Hyperdense Appearance in Active Epidural and Subdural Hematoma: Serial Case Report

Many of traumatic brain injured patients come to the emergency department with active intracranial bleeding, either Epidural Hematoma (EDH) or Subdural Hematoma (SDH). The most common source of bleeding in EDH cases might be either from the oozed bleeding from fracture of adjacent bone or tear of medial meningeal vessel branches. The classic appearance usually found in non-contrast head CT, which formed a biconvex lesion. The active bleeding, usually from blood vessels tearing origin, could also be found in CT imaging. There is hypodense mixed within the hyperdense lesion, sometimes formed a whirlpool-like appearance, which later known as “Swirl Sign”3. The acute subdural hematoma, by its process, is different with EDH. It is usually caused by clot accumulation of adjacent cortical laceration or tearing of bridging veins. The crescent-like appearance is the classical CT image shown in acute SDH. However, up to now, the active bleeding in subdural hematoma is not widely explained. We report 12 cases of epidural and subdural hematoma which indicate active bleeding from imaging study.All of the cases revealed the active bleeding during the surgery.We suggest that hypodense lesion in acute TBI imaging should be considered as active bleeding not only for EDH but also for SDH cases. Thus, more attention must be taken carefully during the surgery

Polylactic Acid Implant for Cranioplasty with 3-dimensional Printing Customization: A Case Report

BACKGROUND: Cranioplasty is aimed to restore the structure and function of the lost portion of the skull defect. Many materials can be used for cranioplasty, such as the bones of the patient (autograft), the bones of other patients (allograft), bones of animals (xenograft), or synthetic materials such as acrylic or titanium mesh. These materials are quite expensive and sometimes require complex processes. Manual shaping of material for cranioplasty is also quite time-consuming and prone to cause esthetic dissatisfaction. The author will discuss the case of using polylactic acid (PLA) implant with 3-dimensional (3D) printing customization as a cheap and accurate cosmetic solution for cranioplasty procedures. CASE REPORT: We report 2 cases of skull defect underwent cranioplasty. The first case, female, 20-year-old, had a history of severe traumatic brain injury (TBI) and epidural hematoma. She underwent decompression craniotomy on the left frontotemporoparietal region of her skull. The second case, male, 46-year-old, had a history of spontaneous intracerebral hemorrhage due to arteriovenous malformation (AVM). He underwent decompression craniotomy on the right frontotemporoparietal region of her skull. Both the data of computerized tomography (CT) scan were reconstructed to get 3D model of skull defect. Prosthesis was made by 3D printer accordingly using PLA as material. There was no complication reported postoperatively and cosmetic satisfaction was obtained on both cases. CONCLUSION: The use of PLA implant with 3D printing customization was proved to be cost-effective and good cosmetic satisfaction with no complication reported following cranioplasty procedure

Bilateral skull fracture with massive epidural hematoma secondary to pin-type head fixation in a pediatric patient: Case report and review of the literature

Introduction A head fixation device containing pins is common equipment used in neurosurgical procedures. Previous reports analysed some of the complications associated with the application of this device for adults and children, even the indications for the use in pediatric are not well defined. Case presentation An 11-year-old girl diagnosed with non-communicating hydrocephalus, caused by posterior fossa tumor. During the surgery, complications were found in the form of acute epidural hematoma due to head fixation pins. So, the operation was stopped. Emergent CT scan was carried out and showed a bilateral skull fracture and a massive right-sided epidural hematoma. An emergency craniotomy for clot removal was performed and five days later, a second surgery was carried out uneventfully for the residual tumor. The patient fully recovered after the second surgery. Discussion Complications due to the use of a pin head fixation are easier to occur in pediatric patients, because the bones are thinner and need more carefull strategy when pinning. With promp identification of any complications and earlier treatment, the good outcome will be achieved. We compared our case report with published literature in order to suggest the way to prevent this complication. Conclusion Skull fractures and associated epidural hematomas in pediatric patients need to be considered as possible complications of the pin-type head fixation application. The head fixation devices in pediatric need to be used with great caution and knowing the risk factors, safe technique for application and management of complications will prevent worse outcome

Neurosurgery at the epicenter of the COVID-19 pandemic in Indonesia: experience from a Surabaya academic tertiary hospital

OBJECTIVE Global outbreak of the novel coronavirus disease 2019 (COVID-19) has forced healthcare systems worldwide to reshape their facilities and protocols. Although not considered the frontline specialty in managing COVID-19 patients, neurosurgical service and training were also significantly affected. This article focuses on the impact of the COVID-19 outbreak at a low- and/or middle-income country (LMIC) academic tertiary referral hospital, the university and hospital policies and actions for the neurosurgical service and training program during the outbreak, and the contingency plan for future reference on preparedness for service and education. METHODS The authors collected data from several official databases, including the Indonesian Ministry of Health database, East Java provincial government database, hospital database, and neurosurgery operative case log. Policies and regulations information was obtained from stakeholders, including the Indonesian Society of Neurological Surgeons, the hospital board of directors, and the dean’s office. RESULTS The curve of confirmed COVID-19 cases in Indonesia had not flattened by the 2nd week of June 2020. Surabaya, the second-largest city in Indonesia, became the epicenter of the COVID-19 outbreak in Indonesia. The neurosurgical service experienced a significant drop in cases (50% of cases from normal days) along all lines (outpatient clinic, emergency room, and surgical ward). Despite a strict preadmission screening, postoperative COVID-19 infection cases were detected during the treatment course of neurosurgical patients, and those with a positive COVID-19 infection had a high mortality rate. The reduction in the overall number of cases treated in the neurosurgical service had an impact on the educational and training program. The digital environment found popularity in the educational term; however, digital resources could not replace direct exposure to real patients. The education stakeholders adjusted the undergraduate students’ clinical postings and residents’ working schemes for safety reasons. CONCLUSIONS The neurosurgery service at an academic tertiary referral hospital in an LMIC experienced a significant reduction in cases. The university and program directors had to adapt to an off-campus and off-hospital policy for neurosurgical residents and undergraduate students. The hospital instituted a reorganization of residents for service. The digital environment found popularity during the outbreak to support the educational process

MANAJEMEN TRAUMA TEMBUS OTAK : LAPORAN KASUS

Pendahuluan. Trauma tembus otak merupakan kegawatan medis yang meskipun jarang terjadi namun sering mengakibatkan mortalitas dan morbiditas yang tinggi. Penanganan trauma tembus otak sendiri masih menjadi tantangan bagi para ahli bedah saraf di seluruh dunia. Menajemen yang optimal pada penaganan trauma tembus otak memerlukan pemahaman yang komprehensif terhadap mekanisme dan patofisiologi terjadinya cedera tersebut. Sampai saat ini penanganan standar pada kasus trauma tembus otak masih menjadi perdebatan. Metode. Artikel ini berbentuk serial kasus, kami melaporkan 3 kasus trauma tembus pada institusi kami. Artikel ini disusun dari berbagai referensi dan pengalaman kasus yang pernah ditangani di Rumah Sakit Umum AkademikDr. Soetomo. Hasil. Pada pasien trauma tembus yang dilakukan kraniotomi debridement kurang dari 12 jam post trauma diikuti pemberikan antibiotik profilaksis empirik dengan ceftriaxone dan metronidazole selama 7 hari dan antikejang phenytoin selama 7 hari didapatkan keluaran yang memuaskan. Kesimpulan Manajemen trauma tembus otak memerlukan metode diagnostic yang cepat dan tepat. Pemeriksaan CT scan kepala menjadi wajib untuk penegakan diagnosis trauma tembus kepala. CT angiografi diperlukan pada kasus kasus yang dicurigai menyebabkan lesi vaskular. Yang kemudian iikuti dengan penangan operasi segera dan pemberian antibiotic yang tepat. Kata Kunci: Trauma tembus otak, kraniotomi debridement, antibiotik profilaksis empiri, CT angiograf

ICP MONITOR PLACEMENT STEPWISE EARLY DECOMPRESSIVE CRANIECTOMY FOR THE MANAGEMENT OF SEVERE TBI PATIENTS: A CASE REPORT

Pendahuluan. Peningkatan tekanan intrakranial (ICP) merupakan kejadian sekunder yang sering terjadi setelah cedera otak traumatis (TBI) dan berkorelasi dengan hasil yang buruk pada pasien. Beberapa penelitian menunjukkan bahwa kraniektomi dekompresif awal (DC) (dalam 48 jam setelah cedera) direkomendasikan untuk pasien dengan TBI berat yang membutuhkan evakuasi perdarahan intrakranial dan DC awal mampu mengurangi komplikasi TBI yang disebabkan oleh peningkatan TIK. Namun, meskipun DC awal telah dilakukan, peningkatan TIK masih dapat berlangsung karena terjadi edema otak yang masif. Metode. Sebuah kasus pasien yang dirawat dengan TBI berat dan perdarahan intrakranial. Pasien kemudian menjalani DC dan pemasangan ICP monitor setelah evakuasi perdarahan intrakranial. Selama observasi pasca operasi di ICU, cairan serebrospinal (CSF) pasien secara bertahap akan dikeluarkan jika ICP lebih dari 15mmHg. Hasil. ICP sesaat setelah dilakukan DC awal yaitu 30cm H20 (22 mmHg). Hari pertama setelah operasi, hemodinamik pasien stabil dan GCS 2X5 dengan ICP pasien sekitar 18 cmH2O. Pada hari ke 2-5, pasien hemodinamik stabil dengan GCS membaik (3X5) dengan penurunan ICP (sekitar 13-15 cmH2O). Pada hari ke-6, ICP monitor dilepaskan dan pasien dipulangkan pada hari ke 19 setelah pulih sepenuhnya. Kesimpulan. Penempatan ICP monitor dan aplikasi pelepasan CSF secara bertahap setelah DC mungkin membantu mengurangi peningkatan ICP pada pasien dengan TBI berat, dan dengan demikian mengurangi morbiditas dan mortalitas

Clinical Outcomes of MLC601 (NeuroAiDTM) in Traumatic Brain Injury: A Pilot Study

Background: MLC601 is a natural product formulation from Chinese medicine that is extensively studied in ischemic stroke. Traumatic brain injury (TBI) shares pathophysiological mechanisms with ischemic stroke, yet there are few studies on the use of MLC601 in treating TBI. This Indonesian pilot study aimed to investigate clinical outcomes of MLC601 for TBI. Methods: This randomized controlled trial included subjects with nonsurgical moderate TBI allocated into two groups: with and without MLC601 over three months in addition to standard TBI treatment. Clinical outcomes were measured by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) observed upon discharge and at months (M) 3 and 6. Results: Thirty-two subjects were included. The MLC601 group (n = 16) had higher GOS than the control group (n = 16) at all observation timepoints, though these differences were not statistically significant (p = 0.151). The BI values indicated a significant improvement for the MLC601 group compared to the control group at M3 (47.5 vs. 35.0; p = 0.014) and at M6 (67.5 vs. 57.5; p = 0.055). No adverse effects were associated with MLC601 treatment. Conclusion: In this cohort of nonsurgical moderate TBI subjects, MLC601 showed potential for a positive effect on clinical outcome with no adverse effects

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

Emergency surgery for traumatic spinal cord injury in a secondary hospital: A case report

Cervical spinal cord injury (SCI) is a life-threatening condition. Prompt surgical intervention is needed to avoid hemodynamic and respiratory catastrophe. In Indonesia, however, spine surgery is more common in tertiary hospitals and thus might prolong the time gap to surgery due to referral waiting time