An unusual bilateral variation of musculocutaneous nerve.

Musculocutaneous nerve arises from the lateral cord (C5,6,7) of brachial plexus. Communications between the branches of brachial plexus are not so common. During routine dissection, we observed bilateral variation in 60-year-old female cadaver. In the present case, median nerve represented as a musculocutaneous nerve which supplied biceps brachii and brachialis, further continued into forearm as lateral cutaneous nerve of forearm on the right arm. This branch did not pass through coracobrachialis muscle but the coracobrachialis was innervated by a branch from lateral cord of brachial plexus. We also observed an abnormal communicating branch between the musculocutaneous and median nerve on left side of the arm. These kinds of variations are important for surgeons while performing surgeries of axilla and upperlimb

Role of Decompressive Craniectomy in the Management of Cerebral Venous Sinus Thrombosis

Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke more often affecting women and younger individuals. Blockage of the venous outflow rapidly causes edema and space-occupying venous infarctions and it seems intuitive that decompressive craniectomy (DC) can effectively reduce intracranial pressure just like it works for malignant middle cerebral artery infarcts and traumatic brain injury. But because of the relative rarity of this type of stroke, strong evidence from randomized controlled trials that DC is a life-saving procedure is not available unlike in the latter two conditions. There is a possibility that other forms of interventions like endovascular recanalization, thrombectomy, thrombolysis, and anticoagulation, which cannot be used in established middle cerebral artery infarcts and TBI, can reverse the ongoing pathology of increasing edema in CVST. Such interventions, although presently unproven, could theoretically obviate the need for DC when used in early stages. However, in the absence of such evidence, we recommend that DC be considered early as a life-saving measure whenever there are large hemorrhagic infarcts, expanding edema, radiological, and clinical features of impending herniation. This review gives an overview of the etiology and risk factors of CVST in different patient populations and examines the effectiveness of DC and other forms of interventions

Complications of Decompressive Craniectomy

Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter

Neurotrauma clinicians' perspectives on the contextual challenges associated with long-term follow-up following traumatic brain injury in low-income and middle-income countries: a qualitative study protocol.

INTRODUCTION: Traumatic brain injury (TBI) is a global public health concern; however, low/middle-income countries (LMICs) face the greatest burden. The WHO recognises the significant differences between patient outcomes following injuries in high-income countries versus those in LMICs. Outcome data are not reliably recorded in LMICs and despite improved injury surveillance data, data on disability and long-term functional outcomes remain poorly recorded. Therefore, the full picture of outcome post-TBI in LMICs is largely unknown. METHODS AND ANALYSIS: This is a cross-sectional pragmatic qualitative study using individual semistructured interviews with clinicians who have experience of neurotrauma in LMICs. The aim of this study is to understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs. For the purpose of the study, we define 'long-term' as any data collected following discharge from hospital. We aim to conduct individual semistructured interviews with 24-48 neurosurgeons, beginning February 2020. Interviews will be recorded and transcribed verbatim. A reflexive thematic analysis will be conducted supported by NVivo software. ETHICS AND DISSEMINATION: The University of Cambridge Psychology Research Ethics Committee approved this study in February 2020. Ethical issues within this study include consent, confidentiality and anonymity, and data protection. Participants will provide informed consent and their contributions will be kept confidential. Participants will be free to withdraw at any time without penalty; however, their interview data can only be withdrawn up to 1 week after data collection. Findings generated from the study will be shared with relevant stakeholders such as the World Federation of Neurosurgical Societies and disseminated in conference presentations and journal publications

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

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

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence [version 2; peer review: 2 approved]

Background The epidemiology of traumatic brain injury (TBI) is unclear – it is estimated to affect 27–69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment. Objective The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research. Design Multi-centre, international, registry-based, prospective cohort study. Subjects Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence. Methods All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol. Data Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint

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

Bilateral ossified pterygospinous ligament and its clinical significance

The ossification of the pterygospinous ligament form the bridge known as pterygospinous bony bridge and it may create a pterygospinous foramen. Close location of this ossified pterygospinous ligament to the foramina ovale, can entrap the mandibular nerve and its branches which emerges through the foramen ovale and may produce the clinical condition known as mandibular neuralgia. Presence of such ossified pterygospinous ligament may also interfere with the mandibular nerve block. Here, we report a rare case of ossified pterygospinous ligament bilaterally in a dried adult skull. The measurements of variant pterygospinous foramen were recorded as 4.25 mm horizontally and 4.55 mm vertically, on the right side and 4mm, 4.10 mm on the left side. This variation is clinically important for Surgeons, Neurologists and Anesthetists