Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review

Background:A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH).To date,few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase.We aimed to define the TDC for the elderly with TASDH and performed literature review.Case presentation:A total of 7 TASDH patients,who were presented and treated by TDC in this retrospective study between January 2009 and May 2017,consisted of 5 men and 2 women,ranging in age from 65 to 89 (average,78.9) years.The patients' baseline characteristics,including age,sex,medical history,received ventriculoperitoneal shunt for hydrocephalus or not,reason for avoiding or refusing large craniotomy,preoperative Glasgow Coma Scale (GCS),suffered from cerebral herniation or not,the location of TASDH,imaging characteristics of TASDH in CT scan,injury/surgery time interval,midline shift,preoperative neurologic deficit,operation time,and infusions of urokinase or not,were collected.The postoperative GCS,postoperative neurologic deficit,rebleeding or not,intracranial infection,and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC.The results showed that the mean time interval from injury to TDC was 68.6 min (30-120 min).The mean distance of midline shift was 14.6 mm (10-20 mm).The preoperative GCS in all patients ranged from 4 to 13(median,9).The mean duration of the operation was 14.4 min (6-19 min).Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases.There were no cases of acute rebleeding and intracranial infection after TDC.No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase.Favorable outcomes were shown in all cases (mRS scores 0-2) at 6 months after surgery.Conclusions:TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase,which was a possible alternative for the elderly.

Can admission lipoprotein-associated phospholipase A2 predict the symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage?

Background:Inflammation has been believed to be related to the development of cerebral vasospasm following aneurysmal subarachnoid hemorrhage(aSAH).A potential biomarker for vascular inflammation that is well recognized is the lipoprotein-associated phospholipase A2(Lp-PLA2).However,whether Lp-PLA2 can predict the occurrence of symptomatic cerebral vasospasm(SCV)in aSAH patients is still unknown.Thus,this study aimed to assess the value of Lp-PLA2 for predicting SCV in patients with aSAH.Methods:Between March 2017 and April 2018,we evaluated 128 consecutive aSAH patients who were admitted in the First Affiliated Hospital of Fujian Medical University.Their Lp-PLA2 level was obtained within 24 h of the initial bleeding.Factors might be related to SCV were analyzed.Results:Compared to patients without SCV,those with SCV(9.4%,12/128)had significantly higher Lp-PLA2 level.Multivariate logistic analysis revealed that worse modified Fisher grade(OR=10.08,95%CI=2.04–49.86,P=0.005)and higher Lp-PLA2 level(OR=6.66,95%CI=1.33–3.30,P=0.021)were significantly associated with SCV,even after adjustment for confounders.Based on the best threshold,Lp-PLA2 had a sensitivity of 83.3%and a specificity of 51.7%for predicting SCV,as shown by the receiver operating characteristic curve analysis.In the poor World Federation of Neurosurgical Societies grade patient sub-group,patients with Lp-PLA2>200μg/L had significantly higher SCV rate than that of patients having Lp-PLA2≤200μg/L.Conclusion:The admission Lp-PLA2 level might be a helpful predictor for SCV in aSAH.

The classification of intracranial aneurysm neck: a single center research experience

There is associating with incidence of unfavorable outcomes compared to microsurgical clippings. We are in order to investigate the outcomes of microsurgical clipping for intracranial aneurysms and determine the ideal clipping methods for different aneurysm subtypes. Method: Retrospectively analyzed the clinical characteristics and follow-up data (completely recorded) of 123 patients with 128 aneurysms were treated. 20 cases were treated as control group from October 2013 to December 2013. Since January 2014, aneurysms were classified base on the 20 cases of aneurysm imaging data. 103 patients were treated as experimental group, the classification of aneurysms previously proposed was used to estimate the way of surgery, and the guiding value of the genotype was verified according to the intraoperative findings. The proposed aneurysm classification is based on the virtual surface of the aneurysm and the parent artery, the aneurysm neck was classified as follows: subtype I, the curved surface of the neck is a single curved surface;subtype II, the neck is hyperboloid;subtype III, neck is a three-curved surface. Aneurysms were divided into further subtypes according to the ratio of the width of the aneurysm neck surface and the length of the artery circumference: subtype A, the ratio of the aneurysm neck surface to the parent artery was not more than 0.5;subtype B, more than 0.5. There are some clamping methods include simple, sliding, interlocking and hybrid. Results: In the control group, patients did not undergo a suitable clipping scheme without classification of aneurysm neck (unclassed clipping). While causing the occurrence of occlusion adverse events, including neck residual, Tumor artery stenosis, electrophysiological changes, the lack of blood supply and so on. The experimental[page1image12073600]group was analyzed by using a predetermined clipping scheme (classed clipping), and the use of aneurysms clamps was approximately the same as expected. Compared the preoperative assessment with the actual situation, the consistency of the control group was 50% and the experimental group was 96%. Adverse events of classed clipping is 2%, another is 60%. There is a significant difference between the two groups (P < 0.05).Classed clipping of subject IA and IB are simple (mean 1.2 and 1.3 clips);classed clipping of subject IIA is simple and interlocking(mean 1.2 clips);classed clipping of subject IIB is sliding and hybrid(mean 2.05 clips);classed clipping of subject IIIA and IIIB are hybrid(mean 2.3 clips). Conclusion: There is a higher consistency in surgery through the above classification of preoperative assessment of clipping. There was no adverse event of intracranial aneurysm clipping in the clipping mode selected by the above classification, and satisfactory surgical clipping rate was achieved and no recurrence was found.

Risk factors of acute coagulation dysfunction after aneurysmal subarachnoid hemorrhage

Background: Although coagulopathy have been proved to be a contributor to a poor outcome of aneurysmal subarachnoid hemorrhage (aSAH), the risk factors for triggering coagulation abnormalities have not been studied after aneurysm clipping. Methods: We investigated risk factors of coagulopathy and analyzed the relationship between acute coagulopathy and outcome after aneurysm clipping. The clinical data of 137 patients with ruptured CA admitted to our institution was collected and retrospectively reviewed. Patient demographic data (age, sex), smoking, alcohol use, hypertension, diabetes, Hunt-Hess grade, Fisher grade, operation time, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, intraoperative hemostatic drug treatment, calcium reduction (preoperative free calcium concentration–postoperative free calcium concentration) were recorded. Coagulation was assessed within 24 h. Postoperative hemorrhage and infarction, deep venous thrombosis (DVT), and mortality were analyzed. Results: Coagulopathy was detected in a total of 51 cases (group I), while not in 86 cases (group II). Univariable analysis demonstrated that age, smoking, alcohol use, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, and calcium reduction (≥1.2 mg/dl) were related to coagulopathy. Non-conditional logistic regression analysis showed that age [OR, 1.037 (95% CI, 1.001–1.074);p=0.045] and calcium reduction (≥1.2 mg/dl) [OR, 5.509 (95% CI, 1.900–15.971);p=0.002] were considered as the risk factors for coagulopathy. Hunt-Hess grade [OR, 2.641 (95% CI, 1.079–6.331);p=0.033] and operation time [OR, 0.107 (95% CI, 1.012–0.928);p=0.043] were considered as the risk factors for hypocoagulopathy. There were 6 cases (11.7%) with cerebral infarction in group I, while 6 cases (6.98%) in group II (χ2=0.918, p=0.338). There were 4 cases (7.84%) with rebleeding in group I, while 5 cases (5.81%) in group II (χ2=0.215, p=0.643). The mortality was 9.80% (5/51) in group I, while 1.16% (1/86) in group II (χ2=5.708, p=0.017). DVT was not detected in all cases. Conclusions: In conclusion, age (≥65 years) and calcium reduction (≥1.2 mg/dl) were considered as the risk factors for coagulopathy and have been proved to be associated with higher mortality after aneurysm clipping.