Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up.Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study.Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948–1.006) and outcome (P = 0.538, 95% CI 0.997–1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity.Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research

Thoracic myelopathy secondary to ossified ligamentum flavum and dural ossification – A series of 19 cases and review of literature

Objective: Thoracic myelopathy has gradually risen to be a prominent diagnosis in patients with persistent upper back pain, bladder symptoms and spastic paraparesis. Often encountered, these conditions pose a serious dilemma to neurosurgeons with respect to surgical planning, timing of surgery, prognosis and possible complications and outcome assessment. In view of these queries and to clarify the indications of when to intervene the following study has been undertaken.To analyze the clinical presentation, radiological features, clinical implications and surgical nuances and outcomes in patients with single and multiple level dorsal canal ossified ligamentum flavum (D-OLF) and associated dural ossification (DO). Patients and methods: Nineteen patients with the diagnosis of thoracic myelopathy (TM) were identified between January 2012 and March 2017. All patients were treated surgically, with decompressive laminectomies, in a single tertiary care center in Southern India. mJOA was calculated preoperatively and assessed postoperatively and a mean mJOA was calculated to assess the significance in neurological improvement. The data was collected from the medical records department and various factors were analyzed, using SPSS software, for correlation. Results: Mean age of our group was 50.84 years with a range of 29 to 71 years. It comprised of 11 males and 8 females. All patients had features of myelopathy. Surgery did have a positive effect on neurological improvement (p = 0.001) in all patients except one. Dural ossification had correlation with pre op and post op urinary disturbances with p value of 0.02. (Mann Whitney Test for 2 independent variables used). A total of ten patients had urinary symptoms pre operatively, out of which six patients showed postoperative improvement at the end of one year. Four of these patients continued to have symptoms, two patients were on Clean Intermittent Catheterisation (CIC), and one patient had features of hesitancy and frequency. Preoperative bladder dysfunction was a strong predictor for continued bladder dysfunction at the end of 1 year (p < 0.004). Conclusions: All patients with D-OLF and or DO presented with myelopathic features. MRI with concurrent CT spine helps to delineate dural ossification from D-OLF and helped to rule out other differentials. The classical “tram track” and “comma sign” is well noted in CT spine and helps to plan surgical approach and anticipate probable complications.Patients with concurrent D-OLF and DO and long segment pathology had increased risk of intraoperative dural tears and postoperative CSF leaks. These subset of patients had a peaked incidence of bladder involvement or non-improvement of existing bladder dysfunction, postoperatively. Patients with D-OLF and DO seemed to do better after surgical decompression. Surgery should be offered once diagnosis is confirmed on imaging, as all patients in out study, except one, showed postoperative neurological improvement.Our study concluded that patients with prolonged preoperative symptoms persisted to have them even after surgery. Patients with concurrent D-OLF and DO showed more significant improvement, postoperatively, in terms of mJOA – postop with a p = 0.002 as compared to patients with D-OLF alone.We recommend that each case be treated individually and treatment should be planned appropriately, based on the radiology and levels involved, keeping in mind the preoperative symptoms and their duration. Keywords: Ossified ligamentum flavum, Dural ossification, Postoperative complications, Decompression, Thoracic myelopathy, Urinary symptom

Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n=190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3−month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0−3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4−5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p=30 ml (p=<0.001, OR 2.45, 95% CI 1.626–3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p<0.015, CI 1.105–2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers