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BACKGROUND: The prior trials investigating triple-H therapy for preventing delayed cerebral ischemia (DCI) enrolled patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent early aneurysm therapy within 3 days. However, surgical clipping might be performed during 4-7 days that high incidence cerebral vasospasm is likely. We examined effects of hypervolemia-augmented blood pressure (HV-ABP) protocol on DCI prevention when clipping was delayed. METHODS: The study enrolled aSAH patients hospitalized during 2013-2019 who underwent clipping 4-7 days after rupture in a university hospital in Thailand. DCI and secondary outcomes were compared among patients who achieved the HV-ABP protocol (3-5 L/day fluid intake and 140-180 mmHg systolic blood pressure maintained for 72 hours postoperatively) and those who did not. The intervention-outcome associations were estimated using logistic regression for the whole group and a patient subgroup with similar propensity scores (PS) for protocol achievement. RESULTS: One hundred seventy-seven aSAH patients were clipped 4-7 days after rupture; 97 patients (54.8%) achieved the HV-ABP protocol, while 80 patients (45.2%) did not. One hundred twenty-two patients with one-to-one PS matching reduced the originally unequal patient characteristics. The observed DCI was lower in patients with protocol-achieved (8.3%) than in their nonachieved counterparts (22.5%). This resulted in an association with the HV-ABP intervention with adjusted odds ratios of 0.201 (95% confidence interval, 0.066-0.613) in the whole sample and 0.228 (0.065-0.794) in the PS-matched subsample. No statistically significant differences in the secondary outcomes were found. CONCLUSIONS: Achieving the targets recommended in the HV-ABP protocol was associated with reducing the DCI incidence in patients with aSAH who underwent delayed clipping.

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OBJECTIVE: A scoring system for aneurysmal subarachnoid hemorrhage (aSAH) is useful for guiding treatment decisions, especially in urgent-care limited settings. This study developed a simple algorithm of clinical conditions and grading to predict outcomes in patients treated by clipping or coiling. METHODS: Data on patients with aSAH hospitalized in a university's neurovascular center in Thailand from 2013 to 2018 were obtained for chart review. Factors associated with poor outcomes evaluated at one year were identified using a stepwise logistic regression model. For each patient, the rounded regression coefficients of independent risk factors were linearly combined into a total score, which was assessed for its performance in predicting outcomes using receiver operating characteristic analysis. An appropriate cutoff point of the scores for poor outcomes was based on Youden's criteria, which maximized the summation between sensitivity or true positive rate and the specificity or true negative rate. RESULTS: Patients (n, 121) with poor outcomes (modified Rankin Scale, mRS score, 4-6) had a significantly higher proportion of old age, underlying hypertension, diabetes and chronic kidney disease, high clinical severity grading, preoperative rebleeding, and hydrocephalus than those (n, 336) with good outcomes (mRS score, 0-3). Six variables, including age >70 years, diabetes mellitus, World Federation of Neurosurgical Societies (WFNS) scaling of IV-V, modified Fisher grading of 3-4, rebleeding, and hydrocephalus, were identified as independent risk factors and were assigned a score weight of 2, 1, 2, 1, 3 and 1, respectively. Among the total possible scores ranging from 0-10, the cut point at score 3 yielded the maximum Youden's index (0.527), which resulted in a sensitivity of 77.7% and specificity of 75.0%. CONCLUSION: A simple 0-10 scoring system on six risk factors for poor outcomes was validated for aSAH and should be advocated for use in limited resource settings.

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BACKGROUND: For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions. METHODS: Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists. RESULTS: Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country's cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively. CONCLUSION: Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.

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OBJECTIVES: To study the effect of endoscopic endonasal transsphenoidal surgery on voice quality in patients with pituitary lesions. METHODS: An observational study comparing voice quality before and after surgery was conducted between September 2015 and September 2017 at Srinagarind Hospital, Khon Kaen University, Thailand. Pituitary tumor patients who underwent endoscopic endonasal transsphenoidal surgery were recruited. The nasal corridors were created with a type I (preserving both middle turbinates with a rescue flap) or type II (cutting one middle turbinate with a raised nasoseptal flap) for the binostril with four-hand technique. All patients were evaluated for nasal resonance, acoustic parameters, acoustic perception, and self-assessment of their satisfaction with postoperative voice changes with a visual analog scale (VAS). The patients were evaluated 1 day before surgery and at 1 and 3 months after surgery. RESULTS: Forty-four patients, including 19 males and 25 females with a mean age of 50.0 ± 15.6 years, were enrolled. Mean scores for nasal resonance and all acoustic parameters were not significantly changed after surgery for either nasal corridor type (p > .05). Regarding acoustic perception, word and sentence and GIRBAS scores showed no significant difference before and after surgery (p > .09) in either type of nasal corridor. There was no incidence of hypernasality voice after surgery. Patients' self-satisfaction ratings (i.e., VAS) with voice quality were high and showed no significant change 1 and 3 months postsurgery (p > .05). CONCLUSIONS: These endoscopic endonasal transsphenoidal approaches are minimally invasive skull base surgery techniques that have minimal effects on postsurgery voice quality. TRIAL REGISTRATION: This trial was registered at ClinicalTrial.gov (NCT02828514). LEVEL OF EVIDENCE: 4.

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BACKGROUND: Delayed ischemic neurologic deficit (DNID) is a problem after cerebral aneurysm clipping. Intraoperative hypotension seems to be indicated as a risk factor, but it remains a controversial issue with varying low-blood pressure levels accepted. METHODS: A retrospective, hospital-based, case-control study was performed with patients who received general anesthesia for cerebral aneurysm clipping. 42 medical record charts were randomly selected and matched 1 : 2 (1 case with DNID : 2 controls without DNID) based on the type of general anesthetic techniques and severity of subarachnoid hemorrhage. The optimal cutoff points of hemodynamic response were calculated by the area under the curve. RESULTS: Data suggested that the optimal cutoff points for lowest blood pressure for prevention of DNID should be systolic blood pressure (SBP) of 95 mmHg (sensitivity of 78.6%; specificity of 53.6%), diastolic blood pressure (DBP) of 50 mmHg (sensitivity of 71.4%; specificity of 67.9%), and mean arterial pressure (MAP) of 61.7 mmHg (sensitivity of 85.7%; specificity of 35.7%). Furthermore, the optimal cutoff point mean difference baseline blood pressure was recommended as Δ SBP of 36 mmHg (sensitivity of 85.7%; specificity of 60.7%), Δ DBP of 27 mmHg (sensitivity of 92.9%; specificity of 71.4%), and Δ MAP of 32 mmHg (sensitivity of 92.9%; specificity of 85.7%). No significant difference between DNID and non-DNID groups was found for end-tidal carbon dioxide (ETCO2) and has poor diagnostic value for predicting DNID. CONCLUSION: To prevent DNID, we recommend that optimal blood pressure should not be lower than 95 for SBP, 50 for DBP, and 61.7 mmHg for MAP. Additionally, we suggest that Δ SBP, Δ DBP, and Δ MAP should be less than 36, 27, and 32 mmHg, respectively.

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OBJECTIVE: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. METHODOLOGY: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol (n = 104) and after initiating the protocol (n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140-180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4-6 on a modified Rankin scale at 6 and 12 months). RESULTS: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% (P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10-1.63) and in the proportion of patients who presented with good WFNS grades (1-3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% (P = 0.03, OR = 0.40, 95% CI = 0.17-0.95). The DCI experienced a significant reduction from 44.2% to 7.7% (P < 0.001, OR = 0.10, 95% CI = 0.04-0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28-2.28). CONCLUSION: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.

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BACKGROUND: Ventriculostomy using the freehand pass method is subject to complications arising from misplacement of the catheter tip. This method may require multiple passes for successful catheterization. Methods of determining the burr-hole location (known as the Kocher point) were derived historically from European patients and may not be appropriate for other populations with different cranial shapes. This study examines the possibility that anatomic variation in interpopulation variation together with sexual dimorphism in cranial size and shape may contribute to this problem. METHODS: Sagittal and parasagittal measurements of the frontal bone were taken of 300 Thai (150 female, 150 male) crania and 300 American white (150 female, 150 male) crania. These measurements were compared to determine sexual dimorphism and interpopulation variation in size and shape. RESULTS: The measurements were statistically significantly larger in males than in females and on the right side than the left in both sexes in both Thai and American white samples. The frontal bone is significantly longer at the sagittal plane in Europeans of both sexes than in Thai, but in the parasagittal plane, there is no difference. This finding indicates a difference in frontal bone shape between the 2 populations and between males and females. CONCLUSIONS: The dimensions of the frontal bone vary between males and females and can vary among populations. The optimal location for the burr hole in freehand pass ventriculostomy may depend on both the gender and the ancestry of the patient.

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BACKGROUND: Skull pin application during craniotomy is a highly noxious stimulus. Therefore, the attenuated effect between dexmedetomidine and fentanyl was investigated. METHOD: A randomized, double-blind controlled trial included sixty patients, randomly allocated into groups A and B. After patients entered the operative room, blood pressure and heart rate were measured (T1). At 5 minutes after propofol induction (T2), group A received dexmedetomidine 1 µg kg⁻¹ whereas group B received normal saline. At 3 minutes before skull pin insertion (T3), group B received a single bolus of fentanyl 1 µg kg⁻¹ whereas group A received normal saline. The hemodynamic responses were recorded at 1 minute before skull pin insertion (T4), during skull pin insertion (T5), then repeated every minute for 5 minutes (T6-T10). RESULTS: Controlling blood pressure in the dexmedetomidine group (Group A) was better than in the fentanyl group (Group B) at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01) for systolic blood pressure whereas diastolic blood pressure was significantly different at T4 and T8 (P < 0.05) and T5-T7 (P < 0.01). Mean arterial pressure, also was better controlled in group A at T4 and T10 (P < 0.05) and T5-T8 (P < 0.01). The heart rate in group A was lower than group B at T9 (P < 0.05) and T3-T6 (P < 0.01). Regarding adverse events, 11 hypertensive and 2 hypotensive responses occurred in group B whereas group A just only had 7 incidences of hypotension. CONCLUSION: The attenuated effect of dexmedetomidine infusion is significantly greater than fentanyl infusion.

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