Objective:Our primary objective was to evaluate various factors (clinical, radiological and laboratory) associated with poor outcome in traumatic brain injury (TBI) patients. We studied 80 TBI patients in this prospective observational study and were followed for 6 months to assess their Glasgow Outcome Scale (GOS). Methods:Admission pulse rate, blood pressure, saturation, Glasgow Coma Scale (GCS), pupillary reactivity, non-contrast computerized tomography head and laboratory parameters like hemogram, blood gas analysis, blood glucose were studied and correlated with outcome (Intensive care unit mortality). Data was analyzed using χ2 test and Haldane-Anscombe correction. The p-value of less than 0.05 or 0.01 was considered as significant. Results:Mean age of patients suffering from TBI was 41 years with male predominance (7:1). Univariate analysis showed hypoxemia, tachycardia, low GCS, non-reacting pupils, hypernatremia and Marshall grade IV was associated with poor outcomes (p<0.05). Multivariate analysis showed low GCS, non-reacting pupils and hypoxemia as major determinants of poor outcome. Low GCS also correlated with prolong hospital stay and poor GOS (I-III). Conclusion:The strong statistical significance of oxygen saturation, low GCS, non-reacting pupils, tachycardia, hypernatremia and Marshall grade IV underscores the critical importance of preventing secondary brain injury and triage in TBI patients.
Osteoporotic spine fractures are among the most prevalent fractures in patients with osteoporosis and pose significant challenges to surgical treatment. Achieving stable fixation of osteoporotic bone is technically challenging and has become an increasing concern in spinal neurosurgery in the aging global population. Numerous studies have described the biomechanical benefits of fixation devices and techniques; however, no standard of care has been identified to provide distinct spinal stabilization in these patients. This study reviews the existing evidence and explores the complexities related to the treatment of pathologic spinal fractures in the context of systemic osteoporosis. Description of clinical cases: We present 2 cases of pathologic osteoporotic spinal fractures with spinal canal compression treated surgically using a modified method that incorporates cemented cannulated transpedicular screws and interbody spondylodesis with cage placement. Patients were followed up for 24 months after surgery. The Visual Analog Scale score improved significantly, decreasing from 7.3 points before surgery to 1.2 points immediately after surgery and to 0.5 points at the end of the follow-up. Similarly, the Oswestry Disability Index improved from 69% before surgery to 41% immediately after surgery and to 20% after 2 years. The Cobb angle improved from 38.0° preoperatively to 29.0° immediately after surgery. No bone resorption around the screws was observed during follow-up. The combination of transpedicular fixation with vertebroplasty is safe and effective for treating osteoporotic spinal fractures. This approach yields satisfactory clinical and radiographic results.
Penetrating spine injuries associated with abdominal and thoracic injuries caused by steel bars are rare. We report a unique case of delayed spinal spondylitis after penetrating abdominal and thoracic injuries from multiple steel bars. A 65-year-old man fell from a 20-m high scaffolding onto vertical steel bars. Steel bars penetrated his scrotum, abdomen, thoracic cavity, thigh, calf, and left ankle. At the accident scene, a fellow worker removed multiple penetrating bars. The first operation included repairs to the liver, diaphragm, transverse colon, sigmoid colon, jejunum, scrotum, and the pelvic wound, as well as open reduction and internal fixation of the left ankle. In a second operation, surgeons resected the sigmoid colon with anastomosis, and then sutured and debrided the peritoneum, mesentery, and the right thigh and calf wounds. The patient complained of anorexia and melena a month and a half after the trauma. Chest computed tomography 57 days after the trauma demonstrated pyogenic spondylitis in the thoracic spine. Culture of a perivertebral abscess 2 months after trauma revealed Pseudomonas aeruginosa. Antibiotic treatment resolved the pyogenic spondylitis. High clinical suspicion and awareness of delayed pyogenic spondylitis support early diagnosis and improve outcomes when appropriate treatment is given.
Objective:To characterize hemodynamic changes during apnea testing for brain death determination and evaluate their clinical relevance while exploring associations with circulating catecholamines. Methods:We retrospectively analyzed 27 patients who underwent apnea testing between January 2020 and March 2024. Each patient underwent two apnea tests, during which heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were measured at baseline and within 1-7 minutes after testing. Peak post-test values were compared with baseline values. Plasma catecholamines were measured before and after the first test in a subset of 13 patients. Results:Both apnea tests were associated with significant increases in cardiovascular parameters. Median SBP increased from 123.5 mmHg (interquartile range [IQR], 109.2 to 142.0) to 147.5 mmHg (IQR, 128.0 to 178.8; p<0.001). Median HR increased from 81.0 beats/min (IQR, 72.0 to 96.0) to 90.0 beats/min (IQR, 75.2 to 102.2), and DBP increased from 70.0 mmHg (IQR, 62.0 to 81.0) to 82.5 mmHg (IQR, 70.5 to 99.0) (all p<0.001). Post-test SBP exceeded 140 mmHg and 160 mmHg in 61.1% and 38.9% of tests, respectively. Peak mean arterial pressure increased to 105.5 mmHg (IQR, 89.3 to 125.7), exceeding 90 mmHg and 100 mmHg in 72.2% and 57.4% of tests, respectively. In subset analysis, epinephrine increased modestly, whereas norepinephrine and dopamine remained unchanged. Conclusion:Apnea testing consistently induced clinically relevant increases in blood pressure and HR without corresponding elevations in circulating catecholamines, suggesting additional mechanisms may contribute to these hemodynamic responses during apnea testing.
Organ transplantation is the ultimate treatment that extends and improves the quality of life for patients with end-stage organ failure, and among these, brain-dead organ donation enables life-sustaining heart and lung transplants. Since the first kidney transplantation from a brain-dead donor in Korea in 1979, the Organs Transplant Act was enacted in 1999 and comprehensively revised in 2010. This amendment marked a shift in the national framework from "Preventing Organ Trafficking and Ensuring Fair Allocation" toward "Establishing an Active Organ Procurement System" to promote donation. The number of brain-dead donors increased every year from 2010 to 2016 following the comprehensive amendment of the Organs Transplant Act. Since 2017, however, this trend has plateaued and subsequently declined, raising concerns about the widening gap between organ supply and demand, increasing reliance on living donation, and prolonged waiting times and mortality among transplant candidates. The major underlying causes of brain death, including traumatic brain injury, intracranial hemorrhage, and hypoxic brain injury, are frequently encountered in neurocritical care. Therefore, neurosurgeons play a crucial role in the brain-dead organ donation pathway. This review examines the institutional framework and current status of brain-dead organ donation in Korea. It also discusses the major clinical conditions leading to brain-dead organ donation and explores the role of neurosurgeons, as well as points of collaboration with the Korea Organ Donation Agency.
Objective:Traumatic cerebral contusions are one of the most clinically significant parenchymal lesions and contribute to great morbidity and mortality. Early identification of radiological factors associated with poor outcome can be helpful in early surgical intervention. To identify the association between contusion morphology and contusion volume and functional outcome and in-hospital mortality of patients suffering from traumatic cerebral contusions. Methods:This prospective observational cohort study included 50 patients with traumatic brain injury and radiologically confirmed cerebral contusions. The Glasgow Coma Scale (GCS) was used and functional outcome at 6-month follow-up was measured as the Glasgow Outcome Scale (GOS). Contusions were evaluated on non-contrast computed tomography for morphology, anatomical location, depth, and volume. Associations between clinical and radiological variables and outcomes were reported using Spearman correlation, Kruskal-Wallis test, χ2 test, and Fisher's exact test. Results:The mean age was 32.2±11.5 years and 64.0% of patients were male. Fracture-associated contusions occurred in 54.0%, coup contusions in 66.0%, and herniation contusions in 20.0%. The frontal lobe was most commonly involved (22.0%). The mean contusion volume was 12.8±5.5 mL and the average admission GCS was 8.4±3.0. Decompressive craniectomy was also performed in 48.0% of the patients. Median GOS at follow-up was 3.0 and in-hospital mortality was 16.0%. Contusion volume was significantly associated with GOS (r=-0.760, p<0.001) and mortality. Conclusion:In patients with traumatic cerebral contusions, a large volume of lesion, herniation-type appearance, and an unfavorable anatomical location were associated with poor functional outcome and in-hospital mortality.
Objective:Spinal cord injury (SCI) imposes substantial long-term physical, psychological, as well as financial burdens on patients in Iran, where high out-of-pocket (OOP) payments remain a major barrier to care. This study examined inequalities in healthcare utilization and OOP expenditures among patients with paraplegia and tetraplegia. Methods:This cross-sectional analyzed data from the 2023 International Spinal Cord Injury Survey for Iran, including 191 patients from the Guilan Province. Data on healthcare utilization and OOP spending for consultations, rehabilitation, medications, diagnostics, mental health, and inpatient services were analyzed. Inequality was assessed using Gini and concentration indices, and further explored through decomposition analysis and recentered influence function regression. Results:Inpatient care accounted for the highest OOP cost (US$516.27/month), followed by rehabilitation (US$178.65/month). Mental health services were the least utilized and most inequitable, with a concentration index of 0.49, indicating pro-rich access. Education, marital status, and place of residence significantly influenced the disparities, with rural and less-educated patients experiencing greater barriers. Conclusion:Patients with SCI in Iran face substantial financial inequities, and wealthier groups enjoy greater access to essential services. Policy reforms aimed at expanding insurance coverage, decentralizing rehabilitation, and subsidizing high-cost care are urgently required to promote equitable healthcare access and improve outcomes.
Mechanical failure of a ventriculoperitoneal shunt catheter due to repeated external trauma is an extremely rare complication. We report a 72-year-old male with type 2 diabetes who developed a purely subcutaneous fluid collection along the catheter tract after 4 years of habitual subcutaneous insulin injections near the shunt path. Notably, despite self-administering insulin daily, the patient was completely unaware of the necessity to avoid the catheter pathway, highlighting a critical gap in routine post-operative counseling. He presented with localized abdominal swelling and erythema without systemic infection. Abdominal computed tomography demonstrated a kinked catheter within a subcutaneous fluid collection, whereas the deeper peritoneal course and distal tip remained completely intact. The distal catheter was externalized, and at revision surgery, the fluid collection was completely excised. The shunt system was replaced using an alternative upper abdominal midline approach via the linea alba, remote from the prior injection zone. This case underscores 2 vital lessons: first, proactive patient education regarding injection site rotation away from implanted hardware is essential; second, in patients requiring lifelong daily abdominal injections, neurosurgeons should prioritize alternative entry sites like the linea alba to ensure long-term shunt integrity.
Objective:Chronic subdural hematoma (CSDH) is a common condition in the elderly population, usually treated by burr-hole trephination and hematoma drainage. Although various surgical techniques have been described, the optimal surgical method remains controversial. This study aimed to compare the recurrence rate of CSDH after burr-hole drainage with or without intraoperative saline irrigation to identify the more effective surgical approach. Methods:From January 2019 to December 2021, a total of 126 patients who underwent burr-hole trephination for CSDH were retrospectively reviewed. Among them, operative records of 145 procedures were analyzed. Patients were divided into two groups according to whether intraoperative saline irrigation was performed (n=91) or not (n=54). Demographic characteristics, medical history, radiologic findings, and recurrence or reoperation rates were compared between the groups. Results:Among 145 procedures, recurrence occurred in 33 cases (22.76%), and reoperation was required in 6 cases (4.14%). The recurrence rate was significantly lower in the irrigation group (14.81%) compared to the non-irrigation group (27.47%). The reoperation rate was also lower with irrigation (1.85% vs. 5.49%). Univariate analysis identified male sex, non-homogeneous hematoma type, and anticoagulation use as significant risk factors for recurrence. Multivariate analysis confirmed intraoperative saline irrigation as a significant independent protective factor. Conclusion:This study demonstrates that intraoperative saline irrigation during burr-hole drainage for CSDH significantly reduces the rates of recurrence and reoperation, showing favorable clinical outcomes.
Objective:Management of patients with severe traumatic brain injury (TBI) presenting with Glasgow Coma Scale (GCS) scores of 3-4 and surgically evacuable intracranial hematomas remains controversial because of perceived futility and poor outcomes. This study compared outcomes of surgical versus conservative management in this patient population. Methods:This retrospective observational study included patients with TBI (GCS 3-4) and surgically evacuable intracranial mass lesions admitted to a tertiary care centre between December 2015 and December 2023. Among 3,657 TBI admissions, 752 patients met inclusion criteria: 568 underwent surgical management and 184 were treated conservatively. Clinical and radiological variables were analysed. Outcomes were assessed at 6 months using the Glasgow Outcome Scale (GOS). Favorable outcome was defined as GOS 3-5, given the high mortality in this cohort. Subgroup analysis and multivariable logistic regression analysis were performed. Results:Six-month mortality was significantly lower in the surgical group (79.2% vs. 94.5%). Surgery was associated with shorter intensive care unit stay (p=0.001) and fewer systemic complications (p=0.003). Favourable outcomes were significantly more frequent following surgery in patients aged <40 years, with extradural hematoma, unilateral or bilateral pupillary dilation, and intervention within 6 hours of injury (all p<0.05). On adjusted analysis, surgical management was significantly associated with favorable outcome (odds ratio, 3.7; 95% confidence interval, 2.0-6.8; p<0.001). Conclusion:Despite an overall poor prognosis, surgical evacuation of mass lesions in TBI patients with GCS 3-4 was associated with improved survival and functional outcomes in selected patients, although causality cannot be inferred.
Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy linked to repetitive head trauma and definitively diagnosed postmortem. Its proposed clinical correlate in living patients is traumatic encephalopathy syndrome (TES). Within this spectrum, diffuse axonal injury (DAI) and post-traumatic hydrocephalus (PTH) represent interacting mechanisms contributing to long-term neurocognitive decline after traumatic brain injury (TBI). While DAI reflects largely irreversible axonal damage, PTH constitutes a potentially reversible disturbance of cerebrospinal fluid (CSF) dynamics. Their coexistence and pathophysiological interplay remain underrecognized. Understanding this continuum is essential to guide therapeutic strategies targeting both structural injury and CSF circulation abnormalities. A narrative review of PubMed-indexed literature (1980-2025) was conducted, focusing on pathophysiological correlations, neuroimaging features, and management strategies for CTE/TES, DAI, and PTH. Case series, clinical trials, and review articles addressing post-traumatic CSF disturbances were prioritized. A total of 100 records were identified (85 via database search, 15 through citation tracking). After screening, 32 were excluded, and 62 articles were included following full-text review. No duplicates were identified. Studies not relevant to pathophysiology, diagnosis, or management were excluded. Persistent ventriculomegaly after TBI is frequently misinterpreted as cerebral atrophy rather than hydrocephalus, leading to missed opportunities for surgical intervention. Advanced neuroimaging improves differentiation between DAI-related atrophy and treatable PTH. Selected patients demonstrate meaningful functional recovery following CSF diversion procedures, including programmable shunts and endoscopic third ventriculostomy. This continuum highlights the importance of recognizing reversible components of post-traumatic injury. Early identification and appropriate management of PTH may significantly improve functional outcomes in patients with chronic TBI.
Hinge craniotomy (HC) is a relatively underused surgical technique for managing increased intracranial pressure in patients with traumatic brain injury (TBI). As an alternative to conventional decompressive craniectomy (DC), HC preserves the native bone flap and may obviate the need for subsequent cranioplasty. This systematic review summarizes and compares the clinical outcomes of HC and DC in adult patients with TBI. Electronic databases were systematically searched for studies evaluating these 2 techniques. Outcomes, including functional recovery, mortality, complications, and reoperation rates, were analyzed and albatross plots were used to synthesize the data. Across studies, HC demonstrated outcomes broadly comparable to those of DC, with some studies suggesting trends toward lower early mortality and fewer poor functional outcomes, although these findings were not statistically significant. Overall, both procedures showed similar safety and efficacy profiles, whereas HC offered the potential advantage of avoiding secondary cranioplasty. Larger, well-designed prospective studies are required to confirm these findings and to better define the appropriate patient selection criteria. Trial Registration:PROSPERO Identifier: CRD42025638233.
Mild traumatic brain injury (mTBI) comprises the majority of all traumatic brain injuries, but clinical evaluation remains challenging because conventional neuroimaging cannot adequately detect subtle structural abnormalities or explain functional disturbances. Blood-based biomarkers have been studied as indicators of tissue injury. They may help reduce unnecessary computed tomography scans and predict unfavorable outcomes. However, biomarkers still have limitations in accurately assessing cognitive and behavioral abnormalities. Cognitive and behavioral evaluation helps characterize the functional consequences of mTBI, including impairments in attention, memory, executive function, and emotional symptoms. Although a range of cognitive and behavioral assessment tools is available, their interpretation is also influenced by factors such as timing, comorbidities, and patient effort. Taken together, blood-based biomarkers and cognitive and behavioral assessment should be interpreted in combination to allow a more comprehensive evaluation of the patients with mTBI. In this review, we summarize blood-based biomarkers and cognitive and behavioral assessment tools in mTBI, discuss their limitations, and propose an integrated approach to support more precise and individualized patient management.
Mild traumatic brain injury (mTBI) is often referred to as a major public health concern due to its high incidence and frequently overlooked long-term sequelae. A critical factor hindering functional recovery and return to daily activities is post-concussive vestibular dysfunction. To optimize rehabilitation outcomes, an early, mechanism-based integrated assessment is essential. Such an approach moves beyond simple symptom relief, focusing instead on identifying specific dysfunctions and underlying pathophysiology to target treatment accurately. Post-concussive vestibular dysfunction is rarely a single-lesion issue; it emerges from complex interactions between the peripheral vestibular system, the central nervous system, and the cervical spine, often exacerbated by impaired sensory reweighting. This review provides updated insights into precise diagnosis and evidencebased, individualized vestibular rehabilitation therapy (VRT). Specifically, it addresses the differential diagnosis of cervicogenic dizziness and structural peripheral lesions, while also discussing persistent postural-perceptual dizziness, which often requires multimodal therapeutic approaches beyond standard VRT alone. The review also explores how advanced technologies, including virtual reality and wearable sensors, are paving the way for digital therapeutics and artificial intelligence-driven precision rehabilitation, potentially expanding access to remote and individualized care for patients with mTBI.
Mild traumatic brain injury (mTBI) is one of the most common neurological injuries, yet its diagnosis remains challenging because of heterogeneous case definitions, the limited sensitivity of conventional imaging, and the nonspecific nature of post-traumatic symptoms. Computed tomography is widely used in acute trauma care to exclude life-threatening intracranial lesions, but it is often normal in patients with mTBI, including those with persistent symptoms. Conventional magnetic resonance imaging (MRI) may improve lesion detection, although many patients still show no clear abnormalities despite ongoing clinical impairment. Recent advances in neuroimaging, including susceptibility-based imaging, diffusion MRI, magnetic resonance spectroscopy, volumetric analysis, and functional MRI, have improved understanding of subtle structural, microstructural, metabolic, and functional changes after mTBI. In parallel, patient-reported outcome measures (PROMs) have become important tools for assessing symptom burden, functional limitations, emotional distress, and health-related quality of life that may not be captured by imaging alone. In this narrative review, we summarize recent advances in neuroimaging and PROMs in the diagnostic assessment of mTBI and discuss their strengths, limitations, and complementary roles. An integrated approach combining clinical evaluation, imaging findings, and patient-reported outcomes may improve diagnostic characterization and support more individualized management.
Historically, mild traumatic brain injury (mTBI) was often overlooked. However, growing clinical consensus emphasizes that active intervention is essential to manage physiological impairments and facilitate functional recovery. As secondary impact syndrome poses fatal risks during the acute phase, transitioning from passive rest to multimodal, active management is critical. This paper reviews current medical and non-surgical strategies for mTBI, shifting the paradigm from simple observation to proactive, evidence-based interventions. The review categorizes non-surgical interventions into 4 primary domains. First, lifestyle modification serves as the foundation, prioritizing 24-48 hours of rest, hydration, and minimized cognitive load from screens and light. Second, manual and physical therapies are employed; osteopathic manipulative medicine addresses musculoskeletal dysfunction, while hyperbaric oxygen therapy and blood flow restriction training support neurovascular repair and physical conditioning. Third, pharmacotherapy and supplementation focus on mitigating oxidative stress via antioxidants like MLC901 and enhancing cognitive function through medications such as methylphenidate or galantamine. Finally, active rehabilitation incorporates early intermediate-level aerobic exercise and vestibular rehabilitation to normalize cerebral blood flow and resolve balance deficits. The management of mTBI has evolved into a multimodal approach. By integrating these specialized strategies, clinicians can effectively mitigate long-term sequelae and promote rapid functional restitution.
Mild traumatic brain injury (mTBI) is the most common form of traumatic brain injury (TBI) and represents a major yet frequently underrecognized public health concern. Although traditionally considered a transient and benign condition, mTBI is not recognized as a biologically complex and clinically heterogeneous disorder, with a substantial proportion of patients experiencing prolonged cognitive, emotional, and somatic symptoms. Current diagnostic frameworks remain largely symptom-based; however, recent consensus efforts have aimed to improve definitional precision and applicability across diverse clinical settings. In Korea, nationwide data indicate that mTBI constitutes a substantial share of the overall TBI burden, with increasing relevance in older adults and notable variation according to occupational and regional context. Mechanistically, mTBI involves not only primary biomechanical injury but also downstream neurometabolic disturbance, blood-brain barrier dysfunction, neuroinflammation, and axonal and network-level alterations. Clinically, recovery is often favorable but highly variable, with distinct trajectories shaped by acute symptom burden, premorbid vulnerability, and environmental factors. Future progress will depend on more biologically informed classification systems, validated biomarkers, and longitudinal studies that better capture heterogeneity in mechanisms and outcomes.
Objective: Burr-hole craniostomy is a common surgical intervention for patients with chronic subdural hematoma (cSDH). Single burr hole craniostomy (SBHC) and double burr hole craniostomy (DBHC) are widely practiced techniques; however, debate continues regarding the superior approach owing to limited comparative literature. This study aimed to compare the clinical outcomes, complications, and recurrence rates between SBHC and DBHC in patients with cSDH. Methods: This prospective, open-label, non-inferiority, randomized controlled trial was conducted at the AIIMS Patna. Sixty-six patients with cSDH were enrolled in this study and randomized to either SBHC or DBHC. Assessments were performed before surgery and at 1 week and one month after surgery. Preoperatively, no differences were observed in the noncontrast computed tomography scans, Glasgow Coma Scale scores, ventilator/intensive care unit days, recurrence, or complications. Statistical analysis was done using SPSS v22.0. Results: Patient characteristics were comparable between groups. One week after surgery, mortality rate was higher in the SBHC group (11.43%) than in the DBHC group (3.12%), but the difference was not statistically significant (p=0.34). The duration of ventilator use was significantly longer in the SBHC group (p=0.001). Subsequent analysis showed that recurrence and reoperation rates were higher with SBHC (20.69% each) than those with DBHC (9.68% each), although the differences were not statistically significant (p=0.13 and 0.07, respectively). Neurological improvements and radiological outcomes showed similar trends. The difference in the non-recurrence rate (11.01%) remained within the noninferiority margin (11.5%). Conclusion: Both SBHC and DBHC were effective in evacuating cSDH. SBHC was shown to be non-inferior to DBHC, but had a slight increase in the recurrence rate and ventilator time. Based on patient characteristics, SBHC may be a simple and less invasive treatment option. Trial Registration: International Standard Randomised Controlled Trial Number Identifier: ISRCTN53688663
