Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

Background  Adult primary intraventricular hemorrhage (PIVH) is a rare type of hemorrhagic stroke that is poorly understood. The study attempts to define the clinical profile, yield of diagnostic cerebral angiography, and prognosis of patients with PIVH. Patients and Methods  Retrospective data analysis of all patients with PIVH admitted between February 2015 and February 2019 at a tertiary care center. Outcome was assessed using the modified Rankin scale (mRS) at 6 months. Results and Discussion  Our study group of 30 patients constituted 3.3% (30/905) of our spontaneous intracerebral hemorrhage (SICH) patients in the study period. The mean Glasgow Coma Score on admission was 11 ± 3.33 and the mean IVH Graeb score was 5.2±2.4. All patients underwent angiography. Angiography detected moyamoya disease in four patients (13.3%) and aneurysms in two patients (6.6%) and these patients were managed surgically. Extraventricular drainage with intraventricular instillation of Streptokinase was performed in five patients. The rest of the patients was managed conservatively. At 6-month follow-up, 25 patients (83.33%) achieved favorable outcome (mRS score of 0.1 or 2), whereas five (16.66%) patients had a poor outcome (mRS score of 3 or more. Three patients succumbed to the illness. IVH Graeb score and presence of hydrocephalus have significant correlation with poor outcome. Conclusion  PIVH is an uncommon entity but carries a better long-term prognosis than SICH angiography helps in diagnosing surgically remediable underlying vascular anomalies and is indicated in all cases of PIVH.

Objectives  Neurosurgeons working in the vicinity of tribal areas face traumatic brain injury (TBI) cases due to bear maul which is on the rise in Chhattisgarh. Most of the literature is focused on the management of maxillofacial injuries. This study intends to describe the challenges in management and outcomes of TBI due to bear maul. Materials and Methods  A retrospective review was conducted from May 2018 to April 2020. The patients without TBI were excluded. The variables studied were age, gender, timing and mode of conflict, Glasgow coma scale (GCS) at arrival, injury spectrum, hospital stay, the modified Rankin score (MRS), mini mental status examination (MMSE), and surgical site infections (SSI). Results  Twenty-eight patients were eligible for analysis. The mean age of presentation was 40.67 ± 13.99 years. There were 23 males (82.15%). Most common time of attack was during dawn ( n = 11, 39.28%) followed by dusk ( n = 9, 32.14%) and day ( n = 8, 28.57%) time. Provoked conflicts were seen in 64.28%. The mean preoperative GCS was 11.07 ± 3.54 and hospital stay was 18.71 ± 9.51 days. Skull fractures were found in 24/28 (85.71%). The mean MRS was 1.67 ± 1.38 at a mean follow-up of 14.53 ± 6.59 months. Favorable outcome (MRS ≤ 2) was seen in 64.28% of patients. The mean MMSE score was 22.28 ± 5.36. Eight patients developed SSI (28.57%). Conclusion  Outcomes of TBI due to bear maul depend on preoperative GCS. There are higher incidences of skull fractures and SSI. Humans need to avoid infiltration in wildlife territory to reduce the number of conflicts.

Objective  Determine predictors of in-hospital mortality in patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy. Materials and Methods  This retrospective study reviewed consecutive patients who underwent a decompressive craniectomy between March 2017 and March 2020 at our institution, and analyzed clinical characteristics, brain tomographic images, surgical details and morbimortality associated with this procedure. Results  Thirty-three (30 unilateral and 3 bifrontal) decompressive craniectomies were performed, of which 27 patients were male (81.8%). The mean age was 52.18 years, the mean Glasgow coma scale (GCS) score at admission was 9, and 24 patients had anisocoria (72.7%). Falls were the principal cause of the trauma (51.5%), the mean anterior-posterior diameter (APD) of the bone flap in unilateral cases was 106.81 mm (standard deviation [SD] 20.42) and 16 patients (53.3%) underwent a right-sided hemicraniectomy. The temporal bone enlargement was done in 20 cases (66.7%), the mean time of surgery was 2 hours and 27 minutes, the skull flap was preserved in the subcutaneous layer in 29 cases (87.8%), the mean of blood loss was 636.36 mL,and in-hospital mortality was 12%. Univariate analysis found differences between the APD diameter (120.3 mm vs. 85.3 mm; p = 0.003) and the presence of midline shift > 5 mm ( p = 0.033). Conclusion  The size of the skull flap and the presence of midline shift > 5 mm were predictors of mortality. In the absence of intercranial pressure (ICP) monitoring, clinical and radiological criteria are mandatory to perform a decompressive craniectomy.