Clinical outcomes of SMILE and WFG-LASIK used to treat myopia and astigmatism: A systematic review and meta-analysis

PURPOSE

To evaluate the safety, efficacy and postoperative visual quality of small incision lenticule extraction (SMILE) and Wavefront-Guided Laser in situ keratomileusis (WFG-LASIK) and to analyze their efficacy in correcting astigmatism.

METHODS

A systematic literature search was performed using Cochrane Collaboration methodology. Databases searched included PubMed, Embase, the Cochrane Library and Web of Science. RevMan software version 5.3.0 was used for meta-analysis.

RESULTS

A total of 976 eyes were included in 8 studies, of which 539 eyes underwent SMILE and 437 eyes underwent WFG-LASIK. There were no statistically significant differences in the proportion of eyes achieving uncorrected distance visual acuity of 20/20 or better (P=0.18), the proportion of eyes within±0.50 diopter of target refraction postoperatively (P=0.10), or the postoperative magnitude of cylinder (P=0.10). Regarding the Alpins vector analysis of astigmatism, there was no statistically significant difference in the surgical magnitude of error (P=0.09) between the two groups. WFG-LASIK has a lower surgical angle of error (P= 0.002) and higher surgical correction index of cylinder (P=0.03) than SMILE. In terms of aberrations, higher order aberrations (P=0.46), spherical aberrations (P=0.22) and trefoil (P=0.56) were not statistically different, while WFG-LASIK induced less coma than SMILE surgery (P=0.02).

CONCLUSION

Both SMILE and WFG-LASIK are safe and effective ways to correct myopia and astigmatism. Compared with SMILE, WFG-LASIK has a lower surgical angle of error, higher surgical correction index of cylinder and induces less coma.

The comparison of corneal higher-order aberration and surgically induced astigmatism between the clear corneal incision and the limbus tunnel incision of posterior chamber implantable collamer lens implantation

BACKGROUND

This study aimed to compare the corneal high-order aberrations and surgically induced astigmatism between the clear corneal incision and limbus tunnel incision for posterior chamber implantable collamer lens (ICL/TICL) implantation.

METHODS

A total of 127 eyes from 73 myopic patients underwent ICL V4c implantation, with 70 eyes receiving clear corneal incisions and 57 eyes receiving limbus tunnel incisions. The anterior and back corneal surfaces were measured and the Root Mean Square of all activated aberrations (TRMS) was calculated, including higher-order aberration (HOA RMS), spherical aberration Z40, coma coefficients (Coma RMS) Z3-1 Z31, and surgically induced astigmatism (SIA). The measurements were taken preoperatively and postoperatively at 1 day, 1 week, and 1, 3, and 6 months. In this study, the corneal higher-order aberration was estimated as the Zernike coefficient calculated up to 5th order. The measurements were taken at a maximum diameter of 6.5 mm using Pentacam.

RESULTS

One week after the operation, the corneal back Z31 of the clear corneal incision group was 0.06 ± 0.06, while the limbus tunnel incision group showed a measurement of 0.05 ± 0.06 (p = 0.031). The corneal back Z40 of the clear corneal incision group was -0.02 ± 0.25, compared to -0.04 ± 0.21 in the limbus tunnel incision group (p = 0.01). One month after the operation, the corneal back SIA of the clear corneal incision group was 0.11 ± 0.11, compared to 0.08 ± 0.11of the limbus tunnel incision group (p = 0.013), the corneal total SIA of the clear corneal incision group was 0.33 ± 0.30, compared to 0.15 ± 0.16 in the limbus tunnel incision group (p = 0.004); the clear corneal incision group exhibited higher levels of back astigmatism and total SIA than the limbus tunnel incision in the post-operation one month period. During the 6- month post-operative follow-up period, no significant difference in Z31, Z40, and other HOA RMS data was observed between the two groups. The total SIA of the corneal incision group and the limbus tunnel incision group were 0.24 ± 0.14 and 0.33 ± 0.32, respectively (p = 0.393), showing no significant difference between the two groups 6 months after the operation.

CONCLUSION

Our data showed no significant difference in the high-order aberration and SIA between clear corneal incision and limbus tunnel incision up to 6 months after ICL-V4c implantation.

A new insight into superacute care for type A acute aortic dissection in the Tokyo Acute Aortic Super Network

OBJECTIVE

To determine the status of type A acute aortic dissection using the Tokyo Acute Aortic Super Network.

METHODS

Data of 6283 patients with acute aortic dissection between 2015 and 2019 were collected. Data of 3303 patients with type A acute aortic dissection were extracted for analysis.

RESULTS

Overall, 51.0% of patients were nondirect admissions. On arrival, 23.1% of patients were in shock, 10.0% in cardiopulmonary arrest, and 11.8% in deep coma or coma. Overall, 9.8% of patients were assessed as untreatable. Of 2979 treatable patients, 18.3% underwent medical treatment, whereas 80.7% underwent surgery (open [78.8%], endovascular [1.9%], and peripheral [1.1%] repair). The early mortality rate was 20.5%, including untreatable cases. Among treatable patients, in-hospital mortality rates were 8.6% for open repair, 10.7% for endovascular repair, and 25.3% for medical treatment. Advanced age, preoperative comorbidities, classical dissection, and medical treatment were risk factors for in-hospital mortality. Nondirect admission did not cause increased deaths. The mortality rates were high during the superacute phase following symptom onset.

CONCLUSIONS

This study demonstrated current practices in the emergency care of type A acute aortic dissection via the Tokyo Acute Aortic Super Network system, specifically a high rate of untreatable or inoperable cases and favorable outcomes in patients undergoing surgical treatment. High mortality rates were observed during the super acute phase after symptom onset or hospital arrival.

Neurological event rates and associated risk factors in acute type B aortic dissections treated by thoracic aortic endovascular repair

OBJECTIVES

Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.

METHODS

Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.

RESULTS

Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.

CONCLUSIONS

In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

Moisture chamber goggles for the treatment of postoperative dry eye in patients receiving SMILE and FS-LASIK surgery

BACKGROUND

The incidence of refractive surgery-related dry eye disease (DED) is rising due to the increasing popularity of corneal refractive surgery. The moisture chamber goggles (MCGs) have been shown to tear evaporation by increasing local humidity and minimizing airflow. The current study aims to evaluate the efficacy of moisture chamber goggles for refractive surgery-related DED.

METHODS

In this nonrandomized open-label controlled study, 78 participants (156 eyes) receiving refractive surgery were enrolled between July 2021 and April 2022, and sequentially allocated to MGC and control groups. 39 participants were allocated to the MGC groups, of which 53.8% received small-incision lenticule extraction (SMILE) and 46.2% received femtosecond laser-assisted in situ keratomileusis (FS-LASIK), and were instructed to wear MCGs for the duration of 1 month postoperatively, in addition to the standard postoperative treatment received by the control groups (56.4% SMILE, 43.6% FS-LASIK). Participants underwent full ophthalmic examinations, including visual acuity, manifest refraction, DED evaluations, and higher-order aberrations (HOAs), both preoperatively and at routine follow-ups 1 day, 1 week, and 1 month after surgery. DED parameters included non-invasive tear film break-up time (NIBUT), tear meniscus height (TMH), conjunctival congestion, lipid layer thickness (LLT), and ocular surface disease index (OSDI) questionnaires. Student's t-test was used for comparisons between control and MCG groups, and between preoperative and postoperative parameters within groups.

RESULTS

Postoperative NIBUT decreased in both SMILE and FS-LASIK control groups 1 day after the surgery (SMILE, P = 0.001; FS-LASIK, P = 0.008), but not in the corresponding MCG groups (SMILE, P = 0.097; FS-LASIK, P = 0.331). TMH in the MCG group was significantly higher at 1 week (P = 0.039) and 1 month (P = 0.015) in SMILE, and 1 day (P = 0.003) in FS-LASIK groups. In FS-LASIK participants, significantly lower HOAs and coma levels in the MCG group were observed 1 day (total HOAs, P = 0.023; coma, P = 0.004) and 1 week (total HOAs, P = 0.010, coma, P = 0.004) after surgery. No consistent statistically significant intergroup difference was observed between MCG and control groups in conjunctival congestion, LLT, and OSDI.

CONCLUSIONS

MCGs effectively slowed tear evaporation, increased tear film stability, and improved HOAs in patients receiving SMILE and FS-LASIK surgeries. MCG is an effective adjuvant therapy in the comprehensive management of refractive surgery-related DED.

Asymmetric All-Femtosecond Laser-Cut Corneal Allogenic Intrastromal Ring Segments

PURPOSE

To describe a novel technique for cutting asymmetric allogenic segments using the femtosecond laser for the management of cases of keratoconus with non-coinciding astigmatism and coma axes.

METHODS

Four eyes of 2 patients with irregular keratoconus and asymmetric allogenic segments were included. Visual, refractive, tomographic, and aberrometric outcomes, and optical coherence tomography (OCT) sections were measured preoperatively and 6 months postoperatively. Evaluations included slit-lamp examination, manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and simulated and maximum anterior keratometry (Kmax) using anterior segment OCT.

RESULTS

Spherical and cylindrical refractive errors decreased from -2.38 ± 2.96 and -2.94 ± 2.16 to -1.81 ± 2.77 (P = .04) and -1.75 ± 2.07 (P = .01) diopters (D), respectively, 6 months postoperatively. There was an average gain of three lines of CDVA. Kmax decreased from 50.02 ± 1.99 to 47.89 ± 3.05 D (P= .03) and coma from 1.05 ± 0.21 to 0.21 ± 0.19 D (P = .01).

CONCLUSIONS

Asymmetric femtosecond laser-cut allogenic segments allow a higher level of customization based on size, shape, and arc length, in contrast to the limited range of available synthetic asymmetrical segments. [J Refract Surg. 2023;39(12):856-862.].

Corneal Higher Order Aberrations and Epithelial Remodeling With Femtosecond Laser-Assisted LASIK Topography-guided and Customized Asphericity Ablation in the Contralateral Eye: A Randomized, Double-Blind, Prospective Study

PURPOSE

To evaluate refractive results, corneal higher order aberrations (HOAs), and epithelial remodeling in the preoperative and postoperative period of regular corneas that had topography-guided femtosecond laser-assisted laser in situ keratomileusis (LASIK) (Contoura WaveLight; Alcon Laboratories, Inc) and compare them with the contralateral eye that underwent ablation customized by asphericity (Custom-Q WaveLight; Alcon Laboratories, Inc) in myopic eyes with or without astigmatism.

METHODS

A prospective, randomized, and double-blind study was conducted. Patients underwent preoperative and postoperative epithelial mapping and corneal tomography to assess the epithelial thickness map, HOAs of the corneal anterior surface, visual acuity, and refractive evaluation.

RESULTS

This study enrolled 96 normal eyes of 48 patients. Uncorrected distance visual acuity of 20/20 or better was achieved in 97% of patients and gains in corrected distance visual acuity and effectiveness in correcting refractive astigmatism were similar in both techniques. Seventeen sectors of the corneal epithelium map were assessed by spectral-domain optical coherence tomography and no significant differences were found between techniques preoperatively and postoperatively (P > .05). HOA root mean square, coma Z3±1, trefoil Z3-3, and tissue consumption exhibited statistically significant between-technique differences (P < .05).

CONCLUSIONS

The Contoura and Custom-Q techniques were similar with respect to refractive and visual outcomes after 3 months, as well as in epithelial remodeling. The Contoura provides lower postoperative HOA root mean square, coma Z3±1, and trefoil Z3-3 values, but the techniques showed no differences in the correction of the corneal astigmatic wavefront component and in the spherical aberration after 3 months. [J Refract Surg. 2023;39(11):751-758.].

Comparing Effective Optical Zones After Myopic Ablation Between LASIK, PRK, and SMILE With Correlation to Higher Order Aberrations

PURPOSE

To explore size, decentration, and eccentricity of effective optical zones (EOZs) in laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and small incision lenticule extraction (SMILE) and correlate them to higher order aberrations (HOAs).

METHODS

This was a retrospective chart review of 188 eyes that underwent refractive surgery for compound myopia (61 LASIK, 84 PRK, 43 SMILE). EOZ measurements were determined using 1-year postoperative Pentacam (Oculus Optikgeräte GmbH) tangential difference maps. HOA data were measured using Pentacam wavefront aberration Zernike polynomials. Correlations between EOZs and HOAs were analyzed.

RESULTS

The EOZs of LASIK and PRK are smaller than SMILE at 19.54 ± 1.44, 19.39 ± 1.66, and 22.18 ± 2.61 mm2, respectively (P < .001). No difference existed in absolute decentration from corneal vertex (P = .078) or pupil center (P = .131), but horizontal and vertical components differed significantly (P < .001). Smaller EOZ areas were correlated with greater spherical aberration induction (rLASIK = -0.378, rPRK = -0.555, rSMILE = -0.501) and total HOA induction in all groups. Absolute decentration from corneal vertex positively correlated with total HOA (rLASIK = 0.396, rPRK = 0.463, rSMILE = 0.399) and directional vertical coma induction negatively correlated with vertical decentration from the corneal vertex (rLASIK = -0.776, rPRK = -0.665, rSMILE = -0.576) in all groups.

CONCLUSIONS

SMILE results in a larger EOZ than LASIK and PRK, and absolute decentration remains comparable regardless of surgical reference center, despite horizontal/vertical differences. Surgical planning to ensure adequate EOZ size and centration may reduce induction of HOAs, including spherical aberrations and vertical coma. [J Refract Surg. 2023;39(11):741-750.].

Is decompressive craniectomy necessary in malignant posterior reversible encephalopathy syndrome with brain edema caused uncal herniation? A case report of reversible coma without surgical decompression

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is considered a benign entity and is usually reversible with only medical management, but persistent neurologic deficits and disability or death can occur without adequate treatment. Favorable outcomes have been associated with surgical decompression in malignant-type PRES in which hemorrhagic transformation or brain stem compression has developed.

CASE DESCRIPTION

Here we report a case of malignant PRES in a 61-year-old female of Asian descent in which the disease rapidly progressed to coma and a near-fatal condition with uncal herniation caused by severe brain edema; however, this patient achieved a dramatic recovery without surgical decompression.

CONCLUSION

After reviewing previous reports regarding malignant PRES, we propose that hemorrhagic transformation is a crucial indicator for surgical decompression and an important prognostic factor in malignant PRES.

Meniscus-Shaped Stromal Lenticule Addition Keratoplasty for Corneal Regularization and Thickening in Advanced Keratoconus

PURPOSE

The aim of this study was to investigate the outcome of the meniscus-shaped stromal lenticule addition keratoplasty (MS-SLAK) in corneal regularization and thickness.

METHODS

Patients waiting for deep anterior lamellar keratoplasty for advanced keratoconus with an intolerance to contact lenses (CLs) underwent the MS-SLAK procedure by FSL 80 kHz ablation (VICTUS, Technolas Perfect Vision, DE). Customized positive meniscus-shaped stromal lenticules were obtained and implanted. Examination was performed at baseline and at 3-, 6-, and 12-month follow-up and included corrected distance visual acuity both with spectacles and CLs (spectacle CDVA and CL-CDVA), manifest refraction spherical equivalent, slit-lamp examination, anterior segment optical coherence tomography, corneal topography, and in vivo confocal microscopy.

RESULTS

Fifteen patients completed the study. Statistical increases in corneal thickness values were found from the first follow-up ( P < 0.001). Improvement in the Surface Asymmetry Index ( P = 0.04), Symmetry Index ( P = 0.02), spherical aberration ( P < 0.001), coma ( P = 0.18), high-order aberration ( P = 0.37), and anterior asphericity index (Q) ( P = 0.31) were found at 12 months. At the 12-month follow-up, no improvement were found in spectacle CDVA ( P = 0.23); however, all patients reported CL wearing tolerance recovery, and significant improvement in CL-CDVA ( P = 0.002) was found. The confocal microscopy at 12 months showed a significant increase in keratocyte density within the lenticule and absence of fibrotic reactions in both anterior and posterior interfaces.

CONCLUSIONS

MS-SLAK seems to be effective in regularizing the corneal surface as showed by the significant improvement in topographic symmetry indices, coma, and high-order aberration. The corneal regularization is also confirmed by the results in anterior Q and the recovery of the CL wearing tolerance.

Comparison of Higher Order Aberrations between Wavefront Optimized Photorefractive Keratectomy and Laser <em>in situ</em> Keratomileusis in Myopic Patients

OBJECTIVE

To compare the higher order aberrations (HOA) between wavefront optimized (WFO) laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) in myopic patients.

STUDY DESIGN

Quasi-experimental study. Place and Duration of the Study: Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan, from December 2021 to December 2022.

METHODOLOGY

Forty-four patients underwent wavefront optimized PRK and fifty-seven patients underwent wavefront optimized LASIK. All variables were recorded before the procedure and at 1, 3, 6, and 12 months postoperatively and included uncorrected visual acuity (UCVA), corrected distance visual acuity (CDVA), root mean square (RMS) of HOAs, spherical aberration (SA), and coma aberration (CA).

RESULTS

A total of 101 eyes of 51 patients were considered in the final analysis. Patients were divided into two groups. Group A comprised of 44 (43.6%) eyes of 22 patients who underwent PRK while group B comprised of 57 (56.4%) eyes of 29 patients who underwent LASIK. UCVA significantly improved postoperatively at 3 and 6 months in both PRK and LASIK groups (p<0.001 for both groups). In this study, the increase in root mean square (RMS) of higher order aberrations from baseline value was 77% after PRK and 28% after LASIK, similar ratio was observed in spherical aberration (SA). The trend of rise in Coma aberrations was more in LASIK group 66.49% as compared to 46.2% in PRK group.

CONCLUSION

Both Wavefront Optimized PRK and LASIK are safe and have elicited comparable results of post-procedure visual recovery. There was a marked increase in RMS of HOAs in PRK group as compared to WFO LASIK group while coma aberration increased more in LASIK as compared to PRK postoperatively.

KEY WORDS

LASIK, PRK, RMSh, HOAs, Spherical aberration, Coma, Myopia.

Evaluation of the Effects of Myopic Astigmatism Correction and Anterior Corneal Curvature on Functional Optical Zone After SMILE

PURPOSE

To evaluate the influence of different degrees of myopic astigmatism correction and preoperative anterior corneal curvature on the functional optical zone (FOZ) following small incision lenticule extraction (SMILE).

METHODS

In this retrospective study, 68 patients (106 eyes) treated with SMILE were grouped according to myopic astigmatism correction: control (0.00 diopters [D]), moderate astigmatism (-0.50 to -2.00 D), and high astigmatism (> -2.00 D). The FOZ was measured and compared between the three groups for 3 months. Correlations between attempted correction, anterior corneal curvature, corneal aberrations, and the FOZ were analyzed.

RESULTS

The preoperative mean treatment spherical equivalent was comparable among the three groups. The average FOZ was 5.06 ± 0.24 mm in the control group, 5.19 ± 0.25 mm in the moderate astigmatism group, and 5.35 ± 0.20 mm in the high astigmatism group The FOZ showed statistically significant differences among the three groups (P < .001), particularly between the high astigmatism group and the other two groups (P < .001 and .018). Correlation analysis showed that the total higher order aberrations, coma, and spherical aberration change were correlated with the FOZ (P < .001). Preoperative steep keratometry, average keratometry, and corneal astigmatism were significantly correlated with the FOZ (P < .05). The correlation remained after excluding the influence of attempted correction on the FOZ (P < .05). After adjusting for other risk factors using multiple linear regression analysis, there was still a significant positive association between preoperative steep keratometry and the FOZ (P < .001).

CONCLUSIONS

Patients with higher myopic astigmatism achieved a larger FOZ and less induced horizontal coma than the control and moderate astigmatism groups. A larger FOZ after SMILE can be achieved in eyes with steeper keratometry. [J Refract Surg. 2023;39(2):135-141.].

Comparison of the Functional Optical Zone in Eyes With High Myopia With High Astigmatism After SMILE and FS-LASIK

PURPOSE

To compare the functional optical zone (FOZ) in eyes with high myopia with high astigmatism after small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK).

METHODS

In total, 45 eyes of 45 patients with high myopia with astigmatism greater than 2.00 diopters (D) who underwent SMILE or FS-LASIK were enrolled. The FOZ, optical zone decentration, and corneal aberrations were analyzed using Scheimpflug imaging. These values were then compared between the two groups 6 months postoperatively.

RESULTS

No postoperative complications were observed during follow-up. The mean FOZ diameter was 5.03 ± 0.31 mm for the FS-LASIK group and 5.24 ± 0.27 mm for the SMILE group (P = .007), corresponding to reductions of 1.18 ± 0.23 and 1.01 ± 0.21 mm, respectively, compared with the programmed optical zone (POZ) (P = .013). A significant difference was noted in the FOZ on the short axis between the two groups (P = .002), whereas no significant difference was observed on the long axis (P = .088). The FOZ area in the FS-LASIK and SMILE groups was 65.39 ± 6.14% and 70.09 ± 5.46% of the POZ area, respectively (P = .010). There was no significant difference in decentration between the two groups (0.29 ± 0.13 mm for the FS-LASIK group vs 0.30 ± 0.13 mm for the SMILE group, P = .798). A significant increase in spherical aberration was observed in the FS-LASIK group (P < .001). However, the induction of vertical coma was higher in the SMILE group than in the FS-LASIK group (P = .002).

CONCLUSIONS

Eyes with high myopia with high astigmatism following SMILE achieved a larger FOZ and less spherical aberration but a larger vertical coma introduction than following FS-LASIK. [J Refract Surg. 2022;38(9):595-601.].

Management of Anterior Stromal Necrosis After Polymethylmethacrylate ICRS: Explantation Versus Exchange With Corneal Allogenic Intrastromal Ring Segments

PURPOSE

To evaluate management of keratoconic eyes with anterior stromal necrosis overlying the intracorneal ring segment (ICRS), by either ICRS explantation alone or exchange with corneal allogenic intrastromal ring segments (CAIRS).

METHODS

Among 643 Intacs SK (Additional Technology, Inc) inserted at one institutional center, 16 eyes (15 patients) with overlying spontaneous anterior stromal necrosis were identified. Data included size of stromal defect and refractive and topographical findings before ICRS insertion, before anterior stromal necrosis, and 6 months after intervention.

RESULTS

The 10-year incidence of anterior stromal necrosis after femtosecond laser-assisted ICRS insertion was 5.5%. Eight eyes underwent ICRS removal only and 8 eyes had ICRS exchanged with CAIRS. In the first group, CDVA worsened from 0.14 before melt to 0.28 logMAR after removal (P = .10), simulated keratometry (SimK) and maximum axial keratometry (Kmax) increased from 44.73 to 46.34 diopters (D) (P = .14) and from 49.23 to 52.26 D (P = .14), respectively, and coma worsened from 0.87 to 1.52 D (P = .02). In the CAIRS group, CDVA of 0.16 before melt improved to 0.11 logMAR postoperatively (P > .99), and topographic indices stabilized with SimK, Kmax, and coma mildly altering from 45.31 to 45.44 D (P > .99), from 49.25 to 49.64 D (P > .99) and from 0.87 to 0.81 D (P > .99), respectively. Whether the ICRS were explanted or exchanged, the visual and topographic mean values were better than those reported before ICRS implantation, whereas higher order aberrations in eyes without CAIRS regressed to levels before ICRS insertion. At the site of melt, thinnest residual stromal thickness averaged 327 µm with ICRS removal and 490 µm with CAIRS. Eyes with larger melt areas resulted in less optimal results with CAIRS implantation.

CONCLUSIONS

Early experience in the management of anterior stromal necrosis by exchange of polymethylmethacrylate ICRS with CAIRS seems to avoid stromal thinning and confer better visual and topographic results, which were more pronounced with thicker segments. The benefit of CAIRS in large stromal melts needs to be investigated. [J Refract Surg. 2022;38(4):256-263.].

Combined cardiac-neurosurgical treatment of acute aortic dissection, stroke, and coma

Coma or stroke with secondary brain malperfusion is usually considered a strong contraindication for emergent surgical treatment of acute aortic dissection. Herein, we present the case of a 30-year-old woman who presented with sudden left hemiplegia and level-7 coma on the Glasgow Coma Scale. Transthoracic echocardiography showed type A aortic dissection. Although the patient was unable to communicate, her family approved an emergency Bentall operation. She regained consciousness but developed anisocoria and Glasgow Coma Scale level-4 coma 30 hours after the operation. Computed tomography showed massive cerebral infarction with hernia of the uncus gyri hippocampi. Emergency surgical cerebral decompression was performed. The patient survived; after 1 year, she had full mental acuity and minor left motor sequelae.

Implementation of percutaneous dilatational tracheostomy on neurosurgical coma patients

OBJECTIVE

To present the authors' experience with percutaneous dilatational tracheostomy (PDT), with special attention to early and late complications, outcomes, and primary disease influence.

METHODS

Between November 2000 and May 2001, 22 PDTs were performed with the aid of dilatating forceps in 21 neurosurgical coma patients. A Seldinger wire was introduced through a cannula into the trachea serving as a guide. The guidewire was threaded through the clamped guidewire dilating forceps and the forceps was advanced through the tracheal wall. The trachea was dilated by opening forceps. The guidewire was then threaded through the obturator of the tracheostomy tube and both were advanced into the trachea. Demographic data, patient disease variables and patient anatomical features, as well as perioperative and late complications were recorded prospectively.

RESULTS

Completion of the procedure consumed 4 - 16 minutes (mean, 12 minutes). The procedure caused complications in 3 operations: 2 cases of stomal bleeding, 1 of intratracheal bleeding, but there was no severe tracheal injury or mediastinal emphysema. Furthermore, none of the cases required intervention due to complications. All patients were followed up for 1 to 6 months. Tracheostomy tubes were removed in 16 patients. All cervical incisions were closed with cosmetic demand. Two patients with tracheostomy tubes were retained for primary diseases. Causes of death in 3 others were unrelated to the PDT. No patient developed tracheomalacia or tracheal stenosis as a late complication.

CONCLUSIONS

Percutaneous dilatational tracheostomy is a fast, safe and simple procedure for neurosurgical coma patients and can be safely performed by neurosurgeons.

Classification of severe head injury based on magnetic resonance imaging

OBJECT

In 1991 a new pioneering classification of severe head injuries had been proposed, based on CT findings. Unfortunately CT cannot visualise all lesions. Especially brain stem lesions may escape CT in spite of modern equipment, but may be demonstrated by MRI. The high incidence of CT negative but MRI positive posttraumatic brain stem lesions has already been demonstrated in a limited number of cases. A statistically significant evaluation is still missing. Therefore we have investigated a series of 102 comatose patients, in whom a statistical evaluation of MRI findings and their correlation with mortality and outcome of survivors was possible.

PATIENTS AND METHODS

MRI was obtained within 8 days after servere head injury in 102 patients with a minimum of 24 hours of coma. The location of the lesions. identified by a neuroradiologist who was unaware of the clinical findings, was correlated with mortality, outcome of surviors and duration of coma. The correlation was analysed statistically. Follow-up ranged from 3 months to 3 years with a mean of 22 months. Four groups of lesions gave significant correlations: Grade I lesions were lesions of the hemispheres only; Grade II lesions were unilateral lesions of the brain stem at any level with or without supratentorial lesions; Grade III lesions were bilateral lesions of the mesencephalon with or without supratentorial lesions. Grade IV lesions were bilateral lesion of the pons with or without any of the foregoing lesions of lesser grades.

RESULTS

Mortality increased from 14% in grade I lesions to 100% in grade IV lesions. The Glasgow outcome score differed significantly for each grade. The mean duration of coma increased from 3 days in grade I patients to 13 days in grade III. The correlations between the lesions grade I to IV with mortality, outcome of survivors and duration of coma were highly significant.

CONCLUSION

The statistically significant correlations between the 4 groups of severe head injury patients, as identified by MRI, with mortality and outcome of survivors justify a new classification based on early MRI findings.

Surgical treatment of primary supratentorial intracerebral hemorrhage in stuporous and comatose patients

Primary supratentorial intracerebral hemorrhage can be considered as one of the most devastating forms of cerebrovascular disease. Reduction in intracranial volume buffering capacity and severe intracranial pressure are the most important factors related to a poor prognosis in cases with huge hematoma and altered state of consciousness. The role of surgery in the management of such cases appears still controversial. Nevertheless, it is conceivable that some cases with poor natural outcome might benefit from surgical evacuation. Fifty patients with altered state of consciousness and primary supratentorial intracerebral hemorrhage ranging from 24 to 75 ml were submitted to surgical evacuation of the hematoma. The decision to operate was based on the presence of signs indicating an oncoming severe intracranial hypertension. In 15 patients, in whom a progression in brain swelling was expected to occur after the hematoma evacuation, a decompressive craniectomy, associated with dural enlargement, was performed after the initial surgical procedure. The overall analysis of the clinical results at one year after surgery showed 40% of complete recovery and 38% of improvement. A significant statistical correlation was found between outcome and pre-operative neurological status. The association of decompressive craniectomy and dural enlargement to hematoma evacuation, proved very useful in a group of severely compromised patients. Surgical treatment of patients with primary supratentorial intracerebral hemorrhage and altered state of consciousness can have a positive role, in selected cases, by minimizing the life-threatening progression of intracranial hypertension.

Ventriculopleural shunt obstruction and positive-pressure ventilation. Case report

The authors report an unusual case of a patient with low-pressure hydrocephalus and a ventriculopleural shunt, in whom routine respiratory management performed using positive-pressure ventilation caused shunt obstruction and coma. While the patient received positive-pressure ventilation with external cerebrospinal fluid (CSF) drainage at subatmospheric pressure, the ventricles returned to normal size and the coma rapidly reversed. After the authors' recognition of the effect of positive-pressure ventilation on intrapleural pressure and ventriculopleural shunt function, and the subsequent removal of positive-pressure ventilation, CSF flow through the shunt resumed and the patient's coma resolved.

Optic nerve decompression in the comatose and conscious patients after trauma

OBJECTIVE

To investigate the efficacy of early optic nerve decompression in comatose and conscious patients with indirect traumatic optic neuropathy.

STUDY DESIGN

Retrospective analysis of 65 optic nerve decompressions.

METHODS

The total collective of optic nerve decompressions comprised 65 patients treated within the period between February 1987 and December 1998. Thirteen of these 65 patients (average age, 32 y) were comatose and required critical care treatment, so visual acuity could not be measured. The indication for surgical decompression in all patients was based on the ophthalmological examination and the finding on computed tomography (CT) scan of a lesion inside the optic nerve canal or the orbit apex, respectively.

RESULTS

In the comatose patients the time interval between trauma and surgery was 16.1+/-12.1 hours (mean +/- standard deviation). During the subsequent postoperative examinations (on average, 12.3 mo postoperatively) five patients showed a normal visual acuity (20/20), two patients a visual acuity of 20/30 and 20/50, and one a visual acuity of 20/200. Three patients (three eyes) remained amaurotic. Two patients died of the general and severe consequences of injury. The beneficial visual acuity results achieved within the group of comatose patients were equivalent to those achieved within the group of patients who were conscious during the preoperative examination. The success rate, defined as an improvement of three lines with a final visual acuity of at least 20/1000, was 57.7% versus 61.5%.

CONCLUSION

The results confirm our concept of early decompression of the optic nerve, based on close interdisciplinary cooperation and the ophthalmological findings.

Recovery from Duret hemorrhage: a rare complication after craniotomy--case report

A 44-year-old female presented with Duret hemorrhage due to transtentorial herniation by extradural hematoma as a complication after craniotomy for treatment of spontaneous middle cranial fossa cerebrospinal fluid leakage through the oval window. Brain computed tomography revealed linear hemorrhage in the midbrain and the rostral pons. She awoke after 2 weeks in a coma, despite showing ocular bobbing and bilateral intranuclear ophthalmoplegia. She was discharged from the hospital with minimal neurological defects. Duret hemorrhage is usually fatal, but this case shows that early surgical decompression is the most important factor to avoid the worst sequelae.

[The effect of shunting operations on the psychopathological symptoms of posttraumatic hydrocephalus]

A total number of 35 patients underwent CSF diversion procedures for posttraumatic hydrocephalus (HCP). To facilitate the analysis of correlation between the onset and clinical course of HCP and psychopathology, all patients were divided into 2 groups. Group 1 consisted of patients who developed HCP within the first 6 months after head injury interfering with the psychiatric recovery. Group 2 was formed by patients who developed HCP after being stable for more than 6 months after injury and having some sort of psychiatric condition (e.g., vegetable status, dementia) before HCP was evident. We considered surgery to be effective if patients had signs of postoperative psychiatric improvement. This was demonstrated in 68.8% of the cases. Mental changes were more prominent in Group 1 vs Group 2. Worsening of the condition was noted only in six patients, all from the second group. It was transient in 4 cases and progressive in 2 cases. All complications occurred due to intracranial infections.

Screening for ocular hemorrhages in patients with ruptured cerebral aneurysms: a prospective study of 99 patients

BACKGROUND

Terson's syndrome (vitreous hemorrhage) and other ocular hemorrhages (retinal hemorrhages) have been reported to occur in up to 40% of patients with ruptured cerebral aneurysms. Because microsurgical vitrectomy can safely restore vision in patients with visual loss secondary to Terson's syndrome, we hypothesized that prospectively screening a selected group of patients with aneurysms would result in a higher rate of vitrectomy in patients with more extensive subarachnoid hemorrhage.

METHODS

Ninety-nine patients with ruptured cerebral aneurysms were prospectively screened for Terson's syndrome and other forms of ocular hemorrhage by an ophthalmologist. Follow-up data were obtained for seven of eight cases of Terson's syndrome, and vitrectomy was performed for visual restoration when indicated.

RESULTS

Ocular hemorrhages were present in 17% of patients with ruptured cerebral aneurysms, and Terson's syndrome was present in 8% of patients. Screening of patients with histories of transient or prolonged comas sensitively identified patients with ocular hemorrhages in 100% of the patients with Terson's syndrome and 89% of the patients with other ocular hemorrhages. Fifty-five percent of the patients in the overall series had histories of transient or prolonged comas, and 53% (specificity) of those patients had ocular hemorrhages. Two of the eight patients with Terson's syndrome underwent vitrectomy, with dramatic improvement in vision. No other ocular hemorrhages required surgery.

CONCLUSIONS

Ophthalmological screening of patients with histories of transient or prolonged comas after ruptured cerebral aneurysms very sensitively identifies patients with ocular hemorrhages, which are relatively common in patients with subarachnoid hemorrhage treated in an academic neurosurgical practice. The present study underestimates the true incidence of Terson's syndrome in that patients who died shortly after their subarachnoid hemorrhage were not included. Vitrectomy for patients who do not exhibit spontaneous improvement in vision results in a dramatic reversal of blindness.

Evolving brain lesions in the first 12 hours after head injury: analysis of 37 comatose patients

From January 1, 1990, to April 30, 1994, 412 patients were admitted to our intensive care unit in coma after head injuries. Our study group consisted of 37 patients who were retrospectively identified as harboring lesions or developing new lesions within a 12-hour period from the time of admission. We defined the evolution of a lesion as an increase or decrease in the size of an already present hematoma or as the appearance of a totally new lesion. There were 25 male and 12 female patients (mean age, 34.9 yr), and the cause of trauma was road traffic accidents in 32 patients. Nine patients presented with shock, and six had evidence of abnormal coagulation at admission. Patients were divided into two different groups. In Group 1, 15 patients harbored lesions that evolved toward reabsorption. In Group 2, 22 patients harbored hematomas that evolved toward lesions requiring surgical removal. Fifteen of these patients had initial diagnoses of diffuse injury that evolved in this manner, whereas the remaining seven patients had already been operated upon and had developed second, noncontiguous, surgical lesions. Patients with lesions that required surgical evacuation had their computed tomographic (CT) scans obtained earlier and had a higher incidence of clinical deterioration. There was a significant difference in the evolution of the different lesions (P < 0.001), with subdural hematomas being more prone to reabsorption and intracerebral and extradural hematomas being more likely to increase in size or to appear as new lesions. Second CT scans were obtained because of clinical deterioration in 10 patients and because of increase in intracranial pressure in 5 patients. Scheduled CT scans were obtained in 13 patients, whereas in the remaining 9 patients, the diagnosis emerged from a combination of scheduled CT scans and intracranial pressure monitoring. There was a trend toward a poorer result among the patients with clinical deterioration, which, however, was not significant. A significant proportion of post-traumatic patients, particularly those who are unconscious, harbor early evolving intracranial lesions. When the first CT scan is performed within 3 hours after injury, a CT scan should be repeated within 12 hours.

[Neurosonography in the diagnosis of brain pathology in severe cranio-cerebral trauma]

The paper analyzes neurosonographic studies of 66 patients with severe brain injury, which were carried out through the diagnostic cutting opening in 19 patients, intraoperatively in 26 and postoperatively in 21. They provided evidence for tomographic characteristics of various types of brain injuries and their dynamics were followed up in acute and subacute brain injuries. Neurosonographic signs of ventricular hemorrhage and temporotentorial wedging are described. The paper also indicates the informative value of dynamic neurosonographic monitoring in patients with severe brain injury in order to define treatment policy.

Severe head injury management in a general surgical department

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.

[Traditional Chinese medicine and Western medicine treatment for severe intractable head injury]

38 cases of severe intractable head injuries were treated by TCM-WM treatment, the survival rate was 68.4%, which was difficult or ineffective for Western medicine treatment. The author lay emphasis on taking the following measures: (1) Place nasal feeding tube in the nose as early as possible; (2) Take Zenye Tang and Shengmai Yin as chief prescription for nourishing Yin and replenishing Qi; (3) Take large dose of citicoline, Angong Niuhuang Wan and Xuefu Zhuyu Tang to promote resuscitation; (4) When pulmonary infection was serious and antibiotic ineffective, Shashen Maidong Tang and Ditan Tang etc. could be used.

Increased intracranial pressure and cardiac arrest after heart transplantation. What about the Cushing response in a denervated heart? Case report

A 13-year-old boy suffered cerebrovascular complications after heart transplantation (ischemic mass effect in the posterior cranial fossa). He had to be resuscitated from cardiac arrest with coma. After a modified cerebellar hemispherectomy the course was favorable.--The most conclusive explanation for the acute event is that a Cushing response was preserved even in the presumably denervated heart.

Bilateral decompressive craniectomy for worsening coma in acute subarachnoid hemorrhage. Observations in support of the procedure

Bilateral craniectomy in a woman comatose and decerebrate after a subarachnoid hemorrhage, resulted in normal mentation in 3 days. The dramatic recovery is unmatched in our experience. The rationale rested on clinicopathologic studies showing that in such cases brain swelling was the cause of death, the brain being otherwise intact. Emergency surgery to relieve the tamponade seemed reasonable. The question is whether the procedure has a role in those patients who fail to respond to current therapeutic measures. The arguments in favor, presented herein, are illustrated by three pathologic studies selected from our longtime experience.

Acute subdural haematoma in adults: an analysis of outcome in comatose patients

The authors analysed a series of 200 adult patients admitted to the Department of Neurosurgery, Medical University of Lódź with a diagnosis of acute subdural haematoma (ASDH). 63% of them were surgically treated within the first 4 hours after head injury, the others were operated on 4 to 16 hours after trauma. All patients had GCS below 10 for the whole time period from trauma to surgery. Younger patients 18-30 year old had lower mortality-25%, while patients above 50 revealed 75% mortality. Analysis of operative timing and outcome, no benefit revealed when surgery was performed within first 4 hours. However, the patients operated on later than 4 hours after trauma had smaller midline shift and less pronounced brain contusion. It must be taken into account that some patients who could benefit from early surgery-those with quickly developing haematomas and intracranial hypertension-had no chance to arrive and died in peripheral hospitals. Despite our results we advocate an urgent evacuation of haematoma, as early as possible after trauma. Significant correlation was found between midline shift, cerebral contusion on CT scans and results of surgery. Patients with bigger midline shift or presence of focal cerebral contusion revealed higher mortality and worse outcome than patients with smaller shift and no cerebral contusion visible on CT pictures.

[Hemodynamic stability in thoracic-abdominal trauma with multiple intrahepatic abscesses. A clinical case]

A case of multiple injury is reported in a young 35-year-old man affecting three different areas of the body which showed a septic-type development. Complete recovery was largely determined by the accuracy of the preoperative diagnosis and the correct maintenance of hemodynamic parameters.

Head injuries with temporal lobe compression

The present study is based on the evolution of 219 cases of temporal compressive craniocerebral trauma admitted to the neurotraumatology department between 1985 and 1990. Correlations are made between the accident-operation time interval and the results obtained. Special emphasis is laid on the paraclinical methods used to make an accurate and complete diagnosis, of which computerized tomography is the most reliable for head injuries. The most frequent compressive lesions found in this series were the indirect cerebral lacerations. Their approach was done by a trephine opening aimed at the anterior 1/3 of the temporal lobe, in its basal part. The prognosis depends on the state of consciousness (patients in deep coma had small chances for survival) and on the time interval between accident and surgery, a rapid and adequately equipped transport of the patient being also of utmost importance.

[Decrease in the incidence of epidural hematomas surgically treated during coma after a lucid interval. Is this an index of quality of care?]

The level of consciousness prior to surgery has been analyzed in a series of 64 patients suffering epidural hematoma (EDH) who underwent surgery during the period from July 1987 to June 1989. The percentage of cases which underwent surgery in coma after a lucid interval have been compared in different periods of time (1978-80, 1981-82, 1983-84 and July 1987 to June 1989). During the period from July 1987 to June 1989 surgery was performed on: 15 patients (23.5%) in coma from the moment of accident, 8 patients (12.5%) underwent surgery in coma but after a lucid interval and 41 patients (64.1%) were conscious. During the different periods of time the number of patients undergoing surgery in coma after a lucid interval were the following: 1979-80, 9 cases (26.5%); 1981-82, 17 cases (43.6%); 1983-84, 8 cases (20%) and during the last period, 1987-89, 7 cases (15.2%). The difference between the percentage of patients intervened in coma after a lucid interval in the previously referred periods of time was statistically significant (p 0.05).

[The characteristics of the diagnosis and clinical course of traumatic hematomas located basally]

The authors analyzed 27 patients with traumatic subdural hematomas of basal location. Hematomas of this location are distinguished by a different clinical course and difficulties of diagnosis. The informative value of different methods of diagnosis is discussed. The method of choice was computerized axial tomography of the brain. Radical surgical treatment is the method of choice.

Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma

Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.

Analysis of management in thirty-three closed head injury patients who "talked and deteriorated"

Of 215 patients with severe head injuries, 33 (15%) closed head injury patients who talked before their conditions deteriorated to a Glasgow coma scale score of 8 or less were identified. Of this select group, 15 died (45%), but none of the remaining were left in a vegetative state and 14 patients had a "favorable" outcome (42%). Twenty-five patients (76%) underwent surgical decompression. In these 25 patients, 14 subdural hematomas, 4 epidural hematomas, and 7 intracerebral contusions and hematomas were the initial surgical lesions. Twenty of the 25 patients were operated on within 4 hours (16 within 2 hours) of their neurological deterioration. Eleven of the 25 surgically treated died, for a mortality rate of 44%. All 15 deaths were studied further. Autopsies with examination of the brain were performed in 13 patients. Five patients died with severe brain injuries not complicated by iatrogenic factors, and 4 patients died of severe associated injuries. Iatrogenic factors significantly complicated the deaths of 6 patients (40%). It is concluded that most patients who "talk and deteriorate" have sustained very serious life-threatening injuries. Intracranial hematomas are the most frequent cause of this situation, and rapid diagnosis and decompression is the most important factor in salvaging these patients.

The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment

The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively). The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered. Subdural hematomas were significantly more common in the "talk and die" group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.

Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours

To discover which factors contributed to recovery after surgical intracranial decompression, we reviewed the records of 82 consecutive comatose patients with traumatic acute subdural hematoma (ASDH) who were treated in a single center under a uniform protocol. The delay from injury to operation was the factor of greatest therapeutic importance. Patients who underwent surgery within the first four hours had a 30 per cent mortality rate, as compared with 90 percent in those who had surgery after four hours (P less than 0.0001). Other important prognostic variables included results of the initial neurologic examination, sex, multimodality-evoked potentials, and postoperative intracranial pressure (ICP). If all patients with traumatic ASDH were taken directly to hospitals equipped to diagnose and remove the hematoma within four hours of injury, mortality rates could be reduced considerably.