1
|
Mustafa AFM, Ab Mukmin L, Mazlan MZ, Ghani ARI, Wan Hassan WMN, Hassan MH. Analysis on Short-Term Outcomes for Cerebral Protection Treatment in Post Severe Traumatic Brain Injury Patients: A Single Neurosurgical Centre Study. Malays J Med Sci 2024; 31:142-152. [PMID: 38694580 PMCID: PMC11057832 DOI: 10.21315/mjms2024.31.2.12] [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: 06/22/2022] [Accepted: 06/29/2023] [Indexed: 05/04/2024] Open
Abstract
Background Severe traumatic brain injury (TBI) is a leading cause of disability worldwide and cerebral protection (CP) management might determine the outcome of the patient. CP in severe TBI is to protect the brain from further insults, optimise cerebral metabolism and prevent secondary brain injury. This study aimed to analyse the short-term Glasgow Outcome Scale (GOS) at the intensive care unit (ICU) discharge and a month after ICU discharge of patients post CP and factors associated with the favourable outcome. Methods This is a prospective cohort study from January 2021 to January 2022. The short-term outcomes of patients were evaluated upon ICU discharge and 1 month after ICU discharge using GOS. Favourable outcome was defined as GOS 4 and 5. Generalised Estimation Equation (GEE) was adopted to conduct bivariate GEE and subsequently multivariate GEE to evaluate the factors associated with favourable outcome at ICU discharge and 1 month after discharge. Results A total of 92 patients with severe TBI with GOS of 8 and below admitted to ICU received CP management. Proportion of death is 17% at ICU discharge and 0% after 1 month of ICU discharge. Proportion of favourable outcome is 26.1% at ICU discharge and 61.1% after 1 month of ICU discharge. Among factors evaluated, age (odds ratio [OR] = 0.96; 95% CI: 0.94, 0.99; P = 0.004), duration of CP (OR = 0.41; 95% CI: 0.20, 0.84; P = 0.014) and hyperosmolar therapy (OR = 0.41; CI 95%: 0.21, 0.83; P = 0.013) had significant association. Conclusion CP in younger age, longer duration of CP and patient not receiving hyperosmolar therapy are associated with favourable outcomes. We recommend further clinical trial to assess long term outcome of CP.
Collapse
Affiliation(s)
- Ahmad Fikri Muhammad Mustafa
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Laila Ab Mukmin
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohd Zulfakar Mazlan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Abdul Rahman Izaini Ghani
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohamad Hasyizan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital USM, Universiti Sains Malaysia, Kelantan, Malaysia
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| |
Collapse
|
2
|
Mutlucan UO, Orhun Ö, Özcan-Ekşi EE, Ekşi MŞ, Uçar T. Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis. Int J Neurosci 2024:1-9. [PMID: 38446112 DOI: 10.1080/00207454.2024.2327400] [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: 04/29/2022] [Accepted: 03/02/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE We aimed to assess the long-term neurological outcomes and the functionality and QoL in patients undergoing decompressive craniectomy for severe traumatic brain injury, respectively. MATERIALS AND METHODS Among the 120 patients who underwent decompressive craniectomy for severe TBI between 2002 and 2007, 101 were included based on the inclusion criteria. Long-term follow-up results (minimum 3 years) were available for 22 patients. The outcomes were assessed using the Glasgow Outcome Scale (GOS) and the functionality and HRQoL were assessed using the Short Form-36 (SF-36) (v2) and Quality of Life After Brain Injury (QoLIBRI) questionnaires. RESULTS Among the patients with severe TBI, 62 (61.4%) died and 39 (38.6%) were discharged to either home or a physical therapy facility. Eleven of the thirty-nine patients could not be reached and were excluded from the final analysis. The mean GOS of the remaining 28 patients was 4.14 ± 0.8 after 6.46 ± 1.64 years of follow-up. The HRQoL was assessed in 22 of the 28 patients. The HRQoL scores were lower in patients with TBI than in healthy controls. Furthermore, there was a significant difference in the HRQoL scores in patients with improved GOS scores than in those with unimproved GOS scores. CONCLUSIONS Health-related outcome scores could help clinicians understand the requirements of survivors of severe TBI to create a realistic rehabilitation target for them. QoLIBRI served as a good way of communication in these subjects.
Collapse
Affiliation(s)
- Umut Ogün Mutlucan
- Department of Neurosurgery, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ömer Orhun
- School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Emel Ece Özcan-Ekşi
- Physical Medicine and Rehabilitation Unit, Acıbadem Bağdat Caddesi Medical Center, Istanbul, Turkey
| | - Murat Şakir Ekşi
- Department of Neurosurgery, School of Medicine, Health Sciences University, Istanbul, Turkey
- FSM Training and Research Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Tanju Uçar
- Department of Neurosurgery, Akdeniz University, School of Medicine, Antalya, Turkey
| |
Collapse
|
3
|
Jussen D, Saeed S, Jablonski T, Krenzlin H, Lucia K, Kraemer T, Kempski O, Czabanka M, Ringel F, Alessandri B. Influence of Blood Components on Neuroinflammation, Blood-Brain Barrier Breakdown, and Functional Damage After Acute Subdural Hematoma in Rats. Neurotrauma Rep 2024; 5:215-225. [PMID: 38463418 PMCID: PMC10924060 DOI: 10.1089/neur.2023.0098] [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] [Indexed: 03/12/2024] Open
Abstract
A central component of injury development after acute subdural hematoma (ASDH) is the increased intracranial pressure and consecutive mechanical reduction of cerebral blood flow (CBF). However, the role of different blood constituents in ASDH as additional lesioning factors remains unclear. This study examines the influence of blood components on neuroinflammation, blood-brain barrier (BBB) breakdown, and functional deficits in a rat model of ASDH. We infused corpuscular (whole blood, whole blood lysate, and red cell blood) and plasmatic (blood plasma, anticoagulated blood plasma, and aqueous isotonic solution) blood components into the subdural space while CBF was monitored. Rats then underwent behavioral testing. Lesion analysis and immunohistochemistry were performed 2 days after ASDH. Inflammatory reaction was assessed using staining for ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein, interleukin-1ß, tumor necrosis factor-alpha, and membrane attack complex. Integrity of the BBB was evaluated with albumin and matrix metalloproteinase 9 (MMP9) staining. We observed a significant drop in CBF in the corpuscular group (75% ± 7.5% of baseline) with distinct post-operative deficits and larger lesion volume compared to the plasmatic group (13.6 ± 5.4 vs. 1.3 ± 0.4 mm3). Further, inflammation was significantly increased in the corpuscular group with stronger immunoreaction. After whole blood infusion, albumin and MMP9 immunoreaction were significantly increased, pointing toward a disrupted BBB. The interaction between corpuscular and plasmatic blood components seems to be a key factor in the detrimental impact of ASDH. This interaction results in neuroinflammation and BBB leakage. These findings underscore the importance of performing surgery as early as possible and also provide indications for potential pharmacological targets.
Collapse
Affiliation(s)
- Daniel Jussen
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Syamend Saeed
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Tatjana Jablonski
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Harald Krenzlin
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Kristin Lucia
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Tobias Kraemer
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Oliver Kempski
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Beat Alessandri
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| |
Collapse
|
4
|
Fotakopoulos G, Gatos C, Georgakopoulou VE, Lempesis IG, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Role of decompressive craniectomy in the management of acute ischemic stroke (Review). Biomed Rep 2024; 20:33. [PMID: 38273901 PMCID: PMC10809310 DOI: 10.3892/br.2024.1721] [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: 10/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.
Collapse
Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Charalambos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| |
Collapse
|
5
|
Zhang J, Deng X, Yuan Q, Fu P, Wang M, Wu G, Yang L, Yuan C, Du Z, Hu J. Staged or simultaneous operations for ventriculoperitoneal shunt and cranioplasty: Evidence from a meta-analysis. CNS Neurosci Ther 2023; 29:3136-3149. [PMID: 37438995 PMCID: PMC10580328 DOI: 10.1111/cns.14347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta-analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols. METHODS A meta-analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion. RESULTS Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04-5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74-4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68-3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50-5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38-4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38-6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25-2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62-7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10-14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42-4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights. CONCLUSIONS Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.
Collapse
Affiliation(s)
- Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Xinyu Deng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Pengfei Fu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Meihua Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Lei Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Cong Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Zhuoying Du
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
- National Center for Neurological DisordersShanghaiChina
- Shanghai Key Laboratory of Brain Function and Restoration and Neural RegenerationShanghaiChina
- Neurosurgical Institute of Fudan UniversityShanghaiChina
- Shanghai Clinical Medical Center of NeurosurgeryShanghaiChina
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical CollegeFudan UniversityShanghaiChina
| |
Collapse
|
6
|
Xu X, Lu Y, Liu J, Xu R, Zhao K, Tao A. Diagnostic Value of the Combination of Ultrasonographic Optic Nerve Sheath Diameter and Width of Crural Cistern with Respect to the Intracranial Pressure in Patients Treated with Decompressive Craniotomy. Neurocrit Care 2023; 39:436-444. [PMID: 37037992 DOI: 10.1007/s12028-023-01711-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/28/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The monitoring of intracranial pressure (ICP) and detection of increased ICP are crucial because such increases may cause secondary brain injury and a poor prognosis. Although numerous ultrasound parameters, including optic nerve sheath diameter (ONSD), width of the crural cistern (WCC), and the flow velocities of the central retinal artery and middle cerebral artery, can be measured in patients after hemicraniectomy, researchers have yet to determine which of these is better for evaluating ICP. This study aimed to analyze the correlation between ICP and ultrasound parameters and investigate the best noninvasive estimator of ICP. METHODS This observational study enrolled 50 patients with brain injury after hemicraniectomy from January 2021 to December 2021. All patients underwent invasive ICP monitoring with microsensor, transcranial, and ocular ultrasound postoperatively. We measured the ONSD including the dura mater (ONSDI), the ONSD excluding the dura mater, the optic nerve diameter (OND), the eyeball transverse diameter (ETD), the WCC, and the flow velocities in the central retinal artery and middle cerebral artery. Then, we calculated the ONSDI-OND (the difference between ONSDI and OND) and ONSDI/ETD (the ratio of ONSDI to ETD). Patients were divided into a normal ICP group (n = 35) and an increased ICP group (≥ 20 mm Hg, n = 15) according to the ICP measurements. Correlations were then assessed between the values of the ultrasound parameters and ICP. RESULTS The ONSDI, ONSDI-OND, and ONSDI/ETD were positively associated with ICP (r = 0.455, 0.482, 0.423 and p = 0.001, < 0.001, 0.002, respectively), whereas the WCC was negatively associated with ICP (r = - 0.586, p < 0.001). The WCC showed the highest predictive power for increased ICP (area under the receiver operating characteristic curve [AUC] = 0.904), whereas the ONSDI-OND and ONSDI also presented with acceptable predictive power among the ONSD-related parameters (AUC = 0.831, 0.803, respectively). The cutoff values for increased ICP prediction for ONSDI, ONSDI-OND, and WCC were 6.29, 3.03, and 3.68 mm, respectively. The AUC of the combination of ONSDI-OND and WCC was 0.952 (95% confidence interval 0.896-1.0, p < 0.001). CONCLUSIONS The ONSDI, ONSDI-OND, and WCC were correlated with ICP and had acceptable accuracy levels in estimating ICP in patients after hemicraniectomy. Furthermore, WCC showed a higher diagnostic value than ONSD-related parameters, and the combination of ONSDI-OND and WCC was a satisfactory predictor of increased ICP.
Collapse
Affiliation(s)
- Xiaolan Xu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Yajing Lu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiqiao Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Renfan Xu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Kai Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Anyu Tao
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| |
Collapse
|
7
|
Biroli A, Bignotti V, Biroli P, Buffoli B, Rasulo FA, Doglietto F, Rezzani R, Fiorindi A, Fontanella MM, Belotti F. Hinge craniotomy versus standard decompressive hemicraniectomy: an experimental preclinical comparative study. Acta Neurochir (Wien) 2023; 165:2365-2375. [PMID: 37452903 DOI: 10.1007/s00701-023-05715-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is the most common surgical procedure to manage increased intracranial pressure (ICP). Hinge craniotomy (HC), which consists of fixing the bone operculum with a pivot, is an alternative method conceived to avoid some DC-related complications; nonetheless, it is debated whether it can provide enough volume expansion. In this study, we aimed to analyze the volume and ICP obtained with HC using an experimental cadaver-based preclinical model and compare the results to baseline and DC. METHODS Baseline conditions, HC, and DC were compared on both sides of five anatomical specimens. Volume and ICP values were measured with a custom-made system. Local polynomial regression was used to investigate volume differences. RESULTS The area of the bone opercula resulting from measurements was 115.55 cm2; the mean supratentorial volume was 955 mL. HC led to intermediate results compared to baseline and DC. At an ICP of 50 mmHg, HC offers 130 mL extra space but 172 mL less than a DC. Based on local polynomial regression, the mean volume difference between HC and the standard craniotomy was 10%; 14% between DC and HC; both are higher than the volume of brain herniation reported in the literature in the clinical setting. The volume leading to an ICP of 50 mmHg at baseline was less than the volume needed to reach an ICP of 20 mmHg after HC (10.05% and 14.95% from baseline, respectively). CONCLUSIONS These data confirm the efficacy of HC in providing sufficient volume expansion. HC is a valid intermediate alternative in case of potentially evolutionary lesions and non-massive edema, especially in developing countries.
Collapse
Affiliation(s)
- Antonio Biroli
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Valentina Bignotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Pietro Biroli
- Department of Economics, University of Bologna, Via Zamboni 33, 40126, Bologna, Italy
| | - Barbara Buffoli
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco A Rasulo
- Unit of Anesthesia, Critical Care and Emergency, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Doglietto
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
- Unit of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Rita Rezzani
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Alessandro Fiorindi
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy.
| |
Collapse
|
8
|
Truckenmueller P, Früh A, Wolf S, Faust K, Hecht N, Onken J, Ahlborn R, Vajkoczy P, Zdunczyk A. Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy. J Neurosurg 2023; 139:554-562. [PMID: 36681955 DOI: 10.3171/2022.10.jns221589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. METHODS The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. RESULTS A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). CONCLUSIONS In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.
Collapse
Affiliation(s)
| | - Anton Früh
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Stefan Wolf
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Katharina Faust
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Nils Hecht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Julia Onken
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Robert Ahlborn
- 2Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Anna Zdunczyk
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| |
Collapse
|
9
|
Kim JH, Park KJ, Kang SH, Park DH, Kim JH. The significance of decompressive craniectomy for older patients with traumatic brain injury: a propensity score matching analysis from large multi-center data. Sci Rep 2023; 13:10498. [PMID: 37380719 DOI: 10.1038/s41598-023-37283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
The efficacy of decompressive craniectomy (DC) for traumatic brain injury (TBI) have been investigated in two recent randomized clinical trials (RCTs) and DC is recommended as an optional treatment for improving overall survival compared to medical treatment. However, the two RCTs enrolled extremely young adults, and the efficacy of DC in older adults remains questionable. Therefore, to identify the efficacy of DC in older adults, we compared patients who received medical care with those who underwent DC after propensity score matching (PSM). From the Korea Multi-center Traumatic Brain Injury Database, 443 patients identified as having intracranial hypertension and a necessity of DC were retrospectively enrolled. The patients were classified into the DC (n = 375) and non-DC (n = 68) groups according to operation records. The PSM was conducted to match the patients in the DC group with those receiving medical care (non-DC). After PSM, the newly matched group (DC, n = 126) was compared with patients without DC (non-DC, n = 63). The mean difference in the logit of the propensity scores (LPS) was 0.00391 and the mean age of enrolled patients were 65 years. The results of the comparative analyses after PSM showed that the 6-month mortality rate of the non-DC group was higher than that of the DC group (61.9% vs. 51.6%, p = 0.179). In terms of favorable outcomes (modified Rankin Scale [mRS] score < 4), the DC group showed a lower rate of favorable mRS scores (11.9% vs. 17.5%, p = 0.296) than the non-DC group.
Collapse
Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyung-Jae Park
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Shin-Hyuk Kang
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong-Hyuk Park
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
| |
Collapse
|
10
|
Carlson AP, Davis HT, Jones T, Brennan KC, Torbey M, Ahmadian R, Qeadan F, Shuttleworth CW. Is the Human Touch Always Therapeutic? Patient Stimulation and Spreading Depolarization after Acute Neurological Injuries. Transl Stroke Res 2023; 14:160-173. [PMID: 35364802 PMCID: PMC9526760 DOI: 10.1007/s12975-022-01014-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Touch and other types of patient stimulation are necessary in critical care and generally presumed to be beneficial. Recent pre-clinical studies as well as randomized trials assessing early mobilization have challenged the safety of such routine practices in patients with acute neurological injury such as stroke. We sought to determine whether patient stimulation could result in spreading depolarization (SD), a dramatic pathophysiological event that likely contributes to metabolic stress and ischemic expansion in such patients. Patients undergoing surgical intervention for severe acute neurological injuries (stroke, aneurysm rupture, or trauma) were prospectively consented and enrolled in an observational study monitoring SD with implanted subdural electrodes. Subjects also underwent simultaneous video recordings (from continuous EEG monitoring) to assess for physical touch and other forms of patient stimulation (such as suctioning and positioning). The association of patient stimulation with subsequent SD was assessed. Increased frequency of patient stimulation was associated with increased risk of SD (OR = 4.39 [95%CI = 1.71-11.24]). The overall risk of SD was also increased in the 60 min following patient stimulation compared to times with no stimulation (OR = 1.19 [95%CI = 1.13-1.26]), though not all subjects demonstrated this effect individually. Positioning of the subject was the subtype of stimulation with the strongest overall effect on SD (OR = 4.92 [95%CI = 3.74-6.47]). We conclude that in patients with some acute neurological injuries, touch and other patient stimulation can induce SD (PS-SD), potentially increasing the risk of metabolic and ischemic stress. PS-SD may represent an underlying mechanism for observed increased risk of early mobilization in such patients.
Collapse
Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, Neurosciences, and Neurology, University of New Mexico, NM, Albuquerque, USA.
| | - Herbert T Davis
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Thomas Jones
- Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA
| | - K C Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Rosstin Ahmadian
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Fares Qeadan
- Department of Public Health Sciences, Loyola University Chicago, Chicago, IL, USA
| | | |
Collapse
|
11
|
Menat S, Jacquens A, Mathon B, Bonnet B, Schotar E, Boch AL, Carpentier A, Puybasset L, Abdennour L, Degos V. Corticosteroid treatment for refractory intracranial hypertension: a rescue therapy in patients with severe traumatic brain injury with contusional lesions-a feedback. Acta Neurochir (Wien) 2023; 165:717-725. [PMID: 36808006 DOI: 10.1007/s00701-023-05507-8] [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: 12/29/2022] [Accepted: 01/21/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Refractory intracranial hypertension (rICH) is a severe complication among patients with severe traumatic brain injury (sTBI). Medical treatment may be insufficient, and in some cases, the only viable treatment option is decompressive hemicraniectomy. The assessment of a corticosteroid therapy against vasogenic edema secondary to severe brain injuries seems interesting to prevent this surgery in sTBI patients with rICH caused by contusional areas. METHODS This is a monocentric retrospective observational study including all consecutive sTBI patients with contusion injuries and a rICH requiring cerebrospinal fluid drainage with external ventricular drainage between November 2013 and January 2018. Patient inclusion criterium was a therapeutic index load (TIL; an indirect measure of TBI severity) > 7. Intracranial pressure (ICP) and TIL were assessed before and 48 h after corticosteroid therapy (CTC). Then, we divided the population into two groups according to the evolution of the TIL: responders and non-responders to corticosteroid therapy. RESULTS During the study period, 512 patients were hospitalized for sTBI, and among them, 44 (8.6%) with rICH were included. They received 240 mg per day [120 mg, 240 mg] of Solu-Medrol for 2 days [1; 3], 3 days after the sTBI. The average ICP in patients with rICH before the CTC bolus was 21 mmHg [19; 23]. After the CTC bolus, the ICP fell significantly to less than 15 mmHg (p < 0.0001) for at least 7 days. The TIL decreased significantly the day after the CTC bolus and until day 2. Among these 44 patients, 68% were included in the responder group (n = 30). DISCUSSION Short and systemic corticosteroid therapy in patients with refractory intracranial hypertension secondary to severe traumatic brain injury seems to be a potentially useful and efficient treatment for lowering intracranial pressure and decreasing the need for more invasive surgeries.
Collapse
Affiliation(s)
- Sophie Menat
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Alice Jacquens
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.
| | - Bertrand Mathon
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Baptiste Bonnet
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Schotar
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Puybasset
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Lamine Abdennour
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| |
Collapse
|
12
|
Schucht P, Nowacki A, Osmanagic A, Murek M, Z'Graggen WJ, Montalbetti M, Beck J, Stieglitz L, Raabe A. Space-expanding flap in decompressive hemicraniectomy for stroke. J Neurosurg 2023; 138:382-389. [PMID: 35901672 DOI: 10.3171/2022.5.jns22381] [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: 02/17/2022] [Accepted: 05/11/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Decompressive hemicraniectomy (DCE) is the standard of care for space-occupying malignant infarction of the medial cerebral artery in suitable patients. After DCE, the brain is susceptible to trauma and at risk for the syndrome of the trephined. This study aimed to assess the feasibility of using temporary space-expanding flaps, implanted during DCE, to shield the brain from these risks while permitting the injured brain to expand. METHODS The authors performed a prospective feasibility study to analyze the safety of space-expanding flaps in 10 patients undergoing DCE and evaluated clinical and radiological outcomes. RESULTS The relatives of 1 patient withdrew consent, leaving 9 patients in the final analysis. No patients required removal of the space-expanding flap because of uncontrolled increase of intracranial pressure or infection. One patient required additional external ventricular drainage and 1 received mannitol. The mean (range) midline shift decreased from 6.67 (3-12) mm to 1.26 (0-2.6) mm after DCE with the space-expanding flap. The authors observed no cases of sinking skin flap syndrome, other complications, or deaths. One patient underwent further treatment due to infection of the reimplanted autologous bone flap. Two patients later refused cranioplasty, preferring to keep the space-expanding flap and thus avoid the potential risks of cranioplasty. CONCLUSIONS This feasibility study showed that the concurrent use of space-expanding flaps appeared to be safe in patients who underwent DCE for malignant infarction of the medial cerebral artery. Moreover, space-expanding flaps may permit patients to avoid a second surgery for reimplantation of the autologous bone flap and the risks inherent to this procedure.
Collapse
Affiliation(s)
- Philippe Schucht
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Nowacki
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Armin Osmanagic
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Murek
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matteo Montalbetti
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- 2Department of Neurosurgery, University Hospital Freiburg im Breisgau, Germany; and
| | - Lennart Stieglitz
- 3Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Raabe
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
13
|
Kumar P, Srivastava C, Bajaj A, Yadav A, Krishna Ojha B. A prospective, randomized, controlled study comparing two surgical procedures of decompressive craniectomy in patients with traumatic brain injury: Dural closure without dural closure. J Clin Neurosci 2023; 108:30-36. [PMID: 36580858 DOI: 10.1016/j.jocn.2022.11.015] [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: 08/31/2022] [Revised: 11/08/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
Decompressive craniectomy (DC) is used to treat severe traumatic brain injury [TBI]. The present study compared dural open and closed surgical procedures for DC and their relationship with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (E) (GOS-E) scores and survival in prospective randomized controlled TBI patients. Patients aged 10-65 (36.97 ± 13.23) with DC were hospitalized in the neurotrauma unit of King George's Medical University, Lucknow, India. The patients were randomized into test; with dural closure (n = 60) and control without dural closure (OD) (n = 60) groups. After decompressive craniectomy, patients were monitored daily until hospital discharge or death and for three months. GSC/E leakage, infection, and functional status were also assessed. Age (p = 0.795), sex (p = 0.104), mode of injury (p = 0.195), GCS score (p = 0.40, p = 0.469), Rotterdam score (p = 0.731), and preoperative midline shift (MLS) (p = 0.378) did not vary between the OD and CD groups. Neither technique affected the mortality, motor score, or pupil response (p > 0.05). After one and three months, GOS extension was associated with open and closed dural procedures (p = 0.089). Intracranial pressure, brain bulge, GCS score, and MLS were not associated with theoperative method(p > 0.05). The open dural group had a significantly shorter procedure time than the closed dural group (P = 0.026). Both groups showed no significant difference (p > 0.05) between CSF leak and post-traumatic hydrocephalus. Dural opensurgery for a compressed craniectomy is shorter and not associated with significant surgical consequences compared to close dural close surgery.
Collapse
Affiliation(s)
- Pankaj Kumar
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Chhitij Srivastava
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India.
| | - Ankur Bajaj
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Awadhesh Yadav
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Bal Krishna Ojha
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| |
Collapse
|
14
|
Choudhary SK, Sharma A. Comparative Study of Cerebral Perfusion in Different Types of Decompressive Surgery for Traumatic Brain Injury. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1760727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Abstract
Introduction Computed tomography perfusion (CTP) brain usefulness in the treatment of traumatic brain injury (TBI) is still being investigated. Comparative research of CTP in the various forms of decompressive surgery has not yet been reported to our knowledge. Patients with TBI who underwent decompressive surgery were studied using pre- and postoperative CTP. CTP findings were compared with patient's outcome.
Materials and Methods This was a single-center, prospective cohort study. A prospective analysis of patients who were investigated with CTP from admission between 2019 and 2021 was undertaken. The patients in whom decompressive surgery was required for TBI, were included in our study after applying inclusion and exclusion criteria. CTP imaging was performed preoperatively and 5 days after decompressive surgery to measure cerebral perfusion. Numbers of cases included in the study were 75. Statistical analysis was done.
Results In our study, cerebral perfusion were improved postoperatively in the all types of decompressive surgery (p-value < 0.05). But association between type of surgery with improvement in cerebral perfusion, Glasgow Coma Scale at discharge, and Glasgow Outcome Scale-extended at 3 months were found to be statistically insignificant (p-value > 0.05).
Conclusion CTP brain may play a role as a prognostic tool in TBI patients undergoing decompressive surgery.
Collapse
Affiliation(s)
- Suresh Kumar Choudhary
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
| | - Achal Sharma
- Department of Neurosurgery, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
| |
Collapse
|
15
|
Wang K, Guo H, Zhu Y, Li J, Niu H, Wang Y, Cai X. Improved strategy for post-traumatic hydrocephalus following decompressive craniectomy: Experience of a single center. Front Surg 2023; 9:935171. [PMID: 36684286 PMCID: PMC9852628 DOI: 10.3389/fsurg.2022.935171] [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: 05/03/2022] [Accepted: 11/14/2022] [Indexed: 01/09/2023] Open
Abstract
Background Patients with head trauma may develop hydrocephalus after decompressive craniectomy. Many studies have referred one-stage cranioplasty (CP) and ventriculoperitoneal shunt (VPS) was applied to treat cranial defect with post-traumatic hydrocephalus (PTH), but the safety and efficiency of the procedure remain controversial. Methods This is a retrospective cohort study including 70 patients of PTH following decompressive craniectomy who underwent simultaneous (50) and separated (20) procedures of cranioplasty and VPS from March 2014 to March 2021 at the authors' institution with at least 30 days of follow-up. Patient characteristics, clinical findings, and complications were collected and analyzed. Results Fifty patients with PTH underwent improved simultaneous procedures and 20 patients underwent staged surgeries. Among the cases, the overall complication rate was 22.86%. Complications suffered by patients who underwent one-stage procedure of CP and VPS did not differ significantly, compared with patients in the group of staged procedures (22% vs. 25%, p = 0.763). The significant difference was not observed in the two groups, regarding the complications of subdural/epidural fluid collection (4%/6% vs. 0/2%, p = 1.000/1.000), epidural hemorrhage (6% vs. 4%, p = 0.942), dysfunction of shunting system (0 vs. 2%, p = 0.286), postoperative seizure (8% vs. 4%, p = 1.000), and reoperation case (0 vs. 2%, p = 0.286). No case of subdural hemorrhage, incision/intracranial/abdominal infection, shunting system dysfunction, or reoperation was observed in the group of simultaneous procedure. Complications including subdural/epidural fluid collection, subdural hemorrhage, and incision/intracranial infection were not shown in the case series of the staged procedure group. Conclusion The improved simultaneous procedure of cranioplasty and VPS is effective and safe to treat cranial defect and post-traumatic hydrocephalus with low risk of complications.
Collapse
Affiliation(s)
- Kun Wang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Hongbin Guo
- Department of Neurosurgery, Hangzhou Xiasha Hospital, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Yinxin Zhu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Jinjian Li
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Huanjiang Niu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China
| | - Yirong Wang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China,Correspondence: Xiujun Cai ; Yirong Wang
| | - Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, China,Correspondence: Xiujun Cai ; Yirong Wang
| |
Collapse
|
16
|
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
|
17
|
Idris Z, Yee AS, Wan Hassan WMN, Hassan MH, Ab Mukmin L, Mohamed Zain KA, Manaf AA, Balandong RP, Tang TB. Clinical outcomes and thermodynamics aspect of direct brain cooling in severe head injury. Surg Neurol Int 2023; 14:158. [PMID: 37151468 PMCID: PMC10159295 DOI: 10.25259/sni_118_2023] [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: 02/05/2023] [Accepted: 04/20/2023] [Indexed: 05/09/2023] Open
Abstract
Background Brain cooling therapy is one of the subjects of interest, and currently, data on direct brain cooling are lacking. Hence, the objective is to investigate the clinical outcomes and discuss the thermodynamics aspect of direct brain cooling on severely injured brain patients. Methods This pilot study recruited the severely injured brain patients who were then randomized to either a direct brain cooling therapy group using a constant cooling temperature system or a control group. All studied patients must be subjected to an emergency neurosurgical procedure of decompressive craniectomy and were monitored with intracranial pressure, brain oxygenation, and temperature. Further, comparison was made with our historical group of patients who had direct brain cooling therapy through the old technique. Results The results disclosed the direct brain cooling treated patients through a newer technique obtained a better Extended Glasgow Outcome Score than a control group (P < 001). In addition, there is a significant outcome difference between the combined cooling treated patients (new and old technique) with the control group (P < 0.001). Focal brain oxygenation and temperature are likely factors that correlate with better outcomes. Conclusion Direct brain cooling is feasible, safe, and affects the clinical outcomes of the severely traumatized brain, and physics of thermodynamics may play a role in its pathophysiology.
Collapse
Affiliation(s)
- Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Corresponding author: Zamzuri Idris, Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.
| | - Ang Song Yee
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | | | - Mohamad Hasyizan Hassan
- Department of Anaesthesiology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Laila Ab Mukmin
- Department of Anaesthesiology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Khairu Anuar Mohamed Zain
- Collaborative Microelectronic Design Excellence Center (CEDEC), Universiti Sains Malaysia, Bayan Lepas, Malaysia
| | - Asrulnizam Abd Manaf
- Collaborative Microelectronic Design Excellence Center (CEDEC), Universiti Sains Malaysia, Bayan Lepas, Malaysia
| | | | - Tong Boon Tang
- Centre for Intelligent Signal and Imaging Research, Universiti Teknologi PETRONAS, Bandar Seri Iskandar, Malaysia
| |
Collapse
|
18
|
Güresir E, Lampmann T, Brandecker S, Czabanka M, Fimmers R, Gempt J, Haas P, Haj A, Jabbarli R, Kalasauskas D, König R, Mielke D, Németh R, Oppong MD, Pala A, Prinz V, Ringel F, Roder C, Rohde V, Schebesch KM, Wagner A, Coch C, Vatter H. PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial. Trials 2022; 23:1027. [PMID: 36539817 PMCID: PMC9764529 DOI: 10.1186/s13063-022-06969-4] [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: 03/30/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear. METHODS PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC. DISCUSSION This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients. TRIAL REGISTRATION DRKS DRKS00017650. Registered on 09 June 2019.
Collapse
Affiliation(s)
- Erdem Güresir
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Tim Lampmann
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Simon Brandecker
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Marcus Czabanka
- grid.7839.50000 0004 1936 9721Department of Neurosurgery, Johann Wolfgang Goethe-University of Frankfurt, Schleusenweg 2-16, D-60529 Frankfurt, Germany
| | - Rolf Fimmers
- grid.15090.3d0000 0000 8786 803XInstitute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Jens Gempt
- grid.6936.a0000000123222966Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Patrick Haas
- grid.10392.390000 0001 2190 1447Department of Neurosurgery, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, D-72076 Tübingen, Germany
| | - Amer Haj
- grid.411941.80000 0000 9194 7179Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, D-93053 Regensburg, Germany
| | - Ramazan Jabbarli
- grid.410718.b0000 0001 0262 7331Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Hufelandstraße 55, D-45147 Essen, Germany
| | - Darius Kalasauskas
- grid.410607.4Department of Neurosurgery, Mainz University Hospital, Langenbeckstraße 1, D-55131 Mainz, Germany
| | - Ralph König
- grid.6582.90000 0004 1936 9748Department of Neurosurgery, University of Ulm/BKH Günzburg, Lindenallee 2, D-89312 Günzburg, Germany
| | - Dorothee Mielke
- grid.7450.60000 0001 2364 4210Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany
| | - Robert Németh
- grid.15090.3d0000 0000 8786 803XInstitute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Marvin Darkwah Oppong
- grid.410718.b0000 0001 0262 7331Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Hufelandstraße 55, D-45147 Essen, Germany
| | - Andrej Pala
- grid.6582.90000 0004 1936 9748Department of Neurosurgery, University of Ulm/BKH Günzburg, Lindenallee 2, D-89312 Günzburg, Germany
| | - Vincent Prinz
- grid.7839.50000 0004 1936 9721Department of Neurosurgery, Johann Wolfgang Goethe-University of Frankfurt, Schleusenweg 2-16, D-60529 Frankfurt, Germany
| | - Florian Ringel
- grid.410607.4Department of Neurosurgery, Mainz University Hospital, Langenbeckstraße 1, D-55131 Mainz, Germany
| | - Constantin Roder
- grid.10392.390000 0001 2190 1447Department of Neurosurgery, Eberhard Karls University Tübingen, Hoppe-Seyler-Str. 3, D-72076 Tübingen, Germany
| | - Veit Rohde
- grid.7450.60000 0001 2364 4210Department of Neurosurgery, Georg-August-University Göttingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany
| | - Karl-Michael Schebesch
- grid.411941.80000 0000 9194 7179Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss Allee 11, D-93053 Regensburg, Germany
| | - Arthur Wagner
- grid.6936.a0000000123222966Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Christoph Coch
- grid.15090.3d0000 0000 8786 803XClinical Study Core Unit, Study Center Bonn (SZB), University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| | - Hartmut Vatter
- grid.15090.3d0000 0000 8786 803XDepartment of Neurosurgery, University Hospital Bonn, Venusberg-Campus 1, D-53127 Bonn, Germany
| |
Collapse
|
19
|
Agarwal N, Wilkins TE, Nwachuku EL, Deng H, Algattas H, Lavadi RS, Chang YF, Puccio A, Okonkwo DO. Long-term Benefits for Younger Patients with Aggressive Immediate Intervention following Severe Traumatic Brain Injury: A Longitudinal Cohort Analysis of 175 Patients from a Prospective Registry. Clin Neurol Neurosurg 2022; 224:107545. [PMID: 36584586 DOI: 10.1016/j.clineuro.2022.107545] [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: 09/04/2022] [Revised: 10/31/2022] [Accepted: 11/24/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prevalence of traumatic brain injury (TBI) continues to rise, in part as a reflection of a growing elderly population. Concomitantly, nihilism may exist following substantial neurotrauma from a myriad of commonplace mechanisms, such as traffic incidents, assaults, or falls. OBJECTIVE This study assesses long-term outcomes following aggressive surgical intervention with invasive neuromonitoring to guard against nihilism, especially for patients with advantageous characteristics such as younger age. METHODS A consecutive series of patients with severe TBI treated between 2008 and 2018 and enrolled into the Brain Trauma Research Center (BTRC) database, an Institutional Review Board (IRB 19030228) approved prospective, longitudinal cohort study, were extracted. Demographic and clinical data were analyzed. Long-term functional outcome was recorded with the eight-point Glasgow Outcome Scale-Extended (GOS-E) score at 3-, 6-, 12-, and 24-months by trained, qualified neuropsychology technicians. Chi-squared and analysis of variance tests were used to evaluate the relationship of age groups between different variables. RESULTS For this analysis, 175 patients with severe TBI who were enrolled in the BTRC database and required decompressive hemicraniectomy during the study period were included. Over one-third of the patients with a severe TBI, who were aged 35 years and younger, had a favorable outcome. CONCLUSIONS Despite enduring a severe TBI, a substantial percentage of younger patients achieved favorable outcomes following aggressive treatment. As such, establishing a prognosis should be deferred to allow for recovery via individualized rehabilitation, multidisciplinary support, and community reintegration programs to cope with various long-term psychological, cognitive, and functional disabilities.
Collapse
Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States.
| | - Tiffany E Wilkins
- Department of General Surgery, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Enyinna L Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hanna Algattas
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ava Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| |
Collapse
|
20
|
Hashmi SMM, Nazir S, Colombo F, Jamil A, Ahmed S. Decompressive Craniectomy for the Treatment of Severe Diffuse Traumatic Brain Injury: A Randomized Controlled Trial. Asian J Neurosurg 2022; 17:455-462. [PMID: 36398189 PMCID: PMC9665987 DOI: 10.1055/s-0042-1756636] [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] [Indexed: 11/17/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) is one of the leading public health problems across the world. TBI is associated with high economic costs to the healthcare system specially in developing countries. Decompressive craniectomy is a procedure in which an area of the skull is removed to increase the volume of intracranial compartment. There are various techniques of decompressive craniectomy used that include subtemporal and circular decompression, and unilateral or bilateral frontotemporoparietal decompression. Objective The aim of this study was to compare the outcome of decompressive craniectomy for the management of severe TBI versus conservative management alone at the Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan. Methods The study (randomized controlled trial) was conducted from February 1, 2014, till June 30, 2017. Results A total of 136 patients were included after following the inclusion criteria. They were randomly assigned to two groups, making it 68 patients in each study group. There were 89 males and 47 females. All the patients received standard care recommended by the Brain Trauma Foundation. The mortality rate observed at 6 months in decompressive craniectomy was 22.05%, while among conservative management group, it was 45.58%. Difference in mortality of both groups at 6 months was significant. Total 61.76% (42) of patients from decompressive craniectomy group had a favorable outcome (Glasgow outcome scale: 4-5) at 6 months. While among conservative management group, total 35.29% (24) had a favorable outcome (Glasgow outcome scale: 4-5). Difference in Glasgow outcome scale at 6 months of both groups was significant. Conclusion In conclusion, decompressive craniectomy is simple, safe, and better than conservative management alone.
Collapse
Affiliation(s)
- Syed Muhammad Maroof Hashmi
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan,Address for correspondence Syed Muhammad Maroof Hashmi, MBBS, MRCSEd, FRCSEd Department of Neurosurgery, Abbasi Shaheed HospitalKarachi, Pakistan. Postal Address: SU 187, Street 11/A, ASKARI 4, Karachi. 75290Pakistan
| | - Sadaf Nazir
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Francesca Colombo
- Department of Neurosurgery, Royal Preston Hospital, Lancashire, United Kingdom
| | - Akmal Jamil
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
| | - Shahid Ahmed
- Department of Neurosurgery, Abbasi Shaheed Hospital, Karachi, Pakistan
| |
Collapse
|
21
|
Yang C, Wang Q, Xu S, Guan C, Li G, Wang G. Early expansive single sided laminoplasty decompression treatment severe traumatic cervical spinal cord injury. Front Surg 2022; 9:984899. [PMID: 36189395 PMCID: PMC9523128 DOI: 10.3389/fsurg.2022.984899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background Severe traumatic cervical spinal cord injury (tcSCI) is a disastrous event for patients and families. Maximizing spinal cord function recovery has become the primary therapeutic goal. This study investigated the effect of early extensive posterior decompression on spinal cord function improvement after severe tcSCI. Methods A retrospective review of 83 consecutive patients who underwent extensive open-door laminoplasty decompression within 24 h after severe tcSCI (American Spinal Injury Association (ASIA) impairment scale (AIS) grade A to C) between 2009 and 2017 at our institution was performed. The patient clinical and demographic data were collected. Neurological functional recovery was evaluated according to the Japanese Orthopaedic Association (JOA) score system, ASIA motor score (AMS) and AIS grade. Results Among the 83 patients initially included, the baseline AIS grade was A in 12, B in 28, and C in 43. Twenty-three patients (27.7%) had a high cervical injury. Cervical spinal stenosis (CSS) was identified in 37 patients (44.6%). The mean intramedullary lesion length was 59.6 ± 20.4 mm preoperatively and 34.2 ± 13.3 mm postoperatively (p < 0.0001). At the final follow-up visit, an improvement of at least one and two AIS grades was found in 75 (90.4%) and 41 (49.4%) patients, respectively. 24 (64.9%) patients with an improvement of least two AIS grades had CSS. The mean AMS and JOA score were significantly improved at discharge and the final follow-up visit compared with on admission (p < 0.0001). Conclusions Our results suggest that early expansive laminoplasty decompression may improve neurological outcomes after severe tcSCI, especially in patients with CSS. Larger and prospective controlled studies are needed to validate these findings.
Collapse
Affiliation(s)
- Chaohua Yang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Orthopedic surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Chaohua Yang Gaoju Wang
| | - Qing Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shuang Xu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Can Guan
- Department of Orthopaedics, Xuanhan People's Hospital, DaZhou, China
| | - Guangzhou Li
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Gaoju Wang
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Correspondence: Chaohua Yang Gaoju Wang
| |
Collapse
|
22
|
Liu Y, Liu X, Chen Z, Wang Y, Li J, Gong J, He A, Zhao M, Yang C, Yang W, Wang Z. Evaluation of decompressive craniectomy in mice after severe traumatic brain injury. Front Neurol 2022; 13:898813. [PMID: 35959411 PMCID: PMC9360741 DOI: 10.3389/fneur.2022.898813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Decompressive craniectomy (DC) is of great significance for relieving acute intracranial hypertension and saving lives after traumatic brain injury (TBI). In this study, a severe TBI mouse model was created using controlled cortical impact (CCI), and a surgical model of DC was established. Furthermore, a series of neurological function assessments were performed to better understand the pathophysiological changes after DC. In this study, mice were randomly allocated into three groups, namely, CCI group, CCI+DC group, and Sham group. The mice in the CCI and CCI+DC groups received CCI after opening a bone window, and after brain injury, immediately returned the bone window to simulate skull condition after a TBI. The CCI+DC group underwent DC and contused tissue removal 6 h after CCI. The mice in the CCI group underwent the same anesthesia process; however, no further treatment of the bone window and trauma was performed. The mice in the Sham group underwent anesthesia and the process of opening the skin and bone window, but not in the CCI group. Changes in Modified Neurological Severity Score, rotarod performance, Morris water maze, intracranial pressure (ICP), cerebral blood flow (CBF), brain edema, blood–brain barrier (BBB), inflammatory factors, neuronal apoptosis, and glial cell expression were evaluated. Compared with the CCI group, the CCI+DC group had significantly lower ICP, superior neurological and motor function at 24 h after injury, and less severe BBB damage after injury. Most inflammatory cytokine expressions and the number of apoptotic cells in the brain tissue of mice in the CCI+DC group were lower than in the CCI group at 3 days after injury, with markedly reduced astrocyte and microglia expression. However, the degree of brain edema in the CCI+DC group was greater than in the CCI group, and neurological and motor functions, as well as spatial cognitive and learning ability, were significantly poorer at 14 days after injury.
Collapse
Affiliation(s)
- Yuheng Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Zhijuan Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuanzhi Wang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
- Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Junjie Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Anqi He
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Mingyu Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Chen Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Weidong Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Weidong Yang
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
- *Correspondence: Zengguang Wang
| |
Collapse
|
23
|
Zhang ZD, Zhao LY, Liu YR, Zhang JY, Xie SH, Lin YQ, Tang ZN, Fang HY, Yang Y, Li SZ, Liu JX, Sheng HS. Absorbable Artificial Dura Versus Nonabsorbable Artificial Dura in Decompressive Craniectomy for Severe Traumatic Brain Injury: A Retrospective Cohort Study in Two Centers. Front Surg 2022; 9:877038. [PMID: 35865039 PMCID: PMC9295144 DOI: 10.3389/fsurg.2022.877038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) patients usually need decompressive craniectomy (DC) to decrease intracranial pressure. Duraplasty is an important step in DC with various dura substitute choices. This study aims to compare absorbable dura with nonabsorbable dura in duraplasty for severe TBI patients. Methods One hundred and three severe TBI patients who underwent DC and dura repair were included in this study. Thirty-nine cases used absorbable artificial dura (DuraMax) and 64 cases used nonabsorbable artificial dura (NormalGEN). Postoperative complications, mortality and Karnofsky Performance Scale (KPS) score in one year were compared in both groups. Results Absorbable dura group had higher complication rates in transcalvarial cerebral herniation (TCH) (43.59% in absorbable dura group vs. 17.19% in nonabsorbable dura group, P = 0.003) and CSF leakage (15.38% in absorbable dura group vs. 1.56% in nonabsorbable dura group, P = 0.021). But severity of TCH described with hernial distance and herniation volume demonstrated no difference in both groups. There was no statistically significant difference in rates of postoperative intracranial infection, hematoma progression, secondary operation, hydrocephalus, subdural hygroma and seizure in both groups. KPS score in absorbable dura group (37.95 ± 28.58) was statistically higher than nonabsorbable dura group (49.05 ± 24.85) in one year after operation (P = 0.040), while no difference was found in the rate of functional independence (KPS ≥ 70). Besides, among all patients in this study, TCH patients had a higher mortality rate (P = 0.008), lower KPS scores (P < 0.001) and lower functionally independent rate (P = 0.049) in one year after surgery than patients without TCH. Conclusions In terms of artificial biological dura, nonabsorbable dura is superior to absorbable dura in treatment of severe TBI patients with DC. Suturable nonabsorbable dura has fewer complications of TCH and CFS leakage, and manifest lower mortality and better prognosis. Postoperative TCH is an important complication in severe TBI which usually leads to a poor prognosis.
Collapse
Affiliation(s)
- Zhong-Ding Zhang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Li-Yan Zhao
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi-Ru Liu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jing-Yu Zhang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shang-Hui Xie
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yan-Qi Lin
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhuo-Ning Tang
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Huang-Yi Fang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yue Yang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shi-Ze Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jian-Xi Liu
- Department of Neurosurgery, Yueqing Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han-Song Sheng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
- Correspondence: Han-Song Sheng
| |
Collapse
|
24
|
Vychopen M, Schneider M, Borger V, Schuss P, Behning C, Vatter H, Güresir E. Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency. Eur J Trauma Emerg Surg 2022; 48:2449-2457. [PMID: 34605961 PMCID: PMC9192399 DOI: 10.1007/s00068-021-01789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. METHODS Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. RESULTS Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6-5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. CONCLUSIONS Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.
Collapse
Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Charlotte Behning
- Department of Medical Biometry, Informatics and Epidemiology, Universität Bonn, Institut für Medizinische Biometrie, Informatik und Epidemiologie (IMBIE), Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| |
Collapse
|
25
|
Papaioannou V, Czosnyka Z, Czosnyka M. Hydrocephalus and the neuro-intensivist: CSF hydrodynamics at the bedside. Intensive Care Med Exp 2022; 10:20. [PMID: 35618965 PMCID: PMC9135922 DOI: 10.1186/s40635-022-00452-9] [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: 03/17/2022] [Accepted: 05/19/2022] [Indexed: 12/05/2022] Open
Abstract
Hydrocephalus (HCP) is far more complicated than a simple disorder of cerebrospinal fluid (CSF) circulation. HCP is a common complication in patients with subarachnoid hemorrhage (SAH) and after craniectomy. Clinical measurement in HCP is mainly related to intracranial pressure (ICP) and cerebral blood flow. The ability to obtain quantitative variables that describe CSF dynamics at the bedside before potential shunting may support clinical intuition with a description of CSF dysfunction and differentiation between normal pressure hydrocephalus and brain atrophy. This review discusses the advanced research on HCP and how CSF is generated, stored and absorbed within the context of a mathematical model developed by Marmarou. Then, we proceed to explain the main quantification analysis of CSF dynamics using infusion techniques for deciding on definitive treatment. We consider that such descriptions of multiple parameters of measurements need to be significantly appreciated by the caring neuro-intensivist, for better understanding of the complex pathophysiology and clinical management and finally, improve of the prognosis of these patients with HCP. In this review article, we present current and novel theories of CSF circulation and pathophysiology of hydrocephalus, along with results from infusion studies for evaluating CSF dynamics at the bedside.
Collapse
Affiliation(s)
- Vasilios Papaioannou
- Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, 68100, Alexandroupolis, Greece. .,Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK. .,Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, Polyviou 6-8, 55132, Thessaloniki, Greece.
| | - Zofia Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
| | - Marek Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
| |
Collapse
|
26
|
Agrawal R, Rompf C, Pranada AB, Vollmar P, De Lorenzo A, Hoyer A, Gousias K. Microbiological profile and infection potential of different cryopreserved skull flaps after decompressive hemicraniectomy. Is cryopreservation at - 80 ℃ better? BMC Res Notes 2022; 15:167. [PMID: 35562808 PMCID: PMC9103457 DOI: 10.1186/s13104-022-06042-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Patterns of cryopreservation of explanted skull bone flaps have long been a matter of debate, in particular the appropriate temperature of storage. To the best of our knowledge no study to date has compared the microbiological profile and the infection potential of skull bone flaps cryostored at the same institution at disparate degrees for neurosurgical purposes. In the context of our clinical trial DRKS00023283, we performed a bacterial culture of explanted skull bone flaps, which were cryopreserved lege artis at a temperature of either - 23 °C or - 80 °C after a decompressive hemicraniectomy. In a further step, we contaminated the bone fragments in a s uspension with specific pathogens (S. aureus, S. epidermidis and C. acnes, Colony forming unit CFU 103/ml) over 24 h and conducted a second culture. RESULTS A total of 17 cryopreserved skull flaps (8: - 23 °C; 9: - 80 °C) explanted during decompressive hemicraniectomies performed between 2019 and 2020 as well as 2 computer-aided-designed skulls (1 vancomycin-soaked) were analyzed. Median duration of cryopreservation was 10.5 months (2-17 months). No microorganisms were detected at the normal bacterial culture. After active contamination of our skull flaps, all samples showed similar bacterial growth of above-mentioned pathogens; thus, our study did not reveal an influence of the storage temperature upon infectious dynamic of the skulls.
Collapse
Affiliation(s)
- R. Agrawal
- Department of Neurosurgery, St Marien Academic Hospital Luenen, University of Muenster, KLW St. Paulus Corporation, Altstadtstrasse 23, 44532 Luenen, Germany
- Medical School, Rheinische Friedrich-Wilhelms University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - C. Rompf
- Department of Medical Microbiology, MVZ Dr. Eberhard & Partner Dortmund, Balkenstrasse 17-19, 44137 Dortmund, Germany
| | - A. B. Pranada
- Department of Medical Microbiology, MVZ Dr. Eberhard & Partner Dortmund, Balkenstrasse 17-19, 44137 Dortmund, Germany
| | - P. Vollmar
- Department of Medical Microbiology, MVZ Dr. Eberhard & Partner Dortmund, Balkenstrasse 17-19, 44137 Dortmund, Germany
| | - A. De Lorenzo
- Department of Psychiatry, LVR, University of Essen-Duisburg, Duisburg, Germany
| | - A. Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstrasse 25, 33615 Bielefeld, Germany
| | - K. Gousias
- Department of Neurosurgery, St Marien Academic Hospital Luenen, University of Muenster, KLW St. Paulus Corporation, Altstadtstrasse 23, 44532 Luenen, Germany
- Medical School, Westfaelische Wilhelms University of Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
- Medical School, University of Nicosia, 2408 Nicosia, Cyprus
| |
Collapse
|
27
|
Presenting Step-Ladder Expansive Cranioplasty as the Next Step After Decompressive Hemicraniectomy: It Is Different! ARCHIVES OF NEUROSCIENCE 2022. [DOI: 10.5812/ans.117417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Decompressive hemicraniectomy (DC) is the final surgical remedy for refractory raised intracranial pressure (ICP). Even with years of experience and profound refination of technique, the procedure has less rewarding results in traumatic brain injury (TBI). Besides, arrangements for bone flap preservation and the necessity of follow-up surgery in the form of cranioplasty bring in unavoidable monetary and logistic burdens to the patients. Step-ladder expansive cranioplasty was conceptualized as an alternative to achieve adequate intracranial volume expansion to help normalize ICP, with immediate reinstitution of the Monro-Kellie doctrine. It is also expected to prevent cerebral cortical pressure injury to the cortex underlying the craniectomy defect. The evolution of this concept, as worked out on different models, the surgical technique, and our experience with this technique are discussed in this article. Evidence Acquisition: Multiple research projects undertaken by our team to build up the concept and acquire data necessary to plan the surgical procedure have been published over last eight years. This review article attempts to evaluate the existing knowledge and our clinical experience so far. Results: Step-ladder expansive cranioplasty allows an assured centrifugal displacement of the inner table and underlying dural bag at craniotomy site by at least 9 mm, thereby achieving a minimum volume expansion of 120 cc. Both of these parameters can be increased as desired, if considered necessary by the surgeon. Conclusions: Step-ladder expansive cranioplasty offers an alternative that takes the centripetal pressure exerted by the combination of the tensile strength of the scalp and atmospheric pressure off the brain surface while achieving an assured augmentation of intracranial volume that can be optimized on a case-to-case basis, based on our future understanding of the subject. While it can be a single-stage surgery for those satisfied with the cosmesis, a revision cranioplasty (if required) will be easier, cheaper, and cosmetically superior to achieving cover over a craniotomy defect routinely done after DC.
Collapse
|
28
|
Hypothermia Therapy for Traumatic Spinal Cord Injury: An Updated Review. J Clin Med 2022; 11:jcm11061585. [PMID: 35329911 PMCID: PMC8949322 DOI: 10.3390/jcm11061585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Although hypothermia has shown to protect against ischemic and traumatic neuronal death, its potential role in neurologic recovery following traumatic spinal cord injury (TSCI) remains incompletely understood. Herein, we systematically review the safety and efficacy of hypothermia therapy for TSCI. The English medical literature was reviewed using PRISMA guidelines to identify preclinical and clinical studies examining the safety and efficacy of hypothermia following TSCI. Fifty-seven articles met full-text review criteria, of which twenty-eight were included. The main outcomes of interest were neurological recovery and postoperative complications. Among the 24 preclinical studies, both systemic and local hypothermia significantly improved neurologic recovery. In aggregate, the 4 clinical studies enrolled 60 patients for treatment, with 35 receiving systemic hypothermia and 25 local hypothermia. The most frequent complications were respiratory in nature. No patients suffered neurologic deterioration because of hypothermia treatment. Rates of American Spinal Injury Association (AIS) grade conversion after systemic hypothermia (35.5%) were higher when compared to multiple SCI database control studies (26.1%). However, no statistical conclusions could be drawn regarding the efficacy of hypothermia in humans. These limited clinical trials show promise and suggest therapeutic hypothermia to be safe in TSCI patients, though its effect on neurological recovery remains unclear. The preclinical literature supports the efficacy of hypothermia after TSCI. Further clinical trials are warranted to conclusively determine the effects of hypothermia on neurological recovery as well as the ideal means of administration necessary for achieving efficacy in TSCI.
Collapse
|
29
|
Gantner D, Wiegers E, Bragge P, Finfer S, Delaney A, van Essen T, Peul WC, Maas A, Cooper DJ. Decompressive craniectomy practice following traumatic brain injury, in comparison with randomized trials. J Neurotrauma 2022; 39:860-869. [PMID: 35243877 DOI: 10.1089/neu.2021.0312] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized CENTER-TBI and OzENTER-TBI Core study datasets. These include patients admitted to ICUs in Europe, the United Kingdom and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI, and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8.9%) of those matching DECRA enrolment, and in 30/224 (13.4%) of those matching RESCUEicp. Of patients who underwent DC 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to be potentially harmful, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.
Collapse
Affiliation(s)
- Dashiell Gantner
- Monash University, 2541, Australian and New Zealand Intensive Care Research Centre, 553 St Kilda Rd, Melbourne, Victoria, Australia, 3004.,Alfred Health, 5392, Department of Intensive Care, 55 Commercial Rd, Melbourne, Victoria, Australia, 3004;
| | - Eveline Wiegers
- Erasmus University Rotterdam, 6984, Department of Public Health, Kortenaerstraat 22, J, Rotterdam, Zuid-Holland, Netherlands, 3012VD;
| | - Peter Bragge
- National Trauma Research Institute, 89 Commercial Road, Prahran, Melbourne, Victoria, Australia, 3004;
| | - Simon Finfer
- Royal North Shore Hospital, Intensive Care Unit, Pacific Highway, Sydney, New South Wales, Australia, 2076;
| | - Anthony Delaney
- The George Institute for Global Health, 211065, Newtown, New South Wales, Australia;
| | | | - Wilco C Peul
- Leiden University Medical Center, 4501, Neurosurgery, LUMC, Albinusdreef 2, Leiden, Holland, Netherlands, 2300 RC.,Medical Centre Haaglanden, 2901, Neurosurgery, Den Haag, Netherlands, 2501 CK;
| | - Andrew Maas
- University Hospital Antwerp, Neurosurgery, Wilrijkstraat 10, Edegem, Belgium, 2650.,Netherlands;
| | - D James Cooper
- The Alfred, Intensive Care, Commercial Road, Melbourne, Victoria, Australia, 3004.,Monash University, ANZIC-RC, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, Australia, 3004;
| |
Collapse
|
30
|
Yu R, Wang S, Xu J, Wang Q, He X, Li J, Shang X, Chen H, Liu Y. Machine Learning Approaches-Driven for Mortality Prediction for Patients Undergoing Craniotomy in ICU. Brain Inj 2022; 35:1658-1664. [PMID: 35080996 DOI: 10.1080/02699052.2021.2008491] [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: 10/19/2022]
Abstract
OBJECTIVES We aimed to predict the mortality of patients with craniotomy in ICU by using predictive models to extract the high-risk factors leading to the death of patients from a retrospective a study. METHODS Five machine-learning (ML) algorithms were applied for training on mortality predictive models with the data from a surgical intensive care unit (ICU) database of the Fujian Provincial Hospital in China. The accuracy, precision, recall, f1 score and the area under the receiver operator characteristic curve (AUC) were used to evaluate the performance of different models, and the calibration of the model was evaluated by brier score. RESULTS We demonstrated that eXtreme Gradient Boosting (XGBoost) was more suitable for the task, demonstrating a AUC of 0.84. We analyzed the feature importance with the Local Interpretable Model-agnostic Explanations (LIME) analysis and further identified the high-risk factors of mortality in ICU through this study. CONCLUSIONS This study established the mortality predictive model of patients who had undergone craniotomy in ICU. Identification of the factors that had great influence on mortality has the potential to provide auxiliary decision support for clinical medical staff on their practices.
Collapse
Affiliation(s)
- Ronguo Yu
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Shaobo Wang
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, China.,Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Jingqing Xu
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Qiqi Wang
- Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Xinjun He
- Yidu Cloud (Beijing) Technology Co. Ltd, Beijing, China
| | - Jun Li
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Xiuling Shang
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Hospital, Fujian, China
| | - Youjun Liu
- College of Life Science and Bioengineering, Beijing University of Technology, Beijing, China
| |
Collapse
|
31
|
Neuromonitoring in Severe Traumatic Brain Injury: A Bibliometric Analysis. Neurocrit Care 2022; 36:1044-1052. [PMID: 35075580 DOI: 10.1007/s12028-021-01428-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of mortality and disability among trauma-related injuries. Neuromonitoring plays an essential role in the management and prognosis of patients with severe TBI. Our bibliometric study aimed to identify the knowledge base, define the research front, and outline the social networks on neuromonitoring in severe TBI. We conducted an electronic search for articles related to neuromonitoring in severe TBI in Scopus. A descriptive analysis retrieved evidence on the most productive authors and countries, the most cited articles, the most frequently publishing journals, and the most common author's keywords. Through a three-step network extraction process, we performed a collaboration analysis among universities and countries, a cocitation analysis, and a word cooccurrence analysis. A total of 1884 records formed the basis of our bibliometric study. We recorded an increasing scientific interest in the use of neuromonitoring in severe TBI. Czosnyka, Hutchinson, Menon, Smielewski, and Stocchetti were the most productive authors. The most cited document was a review study by Maas et al. There was an extensive collaboration among universities. The most common keywords were "intracranial pressure," with an increasing interest in magnetic resonance imaging and cerebral perfusion pressure monitoring. Neuromonitoring constitutes an area of active research. The present findings indicate that intracranial pressure monitoring plays a pivotal role in the management of severe TBI. Scientific interest shifts to magnetic resonance imaging and individualized patient care on the basis of optimal cerebral perfusion pressure.
Collapse
|
32
|
Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
33
|
Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
|
34
|
Kim MJ, Lee HB, Ha SK, Lim DJ, Kim SD. Predictive Factors of Surgical Site Infection Following Cranioplasty: A Study Including 3D Printed Implants. Front Neurol 2021; 12:745575. [PMID: 34795630 PMCID: PMC8592932 DOI: 10.3389/fneur.2021.745575] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022] Open
Abstract
In patients who have undergone decompressive craniectomy (DC), subsequent cranioplasty is required to reconstruct cranial defects. Surgical site infection (SSI) following cranioplasty is a devastating complication that can lead to cranioplasty failure. The aim of the present study, therefore, was to identify predictive factors for SSI following cranioplasty by reviewing procedures performed over a 10-year period. A retrospective analysis was performed for all patients who underwent cranioplasty following DC between 2010 and 2020 at a single institution. The patients were divided into two groups, non-SSI and SSI, in order to identify clinical variables that are significantly correlated with SSI following cranioplasty. Cox proportional hazards regression analyses were then performed to identify predictive factors associated with SSI following cranioplasty. A total of 172 patients who underwent cranioplasty, including 48 who received customized three-dimensional (3D) printed implants, were enrolled in the present study. SSI occurred in 17 patients (9.9%). Statistically significant differences were detected between the non-SSI and SSI groups with respect to presence of fluid collections on CT scans before and after cranioplasty. Presence of fluid collections on computed tomography (CT) scan before (p = 0.0114) and after cranioplasty (p < 0.0000) showed significant association with event-free survival rate for SSI. In a univariate analysis, significant predictors for SSI were fluid collection before (p = 0.0172) and after (p < 0.0001) cranioplasty. In a multivariate analysis, only the presence of fluid collection after cranioplasty was significantly associated with the occurrence of SSI (p < 0.0001). The present study investigated predictive factors that may help identify patients at risk of SSI following cranioplasty and provide guidelines associated with the procedure. Based on the results of the present study, only the presence of fluid collection on CT scan after cranioplasty was significantly associated with the occurrence of SSI. Further investigation with long-term follow-up and large-scale prospective studies are needed to confirm our conclusions.
Collapse
Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Hae-Bin Lee
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Dong-Jun Lim
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| | - Sang-Dae Kim
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Ansan Hospital, Ansan-si, South Korea
| |
Collapse
|
35
|
Long-Term Outcome Following Decompressive Craniectomy in Pediatric Penetrating Blast Brain Injury; a Prospective Study. ARCHIVES OF NEUROSCIENCE 2021. [DOI: 10.5812/ans.117264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Brain penetrating blast injury is a leading cause of early death due to excessively elevated intracranial pressure (ICP), culminating in trans-tentorial herniation. The role of craniectomy to decrease ICP and secondary injuries has been controversial particularly in pediatric patients. Three cases of pediatric penetrating blast injuries undergoing decompressive craniectomy are reported in Methods: The current study was a prospective series, including fifteen cases of pediatric blast-related brain injury referred to the emergency ward during a period of two years. Three survived patients had a Glasgow Coma Scale (GCS) of four along with anisocoric pupillary light reflex (PLR). Decompressive craniectomy and ventriculostomy (EVD) were performed. The patients underwent ICP monitoring for two weeks. Results: Early postoperative GCS (5 days) was 7/15 in all three patients. Two weeks and one month’s GCS were 9 and 14, respectively. After three months, cranioplasty was performed. Long-term follow-up detected no major motor deficits after one year and was associated with excellent school performance. Neuroplasticity resulted in contralateral dominancy and handedness in one case. Conclusions: Survivors of pediatric blast brain injury had a favorable outcome after decompressive craniectomy in the current paper. However, there was a limited number of patients, and the results could not be generalized. Further research in this regard with larger sample size is recommended.
Collapse
|
36
|
Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
Collapse
|
37
|
Hersh DS, Anderson HJ, Woodworth GF, Martin JE, Khan YM. Bone Flap Resorption in Pediatric Patients Following Autologous Cranioplasty. Oper Neurosurg (Hagerstown) 2021; 20:436-443. [PMID: 33469664 DOI: 10.1093/ons/opaa452] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023] Open
Abstract
Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.
Collapse
Affiliation(s)
- David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut.,Department of Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Hanna J Anderson
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan E Martin
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Yusuf M Khan
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut.,Department of Orthopedic Surgery, UConn School of Medicine, Farmington, Connecticut
| |
Collapse
|
38
|
Shah DB, Paudel P, Joshi S, Karki P, Sharma GR. Outcome of Decompressive Craniectomy for Traumatic Brain Injury: An Institutional-Based Analysis from Nepal. Asian J Neurosurg 2021; 16:288-293. [PMID: 34268153 PMCID: PMC8244698 DOI: 10.4103/ajns.ajns_392_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/25/2020] [Accepted: 03/16/2021] [Indexed: 11/11/2022] Open
Abstract
Objective: Decompressive craniectomy (DC) is one of the commonly used treatment modalities for refractory intracranial hypertension after traumatic brain injury. The objective of this study is to assess the functional outcome following DC in closed traumatic brain injury based on Glasgow Outcome Scale (GOS). Materials and Methods: This is a retrospective study conducted at Nepal Mediciti Hospital, Nepal, from September 2017 to October 2019. Data of the patients who had undergone DC for closed traumatic brain injury were reviewed from medical record files. Patients who had DC for nontraumatic causes were excluded from the study. Functional outcome was assessed using GOS at 3 months of follow-up. Results: Of the 52 decompressive craniectomies, 46 were included in the study. The majority was male (71.7%). The mean age and the mean Glasgow Coma Scale (GCS) score at presentation were 41.87 (standard deviation [SD] ± 15.29) and 7.59 (SD ± 2.97), respectively. The most common mode of injury was road traffic accident (76.1%). 60.9% had GCS score ≤8 while 39.1% had >8 GCS on admission. 34.8% had both the pupils reactive while 58.7% were anisocoric. Majority had Marshall IV and above grade of injury (67.4%). Sixteen (34.8%) had inhospital mortality. Favorable outcome was seen in 39.1%. GCS score >8 at presentation (72.2%, P < 0.001), bilaterally intact pupillary reflexes (75%, P < 0.001), Marshall grade injury ≤3 on computed tomography scan (90%, P < 0.001), and age <50 years (50%, P = 0.039) were significantly associated with favorable outcome. Procedure-related complications were seen in 36.9%. Conclusion: Favorable outcome was seen in 39.1%. Age <50 years, higher GCS score at presentation (>8), intact pupillary reflexes, and lower Marshall grade injuries were associated with favorable outcome. We recommend a larger prospective study to assess the long-term functional outcome after DC using extended GOS.
Collapse
Affiliation(s)
| | - Prakash Paudel
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Prasanna Karki
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | | |
Collapse
|
39
|
Sun W, Dong X, Yu G, Shuai L, Yuan Y, Ma C. Transcranial direct current stimulation in patients after decompressive craniectomy: a finite element model to investigate factors affecting the cortical electric field. J Int Med Res 2021; 49:300060520942112. [PMID: 33788619 PMCID: PMC8020252 DOI: 10.1177/0300060520942112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To simulate the process of transcranial direct current stimulation (tDCS) on
patients after decompressive craniectomy (DC), and to model cortical
electric field distributions under different electrode montages, we
constructed a finite element model that represented the human head at high
resolution. Methods Using computed tomography images, we constructed a human head model with high
geometrical similarity. The removed bone flap was simplified to be circular
with a diameter of 12 cm. We then constructed finite element models
according to bioelectrical parameters. Finally, we simulated tDCS on the
finite element models under different electrode montages. Results Inward current had a linear relationship with peak electric field value, but
almost no effect on electric field distribution. If the anode was not over
the skull hole (configuration 2), there was almost no difference in electric
field magnitude and focality between the circular and square electrodes.
However, if the anode was right over the hole (configuration 1), the
circular electrodes led to higher peak electric field values and worse
focality. In addition, configuration 1 significantly decreased focality
compared with configuration 2. Conclusion Our results might serve as guidelines for selecting current and electrode
montage settings when performing tDCS on patients after DC.
Collapse
Affiliation(s)
- Weiming Sun
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
- Yefeng Yuan, Department of Psychosomatic
Medicine, The First Affiliated Hospital of Nanchang University, No.17,
yongwaizheng street, Donghu District, Nanchang , Jiangxi Province 330006, China.
Chaolin Ma, Institute of Life Science,
Nanchang University, No. 999, xuefu road, Honggutan District, Nanchang, Jiangxi
Province 33003, China.
| | - Xiangli Dong
- Department of Psychosomatic Medicine, The Second Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Guohua Yu
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lang Shuai
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yefeng Yuan
- Department of Psychosomatic Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Chaolin Ma
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
| |
Collapse
|
40
|
Hong JH, Jeon I, Seo Y, Kim SH, Yu D. Radiographic predictors of clinical outcome in traumatic brain injury after decompressive craniectomy. Acta Neurochir (Wien) 2021; 163:1371-1381. [PMID: 33404876 DOI: 10.1007/s00701-020-04679-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary decompressive craniectomy (DC) is considered for traumatic brain injury (TBI) patients with clinical deterioration, presenting large amounts of high-density lesions on computed tomography (CT). Postoperative CT findings may be suitable for prognostic evaluation. This study evaluated the radiographic predictors of clinical outcome and survival using pre- and postoperative CT scans of such patients. METHODS We enrolled 150 patients with moderate to severe TBI who underwent primary DC. They were divided into two groups based on the 6-month postoperative Glasgow Outcome Scale Extended scores (1-4, unfavorable; 5-8, favorable). Radiographic parameters, including hemorrhage type, location, presence of skull fracture, midline shifting, hemispheric diameter, effacement of cisterns, parenchymal hypodensity, and craniectomy size, were reviewed. Stepwise logistic regression analysis was used to identify the prognostic factors of clinical outcome and 6-month mortality. RESULTS Multivariable logistic regression analysis revealed that age (odds ratio [OR] = 1.09; 95% confidence interval [CI] 1.032-1.151; p = 0.002), postoperative low density (OR = 12.58; 95% CI 1.247-126.829; p = 0.032), and postoperative effacement of the ambient cistern (OR = 14.52; 95% CI 2.234-94.351; p = 0.005) and the crural cistern (OR = 4.90; 95% CI 1.359-17.678; p = 0.015) were associated with unfavorable outcomes. Postoperative effacement of the crural cistern was the strongest predictor of 6-month mortality (OR = 8.93; 95% CI 2.747-29.054; p = 0.000). CONCLUSIONS Hemispheric hypodensity and effacement of the crural and ambient cisterns on postoperative CT after primary DC seems to associate with poor outcome in patients with TBI.
Collapse
Affiliation(s)
- Jung Ho Hong
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Seong Ho Kim
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Dongwoo Yu
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea.
| |
Collapse
|
41
|
Ndiaye Sy EHC, Cisse Y, Thiam AB, Barry LF, Mbaye M, Diop A, Thioub M, Faye M, Fahad A, Ndongo MM, Soilihi AA, Doumbia N, Codé Ba M, Badiane SB. Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar. Pan Afr Med J 2021; 38:399. [PMID: 34381543 PMCID: PMC8325445 DOI: 10.11604/pamj.2021.38.399.27571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/22/2021] [Indexed: 11/28/2022] Open
Abstract
Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.
Collapse
Affiliation(s)
| | - Yakhya Cisse
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Maguette Mbaye
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Abdoulaye Diop
- Neurosurgery Unit, Ziguinchor Regional Hospital, Ziguinchor, Senegal
| | - Mbaye Thioub
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Mohameth Faye
- Neurosurgery Department, Idrissa Pouye General Hospital, Dakar, Senegal
| | - Attoumane Fahad
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Nantenin Doumbia
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Momar Codé Ba
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | |
Collapse
|
42
|
Williams JR, Meyer MR, Ricard JA, Sen R, Young CC, Feroze AH, Greil ME, Barros G, Durfy S, Hanak B, Morton RP, Temkin NR, Barber JK, Mac Donald CL, Chesnut RM. Re-examining decompressive craniectomy medial margin distance from midline as a metric for calculating the risk of post-traumatic hydrocephalus. J Clin Neurosci 2021; 87:125-131. [PMID: 33863519 DOI: 10.1016/j.jocn.2021.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
Decompressive craniectomy (DC) is a life-saving procedure in severe traumatic brain injury, but is associated with higher rates of post-traumatic hydrocephalus (PTH). The relationship between the medial craniectomy margin's proximity to midline and frequency of developing PTH is controversial. The primary study objective was to determine whether average medial craniectomy margin distance from midline was closer to midline in patients who developed PTH after DC for severe TBI compared to patients that did not. The secondary objective was to determine if a threshold distance from midline could be identified, at which the risk of developing PTH increased if the DC was performed closer to midline than this threshold. A retrospective review was performed of 380 patients undergoing DC at a single institution between March 2004 and November 2014. Clinical, operative and demographic variables were collected, including age, sex, DC parameters and occurrence of PTH. Statistical analysis compared mean axial craniectomy margin distance from midline in patients with versus without PTH. Distances from midline were tested as potential thresholds. No significant difference was identified in mean axial craniectomy margin distance from midline in patients developing PTH compared with patients with no PTH (n = 24, 12.8 mm versus n = 356, 16.6 mm respectively, p = 0.086). No significant cutoff distance from midline was identified (n = 212, p = 0.201). This study, the largest to date, was unable to identify a threshold with sufficient discrimination to support clinical recommendations in terms of DC margins with regard to midline, including thresholds reportedly significant in previously published research.
Collapse
Affiliation(s)
- John R Williams
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA.
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Jocelyn A Ricard
- University of Minnesota, 3 Morrill Hall, 100 Church St. S.E, Minneapolis, MN 55455, USA
| | - Rajeev Sen
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Abdullah H Feroze
- Department of Neurosurgery, Loma Linda University Health, 11234 Anderson St., Suite 2562B, Loma Linda, CA 92354, USA
| | - Madeline E Greil
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Guilherme Barros
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Sharon Durfy
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Brian Hanak
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Ryan P Morton
- Department of Neurosurgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Christine L Mac Donald
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, 325 Ninth Ave, Box 359924, Seattle, WA 98104, USA
| |
Collapse
|
43
|
Sengupta SK, Kumar AN, Maurya V, Bajaj H, Yadav KK, G. AK, Faujdar DS. Bony Union and Flap Resorption in Cranioplasty with Autologous Subcutaneous Pocket Preserved Bone Flap: Early Report on an Ambidirectional CT Scan-Based Study. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1714317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Absence of sufficient number of prospective randomized controlled studies and comparatively small sample size and short follow-up period of most of the studies, available so far, have left ambiguity and lack of standardization of different aspects of cranioplasty.
Materials and Methods This is an early report of a computed tomography scan image-based ambidirectional study on cranioplasties performed with autologous subcutaneous pocket preserved bone flaps. Retrospective arm compared bony union and factors influencing it between cranioplasties and craniotomies. Patients with poor bony union and aseptic resorption were followed up in the prospective arm.
Results Retrospective arm of the study, followed up for five years (mean 32.2 months), comprised 42 patients as cases (Group 1) and 29 as controls (Group 2). Twenty-seven individuals (64.3%) in Group 1 had good bony union, as compared with 20 (68.9%) good unions in Group 2 out of the 29 patients. Four patients (9.5%) in Group 1 showed evidence of flap resorption, a finding absent in any patient in Group 2. Age, sex, smoking habits, superficial skin infection, and method of fixation did not appear to have any implication on bony union. Craniotomies done using Gigli saws fared better as compared with those done with pneumatic saw with lesser flap size–craniectomy size discrepancy, though it was not statistically significant. Fifteen patients have been included in the Prospective arm at the time of submission of this article.
Conclusion Ours is a study with a small sample size, unable to put its weight on any side, but can surely add some more data to help the Neurosurgeons in choosing the best for their patients.
Collapse
Affiliation(s)
- Sudip Kumar Sengupta
- Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
| | - Andrews Navin Kumar
- Department of Maxillofacial Surgery, Command Medical Dental Centre (Eastern Command), Kolkata, West Bengal, India
| | - Vinay Maurya
- Department of Radiodiagnosis, Base Hospital Delhi Cantonment, New Delhi, India
| | - Harish Bajaj
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Krishan Kumar Yadav
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | - Ashwath K. G.
- Department of Neurosurgery, Command Hospital (Eastern Command), Kolkata, West Bengal, India
| | | |
Collapse
|
44
|
Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
Collapse
Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
45
|
Haq IBI, Niantiarno FH, Arifianto MR, Nagm A, Susilo RI, Wahyuhadi J, Goto T, Ohata K. Lifesaving Decompressive Craniectomy for High Intracranial Pressure Attributed to Deep-Seated Meningioma: Emergency Management. Asian J Neurosurg 2021; 16:119-125. [PMID: 34211878 PMCID: PMC8202393 DOI: 10.4103/ajns.ajns_179_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/06/2020] [Accepted: 08/14/2020] [Indexed: 11/05/2022] Open
Abstract
Objects: As the most common intracranial extra-axial tumor among adults who tend to grow slowly with minimal clinical manifestation, the patients with meningioma could also fall in neurological emergency and even life-threatening status due to high intracranial pressure (ICP). In those circumstances, decompressive craniectomy (DC) without definitive tumor resection might offer an alternative treatment to alleviate acute increasing of ICP. The current report defines criteria for the indications of lifesaving DC for high ICP caused by deep-seated meningioma as an emergency management. Patients and Methods: This study collected the candidates from 2012 to 2018 at Dr. Soetomo General Hospital, Surabaya, Indonesia. The sample included all meningioma patients who came to our ER who fulfilled the clinical (life-threatening decrease in Glasgow Coma Scale [GCS]) and radiography (deep-seated meningioma, midline shift in brain computed tomography [CT] >0.5 cm, and diameter of tumor >4 cm or tumor that involves the temporal lobe) criteria for emergency DC as a lifesaving procedure. GCS, midline shift, tumor diameter, and volume based on CT were evaluated before DC. Immediate postoperative GCS, time to tumor resection, and Glasgow Outcome Scale (GOS) were also assessed postoperation. Results: The study enrolled 14 patients, with an average preoperative GCS being 9.29 ± 1.38, whereas the mean midline shift was 15.84 ± 7.02 mm. The average of number of tumor's diameter and volume was 5.59 ± 1.44 cm and 66.76 ± 49.44 cc, respectively. Postoperation, the average time interval between DC and definitive tumor resection surgery was 5.07 ± 3.12 days. The average immediate of GCS postoperation was 10.07 ± 2.97, and the average GOS was 3.93 ± 1.27. Conclusion: When emergency tumor resection could not be performed due to some limitation, as in developing countries, DC without tumor resection possibly offers lifesaving procedure in order to alleviate acute increasing ICP before the definitive surgical procedure is carried out. DC might also prevent a higher risk of morbidity and postoperative complications caused by peritumoral brain edema.
Collapse
Affiliation(s)
- Irwan Barlian Immadoel Haq
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Fajar Herbowo Niantiarno
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Muhammad Reza Arifianto
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Alhusain Nagm
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Neurosurgery, Faculty of Medicine, Al-Azhar University, Nasr City, Cairo, Egypt
| | - Rahadian Indarto Susilo
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Joni Wahyuhadi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Takeo Goto
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| |
Collapse
|
46
|
Tamura G, Inagaki T. Prognostic Factors for Pediatric Acute Encephalopathy Associated with Severe Brain Edema. Pediatr Neurosurg 2021; 56:221-228. [PMID: 33827101 DOI: 10.1159/000515037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute encephalopathy is a life-threatening brain dysfunction in children, often associated with a preceding infection and diffuse noninflammatory brain edema. At present, the role of decompressive craniectomy (DC) over the swollen area of the brain is unclear. The risk factors for predicting clinical deterioration also need clarification. METHODS A retrospective study of pediatric patients admitted between 2015 and 2019 with acute cerebral encephalopathy was carried out. Patients were classified according to: (1) the preceding pathogens, (2) the syndromic classification, and (3) the extent of brain edema. The syndromic classification is a relatively new classification of acute encephalopathy proposed in 2016 and divides patients into 3 groups: those with systemic inflammatory reactions or "cytokine storms" (group 1), those with status epilepticus but no cytokine storm (group 2), and others (group 3). Glasgow Outcome Scale (GOS) scores of 1-3 were defined as unfavorable, while a GOS score of 4 or 5 was defined as a favorable outcome in this study. DC was performed for select patients with life-threatening signs of brainstem compression. RESULTS Nineteen patients (mean age: 23.3 months) were included in the study, 8 (42.1%) of whom had an unfavorable outcome. There was no significant correlation between the types of pathogens and outcome. Unfavorable outcomes were observed in significantly more patients in group 1 (87.5%) than group 2 (14.3%) and group 3 (0%). There was a significant association between diffuse brain edema and unfavorable outcomes (72.7%). Neurosurgical DC was performed in 2 patients to alleviate life-threatening brainstem compression: one with a cytokine storm and diffuse bilateral brain edema, and the other with prolonged status epilepticus causing diffuse right-sided brain edema. The GOS score was 3 and 4, respectively. CONCLUSION The risk factors for clinical deterioration in pediatric acute encephalopathy were evaluated based on a variety of classifications, including the new syndromic classification. Laboratory features of cytokine storms and radiological evidence of diffuse brain edema were associated with unfavorable outcomes. The role of surgical decompression is still controversial and should be assessed on a case-by-case basis.
Collapse
Affiliation(s)
- Goichiro Tamura
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
| | - Takayuki Inagaki
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan
| |
Collapse
|
47
|
Gantner D, Bragge P, Finfer S, Gabbe B, Varma D, Webb S, Waterson S, Saxena M, Rengarajoo P, Reade MC, Coates T, Thomas P, Cooper J. Management of Australian Patients with Severe Traumatic Brain Injury: Are Potentially Harmful Treatments Still Used? J Neurotrauma 2020; 37:2686-2693. [PMID: 32731848 DOI: 10.1089/neu.2020.7152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical trials have shown that intravenous albumin and decompressive craniectomy to treat early refractory intracranial hypertension can cause harm in patients with severe traumatic brain injury (TBI). The extent to which these treatments remain in use is unknown. We conducted a multi-center retrospective cohort study of adult patients with severe TBI admitted to five neurotrauma centers across Australia between April 2013 and March 2015. Patients were identified from local trauma and intensive care unit (ICU) registries and followed until hospital discharge. Main outcome measures were the administration of intravenous albumin, and decompressive craniectomy for intracranial hypertension. Analyses were predominantly descriptive. There were 303 patients with severe TBI, of whom a minority received albumin (6.9%) or underwent early decompressive craniectomy for treatment of refractory intracranial hypertension complicating diffuse TBI (2.3%). The median (intequartile range [IQR]) age was 35 (24, 58), and most injuries were caused by road traffic accidents (57.4%) or falls (25.1%). Overall, 34.3% of patients died while in the hospital and the remainder were discharged to rehabilitation (44.6%), other health care facilities (4.6%), or home (16.5%). There were no patient characteristics significantly associated with use of albumin or craniectomy. Intravenous albumin and craniectomy for treatment of intracranial hypertension were used infrequently in Australian neurotrauma centers, indicating alignment between best available evidence and practice.
Collapse
Affiliation(s)
- Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Simon Finfer
- Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Steve Webb
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sharon Waterson
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Manoj Saxena
- Department of Intensive Care, Bankstown Hospital, Sydney, New South Wales, Australia
| | - Parveta Rengarajoo
- Department of Intensive Care, Bankstown Hospital, Sydney, New South Wales, Australia
| | - Michael C Reade
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tom Coates
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Piers Thomas
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| |
Collapse
|
48
|
Mizrahi CJ, Paldor I, Candanedo C, Mollica S, Itshayek E. Accuracy of freehand external ventricular drain placement in patients after a large decompressive hemicraniectomy. J Clin Neurosci 2020; 81:27-31. [PMID: 33222928 DOI: 10.1016/j.jocn.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/06/2020] [Indexed: 11/19/2022]
Abstract
Our study aim is to evaluate the accuracy of freehand external ventricular drain (EVD) placement, without the use of adjuncts to placement, immediately following a large decompressive hemicraniectomy (DC). We performed a retrospective cohort analysis comparing patients who underwent freehand EVD placement immediately after a DC, to those who underwent freehand EVD placement without DC. Computed tomography (CT) studies were used to assess accuracy based on catheter tip location. Intracranial catheter length, pre- and post-operative Evan's Index, and midline shift pre- and post-operatively were analysed as separate variables in each group. A previously described grading system was used to assess the accuracy of free hand EVD placement. There were a total 110 patients overall; DC group, n = 50; non-DC group, n = 60. There was a significant reduction from pre-operative midline shift to post-operative midline shift in the DC group (9.13 vs 6.02 mm; p = 0.0064). There was no significant difference in accuracy between the two groups (p = 0.8917), and similar rates of Grade 1 - i.e. optimal - catheter tip location (DC = 78% vs non-DC = 81%) were found. All analysed variables comparing both Grade 1 subgroups (pre- and postoperative Evan's Index, and midline shift) showed significant differences between them. Mean catheter length in Grade 1 EVD placement showed a statistically significant difference between the DC and non-DC groups (63.78 vs 59.96 mm, respectively; p = 0.009). An EVD, after DC for traumatic and non-traumatic intracranial pathologies, can be accurately placed by freehand.
Collapse
Affiliation(s)
- Cezar José Mizrahi
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.
| | - Iddo Paldor
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Carlos Candanedo
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Semira Mollica
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Eyal Itshayek
- Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel
| |
Collapse
|
49
|
Shin DS, Hwang SC. Neurocritical Management of Traumatic Acute Subdural Hematomas. Korean J Neurotrauma 2020; 16:113-125. [PMID: 33163419 PMCID: PMC7607034 DOI: 10.13004/kjnt.2020.16.e43] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/15/2022] Open
Abstract
Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.
Collapse
Affiliation(s)
- Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucehon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucehon, Korea
| |
Collapse
|
50
|
Bernstein JE, Ghanchi H, Kashyap S, Podkovik S, Miulli DE, Wacker MR, Sweiss R. Pentobarbital Coma With Therapeutic Hypothermia for Treatment of Refractory Intracranial Hypertension in Traumatic Brain Injury Patients: A Single Institution Experience. Cureus 2020; 12:e10591. [PMID: 33110727 PMCID: PMC7581220 DOI: 10.7759/cureus.10591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039). Conclusion Prolonged cooling time >7 hours was associated with a 10.5-fold increase in mortality and ICP>25 mmHg prior to initiation of pentobarbital and hypothermia is suggestive of a poor response to treatment. We recommend patients with severe TBI who develop RICH should first undergo a 12 x 15 cm decompressive hemicraniectomy because they have better survival and are more likely to have ICP <25 mmHg as the highest elevation of ICP if the ICP were to become and stay elevated again. Pentobarbital and hypothermia should be initiated if the ICP becomes elevated and sustained above 20 mmHg with a prior decompressive hemicraniectomy and refractory to other medical therapies. However, our data suggests that patients are unlikely to survive if there ICP does not decrease to less than 15mmHg at 8 and 12 hours after pentobarbital/hypothermia and remain less than 20 mmHg within first 48 hours.
Collapse
Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Hammad Ghanchi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| |
Collapse
|