Survival analysis and functional outcome at 6 months in surgical treatment of spontaneous supratentorial intracerebral hemorrhage (ICH)

Objectives. The aim of this study is to evaluate the role of surgery in patients with spontaneous supratentorial intracerebral hemorrhage and to identify predictors of outcome and survival including radiological, genetic, biochemical and treatment factors. Study design and method. This is a prospective cohort study, involving patients with spontaneous supratentorial intracerebral hemorrhage, who fulfill the inclusion criteria for surgical evacuation of the hematoma. This study was conducted over a 13 month period, from February 2004 to March 2005 .Surgery consisted of evacuation of hematoma using craniotomy and microsurgical techniques, as well as in some cases, a decompressive craniectomy. The ventriculostomy for intracranial pressure monitoring and drainage and regional cortical cerebral blood flow (rCoBF) monitoring and microdialysis were performed in all subjects. In addition, the association between Apolipoprotein E (APOE) s4 and outcome was also studied. The study end points were survival time and functional outcome at 6 months based on a dichotomised Glasgow Outcome Scale (GOS). GOS of 1-3 was defined as poor or unfavorable outcome and GOS of 4-5 was defined as good or favorable outcome. The selected clinical, radiological, genetic, biochemical and treatment factors that may influence the survival and functional outcome were analysed for its significance. The univariate analysis of the relation between various variables and GOS at 6 months were analysed using the chi-square test and the survival time was analysed using the Kaplan Meier and log rank test. In multivariate analysis, the binary logistic regression for functional outcome and Cox regression analysis for survival function were performed. Results. 36 patients were recruited into the study during the period of February 2004 and March 2005. All of those were followed-up for a period of 6 months. There were 19 males and 17 females with age ranged from 39 to 76 years and a mean age of 58.6 (±10.1) years and a median age of 61 years. 27(75%) patients had Glasgow Coma Score (GCS) between 5 to 8 on admission and 9(25%) were admitted with GCS of 9 on admission. The survival time ranged from 2 to 180 days with a mean survival time of 105.36 ± 76.4 days. At 6 months, 20 (55.6%) patients had GOS I, 1 (2.8%) patient had GOS II, 10 (27.7%) patients had GOS III and 5 (13.9%) had GOS of IV. None of the patients in this study had GOS ofV. The mortality rate at 6 months was 55%. 86 %had a poor or unfavorable outcome (GOS I-III) and 14% had good or favorable outcome (GOS IV-V). The study of Apolipoprotein E showed that the APOE e4 allele was not detected in all patients. In the univariate analysis for the functional outcome based on GOS, 3 significant variables were identified, the midline shift (p=0.009), regional cortical cerebral blood flow (rCoBF), (p=0.034) and tracheostomy status (p=0.047). The univariate analysis for survival function revealed that the regional cortical cerebral blood flow (rCoBF), (p=0.0143), midline shift (p=0.0064) and pupillary status on admission (p=0.0016) were significant predictors of survival function. The selected variables were then incorporated into models generated by binary logistic regression and Cox regression analysis to identify significant predictors of functional outcome and survival function. Midline shift was the single significant predictor of functional outcome at 6 months (OR=20.8; 95% CI = 1.90- 227.26; p=0.013), and the pupillary status was sole significant predictor of survivalfunction (HR = 2.298; 95% CI 1.168- 4.523; p=0.016). Patients with midline shift> 5mm has almost 21 times higher chances of being associated with poor outcome (GOS I-III) and patients with abnormal pupil on admission has 2.3 times risk of mortality compared to patients with normal pupillary reaction on admission. Conclusion. Surgical treatment for spontaneous intracerebral hemorrhage in this group of patients only benefited a small number of patients in terms of favorable outcome (14%) and in the majority of patients (86% ), the outcome was unfavorable. Patients with midline shift > 5mm has almost 21 times higher chances of being associated with poor outcome (GOS 1-111) at 6 months and patients with an abnormal pupil on admission had an increase in mortality risk of about 2 times compared to patients with normal pupiJJary reaction on admission

Alteration in the functional organization of the default mode network following closed non-severe traumatic brain injury

The debilitating effect of traumatic brain injury (TBI) extends years after the initial injury and hampers the recovery process and quality of life. In this study, we explore the functional reorganization of the default mode network (DMN) of those affected with non-severe TBI. Traumatic brain injury (TBI) is a wide-spectrum disease that has heterogeneous effects on its victims and impacts everyday functioning. The functional disruption of the default mode network (DMN) after TBI has been established, but its link to causal effective connectivity remains to be explored. This study investigated the differences in the DMN between healthy participants and mild and moderate TBI, in terms of functional and effective connectivity using resting-state functional magnetic resonance imaging (fMRI). Nineteen non-severe TBI (mean age 30.84 ± 14.56) and twenty-two healthy (HC; mean age 27.23 ± 6.32) participants were recruited for this study. Resting-state fMRI data were obtained at the subacute phase (mean days 40.63 ± 10.14) and analyzed for functional activation and connectivity, independent component analysis, and effective connectivity within and between the DMN. Neuropsychological tests were also performed to assess the cognitive and memory domains. Compared to the HC, the TBI group exhibited lower activation in the thalamus, as well as significant functional hypoconnectivity between DMN and LN. Within the DMN nodes, decreased activations were detected in the left inferior parietal lobule, precuneus, and right superior frontal gyrus. Altered effective connectivities were also observed in the TBI group and were linked to the diminished activation in the left parietal region and precuneus. With regard to intra-DMN connectivity within the TBI group, positive correlations were found in verbal and visual memory with the language network, while a negative correlation was found in the cognitive domain with the visual network. Our results suggested that aberrant activities and functional connectivities within the DMN and with other RSNs were accompanied by the altered effective connectivities in the TBI group. These alterations were associated with impaired cognitive and memory domains in the TBI group, in particular within the language domain. These findings may provide insight for future TBI observational and interventional research

Computed Tomography Perfusion Imaging on Traumatic Cerebral Contusion: A Preliminary Report

Background: Brain ischaemia and infarction are the leading factors in morbidity and mortality of traumatic brain injury. This study aimed to determine the perfusion status of pericontusional hypodense areas in traumatic cerebral contusion. Methods: Ten patients involved in motor vehicle accidents were enrolled in this study, and contusions were diagnosed from plain computed tomography scans of the brain. Subsequent computed tomography perfusion (CTP) was performed to analyse the perfusion of pericontusional hypodense areas, which were divided into 4 regions of interest (ROI). Results: Most ischaemic perfusion was found in ROI 6 (affecting 60% of patients), although the mean of the perfusion parameters were normal. A significant positive correlation was found between the perfusion status in the pericontusional area nearest to the skull vault (ROI 3) and its distance/thickness to the skull vault (r = 0.698, P = 0.025). Two adjacent pericontusional hypodense areas (ROI 4 and ROI 5) showed a significant positive correlation with each other (r = 0.667, P = 0.035) in terms of perfusion status. The presence of a hypodense pericontusional area is suggestive of oedema and perfusion disturbances. Conclusion: CTP is a useful, fast, and appropriate method in evaluating perfusion of pericontusional hypodensity area that may help the treating physician to provide an appropriate treatment to the patient

Role of high augmentation index in spontaneous intracerebral haemorrhage

Background: Intracerebral haemorrhage (ICH) is the most disabling and least treatable form of stroke. Its risk factors include old age, hypertension, diabetes mellitus, hypercholesterolaemia, smoking and high alcohol intake, which are also associated with arterial stiffness. The aim of the present study was to determine the prognostic value of high augmentation index (AI), which is a surrogate marker of arterial stiffness, in patients with spontaneous ICH. Methods: A prospective study of 60 patients with spontaneous supratentorial ICH was conducted. Outcome was assessed using the Modified Rankin Scale at 3 months follow-up. Data were collected on age and sex, risk factors for ICH, clinical parameters, laboratory parameters, radiological findings and hospital management. Logistic regression analysis was carried out to identify independent predictors of 3-month outcome and mortality. Results: Admission Glasgow Coma Scale score (OR, 0.7; 95% CI, 0.450-0.971; p = 0.035), total leukocyte count (OR,1.2; 95% CI, 1.028-1.453; p = 0.023) and haematoma volume (OR, 1.1; 95% CI, 1.024-1.204; p = 0.011) were found to be statistically significant in multivariate analysis of 3-month poor outcome. Factors independently associated with mortality were high AI (OR, 8.6; 95%CI, 1.748-40.940; p = 0.007) and midline shift (OR, 7.5; 95%CI, 1.809-31.004; p = 0.005). Conclusion: Admission Glasgow Coma Scale score, total leukocyte count and haematoma volume were significant predictors for 3-month poor outcome; high AI and midline shift were significant predictors for 3-month mortality. © 2010 Asian Surgical Associatio

Frontal meningioma with psychiatric symptoms

Frontal meningioma is often asymptomatic and patient may present with psychiatric symptoms. We report a case of 45- year-old female patient with no premorbid medical illness presented with 6 months history of depressive symptoms and changes in personality. Her worsening cognitive impairment brought her to psychiatry clinic and led to further investigation with contrast-enhanced computed tomography (CECT) Brain. The result showed well defined markedly enhancing lesion in the frontal region measuring 5.5 cm X5.2 cm X 4.4 cm with mass effect to the adjacent brain parenchyma and associated surrounding edema. Diagnosis of bifrontal tumour-olfactory Groove Meningioma was made. Patient underwent bifrontal craniotomy and tumour excision. The quality of life improved after surgical excision

Role of High Augmentation Index in Spontaneous Intracerebral Haemorrhage

Intracerebral haemorrhage (ICH) is the most disabling and least treatable form of stroke. Its risk factors include old age, hypertension, diabetes mellitus, hypercholesterolaemia, smoking and high alcohol intake, which are also associated with arterial stiffness. The aim of the present study was to determine the prognostic value of high augmentation index (AI), which is a surrogate marker of arterial stiffness, in patients with spontaneous ICH. Methods: A prospective study of 60 patients with spontaneous supratentorial ICH was conducted. Outcome was assessed using the Modified Rankin Scale at 3 months follow-up. Data were collected on age and sex, risk factors for ICH, clinical parameters, laboratory parameters, radiological findings and hospital management. Logistic regression analysis was carried out to identify independent predictors of 3-month outcome and mortality. Results: Admission Glasgow Coma Scale score (OR, 0.7; 95% CI, 0.450–0.971; p = 0.035), total leukocyte count (OR,1.2; 95% CI, 1.028–1.453; p = 0.023) and haematoma volume (OR, 1.1; 95% CI, 1.024–1.204; p = 0.011) were found to be statistically significant in multivariate analysis of 3-month poor outcome. Factors independently associated with mortality were high AI (OR, 8.6; 95%CI, 1.748–40.940; p = 0.007) and midline shift (OR, 7.5; 95%CI, 1.809–31.004; p = 0.005). Conclusion: Admission Glasgow Coma Scale score, total leukocyte count and haematoma volume were significant predictors for 3-month poor outcome; high AI and midline shift were significant predictors for 3-month mortality