1
|
Pisică D, Volovici V, Yue JK, van Essen TA, den Boogert HF, Vande Vyvere T, Haitsma I, Nieboer D, Markowitz AJ, Yuh EL, Steyerberg EW, Peul WC, Dirven CMF, Menon DK, Manley GT, Maas AIR, Lingsma HF. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery 2024:00006123-990000000-01172. [PMID: 38771081 DOI: 10.1227/neu.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery. METHODS This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling. RESULTS In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm3 below 30 cm3), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm3), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died. CONCLUSION Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.
Collapse
Affiliation(s)
- Dana Pisică
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John K Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hugo F den Boogert
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amy J Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, the Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
2
|
Hwang IJ, Jeong TS, Kim WS, Kim JO, Jang MJ. Epidemiology and Outcomes of Severe Traumatic Brain Injury: Regional Trauma Center in Incheon, Korea, 2018-2022. Korean J Neurotrauma 2024; 20:17-26. [PMID: 38576499 PMCID: PMC10990697 DOI: 10.13004/kjnt.2024.20.e9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Objective This study aims to explore the epidemiology and outcomes of severe traumatic brain injury (TBI) in Incheon, focusing on regional characteristics using data from a local trauma center. Methods From January 2018 to December 2022, 559 patients with severe TBI were studied. We analyzed factors related to demography, prehospitalization, surgery, complications, and clinical outcomes, including intensive care unit stay, ventilator use, hospital stay, mortality, and Glasgow outcome scale (GOS) scores at discharge and after 6 months. Results In this study, most severe TBI patients were in the 60-79 age range, constituting 37.4% of cases. Most patients (74.1%) used public emergency medical services for transportation, and 75.3% arrived directly at the hospital, a significantly higher proportion compared to transferred patients. Timewise, 40.0% reached the hospital within an hour of injury. Complication rates stood at 16.1%, with pneumonia being the most common. The mortality rate was 44.0%, and at discharge, 81.2% of patients had unfavorable outcomes (GOS 1-3), reducing to 70.1% at 6 months. Conclusion As a pioneering study at Incheon's trauma center, this research provides insights into severe TBI outcomes, enhancing understanding by contrasting local and national data.
Collapse
Affiliation(s)
- Ik Jun Hwang
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae Seok Jeong
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Woo Seok Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jung Ook Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Myung Jin Jang
- Regional Trauma Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| |
Collapse
|
3
|
Muacevic A, Adler JR, Dighe O, Iratwar S, Bisen G. Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines. Cureus 2023; 15:e33790. [PMID: 36819419 PMCID: PMC9927871 DOI: 10.7759/cureus.33790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.
Collapse
|
4
|
Choi DH, Jeong TS, Kim WK. Clinical Outcome of Patients Diagnosed Traumatic Intracranial Epidural Hematoma With Severe Brain Injury (Glasgow Coma Scale ≤8) Who Undergo Surgery: A Report From the Korean Neuro-Trauma Data Bank System. Korean J Neurotrauma 2022; 18:153-160. [PMID: 36381437 PMCID: PMC9634314 DOI: 10.13004/kjnt.2022.18.e62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcomes and prognostic factors in surgically treated patients with severe brain injury (Glasgow Coma Scale [GCS] score ≤8) diagnosed with traumatic epidural hematoma (EDH). METHODS From January 2018 to June 2021, 1,122 patients with an initial GCS score ≤8 were retrospectively enrolled in the Korean Neuro-Trauma Data Bank System. Clinical data of 79 surgically treated patients with EDH were compared between the unfavorable (scores of 1-4 on the Glasgow Outcome Scale-Extended [GOSE]) and favorable (score of 5-8 on the GOSE) outcome groups. RESULTS The overall mortality rate was 13.9%, and 60.8% of the patients had good outcomes at six months post-trauma. In the univariate analysis, increasing age (p=0.010), lower initial GCS score (p=0.001), higher Rotterdam computed tomography (CT) score (p=0.012), craniotomy rather than craniectomy (p=0.032), larger EDH volume (p=0.007), and loss of pupillary reactivity (unilateral unreactive pupil, p=0.026; bilateral unreactive pupils, p<0.001), were significantly correlated with unfavorable outcomes. Of these factors, increasing age (p=0.011) and bilateral unreactive pupils (p=0.002) were the most significant risk factors in the multivariate logistic regression analysis. The interval from admission to the brain CT scan was not correlated with the outcome; however, it was significantly longer in the unfavorable outcome group. CONCLUSION Despite severe brain injury, more than half of the patients with EDH had favorable outcomes after surgical treatment. Our findings suggest that prompt diagnosis and surgical treatment should be considered for such cases.
Collapse
Affiliation(s)
- Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae Seok Jeong
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Seoul, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - KNTDB Investigators
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Seoul, Korea
| |
Collapse
|
5
|
The unmet global burden of cranial epidural hematomas: A systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 219:107313. [PMID: 35688003 DOI: 10.1016/j.clineuro.2022.107313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Approximately 69 million people suffer from traumatic brain injury (TBI) annually. Patients with isolated epidural hematomas (EDH) with access to timely surgical intervention often sustain favorable outcomes. Efforts to ensure safe, timely, and affordable access to EDH treatment may offer tremendous benefits. METHODS A comprehensive literature search was conducted. A random-effects model was used to pool the outcomes. Studies were further categorized into groups by World Bank Income classification: high-income countries (HICs) and low- and middle-income countries (LMICs). RESULTS Forty-nine studies were included, including 36 from HICs, 12 from LMICs, and 1 from HIC / LMIC. Incidence of EDH amongst TBI patients 8.2 % (95 % CI: 5.9,11.2), including 9.2 % (95 %CI 6.4,13.2) in HICs and 5.8 % (95 % CI: 3.1,10.7) in LMICs (p = 0.20). The overall percent male was 73.7 % and 47.4 % were caused by road traffic accidents. Operative rate was 76.0 % (95 %CI: 67.9,82.6), with a numerically lower rate of 74.2 % (95 %CI: 64.0,81.8) in HICs than in LMICs 82.9 % (95 %CI: 65.4,92.5) (p = 0.33). This decreased to 55.5 % after adjustment for small study effect. The non-operative mortality (5.3 %, 95 %CI: 2.2,12.3) was lower than the operative mortality (8.3 %, 95 %CI: 4.6,14.6), with slightly higher rates in HICs than LMICs. This relationship remained after adjustment for small study effect, with 9.3 % operative mortality compared to 6.9 % non-operative mortality. CONCLUSION With an overall EDH incidence of 8.2 % and an operative rate of 55.5 %, 3.1 million people worldwide require surgery for traumatic EDH every year, most of whom are in prime working age. Given the favorable prognosis with treatment, traumatic EDH is a strong investment for neurosurgical capacity building.
Collapse
|
6
|
Liu Z, Du S, Wu Y, Chen T, Luo X, Bi C, Lan S, Chen X, Liu J. Intracranial pressure after closure of dura predicts decompressive craniectomy in patients with head trauma. J Neurotrauma 2022; 39:1231-1239. [PMID: 35538792 DOI: 10.1089/neu.2021.0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study aimed to address the risk factors of second decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) who initially underwent mass lesion evacuation, but no primary DC. Patients were enrolled if they had a hospital visit to Xiangya Hospital, Central South University with acute closed TBI from January 1, 2017, to December 31, 2019, and had undergone craniotomic mass lesion evacuation. Socio-demographic information, computed tomography (CT) information, clinical profiles, and surgical information were obtained from an electronic database. Twenty-four patients who had undergone a second DC (SDC) and 39 patients who did not (NSO) were included in the analysis. The prevailing lesions differed between the groups (P = 0.010). The SDC group had more compressed/obliterated basal cisterns than the NSO group (P = 0.028). After closure of dura, the SDC group also had higher intracranial pressure (ICP) than the NSO group (10.9 mmHg vs. 6.5 mmHg, P = 0.005). Binary logistic regression indicated that ICP after dura closure was an independent predictor of second DC (OR = 1.317, P = 0.011). A model using ICP after dura closure alone had an area under the curve value of 0.757 in its receiver operating characteristic curve. An ICP above 10.5 mmHg after closure of dura for the prediction of second DC had a sensitivity of 56.3% and specificity of 92.6%.
Collapse
Affiliation(s)
- Ziyuan Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Shan Du
- Xiangya Hospital Central South University, 159374, Department of Gastroenterology, Changsha, China;
| | - Yun Wu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Tiange Chen
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Xiangying Luo
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Changlong Bi
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Song Lan
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Xin Chen
- Xiangya Hospital Central South University, 159374, Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
| | - Jinfang Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
| |
Collapse
|
7
|
Yang C, Hui J, Xie L, Feng J, Jiang J. Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH). BMJ Open 2022; 12:e051247. [PMID: 35264341 PMCID: PMC8915281 DOI: 10.1136/bmjopen-2021-051247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed. METHODS AND ANALYSIS This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury. ETHICS AND DISSEMINATION The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04229966.
Collapse
Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| |
Collapse
|
8
|
Yang C, Huang X, Feng J, Xie L, Hui J, Li W, Jiang J. Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial. Trials 2021; 22:421. [PMID: 34187537 PMCID: PMC8244162 DOI: 10.1186/s13063-021-05359-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy. Methods/design Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury. Discussion This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice. Trial registration ClinicalTrials.govNCT 04261673. Registered on 04 February 2020
Collapse
Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Xianjian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, 227 Chongqing South Road, Shanghai, People's Republic of China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Weiping Li
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China.
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China. .,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China.
| |
Collapse
|
9
|
Sobti S, Goyari M, Harpanahalli R, Gupta LN, Choudhary A, Taneja A. Clinico-radiological Correlation with Outcome in Traumatic Pediatric Extradural Hematoma: A Single Institutional Experience. J Pediatr Neurosci 2021; 16:113-118. [PMID: 35018178 PMCID: PMC8706599 DOI: 10.4103/jpn.jpn_61_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/29/2020] [Accepted: 08/27/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Head injury is one of the leading causes of mortality and morbidity in the developing as well as developed countries. Extradural hematoma is seen in 1-2% of cases of head injury patients. Extradural hematoma is infrequent in the pediatric age group (less than 18 years) as duramater is tightly adherent to the inner table of the skull and is present in about 1-3% of all pediatric head injuries. MATERIALS AND METHODS The study was a prospective study conducted in the Department of Neurosurgery at PGIMER, Dr. RML Hospital, New Delhi, over a period of 19 months with a follow-up of 6 months. In total, 38 patients were enrolled in the study. All traumatic extradural hematoma below 18 years of age of both sexes were included. Follow-up of all patients was done at 2 weeks, 1, 2, and 6 months. Noncontrast computed tomography (NCCT) head was done in all patients at the time of admission and whenever their neurological status deteriorated. Routine postoperative NCCT head was done. Outcome assessment was done by Glasgow outcome scale. RESULTS Of the 38 children, 21 were males and 17 were females. The maximum number of patients was between the ages of 1-5 years (55.26%). Fall from height was the most common cause. Loss of consciousness was the most common presenting symptom (78.94%). Thirty-three patients had GCS of 14-15 at the time of presentation. The parietal region was the most common location of EDH in our study (44.74%). Thirty-five patients had supratentorial and three patients had infratentorial EDH. Eighteen patients had associated brain injury, commonest being brain edema. Six patients were operated. There was no mortality in our study. Two patients had limb paresis. CONCLUSION Pediatric EDH is a rare entity but a potentially life-threatening condition. Prompt diagnosis and timely intervention decrease morbidity and mortality.
Collapse
Affiliation(s)
- Shivender Sobti
- Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana
| | | | | | | | - Ajay Choudhary
- Department of Neurosurgery, ABVIMS & Dr. RML Hospital, New Delhi
| | - Anil Taneja
- Department of Radiology, ABVIMS & Dr. RML Hospital, New Delhi
| |
Collapse
|
10
|
Rosyidi RM, Priyanto B, Al Fauzi A, Sutiono AB. Toward zero mortality in acute epidural hematoma: A review in 268 cases problems and challenges in the developing country. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2019. [DOI: 10.1016/j.inat.2019.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
11
|
Al-Mamoori M. Management of epidural hematoma in the pediatric age group. MEDICAL JOURNAL OF BABYLON 2019. [DOI: 10.4103/mjbl.mjbl_47_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
12
|
De Vloo P, Nijs S, Verelst S, van Loon J, Depreitere B. Prehospital and Intrahospital Temporal Intervals in Patients Requiring Emergent Trauma Craniotomy. A 6-Year Observational Study in a Level 1 Trauma Center. World Neurosurg 2018; 114:e546-e558. [PMID: 29548947 DOI: 10.1016/j.wneu.2018.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE According to level 2 evidence, earlier evacuation of acute subdural or epidural hematomas necessitating surgery is associated with better outcome. Hence, guidelines recommend performing these procedures immediately. Literature on the extent and causes of prehospital and intrahospital intervals in patients with trauma requiring emergent craniotomies is almost completely lacking. Studies delineating and refining the interval before thrombolytic agent administration in ischemic stroke have dramatically reduced the door-to-needle time. A similar exercise for trauma-to-decompression time might result in comparable reductions. We aim to map intervals in emergent trauma craniotomies in our level 1 trauma center, screen for associated factors, and propose possible ways to reduce these intervals. METHODS We analyzed patients who were primarily referred (1R; n = 45) and secondarily referred (after computed tomography imaging in a community hospital [2R; n = 22]) to our emergency department (ED) and underwent emergent trauma craniotomies between 2010 and 2016. RESULTS Median prehospital interval (between emergency call and arrival at the ED) was 42 minutes for 1R patients. Median intrahospital interval (between initial ED arrival and skin incision [SI]) was 140 minutes and 268 minutes for 1R and 2R patients, respectively. In 1R patients, ED-SI interval was positively correlated with Glasgow Coma Scale score (ρ=.49; P < 0.001), but not with age, time of ED arrival, or extended Glasgow Outcome Scale score at 6 months. Based on outlier analysis, we propose prehospital and intrahospital measures to improve performance. CONCLUSIONS This is the first report on emergency call-SI interval in emergent trauma craniotomy, with a median of 174 minutes and >297 minutes for 1R and 2R patients, respectively, in our center.
Collapse
Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | - Stefaan Nijs
- Department of Traumatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Sandra Verelst
- Department of Emergency Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| |
Collapse
|
13
|
Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
Collapse
Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | | | | | | | | | | | | | | |
Collapse
|
14
|
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
|
15
|
Khaled CN, Raihan MZ, Chowdhury FH, Ashadullah ATM, Sarkar MH, Hossain SS. Surgical management of traumatic extradural haematoma: Experiences with 610 patients and prospective analysis. INDIAN JOURNAL OF NEUROTRAUMA 2017. [DOI: 10.1016/s0973-0508(08)80004-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AbstractThis study was carried out to find out the age, sex, mode of injury, localization, clinical presentation, CT findings, operative measures and outcome of extradural haematoma in the patient population at Dhaka Medical College. 610 consecutive patients with cranial extradural haematoma who underwent surgery in department of Neurosurgery from 1st January 2006 to 6th October 2008 were included in this prospective study. Each of the patients were evaluated in term of age, sex, mode of injury, localization of haematoma, clinical presentation, CT findings, operative measures and outcome. Out of 610 cases 86.32 % were male and 13.78 % were female. The male and female ratio was 6.27: 1. Age ranged from 2.5 to 83 years. Commonest age group was 21 to 30 years. Commonest mode of injury was Road traffic Accident 53.45%, followed by Assaults. Most common clinical presentation was headache / Vomiting 63.61 %, followed by altered sensorium 60.66 %. In this present prospective study of 610 cases of EDH, temporo parietal site was involved in 33.45 % followed by frontal region in 23.28 %. Sixty five patients (10.66 %) died; 19 of these had associated brain injuries and 28 cases were deeply unconscious. Extradural haematoma is a neurosurgical emergency where early surgical intervention is associated with the best prognosis. Many factors affects the outcome of extradural haematoma surgery and the most important one is the duration of time between incident/accident and operation in neurosurgical operation theater; mortality can be close to 0% if this time interval can be minimized.
Collapse
|
16
|
Jussen D, Krenzlin H, Papaioannou C, Ens S, Kempski O, Alessandri B. Blood Aggravates Histological and Functional Damage after Acute Subdural Hematoma in Rats. J Neurotrauma 2017; 34:906-913. [DOI: 10.1089/neu.2016.4464] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Daniel Jussen
- Department Of Neurosurgery, HELIOS Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
- Institute for Neurosurgical Pathophysiology, University Medical Centre Mainz, Germany
| | - Harald Krenzlin
- Department Of Neurosurgery, HELIOS Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
- Institute for Neurosurgical Pathophysiology, University Medical Centre Mainz, Germany
| | | | - Swetlana Ens
- Institute for Neurosurgical Pathophysiology, University Medical Centre Mainz, Germany
| | - Oliver Kempski
- Institute for Neurosurgical Pathophysiology, University Medical Centre Mainz, Germany
| | - Beat Alessandri
- Institute for Neurosurgical Pathophysiology, University Medical Centre Mainz, Germany
| |
Collapse
|
17
|
Zangbar B, Serack B, Rhee P, Joseph B, Pandit V, Friese RS, Haider AA, Tang AL. Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study. Am Surg 2016. [DOI: 10.1177/000313481608201228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.
Collapse
Affiliation(s)
- Bardiya Zangbar
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bradley Serack
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S. Friese
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Ansab A. Haider
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew L. Tang
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| |
Collapse
|
18
|
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Imaging plays an important role in the evaluation, diagnosis, and triage of patients with TBI. Recent studies suggest that it also helps predict patient outcomes. TBI consists of multiple pathoanatomic entities. This article reviews the current state of TBI imaging including its indications, benefits and limitations of the modalities, imaging protocols, and imaging findings for each of these pathoanatomic entities. Also briefly surveyed are advanced imaging techniques, which include several promising areas of TBI research.
Collapse
Affiliation(s)
- Christopher A Mutch
- Department of Radiology, University of California, San Francisco, 505 Parnassus Avenue, M391, San Francisco, CA 94143, USA
| | - Jason F Talbott
- Department of Radiology, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
| | - Alisa Gean
- Department of Radiology, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| |
Collapse
|
19
|
Ganz JC, Thuomas KÅ, Vlajkovic S, Nilsson P, Bergström K, Pontén U, Zwetnow NN. Changes in Intracranial Morphology, Regional Cerebral Water Content and Vital Physiological Variables during Epidural Bleeding. Acta Radiol 2016. [DOI: 10.1177/028418519303400316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Epidural bleeding was produced in 8 anaesthetised and heparinised dogs by an artificial system. Changes in vital physiological variables were related to intracranial shifts and tissue water content assessed with MR imaging. Six animals survived while 2 succumbed. In the surviving animals intracranial shifts and compressions remained unchanged from an early stage. The cerebral perfusion pressure was reduced from between 80 and 110 mm Hg to between 40 and 60 mm Hg. Some increase in supratentorial white matter tissue water was observed. In the lethal experiments cerebral perfusion pressure fell to less than 40 mm Hg. Moreover, secondary delayed anatomical changes were seen including hydrocephalus. Increase in cerebral tissue water was more intense and widespread than in the survivors. These findings indicate that the outcome of epidural bleeding is related to cerebral perfusion pressure with secondary deterioration resulting from additional volume loading from increased tissue water and hydrocephalus.
Collapse
|
20
|
Potapov AA, Krylov VV, Gavrilov AG, Kravchuk AD, Likhterman LB, Petrikov SS, Talypov AE, Zakharova NE, Solodov AA. [Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 80:93-101. [PMID: 27070263 DOI: 10.17116/neiro201680293-101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Traumatic brain injury (TBI) is one of the main causes of mortality and severe disability in young and middle age patients. Patients with severe TBI, who are in coma, are of particular concern. Adequate diagnosis of primary brain injuries and timely prevention and treatment of secondary injury mechanisms markedly affect the possibility of reducing mortality and severe disability. The present guidelines are based on the authors' experience in developing international and national recommendations for the diagnosis and treatment of mild TBI, penetrating gunshot wounds of the skull and brain, severe TBI, and severe consequences of brain injury, including a vegetative state. In addition, we used the materials of international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe TBI, which were published in recent years. The proposed recommendations for surgical treatment of severe TBI in adults are addressed primarily to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in treating these patients.
Collapse
Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V V Krylov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A G Gavrilov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Kravchuk
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - S S Petrikov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A E Talypov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | | | - A A Solodov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| |
Collapse
|
21
|
Moon RDC, Abdulla MAH, Kolias AG, Patel K, Kirollos RW, Hutchinson PJ, Timofeev IS. The impact of major trauma centre implementation on the pathways and outcome of traumatic intracranial extradural haematoma in a regional centre. Br J Neurosurg 2016; 30:541-4. [PMID: 27215665 DOI: 10.1080/02688697.2016.1187252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A new trauma care system with regional major trauma centres (MTC) was implemented on 1st April 2012 across England. We aimed to assess whether this has affected the referral pathways and mortality of patients undergoing emergency craniotomy for extradural haematoma (EDH), where clinical outcome is correlated with the time to intervention. MATERIALS AND METHODS This was a retrospective cohort comparison study. All patients who had undergone evacuation of EDH from January 2011 to December 2013 were identified. Only those in whom a decision for emergency craniotomy had been made at the time of referral to the on-call neurosurgeon were included. The CRASH predicted risk of mortality was calculated for individual patients. Mortality was assessed at 14 days in order to compute standardised mortality ratios (SMR). RESULTS Overall, 65 patients underwent EDH evacuation during the study period (21 pre-MTC and 44 post-MTC). Of those, 43 emergency procedures according to the aforementioned definition were included for further analysis (13 pre-MTC, 30 post-MTC). The mean CRASH predicted risk of mortality was 0.21 for the pre-MTC cohort (95% CI: 0.07-0.34) and 0.094 for the post-MTC cohort (95% CI: 0.039-0.15; p = 0.052). There was no significant difference in the rate of secondary transfers before and after MTC implementation (9/13 vs. 23/30, p = 0.71). The mean interval from referral to operation was 198 min for the pre-MTC cohort (95% CI: 123-273) and 201 min for the post-MTC cohort (95% CI: 141-262; p = 0.95). The SMR was 0.37 for the pre-MTC cohort (95% CI: 0.02-1.81; 1 death) and 0.71 for the post-MTC cohort (95% CI: 0.12-2.34; 2 deaths). CONCLUSIONS MTC implementation has not affected the time to operation or the mortality following EDH evacuation.
Collapse
Affiliation(s)
- Richard D C Moon
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Mutwakil A H Abdulla
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Krunal Patel
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Ramez W Kirollos
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Peter J Hutchinson
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Ivan S Timofeev
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| |
Collapse
|
22
|
Yan P, Yan L, Hu T, Zhang Z, Feng J, Zhao H. Assessment of the accuracy of ABC/2 variations in traumatic epidural hematoma volume estimation: a retrospective study. PeerJ 2016; 4:e1921. [PMID: 27077012 PMCID: PMC4830250 DOI: 10.7717/peerj.1921] [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] [Received: 11/09/2015] [Accepted: 03/19/2016] [Indexed: 11/27/2022] Open
Abstract
Background. The traumatic epidural hematoma (tEDH) volume is often used to assist in tEDH treatment planning and outcome prediction. ABC/2 is a well-accepted volume estimation method that can be used for tEDH volume estimation. Previous studies have proposed different variations of ABC/2; however, it is unclear which variation will provide a higher accuracy. Given the promising clinical contribution of accurate tEDH volume estimations, we sought to assess the accuracy of several ABC/2 variations in tEDH volume estimation. Methods. The study group comprised 53 patients with tEDH who had undergone non-contrast head computed tomography scans. For each patient, the tEDH volume was automatically estimated by eight ABC/2 variations (four traditional and four newly derived) with an in-house program, and results were compared to those from manual planimetry. Linear regression, the closest value, percentage deviation, and Bland-Altman plot were adopted to comprehensively assess accuracy. Results. Among all ABC/2 variations assessed, the traditional variations y = 0.5 × A1B1C1 (or A2B2C1) and the newly derived variations y = 0.65 × A1B1C1 (or A2B2C1) achieved higher accuracy than the other variations. No significant differences were observed between the estimated volume values generated by these variations and those of planimetry (p > 0.05). Comparatively, the former performed better than the latter in general, with smaller mean percentage deviations (7.28 ± 5.90% and 6.42 ± 5.74% versus 19.12 ± 6.33% and 21.28 ± 6.80%, respectively) and more values closest to planimetry (18/53 and 18/53 versus 2/53 and 0/53, respectively). Besides, deviations of most cases in the former fell within the range of <10% (71.70% and 84.91%, respectively), whereas deviations of most cases in the latter were in the range of 10–20% and >20% (90.57% and 96.23, respectively). Discussion. In the current study, we adopted an automatic approach to assess the accuracy of several ABC/2 variations for tEDH volume estimation. Our initial results showed that the variations y = 0.5 × A1B1C1 (or A2B2C1) performed better than the other traditional variations, suggesting that the adjusted depth is favorable. In addition, linear regression has been shown to be useful for improving the estimation accuracy of the ABC/2 method, and future studies are warranted to investigate the applicability of such linear regression-derived formulas for clinical application.
Collapse
Affiliation(s)
- Pengfei Yan
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Yan
- Department of Computer Science, University of Northern BC, Prince George, Canada
| | - Tingting Hu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Zhang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Feng
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongyang Zhao
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
23
|
Nakae R, Takayama Y, Kuwamoto K, Naoe Y, Sato H, Yokota H. Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury. J Neurotrauma 2015; 33:688-95. [PMID: 26414158 DOI: 10.1089/neu.2015.4039] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.
Collapse
Affiliation(s)
- Ryuta Nakae
- 1 Emergency and Critical Care Center, Kawaguchi Municipal Medical Center , Saitama, Japan
| | - Yasuhiro Takayama
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Kentaro Kuwamoto
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Yasutaka Naoe
- 1 Emergency and Critical Care Center, Kawaguchi Municipal Medical Center , Saitama, Japan
| | - Hidetaka Sato
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| | - Hiroyuki Yokota
- 2 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
| |
Collapse
|
24
|
Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States. Clin Neurol Neurosurg 2015; 138:99-103. [DOI: 10.1016/j.clineuro.2015.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 07/22/2015] [Accepted: 07/24/2015] [Indexed: 11/19/2022]
|
25
|
Mao X, Miao G, Hao S, Tao X, Hou Z, Li H, Tian R, Zhang H, Lu T, Ma J, Zhang X, Cheng H, Liu B. Decompressive craniectomy for severe traumatic brain injury patients with fixed dilated pupils. Ther Clin Risk Manag 2015; 11:1627-33. [PMID: 26543370 PMCID: PMC4622445 DOI: 10.2147/tcrm.s89820] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The outcome of decompressive craniectomy (DC) for severe traumatic brain injury (sTBI) patients with fixed dilated pupils (FDPs) is not clear. The objective of this study was to validate the outcome of DC in sTBI patients with FDPs. PATIENTS We retrospectively collected data from 207 sTBI patients with FDPs during the time period of May 4, 2003-October 22, 2013: DC group (n=166) and conservative care (CC) group (n=41). MEASUREMENTS Outcomes that were used as indicators in this study were mortality and favorable outcome. The analysis was based on the Glasgow Outcome Scale recorded at 6 months after trauma. RESULTS A total of 49.28% patients died (39.76% [DC group] vs 87.80% [CC group]). The mean increased intracranial pressure values after admission before operation were 36.20±7.55 mmHg in the DC group and 35.59±8.18 mmHg in the CC group. After performing DC, the mean ICP value was 14.38±2.60 mmHg. Approximately, 34.34% sTBI patients with FDPs in the DC group gained favorable scores and none of the patients in the CC group gained favorable scores. CONCLUSION We found that DC plays a therapeutic role in sTBI patients with FDPs, and it is particularly important to reduce intracranial pressure as soon as possible after trauma. For the patients undergoing DC, favorable outcome and low mortality could be achieved.
Collapse
Affiliation(s)
- Xiang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Guozhuan Miao
- Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Huan Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Hao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Te Lu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Jun Ma
- Imaging Center of Neuroscience, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaodong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| |
Collapse
|
26
|
Motorcycle-Related Traumatic Brain Injuries: Helmet Use and Treatment Outcome. NEUROSCIENCE JOURNAL 2015; 2015:696787. [PMID: 26317112 PMCID: PMC4437263 DOI: 10.1155/2015/696787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 11/17/2022]
Abstract
Summary. With increasing use of motorcycle as means of transport in developing countries, traumatic brain injuries from motorcycle crashes have been increasing. The only single gadget that protects riders from traumatic brain injury is crash helmet. Objective. The objectives were to determine the treatment outcome among traumatic brain injury patients from motorcycle crashes and the rate of helmet use among them. Methods. It was a prospective, cross-sectional study of motorcycle-related traumatic brain injury patients managed in our center from 2010 to 2014. Patients were managed using our unit protocol for traumatic brain injuries. Data for the study were collected in accident and emergency, intensive care unit, wards, and outpatient clinic. The data were analyzed using Environmental Performance Index (EPI) info 7 software. Results. Ninety-six patients were studied. There were 87 males. Drivers were 65. Only one patient wore helmet. Majority of them were between 20 and 40 years. Fifty-three patients had mild head injuries. Favorable outcome among them was 84.35% while mortality was 12.5%. Severity of the injury affected the outcome significantly. Conclusion. Our study showed that the helmet use by motorcycle riders was close to zero despite the existing laws making its use compulsory in Nigeria. The outcome was related to severity of injuries.
Collapse
|
27
|
Stocchetti N, Picetti E, Berardino M, Buki A, Chesnut RM, Fountas KN, Horn P, Hutchinson PJ, Iaccarino C, Kolias AG, Koskinen LO, Latronico N, Maas AIR, Payen JF, Rosenthal G, Sahuquillo J, Signoretti S, Soustiel JF, Servadei F. Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference. Acta Neurochir (Wien) 2014; 156:1615-22. [PMID: 24849391 DOI: 10.1007/s00701-014-2127-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 05/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI. METHODS A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.
Collapse
|
28
|
Leitgeb J, Mauritz W, Brazinova A, Majdan M, Wilbacher I. Outcome after severe brain trauma associated with epidural hematoma. Arch Orthop Trauma Surg 2013; 133:199-207. [PMID: 23161150 DOI: 10.1007/s00402-012-1652-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) associated with epidural hematoma (EDH). METHODS Between 02/2002 and 4/2010 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (=Glasgow Coma Scale score <9) and EDH were selected. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale (GOS) scores were 5 or 4, and were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify computed tomography (CT) findings; the scores published by Hukkelhoven et al. (J Neurotrauma 22:1025-1039, 2005) were used to estimate predicted rates of death and of unfavorable outcomes. Univariate (Fisher's exact test, t test, Chi(2)-test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome. RESULTS Of the 738 patients with severe TBI 159 (21.5 %) had EDH. Of these, 49 (30.8 %) died in the hospital, 21 (13.2 %) survived with unfavorable outcome, 82 (51.6 %) with favorable outcome; long-term outcome was unknown in 7 survivors (4.4 %). Mortality rates predicted by the Rotterdam score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 0.94 and 0.97, respectively. Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI associated with EDH. We were unable to demonstrate significant effects of treatment factors.
Collapse
Affiliation(s)
- Johannes Leitgeb
- Department of Traumatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | | | | | | | | |
Collapse
|
29
|
Gürer B, Kertmen H, Yilmaz ER, Sekerci Z. The surgical outcome of traumatic extra-axial hematomas causing brain herniation in children. Pediatr Neurosurg 2013; 49:215-22. [PMID: 25073982 DOI: 10.1159/000363193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/20/2014] [Indexed: 11/19/2022]
Abstract
AIM The aim of this study was to assess the surgical outcome and prognostic importance of clinical and radiological data from children operated on under emergency conditions due to an extra-axial hematoma causing brain herniation. METHODS This retrospective study included 25 children operated on due to herniated traumatic extra-axial hematomas from January 2000 to December 2010. RESULTS Of those 25 children, 17 (68%) were diagnosed with subdural hematoma (SDH), 7 (28%) with epidural hematoma (EDH) and only 1 patient (4%) suffered from both SDH and EDH. Overall mortality from a herniated extra-axial hematoma was 44%. The mortality rate for herniated SDH patients was 52.9%, and only 1 patient died from a herniated EDH (14.2%). Low Glasgow coma scale scores at admission, high postoperative intracranial pressure (ICP) values, longer intervals from trauma to surgery, longer durations of brain herniation, the presence of intraoperative brain swelling, larger and thicker hematomas and more displacement of the midline structures and obliteration of the basal cisterns were all correlated with mortality and an unfavorable outcome. CONCLUSIONS Brain herniation is a serious consequence of traumatic extra-axial hematomas in children, and approximately one third of these patients have the potential for a favorable outcome. We recommend postoperative ICP monitoring to predict outcome and early decompressive surgery when possible for promising results.
Collapse
Affiliation(s)
- Bora Gürer
- Neurosurgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, Ministry of Health, Istanbul, Turkey
| | | | | | | |
Collapse
|
30
|
Miki S, Fujita K, Katayama W, Sato M, Kamezaki T, Matsumura A, Sakashita S. Encapsulated acute subdural hematoma mimicking acute epidural hematoma on computed tomography. Neurol Med Chir (Tokyo) 2012. [PMID: 23183078 DOI: 10.2176/nmc.52.826] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An 87-year-old woman presented with an atypical case of acute subdural hematoma (ASDH) manifesting as disturbance of consciousness and left hemiparesis. Computed tomography revealed a high density lentiform lesion in the right convexity, which was thought to be acute epidural hematoma preoperatively. Emergent decompressive craniotomy revealed an encapsulated solid fresh clot in the subdural space and a bleeding small cortical artery under the clot. The arachnoid membrane and the brain parenchyma were intact, and no other abnormal feature such as aneurysm or arteriovenous malformation was observed. The encapsulated ASDH was removed en bloc and the patient fully recovered. Histological examination confirmed that both the outer thicker and the inner membrane were fibrinous single structures without vasculature. The red blood cells constituting the clot in the capsule maintained their cell structure. The reported pathological mechanisms of lentiform ASDH are adhesion of the arachnoid membrane and the dura mater or intracapsular bleeding from sinusoidal vessels in the outer membrane of the chronic subdural hematoma. However, in our case, the arachnoid membrane had not adhered to the dura mater and the capsule was a fibrinous single structural membrane without vasculature, which probably resulted from a previous hematoma due to initial bleeding from the cortical artery. The possible mechanism in our case was that the re-bleeding dissected and flowed into the fibrinous single structural membrane, resulting in formation of the lentiform ASDH.
Collapse
Affiliation(s)
- Shunichiro Miki
- Department of Neurosurgery, Ibaraki Seinan Medical Center Hospital, Sashima-gun, Ibaraki, Japan
| | | | | | | | | | | | | |
Collapse
|
31
|
Mayr R, Troyer S, Kastenberger T, Krappinger D, Rosenberger R, Obwegeser A, El Attal R. The impact of coagulopathy on the outcome of traumatic epidural hematoma. Arch Orthop Trauma Surg 2012; 132:1445-50. [PMID: 22678529 DOI: 10.1007/s00402-012-1559-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the impact of trauma-associated coagulation disorders on the neurological outcome in patients with traumatic epidural hematoma undergoing surgical or non-surgical treatment. A retrospective analysis was performed using prospectively collected data in a consecutive patient series from a level 1 trauma center. METHODS Eighty-five patients with traumatic epidural hematoma were identified out of 1,633 patients admitted to our emergency room with traumatic head injuries between October 2004 and December 2008. The following prospectively assessed parameters were analyzed: Glasgow Coma Scale, coagulopathy, presence of skull fractures, additional injuries, the Injury Severity Score, hematoma volume and thickness at admission, hematoma volume progression over time and neurologic symptoms. Furthermore, patients were grouped based on whether they had undergone surgical or non-surgical treatment of the epidural hematoma. Clinical outcome was determined according to the Glasgow Outcome Score (GOS) at hospital discharge. RESULTS Patients with coagulopathy showed significantly lower GOS values compared to patients with intact blood coagulation. Initial and progressive hematoma volumes did not influence neurological outcome. Patients with multiple injuries did not show a worse outcome compared to those with isolated epidural hematoma. There was no difference in patient's outcome after surgical or non-surgical treatment. CONCLUSIONS Poor outcome after traumatic epidural hematoma was associated with coagulopathy. Progression of epidural hematoma volume was not associated with coagulopathy or with poor neurological outcome. Prospective studies are needed to confirm these results.
Collapse
Affiliation(s)
- R Mayr
- Department of Trauma Surgery, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
| | | | | | | | | | | | | |
Collapse
|
32
|
Ruff LM, Mendelow AD, Lecky FE. Improving mortality after extradural haematoma in England and Wales. Br J Neurosurg 2012; 27:19-23. [DOI: 10.3109/02688697.2012.709555] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
33
|
Impact of secondary transfer on patients with severe traumatic brain injury. J Trauma Acute Care Surg 2012; 72:487-90. [DOI: 10.1097/ta.0b013e318226ed59] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
34
|
Balik V, Lehto H, Hoza D, Phornsuwannapha S, Toninelli S, Romani R, Sulla I, Hernesniemi J. Post-Traumatic Frontal and Parieto-Occipital Extradural Haematomas: a Retrospective Analysis of 41 Patients and Review of the Literature. ACTA ACUST UNITED AC 2011; 72:169-75. [DOI: 10.1055/s-0031-1286261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AbstractThe purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors.In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a “good” or “favourable outcome”, whereas severe disability, a vegetative state or death was a “poor outcome”.In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had “good outcomes” than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.
Collapse
|
35
|
Nayil K, Ramzan A, Arif S, Wani A, Sheikh Z, Wani T, Laharwal M, Dhar A. Hypodensity of extradural hematomas in children: an ominous sign. J Neurosurg Pediatr 2011; 8:417-21. [PMID: 21961552 DOI: 10.3171/2011.7.peds11123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to analyze the correlation of hypodensity in extradural hematomas on CT with the clinical profile in pediatric patients. This is the only study available in this age group. METHODS This was a prospective study conducted over a period of 3 years in which all children 18 years old or younger with a diagnosis of cranial extradural hematoma were included. The patients were allocated to 2 groups: those with mixed-density clots (17 cases) and those with classically hyperdense clots (52 cases). A comparative analysis between the 2 groups was conducted. RESULTS Patients with mixed-density clots presented earlier to the hospital, had poor Glasgow Coma Scale scores at admission, exhibited large clot volumes, had a high incidence of active bleeding at surgery, and had increased morbidity and mortality as compared with the patients with hyperdense extradural hematomas. CONCLUSIONS Early recognition and rapid evacuation of the mixed-density clot with restoration of hemostasis may result in a decline in morbidity and death in children with this entity.
Collapse
Affiliation(s)
- Khursheed Nayil
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Kim YJ. A systematic review of factors contributing to outcomes in patients with traumatic brain injury. J Clin Nurs 2011; 20:1518-32. [PMID: 21453293 DOI: 10.1111/j.1365-2702.2010.03618.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM AND OBJECTIVE To review, systematically, factors contributing to outcomes in patients with traumatic brain injury. BACKGROUND Traumatic brain injury is a leading cause of death and disability. Several studies have determined the significant predictors of outcomes after traumatic brain injury. The comprehensive identification of these reliable factors for traumatic brain injury is critical to both clinical practice and research. DESIGN Systematic literature review. METHODS Eligible studies that combined at least two variables to predict outcomes in patient with traumatic brain injury were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 15 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined inclusion criteria. RESULTS A total of 46 studies which met review criteria were finally selected. Most studies satisfied internal validity in terms of validity of research variables and multivariate analysis, but few were validated externally. The following factors were significantly associated with unfavourable outcomes: sociodemographic factors such as older age, male gender, lower level of education; clinical factors such as lower Glasgow Coma Scale score, injury caused by motor vehicle crash, hypotension, hypoxia, increased intracranial pressure, no pupil reaction, hypo- or hyperglycaemia, anaemia, coagulopathy, hypo- or hyperthermia, abnormal level of electrolytes, duration of coma; higher level of computed tomography classification by Marshall category; type of intracerebral lesions. CONCLUSION Further studies on integrating the sociodemographic factors, the course of the clinical condition and a unified CT scoring system, are recommended for the evaluation and improvement of the prognosis of traumatic brain injury. RELEVANCE TO CLINICAL PRACTICE A systematic review of factors contributing to outcome for patients with traumatic brain injury will be invaluable in triage criteria, injury prognostication, care and discharge planning, resource use and patient and family counselling.
Collapse
Affiliation(s)
- Young-Ju Kim
- College of Nursing, Sungshin Women's University, Seoul, Korea.
| |
Collapse
|
37
|
Jacobs B, Beems T, van der Vliet TM, Diaz-Arrastia RR, Borm GF, Vos PE. Computed Tomography and Outcome in Moderate and Severe Traumatic Brain Injury: Hematoma Volume and Midline Shift Revisited. J Neurotrauma 2011; 28:203-15. [DOI: 10.1089/neu.2010.1558] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Bram Jacobs
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Tjemme Beems
- Department of Neurosurgery, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Ton M. van der Vliet
- Department of Radiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Ramon R. Diaz-Arrastia
- Department of Neurology, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - George F. Borm
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Pieter E. Vos
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
38
|
Postoperative intracranial haemorrhage: a review. Neurosurg Rev 2011; 34:393-407. [DOI: 10.1007/s10143-010-0304-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 09/27/2010] [Accepted: 11/10/2010] [Indexed: 01/31/2023]
|
39
|
Surgical Outcome Following a Decompressive Craniectomy for Acute Epidural Hematoma Patients Presenting with Associated Massive Brain Swelling. BRAIN EDEMA XIV 2010; 106:261-4. [DOI: 10.1007/978-3-211-98811-4_49] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
40
|
Mixed-density extradural hematomas on computed tomography—prognostic significance. ACTA ACUST UNITED AC 2009; 71:202-6. [DOI: 10.1016/j.surneu.2007.10.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 10/21/2007] [Indexed: 11/21/2022]
|
41
|
Singh SK, Ojha BK, Rastogi M, Chandra A, Husain M. Trephine craniotomy for evacuation of posterior fossa extradural hematoma. INDIAN JOURNAL OF NEUROTRAUMA 2008. [DOI: 10.1016/s0973-0508(08)80005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AbstractExtradural hematomas (EDH) commonly occur in the supratentorial region where these are evacuated by trephine or craniotomy. Posterior fossa EDH (PFEDH) account for 4% to 12.9% of all cranial EDH and the standard method for evacuation of PFEDH involves a suboccipital craniectomy. Use of a trephine craniotomy for evacuation of PFEDH has not yet been described. This is the first report describing our experience in 8 patients with PFEDH where a sub occipital trephine craniotomy was used for evacuation of PFEDH. Eight patients with PFEDH were operated at our institution using a trephine for making a sub occipital craniotomy. Park bench position was used in all patients. The procedure was safely and expeditiously completed with no significant peri-operative complications related to the procedure. Operative time was comparatively shorter than for traditionally described procedures. Replacing the bone flap also avoids any scope for the possibility of occurrence of the sinking skin flap syndrome. We think that using a trephine for making a sub occipital craniotomy for evacuation of PFEDH is a feasible and safe option. There is no added risk of venous sinus injury. Replacing the bone flap helps to restore the normal anatomy. Use of central and peripheral dural hitch sutures in patients of traumatic PFEDH is feasible and avoids any possible reaccumulation of hematoma.
Collapse
|
42
|
Turtz AR, Goldman HW. Head Injury. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
43
|
Ematomi intracranici post-traumatici in fase acuta. Neurologia 2008. [DOI: 10.1016/s1634-7072(08)70523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
44
|
Moppett IK. Traumatic brain injury: assessment, resuscitation and early management. Br J Anaesth 2007; 99:18-31. [PMID: 17545555 DOI: 10.1093/bja/aem128] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This review examines the evidence base for the early management of head-injured patients. Traumatic brain injury (TBI) is common, carries a high morbidity and mortality, and has no specific treatment. The pathology of head injury is increasingly well understood. Mechanical forces result in shearing and compression of neuronal and vascular tissue at the time of impact. A series of pathological events may then ensue leading to further brain injury. This secondary injury may be amenable to intervention and is worsened by secondary physiological insults. Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention. There is very little evidence positively in favour of any treatments or packages of early care; however, prompt, specialist neurocritical care is associated with improved outcome. Various drugs that target specific pathways in the pathophysiology of brain injury have been the subject of animal and human research, but, to date, none has been proved to be successful in improving outcome.
Collapse
Affiliation(s)
- I K Moppett
- Division of Anaesthesia and Intensive Care, University of Nottingham and Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
| |
Collapse
|
45
|
Abstract
BACKGROUND Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care. METHODS During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail. RESULTS A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5. CONCLUSIONS Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.
Collapse
Affiliation(s)
- Thomas S Helling
- Missouri Committee on Trauma and the Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
| |
Collapse
|
46
|
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE. Surgical Management of Acute Epidural Hematomas. Neurosurgery 2006. [DOI: 10.1227/01.neu.0000210363.91172.a8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
RECOMMENDATIONS (see Methodology)
Indications for Surgery
Timing
Methods
Collapse
Affiliation(s)
- M Ross Bullock
- Department of Neurological Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Randall Chesnut
- Department of Neurological Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington
| | - Jamshid Ghajar
- Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York
| | - David Gordon
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York
| | - Roger Hartl
- Department of Neurological Surgery, Weil Cornell Medical College of Cornell University, New York, New York
| | - David W. Newell
- Department of Neurological Surgery, Swedish Medical Center, Seattle, Washington
| | - Franco Servadei
- Department of Neurological Surgery, M. Bufalini Hospital, Cesena, Italy
| | - Beverly C. Walters
- Department of Neurological Surgery, New York University School of Medicine, New York, New York
| | - Jack E. Wilberger
- Department of Neurological Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| |
Collapse
|
47
|
Yilmazlar S, Kocaeli H, Dogan S, Abas F, Aksoy K, Korfali E, Doygun M. Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases. Acta Neurochir (Wien) 2005; 147:1241-8; discussion 1248. [PMID: 16133767 DOI: 10.1007/s00701-005-0623-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2004] [Accepted: 07/14/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. METHOD Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). FINDINGS The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploë (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 +/- 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4-5) and 8 (26.7%) had poor results (GOS 1-3). CONCLUSIONS Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.
Collapse
Affiliation(s)
- S Yilmazlar
- Department of Neurosurgery, Uludag University School of Medicine, Bursa, Turkey.
| | | | | | | | | | | | | |
Collapse
|
48
|
Alliez JR, Hilal N, Kaya JM, Leone M, Reynier Y, Alliez B. Hématomes intra-crâniens extra-duraux : à propos de 100 cas récents. Neurochirurgie 2005; 51:464-70. [PMID: 16327679 DOI: 10.1016/s0028-3770(05)83504-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present a retrospective study on the management of 100 patients who presented epidural hematoma over a four-year period. Our goal was to provide an update on management of this injury. Computed tomography was performed because of the clinical presentation. Results provided information on the type of injury and appropriate treatment. A three-phase clinical progression was observed in only 6% of the patients. Despite state-of-the-art management, mortality remained high in these brain-injured patients (21%). No progress appears to have been achieved in the last ten years. This paradoxical fact probably results from the enhanced severity observed in our patients, who often suffered from associated intracranial injuries as well as multiple trauma (thoracic, abdominal trauma). Analysis study of the results confirms an improvement in mortality among patients with isolated epidural hematoma (6.6%), but great concern remains about the high mortality among patients with associated intracranial lesions (33.3%) or multiple trauma (32%).
Collapse
Affiliation(s)
- J-R Alliez
- Service de Neurochirurgie, CHU Nord/Université de la Méditerranée, Marseille.
| | | | | | | | | | | |
Collapse
|
49
|
Abstract
The management of pediatric head injuries has evolved over the past decade,and a number of significant advances have been made. Evidence-based guide-lines and algorithms for the management of severe pediatric head injuries have recently been published, and all pediatricians who care for children with severe head injuries should be familiar with these guidelines. It is hoped the guidelines will streamline the clinical management of these children and stimulate future research into the many areas that require further investigation.
Collapse
Affiliation(s)
- Mark S Dias
- Department of Pediatric Neurosurgery, Penn State University College of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
| |
Collapse
|
50
|
Hukkelhoven CWPM, Steyerberg EW, Rampen AJJ, Farace E, Habbema JDF, Marshall LF, Murray GD, Maas AIR. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg 2003; 99:666-73. [PMID: 14567601 DOI: 10.3171/jns.2003.99.4.0666] [Citation(s) in RCA: 415] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECT Increasing age is associated with poorer outcome in patients with closed traumatic brain injury (TBI). It is uncertain whether critical age thresholds exist, however, and the strength of the association has yet to be investigated across large series. The authors studied the shape and strength of the relationship between age and outcome, that is, the 6-month mortality rate and unfavorable outcome based on the Glasgow Outcome Scale. METHODS The shape of the association was examined in four prospective series with individual patient data (2664 cases). All patients had a closed TBI and were of adult age (96% < 65 years of age). The strength of the association was investigated in a metaanalysis of the aforementioned individual patient data (2664 cases) and aggregate data (2948 cases) from TBI studies published between 1980 and 2001 (total 5612 cases). Analyses were performed with univariable and multivariable logistic regression. Proportions of mortality and unfavorable outcome increased with age: 21 and 39%, respectively, for patients younger than 35 years and 52 and 74%, respectively, for patients older than 55 years. The association between age and both mortality and unfavorable outcome was continuous and could be adequately described by a linear term and expressed even better statistically by a linear and a quadratic term. The use of age thresholds (best fitting threshold 39 years) in the analysis resulted in a considerable loss of information. The strength of the association, expressed as an odds ratio per 10 years of age, was 1.47 (95% confidence interval [CI] 1.34-1.63) for death and 1.49 (95% CI 1.43-1.56) for unfavorable outcome in univariable analyses, and 1.39 (95% CI 1.3-1.5) and 1.46 (95% CI 1.36-1.56), respectively, in multivariable analyses. Thus, the odds for a poor outcome increased by 40 to 50% per 10 years of age. CONCLUSIONS An older age is continuously associated with a worsening outcome after TBI; hence, it is disadvantageous to define the effect of age on outcome in a discrete manner when we aim to estimate prognosis or adjust for confounding variables.
Collapse
Affiliation(s)
- Chantal W P M Hukkelhoven
- Center for Clinical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|