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Habibzadeh A, Khademolhosseini S, Kouhpayeh A, Niakan A, Asadi MA, Ghasemi H, Tabrizi R, Taheri R, Khalili HA. Machine learning-based models to predict the need for neurosurgical intervention after moderate traumatic brain injury. Health Sci Rep 2023; 6:e1666. [PMID: 37908638 PMCID: PMC10613807 DOI: 10.1002/hsr2.1666] [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: 07/25/2023] [Revised: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
Background and Aims Traumatic brain injury (TBI) is a widespread global health issue with significant economic consequences. However, no existing model exists to predict the need for neurosurgical intervention in moderate TBI patients with positive initial computed tomography scans. This study determines the efficacy of machine learning (ML)-based models in predicting the need for neurosurgical intervention. Methods This is a retrospective study of patients admitted to the neuro-intensive care unit of Emtiaz Hospital, Shiraz, Iran, between January 2018 and December 2020. The most clinically important variables from patients that met our inclusion and exclusion criteria were collected and used as predictors. We developed models using multilayer perceptron, random forest, support vector machines (SVM), and logistic regression. To evaluate the models, their F1-score, sensitivity, specificity, and accuracy were assessed using a fourfold cross-validation method. Results Based on predictive models, SVM showed the highest performance in predicting the need for neurosurgical intervention, with an F1-score of 0.83, an area under curve of 0.93, sensitivity of 0.82, specificity of 0.84, a positive predictive value of 0.83, and a negative predictive value of 0.83. Conclusion The use of ML-based models as decision-making tools can be effective in predicting with high accuracy whether neurosurgery will be necessary after moderate TBIs. These models may ultimately be used as decision-support tools to evaluate early intervention in TBI patients.
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Affiliation(s)
- Adrina Habibzadeh
- Student Research CommitteeFasa University of Medical SciencesFasaIran
- USERN OfficeFasa University of Medical SciencesFasaIran
- Shiraz Trauma Research CenterShirazIran
| | | | - Amin Kouhpayeh
- Department of PharmacologyFasa University of Medical SciencesFasaIran
| | - Amin Niakan
- Shiraz Trauma Research CenterShirazIran
- Shiraz Neurosurgery DepartmentShiraz University of Medical SciencesShirazIran
| | - Mohammad Ali Asadi
- Department of Computer Engineering, Shiraz BranchIslamic Azad University, Shiraz UniversityShirazIran
| | - Hadis Ghasemi
- Biology and Medicine FacultyTaras Shevchenko National University of KyivKyivUkraine
| | - Reza Tabrizi
- USERN OfficeFasa University of Medical SciencesFasaIran
- Noncommunicable Diseases Research CenterFasa University of Medical SciencesFasaIran
- Clinical Research Development Unit, Valiasr HospitalFasa University of Medical SciencesFasaIran
| | - Reza Taheri
- Shiraz Trauma Research CenterShirazIran
- Clinical Research Development Unit, Valiasr HospitalFasa University of Medical SciencesFasaIran
- Shiraz Neuroscience Research CenterShiraz University of Medical SciencesShirazIran
| | - Hossein Ali Khalili
- Shiraz Trauma Research CenterShirazIran
- Shiraz Neurosurgery DepartmentShiraz University of Medical SciencesShirazIran
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Kamabu LK, Bbosa GS, Lekuya HM, Cho EJ, Kyaruzi VM, Nyalundja AD, Deng D, Sekabunga JN, Kataka LM, Obiga DOD, Kiryabwire J, Kaddumukasa MN, Kaddumukasa M, Fuller AT, Galukande M. Burden, risk factors, neurosurgical evacuation outcomes, and predictors of mortality among traumatic brain injury patients with expansive intracranial hematomas in Uganda: a mixed methods study design. BMC Surg 2023; 23:326. [PMID: 37880635 PMCID: PMC10601114 DOI: 10.1186/s12893-023-02227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Expansive intracranial hematomas (EIH) following traumatic brain injury (TBI) continue to be a public health problem in Uganda. Data is limited regarding the neurosurgical outcomes of TBI patients. This study investigated the neurosurgical outcomes and associated risk factors of EIH among TBI patients at Mulago National Referral Hospital (MNRH). METHODS A total of 324 subjects were enrolled using a prospective cohort study. Socio-demographic, risk factors and complications were collected using a study questionnaire. Study participants were followed up for 180 days. Univariate, multivariable, Cox regression analyses, Kaplan Meir survival curves, and log rank tests were sequentially conducted. P-values of < 0.05 at 95% Confidence interval (CI) were considered to be statistically significant. RESULTS Of the 324 patients with intracranial hematomas, 80.6% were male. The mean age of the study participants was 37.5 ± 17.4 years. Prevalence of EIH was 59.3% (0.59 (95% CI: 0.54 to 0.65)). Participants who were aged 39 years and above; PR = 1.54 (95% CI: 1.20 to 1.97; P = 0.001), and those who smoke PR = 1.21 (95% CI: 1.00 to 1.47; P = 0.048), and presence of swirl sign PR = 2.26 (95% CI: 1.29 to 3.95; P = 0.004) were found to be at higher risk for EIH. Kaplan Meier survival curve indicated that mortality at the 16-month follow-up was 53.4% (95% CI: 28.1 to 85.0). Multivariate Cox regression indicated that the predictors of mortality were old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having GOS < 3, QoLIBRI < 50, SDH, contusion, and EIH. CONCLUSION EIH is common in Uganda following RTA with an occurrence of 59.3% and a 16-month higher mortality rate. An increased age above 39 years, smoking, having severe systemic disease, and the presence of swirl sign are independent risk factors. Old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having a GOS < 3, QoLIBRI < 50, ASDH, and contusion are predictors of mortality. These findings imply that all patients with intracranial hematomas (IH) need to be monitored closely and a repeat CT scan to be done within a specific period following their initial CT scan. We recommend the development of a protocol for specific surgical and medical interventions that can be implemented for patients at moderate and severe risk for EIH.
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Affiliation(s)
- Larrey Kasereka Kamabu
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda.
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
- Department of Surgery, Makerere University College of Health Medicine, Mulago Upper Hill, Kampala, Uganda.
| | - Godfrey S Bbosa
- Department of Pharmacology & Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hervé Monka Lekuya
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
- Department of Human Structure & Repair/ Neurosurgery, Faculty of Medicine, Ghent University, Ghent, Belgium
| | | | - Victor Meza Kyaruzi
- Department of Surgery, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, South Kivu, Democratic Republic of the Congo
| | - Daniel Deng
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Juliet Nalwanga Sekabunga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Louange Maha Kataka
- Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
| | - Doomwin Oscar Deogratius Obiga
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Joel Kiryabwire
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
- Directorate of Surgical Services, Neurosurgical Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin N Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Anthony T Fuller
- Duke University, Durham, NC, USA
- Duke Global Neurosurgery, Neurology and Health System, Duke University, Durham, NC, USA
| | - Moses Galukande
- Department of Surgery, Neurosurgery, College of Medicine, Makerere University, Kampala, Uganda
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3
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Su TM, Lin CC, Lan CM, Lee TH, Hsu SW, Lu CH. Head Trauma Associated with Supra- and Infratentorial Epidural Hematoma: Diagnostic and Surgical Considerations. World Neurosurg 2023; 176:e273-e280. [PMID: 37207722 DOI: 10.1016/j.wneu.2023.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Supra- and infratentorial epidural hematoma (SIEDH) is a rare type of intracranial epidural hematoma. Due to the potential of vigorous hemorrhage from the injured transverse sinus (TS), it poses a challenge for neurosurgeons to evacuate the SIEDH. METHODS The medical records and radiographic studies were retrospectively reviewed to investigate the clinical and radiographic characteristics, clinical course, surgical findings and outcome in 34 patients with head trauma associated with SIEDH. RESULTS Patients treated surgically had a lower Glasgow Coma Scale score than those treated conservatively (P = 0.005). The surgical group had statistically larger thickness and volume of the SIEDH than those in the conservative group (P < 0.0001 and P < 0.0001, respectively). Six patients experienced significant intraoperative blood loss, and copious bleeding from the injured TS was noted in 5 (83.3%) of these patients. Five (50%) of 10 patients undergoing simple craniotomy experienced significant blood loss. However, only 1 patient (11.1%) undergoing strip craniotomy experienced significant blood loss, but no intraoperative shock. All patients experiencing massive blood loss and intraoperative shock underwent simple craniotomy. There was no statistical difference in the outcome between the conservative and surgical groups. CONCLUSIONS When operating on SIEDH, the possibility of vigorous bleeding from the injured TS and intraoperative massive bleeding should be kept in mind. Strip craniotomy that allows hitching the stripped dura to the bone strip overlying the TS may be a better method for the evacuation of SIEDH.
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Affiliation(s)
- Tsung-Ming Su
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Cheng Lin
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chu-Mei Lan
- Department of Health Psychology, Chang Jung Christian University, Tainan, Taiwan
| | - Tsung-Han Lee
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Wei Hsu
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Honeybul S, Ho KM, Rosenfeld JV. The role of tranexamic acid in traumatic brain injury. J Clin Neurosci 2022; 99:1-4. [PMID: 35220154 DOI: 10.1016/j.jocn.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/12/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia; Royal Perth Hospital, Wellington Street, Perth, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Emeritus Professor of Surgery Monash University, Melbourne, Australia; Surgery, F.Edward Hebert School of Medicine, Uniformed, Services University of the Health Sciences, Bethesda, MD, USA
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5
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Sheng J, Yang J, Cai S, Zhuang D, Li T, Chen X, Wang G, Dai J, Ding F, Tian L, Zheng F, Tian F, Huang M, Li K, Chen W. Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion. Sci Rep 2021; 11:2042. [PMID: 33479430 PMCID: PMC7819987 DOI: 10.1038/s41598-021-81685-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 01/11/2021] [Indexed: 02/05/2023] Open
Abstract
Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Gefei Wang
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jianping Dai
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Faxiu Ding
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Lu Tian
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fengqing Zheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Kangsheng Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China.
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China.
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Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review. Curr Neurol Neurosci Rep 2020; 20:63. [PMID: 33136200 DOI: 10.1007/s11910-020-01080-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers. RECENT FINDINGS To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.
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Choudhary A, Kaushik K, Bhaskar SN, Gupta LN, Sharma R, Varshney R. Correlation of Initial Computed Tomography Findings with Outcomes of Patients with Acute Subdural Hematoma: A Prospective Study. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Introduction In modern emergency service systems, patients are often treated with sedation, intubation, and ventilation at the accident site. But neurosurgical assessment before all these emergency services is important. Thus, this study was designed to investigate the relationships between various parameters of initial CT scan findings and the outcomes of the patients.
Methodology A total of 56 adult patients of traumatic acute subdural hematoma (SDH) whose computed tomography (CT) scan was performed within 8 hours of injury were recruited. The patients with prolonged hypotension, open head injury or depressed skull fracture, bilateral side acute SDH, or contusions/hematoma/extradural hematoma on the contralateral side were excluded. Six separate CT findings were analyzed and recorded, including hematoma, midline shift, subarachnoid hemorrhage (SAH), presence of basal cistern obliteration (BCO), intraparenchymal hematoma/contusion in the same hemisphere, and presence of effacement of the sulcal spaces, and were followed up for three months for outcome analysis.
Results The overall mortality and functional recovery rate were 27 and 50%, respectively. The patients with obliterated basal cisterns and the presence of underlying SAH in patients with acute SDH had statistically significant poorer outcomes as compared with others. However, the extent of midline shift, SDH thickness, and the presence of underlying contusions and sulcal effacement on initial CT scan showed no statistically significant correlation with patients’ outcomes.
Conclusions BCO and presence of subarchnoid hemorrhage underlying acute SDH on the earliest scan in head injury patients signify the severity of brain parenchymal injury. Along with the initial Glasgow Coma Scale score after resuscitation, these two factors should be considered as the most significant ones for predicting the outcomes in traumatic acute SDH patients.
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Affiliation(s)
- Ajay Choudhary
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Kaviraj Kaushik
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Surya Narayanan Bhaskar
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Laxmi Narayan Gupta
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rajesh Sharma
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rahul Varshney
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
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Mathieu F, Zeiler FA, Whitehouse DP, Das T, Ercole A, Smielewski P, Hutchinson PJ, Czosnyka M, Newcombe VFJ, Menon DK. Relationship Between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute TBI Patients: an Exploratory Analysis. Neurocrit Care 2020; 32:373-382. [PMID: 31797278 PMCID: PMC7082305 DOI: 10.1007/s12028-019-00885-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI. METHODS We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses. RESULTS We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status. CONCLUSIONS Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, University of Toronto, Toronto, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Daniel P Whitehouse
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Brain Physics LaboratoryDivision of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 167, Cambridge, CB2 0QQ, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia F J Newcombe
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
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9
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Ben Zvi I, Matsri S, Felzensztein D, Yassin S, Orlev A, Ben Shalom N, Gavrielli S, Inbar E, Loeub A, Schwartz N, Rajz G, Novitsky I, Kanner A, Berkowitz S, Harnof S. The Utility of Early Postoperative Neuroimaging in Elective/Semielective Craniotomy Patients: A Single-Arm Prospective Trial. World Neurosurg 2020; 138:e381-e388. [PMID: 32145412 DOI: 10.1016/j.wneu.2020.02.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND The necessity and timing of early postoperative imaging (POI) are debated in many studies. Despite the consensus that early POI does not change patient management, these examinations are routinely performed. This is the first prospective study related to POI. Our aims were to assess the necessity of early POI in asymptomatic patients and to verify accuracy of the presented algorithm. METHODS This was an algorithm-based prospective single-center study. The algorithm addressed preoperative, perioperative, and postoperative considerations, including estimated pathology type, device placement, and postoperative neurologic change. Early computed tomography scans were obtained in all patients, but if postoperative algorithm indications did not recommend a scan, the treating team was blinded to them, and patient management was conducted based on clinical examinations alone. A neuroradiologist and study-independent neurosurgeon reviewed all the scans. RESULTS Of 103 enrolled patients, 88 remained asymptomatic, and 15 experienced symptoms postoperatively. Pathology was present on POI in 1% of the asymptomatic patients and 53% of the symptomatic patients (P < 0.001). In the asymptomatic group, no treatment modifications were made postoperatively. Blinding of the surgical team was not removed, and 20% of the symptomatic patients returned to the operating room because of imaging and neurologic findings. The goal of <5% algorithm failure was reached with statistical significance. CONCLUSIONS In asymptomatic postoperative patients in whom early imaging is not performed for oncologic indications, device placement verification, or similar reasons, POI is unnecessary and does not change the management of these patients.
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Affiliation(s)
- Ido Ben Zvi
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel.
| | - Sher Matsri
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | | | - Saeed Yassin
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Alon Orlev
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | | | - Shlomo Gavrielli
- Department of Diagnostic Radiology, Rabin Medical Center, Petah Tikva, Israel
| | - Edna Inbar
- Department of Diagnostic Radiology, Rabin Medical Center, Petah Tikva, Israel
| | - Adam Loeub
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Noa Schwartz
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Gustavo Rajz
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Ivan Novitsky
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Andrew Kanner
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Shani Berkowitz
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
| | - Sagi Harnof
- Neurosurgery Department, Rabin Medical Center, Petah Tikva, Israel
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10
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Nasi D, di Somma L, Gladi M, Moriconi E, Scerrati M, Iacoangeli M, Dobran M. New or Blossoming Hemorrhagic Contusions After Decompressive Craniectomy in Traumatic Brain Injury: Analysis of Risk Factors. Front Neurol 2019; 9:1186. [PMID: 30697186 PMCID: PMC6340989 DOI: 10.3389/fneur.2018.01186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/24/2018] [Indexed: 01/02/2023] Open
Abstract
Background: The development or expansion of a cerebral hemorrhagic contusion after decompressive craniectomy (DC) for traumatic brain injury (TBI) occurs commonly and it can result in an unfavorable outcome. However, risk factors predicting contusion expansion after DC are still uncertain. The aim of this study was to identify the factors associated with the growth or expansion of hemorrhagic contusion after DC in TBI. Then we evaluated the impact of contusion progression on outcome. Methods: We collected the data of patients treated with DC for TBI in our Center. Then we analyzed the risk factors associated with the growth or expansion of a hemorrhagic contusion after DC. Results: 182 patients (149 males and 41 females) were included in this study. Hemorrhagic contusions were detected on the initial CT scan or in the last CT scan before surgery in 103 out of 182 patients. New or blossoming hemorrhagic contusions were registered after DC in 47 patients out of 182 (25.82%). At multivariate analysis, only the presence of an acute subdural hematoma (p = 0.0076) and a total volume of contusions >20 cc before DC (p = < 0.0001) were significantly associated with blossoming contusions. The total volume of contusions before DC resulted to have higher accuracy and ability to predict postoperative blossoming of contusion with strong statistical significance rather than the presence of acute subdural hematoma (these risk factors presented respectively an area under the curve [AUC] of 0.896 vs. 0.595; P < 0.001). Patients with blossoming contusions presented an unfavorable outcome compared to patients without contusion progression (p < 0.0185). Conclusions: The presence of an acute subdural hematoma was associated with an increasing rate of new or expanded hemorrhagic contusions after DC. The total volume of hemorrhagic contusions > 20 cc before surgery was an independent and extremely accurate predictive radiological sign of contusion blossoming in decompressed patients for severe TBI. After DC, the patients who develop new or expanding contusions presented an increased risk for unfavorable outcome.
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Affiliation(s)
- Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia di Somma
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Gladi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Moriconi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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11
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Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B, Morrison JF, Williams JR, Collins S, Monteiro K, Asaad WF. Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 2018; 129:1305-1316. [PMID: 29303442 DOI: 10.3171/2017.7.jns17988] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David J Segar
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 2Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Meghal Shah
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Benjamin Drapcho
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John F Morrison
- 3Department of Neurosurgery, University at Buffalo, New York
| | - John R Williams
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - Kristina Monteiro
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 7Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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12
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Pandya U, Pattison J, Karas C, O'Mara M. Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?. Am Surg 2018. [DOI: 10.1177/000313481808400327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.
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Affiliation(s)
- Urmil Pandya
- Trauma Services, Grant Medical Center, Columbus, Ohio
| | - Jill Pattison
- Trauma Services, Grant Medical Center, Columbus, Ohio
| | - Chris Karas
- Trauma Services, Grant Medical Center, Columbus, Ohio
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13
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Campos-Pires R, Koziakova M, Yonis A, Pau A, Macdonald W, Harris K, Edge CJ, Franks NP, Mahoney PF, Dickinson R. Xenon Protects against Blast-Induced Traumatic Brain Injury in an In Vitro Model. J Neurotrauma 2018; 35:1037-1044. [PMID: 29285980 PMCID: PMC5899289 DOI: 10.1089/neu.2017.5360] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The aim of this study was to evaluate the neuroprotective efficacy of the inert gas xenon as a treatment for patients with blast-induced traumatic brain injury in an in vitro laboratory model. We developed a novel blast traumatic brain injury model using C57BL/6N mouse organotypic hippocampal brain-slice cultures exposed to a single shockwave, with the resulting injury quantified using propidium iodide fluorescence. A shock tube blast generator was used to simulate open field explosive blast shockwaves, modeled by the Friedlander waveform. Exposure to blast shockwave resulted in significant (p < 0.01) injury that increased with peak-overpressure and impulse of the shockwave, and which exhibited a secondary injury development up to 72 h after trauma. Blast-induced propidium iodide fluorescence overlapped with cleaved caspase-3 immunofluorescence, indicating that shock-wave–induced cell death involves apoptosis. Xenon (50% atm) applied 1 h after blast exposure reduced injury 24 h (p < 0.01), 48 h (p < 0.05), and 72 h (p < 0.001) later, compared with untreated control injury. Xenon-treated injured slices were not significantly different from uninjured sham slices at 24 h and 72 h. We demonstrate for the first time that xenon treatment after blast traumatic brain injury reduces initial injury and prevents subsequent injury development in vitro. Our findings support the idea that xenon may be a potential first-line treatment for those with blast-induced traumatic brain injury.
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Affiliation(s)
- Rita Campos-Pires
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom .,2 Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London , London, United Kingdom
| | - Mariia Koziakova
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom .,2 Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London , London, United Kingdom
| | - Amina Yonis
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom
| | - Ashni Pau
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom
| | - Warren Macdonald
- 2 Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London , London, United Kingdom .,3 Department of Bioengineering, Imperial College London , London, United Kingdom
| | - Katie Harris
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom
| | - Christopher J Edge
- 4 Department of Life Sciences, Imperial College London , London, United Kingdom .,5 Department of Anaesthetics, Royal Berkshire Hospital NHS Foundation Trust , Reading, United Kingdom
| | - Nicholas P Franks
- 4 Department of Life Sciences, Imperial College London , London, United Kingdom
| | - Peter F Mahoney
- 6 Royal Centre for Defence Medicine , Medical Directorate Joint Force Command, ICT Centre, Birmingham, United Kingdom
| | - Robert Dickinson
- 1 Anaesthetics, Pain Medicine and Intensive Care Section, Department of Surgery and Cancer, Imperial College London , London, United Kingdom .,2 Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London , London, United Kingdom
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14
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Bodanapally UK, Shanmuganathan K, Issa G, Dreizin D, Li G, Sudini K, Fleiter TR. Dual-Energy CT in Hemorrhagic Progression of Cerebral Contusion: Overestimation of Hematoma Volumes on Standard 120-kV Images and Rectification with Virtual High-Energy Monochromatic Images after Contrast-Enhanced Whole-Body Imaging. AJNR Am J Neuroradiol 2018; 39:658-662. [PMID: 29439124 DOI: 10.3174/ajnr.a5558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/11/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with hemorrhagic contusions, hematoma volumes are overestimated on follow-up standard 120-kV images obtained after contrast-enhanced whole-body CT. We aimed to retrospectively determine hemorrhagic progression of contusion rates on 120-kV and 190-keV images derived from dual-energy CT and the magnitude of hematoma volume overestimation. MATERIALS AND METHODS We retrospectively analyzed admission and follow-up CT studies in 40 patients with hemorrhagic contusions. After annotating the contusions, we measured volumes from admission and follow-up 120-kV and 190-keV images using semiautomated 3D segmentation. Bland-Altman analysis was used for hematoma volume comparison. RESULTS On 120-kV images, hemorrhagic progression of contusions was detected in 24 of the 40 patients, while only 17 patients had hemorrhagic progression of contusions on 190-keV images (P = .008). Hematoma volumes were systematically overestimated on follow-up 120-kV images (9.68 versus 8 mm3; mean difference, 1.68 mm3; standard error, 0.37; P < .001) compared with 190-keV images. There was no significant difference in volumes between admission 120-kV and 190-keV images. Mean and median percentages of overestimation were 29% (95% CI, 18-39) and 22% (quartile 3 - quartile 1 = 36.8), respectively. CONCLUSIONS The 120-kV images, which are comparable with single-energy CT images, significantly overestimated the hematoma volumes, hence the rate of hemorrhagic progression of contusions, after contrast-enhanced whole-body CT. Hence, follow-up of hemorrhagic contusions should be performed on dual-energy CT, and 190-keV images should be used for the assessment of hematoma volumes.
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Affiliation(s)
- U K Bodanapally
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - K Shanmuganathan
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland.,Department of Environmental Health Sciences (K.S.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - G Issa
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - D Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - G Li
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - K Sudini
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - T R Fleiter
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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15
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Alliez JR, Kaya JM, Leone M. Ematomi intracranici post-traumatici in fase acuta. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Shah JM, Shah KS, Kumar J, Sundaram PK. Role of routine repeat computed tomography of brain in patients with mild and moderate traumatic brain injury: A prospective study. Asian J Neurosurg 2017; 12:412-415. [PMID: 28761517 PMCID: PMC5532924 DOI: 10.4103/1793-5482.180968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Computed tomography (CT) has become the primary investigative modality for traumatic brain injury (TBI) and there are established guidelines for the initial CT (CT-1). There are no specific guidelines for scheduling repeat CT in TBI. This study was carried out to compare the usefulness of unscheduled repeat CT (UCT-2) with scheduled repeat CT (SCT-2) in the presence or absence of neurological deterioration and to identify risk factors associated with radiological worsening (RW). METHODS This prospective study comprised admitted patients with mild and moderate TBI between February and May, 2014 and all patients were subjected to repeat CT brain. Patients with penetrating brain injuries and surgical conditions after CT-1, and age < 5 years were excluded. Positive yield after the second CT (SCT-2 and UCT-2) leading to modification of management were compared between the two groups. RESULTS In this study, 214 patients (214/222) underwent SCT-2 and 8 underwent UCT-2 (8/222). Surgery was required in 2 (0.9%) from the first group and 7 (87.5%) in the latter. UCT-2 was more likely to show RW warranting surgery as compared to SCT-2 (P < 0.05). In the SCT-2 group, CT-1 had been done within 2 h after trauma in 30 patients and 8 (8/30; 26.7%) showed RW and; after 2 h in the remaining 184 (184/214) with RW seen in 23 (23/184; 12.5%). RW was more common when the CT-1 was within 2 h from trauma (P < 0.05). In our study, the age of the patient and admission Glasgow Coma Scores did not significantly affect the findings in repeat CT. CONCLUSION Repeating CT brain is costly besides needing significant logistical support to shift an injured and often unstable patient. SCT-2 is more likely to show RW when CT-1 is done within 2 h after trauma. UCT-2 is more likely to show RW and findings warranting surgery as compared to SCT-2. Hence, a repeat CT may be preferred only in the presence of clinical worsening and when CT-1 is done within 2 h after trauma.
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Affiliation(s)
- Jayun M Shah
- Department of Neurosurgery, Goa Medical College, Goa, India
| | - Kairav S Shah
- Department of Neurosurgery, Goa Medical College, Goa, India
| | - Jinendra Kumar
- Department of Neurosurgery, Goa Medical College, Goa, India
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17
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Oh MJ, Jeong JH, Shin DS, Hwang SC, Im SB, Kim BT, Shin WH. Postoperative Contralateral Hematoma in Patient with Acute Traumatic Brain Injury. Korean J Neurotrauma 2017; 13:24-28. [PMID: 28512614 PMCID: PMC5432445 DOI: 10.13004/kjnt.2017.13.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 11/23/2022] Open
Abstract
Objective Head injury is a leading cause of death and disability in subjects who suffer a traumatic accident. Contralateral hematomas after surgery for traumatic brain injury are rare. However, an unrecognized, these hematomas can cause devastating results. We presented our experience of these patients and discussed diagnosis and management. Methods This study included 12 traumatic patients with acute traumatic brain injury who developed delayed contralateral hematoma after evacuation of an acute hematoma. Clinical and radiographic data was obtained through review of medical records and radiographs retrospectively. Results Ten males and two females were included in the study. Ten (83.3%) patients had severe head injury (Glasgow Coma Scale [GCS] score <8). Intraoperative brain swelling during removal of the traumatic subdural hematoma was noted in 10 (83.3%) patients. A skull fracture on the side contralateral to the acute hematoma was noted on computed tomography (CT) scans of nine (75%) patients. Three (33.3%) patients with severe head injury (GCS <8) died. Only (10%) one patient with a severe head injury had less severe disability. Conclusion A postoperative CT scan is essential in patients with acute traumatic brain injury and a contralateral skull fracture or a low GCS score. Our results indicated that it is very important to evaluate this rare but potentially devastating complication.
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Affiliation(s)
- Myeong-Jin Oh
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Won-Han Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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18
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Gómez PA, Castaño-León AM, Lora D, Cepeda S, Lagares A. Evolución temporal en las características de la tomografía computarizada, presión intracraneal y tratamiento quirúrgico en el traumatismo craneal grave: análisis de la base de datos de los últimos 25 años en un servicio de neurocirugía. Neurocirugia (Astur) 2017; 28:1-14. [DOI: 10.1016/j.neucir.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/05/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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19
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Wijdicks EFM. Why you may need a neurologist to see a comatose patient in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:193. [PMID: 27320897 PMCID: PMC4913428 DOI: 10.1186/s13054-016-1372-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This commentary summarizes the value of a neurologist in the diagnosis and prognostication of coma. Evaluating coma is inherently complex, and neurologic consultation and management can be useful. We often find that management changes after a neurologic consultation.
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20
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Umerani MS, Abbas A, Bakhshi SK, Qasim UM, Sharif S. Evolving brain lesions in the follow-up CT scans 12 h after traumatic brain injury. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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A second look at the utility of serial routine repeat computed tomographic scans in patients with traumatic brain injury. Am J Surg 2015; 210:1088-93; discussion 1093-4. [DOI: 10.1016/j.amjsurg.2015.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/24/2022]
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22
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Coagulation Parameters and Risk of Progressive Hemorrhagic Injury after Traumatic Brain Injury: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:261825. [PMID: 26457298 PMCID: PMC4589576 DOI: 10.1155/2015/261825] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/03/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022]
Abstract
Intracranial hemorrhage (ICH) after traumatic brain injury (TBI) commonly increases in size and coagulopathy has been implicated in such progression. Our aim is to perform a meta-analysis to assess their relationship. Cochrane library, PubMed, and EMBASE were searched for literatures. Pooled effect sizes and 95% confidential intervals (CIs) were calculated using random-effects model. We included six studies, involving 1700 participants with 540 progressive hemorrhagic injuries (PHIs). Our findings indicate that PT, D-dimer level, and INR value are positively associated with the risk of PHI. Higher level of PLT and Fg seemed to suggest a lower risk of PHI. Among these parameters, higher D-dimer level and INR value would possess more powerful strength in predicting PHI.
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23
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Kim WH, Lim DJ, Kim SH, Ha SK, Choi JI, Kim SD. Is Routine Repeated Head CT Necessary for All Pediatric Traumatic Brain Injury? J Korean Neurosurg Soc 2015; 58:125-30. [PMID: 26361528 PMCID: PMC4564744 DOI: 10.3340/jkns.2015.58.2.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 12/21/2022] Open
Abstract
Objective Repeated computed tomography (CT) follow up for traumatic brain injury (TBI) patients is often performed. But there is debate the indication for repeated CT scans, especially in pediatric patients. Purpose of our study is to find risk factors of progression on repeated CT and delayed surgical intervention based on the repeated head CT. Methods Between March, 2007 and December, 2013, 269 pediatric patients (age 0-18 years) had admitted to our hospital for head trauma. Patients were classified into 8 subgroups according to mechanisms of injury. Types, amount of hemorrhage and amount changes on repeated CT were analyzed as well as initial Glasgow Coma Scale (GCS) scores. Results Within our cohort of 269 patients, 174 patients received repeat CT. There were progression in the amount of hemorrhage in 48 (27.6%) patients. Among various hemorrhage types, epidural hemorrhage (EDH) more than 10 cc measured in initial CT was found to be at risk of delayed surgical intervention significantly after routine repeated CT with or without neurological deterioration than other types of hemorrhage. Based on initial GCS, severe head trauma group (GCS 3-8) was at risk of delayed surgical intervention after routine repeated CT without change of clinical neurologic status. Conclusion We suggest that the patients with EDH more than 10 cc or GCS below 9 should receive repeated head CT even though absence of significant clinical deterioration.
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Affiliation(s)
- Won-Hyung Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dong-Jun Lim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sang-Dae Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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24
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Cepeda S, Gómez PA, Castaño-Leon AM, Martínez-Pérez R, Munarriz PM, Lagares A. Traumatic Intracerebral Hemorrhage: Risk Factors Associated with Progression. J Neurotrauma 2015; 32:1246-53. [PMID: 25752340 DOI: 10.1089/neu.2014.3808] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The increase in the volume of a traumatic intracerebral hemorrhage (TICH) is a widely studied phenomenon that has a direct impact on the prognosis of patients. The objective of this study was to identify the risk factors associated with the progression of TICH. We retrospectively analyzed the records of 1970 adult patients >15 years of age who were consecutively admitted after sustaining a closed severe traumatic brain injury (TBI) between January 1987 and November 2013 at a single center. Beginning in 2007, patients with moderate TBIs were also included. A total of 782 patients exhibited one or more TICH on the initial CT scan, and met the selection criteria. The main outcome variable was the presence or absence of progression of the TICH. Univariate and multivariate statistical analyses were performed. Factors independently associated with the growth of TICH obtained through logistic regression included the following: an initial volume <5 cc (odds ratio [OR] 2.42, p<0.001), cisternal compression (OR 1.95, p<0.001), decompressive craniectomy (OR 2.18, p<0.001), age (mean 37.67 vs. 42.95 years; OR 1.01, p<0.001), falls as mechanism of trauma (OR 1.72, p=0.001), multiple TICHs (OR 1.56, p=0.007), and hypoxia (OR 1.56, p=0.02). TICH progression occurred with a frequency of 63% in our study. We showed that there was a correlation between TICH growth and some variables, such as multiple TICHs, a lower initial volume, acute subdural hematoma, cisternal compression, older patient age, hypoxia, falls, and decompressive craniectomy.
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Affiliation(s)
- Santiago Cepeda
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Ana María Castaño-Leon
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Rafael Martínez-Pérez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
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Kim SC, Song KJ, Shin SD, Lee SC, Park JO, Holmes JF. Preventable deaths in patients with traumatic brain injury. Clin Exp Emerg Med 2015; 2:51-58. [PMID: 27752573 PMCID: PMC5052850 DOI: 10.15441/ceem.14.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/25/2014] [Accepted: 01/08/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the rate of and etiology for preventable deaths in patients with traumatic brain injuries (TBIs). METHODS We conducted a retrospective, multicenter review of patients with TBIs who died within 7 days of their traumatic event from June 2008 to May 2009. Three board certified emergency physicians independently reviewed every case using a structured survey format. Cases were considered preventable deaths only if all physicians independently agreed the death was preventable. Management errors contributing to the preventable death were determined. RESULTS Forty-one patients who died from TBI were eligible. Preventable deaths were identified in nine (22%; 95% confidence interval [CI], 11 to 28) cases. Fifty-six management errors were identified including 36 (64%; 95% CI, 50 to 77) in the emergency department and 13 (23%; 95% CI, 13 to 36) in the prehospital phase. Thirty (54%; 95% CI, 40 to 67) management errors were process-related, and 26 (46%; 95% CI, 33 to 60) were structure-related. CONCLUSION An important and measurable rate of preventable mortality occurs in the initial care of TBI patients. Errors were common and most occurred in the emergency department. In addition, errors were common in the prehospital phase but did not always lead to mortality. When analyzed by type of problem, both process-related and structure-related errors occurred in similar proportions.
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Affiliation(s)
- Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Chul Lee
- Department of Emergency Medicine, Dongkuk University College of Medicine, Ilsan, Korea
| | - Ju Ok Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - James F. Holmes
- Department of Emergency Medicine, UC Davis Medical Center (JFH), Davis, CA, USA
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Abstract
Coagulopathy is often observed after traumatic brain injury (TBI), but the pathogenic mechanisms of this phenomenon remain elusive. Brain injury is the leading cause of trauma deaths, and the development of coagulopathy after TBI is associated with increased morbidity and mortality in these patients. The coagulopathy after TBI comprises a hypocoagulable and a hypercoagulable state with hemorrhagic and thrombotic phenotypes that are both associated with worse outcome. Some theories of its pathogenesis include massive release of tissue factor, altered protein C homeostasis, microparticle upregulation, and platelet hyperactivity. This article aims to examine the coagulopathy associated with blunt head injury, to review its effect on progression of hemorrhagic injury, and to discuss the possible relevant pathophysiological mechanisms.
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Affiliation(s)
- Monisha A Kumar
- Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, 3 West Gates Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA,
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Joseph B, Aziz H, Pandit V, Kulvatunyou N, Hashmi A, Tang A, Sadoun M, O'Keeffe T, Vercruysse G, Green DJ, Friese RS, Rhee P. A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. J Am Coll Surg 2014; 219:45-51. [PMID: 24745622 DOI: 10.1016/j.jamcollsurg.2013.12.062] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 12/12/2013] [Accepted: 12/17/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND A definitive consensus on the standardization of practice of a routine repeat head CT (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking. We hypothesized that in examinable patients without neurologic deterioration, RHCT scan does not lead to neurosurgical intervention (craniotomy/craniectomy). STUDY DESIGN This was a 3-year prospective cohort analysis of patients aged 18 years and older, without antiplatelet or anticoagulation therapy, presenting to our level 1 trauma center with intracranial hemorrhage on initial head CT and a follow-up RHCT. Neurosurgical intervention was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurologic deficits, and/or pupillary changes. RESULTS A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216 of 1,099), with subsequent neurosurgical intervention in 4 patients. Four patients had an abnormal neurologic examination, with a Glasgow Coma Scale (GCS) of ≤8 requiring intubation. Thirty patients had an RHCT secondary to neurologic deterioration; 53% (16 of 30) had progression on RHCT, of which 75% (12 of 16) required neurosurgical intervention. There was an association between deterioration in neurologic examination and need for neurosurgical intervention (odds ratio 3.98; 95% CI 1.7 to 9.1). The negative predictive value of a deteriorating neurologic examination in predicting the need for neurosurgical intervention was 100% in patients with GCS > 8. CONCLUSIONS Routine repeat head CT scan is not warranted in patients with normal neurologic examination. Routine repeat head CT scan does not supplement the need for neurologic examination for determining management in patients with traumatic brain injury.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
| | - Hassan Aziz
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Viraj Pandit
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Ammar Hashmi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Moutamn Sadoun
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Gary Vercruysse
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Donald J Green
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Randall S Friese
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
| | - Peter Rhee
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ
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Routine follow-up cranial computed tomography for deeply sedated, intubated, and ventilated multiple trauma patients with suspected severe head injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:361949. [PMID: 24563862 PMCID: PMC3915917 DOI: 10.1155/2014/361949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022]
Abstract
Background. Missed or delayed detection of progressive neuronal damage after traumatic brain injury (TBI) may have negative impact on the outcome. We investigated whether routine follow-up CT is beneficial in sedated and mechanically ventilated trauma patients.
Methods. The study design is a retrospective chart review. A routine follow-up cCT was performed 6 hours after the admission scan. We defined 2 groups of patients, group I: patients with equal or recurrent pathologies and group II: patients with new findings or progression of known pathologies.
Results. A progression of intracranial injury was found in 63 patients (42%) and 18 patients (12%) had new findings in cCT 2 (group II).
In group II a change in therapy was found in 44 out of 81 patients (54%). 55 patients with progression or new findings on the second cCT had no clinical signs of neurological deterioration. Of those 24 patients (44%) had therapeutic consequences due to the results of the follow-up cCT. Conclusion. We found new diagnosis or progression of intracranial pathology in 54% of the patients. In 54% of patients with new findings and progression of pathology, therapy was changed due to the results of follow-up cCT. In trauma patients who are sedated and ventilated for different reasons a routine follow-up CT is beneficial.
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Iaccarino C, Schiavi P, Picetti E, Goldoni M, Cerasti D, Caspani M, Servadei F. Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg 2014; 120:908-18. [PMID: 24506250 DOI: 10.3171/2013.12.jns131090] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traumatic parenchymal mass lesions are common sequelae of traumatic brain injuries (TBIs). They occur in up to 8.2% of all TBI cases and 13%-35% of severe TBI cases, and they account for up to 20% of surgical intracranial lesions. Controversy exists concerning the association between radiological and clinical evolution of brain contusions. The aim of this study was to identify predictors of unfavorable outcome, analyze the evolution of brain contusions, and evaluate specific indications for surgery. METHODS In a retrospective, multicenter study, patients with brain contusions were identified in separate patient cohorts from 11 hospitals over a 4-year period (2008-2011). Data on clinical parameters and course of the contusion were collected. Radiological parameters were registered by using CT images taken at the time of hospital admission and at subsequent follow-up times. Patients who underwent surgical procedures were identified. Outcomes were evaluated 6 months after trauma by using the Glasgow Outcome Scale-Extended. RESULTS Multivariate analysis revealed the following reliable predictors of unfavorable outcome: 1) increased patient age, 2) lower Glasgow Coma Scale score at first evaluation, 3) clinical deterioration in the first hours after trauma, and 4) onset or increase of midline shift on follow-up CT images. Further multivariate analysis identified the following as statistically significant predictors of clinical deterioration during the first hours after trauma: 1) onset of or increase in midline shift on follow-up CT images (p < 0.001) and 2) increased effacement of basal cisterns on follow-up CT images (p < 0.001). CONCLUSIONS In TBI patients with cerebral contusion, the onset of clinical deterioration is predictably associated with the onset or increase of midline shift and worsened status of basal cisterns but not with hematoma or edema volume increase. A combination of clinical deterioration and increased midline shift/basal cistern compression is the most reasonable indicator for surgery.
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Affiliation(s)
- Corrado Iaccarino
- Arcispedale Santa Maria Nuova-Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia; and Neurosurgery-Neurotraumatology Unit
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Neurologic outcome of minimal head injury patients managed with or without a routine repeat head computed tomography. J Trauma Acute Care Surg 2013; 75:273-8. [PMID: 23702628 DOI: 10.1097/ta.0b013e3182905eb4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies proposed that routine repeat head computed tomography (RHCT) is of little value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). As of 2003, routine RHCT in these MHI patients was ordered at the discretion of the attending physician. The goal of this study was to compare the neurologic outcomes of MHI patients with an intracranial bleed and a normal NE who were managed with or without a routine RHCT. METHODS A retrospective chart review of adult patients with MHI presenting to a Level I trauma center from August 2003 to December 2008 was performed. Demographics, injury severity, and HCT findings were collected for patients managed with or without a routine RHCT. Outcome measures included delayed neurologic deterioration, neurosurgical interventions, Glasgow Outcome Scale, and hospital length of stay (LOS). RESULTS A total of 321 MHI patients with an intracranial bleed had a normal NE 24 hours after presentation. There were no significant differences in demographics, arrival Glasgow Coma Scale score, or injury severity between the 142 (44%) patients managed with RHCT and the 179 (56%) managed without RHCT. No patient had a neurologic deterioration or required a neurosurgical intervention, regardless of initial management. There was no significant difference in the neurologic outcomes, mortality, or discharge dispositions between both groups. Patients managed without an RHCT had significantly shorter LOS (2.2 ± 2.3 days vs. 4.3 ± 6.0 days; p < 0.001) compared with those with RHCT. CONCLUSION Our study is the first to compare early neurologic outcomes of MHI patients with or without a routine RHCT. Patients managed without an RHCT had similar neurologic outcomes and shorter hospital LOS. Our data suggest that initial HCT followed by serial NEs (not routine RHCT) should be the standard of care in this patient population.
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Neuroprotection against Traumatic Brain Injury by Xenon, but Not Argon, Is Mediated by Inhibition at the N-Methyl-d-Aspartate Receptor Glycine Site. Anesthesiology 2013; 119:1137-48. [DOI: 10.1097/aln.0b013e3182a2a265] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background:
Xenon, the inert anesthetic gas, is neuroprotective in models of brain injury. The authors investigate the neuroprotective mechanisms of the inert gases such as xenon, argon, krypton, neon, and helium in an in vitro model of traumatic brain injury.
Methods:
The authors use an in vitro model using mouse organotypic hippocampal brain slices, subjected to a focal mechanical trauma, with injury quantified by propidium iodide fluorescence. Patch clamp electrophysiology is used to investigate the effect of the inert gases on N-methyl-d-aspartate receptors and TREK-1 channels, two molecular targets likely to play a role in neuroprotection.
Results:
Xenon (50%) and, to a lesser extent, argon (50%) are neuroprotective against traumatic injury when applied after injury (xenon 43 ± 1% protection at 72 h after injury [N = 104]; argon 30 ± 6% protection [N = 44]; mean ± SEM). Helium, neon, and krypton are devoid of neuroprotective effect. Xenon (50%) prevents development of secondary injury up to 48 h after trauma. Argon (50%) attenuates secondary injury, but is less effective than xenon (xenon 50 ± 5% reduction in secondary injury at 72 h after injury [N = 104]; argon 34 ± 8% reduction [N = 44]; mean ± SEM). Glycine reverses the neuroprotective effect of xenon, but not argon, consistent with competitive inhibition at the N-methyl-d-aspartate receptor glycine site mediating xenon neuroprotection against traumatic brain injury. Xenon inhibits N-methyl-d-aspartate receptors and activates TREK-1 channels, whereas argon, krypton, neon, and helium have no effect on these ion channels.
Conclusions:
Xenon neuroprotection against traumatic brain injury can be reversed by increasing the glycine concentration, consistent with inhibition at the N-methyl-d-aspartate receptor glycine site playing a significant role in xenon neuroprotection. Argon and xenon do not act via the same mechanism.
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Kurland DB, Tosun C, Pampori A, Karimy JK, Caffes NM, Gerzanich V, Simard JM. Glibenclamide for the treatment of acute CNS injury. Pharmaceuticals (Basel) 2013; 6:1287-303. [PMID: 24275850 PMCID: PMC3817601 DOI: 10.3390/ph6101287] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 12/22/2022] Open
Abstract
First introduced into clinical practice in 1969, glibenclamide (US adopted name, glyburide) is known best for its use in the treatment of diabetes mellitus type 2, where it is used to promote the release of insulin by blocking pancreatic KATP [sulfonylurea receptor 1 (Sur1)-Kir6.2] channels. During the last decade, glibenclamide has received renewed attention due to its pleiotropic protective effects in acute CNS injury. Acting via inhibition of the recently characterized Sur1-Trpm4 channel (formerly, the Sur1-regulated NCCa-ATP channel) and, in some cases, via brain KATP channels, glibenclamide has been shown to be beneficial in several clinically relevant rodent models of ischemic and hemorrhagic stroke, traumatic brain injury, spinal cord injury, neonatal encephalopathy of prematurity, and metastatic brain tumor. Glibenclamide acts on microvessels to reduce edema formation and secondary hemorrhage, it inhibits necrotic cell death, it exerts potent anti-inflammatory effects and it promotes neurogenesis—all via inhibition of Sur1. Two clinical trials, one in TBI and one in stroke, currently are underway. These recent findings, which implicate Sur1 in a number of acute pathological conditions involving the CNS, present new opportunities to use glibenclamide, a well-known, safe pharmaceutical agent, for medical conditions that heretofore had few or no treatment options.
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Affiliation(s)
- David B. Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Adam Pampori
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Jason K. Karimy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Nicholas M. Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-410-328-0850; Fax: +1-410-328-0124
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Microstructural basis of contusion expansion in traumatic brain injury: insights from diffusion tensor imaging. J Cereb Blood Flow Metab 2013; 33:855-62. [PMID: 23423189 PMCID: PMC3677102 DOI: 10.1038/jcbfm.2013.11] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Traumatic brain injury (TBI) is often exacerbated by events that lead to secondary brain injury, and represent potentially modifiable causes of mortality and morbidity. Diffusion tensor imaging was used to characterize tissue at-risk in a group of 35 patients scanned at a median of 50 hours after injury. Injury progression was assessed in a subset of 16 patients with two scans. All contusions within the first few days of injury showed a core of restricted diffusion, surrounded by an area of raised apparent diffusion coefficient (ADC). In addition to these two well-defined regions, a thinner rim of reduced ADC was observed surrounding the region of increased ADC in 91% of patients scanned within the first 3 days after injury. In patients who underwent serial imaging, the rim of ADC hypointensity was subsumed into the high ADC region as the contusion enlarged. Overall contusion enlargement tended to be more frequent with early lesions, but its extent was unrelated to the time of initial imaging, initial contusion size, or the presence of hemostatic abnormalities. This rim of hypointensity may characterize a region of microvascular failure resulting in cytotoxic edema, and may represent a 'traumatic penumbra' which may be rescued by effective therapy.
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Wen L, Li QC, Wang SC, Lin Y, Li G, Gong JB, Wang F, Su L, Zhan RY, Yang XF. Contralateral haematoma secondary to decompressive craniectomy performed for severe head trauma: A descriptive study of 15 cases. Brain Inj 2013; 27:286-92. [DOI: 10.3109/02699052.2012.743180] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shen J, Pan JW, Fan ZX, Zhou YQ, Chen Z, Zhan RY. Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review. Acta Neurochir (Wien) 2013; 155:335-41. [PMID: 23238942 DOI: 10.1007/s00701-012-1569-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 11/16/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The occurrence of a contralateral acute epidural hematoma (AEDH) following removal of an acute subdural hematoma (ASDH) is a rare but nearly devastating postoperative complication. Here, we describe a series of five patients with contralateral AEDH and provide a review of the literature to elucidate the characteristics and improve management of these patients. METHODS A total of 386 patients underwent ASDH evacuations in our hospital between August 2008 and July 2011. Five of these patients (1.3 %) developed AEDH that required surgery. Thirty-two additional patients were identified by a search of the PubMed database. Clinical features, surgical treatment, and outcomes (scored by Glasgow outcome scale, GOS) of the collective 37 AEDH cases were analyzed retrospectively. RESULTS Contralateral AEDH after ASDH evacuation occurred in 27 males (73 %) and 10 females (27 %) (mean age: 35.9 ± 14.2 years). Twenty-six patients (70 %) had unfavorable outcomes (GOS 1-3), and 11 patients (30 %) had favorable outcomes (GOS 4-5). Contralateral skull fractures and intraoperative acute brain swelling occurred in 30 (81 %) and 28 (76 %) patients, respectively. The preoperative Glasgow coma score (GCS) was significantly associated with outcome (p < 0.05). CONCLUSIONS Lower preoperative GCS score is an independent risk factor for prognosis of contralateral AEDH after ASDH. Postoperative management should include assessment of AEDH in patients treated for contralateral skull fractures and who experienced intraoperative acute brain swelling. We recommend early decompression with a burr-hole craniotomy, immediately followed by a decompressive craniectomy. This strategy provides gradual decompression, while advancing the initial surgical time and preventing the suddle decreased tamponade effect. As such, it may help decrease the risk of contralateral AEDH associated with decompression.
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Flaherty BF, Loya J, Alexander MD, Pandit R, Ha BY, Torres RA, Schroeder AR. Utility of clinical and radiographic findings in the management of traumatic epidural hematoma. Pediatr Neurosurg 2013; 49:208-14. [PMID: 25096980 DOI: 10.1159/000363143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 04/20/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups. METHODS We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center. RESULTS Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation. CONCLUSIONS Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.
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Takeuchi S, Takasato Y, Suzuki G, Maeda T, Masaoka H, Hayakawa T, Otani N, Yatsushige H, Shigeta K, Momose T. Computed tomography after decompressive craniectomy for head injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 118:235-237. [PMID: 23564139 DOI: 10.1007/978-3-7091-1434-6_44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
New findings (NF) on postoperative CTs are -occasionally found in patients who undergo surgery for traumatic brain injury (TBI). We conducted a retrospective -registry-based review of the care of 102 patients who underwent decompressive craniectomy (DC) for TBI to investigate the prognostic factors of new findings on CT early after -surgery. Of the 102 patients, the mean age was 50 years and 69.6 % were male. The overall survival was 72.5 %. The primary indication for DC included subdural hematoma in 72 (70.6 %), epidural hematoma in 17 (16.7 %), and intraparenchymal contusion in 13 (12.7 %). New findings on postoperative CTs were observed in 26 patients (25.5 %). The univariate analysis showed that a GCS score ≤8 (P = 0.012) and the absence of a basal cistern (P = 0.012) were significantly associated with NF on postoperative CT. The logistic regression analysis demonstrated that the GCS score ≤8 (P = 0.041; OR, 3.0; 95 % CI, 1.048-8.517) was the only significant factor. TBI patients with a low GCS score who underwent DC should undergo additional CT evaluations immediately after surgery.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan.
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Sturiale CL, De Bonis P, Rigante L, Calandrelli R, D'Arrigo S, Pompucci A, Mangiola A, D'Apolito G, Colosimo C, Anile C. Do Traumatic Brain Contusions Increase in Size after Decompressive Craniectomy? J Neurotrauma 2012; 29:2723-6. [DOI: 10.1089/neu.2012.2556] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
| | - Pasquale De Bonis
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | - Luigi Rigante
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | | | - Sonia D'Arrigo
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Angelo Pompucci
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | - Annunziato Mangiola
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | - Gabriella D'Apolito
- Department of Bio Imaging, Catholic University School of Medicine, Rome, Italy
| | - Cesare Colosimo
- Department of Bio Imaging, Catholic University School of Medicine, Rome, Italy
| | - Carmelo Anile
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
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40
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Spontaneous disappearance of an acute epidural hematoma with emergence of a contralateral subdural hematoma after traumatic brain injury. Tzu Chi Med J 2012. [DOI: 10.1016/j.tcmj.2012.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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41
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Mezue WC, Ndubuisi CA, Chikani MC, Achebe DS, Ohaegbulam SC. Traumatic extradural hematoma in enugu, Nigeria. Niger J Surg 2012; 18:80-4. [PMID: 24027399 PMCID: PMC3762009 DOI: 10.4103/1117-6806.103111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim: Acute traumatic extradural hematoma (EDH) is life threatening and requires prompt intervention. This is a study of incidence and outcome of consecutive patients with EDH managed in Enugu, Nigeria against a background of delayed referral. Materials and Methods: We retrospectively examined all consecutive trauma cases managed between 2003 and 2009 and analyzed patients with acute traumatic extradural hematoma in isolation or in combination with other intra cranial lesions. Age, sex, cause of injury, time of presentation, Glasgow Coma Score (GCS), pupil reactivity, treatment and clinical outcomes were determined. Results: Of 817 head injuries, 69 (8.4%) had EDH, a mean of 9.9 patients per year. Males were 57 (83%) and females 12 (17%). Peak age incidences were the second and third decades of life, with a mean age of 30.2 years. Causes were road traffic accidents (57%), assault (22%) and falls (9%). Twenty-six (38%) patients presented within 24 h of injury and only one patient presented within 4 h. The average time lag before presentation was 94.2 h. At presentation 39% had GCS of 13-15, 27% had 9-12 and 34% had 3-8. The most common location of hematoma was temporal (27.5%). Forty (59%) patients had surgery while 14 (20%) were managed conservatively. Ten patients (14.5%) died and of these 70% had GCS <8 and 60% had a seizure. Conclusion: We conclude that early appropriate treatment of EDH results in good high quality survival (Glasgow Outcome Score 4 or 5). Low GCS should not be an absolute contraindication for surgery. Seizure prophylaxis should be considered in patients with GCS <8.
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Affiliation(s)
- Wilfred C Mezue
- Department of Surgery, Neurosurgery Unit, University of Nigeria Teaching Hospital, Enugu, Nigeria
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42
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Doddamani RS, Gupta SK, Singla N, Mohindra S, Singh P. Role of repeat CT scans in the management of traumatic brain injury. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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43
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Tong WS, Zheng P, Zeng JS, Guo YJ, Yang WJ, Li GY, He B, Yu H, Li YS, Tang XF, Lin TS, Xu JF. Prognosis analysis and risk factors related to progressive intracranial haemorrhage in patients with acute traumatic brain injury. Brain Inj 2012; 26:1136-42. [DOI: 10.3109/02699052.2012.666437] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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SHIGEMORI M, ABE T, ARUGA T, OGAWA T, OKUDERA H, ONO J, ONUMA T, KATAYAMA Y, KAWAI N, KAWAMATA T, KOHMURA E, SAKAKI T, SAKAMOTO T, SASAKI T, SATO A, SHIOGAI T, SHIMA K, SUGIURA K, TAKASATO Y, TOKUTOMI T, TOMITA H, TOYODA I, NAGAO S, NAKAMURA H, PARK YS, MATSUMAE M, MIKI T, MIYAKE Y, MURAI H, MURAKAMI S, YAMAURA A, YAMAKI T, YAMADA K, YOSHIMINE T. Guidelines for the Management of Severe Head Injury, 2nd Edition Guidelines from the Guidelines Committee on the Management of Severe Head Injury, the Japan Society of Neurotraumatology. Neurol Med Chir (Tokyo) 2012; 52:1-30. [PMID: 22278024 DOI: 10.2176/nmc.52.1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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45
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Kurland D, Hong C, Aarabi B, Gerzanich V, Simard JM. Hemorrhagic progression of a contusion after traumatic brain injury: a review. J Neurotrauma 2011; 29:19-31. [PMID: 21988198 DOI: 10.1089/neu.2011.2122] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.
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Affiliation(s)
- David Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA
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46
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Do Routinely Repeated Computed Tomography Scans in Traumatic Brain Injury Influence Management? Ann Surg 2011; 254:1028-31. [DOI: 10.1097/sla.0b013e318219727f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Schnellinger MG, Reid S, Louie J. Are serial brain imaging scans required for children who have suffered acute intracranial injury secondary to blunt head trauma? Clin Pediatr (Phila) 2010; 49:569-73. [PMID: 20118091 DOI: 10.1177/0009922809352375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In most instances, infants and children with moderate to severe head trauma undergo a head computed tomography (CT) scan as part of their initial evaluation. Several authors have advocated a routine second head CT after traumatic brain injury (TBI) to identify progressive lesions that may require surgical intervention. However, recent studies have challenged the need for a routine second brain imaging study after TBI. In addition, recent reports have raised concerns about the potential for malignancy following CT scanning, especially in pediatric patients. The authors performed a retrospective case series of all patients, aged 0 to 21 years, who presented to their 2 emergency departments (EDs) and received an International Classification of Disease-9th revision code related to intracranial injury. Out of 47 children, 5 (11%) underwent neurosurgical intervention following their second imaging study, and 1 of these interventions was unplanned after the first study. Compared with children who did not require an intervention following their second scan, children who received an intervention were more likely to have been subjected to nonaccidental trauma and to have presented to the ED more than 4 hours after the injury. Most children with intracranial injury following blunt trauma who did not require immediate neurosurgical intervention but instead underwent a follow-up brain imaging study did not require subsequent unplanned neurosurgical intervention. Serial brain imaging may not be required for all children with intracranial injury.
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Thomas BW, Mejia VA, Maxwell RA, Dart BW, Smith PW, Gallagher MR, Claar SC, Greer SH, Barker DE. Scheduled Repeat CT Scanning for Traumatic Brain Injury Remains Important in Assessing Head Injury Progression. J Am Coll Surg 2010; 210:824-30, 831-2. [DOI: 10.1016/j.jamcollsurg.2009.12.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 12/30/2009] [Indexed: 11/27/2022]
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49
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Tian HL, Chen H, Wu BS, Cao HL, Xu T, Hu J, Wang G, Gao WW, Lin ZK, Chen SW. D-dimer as a predictor of progressive hemorrhagic injury in patients with traumatic brain injury: analysis of 194 cases. Neurosurg Rev 2010; 33:359-65; discussion 365-6. [PMID: 20349100 DOI: 10.1007/s10143-010-0251-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 10/08/2009] [Accepted: 01/02/2010] [Indexed: 10/19/2022]
Abstract
This study sought to describe and evaluate any relationship between D-dimer values and progressive hemorrhagic injury (PHI) after traumatic brain injury (TBI). In patients with TBI, plasma D-dimer was measured while a computed tomography (CT) scan was conducted as soon as the patient was admitted to the emergency department. A series of other clinical and laboratory parameters were also measured and recorded. A logistic multiple regression analysis was used to identify risk factors for PHI. A cohort of 194 patients with TBI was evaluated in this clinical study. Eighty-one (41.8%) patients suffered PHI as determined by a second CT scan. The plasma D-dimer level was higher in patients who demonstrated PHI compared with those who did not (P < 0.001. Using a receiver-operator characteristic curve to predict the possibility by measuring the D-dimer level, a value of 5.00 mg/L was considered the cutoff point, with a sensitivity of 72.8% and a specificity of 78.8%. Eight-four patients had D-dimer levels higher than the cut point value (5.0 mg/L); PHI was seen in 71.4% of these patients and in 19.1% of the other patients (P < 0.01). Factors with P < 0.2 on bivariate analysis were included in a stepwise logistic regression analysis to identify independent risk factors for TBI coagulopathy. Logistic regression analysis showed that the D-dimer value was a predictor of PHI, and the odds ratio (OR) was 1.341 with per milligram per liter (P = 0.020). The stepwise logistic regression also identified that time from injury to the first CT shorter than 2 h (OR = 2.118, P = 0.047), PLT counts lesser than 100 x 109/L (OR = 7.853, P = 0.018), and Fg lower than 2.0 g/L (OR = 3.001, P = 0.012) were risk factors for the development of PHI. When D-dimer values were dichotomized at 5 mg/L, time from injury to the first CT scan was no longer a risk factor statistically while the OR value of D-dimer to the occurrence of PHI elevated to 11.850(P < 0.001). The level of plasma D-dimer after TBI can be a useful prognostic factor for PHI and should be considered in the clinical management of patients in combination with neuroimaging and other data.
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Affiliation(s)
- Heng-Li Tian
- Department of Neurosurgery, Shanghai 6th People Hospital, Shanghai Jiaotong University, No. 600, Yishan Road, Xuhui District, Shanghai, China 200233
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50
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Simard JM, Kilbourne M, Tsymbalyuk O, Tosun C, Caridi J, Ivanova S, Keledjian K, Bochicchio G, Gerzanich V. Key role of sulfonylurea receptor 1 in progressive secondary hemorrhage after brain contusion. J Neurotrauma 2010; 26:2257-67. [PMID: 19604096 DOI: 10.1089/neu.2009.1021] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An important but poorly understood feature of traumatic brain injury (TBI) is the clinically serious problem of spatiotemporal progression ("blossoming") of a hemorrhagic contusion, a phenomenon we term progressive secondary hemorrhage (PSH). Molecular mechanisms of PSH are unknown and efforts to reduce it by promoting coagulation have met with equivocal results. We hypothesized that PSH might be due to upregulation and activation of sulfonylurea receptor 1 (SUR1)-regulated NC(Ca-ATP) channels in capillary endothelial cells, predisposing to oncotic death of endothelial cells and catastrophic failure of capillary integrity. Anesthetized adult male rats underwent left parietal craniectomy for induction of a focal cortical contusion. The regulatory subunit of the channel, SUR1, was prominently upregulated in capillaries of penumbral tissues surrounding the contusion. In untreated rats, PSH was characterized by progressive enlargement of the contusion deep into the site of cortical impact, including corpus callosum, hippocampus, and thalamus, by progressive accumulation of extravasated blood, with a doubling of the volume during the first 12 h after injury, and by capillary fragmentation in penumbral tissues. Block of SUR1 using low-dose (non-hypoglycemogenic) glibenclamide largely eliminated PSH and capillary fragmentation, and was associated with a significant reduction in the size of the necrotic lesion and in preservation of neurobehavioral function. Antisense oligodeoxynucleotide against SUR1, administered after injury, reduced both SUR1 expression and PSH, consistent with a requirement for transcriptional upregulation of SUR1. Our findings provide novel insights into molecular mechanisms responsible for PSH associated with hemorrhagic contusions, and point to SUR1 as a potential therapeutic target in TBI.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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