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Șerban NL, Florian IS, Florian IA, Atena Zaha A, Ionescu D. Posttraumatic hydrocephalus as a complication of decompressive craniectomy-same old story, new perspectives. Front Surg 2024; 11:1415938. [PMID: 39170100 PMCID: PMC11335545 DOI: 10.3389/fsurg.2024.1415938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Objective Decompressive craniectomy (DC) serves as a vital life-saving intervention, demonstrating efficacy in reducing intracranial pressure (ICP). However, its efficacy hinges on meticulous surgical execution, perioperative management, and vigilance toward potential complications. The incidence of complications associated with DC plays a pivotal role in determining its superiority over medical management for patients experiencing intracranial hypertension following traumatic brain injury (TBI). Methods Severe cases often require more intensive therapy, prolonged mechanical ventilation, and vasopressor treatment. Identifying the optimal moment for early extubation and minimizing vasopressor use is crucial to reducing the risk of complications, including PTH. Our study aims to highlight the potential risks associated with prolonged mechanical ventilation and long-term vasopressor administration. The collected data were demographics, the craniectomy size, the distance from the midline of the craniectomy, the presence or absence of hydrocephalus, duration of mechanical ventilation and vasopressor treatment, and outcome at 30 days. Results Seventy-two patients with a mean age of 44.2 (range 5-83) were included in the study, with a median craniectomy size of 119.3 cm2. In our series, craniectomy areas ranged between 30 and 207.5 cm2 and had a similar decrease in midline shift in all cases. We did not observe any associations between the surface of craniectomy and the complication rate (p = 0.6302). There was no association between craniectomy size and mortality rate or length of hospital stay. The most common complication of decompressive craniectomy in our study group was posttraumatic hydrocephalus, with an incidence of 13.8%. Our results showed that craniectomy size did not independently affect PTH development (p = 0.5125). Still, there was a strong correlation between prolonged time of vasopressor treatment (p = 0.01843), period of mechanical ventilation (p = 0.04928), and the development of PTH. Conclusions This study suggests that there is no clear correlation between craniectomy size, midline shift reduction, and survival rate. An extended period of vasopressor treatment or mechanical ventilation is linked with the development of posttraumatic hydrocephalus. Further studies on larger series or randomized controlled studies are needed to better define this correlation.
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Affiliation(s)
- Nicoleta-Larisa Șerban
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- Department of Neurosurgery, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioan Stefan Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
- Department of Neurosurgery, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Andreea Atena Zaha
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniela Ionescu
- Department of Anesthesia and Intensive Care I, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Association for Research in Anesthesia and Intensive Care (ACATI), Cluj-Napoca, Romania
- Onco-Anaesthesia Research Group, ESAIC, Brussels, Belgium
- Outcome Research Consortium, Cleveland, OH, United States
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Amorim RL, da Silva VT, Martins HO, Brasil S, Godoy DA, Mendes MT, Gattas G, Bor-Seng-Shu E, Paiva WS. Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series. J Clin Monit Comput 2024; 38:783-789. [PMID: 38381360 DOI: 10.1007/s10877-024-01133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/28/2024] [Indexed: 02/22/2024]
Abstract
Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.
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Affiliation(s)
- Robson Luís Amorim
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
- Health Sciences Faculty, Federal University of Amazonas, Manaus, Brazil
| | | | | | - Sérgio Brasil
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.
- Division of Neurosurgery, University of São Paulo, 255. Eneas de Carvalho Aguiar Av., São Paulo, 05403-000, Brazil.
| | - Daniel Agustín Godoy
- Critical Care Department, Division Neurocritical Care, Sanatorio Pasteur, Catamarca, Argentina.
- Neurointensive Care Unit, Sanatorio Pasteur. Chacabuco 747, Catamarca, 4700, Argentina.
| | | | - Gabriel Gattas
- Institute of Radiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Silva Paiva
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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Oliveira AMP, De Andrade AF, Pipek LZ, Iaccarino C, Rubiano AM, Amorim RL, Teixeira MJ, Paiva WS. New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment. Front Surg 2024; 11:1329019. [PMID: 38379817 PMCID: PMC10876786 DOI: 10.3389/fsurg.2024.1329019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Background Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.
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Affiliation(s)
- Arthur Maynart Pereira Oliveira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Almir Ferreira De Andrade
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andres M. Rubiano
- Department of Neurosurgery, Universidad de Bogotá Jorge Tadeo Lozano, Bogotá, Colombia
- Centre for Neuroscience in Education, University of Cambridge, Cambridge, United Kingdom
| | - Robson Luis Amorim
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Choudhary SK, Sharma A. Comparative Study of Cerebral Perfusion in Different Types of Decompressive Surgery for Traumatic Brain Injury. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1760727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Abstract
Introduction Computed tomography perfusion (CTP) brain usefulness in the treatment of traumatic brain injury (TBI) is still being investigated. Comparative research of CTP in the various forms of decompressive surgery has not yet been reported to our knowledge. Patients with TBI who underwent decompressive surgery were studied using pre- and postoperative CTP. CTP findings were compared with patient's outcome.
Materials and Methods This was a single-center, prospective cohort study. A prospective analysis of patients who were investigated with CTP from admission between 2019 and 2021 was undertaken. The patients in whom decompressive surgery was required for TBI, were included in our study after applying inclusion and exclusion criteria. CTP imaging was performed preoperatively and 5 days after decompressive surgery to measure cerebral perfusion. Numbers of cases included in the study were 75. Statistical analysis was done.
Results In our study, cerebral perfusion were improved postoperatively in the all types of decompressive surgery (p-value < 0.05). But association between type of surgery with improvement in cerebral perfusion, Glasgow Coma Scale at discharge, and Glasgow Outcome Scale-extended at 3 months were found to be statistically insignificant (p-value > 0.05).
Conclusion CTP brain may play a role as a prognostic tool in TBI patients undergoing decompressive surgery.
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Affiliation(s)
- Suresh Kumar Choudhary
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Achal Sharma
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
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Oliveira AMP, Amorim RLO, Brasil S, Gattás GS, de Andrade AF, Junior FMP, Bor-Seng-Shu E, Iaccarino C, Teixeira MJ, Paiva WS. Improvement in neurological outcome and brain hemodynamics after late cranioplasty. Acta Neurochir (Wien) 2021; 163:2931-2939. [PMID: 34387743 DOI: 10.1007/s00701-021-04963-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/30/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Early cranioplasty has been encouraged after decompressive craniectomy (DC), aiming to reduce consequences of atmospheric pressure over the opened skull. However, this practice may not be often available in low-middle-income countries (LMICs). We evaluated clinical improvement, hemodynamic changes in each hemisphere, and the hemodynamic balance between hemispheres after late cranioplasty in a LMIC, as the institution's routine resources allowed. METHODS Prospective cohort study included patients with bone defects after DC evaluated with perfusion tomography (PCT) and transcranial Doppler (TCD) and performed neurological examinations with prognostic scales (mRS, MMSE, and Barthel Index) before and 6 months after surgery. RESULTS A final sample of 26 patients was analyzed. Satisfactory improvement of neurological outcome was observed, as well as significant improvement in the mRS (p = 0.005), MMSE (p < 0.001), and Barthel Index (p = 0.002). Outpatient waiting time for cranioplasty was 15.23 (SD 17.66) months. PCT showed a significant decrease in the mean transit time (MTT) and cerebral blood volume (CBV) only on the operated side. Although most previous studies have shown an increase in cerebral blood flow (CBF), we noticed a slight and nonsignificant decrease, despite a significant increase in the middle cerebral artery flow velocity in both hemispheres on TCD. There was a moderate correlation between the MTT and contralateral muscle strength (r = - 0.4; p = 0.034), as well as between TCD and neurological outcomes ipsilateral (MMSE; r = 0.54, p = 0.03) and contralateral (MRS; p = 0.031, r = - 0.48) to the operated side. CONCLUSION Even 1 year after DC, cranioplasty may improve cerebral perfusion and neurological outcomes and should be encouraged.
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Affiliation(s)
- Arthur Maynart Pereira Oliveira
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
- Division of Neurosurgery, Surgery Hospital - FBHC, Aracaju, Brazil
| | - Robson Luis Oliveira Amorim
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
- Department of Surgery, Federal University of Amazonas, Manaus, Brazil
| | - Sérgio Brasil
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil.
| | | | - Almir Ferreira de Andrade
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
| | | | - Edson Bor-Seng-Shu
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
| | - Wellingson Silva Paiva
- Division of Neurosurgery, University of São Paulo, 255 Enéas de Carvalho Aguiar, São Paulo, 05403-010, Brazil
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Avsenik J, Bajrović FF, Gradišek P, Kejžar N, Šurlan Popović K. Prognostic value of CT perfusion and permeability imaging in traumatic brain injury. J Trauma Acute Care Surg 2021; 90:484-491. [PMID: 33009337 DOI: 10.1097/ta.0000000000002964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently established prognostic models in traumatic brain injury (TBI) include noncontrast computed tomography (CT) which is insensitive to early perfusion alterations associated with secondary brain injury. Perfusion CT (PCT) on the other hand offers insight into early perfusion abnormalities. We hypothesized that adding CT perfusion and permeability data to the established outcome predictors improves the performance of the prognostic model. METHODS A prospective cohort study of consecutive 50 adult patients with head injury and Glasgow Coma Scale score of 12 or less was performed at a single Level 1 Trauma Centre. Perfusion CT was added to routine control CT 12 hours to 24 hours after admission. Region of interest analysis was performed in six major vascular territories on perfusion and permeability parametric maps. Glasgow Outcome Scale (GOS) was used 6 months later to categorize patients' functional outcomes to favorable (GOS score > 3) or unfavorable (GOS score ≤ 3). We defined core prognostic model, consisting of age, motor Glasgow Coma Scale score, pupillary reactivity, and CT Rotterdam Score. Next, we added perfusion and permeability data as predictors and compared updated models to the core model using cross-validated areas under the receiver operator curves (cv-AUC). RESULTS Significant advantage over core model was shown by the model, containing both mean cerebral extravascular-extracellular volume per unit of tissue volume and cerebral blood volume of the least perfused arterial territory in addition to core predictors (cv-AUC, 0.75; 95% confidence interval, 0.51-0.84 vs. 0.6; 95% confidence interval, 0.37-0.74). CONCLUSION The development of cerebral ischemia and traumatic cerebral edema constitutes the secondary brain injury and represents the target for therapeutic interventions. Our results suggest that adding CT perfusion and permeability data to the established outcome predictors improves the performance of the prognostic model in the setting of moderate and severe TBI. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Jernej Avsenik
- From the Clinical Institute of Radiology (J.A., K.Š.P.), University Medical Centre Ljubljana; Department of Radiology (J.A., K.Š.P.), Faculty of Medicine, University of Ljubljana; Division of Neurology (F.F.B.), University Medical Centre Ljubljana; Institute of Pathophysiology (F.F.B.), Faculty of Medicine, University of Ljubljana; Clinical Department of Anaesthesiology and Intensive Therapy (P.G.), Centre for Intensive Therapy, University Medical Centre Ljubljana; Department of Anaesthesiology with Reanimatology (P.G.), Faculty of Medicine, University of Ljubljana and Institute for Biostatistics and Medical Informatics (N.K.), Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Cooper S, Bendinelli C, Bivard A, Parsons M, Balogh ZJ. Abnormalities on Perfusion CT and Intervention for Intracranial Hypertension in Severe Traumatic Brain Injury. J Clin Med 2020; 9:E2000. [PMID: 32630511 PMCID: PMC7356931 DOI: 10.3390/jcm9062000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
The role of invasive intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (STBI) remain unclear. Perfusion computed tomography (CTP) provides crucial information about the cerebral perfusion status in these patients. We hypothesised that CTP abnormalities would be associated with the severity of intracranial hypertension (ICH). To investigate this hypothesis, twenty-eight patients with STBI and ICP monitors were investigated with CTP within 48 h from admission. Treating teams were blind to these results. Patients were divided into five groups based on increasing intervention required to control ICH and were compared. Group I required no intervention above routine sedation, group II required a single first tier intervention, group III required multiple different first-tier interventions, group IV required second-tier medical therapy and group V required second-tier surgical therapy. Analysis of the results showed demographics and injury severity did not differ among groups. In group I no patients showed CTP abnormality, while patients in all other groups had abnormal CTP (p = 0.003). Severe ischaemia observed on CTP was associated with increasing intervention for ICH. This study, although limited by small sample size, suggests that CTP abnormalities are associated with the need to intervene for ICH. Larger scale assessment of our results is warranted to potentially avoid unnecessary invasive procedures in head injury patients.
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Affiliation(s)
- Shannon Cooper
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
| | - Andrew Bivard
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
- Department of Neurology, University of Melbourne, Melbourne, VIC 3050, Australia
| | - Mark Parsons
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
- Department of Neurology, University of Melbourne, Melbourne, VIC 3050, Australia
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Split Calvarial Grafting for Closure of Large Cranial Defects: The Ideal Option? J Maxillofac Oral Surg 2019; 18:518-530. [PMID: 31624429 DOI: 10.1007/s12663-019-01198-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/02/2019] [Indexed: 10/27/2022] Open
Abstract
Among the various cranioplasty options for reconstruction of large post-craniectomy defects, split calvarial grafting offers numerous significant advantages such as the provision of viable autogenous bone graft material comprising of living, immunocompatible bony cells that integrate fully with the skull bone bordering the cranial defect. Its potential for revascularization and subsequent integration and consolidation allows its successful use even in previously infected or otherwise compromised recipient sites. Its excellent contour match at the recipient site and low cost as compared to various alloplastic implant materials often makes it preferable to the latter. Surgeon's skill, dexterity, expertise and experience are important factors to be considered in this highly technique-sensitive procedure.
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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11
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Bor-Seng-Shu E, de-Lima-Oliveira M, Nogueira RC, Almeida KJ, Paschoal EHA, Paschoal FM. Decompressive Craniectomy for Traumatic Brain Injury: Postoperative TCD Cerebral Hemodynamic Evaluation. Front Neurol 2019; 10:354. [PMID: 31031689 PMCID: PMC6473100 DOI: 10.3389/fneur.2019.00354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 03/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background: There are no studies describing the cerebral hemodynamic patterns that can occur in traumatic brain injury (TBI) patients following decompressive craniectomy (DC). Such data have potentially clinical importance for guiding the treatment. The objective of this study was to investigate the postoperative cerebral hemodynamic patterns, using transcranial Doppler (TCD) ultrasonography, in patients who underwent DC. The relationship between the cerebral circulatory patterns and the patients' outcome was also analyzed. Methods: Nineteen TBI patients with uncontrolled brain swelling were prospectively studied. Cerebral blood circulation was evaluated by TCD ultrasonography. Patients and their cerebral hemispheres were categorized based on TCD-hemodynamic patterns. The data were correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury. Results: Different cerebral hemodynamic patterns were observed. One patient (5.3%) presented with cerebral oligoemia, 4 patients (21%) with cerebral hyperemia, and 3 patients (15.8%) with cerebral vasospasm. One patient (5.3%) had hyperemia in one cerebral hemisphere and vasospasm in the other hemisphere. Ten patients (52.6%) had nonspecific circulatory pattern. Abnormal TCD-circulatory patterns were found in 9 patients (47.4%). There was no association between TCD-cerebral hemodynamic findings and outcome. Conclusion: There is a wide heterogeneity of postoperative cerebral hemodynamic findings among TBI patients who underwent DC, including hemodynamic heterogeneity between their cerebral hemispheres. DC was proved to be effective for the treatment of cerebral oligoemia. Our data support the concept of heterogeneous nature of the pathophysiology of the TBI and suggest that DC as the sole treatment modality is insufficient.
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Affiliation(s)
- Edson Bor-Seng-Shu
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Marcelo de-Lima-Oliveira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Ricardo Carvalho Nogueira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Kelson James Almeida
- Department of Neurology, Federal University of Piauí Medical School, Teresina, Brazil
| | | | - Fernando Mendes Paschoal
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil.,Department of Neurology, Federal University of Pará Medical School, São Paulo, Brazil
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12
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Shin SS, Huisman TAGM, Hwang M. Ultrasound Imaging for Traumatic Brain Injury. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1857-1867. [PMID: 29388231 DOI: 10.1002/jum.14547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/17/2017] [Accepted: 10/30/2017] [Indexed: 06/07/2023]
Abstract
Traumatic brain injury (TBI) is challenging to assess even with recent advancements in computed tomography and magnetic resonance imaging. Ultrasound (US) imaging has previously been less utilized in TBI compared to conventional imaging because of limited resolution in the intracranial space. However, there have been substantial improvements in contrast-enhanced US and development of novel techniques such as intravascular US. Also, continued research provides further insight into cerebrovascular parameters from transcranial Doppler imaging. These advancements in US imaging provides the community of TBI imaging researchers and clinicians new opportunities in clinically monitoring and understanding the pathologic mechanisms of TBI.
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Affiliation(s)
- Samuel S Shin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Misun Hwang
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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Jiang Y, Wang YK, Shi XL, Wang SH, Li YM, Wang JY, Zhang DF, Ma C, Yu MK, Hou LJ. Improvement of cerebral blood perfusion in certain cerebral regions after cranioplasty could be monitored via tympanic membrane temperature changes. Brain Inj 2018; 32:1405-1412. [PMID: 29985665 DOI: 10.1080/02699052.2018.1493615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Ying Jiang
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Yun-Kun Wang
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Xiao-Lei Shi
- Radiology, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Shen-Hao Wang
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Yi-Ming Li
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Jun-Yu Wang
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Dan-Feng Zhang
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Chao Ma
- Radiology, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Ming-Kun Yu
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
| | - Li-Jun Hou
- Department of Neurosurgery, Shanghai Chang Zheng Hospital affiliated to China Second Military Medical University, Shanghai, PR China
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14
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Salih F, Finger T, Vajkoczy P, Wolf S. Brain death after decompressive craniectomy: Incidence and pathophysiological mechanisms. J Crit Care 2017; 39:205-208. [PMID: 28254437 DOI: 10.1016/j.jcrc.2017.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/24/2017] [Accepted: 02/14/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients who received decompressive craniectomy (DC) are usually not regarded to qualify for brain death (BD) as intracranial pressure (ICP) is not assumed to reach levels critical enough to cause cerebral perfusion failure. Here we investigated the incidence of BD after DC and analyzed the pathophysiological mechanisms. MATERIALS AND METHODS We searched our chart records of patients with DC for individuals who developed BD (2010-2016). We then analyzed the course of ICP and cerebral perfusion pressure (CPP) prior to BD and results from radiological tests that aim at demonstrating loss of cerebral perfusion in BD. RESULTS BD was diagnosed in 12 of 164 (incidence 7.3%) patients (age=16-70years; male=7; mean longitudinal diameter: 136.2mm). Mean latency between DC and BD was 69.4h. Immediately after DC, mean ICP was 30.0mmHg (standard deviation±24.7mmHg), CPP was 56.8mmHg (±28.1). In the course to BD, ICP increased to 95.8mmHg (±16.1), CPP decreased to -9.9mmHg (±11.2). In patients in whom radiological methods were performed (n=5) loss of cerebral perfusion was demonstrated. CONCLUSIONS Our study evidences that DC does not exclude BD. Even after DC, BD is preceded by a severely reduced CPP, supporting loss of cerebral perfusion as a critical step in BD pathophysiology.
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Affiliation(s)
- Farid Salih
- Department of Neurology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Tobias Finger
- Department of Neurosurgery, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany
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15
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Wintermark M, Sanelli PC, Anzai Y, Tsiouris AJ, Whitlow CT. Imaging evidence and recommendations for traumatic brain injury: advanced neuro- and neurovascular imaging techniques. AJNR Am J Neuroradiol 2014; 36:E1-E11. [PMID: 25424870 DOI: 10.3174/ajnr.a4181] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
SUMMARY Neuroimaging plays a critical role in the evaluation of patients with traumatic brain injury, with NCCT as the first-line of imaging for patients with traumatic brain injury and MR imaging being recommended in specific settings. Advanced neuroimaging techniques, including MR imaging DTI, blood oxygen level-dependent fMRI, MR spectroscopy, perfusion imaging, PET/SPECT, and magnetoencephalography, are of particular interest in identifying further injury in patients with traumatic brain injury when conventional NCCT and MR imaging findings are normal, as well as for prognostication in patients with persistent symptoms. These advanced neuroimaging techniques are currently under investigation in an attempt to optimize them and substantiate their clinical relevance in individual patients. However, the data currently available confine their use to the research arena for group comparisons, and there remains insufficient evidence at the time of this writing to conclude that these advanced techniques can be used for routine clinical use at the individual patient level. TBI imaging is a rapidly evolving field, and a number of the recommendations presented will be updated in the future to reflect the advances in medical knowledge.
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Affiliation(s)
- M Wintermark
- From the Division of Neuroradiology (M.W.), Stanford University, Palo Alto, California
| | - P C Sanelli
- Department of Radiology (P.C.S.), North Shore-LIJ Health System, Manhasset, New York
| | - Y Anzai
- Department of Radiology (Y.A.), University of Washington, Seattle, Washington
| | - A J Tsiouris
- Department of Radiology (A.J.T.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - C T Whitlow
- Department of Radiology and Translational Science Institute (C.T.W.), Wake Forest School of Medicine, Winston-Salem, North Carolina
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16
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Sedney CL, Julien T, Manon J, Wilson A. The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center. J Neurosci Rural Pract 2014; 5:212-7. [PMID: 25002758 PMCID: PMC4078603 DOI: 10.4103/0976-3147.133555] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Decompressive craniectomy (DC) has increasing support with current studies suggesting an improvement in both survival rates and outcomes with this intervention. However, questions surround this procedure; specifically, no evidence has indicated the optimal craniectomy size. Larger craniectomy is thought to better decrease intracranial pressure, but with a possible increase in complication rates. Our hypothesis is that a larger craniectomy may improve mortality and outcome, but may increase complication rates. Materials and Methods: A retrospective observational therapeutic study was undertaken to determine if craniectomy size is related to complication rates, mortality, or outcome. Our institution's Trauma Registry was searched for patients undergoing DC. Craniectomy size was measured by antero-posterior (AP) diameter. Mortality, outcome (through admission and discharge Glasgow Coma Score and Glasgow Outcome Scale), and complications (such as re-bleeding, re-operation, hygroma, hydrocephalus, infection, and syndrome of the trephined) were noted. Complications, mortality, and outcome were then compared to craniectomy size, to determine if any relation existed to support our hypothesis. Results: 20 patients met criteria for inclusion in this study. Craniectomy size as measured by AP diameter was correlated with a statistically significant improvement in mortality within the group. All patients with a craniectomy size less than 10 cm died. However, outcome was not significantly related to craniectomy size in the group. Similarly, complication rates did not differ significantly compared to craniectomy size. Discussion: This study provides Level 3 evidence that craniectomy size may be significantly related to improved mortality within our group, supporting our initial hypothesis; however, no significant improvement in outcome was seen. Similarly, in contrast to our hypothesis, complication rates did not significantly correlate with craniectomy size.
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Affiliation(s)
- Cara L Sedney
- Department of Neurosurgery, West Virginia University, USA
| | | | - Jacinto Manon
- Penrose Centura Hospital, Memorial Hospital, Colorado Springs, Colorado, USA
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17
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Amorim RL, de Andrade AF, Gattás GS, Paiva WS, Menezes M, Teixeira MJ, Bor-Seng-Shu E. Improved Hemodynamic Parameters in Middle Cerebral Artery Infarction After Decompressive Craniectomy. Stroke 2014; 45:1375-80. [DOI: 10.1161/strokeaha.113.003670] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Decompressive craniectomy (DC) reduces mortality and improves functional outcome in patients with malignant middle cerebral artery infarction. However, little is known regarding the impact of DC on cerebral hemodynamics. Therefore, our goal was to study the hemodynamic changes that may occur in patients with malignant middle cerebral artery infarction after DC and to assess their relationship with outcomes.
Methods—
Twenty-seven patients with malignant middle cerebral artery infarction who were treated with DC were studied. The perfusion CT hemodynamic parameters, mean transit time, cerebral blood flow, and cerebral blood volume were evaluated preoperatively and within the first 24 hours after DC.
Results—
There was a global trend toward improved cerebral hemodynamics after DC. Preoperative and postoperative absolute mean transit times were associated with mortality at 6 months, and the ratio of post- and preoperative cerebral blood flow was significantly higher in patients with favorable outcomes than those with unfavorable outcomes. Patients who underwent surgery 48 hours after stroke, those with midline brain shift >10 mm, and those who were >55 years showed no significant improvement in any perfusion CT parameters.
Conclusions—
DC improves cerebral hemodynamics in patients with malignant middle cerebral artery infarction, and the level of improvement is related to outcome. However, some patients did not seem to experience any additional hemodynamic benefit, suggesting that perfusion CT may play a role as a prognostic tool in patients undergoing DC after ischemic stroke.
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Affiliation(s)
- Robson Luis Amorim
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Almir Ferreira de Andrade
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Gabriel S. Gattás
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Silva Paiva
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Marcos Menezes
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- From the Division of Neurosurgery (R.L.A., A.F.d.A., W.S.P., M.J.T., E.B.-S.-S.) and Department of Radiology (G.S.G., M.M.), University of São Paulo Medical School, São Paulo, Brazil
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18
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Sarubbo S, Latini F, Ceruti S, Chieregato A, d'Esterre C, Lee TY, Cavallo M, Fainardi E. Temporal changes in CT perfusion values before and after cranioplasty in patients without symptoms related to external decompression: a pilot study. Neuroradiology 2014; 56:237-43. [PMID: 24430116 DOI: 10.1007/s00234-014-1318-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/03/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Little is known about hemodynamic disturbances affecting cerebral hemispheres in traumatic brain injury (TBI) after cranioplasty. METHODS We prospectively investigated six stable TBI patients who underwent cranioplasty more than 90 days after effective decompressive craniectomy. Computerized tomography perfusion (CTP) studies and evaluation of clinical outcome were performed for each patient before cranioplasty and at 7 days and 3 months after surgery. Cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were measured in multiple cortical circular regions positioned in cranioplasty-treated and contralateral hemispheres. RESULTS Neither complications associated with cranioplasty nor changes in outcome were observed. On the treated side, CBF and CBV values were higher before and 7 days after cranioplasty than at 3 months after surgery, whereas MTT values were lower at 7 days than at 3 months after surgical treatment. CONCLUSIONS Our results indicate that cortical perfusion progressively declines in the cranioplasty treated hemisphere but remains stable in the contralateral hemisphere after surgery and suggest that CTP can represent a promising tool for a longitudinal analysis of hemodynamic abnormalities occurring in TBI patients after cranioplasty. In addition, these data imply a possible role of cranioplasty in restoring flow to meet the prevailing metabolic demand.
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Affiliation(s)
- Silvio Sarubbo
- Neurosurgery Unit, Department of Neurosciences, "S. Chiara" Hospital, APSS Trento, Trento, Italy
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19
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Coelho F, Oliveira AM, Paiva WS, Freire FR, Calado VT, Amorim RL, Neville IS, de Andrade AF, Bor-Seng-Shu E, Anghinah R, Teixeira MJ. Comprehensive cognitive and cerebral hemodynamic evaluation after cranioplasty. Neuropsychiatr Dis Treat 2014; 10:695-701. [PMID: 24833902 PMCID: PMC4014378 DOI: 10.2147/ndt.s52875] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Decompressive craniectomy is an established procedure to lower intracranial pressure and can save patients' lives. However, this procedure is associated with delayed cognitive decline and cerebral hemodynamics complications. Studies show the benefits of cranioplasty beyond cosmetic aspects, including brain protection, and functional and cerebrovascular aspects, but a detailed description of the concrete changes following this procedure are lacking. In this paper, the authors report a patient with trephine syndrome who underwent cranioplasty; comprehensive cognitive and cerebral hemodynamic evaluations were performed prior to and following the cranioplasty. The discussion was based on a critical literature review.
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Affiliation(s)
- Fernanda Coelho
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Fabio Rios Freire
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vanessa Tome Calado
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Robson Luis Amorim
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Neurosonology and Cerebral Hemodynamics Group, University of São Paulo Medical School, São Paulo, Brazil
| | - Renato Anghinah
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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