Bunpot Sitthinamsuwan

Background: Fixed brain retractors risk focal ischemia and cortical injury. Although retractorless dynamic retraction is established in skull base surgery, its role in epilepsy surgery remains poorly characterized. Objective: To evaluate long-term seizure outcomes, safety, and reliability of retractorless standard anterior temporal lobectomy (ATL) in drug-resistant mesial temporal lobe epilepsy (MTLE), and identify predictors of seizure freedom. Methods: We retrospectively analyzed 42 patients who underwent retractorless standard ATL for drug-resistant MTLE. Dynamic retraction used bipolar forceps and pressure-controlled suction. The primary outcome was seizure freedom (Engel Class Ia) at minimum 24-month follow-up; secondary outcomes were complications and resection adequacy on postoperative magnetic resonance imaging (MRI). Predictors were identified using multivariable logistic regression and Cox proportional hazards models. Results: At a mean follow-up of 66.3 months, 69% of patients achieved complete seizure freedom (Engel Class Ia), and 83.3% achieved freedom from disabling seizures (Engel Class I). Postoperative MRI confirmed adequate resection in 95.2% of cases. Complications were uncommon and unrelated to retraction injury. Low preoperative seizure frequency (< 3 seizures/week) was the sole independent predictor of seizure freedom (odds ratio, 24.21; P = 0.026), while higher frequency (≥ 3 seizures/week) was associated with increased recurrence risk (hazard ratio, 7.34; P = 0.042). Conclusion: Retractorless standard ATL is safe and effective for drug-resistant MTLE, achieving long-term seizure control while minimizing retraction-associated risks. Preoperative seizure burden was the dominant prognostic marker, supporting early surgical intervention.

Prolonged warfarin use is associated with vascular calcification in several organs; however, its relationship with intracranial arterial calcification (IAC) remains unclear. This study investigated the association between warfarin exposure and IAC while identifying other predictive factors. Nontraumatic adult patients underwent non-contrast cranial computed tomography to evaluate IAC, which was classified as absent, mild, moderate, or severe across all intracranial arterial locations. Participants were divided into warfarin users and non-users, and data on age, duration of warfarin use, underlying diseases, and smoking were collected. Of 645 patients enrolled, 113 (17.5%) were warfarin users and 532 (82.5%) were non-users, with a median age of 73 years and median warfarin use duration of 4.5 years. Severe intracranial internal carotid artery calcification was statistically significantly more common in warfarin users (p = 0.012); however, multivariable analysis revealed no association between warfarin use and IAC at any location. Independent factors associated with severe IAC were older age, diabetes mellitus, coronary artery disease, ischemic cerebrovascular disease, and chronic kidney disease. Older age, hypertension, and ischemic cerebrovascular disease were associated with mild to moderate IAC. This study found no evidence supporting an association between warfarin exposure and IAC.

BACKGROUND: Postoperative delirium (POD) is a frequent complication following neurosurgery, yet research on its specific impact on multidimensional recovery in craniotomy patients is limited. This study aimed to determine the incidence of POD and investigate its impact on physical, psychological, and cognitive recovery at both hospital discharge and the first follow-up visit. METHODS: A prospective cohort study was conducted with 164 postcraniotomy patients at a tertiary hospital in Bangkok. POD was assessed 48 to 72 hours postoperatively using the Confusion Assessment Method for the ICU (CAM-ICU). Recovery was evaluated across 3 dimensions: physical (Sickness Impact Profile), psychological (State Anxiety Inventory), and cognitive (Montreal Cognitive Assessment). Multiple regression analysis was used to analyze the impact of CAM-ICU positive, adjusting for surgical duration, postoperative complications, and consciousness levels. RESULTS: The incidence of CAM-ICU positive was 18.29%. Patients who were CAM-ICU negative demonstrated significantly better physical and cognitive recovery and shorter lengths of stay, although they reported poorer psychological recovery. At the first follow-up, better physical and poorer psychological recovery persisted in the CAM-ICU–negative group, while cognitive recovery no longer differed between groups. After adjusting for confounding variables, CAM-ICU positive was a significant predictor of poorer physical ( B =8.218, P =.01) and cognitive ( B =−1.545, P <.001) recovery. CONCLUSIONS: POD significantly impairs physical and cognitive recovery in patients following craniotomy. Routine perioperative screening for delirium is essential for neuroscience nurses to identify at-risk patients early and implement interventions to promote recovery across all dimensions.

Background: An Evans index greater than 0.3 is a key diagnostic criterion for idiopathic normal pressure hydrocephalus (iNPH). However, some patients with iNPH symptoms and an Evans index below 0.3 achieve favorable outcomes after cerebrospinal fluid (CSF) shunt surgery. This study aimed to evaluate the clinical and radiographic characteristics and CSF shunt outcomes of these patients. Methods: This prospective study enrolled patients presenting with iNPH symptoms and an Evans index below 0.3. Patients who showed clinical improvement after a spinal tap test underwent CSF shunt placement via ventriculoperitoneal or lumboperitoneal shunting. Outcomes were assessed using subjective tools and symptom-specific scores at baseline and at 3 days, 1 month, 3 months, and 6 months post-surgery. Results: Thirty-five patients with a mean (SD) Evans index of 0.26 (0.02) underwent CSF shunt placement. All clinical domains showed statistically significant improvement at 6 months compared with baseline, except cognition. Subgroup analysis revealed no statistically significant difference in preoperative and final postoperative iNPH grading scale scores between patients undergoing ventriculoperitoneal and lumboperitoneal shunting. One patient experienced shunt overdrainage causing bilateral chronic subdural hematoma that required burr hole craniostomy. Conclusions: These findings suggest that patients with iNPH-like symptoms and an Evans index below 0.3 can benefit from CSF shunt surgery. Multiple assessment tools demonstrated substantial postoperative improvement in this group. In patients with typical iNPH symptoms, a positive spinal tap response, and supportive imaging findings, an iNPH diagnosis is justified regardless of ventricular size. Such patients may be considered surgical candidates for CSF shunt placement.

Spinal cord stimulation (SCS) is an effective therapy for intractable pain, but it is used less frequently for upper extremity than for lower limb pain. Evidence supporting SCS for the upper extremity remains limited. This study evaluated the efficacy of SCS for severe refractory upper extremity pain. Thirteen patients with refractory upper extremity pain underwent a trial of SCS. Eleven patients, who achieved marked pain relief during the trial, proceeded to permanent implantation. We collected clinical characteristics and outcomes, including numeric pain rating scale (NPRS) measurements. We then compared pain reduction among subgroups: neural versus non-neural lesions, and complex regional pain syndrome (CRPS) versus non-CRPS. In the 11 implanted patients, the mean NPRS score decreased from 9.5 of 10 preoperatively to 3.6 of 10 postoperatively ( p < 0.001). Analysis showed significant pain improvement in each subgroup ( p < 0.05). At last follow-up, the NPRS scores remained below baseline levels in 10 of 11 patients. However, the magnitude of the NPRS score reduction did not differ significantly between neural and non-neural lesions ( p = 0.350), or CRPS and non-CRPS ( p = 0.245). One participant with CRPS type 2 experienced treatment failure during long-term follow-up. This study demonstrated that SCS effectively alleviates refractory upper extremity pain caused by various etiologies. No single pain etiology, including CRPS, conferred a superior response, suggesting broad potential benefits of SCS in these patients.

Spinal cord stimulation (SCS) is commonly used to treat refractory neuropathic pain. However, no prior study has compared SCS outcomes between neuropathic pain of peripheral nerve origin and neuropathic pain of spinal cord origin. This study aimed to compare SCS outcomes between these two patient groups. Twenty-seven patients with refractory neuropathic pain underwent SCS. Of these, 14 had peripheral nerve lesions, whereas 13 had spinal cord lesions. Demographic data, numeric pain rating scores, and SCS outcomes were collected. These parameters were then compared between the two groups. Patients with neuropathic pain of peripheral nerve origin had more localized pain distribution ( p = 0.012, OR = 8.33, 95% CI = 1.47‒47.23) than those with spinal cord origin. They also had a higher rate of successful trial stimulation ( p = 0.018, OR = 9.60, 95% CI = 1.48‒62.16) and better long-term pain relief ( p = 0.006). The poorest outcomes were observed in those with traumatic spinal cord injury. No complications occurred in this series. Patients harboring neuropathic pain of peripheral nerve origin demonstrated a higher success rate of trial stimulation and superior long-term outcomes following SCS compared with patients who had spinal cord lesions. These findings may aid clinicians in forecasting SCS outcomes and selecting appropriate candidates for the procedure.

Malignant brain edema (MBE) is a life-threatening complication of large hemispheric infarction (LHI). While early decompressive hemicraniectomy has been shown to improve outcomes in selected patients, identifying those at risk for MBE remains a clinical challenge. This study aimed to develop a simple and practical scoring system based on non-contrast CT imaging obtained approximately 24 h after stroke onset to support early prediction and timely intervention. We conducted a retrospective cohort study of LHI patients who underwent non-contrast CT imaging within 24 ± 8 h of symptom onset. Radiographic parameters assessed included infarct volume (ABC/2 method), ASPECTS, anterior or posterior cerebral artery territory involvement, temporal lobe involvement, midline shift, lateral ventricle compression, intercaudate distance, Sylvian fissure effacement and sulcal effacement. Multivariate logistic regression identified independent predictors of MBE. A weighted scoring system was then developed based on the regression model and internally validated using ROC analysis. Among 62 patients included, 38 (61.3%) developed MBE. Infarct volume and midline shift were independently associated with MBE. A scoring system (SIriraj Malignant Brain Edema Prediction by Lesion Volume and Edema Shift – SIMPLE) was derived using infarct volume ≥ 106 mL (two points) and midline shift ≥ 1.6 mm (one point). The score demonstrated excellent discriminative performance (AUC 0.951, 95% CI: 0.899–1.002). A cutoff score ≥ 2 yielded 89.5% sensitivity and 91.7% specificity. A dual-threshold strategy, using score 0 to rule out and score three to rule in, achieved 97.4% sensitivity and 100% specificity, providing clear clinical guidance for observation, medical management, or early neurosurgical intervention. The SIMPLE score is a rapid and reliable tool using routine CT imaging to predict MBE in LHI patients at an optimal 24-hour timepoint. Its simplicity and strong predictive accuracy may assist clinicians in early risk stratification and timely treatment decisions. Further prospective validation is recommended.

Brain tumors located in the posterior cranial fossa frequently lead to hydrocephalus. However, few investigations have delineated factors predicting preoperative hydrocephalus. This study aimed to identify risk factors for hydrocephalus prior to tumor resection in the posterior cranial fossa and to develop a predictive scoring model. We reviewed 421 patients with posterior cranial fossa tumors, stratifying them into groups with ( n = 160, 38%) and without ( n = 261, 62%) hydrocephalus on initial neuroimaging. Demographic, radiographic, and craniometric variables were collected. Univariate and multivariable logistic regression analyses were performed, and odds ratios with 95% confidence intervals were determined. Factors that remained significant in the multivariable model were incorporated into a novel scoring system. Multiple factors were associated with preoperative hydrocephalus in univariate analysis. In the final multivariable model, increased intracranial pressure, ataxia, cognitive impairment, large tumor volume, and peritumoral vasogenic edema showed strong correlations with hydrocephalus. Pre-resection hydrocephalus in patients with posterior cranial fossa tumors was strongly associated with clinical symptoms (increased intracranial pressure, ataxia, and cognitive impairment) and radiographic findings (large tumor volume and peritumoral vasogenic edema). These results may guide early surveillance and facilitate surgical prioritization to avert severe complications in this patient population.

Seizure is a relatively common neurological consequence after spontaneous intracerebral hemorrhage (SICH). This study aimed to investigate risk factors of early, late, and overall seizures in patients with SICH. Retrospective analysis was performed on all patients with SICH who completed two years of follow-up. The variables collected were obtained from demographic, clinical, radiographic and treatment data, in-hospital complications, and follow-up results. Univariate and multivariate analyzes were used to identify risk factors for post-hemorrhagic stroke seizure. Of 400 SICH patients recruited, 30 (7.5%) and 40 (10%) developed early and late seizures during the 2-year follow-up period, respectively. In the final result of the multivariate analysis, factors associated with the occurrence of the early seizure included lobar location of hematoma ( p = 0.018), and GCS ≤ 12 on initial clinical presentation ( p = 0.007). Factors associated with the occurrence of the late seizure included lobar location of hematoma ( p = 0.001), volume of hematoma greater than 10 ml ( p = 0.009), and midline shift on initial cranial CT ( p = 0.036). Risk factors of the overall seizure after SICH included lobar location of hematoma ( p < 0.001), volume of hematoma greater than 10 ml ( p < 0.001), and craniotomy with evacuation of hematoma ( p = 0.007). Furthermore, seizure was also associated with a poor functional outcome 2 years after the onset of SICH. Several factors associated with the appearance of post-ICH seizures were revealed. In patients with increased risk of post-SICH seizures, appropriate surveillance and management of seizures should be carried out.

Introduction Differentiation between glioblastoma (GBM), primary central nervous system lymphoma (PCNSL), and metastasis is important in decision-making before surgery. However, these malignant brain tumors have overlapping features. This study aimed to identify predictors differentiating between GBM, PCNSL, and metastasis. Materials and Methods Patients with a solitary intracranial enhancing tumor and a histopathological diagnosis of GBM, PCNSL, or metastasis were investigated. All patients with intracranial lymphoma had PCNSL without extracranial involvement. Demographic, clinical, and radiographic data were analyzed to determine their associations with the tumor types. Results The predictors associated with GBM were functional impairment (p = 0.001), large tumor size (p < 0.001), irregular tumor margin (p < 0.001), heterogeneous contrast enhancement (p < 0.001), central necrosis (p < 0.001), intratumoral hemorrhage (p = 0.018), abnormal flow void (p < 0.001), and hypodensity component on noncontrast cranial computed tomography (CT) scan (p < 0.001). The predictors associated with PCNSL comprised functional impairment (p = 0.005), deep-seated tumor location (p = 0.006), homogeneous contrast enhancement (p < 0.001), absence of cystic appearance (p = 0.008), presence of hypointensity component on precontrast cranial T1-weighted magnetic resonance imaging (MRI; p = 0.027), and presence of isodensity component on noncontrast cranial CT (p < 0.008). Finally, the predictors for metastasis were an infratentorial (p < 0.001) or extra-axial tumor location (p = 0.035), smooth tumor margin (p < 0.001), and presence of isointensity component on cranial fluid-attenuated inversion recovery MRI (p = 0.047). Conclusion These predictors may be used to differentiate between GBM, PCNSL, and metastasis, and they are useful in clinical management.