Abstract Background Chronic subdural hematoma (CSDH) is one of the most frequently encountered conditions in neurosurgical practice, particularly among older adults, and its incidence is expected to rise with population aging and increasing antithrombotic medication use. Although surgical evacuation is effective in most patients, recurrence requiring further treatment is a well-recognized complication. This retrospective cohort study aimed to describe the clinical, radiological, hematological, and surgical characteristics of patients surgically treated for CSDH and to examine their association with postoperative recurrence. Results Fifty-seven patients treated surgically for CSDH were included. Recurrence occurred in 13 patients (22.8%); all recurrences were radiologically confirmed on computed tomography (CT), and 7 of 13 (53.8%) were symptomatic. Median time to recurrence was 39 days (interquartile range [IQR] 22–55 days). Six of 13 patients with recurrence (46.2%) underwent reoperation (repeat burr-hole drainage in 3, craniotomy in 3). The cohort had a median age of 78 years (IQR 68–83) and was predominantly male (42/57, 73.7%). Burr-hole craniostomy was the most common surgical technique (42/57, 73.7%), and a subdural or subperiosteal drain was used in 51/57 (89.5%). No continuous variable (age, Glasgow Coma Scale [GCS] score, hematoma thickness, midline shift, hematoma volume, hemoglobin, platelet count, international normalized ratio [INR], number of burr holes, drain duration) differed significantly between patients with and without recurrence (all Mann–Whitney U p > 0.05). Among categorical variables, direct oral anticoagulant (DOAC) use was the only factor significantly associated with recurrence (3 of 4 DOAC users recurred versus 10 of 53 non-users; Fisher’s exact p = 0.034); no other clinical, radiological, or surgical categorical variable showed a statistically significant association with recurrence. Conclusions In this cohort, approximately one in five patients experienced recurrence after surgical evacuation of CSDH. Preoperative DOAC use was associated with a higher rate of recurrence, whereas no other clinical, radiological, hematological, or surgical variable reached statistical significance, likely reflecting the limited statistical power afforded by a small sample and a small number of recurrence events. These findings should be interpreted as hypothesis-generating associations rather than validated predictors and require confirmation in larger, adequately powered cohorts before informing clinical decision-making.
Pott’s puffy tumor (PPT) is a subperiosteal abscess and osteomyelitis of the frontal bone, a potential complication of frontal sinusitis. Bleeding disorders, such as von Willebrand disease (vWD), can be potentially life-threatening in the case of surgery if not managed preoperatively. This appears to be the first documented case report of a PPT along with vWD. Moreover, to the best of our knowledge, it may also represent the earliest presentation of Pott’s puffy tumor in Pakistan, occurring in a child as young as one year of age. A one-year-old boy, a known case of vWD, presented with a six-month history of progressive forehead swelling with no other associated symptoms. On examination, there was a firm, non-tender 3 × 3 cm swelling on the forehead with an unremarkable neurological examination. Laboratory evaluation showed an elevated activated partial thromboplastin time (aPTT), revealing an underlying bleeding disorder. A non-contrast computerized tomography (CT) revealed a hypodense lesion with frontal bone erosion. A magnetic resonance imaging (MRI) of the brain revealed an intracranial abscess in the frontal region, leading to the diagnosis of PPT. Treatment involved preoperative optimization, followed by frontal craniectomy and capsulectomy, resulting in discharge on intravenous antibiotic therapy and subsequent complete resolution of symptoms. This case underscores the critical importance of thorough preoperative evaluation and multidisciplinary management in patients with bleeding disorders undergoing surgery for rare complications such as PPT. It represents the first reported association of PPT with vWD, and possibly the youngest documented case in Pakistan, emphasizing the need for heightened clinical vigilance in similar presentations during early childhood.
Abstract Background Traumatic spinal cord injury (SCI) is a major cause of long-term disability worldwide. While early surgical decompression is increasingly recommended to optimize neurological recovery, timely intervention remains challenging in many low- and middle-income countries (LMICs) due to delayed referrals, limited specialist availability, and resource constraints. This study evaluated neurological outcomes following delayed surgical management of traumatic SCI in a resource-limited setting and identified factors associated with recovery. Methods This retrospective cohort study included 68 patients with traumatic SCI who underwent surgical intervention at Ayub Teaching Hospital, Abbottabad, Pakistan, between January 2019 and February 2022. Due to healthcare system constraints, all patients underwent surgery more than 10 days after injury. Patients with fractures below L2, those who died within 12–18 months of surgery, and those with incomplete records were excluded. Neurological recovery was assessed by change in Frankel grade between preoperative assessment and final follow-up. Associations with clinical variables were analyzed using Chi-square and Fisher’s exact tests. Results The cohort comprised 39 males and 29 females with a mean age of 35 years. Lumbar fractures were the most common injury pattern, and instrumentation combined with decompression was the most frequently performed procedure. Despite delayed intervention, neurological improvement was observed in 72.1% of patients, with no patient experiencing deterioration. Preoperative Frankel grade was strongly associated with postoperative recovery ( p < 0.001), and fracture level was also significant ( p = 0.042), with lumbar injuries showing the most favorable outcomes. Age, sex, fracture multiplicity, and surgical technique were not significantly associated with improvement. Conclusion Meaningful neurological recovery remains achievable following delayed surgical management of traumatic SCI in resource-constrained settings. Preoperative neurological status and fracture level were the strongest predictors of recovery. These findings provide important outcome data from an LMIC setting and may assist clinicians in counseling patients when early intervention is not feasible.
Abstract Background Segmental location changes the arterial and branch relationships encountered during middle cerebral artery (MCA) aneurysm clipping, but its ability to anticipate a multiple-clip construct is uncertain. This study evaluated the association between aneurysm segmental location and multiple-clip reconstruction. Methods This retrospective single-center cohort screened 107 adults who underwent microsurgical clipping of MCA aneurysms. The location analysis included 86 operations with recorded segmental location. The primary exposure compared bifurcation-involving aneurysms with proximal or distal M1 aneurysms. Multiple-clip reconstruction was operationally defined as use of at least two documented permanent clips. Exact tests and logistic regression adjusted for aneurysm size category and the presence of multiple aneurysms were used. Results The cohort included 62 bifurcation-involving and 24 M1-segment aneurysms. Multiple-clip reconstruction was used in 31/86 operations (36.0%): 21/62 bifurcation-involving cases (33.9%) and 10/24 M1-segment cases (41.7%; exact odds ratio 0.72, 95% confidence interval 0.25–2.14; p = 0.618). Segmental location was not independently associated with the outcome after adjustment (adjusted odds ratio 0.61, 95% confidence interval 0.22–1.73; p = 0.351). Non-small aneurysm category was independently associated with multiple-clip reconstruction (adjusted odds ratio 5.99, 95% confidence interval 1.93–18.56; p = 0.002). Four-category and sensitivity analyses were concordant. Conclusions Multiple-clip reconstruction occurred across all recorded MCA segmental locations. Segmental location alone did not identify operations requiring multiple clips, whereas recorded aneurysm size category provided stronger information. Location should therefore be integrated with lesion morphology rather than used as a stand-alone marker of clip-construct complexity.
