Secondary Trigeminal Neuralgia Caused by Cerebellopontine Angle Arachnoid Cyst in A 27-Year-Old Female: A Case Report

PURPOSE

Secondary (TN) caused by an arachnoid cyst in the (CPA) region is a rare finding. Based on the reported literature, there are only 5 cases of secondary trigeminal neuralgia caused by an arachnoid cyst in the cerebellopontine angle region.

CASE REPORT

A 27-year-old female presented to our neurosurgery clinic with a 2-year history of brief episodes of paroxysm pain in the left cheek. The pain was described as an electric shock-like pain triggered by simple stimuli. The magnetic resonance imaging (MRI) showed a well-confined cystic lesion in the left CPA, which compresses the left pons and the cisternal segment of the left trigeminal nerve. The patient was managed operatively to fenestrate the cyst and decompress the trigeminal nerve. The histopathological result of the cyst wall was consistent with an arachnoid cyst. Six months after surgery, the patient is in good health condition and symptom-free without medication.

CONCLUSION

Arachnoid cyst in the CPA region is one of the rare causes of secondary TN. Preoperative imaging with MRI is important to provide better results to differentiate the pathology. Surgical treatment to fenestrate the arachnoid cyst and decompress the trigeminal nerve have a good result and can improve the patient's quality of life.

Anal extrusion of a ventriculoperitoneal shunt in a 1-month-old patient: a case report

The ventriculoperitoneal shunt procedure represents a frequently conducted neurosurgical intervention; nevertheless, it harbors inherent risks that can precipitate complications in patients. Intestinal perforation accompanied by distal shunt protrusion through the anus is an uncommon phenomenon, observed in ~0.1% to 0.7% of cases, with mortality rates reaching up to 15%. Timely identification and comprehensive management of such complications are imperative to prevent further deterioration of the patient's condition. Herein, we present a case involving a 1-month-old female infant who presented with a tube protruding from the anal orifice. Immediate surgical intervention was undertaken to remove the distal shunt and prevent further infection in the patient.

Effects of Moleac 901 after severe spinal cord injury on chronic phase in Wistar rats

Background

MLC901 is a phytopharmaceutical comprising significant compounds that can induce microenvironments conducive to the proliferation and specialization of neural cell progenitors. This study investigates the impact of administering MLC901, reducing the expression of NG2 and caspase-3 and increasing IL-10 levels, as well as histopathological and motor function, after severe spinal cord injury (SCI) in the chronic phase.

Methods

The study employed a randomized post-test-only control group design conducted between February and April 2023 at the Integrated Biomedical Laboratory. The participants in this study were categorized into three distinct groups: normal control, negative control, and therapy. A cohort of 18 rats was utilized for the study, with each group assigned a random allocation of six rats as subjects.

Results

The findings demonstrated a statistically significant disparity in the average NG2 expression (-52.00 ± 20.03; p ≤ 0.05), as well as Caspase-3 expression (-94.89 ± 8.57; p ≤ 0.05), which exhibited a lower magnitude. The levels of IL-10 (8.96 ± 3.98; p ≤ 0.05) were observed to be higher, along with an elevation in BBB score (7.67 ± 0.89; p ≤ 0.05), which was more pronounced in the treatment group compared to the negative control group. The cut-off point for cavitation diameter is determined to be 114.915 μm, exhibiting a sensitivity and specificity of 100%. The area under curve (AUC) value is 1.0. The administration of MLC901 demonstrated a strong positive correlation with the increase in IL-10 levels (B 8.968; p ≤ 0.05), as well as a substantial negative correlation with the decrease in Caspase-3 expression (B -52.000; p ≤ 0.05) and NG2 expression (B -94.892; p ≤ 0.05). The administration of MLC901 via the upregulation of NG2 and Caspase-3 significantly increased the Basso, Beattie, and Bresnahan (BBB) scores.

Conclusions

MLC901 positively affects motor and histopathological outcomes in the chronic phase of severe SCI in the Wistar rat model. These benefits are believed to be achieved by suppressing gliosis, neuroapoptosis, and neuroinflammation processes.

Successful reconstruction of severe traumatic scalp defect with exposed bones in a 6-year-old boy: a case report

Full-thickness scalp defect reconstruction is considered challenging for the surgeon. The goal of this procedure is to provide coverage of the calvarium. Scalp defect needs thorough and careful planning in reconstruction, not only in choosing the best closure strategy but also in post-operative care. We report a case of successful reconstruction of traumatic severe scalp and bone loss using local scalp flap in a 6-year-old trauma patient. Free flap reconstruction should be considered in such a defect. However, limited resources prevented us to do so. In craniofacial trauma, the plastic surgeon may be involved as an attending physician in facial trauma or assisting in other trauma, especially in defect closure.

Particular Surgical Technique for Transorbital-Penetrating Craniocerebral Injury Inflicted by a Screwdriver: Technical Case Report

Surgical techniques for non-missile penetrating brain injuries (PBI) are challenging because they require good preoperative planning. Generally, extraction is performed ipsilaterally at the entry site. In certain cases, the extraction can be performed contralaterally through the inner end of the foreign body; however, this requires special consideration. We present a case report of a patient who had a stab wound on the head via a screwdriver and underwent surgery, during which extraction was performed contralaterally through the inner end of the screwdriver without inducing any neurological deficit. Careful preoperative planning and surgical technique modification are required to minimize morbidity and mortality in patients with PBIs.

Correlation of MLR with CRP and MPVPCR with LED in Traumatic Brain Injury

BACKGROUND: Traumatic brain injury (TBI) contributes greatly to high rates of death and disability globally. It may be divided into primary and secondary injuries. Primary head injuries occur at the moment of impact which causes mechanical loads and accelerations both linearly and rotationally, causing injury to the brain. After the primary brain injury, further biochemical and cellular processes occur that lead to secondary injury. Secondary insult in TBI may lead to several neuroinflammation processes that are reflected on laboratory markers. The monocyte-lymphocyte ratio and mean platelet volume-platelet count ratio (MPVPCR) theoretically have the potential to be used as neuroinflammation markers in TBI. AIM: This study was conducted to assess the relationship between monocyte-lymphocyte ratio (MLR), MPVPCR with both C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) regarded as inflammation markers in relation to secondary brain injury. METHODS: This study was a cross-sectional prospective analytic observational study conducted at the Sanglah hospital emergency department from February to May 2022. Patients diagnosed with TBI aged 18 years and over that were willing to be included in the study by consecutive sampling. Patients with a history of autoimmune disease, history of taking immunosuppressant drugs, and fractures of > 2 long bones were excluded and the presence of infection characterized by fever was excluded from the study. History taking and physical examination were done to obtain data regarding age, gender, mechanism of injury, Glasgow Coma Scale, fainting duration, and memory loss. The blood sample was taken at 24 h after trauma to obtain MLR, MPVPCR, CRP, and ESR results. Pearson correlation test was done to determine the correlation between MLR and MPVPCR with CRP and LED. RESULTS: There are a total of 85 patients included in this study with the mean of age which is 36 ± 2.5 years old. Most of them are men (71.3%) with the mean of GCS on admission which is 12. Mean ± (SD) of the monocyte, lymphocyte, and platelet was 1.12 ± 0.82 × 103/μL, 1.83 ± 1.69 × 103/μL, and 259.34 ± 85.79 × 103/μL consecutively. MLR with CRP had a weak positive correlation and was statistically significant (r = 0.215; p = 0.045), as well as MPVPCR with ESR also had a weak positive correlation and was statistically significant (r = 0.276; p = 0.010). While both MLR with ESR and MPVPCR with CRP had no correlation. CONCLUSION: MLR can be an option representing CRP in predicting the magnitude of inflammation in head injury and MPVPCR can be considered to be used as a predictor of thrombotic phenomena in TBI.

Massive subdural empyema secondary to infectious parotitis: a case report

Background: Subdural empyema is an intracranial focal collection of purulent material between the dura and arachnoid mater. The most common causes are purulent meningitis in infants and sinusitis and otitis media in older children through a direct extension of the infection. Although it is very rare, parotitis may also cause subdural empyema. This report presents our case of subdural empyema due to infectious parotitis in a pediatric patient. Case report: A 1-year-old boy was referred from other hospitals for multiple seizure episodes. He also had a complaint of vomit and fever 3 weeks ago. On the neurological examination, we found that he had a GCS of 8, no meningeal sign was found, and with dilated pupil on the right side. A contrast-enhanced head computed tomography (CT) scan revealed multiple hypodense masses with ring enhancement over the right hemisphere, and a severe midline shift suggested as subdural empyema. We then performed a craniotomy to evacuate the empyema. Two weeks after surgery, he was fully alert without any surgical morbidity. Conclusion: Although parotitis is the less likely disease that can cause subdural empyema, we should also include the disease as the possible cause before we examine the patient more thoroughly and exclude them as the disease that can cause subdural empyema.

Chitosan as Bone Scaffold for Craniofacial Bone Regeneration: A Systematic Review

Background: The reconstruction of bone defect in the face and head is indispensable yet one of the most challenging procedure to date. Chitosan has emerged as a promising low-cost natural biopolymer for the bone scaffold as an alternative to surgery. This study aims to review the effectiveness of chitosan as a bone scaffold for craniofacial bone regeneration. Methods: This systematic review used Google Scholar and PubMed as database sources. Study selection using PRISMA diagram and Boolean operator to specify the study search. The quality assessment of the study used a checklist from Joanna Briggs Institute for experimental study. Result: We included 18 experimental studies, both in vivo and in vitro study—the in vivo study used animal subjects such as mice, goats and rabbits. The studies mostly used chitosan combined with other biomaterials such as demineralized bone matrix (DBM), genipin (GP), sodium alginate (SA), resveratrol (Res), polycaprolactone (PCL) and collagen, growth factor and stem cells such as bone morphogenic protein-2 (BMP-2), dental pulp stem cell (DPSC), and human umbilical cord mesenchymal stem cells (hUCMSC). Conclusion: Chitosan is a natural polymer with promising osteoconductive, osteoinductive and osteo-integrative effects in bone regeneration. Chitosan utilization for bone scaffolds combined with other biomaterials, growth factors, or stem cells gives better bone regeneration results than chitosan alone.

Comparison between Dura-Splitting Technique with Duraplasty in Symptomatic Patients with Chiari Malformation Type I: A Systematic Review and Meta-analysis

BACKGROUND: There are many surgical procedures for CIM patients, posterior fossa decompression with fibrous band excision, with additional duraplasty, or syringosubdural shunt for syringomyelia related CIM. Prospective studies have been carried out but yet no conclusion, on which one is the best option. The objective of this study was to assess qualitatively the outcome of posterior fossa decompression with dura-splitting (PFDDS) technique compared to posterior fossa decompression with duraplasty (PFDDP) for treating CIM patients. AIM: This study aimed to give us a preference while conducting surgery in a patient with Chiari malformation type I (CIM) between posterior fossa decompression with incision of the fibrous band of the dura (dura-splitting/DS) technique and duraplasty (DP) technique. METHODS: The analysis conducted using PRISMA flowchart with PICO framework (Patient: Chiari malformation type I patient over preschool age; Intervention: Dura-splitting; Comparison: Duraplasty; and Outcome: Complication rate, length of stay, reoperation rate, syrinx reduction, symptomatic improvement, and operation time) and already registered for meta-analysis study with database searching from PubMed, the Cochrane Library, and Google Scholar that following inclusion criteria: (1) Original study; (2) study that compares DS and DP in CM- I; and (3) patient age over preschool age. RESULTS: A review of five included studies involving 458 patients met the inclusion criteria, in which 319 patients treated with DS surgery and 139 for DP surgery for this study. Significantly DS technique correlated lower rate of complication (RR = 0.20; p < 0.0001), shorter length of stay (MD = −3.53; p = 0.0002), and shorter operation time (MD = −58.59; p = 0.0004). No significant differences in reoperation rate (RR = 1.90; p = 0.22), symptom improvement (RR = 1.12; p = 0.44), and syrinx reduction (RR = 1.11; p = 0.56) were noted. CONCLUSIONS: Posterior fossa decompression using the DS technique is associated with a lower rate of complication, shorter length of stay, and shorter operation time. However, no significant differences were found in the reoperation rate, symptom improvement, and syringomyelia reduction between these two techniques.

Effect of immediate electrical stimulation in the distal segment of the nerve with Wallerian degeneration in rats with sciatic nerve injury

BACKGROUND Electrical stimulation in the proximal segment is one of the modalities for peripheral nerve injury, although it is prone to cause excessive axonal sprouting growth in the proximal segment of the nerve. This study aimed to show that immediate electrical stimulation in the distal segment of the sciatic nerve in Wistar rats accelerated Wallerian degeneration by increasing the expression of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-10, and galectin-3/MAC-2 macrophages to avoid sprouting axons excessively in the proximal segment. METHODS This was an experimental study using male Wistar rats (Rattus norvegicus) with a randomized post-test only control group design. The treatment group received immediate electrical stimulation (20 Hz, 2 mA, for 5 sec) to the distal nerve after sciatic nerve injury, while the control group received no treatment. After 3 days, tissue samples were extracted from the distal segment of the sciatic nerve to examine the level of TNF-α, IL-10, and galectin 3/Mac-2 macrophages using ELISA and from proximal nerves to histologically examine the sprouting axons. RESULTS Rats in the treatment group had higher TNF-α (52.1 [10.32] versus 40.4 [17.71] pg/100 mg, p = 0.031) and higher IL-10 (918 [167.6] versus 759 [158.9] pg/ml, p = 0.010). Expression of galectin 3/Mac-2 macrophages was similar in both groups (465 [49.5] versus 444 [54.4] pg/100 mg, p = 0.247). The number of sprouting axons was lower in the treatment group (2 [IQR 1–2] versus 2.5 [IQR 2–3], p = 0.003). CONCLUSIONS Immediate electrical stimulation in the distal segment of the sciatic nerve can accelerate nerve regeneration.

Can Early Electrical Stimulation Accelerates the Neural Regeneration by Increasing the Expression of BDNF and GDNF in Distal Part of Injured Peripheral Nerve? An Animal Experimental Study

BACKGROUND: The role of neurotrophic factors (brain-derived neurotrophic factors and glial cell line-derived neurotrophic factors) and early electrical stimulation (EES) in the injured nerve has found promising in several studies. However, there is still limited knowledge about the effect of EES in the distal part of the nerve to sustain this level of expression of growth factors. AIM: We aim to evaluate the effects of EES in in neural regeneration by measuring the expression of brain-derived neurotrophic factor (BDNF) and glial cell line-derived neurotrophic factor (GDNF) in animal model. METHODS: The research was conducted starting from April to May 2021 using male Wistar rats. Using general anesthesia, the sciatic nerve was cut. The intervention group was treated with EES in the distal stump, right after nerve resection (20 Hz, 1–2 mA, 2–5 s), while the control group received no treatment after nerve resection. A reoperation on day 3 was performed in both groups to measure BDNF and GDNF expression level of the distal nerve tissue by ELISA as well as histopathological examination of sprouting axons of the injured proximal nerve. RESULTS: A total of 32 samples were included in the study. A statistically significant levels of GDNF is found higher in the EES group (n = 16) than the control group (n = 16) (35. 71 pg/100 mg, confidence interval (CI) 95% 23.93, 47.48, p < 0.05). The number of sprouting axons is found lower in the EES group (p < 0.05). The BDNF level is similar between the two groups, however not significant. After a subgroup analysis, it was found that the greater the level of GDNF, the fewer the axon sprouts in both groups (fewer axon group 58.35 [n = 22, CI 95% 45.14, 71.55] vs. more axon group 47.14 [n = 10, CI 95% 35.33, 58.95]), p < 0.05. CONCLUSION: The EES proves its benefit in accelerating the axonal regeneration by increasing the expression GDNF in the distal nerve stumps in the electrical excited degenerated sciatic nerve in the rat model.

Determination of Significant Pretreatment Factors that Predict Survival in Indonesian Subjects with Breast Cancer

BACKGROUND: The determination of the pre-treatment’s survival predictive factors is very important as a basis for clinicians to educate and determine appropriate management for patients. AIM: This study aimed to determine the pre-treatment risk factors that predict survival in Indonesian subjects with breast cancer. METHODS: This was a cohort retrospective study conducted on breast cancer subjects visiting Sanglah General Hospital from 2016 to 2020. Data were collected from Indonesian Cancer Registry medical records such as age, tumor size, lymph nodes, metastasis, Karnofsky score, serum CA15-3 level, hormonal receptor status (ER/PR), HER2, Ki-67, LVI, tumor-infiltrating lymphocytes, cell type, histological grade, and survival status until December 2020. Data were tabulated and analyzed statistically using SPSS 25.0. RESULTS: The median survival of breast cancer in this study was 47 months (SD 4.851). Majority of breast cancer subjects with mortality outcome were those who had Karnofsky score less than 70, tumor size ≥5 cm with infiltration, presence of contralateral lymph node, with metastasis, serum CA15-3 level >25 IU/mL, negative hormonal receptor, negative HER2 receptor, Ki67 higher than 14, negative lymphovascular invasion, negative tumor-infiltrating lymphocytes, and histological Grade 3. Age and pathological type were not significantly differed the breast cancer outcome. CONCLUSION: There were significant effects of tumor size, KGB status, metastasis, serum CA15-3 levels, hormone receptor, HER2 receptor, Karnofsky score, lymphovascular invasion, tumor-infiltrating lymphocytes, and histological grade on breast cancer subjects’ survival.

Role of Monocyte-to-lymphocyte Ratio, Mean Platelet Volume-to-Platelet Count Ratio, C-Reactive Protein and Erythrocyte Sedimentation Rate as Predictor of Severity in Secondary Traumatic Brain Injury: A Literature Review

BACKGROUND: Secondary traumatic brain injury (TBI) is injury to the brain following primary TBI because of neuroinflammation as consequences of neuronal and glial cell injury which cause release of various inflammation cytokine and chemokine. Biomarker examination to predict the severity of secondary TBI is important to provide appropriate treatment to the patient. This article reviews possibility several common laboratory parameter such as monocyte-to-lymphocyte ratio (MLR), mean platelet volume-to-platelet count (PC) ratio (MPV-PCR), c-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to predict severity of secondary TBI. LITERATURE REVIEW: TBI activates microglia which increase infiltration and proliferation of monocyte. Neuroinflammation also increases thrombopoiesis which leads to increase megakaryocytes production. In the other hand, due to disruption of brain blood vessels because of trauma, coagulation cascade is also activated and leads to consumptive coagulopathy. These are reflected as high monocyte count, low PC, and high MPV. Lymphocyte count is reported low in TBI especially in poor outcome patients. CRP is an acute phase reactant that increased in inflammation condition. In TBI, increased production of Interleukin-6 leads to increase CRP production. In head injured patients, ESR level does not increase significantly in the acute phase of inflammation but last longer when compared to CRP. CONCLUSION: MLR, MPV-PCR, CRP, and ESR could be predictor of severity in secondary TBI.

Financial Risk Protection for Neurosurgical Care in Indonesia and the Philippines: A Primer on Health Financing for the Global Neurosurgeon

Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio Correlations with C-reactive Protein and Erythrocyte Sedimentation Rate in Traumatic Brain Injury

BACKGROUND: Immune system and inflammatory response play an essential role in the development of secondary brain injury (SBI) after traumatic brain injury (TBI). An inflammatory biomarker that can reflect the SBI severity is needed to increase the effectivity of TBI management and prevent morbidity and mortality post-TBI. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), which are more affordable than C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), theoretically have the potential to be used as a marker of the SBI severity. However, NLR and PLR in daily medical practice are not yet fully utilized. AIM: The aim of the study was to correlate NLR and PLR with CRP and ESR as a marker of SBI severity post-TBI. METHODS: This cross-sectional study was conducted at Sanglah Hospital Denpasar from January to April 2020. Patients diagnosed with TBI were included in this study by consecutive sampling. The blood samples were taken at 24-h post-TBI to obtain the NLR, PLR, CRP, and ESR results. Spearman’s correlation test was conducted to determine the correlation between NLR and PLR with CRP and ESR. RESULTS: Eighty-five patients were included in data analysis. Median ± (interquartile range) of the NLR, PLR, CRP, and ESR were 7.60 ± (6.83), 145.58 ± (76.95), 60.83 ± (66.3), and 12.50 ± (13.85) consecutively. NLR and PLR had a significant positive correlation with CRP (r = 0.472, **p < 0.01; r = 0.283, **p < 0.01 consecutively). But, NLR and PLR were not correlated with ESR. CONCLUSION: NLR and PLR can become a useful and more affordable marker for reflecting the SBI severity in acute TBI.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as an Inflammatory Biomarker in Predicting the Severity of Secondary Brain Injury: A Review Article

Traumatic brain injury (TBI) is one of the leading causes of death and disability, which affects millions of people globally with a significant economic burden. The inflammatory reactions and immune system activity play a significant role in the severity development of secondary brain injury (SBI) after a TBI event. Neutrophils, platelets, and lymphocytes are involved in these inflammatory reactions and have potential in reflecting the severity level of SBI that occurred post-TBI. Some recent studies have shown that the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) can be used as a potential biomarker for determining the severity of an inflammatory reaction, including SBIs in post-TBI. However, the results of NLR and PLR in TBI patients in daily medical practice are still not fully utilized. This review summarizes the neutrophil’s, platelet’s, and lymphocyte’s role in SBI, also the NLR and PLR potential as a marker of the severity of the SBI process in TBI cases.

Comparison of Clinical Outcome between Craniectomy and Craniotomy as Surgical Management of Traumatic Acute Subdural Hematoma: A Systematic Review and Meta-analysis

BACKGROUND: Acute subdural hematoma (ASDH) is a major problem in traumatic brain injury. Surgical techniques for treating ASDH are varied, including cranioplastic craniotomy and large decompressive craniectomy. The superiority of craniectomy and craniotomy for treating ASDH is still controversial. AIM: The aim of this study was to compare the clinical outcome between craniectomy and craniotomy for treating traumatic ASDH through systematic review and meta-analysis. METHODS: This study used electronic articles published in PubMed, EBSCO, Google Scholar, and Directory of Open Access Journal. Articles included were full-text observational studies in Indonesian or English. Clinical outcome using the Glasgow Outcome Scale was compared between craniectomy and craniotomy. Statistical analysis was done using Review Manager 5.3. RESULTS: Six articles met our inclusion and exclusion criteria. We performed random effect model analysis because of high heterogeneity between studies (I2 = 77%; X2 = 21.98). The pooled risk ratio between craniectomy and craniotomy on poor outcomes was 1.41 (p = 0.02; 95% CI: 1.06–1.88). CONCLUSION: Craniectomy increases the risk of poor clinical outcomes in treating a traumatic ASDH.

Hematoma Recurrence in Burr Hole Drainage Compared to Burr Hole Irrigation as Treatment of Chronic Subdural Hematoma: A Systematic Review and Meta-analysis

BACKGROUND: Subdural hematoma is a common phenomenon following a traumatic brain injury where a hematoma is formed below the dura mater of brain meningeal layer, usually with a coup-contrecoup mechanism of injury. The chronic counterpart of subdural hematoma is frequently occurring in elderly patients. There are several techniques being used by many practitioners, including burr hole with or without irrigation, with little evidence of which technique is favorable, especially in terms of recurrence rates following the procedure. AIM: This study aimed to compare the recurrences of chronic subdural hematoma (CSDH) following burr hole with and without saline irrigation technique by systematic review and meta-analysis. METHODS: This study included all articles that describe the two specified burr hole techniques in treating patients with a CSDH. We extracted the eligibility criteria into keywords using Boolean Operator. In this study, we used keywords (CSDH) and (burr hole) and (irrigation) and ((drainage) or no irrigation)) in PubMed, directory of open access journal, and Google Scholar database. RESULTS: This study included seven retrospective cohort studies from 2002 to 2017 with a total of 635 samples. The incidence of hematoma recurrences between burr hole irrigation and burr hole drainage was 14.7% and 12.0%, respectively. Based on random effect model with high heterogeneity (I2 = 60%; X2 = 14.92; p = 0.02), pooled risk ratio between burr hole irrigation and burr hole drainage on hematoma recurrences was 1.05 (p = 0.92; 95% confidence interval, 0.43–2.54). CONCLUSION: There was no superiority between one procedure toward other in preventing recurrences of chronic subdural hematoma.

Case Report: Meningitis Streptococcus suis Presented with spondylodiscitis in Bali

BACKGROUND: Human infection of Streptococcus suis in Indonesia was increasing in the following years. Many cases presented with meningitis and sepsis, but in the current case, we presented a rare case of meningitis S. suis infection with spondylodiscitis. CASE REPORT: A 60-year-old man, Balinese, presented with the 3-day onset of fever, headache, and nausea. Three-hour before admission, he became agitated and decreased of consciousness. He had a history of pork consumption 4 days before admission. He was subsequently diagnosed with acute bacterial meningitis and sensorineural hearing impairment. In the next 2 weeks, he developed low back pain, confirmed as spondylodiscitis from magnetic resonance imaging, a less common presentation of S. suis infection. After 4-week intravenous ceftriaxone treatment, he improved significantly with only hearing impairment remaining. CONCLUSION: Meningitis suis is a systemic infection which can manifest in any organ. The clinician should suspect any low back pain as spondylodiscitis in a patient who had S. suis meningitis.

Erythropoietin protects the subventricular zone and inhibits reactive astrogliosis in kaolin-induced hydrocephalic rats

PURPOSE

To elucidate the potential role of erythropoietin (EPO) as a neuroprotective agent against reactive astrogliosis and reducing the thinning rate of subventricular zone (SVZ) in kaolin-induced hydrocephalic rats.

METHOD

Thirty-six ten-week-old Sprague-Dawley rats were used in this study. Hydrocephalus was induced with 20% kaolin suspension injected into the cistern of thirty rats and leaving the six rats as normal group. The hydrocephalic rats were randomly divided into hydrocephalic and treatment group. The treatment group received daily dose of recombinant human erythropoietin (rhEPO) from day 7 to day 21 after induction. The animals were sacrificed at 7 (only for hydrocephalic group) and 14 or 21 (for both groups) days after induction. Brain was removed and was prepared for histological analysis by hematoxylin and eosin staining as well as immunohistochemistry for 4-HNE, GFAP, Iba-1, and Ki-67.

RESULTS

Histopathological analysis showed that animals treated with rhEPO had a reduced astrocyte reactivity displayed by lower GFAP expression. Hydrocephalic rats received rhEPO also displayed reduced microglial activation shown by lower Iba-1 protein expression. Exogenous rhEPO exerted its protective action in reducing astrogliosis by inhibiting lipid peroxidation that was documented in this study as lower expression of 4-HNE than non-treated group. The SVZ thickness was progressively declining in hydrocephalus group, while the progression rate could be reduced by rhEPO.

CONCLUSION

Erythropoietin has a potential use for inhibiting lipid peroxidation, and reactive astrogliosis in hydrocephalic animal model. The reduced thinning rate of SVZ demonstrated that EPO also had effect in reducing the hydrocephalus progressivity. Further research is warranted to explore its efficacy and safety to use in clinical setting.

Single - Door Cervical Laminoplasty Using Basket Laminoplasty Device: A Case Report

BACKGROUND:

The management of the cervical canal stenosis as a result of ossification of the posterior longitudinal ligament (OPLL) is still evolving. Anterior and posterior approaches are still much in demand by the surgeons. In Japan, a posterior approach is more well-known to be used as the case OPLL is often on the populace. Single-door laminoplasty technique or “Hirabayashi” often used with either autograft or allograft, with or without an additional miniplate.

CASE PRESENTATION:

In this case report, we would like to report the treatment of tetraparesis patients with “basket laminoplasty” using a special device with some advantages, not only providing stability of the lamina but also at the same time providing bone-graft container/basket for the benefit of the patient’s bone fusion.

CONCLUSION:

Basket laminoplasty device is an excellent choice for cervical OPLL. We believe the use of this device is very favourable for long-term patient outcome.

Cervical Spondylotic Myelopathy: Pathophysiology and Surgical Approaches

This paper reviews the pathophysiology of cervical spondylotic myelopathy (CSM) and several surgical approaches for the treatment of CSM. CSM is a degenerative disease with severe morbidity. The pathophysiology of CSM involves static, dynamic, and ischemic factors. The management of mild CSM typically involves conservative treatments and medication; whereas, moderate and severe CSM are better treated surgically. Surgical treatments for CSM are basically classified into anterior and posterior surgeries. The common techniques are anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), laminectomy, and laminoplasty. Each technique has its own advantages and disadvantages. In this paper, we review the research papers from PubMed database to elaborate the advantages and disadvantages of each technique.

Clinical analysis of non-accidental head injury in infants

We present the clinical features, radiological findings and outcome of infants with non-accidental head injury presenting to our department between 2001 and 2003. There were 26 male and 13 female infants, aged between 7 days and 5 months. Presenting symptoms included seizures, vomiting, bulging fontanel, decreased level of consciousness, focal neurological signs, anemia and respiratory distress. We classified the patients into three groups: mild head injury (8 patients), moderate head injury (11 patients) and severe head injury (20 patients). Detailed history taking and thorough physical examination, did not reveal obvious injury or abuse (by the parents), other external visible injury or significant incidence of retinal bleeding. CT scan showed intracranial hemorrhage in all patients, most commonly including acute or acute on chronic subdural hematoma (SDH) and subarachnoid hemorrhage (SAH) in the parafalcine and tentorial regions and over the brain convexity, associated with focal or diffuse hypodensity of the parenchyma. Intracranial lesions were mostly bilateral (80%). These patients generally had a poor outcome; 31% died, 23% had a good outcome, and the remainder recovered with neurological impairment of varying types and degrees. After comprehensive assessment, we concluded that all the cases in our series were "non-accidental" head injuries. However, the absence of retinal bleeding, visible external injury and recognised abuse in our series differed from reports by other investigators. In our opinion these features are not absolute requirements in diagnosing "non-accidental" injury and detailed history taking, thorough clinical examination and radiological studies were the key indicators of the diagnosis.

Cellular blue naevus of the scalp with brain invasion

A case of a 28 year old woman with an intracranial cellular blue naevus (CBN) which was believed to be the extension from a pigmented skin/scalp lesion is reported. There was no similar pigmented skin lesion noted on other parts of her body. Radical intervention, including wide excision of the affected skin of the scalp, removal of the underlying pigmented skull bone and wide excision of the pigmented dura, together with wide excision of the intracranial mass, were performed. The skin defect was covered by rotation flap and free skin graft. The dura was closed by grafting with fascia lata. The skull defect was left open and would be repaired later at a second planned surgery.