BACKGROUNDWhether fixed-duration acalabrutinib-venetoclax (with or without obinutuzumab) would result in better progression-free survival than chemoimmunotherapy in patients with untreated chronic lymphocytic leukemia (CLL) is unknown.METHODSIn this phase 3, open-label trial, we included patients 18 years of age or older who had an Eastern Cooperative Oncology Group performance-status score of 0 to 2 (range, 0 to 5, with higher numbers indicating greater disability) and who did not have a 17p deletion or T P53 mutation. Patients were randomly assigned, in a 1:1:1 ratio, to receive acalabrutinib-venetoclax (acalabrutinib, cycles 1 to 14; venetoclax, cycles 3 to 14), acalabrutinib-venetoclax-obinutuzumab (as above, plus obinutuzumab, cycles 2 to 7), or chemoimmunotherapy with the investigator's choice of f ludarabine-cyclophospha-mide-rituximab or bendamustine-rituximab (cycles 1 to 6). The primary end point was progression-free survival (acalabrutinib-venetoclax vs. chemoimmunotherapy) in the intention-to-treat population, assessed by blinded independent central review.RESULTSA total of 867 patients underwent randomization: 291 were assigned to receive acalabrutinib-venetoclax, 286 acalabrutinib-venetoclax-obinutuzumab, and 290 che-moimmunotherapy (of whom 143 received f ludarabine-cyclophosphamide-rituximab and 147 bendamustine-rituximab). The median age of the patients was 61 years (range, 26 to 86), 64.5% were men, and 58.6% had unmutated IGHV. Estimated 36-month progression-free survival at a median follow-up of 40.8 months was 76.5% with acalabrutinib-venetoclax, 83.1% with acalabrutinib-venetoclax-obinutuzumab, and 66.5% with chemoimmunotherapy (hazard ratio for disease progression or death with acalabrutinib-venetoclax vs. chemoimmunotherapy, 0.65 [95% confidence in-terval {CI}, 0.49 to 0.87], P = 0.004; for the comparison of acalabrutinib-venetoclax-obinutuzumab with chemoimmunotherapy, P<0.001). Estimated 36-month overall survival was 94.1% with acalabrutinib-venetoclax, 87.7% with acalabrutinib-veneto-clax-obinutuzumab, and 85.9% with chemoimmunotherapy. Neutropenia, the most common adverse event of clinical interest of grade 3 or higher, was reported in 32.3%, 46.1%, and 43.2% in the three groups, respectively; death from coronavirus disease 2019 was reported in 10, 25, and 21 patients in the three groups.CONCLUSIONSAcalabrutinib-venetoclax with or without obinutuzumab significantly prolonged progression-free survival as compared with chemoimmunotherapy in fit patients with previously untreated CLL. (Funded by AstraZeneca; AMPLIFY ClinicalTrials.gov number, NCT03836261.)

Traumatic brain injury with a Glasgow Coma Scale (GCS) score of 3-5 is characterized by severe injury, poor prognosis, and low survival rates. Deciding between aggressive neurosurgery and treatment discontinuation is challenging among older adults. This study analyzed the characteristics, treatment, and outcomes of acute subdural hematoma (ASDH) in older adults with a GCS score of 3-5 to assess the benefits of surgery and guide future treatment decisions. We analyzed the data of 205 older adults (aged 65 years or older) with ASDH and a GCS score of 3-5 registered in the Korean Neuro-Trauma Data Bank System from January 2018 to June 2021. The patients were divided into death and survival groups, and the demographic, clinical, and radiological characteristics; treatment methods; mortality rates; and treatment outcomes were analyzed, along with the relationship between variables and mortality. We also compared the Glasgow Outcome Scale-Extended (GOSE) scores and investigated whether surgical treatment affected mortality and good recovery rates according to age. According to the GOSE, 76.1% of patients died, 12.7% survived in a vegetative state, 3.9% had severe disabilities, and only 4.0% showed good recovery. The GCS score at admission was significantly associated with pupil reactivity; Rotterdam computed tomography score; time interval from injury to operation and arrival to operation; treatment; and hospital stay between patients who died and those who survived. Surgical treatment was significantly associated with a lower mortality rate but not with good recovery rates.

Non-neoplastic intracranial cysts (NICCs) are usually stable and typically do not cause symptoms throughout life. Among the various NICCs, rare spontaneous disappearances of arachnoid cysts, colloid cysts, and Rathke's cleft cysts in various locations have been reported. To our knowledge, no reports to date have described spontaneous disappearance of choroid plexus cysts (CPCs). We here report the first case of spontaneous bilateral disappearance of CPCs. Although the exact pathogenic mechanisms remain unclear, we believe that a sudden transient change in intracranial pressure or cerebrospinal fluid circulation plays an important role in the bilateral disappearance of CPCs. Further research is warranted to clarify this rare phenomenon.

Objective : Acute subdural hematoma (A-SDH) in patients with a Glasgow coma scale (GCS) score of 3 presents significant challenges in clinical decision-making owing to high mortality rates and the likelihood of severe disability. Here, we analyzed data to assess the number of surgical treatments and overall treatment outcomes for patients with A-SDH admitted in a comatose state and discussed the value of such aggressive surgical interventions based on these findings. Methods : A retrospective analysis was conducted using data from five regional trauma centers in Korea registered with the Korean Neurotrauma Data Bank System. This study included adult patients (aged >= 19 years) admitted between January 2018 and June 2021 to a comatose state due to A-SDH. Patients were classified into death and survivor groups based on their outcomes, and their demographic, clinical, and radiological characteristics were compared. Additionally, patients were divided into a combined group of deaths and vegetative state survivors and a group of remaining survivors to compare the differences and assess the impact of death and vegetative state. Results : Among a total of 109 patients, the mean age was 59.28 years, and the mortality rate was 80.7%. Among the 21 survivors, 12 (57.1%) remained vegetative. Surgical treatment was performed in 42 patients (38.5%), resulting in a lower mortality rate (64.3%) than conservative treatment (91.0%). However, the rate of the vegetative state was higher in the surgical group (21.4%) than in the conservative group (4.5%). Pupil reactivity was a significant predictor, with mortality rates of 44.4%, 57.1 %, and 85.9% for reactive, unilaterally unreactive, and bilaterally unreactive pupils, respectively. The surgical group had a significantly longer hospital stay (23.69 +/- 29.15 days) compared to the conservative group (6.45 +/- 13.75 days). Conclusion : It is time to go one step further from death with the dignity law and have a comprehensive consideration and social consensus on 'how to end life.' A model that can more accurately predict situations in which decompressive surgery should be considered for patients in a comatose state due to A-SDH is required. Neurosurgeons must have a comprehensive understanding of the patient's progress, the anticipated prognosis, and the various financial and psychological burdens on the family and must be able to communicate this information thoroughly.

Bone mass is maintained by a balance between bone formation by osteoblasts and resorption by osteoclasts. Calvarial thinning can occur because of various factors. However, no previous studies have described bilateral temporal thinning (BTT) of the skull. This report presents a case of a squamous part of the bilateral temporal bone in a patient with alcohol-induced liver cirrhosis. This is the first case of BTT exhibiting an appearance similar to that of bilateral parietal thinning (BPT) in a patient with osteoporosis caused by liver cirrhosis. Although the precise pathogenic mechanism underlying thinning of the squamous part of the temporal bone remains unclear, osteoporosis associated with diploë is presumed to have contributed to its development in this patient, and BTT is considered a variant of BPT.

The past decade has witnessed rapid advancements in various surgical techniques for the clivus and surrounding structures. However, effective treatment of this region still poses significant challenges for neurosurgeons. The advent of endoscopic surgical procedure has reshaped skull base surgery in recent years. We present the rare case of a 67-year-old male gunshot victim who underwent endoscopic endonasal removal of a bullet lodged in the anterior lower clivus. The patient did not receive prophylactic antibiotic therapy. Based on this case, we propose that the endonasal endoscopic approach is highly advantageous for removing foreign bodies from the clivus. Furthermore, intraoperative navigation facilitates rapid lesion identification and reduces the surgical duration.

Although anterior cervical discectomy and fusion (ACDF) is one of the most common surgical procedures performed for the treatment of cervical disease, it is associated with a variety of postoperative complications. Esophageal perforation is a rare but very serious post-ACDF complication, and cases in which screws extrude through the mouth are even rarer. Herein, we present the case of a 61-year-old woman who visited our emergency center with oral extrusion of a screw 6 months after undergoing ACDF. Although diagnostic imaging did not confirm esophageal perforation, the oral extrusion of the screw was clear evidence of the complication. To the best of our knowledge, this is the first reported case of oral screw extrusion without confirmed esophageal injury. This case suggests that screw migration and esophageal perforation can occur depending on the patient's underlying condition, and if the symptoms are mild, conservative treatment alone may be sufficient to treat the perforation.

A depressed skull fracture (DSF) is comminuted fractures in which the broken bones displace inward due to a blunt head trauma, such as when the broken outer table is located below the normal anatomical position of the inner table. The author presents an extremely rare case of a 38-year-old man with a DSF that affected only the inner table. In the literature, only 2 cases of DSF involving only the inner table have been reported, and the underlying mechanism remains unclear. The author believes that this phenomenon was not enough for the impact force to depress the outer table, but the tensile stress was sufficient to depress the relatively thin and weak inner table.

PurposePatients’ gender, which can be one of the most important determinants of traumatic brain injury (TBI) outcomes, is also likely to interact with many other outcome variables of TBI. This multicenter descriptive study investigated gender differences in epidemiological, clinical, treatment, mortality, and variable characteristics in adult TBI patients.MethodsThe selection criteria were defined as patients who had been diagnosed with TBI and were admitted to the hospital between January 1, 2016 and December 31, 2018. A total of 4468 adult TBI patients were enrolled at eight University Hospitals. Based on the list of enrolled patients, the medical records of the patients were reviewed and they were registered online at each hospital. The registered patients were classified into three groups according to the Glasgow coma scale (GCS) score: mild (13–15), moderate (9−12), and severe (3–8), and the differences between men and women in each group were investigated. The risk factors of moderated and severe TBI compared to mild TBI were also investigated.ResultsThe study included 3075 men and 1393 women and the proportion of total males was 68.8%. Among all the TBI patients, there were significant differences between men and women in age, past history, and GCS score. While the mild and severe TBI groups showed significant differences in age, past history, and clinical symptoms, the moderate TBI group showed significant differences in age, past history, cause of justice, and diagnosis.ConclusionTo the best of our knowledge, this multicenter study is the first to focus on gender differences of adult patients with TBI in Korea. This study shows significant differences between men and women in many aspects of adult TBI. Therefore, gender differences should be strongly considered in TBI studies.

Unexpected bleeding is a common complication that can occur during surgery. This unexpected bleeding can be managed by checking the patients' preoperative hemodynamic state or by autologous transfusion of an appropriate volume during surgery depending on the amount of blood loss and hemodynamic condition. However, patients like Jehovah's Witnesses, who refuse autologous transfusions for religious reasons even in life-threatening situations, present a predicament for treating physicians. The author reports on a large meningioma on the posterior fossa of a Jehovah's Witness patient who underwent surgery without autologous blood transfusion. There were no major problems other than the fear of unexpected massive bleeding. The surgeon's attention and efforts to minimize bleeding during surgery seemed to be the most important factors for success.

Purpose: Pedicle screw fixation provides 3-column stabilization, multidimensional control, and a higher rate of interbody fusion. Although computed tomography (CT) is recommended for the postoperative assessment of pedicle screw fixation, its use is limited due to the radiation exposure dose. The purpose of this preliminary retrospective study was to assess the clinical usefulness of low-dose mobile cone-beam CT (CBCT) for the postoperative evaluation of pedicle screw fixation. Methods: The author retrospectively reviewed postoperative mobile CBCT images of 15 patients who underwent posterior pedicle screw fixation for spinal disease from November 2019 to April 2020. Pedicle screw placement was assessed for breaches of the bony structures. The breaches were graded based on the Heary classification. Results: The patients included 11 men and four women, and their mean age was 66±12 years. Of the 122 pedicle screws, 34 (27.9%) were inserted in the thoracic segment (from T7 to T12), 82 (67.2%) in the lumbar segment (from L1 to L5), and six (4.9%) in the first sacral segment. Although there were metal-related artifacts, the image of the screw position (according to Heary classification) after surgery could be assessed using mobile CBCT at all levels (T7–S1). Conclusions: Mobile CBCT was accurate in determining the location and integrity of the pedicle screw and identifying the surrounding bony structures. In the postoperative setting, mobile CBCT can be used as a primary modality for assessing the accuracy of pedicle screw fixation and detecting postoperative complications.

OBJECTIVE:It is important to know the epidemiologic aspects of traumatic brain injury (TBI) for its rapid detection, appropriate treatment, and prevention. The purpose of this study is to classify the time of arrival of patients in the emergency room (ER) by time of day, day of the week, month, and season, and to analyze the relationship between the frequency of presentation at different times and TBI.METHODS:The time of arrival of 327 patients with TBI between January 2016 to December 2017 at the ER was analyzed retrospectively. The trends regarding the frequency of presentation of patients with TBI were analyzed in relation to arrival time at the ER.RESULTS:Patients with TBI were found to have the greatest number of hospitalizations at 13:00-18:00, on Saturdays, in December, and during the summer. Surgical treatment was not related to the temporal pattern of TBI patient admission. Patients with TBI in the severe group (GCS score <8) arrived at the ER mainly at 07:00-12:00 (p=0.015). Patients with TBI in the mild group (GCS score 13-15) mainly presented in the ER during the summer (p=0.003), while patients TBI in the moderate group (GCS score 9-12) presented mainly in the winter (p=0.244). The combination of the mild and moderate group presented more often in the winter (p=0.014).CONCLUSION:It is worthwhile understanding the temporal trends of TBI patients. These data may provide useful information in predicting the ER visits of TBI patients in advance and preparing for prompt and appropriate treatment.

Pneumocephalus is defined as an abnormal presence of intracranial air or gas. Traumatic pneumocephalus (TP) typically occurs on the injured side and is in communication with the external environment. This report presented an extremely rare case of TP that occurred on the opposite side of the injured site, even with the absence of any traumatic injury. The patient sustained injuries, including linear skull fracture, acute epidural hematoma, fractures in the clavicle and scapula, and subcutaneous emphysema, on the left side of the body. However, TP occurred on the right side. Although the exact underlying pathogenic mechanism remains unclear, the condition might be attributed to the migration of air bubbles or negative pressure on the opposite side caused by side-to-side closed head injury.

OBJECTIVE:Traumatic pneumocephalus (TP) is a common complication of traumatic brain injury (TBI), which is characterized by the abnormal entrapment of air in the intracranial cavity after TBI to the meninges. The purpose of this study was to investigate the clinical and radiological characteristics related to TP associated with TBI.METHODS:From January 2013 to March 2018, the data from 71 patients with TP after TBI were collected. Demographic and clinical characteristics were investigated and the distribution of TP was investigated as radiological characteristics. The author compared the demographic characteristics of TP to the data from the Korean Neurotrauma Data Bank System (KNTDBS).RESULTS:There was a higher ratio of males in patients with TP compared with KNTDBS. The mean age was 48.4±20.5 years and the incidence was highest in those 41-60 years of age (42.3%). Surgical treatment was performed in 23.9% patients. The mortality associated with the TP was 4.2%. The most common cause of injury was a traffic accident (52.1%). TP was mainly located in the epidural space (53.5%) and showed a scatter pattern (60.6%). It was mostly located in the frontal and temporal area (81.7%). Skull fractures were observed in 40.8% in the temporal bone and 25.4% in the frontal bone.CONCLUSION:The author identified epidemiology, clinical, and radiological characteristics of TP associated with TBI. Although this study has many limitations, the author believes it is worthwhile as it examines various characteristics of TP, which previously had relatively little clinical interest.

Because solitary fibrous tumor (SFT) and hemangiopericytoma (HPC) contain identical genetic abnormalities, the World Health Organization coined the term SFT/HPC to describe these lesions. Here, we present a rare case of SFT/HPC in a 40-year-old man with massive repeated intracranial hemorrhage (ICH) in right medial temporal lobe. ICHs from a SFT/HPC were repeatedly misdiagnosed as hypertensive ICH by several departments and hospitals over approximately eight months, and the patient underwent inappropriate treatments. The amount of repeated ICH accompanying the tumor has increased significantly compared to the first ICH, which may suggest rapid tumor growth. To avoid misdiagnosis and inappropriate treatment, surgeons should carefully examine all past and current patient-related radiological images and medical records before considering surgery.

Hydrocephalus refers to a pathological condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain due to imbalance in the production and absorption of CSF. The most commonly used treatment method for hydrocephalus is ventriculoperitoneal (VP) shunt. Many complications can occur after VP shunt for the management of hydrocephalus. Here, we present rare two cases of distal catheter migration into the abdominal wall after VP shunt. The mechanism of this rare phenomenon was also discussed.

Although the exact timing depends on the location of the traumatic brain injury (TBI) and the amount of hemorrhage, in the absence of neurosurgical interventions it usually takes several weeks or months for spontaneous resolution of the hemorrhage or hematoma. The occasional rapid disappearance of an intracranial hemorrhage after a TBI has been well-described in the literature. However, early spontaneous disappearance of traumatic intraventricular hemorrhage (TIVH) has not previously been reported in the literature. Herein, the author described a rare case of TIVH that disappeared rapidly without surgical intervention and speculated that the thrombolytic enzyme system in the cerebrospinal fluid (CSF) or circulation of CSF plays an important role in the rapid disappearance of TIVH.

Although traumatic posterior fossa subdural hematoma (TPFSH) in neonates immediately after birth is extremely rare, it can pose a serious clinical problem in the neonatal period. Here, the author presents the case of a 3-day-old male infant who underwent emergency surgical treatment of TPFSH with a favorable outcome. Debate continues about surgical versus conservative treatment of TPFSH in neonates. The clinical symptoms, extent of hemorrhage, early diagnosis, and prompt and appropriate surgery are the most important factors in the treatment of TPFSH in neonates. Therefore, neurosurgeons should establish treatment strategies based on the newborn’s clinical condition, the size and location of the TPFSH, and the potential of the hematoma to cause long-term complications.

Objective Traditionally, staged surgery has been preferred in the treatment of compound comminuted depressed fracture (FCCD) after traumatic brain injury (TBI) and involves the removal of primarily damaged bone and subsequent cranioplasty. The main reason for delayed cranioplasty was to reduce the risk of infection-related complications. Here, the author performed immediate reconstruction using a titanium mesh in consecutive patients with FCCD after TBI, reported the surgical results, and reviewed previous studies. Methods Nineteen consecutive patients who underwent single-stage reconstruction with titanium mesh for FCCD of the skull from April 2014 to June 2018 were retrospectively analyzed. The demographic and radiological characteristics of the patients with FCCD were investigated. The characteristics associated with surgery and outcome were also evaluated. Results The frequency of TBI in men (94.7%) was significantly higher than that in women. Most FCCDs (73.7%) occurred during work, the rest were caused by traffic accidents. The mean interval between TBI and surgery was 7.0±3.9 hours. The median Glasgow coma scale score was 15 (range, 8–15) at admission and 15 (range, 10–15) at discharge. FCCD was frequently located in the frontal (57.9%) and parietal (31.6%) bones than in other regions. Of the patients with FCCDs in the frontal bone, 62.5% had paranasal sinus injury. There were five patients with fractures of orbital bone, and they were easily reconstructed using titanium mesh. These patients were cosmetically satisfied. Postoperatively, antibiotics were used for an average of 12.6 days. The mean hospital stay was 17.6±7.5 days (range, 8–33). There was no postoperative seizure or complications, such as infection. Conclusion Immediate bony fragments replacement and reconstruction with reconstruction titanium mesh for FCCD did not increase infectious sequelae, even though FCCD involved sinus. This suggests that immediate single-stage reconstruction with titanium mesh for FCCD is a suitable surgical option with potential benefits in terms of cost-effectiveness, safety, and cosmetic and psychological outcomes.

OBJECTIVE:Although traumatic brain injury (TBI) occurs in people of all age groups, the elderly population is at a particular risk. The proportion of elderly population in the society is markedly increasing and Korea is one of the most rapidly aging societies. Here, we analyzed the data from 904 patients older over 65 years who were registered in the Korean Neuro-Trauma Data Bank System (KNTDBS).METHODS:The Korean Society of Neurotraumatology recorded data from 20 institutions between September 2010 and March 2014. This retrospective study examined the clinical epidemiology, sex difference, outcome epidemiology, sociodemographic variables, and outcomes in the geriatric population related to TBI based on data from the KNTDBS.RESULTS:The study included 540 men and 364 women. The age distributions in the male and female groups were statistically significantly different. The most common cause of trauma was a fall and diagnosis was acute subdural hematoma. The incidence was the highest in men aged 80-84 years and in women aged 75-79 years. The most common time of arrival to hospital after TBI was within 1 hour and 119 rescue team provided first aid earliest to patients with TBI. The mortality rate stratified according to the cause of trauma was significantly different, with mortality rates of 3.77% in fall and 11.65% in traffic accident. The mortality rates according the severity of brain injury, Glasgow Coma Scale score, and treatment were statistically significant.CONCLUSION:To our knowledge, this study is the first to focus on elderly patients with TBI in Korea and particularly investigate mortality and characteristics related to TBI-related death based on data from the KNTDBS. Although the study has some limitations, our results may be used to obtain useful information to study targeted prevention and more effective treatment options for older TBI patients and establish novel treatment guidelines and health polish for the geriatric population.