A Randomised Control Trial on the Use of Topical Methicillin in Reducing Post-Operative Ventriculoperitoneal Shunt Infection

Background: A double-blind randomised control study was conducted on all patients who were admitted or referred to the Department of Neurosurgery, Sultanah Aminah Hospital, Johor Bahru, with a diagnosis of hydrocephalus where a ventriculoperitoneal shunt was indicated. Methods: The period of study was from November 2005 to May 2007, and the follow-up period was 3 months after surgery. Randomisation was carried out in the operating room prior to the procedure. The scrub nurse selected a sealed envelope, which contained the assignment of each patient to 1 of 2 treatment groups: Group 1 patients were treated with topical methicillin, and Group 2 patients were not treated with topical methicillin. Prophylactic antibiotic, cefuroxime (25 mg/kg) was given intravenously at induction. Standard sterile operative technique was followed in preparing and draping the patients. Results: A total of 90 patients were recruited in the study, and 13 (14.4%) patients developed an infection within 3 months post-operation. Group 1 had a 8.9% risk of infection, and Group 2 had a 20% risk; however, there was no statistically significant post-operative ventriculoperitoneal shunt (VPS) infection reduction with the use of topical methicillin in VPS surgery (P = 0.230). Multivariate analysis showed that only duration of surgery had a significant influence on the incidence of post-operative VPS infection in the non-methicillin group (P = 0.02). The non-methicillin group had an 8 times greater risk of developing post-operative VPS infection than the methicillin group if surgery lasted longer than 1 hour. Conclusion: Topical methicillin had no significance in the reduction of post-operative VPS infection

Treatment Outcome of Superficial Cerebral Abscess: An Analysis of Two Surgical Methods

Background: The purpose of the study is to compare the two surgical methods (burr hole and craniotomy) used as treatment for superficial cerebral abscess and its outcome in terms of radiological clearance on brain CT, improvement of neurological status, the need for repeated surgery, and survival and morbidity at three months after surgery. This report is a retrospective case review of the patients who were treated surgically for superficial cerebral abscess in Hospital Kuala Lumpur (HKL) and Hospital Sultanah Aminah (HSA) over a period of four years (2004 to 2007). Methods: Fifty-one cases were included in this study: 64.7% of patients were male and 35.5% were female. Most of the patients were Malay (70.6%); 28 patients (54.9%) had undergone craniotomy and excision of abscess, and the rest had undergone burr hole aspiration as their first surgical treatment. Results: This study reveals that patients who had undergone craniotomy and excision of abscess showed a significantly earlier improvement in neurological function, better radiological clearance and lower rate of re-surgery as compared to the burr hole aspiration group (P-value < 0.05). However, with respect to neurological improvement at 3 months, morbidity and mortality, there is no significant difference between the two surgical methods. Conclusion: The significance of these findings can only be confirmed by a prospective randomised series. Further study will be required to assess the cost effectiveness, intensive care needs, and possibility of shorter antibiotic usage as compared to burr hole aspiration

Delayed Traumatic Intracranial Haemorrhage and Progressive Traumatic Brain Injury in a Major Referral Centre Based in a Developing Country

A repeat Computer Tomographic (CT) brain after 24–48 hours from the 1st scanning is usually practiced in most hospitals in South East Asia where intracranial pressure monitoring (ICP) is routinely not done. This interval for repeat CT would be shortened if there was a deterioration in Glasgow Coma Scale (GCS). Most of the time the prognosis of any intervention may be too late especially in hospitals with high patient-to-doctor ratio causing high mortality and morbidity. The purpose of this study was to determine the important predictors for early detection of Delayed Traumatic Intracranial Haemorrhage (DTICH) and Progressive Traumatic Brain Injury (PTBI) before deterioration of GCS occurred, as well as the most ideal timing of repeated CT brain for patients admitted in Malaysian hospitals. A total of 81 patients were included in this study over a period of six months. The CT scan brain was studied by comparing the first and second CT brain to diagnose the presence of DTICH/PTBI. The predictors tested were categorised into patient factors, CT brain findings and laboratory investigations. The mean age was 33.1 ± 15.7 years with a male preponderance of 6.36:1. Among them, 81.5% were patients from road traffic accidents with Glasgow Coma Scale ranging from 4 – 15 (median of 12) upon admission. The mean time interval delay between trauma and first CT brain was 179.8 ± 121.3 minutes for the PTBI group. The DTICH group, 9.9% of the patients were found to have new intracranial clots. Significant predictors detected were different referral hospitals (p=0.02), total GCS status (p=0.026), motor component of GCS (p=0.043), haemoglobin level (p<0.001), platelet count (p=0.011) and time interval between trauma and first CT brain (p=0.022). In the PTBI group, 42.0% of the patients were found to have new changes (new clot occurrence, old clot expansion and oedema) in the repeat CT brain. Univariate statistical analysis revealed that age (p=0.03), race (p=0.035), types of admission (p=0.024), GCS status (p=0.02), pupillary changes (p=0.014), number of intracranial lesion (p=0.004), haemoglobin level (p=0.038), prothrombin time (p=0.016) as the best predictors of early detection of changes. Multiple logistics regression analysis indicated that age, severity, GCS status (motor component) and GCS during admission were significantly associated with second CT scan with changes. This study showed that 9.9% of the total patients seen in the period of study had DTICH and 42% had PTBI. In the early period after traumatic head injury, the initial CT brain did not reveal the full extent of haemorrhagic injury and associated cerebral oedema. Different referral hospitals of different trauma level, GCS status, motor component of the GCS, haemoglobin level, platelet count and time interval between trauma and the first CT brain were the significant predictors for DTICH. Whereas the key determinants of PTBI were age, race, types of admission, GCS status, pupillary changes, number of intracranial bleed, haemoglobin level, prothrombin time and of course time interval between trauma and first CT brain. Any patients who had traumatic head injury in hospitals with no protocol of repeat CT scan or intracranial pressure monitoring especially in developing countries are advised to have to repeat CT brain at the appropriate quickest time

Head Injury from Fan Blades Among Children

Head injury caused by fan blades is rare among children. We analysed 14 cases of such injury and discuss the causes, type of injury and preventive measures. Methods: A retrospective analysis of 14 cases of children who were admitted to the Pediatric Neurosurgical Unit of Hospital Kuala Lumpur after sustaining head injuries caused by fan blades between January 2000 and December 2002 was performed. Results: The causes of fan-blade head injury included jumping on the upper bunk of a bunk-bed, climbing on a ladder, climbing up onto a table, and being lifted by an adult. Thirteen patients were injured by ceiling fans and one by falling onto an uncovered table fan. School-aged boys were the predominant victims. Mean patient age was 7.9 years (range, 1.0-12.2 years). There was a twin peak incidence of when the accidents occurred: just before lunch in the afternoon and bedtime at night. The types of injury were scalp lacerations, compound depressed fractures and multiple intracranial haemorrhages. Two patients had the complication of wound infection, and one of these patients developed cerebral spinal fluid leak. One patient died from severe head injuries. Conclusion: Safety awareness among parents and caretakers are important as fan-blade head injury among children is preventable