Mini-craniotomy under local anaesthesia and sedation as a less invasive procedure for spontaneous intracerebral haemorrhage in a developing country

Background: Minimally invasive surgery (MINS) is being viewed as the more practical alternative to the traditional craniotomy for the evacuation of spontaneous intracerebral haemorrhage (sICH). Most such sICH arises as complications of systemic hypertension. The techniques of MINS described are not currently affordable in most developing countries.Methods: An annotated technique of mini-craniotomy under local anaesthesia (LA) is here described as a stop-gap solution to this problem. An outcome study of this surgical technique in a prospective consecutive patient population is also presented.Results: Twenty-one patients, 13 males, mean age 41.1 years, underwent this surgical procedure. Clinical presentation of the sICH was generally severe: 48% in coma, 81% critically ill, and many of these cases were complicated with high fever, meningism, and chest morbidity. The Glasgow Coma Scale score was 3/15 to 8/15 and 9/15 to 12/15, respectively, in 9 of 21 cases (42.9%) each. The ICH showed evidence of significant mass effect on brain computed tomography (CT) scan in 95% and was associated with intraventricular haemorrhage in 43%. The bleed was deep-seated in the white matter and basal ganglia in 16 of 21 cases, and superficial-cortical in the rest. The midline shift was at least 5 mm in all of these. The surgical procedure was successfully completed in all cases. The in-hospital results were: mortality of 62% and postoperative survival of 38%, which is well within the range of global outcome statistics related to sICH.Conclusions: In well-selected patient groups mini-craniotomy under LA appears effectual in the surgical evacuation of sICH. It has a particular attraction as a low-cost treatment option for developing countries.Keywords: spontaneous ICH; surgical evacuation; minimally invasive surgery; surgical technique; mini-craniotomy; local anaesthesia; low-cost procedure; developing countr

Physicians’ Knowledge of the Glasgow Coma Scale in a Nigerian University Hospital: Is the Simple GCS Still Too Complex?

Objective: The Glasgow Coma Scale, GCS, is a universal clinical means of quantifying the level of impaired consciousness. Although physicians usually receive undergraduate and postgraduate training in the use of this scale in our university hospital we are aware of studies suggesting that the working knowledge of the GCS among practising physicians might not be adequate. Methods: We carried out a questionnaire-based survey across all specialties and levels of training of physicians in active patient care in a Nigerian university hospital. Results: Of the 100 physicians sampled, 98 correctly spelled out what the three-letter abbreviation, GCS, stands for. Ninety-three percent also conceded it to be an important clinical rating scale. However, only 55–89% of the participants correctly identified the three respective clinical variables, (eye opening, verbal response, and motor response), of the GCS. More particularly, the participants’ ability to itemize and correctly score all the respective components of each of the three clinical variables ranged from 0 to 35% across specialties and levels of training. Performance was best for the four-item eye opening variable and, worst for the six-item motor response variable. Conclusion: In our university hospital, practising physicians’ working knowledge of the GCS is inadequate and is dependent on the degree of the complexity of each of the three clinical variables of the scale

Knowledge of the Glasgow Coma Scale among Physician Interns in a Nigerian Tertiary Health Facility

Background: The Glasgow coma scale (GCS) is the most utilized level of consciousness scale globally. Insufficient working knowledge of the GCS by physicians may contribute to poor outcomes in patients with altered levels of consciousness. Aim: This study aims to assess the knowledge of the GCS among the physician interns, also known as house officers, in a rural tertiary health facility in Nigeria. Materials and Methods: This was a questionnaire‑based survey among physician interns in a rural tertiary hospital in Nigeria. Results: All the 77 respondents graduated from medical school within 2 years of the study. Seventy‑two (93.5%) of the participants had been actively involved in the management of patients at the hospital’s accident and emergency department within a month before the study, while 71.4% had been involved in emergency care outside the accident and emergency department within a month prior. Seventy‑five (97.4%) conceded to having received didactic lectures on the GCS in the course of their medical training. About three‑quarters (74.03%) of the respondents correctly defined GCS as GCS; about 85.7% were able to correctly identify all the clinical variables of the GCS, while only 15.6% could correctly describe and score all the parameters of the grading scale. The eye‑opening response was the most correctly remembered (64.9%), followed by the verbal response (42.9%), while the motor response was remembered by 29.9% of the respondents (P = 0.04). Only 36 (46.8%) participants were aware of any subsequent modification to the original GCS score. Conclusion: The working knowledge of GCS is poor among physician interns surveyed in this study. The clinical variable of the GCS with the highest number of items, the motor response, was the least correctly remembered

The role of decompressive craniectomy in limited resource environments

Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain’s tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments

The Role of Decompressive Craniectomy in Limited Resource Environments

Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments

Hinge/floating craniotomy as an alternative technique for cerebral decompression: a scoping review

Funder: National Institute for Health Research; doi: http://dx.doi.org/10.13039/501100000272Funder: Great Ormond Street Hospital for Children; doi: http://dx.doi.org/10.13039/501100003784Abstract: Hinge craniotomy (HC) is a technique that allows for a degree of decompression whilst retaining the bone flap in situ, in a ‘floating’ or ‘hinged’ fashion. This provides expansion potential for ensuing cerebral oedema whilst obviating the need for cranioplasty in the future. The exact indications, technique and outcomes of this procedure have yet to be determined, but it is likely that HC provides an alternative technique to decompressive craniectomy (DC) in certain contexts. The primary objective was to collate and describe the current evidence base for HC, including perioperative parameters, functional outcomes and complications. The secondary objective was to identify current nomenclature, operative technique and operative decision-making. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Fifteen studies totalling 283 patients (mean age 45.1 and M:F 199:46) were included. There were 12 different terms for HC. The survival rate of the cohort was 74.6% (n = 211). Nine patients (3.2%) required subsequent formal DC. Six studies compared HC to DC following traumatic brain injury (TBI) and stroke, finding at least equivalent control of intracranial pressure (ICP). These studies also reported reduced rates of complications, including infection, in HC compared to DC. We have described the current evidence base of HC. There is no evidence of substantially worse outcomes compared to DC, although no randomised trials were identified. Eventually, a randomised trial will be useful to determine if HC should be offered as first-line treatment when indicated

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course

Decompressive craniotomy: an international survey of practice.

Funder: National Institute for Health Research; doi: http://dx.doi.org/10.13039/501100000272Funder: University of Cambridge and the Royal College of Surgeons of EnglandBACKGROUND: Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. METHOD: A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. RESULTS: We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. CONCLUSION: Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial

The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis

Background A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. Methods In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. Findings Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I 2 of > 75%) between estimates for almost half of the outcomes. Interpretation To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. Funding Public Health Wales. © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licens

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

Abstract: Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction