorporated routinely into neurosurgical clinical pathways.

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.

P14 Management of traumatic skull base fractures and their complications – a seven-year experience

Objectives

We aim to present our experience of managing traumatic base of skull fractures and our outcomes.

Design

Retrospective case note review.

Subjects

All patients in our trauma database with radiographic evidence of a skull base fracture from January 2010 to June 2017.

Methods

Skull base fractures were classified according to their anatomical location. Evidence of vascular injury, CSF leak or cranial nerve injury were recorded. The mechanism of injury, length of follow up, interventions and outcomes were documented.

Results

872 cases had a skull base fracture diagnosed by head CT scan, of which 760 had sufficient radiological and clinic data to analyse. 79.4% of the cohort were male, with a mean age of 43 years. Median length of stay was 8 days and median length of follow up was 114 days. 40.1% were lost to follow up. The mortality rate was 14.9%. Injuries predominantly affected the middle cranial fossa. Vascular injury was the commonest complication (n=87), followed by CSF leak (n=38). 28 patients sustained injury to the facial nerve. Complications were managed conservatively in most cases.

Conclusions

There is little reported literature on the long term outcomes of patients who sustain CSF leak, vascular injury or cranial nerve deficit following a base of skull fracture. In our experience, many of these patients are lost to follow up and indeed, the nature of this study is limited by it’s retrospective nature. Further prospective work must be done in this patient group to better understand the history of these patients.

TP1-7 Extended glasgow outcome scale – when would you rather die?

Objectives

Extended Glasgow Outcome Scale is the primary outcome measure in trials involving neurotrauma patients. Conventional dichotomization characterises unfavourable outcomes as upper severe disability or worse, however RESCUE-ICP changed this to consider upper severe disability as a favourable outcome. As the recent consensus meeting in Cambridge proved, opinion of what constitutes acceptable recovery can vary widely between individuals.

Design

To survey patients with brain injury and compare them to the opinions of staff routinely involved in the care of such patients.

Subjects

Patients with brain injuries, neurosurgery staff and ITU staff.

Method

GOS-E sheets were given to neurotrauma patients and asked to circle the outcome they considered unfavourable and therefore would rather not survive. This was compared to the same question posed to neurosurgery staff members, and ITU staff members.

Results

67 responses collected (20 patients, 27 neurosurgery staff, 20 ITU staff). Mean GOS-E score deemed unfavourable and therefore not worth survival was 3.6, mode 3 (Patient mean 3.15, mode 3. Neurosurgery mean 3.63, mode 4. ITU mean 4.0, mode 5. p>0.05).

Conclusion

What constitutes unfavourable outcome varies between each group of people questioned. Patients who have experienced brain injuries were more likely to feel that upper severe disability was an acceptable outcome when compared to the staff that care for them. It is imperative we take this in to consideration when recommending treatment strategies in an acute setting.

Vessel wall enhancement of a ruptured intra-nidal aneurysm in a brain arteriovenous malformation

Ruptured arteriovenous malformations are a frequently encountered pathology with significant associated morbidity and mortality. Identifying and securing the rupture point is mandatory; however, this can often be difficult. Black blood vessel wall magnetic resonance imaging is a promising technique for identifying ruptured saccular aneurysms and has been used in cases of multiple aneurysms. Here we describe a case of using this imaging technique to identify the rupture point in a ruptured arteriovenous malformation with histopathological correlation.

Spinal epidural hematoma caused by pseudogout: a case report and literature review

Study Design Case report. Objective We present the first reported case of spontaneous spinal epidural hematoma secondary to calcium pyrophosphate crystal deposition disease (pseudogout) in a 75-year-old woman. Methods A retrospective review of the patient's case notes was undertaken and the limited literature on this subject reviewed. Results This patient presented with sudden-onset lower limb paresis, sensory loss, urinary retention, and back pain. Magnetic resonance imaging showed an epidural hematoma, which was evacuated. Histologic specimens of the clot showed calcium pyrophosphate dihydrate crystal deposits (pseudogout). Conclusion The importance of histopathologic review of surgical specimens is highlighted when considering the differential diagnosis of apparently spontaneous spinal epidural hematoma.

Suppression of macrophage function by suture materials and anastomotic recurrence of Crohn's disease

After surgical excision of bowel, Crohn's disease is likely to recur around the anastomosis. It is suggested that this may indicate a biological effect of suture materials on gastrointestinal immunology. To investigate this, the influence of six suture materials on the function of macrophages obtained from the rat peritoneal cavity and human intestinal mucosa was assessed. All materials significantly impaired macrophage function.

Experimental carcinogenesis at sutured and sutureless colonic anastomoses

This study explores the role of sutures and the healing colonic wound in experimental carcinogenesis. One hundred sixty rats underwent surgery with colotomy and repair using silk, steel, or Vicryl (Ethicon, Somerville, NJ) sutures or a sutureless technique. Forty rats had a sham procedure. All animals received azoxymethane for 12 weeks at a dose of 10 mg/kg/week. Half the rats commenced carcinogen before surgery, and half commenced it eight weeks after surgery. Animals with anastomotic tumors were found in 46 percent of the sham group (P less than 0.05 cf. sutured), 41 percent of the sutureless group (P less than 0.02 cf. sutured), and 68 percent of the sutured group. The corresponding figures for anastomotic carcinoma were 9 percent (P less than 0.001 cf. sutured), 22 percent, and 38 percent. No significant differences in tumor yield were noted among the different sutures. However, several differences were noted between the two carcinogen models. In those animals that received surgery first, there was a higher incidence of anastomotic tumors (P less than 0.002) and cancers (P less than 0.0001) in the sutured and sutureless groups, and those tumors that occurred in the sutured group were considerably larger than in those that had carcinogen first (15.9 mm cf. 4.9 mm; P less than 0.0001). Overall, all sutures seem to enhance anastomotic tumor formation, and we would suggest that a sutureless anastomosis may diminish this risk.