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Niu Y, Zhang Q, Jiang Z, Li W, Chen Z. Middle meningeal artery embolization for the treatment of unilateral large chronic subdural hematoma patients with significant midline shift: A single-center experience. Interv Neuroradiol 2024:15910199241239706. [PMID: 38515352 DOI: 10.1177/15910199241239706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The amount of midline shift (MLS) considered safe for middle meningeal artery embolization (MMAE) in patients with chronic subdural hematoma (CSDH) has not been established. Whether MMAE could be used as upfront treatment for unilateral large CSDH patients with significant MLS (>1 cm) has not been reported. OBJECTIVE To investigate the efficacy and safety of MMAE in unilateral large CSDH patients with MLS > 1 cm. METHODS Eleven carefully selected CSDH patients with mild or moderate symptoms and significant MLS > 1 cm from 1 May 2021 to 31 August 2022 were included in the study. All patients were treated with MMAE using polyvinyl alcohol (PVA) particles. Outcomes were assessed clinically and with interval imaging studies at follow-up. RESULTS All 19 MMAs (unilateral embolization in three patients and bilateral embolization in eight patients) were successfully embolized. All 11 patients were followed for subsequent months, and there was no recurrence and enlargement of CSDH. Procedural adverse events, mortality, or complications were not observed. The average time to achieve a 50% reduction in MLS was approximately four weeks, while it took approximately eight weeks to achieve a 50% reduction in maximal volume. All 11 patients showed improvement in their neurological symptoms at three days post-operation, including four hemiplegic patients. CONCLUSIONS MMAE may demonstrate safety in carefully selected CSDH patients with significant midline shift (MLS > 1 cm), particularly in those who are not suitable for surgery, thus providing a potential alternative approach.
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Affiliation(s)
- Yin Niu
- Department of Neurosurgery, Third Military Medical University (Army Medical University), Southwest Hospital, Chongqing, China
| | - Qiang Zhang
- Department of Neurosurgery, The 961st Hospital of the Chinese People's Liberation Army Joint Logistic Support Force, Qiqihaer, Heilongjiang, China
| | - Zhouyang Jiang
- Department of Neurosurgery, Third Military Medical University (Army Medical University), Southwest Hospital, Chongqing, China
| | - Wenyan Li
- Department of Neurosurgery, Third Military Medical University (Army Medical University), Southwest Hospital, Chongqing, China
| | - Zhi Chen
- Department of Neurosurgery, Third Military Medical University (Army Medical University), Southwest Hospital, Chongqing, China
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Khorasanizadeh M, Paul U, Chang YM, Moore JM, Ogilvy CS, Thomas AJ. The effect of patient age on the degree of midline shift caused by chronic subdural hematomas: a volumetric analysis. J Neurosurg 2024; 140:537-543. [PMID: 37877977 DOI: 10.3171/2023.6.jns222890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/04/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH. METHODS The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis. RESULTS Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001). CONCLUSIONS For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Umika Paul
- 2UMass Chan Medical School, Worcester, Massachusetts
| | - Yu-Ming Chang
- 3Department of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 4Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
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Maramattom BV, Abraham M, Sundararajan A. Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography. Neurol India 2023; 71:1167-1171. [PMID: 38174452 DOI: 10.4103/0028-3886.391386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. Aims and Objectives To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Materials and Methods Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. Results A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Conclusion Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.
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Affiliation(s)
- Boby V Maramattom
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Abraham
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Ananthram Sundararajan
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
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Kim JH, Chung KM, Lee JJ, Choi HJ, Kwon YS. Predictive Modeling and Integrated Risk Assessment of Postoperative Mortality and Pneumonia in Traumatic Brain Injury Patients through Clustering and Machine Learning: Retrospective Study. Biomedicines 2023; 11:2880. [PMID: 38001880 PMCID: PMC10669264 DOI: 10.3390/biomedicines11112880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/26/2023] Open
Abstract
This study harnessed machine learning to forecast postoperative mortality (POM) and postoperative pneumonia (PPN) among surgical traumatic brain injury (TBI) patients. Our analysis centered on the following key variables: Glasgow Coma Scale (GCS), midline brain shift (MSB), and time from injury to emergency room arrival (TIE). Additionally, we introduced innovative clustered variables to enhance predictive accuracy and risk assessment. Exploring data from 617 patients spanning 2012 to 2022, we observed that 22.9% encountered postoperative mortality, while 30.0% faced postoperative pneumonia (PPN). Sensitivity for POM and PPN prediction, before incorporating clustering, was in the ranges of 0.43-0.82 (POM) and 0.54-0.76 (PPN). Following clustering, sensitivity values were 0.47-0.76 (POM) and 0.61-0.77 (PPN). Accuracy was in the ranges of 0.67-0.76 (POM) and 0.70-0.81 (PPN) prior to clustering and 0.42-0.73 (POM) and 0.55-0.73 (PPN) after clustering. Clusters characterized by low GCS, small MSB, and short TIE exhibited a 3.2-fold higher POM risk compared to clusters with high GCS, small MSB, and short TIE. In summary, leveraging clustered variables offers a novel avenue for predicting POM and PPN in TBI patients. Assessing the amalgamated impact of GCS, MSB, and TIE characteristics provides valuable insights for clinical decision making.
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Affiliation(s)
- Jong-Ho Kim
- Department of Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea; (J.-H.K.); (J.-J.L.)
- Institute of New Frontier Research Team, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Kyung-Min Chung
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea;
| | - Jae-Jun Lee
- Department of Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea; (J.-H.K.); (J.-J.L.)
- Institute of New Frontier Research Team, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Hyuk-Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea;
| | - Young-Suk Kwon
- Department of Anesthesiology and Pain Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea; (J.-H.K.); (J.-J.L.)
- Institute of New Frontier Research Team, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
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Yang W, Chen Q, Yao H, Zhang J, Zhang Q, Fang J, Wu G, Hu J. Predicting the progression of chronic subdural hematoma based on skull density. Front Neurol 2023; 14:1279292. [PMID: 37928152 PMCID: PMC10623350 DOI: 10.3389/fneur.2023.1279292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Objective The objective of this study was to investigate potential correlations between skull density and the progression of chronic subdural hematoma (CSDH). Methods Patients with unilateral CSDH were retrospectively enrolled between January 2018 and December 2022. Demographic and clinical characteristics, as well as hematoma and skull density (Hounsfield unit, Hu), were collected and analyzed. Results The study enrolled 830 patients with unilateral CSDH until the resolution of the CDSH or progressed with surgical treatment. Of the total, 488 patients (58.80%) necessitated surgical treatment. The study identified a significant correlation between the progression of CSDH and three variables: minimum skull density (MiSD), maximum skull density (MaSD), and skull density difference (SDD) (p < 0.001). Additionally, in the multivariable regression analysis, MiSD, MaSD, and SDD were independent predictors of CSDH progression. The MiSD + SDD model exhibited an accuracy of 0.88, as determined by the area under the receiver operating characteristic curve, with a sensitivity of 0.77 and specificity of 0.88. The model's accuracy was validated through additional analysis. Conclusion The findings suggest a significant correlation between skull density and the CSDH progression.
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Affiliation(s)
- Weijian Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qifang Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Nursing, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Haijun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Quan Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jiang Fang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Chen C, Yang J, Han Q, Wu Y, Li J, Xu T, Sun J, Gao X, Huang Y, Parsons MW, Lin L. Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke. Front Neurol 2023; 14:1246775. [PMID: 37840922 PMCID: PMC10570612 DOI: 10.3389/fneur.2023.1246775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/25/2023] [Indexed: 10/17/2023] Open
Abstract
Objective The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients. Methods This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS. Results A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model. Conclusion Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.
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Affiliation(s)
- Cuiping Chen
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jianhong Yang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qing Han
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yuefei Wu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jichuan Li
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Tianqi Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jie Sun
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yi Huang
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Mark W. Parsons
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
| | - Longting Lin
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
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Amakhian AO, Obi-Egbedi-Ejakpovi EB, Morgan E, Adeyekun AA, Abubakar MM. Correlation Between Optic Nerve Sheath Diameter at Initial Head CT and the Rotterdam CT Score. Cureus 2023; 15:e41995. [PMID: 37593265 PMCID: PMC10428083 DOI: 10.7759/cureus.41995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Intracranial findings on imaging have long been used in assessing the severity of traumatic brain injury (TBI); the Rotterdam CT scoring (RCTS) is a more recent tool. Estimating the optic nerve sheath diameter (ONSD) at computed tomography (CT) can be another valuable predictor of the severity of the injury, especially as both ONSD and the RCTS are proven to be independent predictors of raised intracranial pressure (ICP). The study objective was to determine the correlation between ONSD at initial head CT and RCTS. Material and methods We observed 40 consecutive confirmed TBI cases at their initial head CT examinations in the emergency department for ONSD and the presence of other intracranial findings necessary to derive RCTS. The data were prospectively collected and analyzed, with statistical significance set at p ≤0.05 at 95% CI. Results The mean ONSD positively correlated with the Rotterdam CT score (r=0.368, p=0.019). A cut-off value of 6.83 mm was extrapolated from the receiver operator characteristic (ROC) curve as the mean binocular ONSD that best predicted severe RCTS (≥4) (sensitivity: 73.3%, specificity: 80%, positive predictive value: 68.7%, negative predictive value: 83.3%). The area under the curve (AUC) was 0.780 (p=0.003). Binary logistic regression analysis revealed an odd ratio (OR) of 11.000 (95% CI: 2.438-49.627; p=0.002). Conclusion TBI patients with high RCTS have wide mean binocular ONSD. Those with average binocular ONSD above the cut-off value are likelier to have severe TBI. With the documented good correlation, ONSD may become very useful in informing the clinical decision for sequential CT scans in TBI patients and, therefore, reducing the cumulative radiation burden from needless exposures. Furthermore, the non-invasive nature of its assessment will have more clinical relevance in resource-limited settings, where the skills and equipment for ICP monitoring are either not readily available or too expensive to be used routinely.
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Affiliation(s)
- Aletor O Amakhian
- Radiology, Sandwell and West Birmingham NHS (National Health Service) Trust, Birmingham, GBR
- Radiology, Irrua Specialist Teaching Hospital, Irrua, NGA
| | | | - Eghosa Morgan
- Neurosurgery, Irrua Specialist Teaching Hospital, Irrua, NGA
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Dhar R, Kumar A, Chen Y, Begunova Y, Olexa M, Prasad A, Carey G, Gonzalez I, Bhatia K, Hamed M, Heitsch L, Mainali S, Petersen N, Lee JM. Imaging biomarkers of cerebral edema automatically extracted from routine CT scans of large vessel occlusion strokes. J Neuroimaging 2023; 33:606-616. [PMID: 37095592 PMCID: PMC10524672 DOI: 10.1111/jon.13109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND PURPOSE Volumetric and densitometric biomarkers have been proposed to better quantify cerebral edema after stroke, but their relative performance has not been rigorously evaluated. METHODS Patients with large vessel occlusion stroke from three institutions were analyzed. An automated pipeline extracted brain, cerebrospinal fluid (CSF), and infarct volumes from serial CTs. Several biomarkers were measured: change in global CSF volume from baseline (ΔCSF); ratio of CSF volumes between hemispheres (CSF ratio); and relative density of infarct region compared with mirrored contralateral region (net water uptake [NWU]). These were compared to radiographic standards, midline shift and relative hemispheric volume (RHV) and malignant edema, defined as deterioration resulting in need for osmotic therapy, decompressive surgery, or death. RESULTS We analyzed 255 patients with 210 baseline CTs, 255 24-hour CTs, and 81 72-hour CTs. Of these, 35 (14%) developed malignant edema and 63 (27%) midline shift. CSF metrics could be calculated for 310 (92%), while NWU could only be obtained from 193 (57%). Peak midline shift was correlated with baseline CSF ratio (ρ = -.22) and with CSF ratio and ΔCSF at 24 hours (ρ = -.55/.63) and 72 hours (ρ = -.66/.69), but not with NWU (ρ = .15/.25). Similarly, CSF ratio was correlated with RHV (ρ = -.69/-.78), while NWU was not. Adjusting for age, National Institutes of Health Stroke Scale, tissue plasminogen activator treatment, and Alberta Stroke Program Early CT Score, CSF ratio (odds ratio [OR]: 1.95 per 0.1, 95% confidence interval [CI]: 1.52-2.59) and ΔCSF at 24 hours (OR: 1.87 per 10%, 95% CI: 1.47-2.49) were associated with malignant edema. CONCLUSION CSF volumetric biomarkers can be automatically measured from almost all routine CTs and correlate better with standard edema endpoints than net water uptake.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | | | - Madelynne Olexa
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Ayush Prasad
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Grace Carey
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Isabella Gonzalez
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Kunal Bhatia
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Mohammad Hamed
- Department of Neurology, The Ohio State University, Columbus, OH
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
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Diren F, Ozdemir O. The effectiveness of Burr-hole sizes on midline shift and hematoma thickness in the treatment of chronic subdural hematoma. World Neurosurg 2023:S1878-8750(23)00546-6. [PMID: 37087033 DOI: 10.1016/j.wneu.2023.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND The aim of this study was to investigate the effect of burr hole width on postoperative chronic subdural hematoma thickness and midline shift radiologically. METHODS The files of 92 patients who were operated after diagnosis of Chronic Subdural Hematoma between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computerized tomography (CT) scans were scrutinized and the thickness of hematoma and midline shift and the diameters of two burr holes opened were measured and recorded. The correlation between burr hole diameter width and chronic subdural hematoma thickness in postoperative CT and improvement in midline shift was investigated statistically. RESULTS When the CT scans performed on the postoperative 1st day and postoperative 1st month were examined, it was determined that the preoperative hematoma thickness and midline shift were significantly reduced (p<0.001). A positive significant correlation was found between the improvement of the midline shift, the posterior burr hole diameter and the anterior-posterior burr hole arithmetic mean (p<0.001; p=0.029, respectively). CONCLUSION Having examined the current surgical treatment techniques in the treatment of chronic subdural hematoma, we found that an increase in the width of burr hole craniotomies (BHC), especially the posterior BHC, contributed to the improvement in midline shift.
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Affiliation(s)
- Furkan Diren
- University of Health Sciences Gaziosmanpasa Training and Research Hospital, Department of Neurosurgery
| | - Omer Ozdemir
- University of Health Sciences Gaziosmanpasa Training and Research Hospital, Department of Neurosurgery.
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10
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Yi TY, Wu YM, Lin DL, Lang FL, Yang YY, Pan ZN, Zheng XF, Hong GJ, Wu MH, Lin XH, Chen RC, Zeng L, Chen WH, Sui Y. Association of baseline core volume and early midline shift in acute stroke patients with a large ischaemic core. Front Neurol 2023; 13:1077824. [PMID: 36698883 PMCID: PMC9868771 DOI: 10.3389/fneur.2022.1077824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023] Open
Abstract
Background Midline shift (MLS) is troublesome problem that may occur in patients with a large infarct core (LIC) and may be related to the baseline infarct core volume. The purpose of this study was to explore the relationship between baseline infarct core volume and early MLS presence. Materials and methods Patients with acute intracranial large artery occlusion and a pretreatment relative cerebral blood flow (rCBF) <30% volume ≥50 ml on CT perfusion (CTP) were included, clinical outcomes following endovascular treatment (EVT) were retrospectively analyzed. The primary endpoint was MLS within 48 h (early MLS presence). The association between baseline ICV and early MLS presence was evaluated with multivariable regression. Results Ultimately, 95 patients were included, and 29.5% (28/95) of the patients had early MLS. The number of patients with a baseline rCBF < 15% volume (median [interquartile range], 46 [32-60] vs. 29 [19-40]; P < 0.001) was significantly larger in the early severe MLS presence group. A baseline rCBF < 15% volume showed significantly better predictive accuracy for early MLS presence than an rCBF < 30% volume (area under the curve, 0.74 vs. 0.64, P = 0.0023). In addition, an rCBF < 15% volume ≥40 ml (odds ratio, 4.34 [95% CI, 1.571-11.996]) was associated with early MLS presence after adjustment for sex, age, baseline National Institutes of Health Stroke Scale score, onset-to-recanalization time. Conclusion In patients with an acute LIC following EVT, a pretreatment infarct core volume > 40 ml based on an rCBF < 15% showed good predictive value for early MLS occurrence.
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Affiliation(s)
- Ting-yu Yi
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yan-min Wu
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Ding-lai Lin
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Feng-long Lang
- Department of Neurology, Fushun Central Hospital, Fushun, Liaoning, China
| | - Yu-yan Yang
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Zhi-nan Pan
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiu-fen Zheng
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Gan-ji Hong
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Mei-hua Wu
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiao-hui Lin
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Rong-cheng Chen
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Lisan Zeng
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Wen-huo Chen
- Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China,*Correspondence: Wen-huo Chen ✉
| | - Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College, Shenyang, China,Yi Sui ✉
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11
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Kim ISY, Balogun OO, Prescott BR, Saglam H, Olson DM, Speir K, Stutzman SE, Schneider N, Aguilera V, Lussier BL, Smirnakis SM, Dupuis J, Mian A, Greer DM, Ong CJ. Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study. Front Neurol 2022; 13:1046548. [PMID: 36561299 PMCID: PMC9763295 DOI: 10.3389/fneur.2022.1046548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non-invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics. Methods We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm3. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications. Results Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07). Conclusion We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.
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Affiliation(s)
- Ivy So Yeon Kim
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Oluwafemi O. Balogun
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Brenton R. Prescott
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Hanife Saglam
- Mass General Brigham, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - DaiWai M. Olson
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kinley Speir
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sonja E. Stutzman
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nathan Schneider
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Veronica Aguilera
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bethany L. Lussier
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stelios M. Smirnakis
- Mass General Brigham, Boston, MA, United States,Jamaica Plain Veterans Administration Medical Center, Boston, MA, United States
| | - Josée Dupuis
- Boston University School of Public Health, Boston, MA, United States,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Asim Mian
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States
| | - David M. Greer
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States
| | - Charlene J. Ong
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States,Harvard Medical School, Boston, MA, United States,*Correspondence: Charlene J. Ong
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12
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Mooney J, Erickson N, Saccomano B, Maleknia P, Fisher WS. Predictors and Outcomes of Subdural Hematomas Managed via Subdural Evacuation Port System. World Neurosurg X 2022; 17:100145. [PMID: 36341136 PMCID: PMC9626382 DOI: 10.1016/j.wnsx.2022.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Background Subacute subdural hematoma (SDH) is a common pathology most frequently affecting older patients and may be treated operatively through burr holes versus craniotomy or minimally invasively with bedside twist drill craniostomy. Less invasive intervention is favored when possible given a frequently comorbid population. The subdural evacuation port system (SEPS) is a popular treatment option that warrants investigation and reporting of its use and outcomes. Methods A retrospective review of consecutive patients undergoing SEPS drain placement for chronic or mixed density SDH between 2010 and 2021 was conducted. Outcomes of SDH recurrence, need for operating room procedure after SEPS placement, discharge disposition other than home, and modified Rankin Scale score <3 at discharge were modeled with logistic regression using multiple demographic, clinical, and radiographic features. Results Ultimately, 86 patients (mean age 68) were included in the analysis with 66 (78%) presenting with mixed-density SDHs. Radiographic factors such as hematoma thickness and midline shift were not associated with the need for an operating room procedure after SEPS placement or discharge disposition. However, the presence of septations and mixed-density SDH versus chronic SDH was significantly associated with increased odds of requiring an operative intervention after SEPS placement. Conclusions Subacute SDHs are a frequent neurosurgical issue in patient populations where less invasive measures are favored. SEPS drainage continues to be an effective treatment option. However, the presence of septations and mixed-density SDHs has a significantly increased odds of requiring surgical intervention that must be considered in the decision to pursue SEPS drainage.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA,To whom correspondence should be addressed: James Mooney, M.D.
| | - Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Ben Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Pedram Maleknia
- School of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Winfield S. Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
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13
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Romagnosi F, Bernini A, Bongiovanni F, Iaquaniello C, Miroz JP, Citerio G, Taccone FS, Oddo M. Neurological Pupil Index for the Early Prediction of Outcome in Severe Acute Brain Injury Patients. Brain Sci 2022; 12. [PMID: 35624996 DOI: 10.3390/brainsci12050609] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/27/2022] Open
Abstract
In this study, we examined the early value of automated quantitative pupillary examination, using the Neurological Pupil index (NPi), to predict the long-term outcome of acute brain injured (ABI) patients. We performed a single-centre retrospective study (October 2016−March 2019) in ABI patients who underwent NPi measurement during the first 3 days following brain insult. We examined the performance of NPi—alone or in combination with other baseline demographic (age) and radiologic (CT midline shift) predictors—to prognosticate unfavourable 6-month outcome (Glasgow Outcome Scale 1−3). A total of 145 severely brain-injured subjects (65 traumatic brain injury, TBI; 80 non-TBI) were studied. At each time point tested, NPi <3 was highly predictive of unfavourable outcome, with highest specificity (100% (90−100)) at day 3 (sensitivity 24% (15−35), negative predictive value 36% (34−39)). The addition of NPi, from day 1 following ABI to age and cerebral CT scan, provided the best prognostic performance (AUROC curve 0.85 vs. 0.78 without NPi, p = 0.008; DeLong test) for 6-month neurological outcome prediction. NPi, assessed at the early post-injury phase, has a superior ability to predict unfavourable long-term neurological outcomes in severely brain-injured patients. The added prognostic value of NPi was most significant when complemented with baseline demographic and radiologic information.
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14
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Yan JL, Chen YL, Chen MY, Chen BA, Chang JX, Kao CC, Hsieh MC, Peng YT, Huang KC, Chen PY. A Robust, Fully Automatic Detection Method and Calculation Technique of Midline Shift in Intracranial Hemorrhage and Its Clinical Application. Diagnostics (Basel) 2022; 12. [PMID: 35328245 DOI: 10.3390/diagnostics12030693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
A midline shift (MLS) is an important clinical indicator for intracranial hemorrhage. In this study, we proposed a robust, fully automatic neural network-based model for the detection of MLS and compared it with MLSs drawn by clinicians; we also evaluated the clinical applications of the fully automatic model. We recruited 300 consecutive non-contrast CT scans consisting of 7269 slices in this study. Six different types of hemorrhage were included. The automatic detection of MLS was based on modified Keypoint R-CNN with keypoint detection followed by training on the ResNet-FPN-50 backbone. The results were further compared with manually drawn outcomes and manually defined keypoint calculations. Clinical parameters, including Glasgow coma scale (GCS), Glasgow outcome scale (GOS), and 30-day mortality, were also analyzed. The mean absolute error for the automatic detection of an MLS was 0.936 mm compared with the ground truth. The interclass correlation was 0.9899 between the automatic method and MLS drawn by different clinicians. There was high sensitivity and specificity in the detection of MLS at 2 mm (91.7%, 80%) and 5 mm (87.5%, 96.7%) and MLSs greater than 10 mm (85.7%, 97.7%). MLS showed a significant association with initial poor GCS and GCS on day 7 and was inversely correlated with poor 30-day GOS (p < 0.001). In conclusion, automatic detection and calculation of MLS can provide an accurate, robust method for MLS measurement that is clinically comparable to the manually drawn method.
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15
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Xia X, Zhang X, Huang Z, Ren Q, Li H, Li Y, Liang K, Wang H, Han K, Meng X. Automated detection of 3D midline shift in spontaneous supratentorial intracerebral haemorrhage with non-contrast computed tomography using deep convolutional neural networks. Am J Transl Res 2021; 13:11513-11521. [PMID: 34786077 PMCID: PMC8581948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/28/2021] [Indexed: 06/13/2023]
Abstract
Deep learning (DL)-based convolutional neural networks facilitate more accurate detection and rapid analysis of MLS. Our objective was to assess the feasibility of applying a DL-based convolutional neural network to non-contrast computed tomography (CT) for automated 2D/3D brain midline shift measurement and outcome prediction after spontaneous intracerebral haemorrhage. In this retrospective study, 140 consecutive patients were referred for CT assessment of sICH from January 2014 to April 2019. The level of consciousness of patients was evaluated using the Glasgow Coma Scale (GCS) score, and the Glasgow Outcome Scale (GOS) score was calculated to classify the outcome. The distance of midline shift (MLS-D) and volume of midline shift (MLS-V) were automatically measured via DL methods. Patients were divided into three groups based on GCS scores: mild degree (GCS score: 13-15), moderate degree (GCS score: 9-12), and severe degree (GCS score: 3-8). Spearman's correlation analysis revealed statistically significant (P<0.01) positive correlation between GCS and MLS-D (r=0.709) and MLS-V (r=0.754). The AUC of MLS-V was slightly larger than that of MLS-D (0.831 vs 0.799, P=0.318) in the midline shifting group. The AUC of MLS-V was significantly larger than that of MLS-D (0.854 vs 0.736, P=0.03) in patients with severe degree GCS scores. The DL-based measurements of both MLS-D and MLS-V enable the assessment of consciousness and the prediction of the outcome of sICH. Compared to MLS-D, MLS-V measurement can better indicate mass effect and predict outcomes, particularly in severe cases.
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Affiliation(s)
- Xiaona Xia
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
| | - Xiaoqian Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical CollegeBeijing, China
| | - Zhaodi Huang
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
| | - Qingguo Ren
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
| | - Hui Li
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
| | - Ye Li
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
| | | | | | - Kai Han
- Deepwise AI LabBeijing, China
| | - Xiangshui Meng
- Shandong University, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Department of RadiologyQingdao, China
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16
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Yuan R, Wu S, Cheng Y, Ye K, Hao Z, Zhang S, Liu Y, Liu M. Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction. Curr Neurovasc Res 2021; 17:131-139. [PMID: 32031070 DOI: 10.2174/1567202617666200207125552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown. METHODS We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes. RESULTS Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate. CONCLUSION Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.
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Affiliation(s)
- Ruozhen Yuan
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Simiao Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yajun Cheng
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Kaili Ye
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zilong Hao
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shihong Zhang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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17
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V. V, Gudigar A, Raghavendra U, Hegde A, Menon GR, Molinari F, Ciaccio EJ, Acharya UR. Automated Detection and Screening of Traumatic Brain Injury (TBI) Using Computed Tomography Images: A Comprehensive Review and Future Perspectives. Int J Environ Res Public Health 2021; 18:6499. [PMID: 34208596 PMCID: PMC8296416 DOI: 10.3390/ijerph18126499] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 12/17/2022]
Abstract
Traumatic brain injury (TBI) occurs due to the disruption in the normal functioning of the brain by sudden external forces. The primary and secondary injuries due to TBI include intracranial hematoma (ICH), raised intracranial pressure (ICP), and midline shift (MLS), which can result in significant lifetime disabilities and death. Hence, early diagnosis of TBI is crucial to improve patient outcome. Computed tomography (CT) is the preferred modality of choice to assess the severity of TBI. However, manual visualization and inspection of hematoma and its complications from CT scans is a highly operator-dependent and time-consuming task, which can lead to an inappropriate or delayed prognosis. The development of computer aided diagnosis (CAD) systems could be helpful for accurate, early management of TBI. In this paper, a systematic review of prevailing CAD systems for the detection of hematoma, raised ICP, and MLS in non-contrast axial CT brain images is presented. We also suggest future research to enhance the performance of CAD for early and accurate TBI diagnosis.
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Affiliation(s)
- Vidhya V.
- Department of Computer Science and Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Anjan Gudigar
- Department of Instrumentation and Control Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal 576104, India;
| | - U. Raghavendra
- Department of Instrumentation and Control Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Ajay Hegde
- Institute of Neurological Sciences, Glasgow G51 4LB, UK;
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Girish R. Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Filippo Molinari
- Department of Electronics, Politecnico di Torino, 24 Corso Duca degli Abruzzi, 10129 Torino, Italy;
| | - Edward J. Ciaccio
- Department of Medicine, Columbia University, New York, NY 10032, USA;
| | - U. Rajendra Acharya
- School of Engineering, Ngee Ann Polytechnic, 535 Clementi Road, Singapore 599489, Singapore;
- Department of Biomedical Engineering, School of Science and Technology, SUSS University, 463 Clementi Road, Singapore 599491, Singapore
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung 41354, Taiwan
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18
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Abstract
OBJECTIVE This study was performed to determine the maximum voluntary molar bite force (MVMBF) in relation to age, sex, lip competency, midline shifting, dental and skeletal malocclusion, overjet, overbite, and crowding. METHODS One hundred Saudi patients with orthodontic malocclusion aged 14 to 25 years (51 male and 49 female patients) were investigated in this cross-sectional study. The baseline MVMBF on the right and left side was evaluated in all patients before commencing any orthodontic treatment. The MVMBF was registered with a portable occlusal force gauge in the first molar region during maximal clenching. RESULTS The MVMBF significantly varied with respect to all nine confounding variables. The MVMBF significantly increased with an age of >18 years, male sex, right-side lip competency, no midline shift, dental and skeletal Class I malocclusion, normal overjet, normal overbite, and mild crowding. CONCLUSION All nine variables examined in the present study significantly influenced the MVMBF.
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Affiliation(s)
- Mohammad Khursheed Alam
- Orthodontic Division, Department of Preventive Dental Science, College of Dentistry, Jouf University, Sakaka, Saudi Arabia
| | - Ahmed Ali Alfawzan
- Department of Preventive Dentistry, College of Dentistry in Ar Rass, Qassim University, Ar Rass, Saudi Arabia
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19
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Gomez-Paz S, Akamatsu Y, Salem MM, Enriquez-Marulanda A, Robinson TM, Ogilvy CS, Thomas AJ, Moore JM. Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift. Interv Neuroradiol 2020; 27:571-576. [PMID: 33375866 DOI: 10.1177/1591019920982816] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There is limited data on upfront middle meningeal artery (MMA) embolization in the context of significant midline shift (MLS) (greater than 5mm) for the treatment of chronic subdural hematomas (cSDH). This study reports the temporal changes following MMA embolization as an upfront treatment of cSDH in patients with or without MLS and either mild, no symptoms or mild and stable neurological deficits. METHODS A retrospective series of patients with a cSDH from a single institution in the United States between 2018-2020 was conducted. Eligible patients were treated with upfront MMA embolization. RESULTS 27 upfront MMA embolization procedures in 23 patients were included. Twelve patients had MLS of 5 millimeters or more (52%). The median maximal thickness at diagnosis was 18 mm [11-22]. The mean distance of MLS was 5 mm ±4. There were no procedural complications. The overall rescue surgery rate was 15%. A single rescue surgery secondary to an increase in hematoma thickness was required (4%). The temporal changes for both hematoma and MLS showed gradual improvement between 2 weeks and 4 weeks post-procedure. The average time-to-resolution of MLS was 46 days in patients with less than 5 mm MLS and 51 days in those with 5 mm or more. CONCLUSION Upfront MMA embolization for cSDH with a thickness up to 25 mm provides adequate symptom relief, stabilization and/or progressive resorption of the cSDH during follow-up in carefully selected asymptomatic or mildly symptomatic patients even in the presence of a MLS greater than 5 mm.
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Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Timothy M Robinson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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20
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Howley IW, Bennett JD, Stein DM. Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention. Am Surg 2020; 87:1504-1510. [PMID: 33345574 DOI: 10.1177/0003134820973355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.
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Affiliation(s)
- Isaac W Howley
- Department of Surgery, 12325University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Jonathan D Bennett
- Department of Surgery, 6886Virginia Commonwealth University, Richmond, VA, USA
| | - Deborah M Stein
- Department of Surgery, 12224University of California San Francisco School of Medicine, San Francisco, CA, USA
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21
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Zhang S, Lin L, Zhang R, Wang M, Yu Y, Shi Z, Parsons M, Geng Y. Absent Contrast Filling of Ipsilateral Superficial Middle Cerebral Vein Predicts Midline Shift in Acute Middle Cerebral Artery Occlusion. Front Neurol 2020; 11:570844. [PMID: 33224087 PMCID: PMC7674643 DOI: 10.3389/fneur.2020.570844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/16/2020] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Midline shift is a life-threatening complication of acute large artery occlusion (LAO). The value of superficial middle cerebral vein (SMCV) for predicting midline shift is currently unclear for patients with acute LAO. Methods: Consecutive acute LAO (middle cerebral artery M1 ± intracranial internal carotid artery) patients between March 2018 and May 2019 were included. Absent filling of ipsilateral cortical vein (marked as SMCV–) was defined as no contrast filling into the vein across the whole venous phase of four-dimensional computed tomography (CT) angiography derived from CT perfusion in the ischemic hemisphere. Results: In the total of 81 patients, 31 (38.4%) were identified as SMCV–. SMCV– independently predicted midline shift, with sensitivity of 87.5% and specificity of 82.5%. Receiver operating characteristic analysis showed that including SMCV– as a predictor in addition to baseline ischemic core volume significantly increased the area under the curve in predicting midline shift (SMCV– with baseline ischemic core volume vs. baseline ischemic core volume: AUC = 0.903 vs. 0.841, Z = 2.451, P = 0.014). Conclusion: In acute LAO patients, the presence of SMCV– was a sensitive and specific imaging marker for midline shift. SMCV– had supplementary value to baseline ischemic core volume in predicting midline shift.
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Affiliation(s)
- Sheng Zhang
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Ruiting Zhang
- Department of Radiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Meiping Wang
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Yannan Yu
- School of Medicine, Stanford University, Los Angeles, CA, United States
| | - Zongjie Shi
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Mark Parsons
- Department of Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Yu Geng
- Department of Neurology, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
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22
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Ha BJ, Bae IS, Kim JM, Cheong JH, Ryu JI, Han MH. Effects of Possible Osteoporotic Conditions on the Recurrence of Chronic Subdural Hematoma. Front Neurol 2020; 11:538257. [PMID: 33071940 PMCID: PMC7542308 DOI: 10.3389/fneur.2020.538257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/27/2020] [Indexed: 01/30/2023] Open
Abstract
The recurrence rate of chronic subdural hematoma (CSDH) has been reported to range from 2.3 to 33%. As bridging veins are composed of abundant collagen bundles and bone matrix, we aimed to investigate the possible associations between skull Hounsfield unit (HU) values and the recurrence of CSDH. We retrospectively enrolled patients with CSDH who underwent burr hole surgery. The HU values of the frontal skull were measured on brain CT scans. The cumulative hazard for recurrence was estimated according to predictive factors. To identify the independent predictors associated with the recurrence of CSDH, hazard ratios (HRs) were estimated using multivariate Cox regression analysis. A total of 208 consecutive patients who underwent burr hole trephination for CSDH over a 7-years period at a single institution were enrolled in this study. We found that age, greater midline shift (≥10.5 mm), lower skull HU (<769.5), and diabetes were independent predictors for the recurrence of CSDH (HR 1.06, 95% confidence interval [CI] 1.00–1.12, p = 0.042; HR 5.37, 95% CI 1.48–19.46, p = 0.010; HR 6.71, 95% CI 1.84–24.45, p = 0.004; and HR 3.30, 95% CI 1.05–10.43, p = 0.042, respectively). A relationship between possible low bone mineral density (BMD) and CSDH recurrence was observed. In addition, age, greater preoperative midline shift, and diabetes were also identified as predictive factors for recurrence. We expect that our findings may facilitate our understanding of the possible association between CSDH and BMD.
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Affiliation(s)
- Byeong Jin Ha
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, South Korea
| | - In-Suk Bae
- Department of Neurosurgery, Eulji University Hospital, Seoul, South Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, South Korea
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Barton JJS, Ranalli PJ. Vision therapy: Occlusion, prisms, filters, and vestibular exercises for mild traumatic brain injury. Surv Ophthalmol 2020; 66:346-353. [PMID: 32827496 DOI: 10.1016/j.survophthal.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/04/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
A number of treatment approaches have been advocated for persistent visual complaints following mild traumatic brain injury. These include devices such as binasal occlusion, yoked prisms, vertical prisms, and filters, as well as vestibular training. We discuss the rationale and the evidence for each of these approaches. Binasal occlusion has been advocated for visual motion sensitivity, but it is not clear why this should help, and there is no good evidence for its symptomatic efficacy. Base-in prisms can help manage convergence insufficiency, but there are few data on their efficacy. Midline shift is an unproven concept, and while the yoked prisms advocated for its treatment may have some effect on egocentric neglect, their use in mild traumatic brain injury is more questionable. A wide variety of posttraumatic symptoms have been attributed to vertical heterophoria, but this is an unproven concept and there are no controlled data on the use of vertical prisms for mild traumatic brain injury symptoms. Filters could plausibly ameliorate light intolerance but studies are lacking. Better evidence is emerging for the effects of vestibular therapy, with a few randomized controlled trials that included blinded assessments and appropriate statistical analyses. Without more substantial evidence, the use of many of these techniques cannot be recommended and should be regarded as unproven and in some cases implausible.
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Affiliation(s)
- Jason J S Barton
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, Psychology, University of British Columbia, Vancouver, Canada.
| | - Paul J Ranalli
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, Otolaryngology, University of Toronto, Toronto, Canada
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24
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Volbers B, Niesen WD, Amiri-Soltani S, Staykov D, Shah MJ, Lang S, Lücking H, Kuramatsu JB, Huttner HB, Schwab S, Bardutzky J. Bedside Catheter Hematoma Evacuation in Vitamin K Antagonist-Related Intracerebral Hemorrhage: A Safe and Feasible Approach. Front Neurol 2020; 11:807. [PMID: 32922349 PMCID: PMC7456824 DOI: 10.3389/fneur.2020.00807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/29/2020] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: Although outcome in intracerebral hemorrhage (ICH) patients is generally not improved by surgical intervention, the use of minimally invasive surgery (MIS) has shown promising results. However, vitamin K antagonist (VKA)-related ICH patients are underrepresented in surgical treatment trials. We therefore assessed the safety and efficacy of a bedside MIS approach including local application of urokinase in VKA-related ICH. Methods: Patients with a VKA-related ICH > 20 ml who received bedside hematoma evacuation treatment (n = 21) at the University Medical Center Freiburg were retrospectively included for analysis and compared to a historical control group (n = 35) selected from an institutional database (University Medical Center Erlangen) according to identical inclusion criteria. Propensity score matching was performed to obtain comparable cohorts. The evolution of hematoma and peri-hemorrhagic edema (PHE) volumes, midline shift, and the occurrence of adverse events were analyzed. Furthermore, we assessed the modified Rankin Scale and NIHSS scores recorded at discharge. Results: Propensity score matching resulted in 16 patients per group with well-balanced characteristics. Median ICH volume at admission was 45.7 (IQR: 24.2-56.7) ml in the control group and 48.4 (IQR: 28.7-59.6) ml in the treatment group (p = 0.327). ICH volume at day 7 was less pronounced in the treatment group [MIS: 23.2 ml (IQR: 15.8-32.3) vs. control: 43.2 ml (IQR: 27.5-52.4); p = 0.013], as was the increase in midline shift up to day 7 [MIS: -3.75 mM (IQR: -4.25 to -2) vs. control: 1 mM (IQR: 0-2); p < 0.001]. No group differences were observed in PHE volume on day 7 [MIS: 42.4 ml (IQR: 25.0-72.3) vs. control: 31.0 ml (IQR: 18.8-53.8); p = 0.274] or mRS at discharge [MIS: 5 (IQR: 4-5) and 5 (IQR: 4-5); p = 0.949]. No hematoma expansion was observed. The catheter had to be replaced in 1 patient (6%). Conclusions: Bedside catheter-based hematoma evacuation followed by local thrombolysis with urokinase appears to be feasible and safe in cases of large VKA-related ICH. Further studies that assess the functional outcome associated with this technique are warranted. Clinical Trial Registration: DRKS00007908 (German Clinical Trial Register; www.drks.de).
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Dimitre Staykov
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Mukesch Johannes Shah
- Department of Neurosurgery, University Medical Center Freiburg, Freiburg im Breisgau, Germany
| | - Stefan Lang
- Department of Neuroradiology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Joji B. Kuramatsu
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Hagen B. Huttner
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany
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25
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio A, Diaz-Arrastia R, Okonkwo DO. Long-term outcome in traumatic brain injury patients with midline shift: a secondary analysis of the Phase 3 COBRIT clinical trial. J Neurosurg 2019; 131:596-603. [PMID: 30074459 DOI: 10.3171/2018.2.jns173138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Following traumatic brain injury (TBI), midline shift of the brain at the level of the septum pellucidum is often caused by unilateral space-occupying lesions and is associated with increased intracranial pressure and worsened morbidity and mortality. While outcome has been studied in this population, the recovery trajectory has not been reported in a large cohort of patients with TBI. The authors sought to utilize the Citicoline Brain Injury Treatment (COBRIT) trial to analyze patient recovery over time depending on degree of midline shift at presentation. METHODS Patient data from the COBRIT trial were stratified into 4 groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 days postinjury. A recovery trajectory analysis was performed identifying patients with outcome measures at all 3 time points to analyze the degree of recovery based on midline shift at presentation. RESULTS There were 892, 1169, and 895 patients with adequate outcome data at 30, 90, and 180 days, respectively. Rates of favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] scores 4-8) at 6 months postinjury were 87% for patients with no midline shift, 79% for patients with 1-5 mm of shift, 64% for patients with 6-10 mm of shift, and 47% for patients with > 10 mm of shift. The mean improvement from unfavorable outcome (GOS-E scores 2 and 3) to favorable outcome (GOS-E scores 4-8) from 1 month to 6 months in all groups was 20% (range 4%-29%). The mean GOS-E score for patients in the 6- to 10-mm group crossed from unfavorable outcome (GOS-E scores 2 and 3) into favorable outcome (GOS-E scores 4-8) at 90 days, and the mean GOS-E of patients in the > 10-mm group nearly reached the threshold of favorable outcome by 180 days postinjury. CONCLUSIONS In this secondary analysis of the Phase 3 COBRIT trial, TBI patients with less than 10 mm of midline shift on admission head CT had significantly improved functional outcomes through 180 days after injury compared with those with greater than 10 mm of midline shift. Of note, nearly 50% of patients with > 10 mm of midline shift achieved a favorable outcome (GOS-E score 4-8) by 6 months postinjury.
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Affiliation(s)
- Ross C Puffer
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - John K Yue
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | | | | | | | | | - Ava Puccio
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | - Ramon Diaz-Arrastia
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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26
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Kalli M, Voutouri C, Minia A, Pliaka V, Fotis C, Alexopoulos LG, Stylianopoulos T. Mechanical Compression Regulates Brain Cancer Cell Migration Through MEK1/Erk1 Pathway Activation and GDF15 Expression. Front Oncol 2019; 9:992. [PMID: 31612114 PMCID: PMC6777415 DOI: 10.3389/fonc.2019.00992] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/16/2019] [Indexed: 12/18/2022] Open
Abstract
Mechanical compression is a common abnormality of brain tumors that has been shown to be responsible for the severe neurological defects of brain cancer patients representing a negative prognostic factor. Indeed, it is of note that patients that undergo resection exhibited higher survival rates than those subjected to biopsy only, suggesting that compressive forces generated during brain tumor growth play a key role in tumor progression. Despite the importance of mechanical compression in brain tumors, there is a lack of studies examining its direct effects on brain cancer cells and the mechanisms involved. In the present study, we used two brain cancer cell lines with distinct metastatic potential, the less aggressive H4 and the highly aggressive A172 cell lines, in order to study the effect of compression on their proliferative and migratory ability. Specifically, we used multicellular tumor spheroids (MCS) embedded in agarose matrix to show that compression strongly impaired their growth. Using mathematical modeling, we estimated the levels of compressive stress generated during the growth of brain MCS and then we applied the respective stress levels on brain cancer cell monolayers using our previously established transmembrane pressure device. By performing a scratch assay, we found that compression strongly induced the migration of the less aggressive H4 cells, while a less pronounced effect was observed for A172 cells. Analysis of the gene expression profile of both cell lines revealed that GDF15 and small GTPases are strongly regulated by mechanical compression, while GDF15 was further shown to be necessary for cells to migrate under compression. Through a phospho-proteomic screening, we further found that compressive stimulus is transmitted through the MEK1/Erk1 signaling pathway, which is also necessary for the migration of brain cancer cells. Finally, our results gave the first indication that GDF15 could regulate and being regulated by MEK1/Erk1 signaling pathway in order to facilitate the compression-induced brain cancer cell migration, rendering them along with small GTPases as potential targets for future anti-metastatic therapeutic innovations to treat brain tumors.
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Affiliation(s)
- Maria Kalli
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
| | - Chrysovalantis Voutouri
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
| | | | | | - Christos Fotis
- Department of Mechanical Engineering, National Technical University of Athens, Athens, Greece
| | - Leonidas G Alexopoulos
- ProtATonce Ltd, Athens, Greece.,Department of Mechanical Engineering, National Technical University of Athens, Athens, Greece
| | - Triantafyllos Stylianopoulos
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
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27
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Labreche T, Wild B, Dalton K, Leat SJ. Post-stroke visual midline shift syndrome. Clin Exp Optom 2019; 103:290-295. [PMID: 31321827 DOI: 10.1111/cxo.12944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 03/13/2019] [Accepted: 06/24/2019] [Indexed: 11/27/2022] Open
Abstract
The state of research on the topic of visual midline shift syndrome following a cerebrovascular accident is unknown. A scoping review was conducted using the search terms of 'visual midline shift' (or equivalent) and 'cerebrovascular accident' (or equivalent). Articles were selected from eight academic and one grey literature database, and went through two levels of review, as per Arksey and O'Malley, before being deemed acceptable for inclusion. Of the 931 abstracts reviewed, 27 articles met the criteria for inclusion. Data extracted from the selected articles included terminology and definition, symptoms, underlying pathophysiology, duration, assessment method, and management of visual midline shift syndrome following cerebrovascular accident. There is agreement on the existence of a midline shift following a cerebrovascular accident resulting in poor posture and imbalance. Much uncertainty exists in the literature regarding terminology, underlying pathophysiology, assessment method and management of this condition. Further research is required.
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Affiliation(s)
- Tammy Labreche
- Waterloo School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada
| | - Benjamin Wild
- Waterloo School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada
| | - Kristine Dalton
- Waterloo School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada
| | - Susan J Leat
- Waterloo School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada
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28
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Huang LC, Liew HK, Cheng HY, Peng HF, Yang HI, Kuo JS, Hsu WL, Pang CY. Collagenase-Induced Rat Intra-Striatal Hemorrhage Mimicking Severe Human Intra-Striatal Hemorrhage. CHINESE J PHYSIOL 2018; 60:259-266. [PMID: 28950689 DOI: 10.4077/cjp.2017.baf478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Basal ganglia hemorrhage accounts for approximately 50% of all hemorrhagic strokes. A
good rat model that produces severe intrastriatal hemorrhage (ISH) mimicking human severe ISH is
lacking. The present study compared the intra-striatal injection of 0.2 U with that of 0.6 U of collagenase
in inducing severe ISH in rats. Three-Tesla (3T) magnetic resonance imaging (MRI) was used to
evaluate brain injuries in terms of hematoma size (volume), midline shift (MLS), and brain edema.
This evaluation was further substantiated by determination of behavior and neurologic functions and
mortality over 56 h. The 0.2 U collagenase caused hematoma volume increases for 10.3 to 30.1 mm³,
while the 0.6 U caused 36.4 to 114.8 mm³, at post-ISH 1 h to 56 h. The 0.6 U collagenase significantly
increased MLS to 1.5-3.0 times greater than the 0.2 U did at all post-intracerebral hemorrhage (ICH)
time points. The MLS increased dependently with hematoma expansion with high correlation coefficients,
yet no mortality occurred. These two dosages, nevertheless, caused the same pattern and severity
in relative apparent diffusion coefficient (rADC) changes for three regions of interest (ROIs).
Both ISH models induced consistent behavior deficits. The larger dosage produced severe brain
injuries as well as neurological deficits, more closely mimicking severe human ISH. Hematoma volume
and MLS can be the most useful parameters for evaluating the ISH severity in the present experimental
model. The larger dosage, therefore, would be useful for investigating the pathophysiology of the severer
ISH in the striatum. This may be applied for evaluating potential therapeutic strategies and
outcomes in the future.
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Affiliation(s)
- Li-Chuan Huang
- Department of Radiology, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC.,Insititute of Medical Sciences, Tzu Chi University, Hualien 97004, Taiwan, ROC
| | - Hock-Kean Liew
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC
| | - Hung-Yu Cheng
- Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien 97004, Taiwan, ROC
| | - Hsiao-Fen Peng
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC
| | - Hui-I Yang
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC
| | - Jon-Son Kuo
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC.,Master Program and PhD Program in Pharmacology and Toxicology, Tzu Chi University, Hualien 97004, Taiwan, ROC
| | - Wen-Lin Hsu
- Department of Radiation Oncology, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC
| | - Cheng-Yoong Pang
- Insititute of Medical Sciences, Tzu Chi University, Hualien 97004, Taiwan, ROC.,Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien 97002, Taiwan, ROC
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29
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Jeong WJ, Bang JS, Yum KS, Lee S, Chung I, Kwon OK, Oh CW, Kim BJ, Bae HJ, Han MK. Radiologic Measurement of Brain Swelling in Patients with Large Hemispheric Infarctions During Targeted Temperature Management. Ther Hypothermia Temp Manag 2018; 8:136-142. [PMID: 29447082 DOI: 10.1089/ther.2017.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Brain herniation is most often the result of severe brain swelling and can rapidly lead to death or brain death. We retrospectively identified radiologic indicators to evaluate the effects of targeted temperature management (TTM) on the extent of cerebral edema and determine the cutoff values that best predict TTM outcomes in patients with large hemispheric infarction. We retrospectively reviewed brain computed tomography (CT) scans of 21 patients with large hemispheric infarctions, who were treated with TTM. We excluded 4 patients whose CT scans were inadequate for evaluation, which left 17 patients. We divided the patients into success and failure groups. TTM failure was defined as death or the need for decompressive hemicraniectomy (DHC) after TTM. Infarction size was measured as the total restricted area in diffusion-weighted imaging that was performed on admission. CT scans were obtained on the first and second days after TTM initiation and then every 2 days. We measured septum pellucidum shifts (SPS) and pineal gland shifts (PGS) on CT scans. The median time from symptom onset to TTM initiation was 14.5 hours. Ten patients were successfully treated with TTM, six patients died, and one patient underwent a DHC. Initial infarction sizes were not significantly different between the success and failure groups (p = 0.529), but the SPS and PGS at 36-72 hours after TTM initiation were (mean SPS: 5.0 vs. 14.9 mm, p = 0.001; mean PGS: 2.3 vs. 7.9 mm, p = 0.001). The sensitivity and negative predictive value for TTM failure caused by cerebral edema (SPS ≥9.25 mm and PGS ≥3.70 mm) at 36-72 hours after TTM initiation were both 100%. The SPS and PGS on CT scans taken 36-72 hours after TTM initiation may help to estimate the effect of TTM on cerebral edema and guide further treatment.
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Affiliation(s)
- Won Joo Jeong
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Jae Seung Bang
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Kyu Sun Yum
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Sangkil Lee
- 3 Department of Neurology, Chungbuck National University Hospital , Cheongju, South Korea
| | - Inyoung Chung
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - O-Ki Kwon
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Chang Wan Oh
- 1 Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Beom Joon Kim
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Hee-Joon Bae
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
| | - Moon-Ku Han
- 2 Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine , Seongnam, South Korea
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Oliveira RAG, de Oliveira Lima M, Paiva WS, de Sá Malbouisson LM, Teixeira MJ, Bor-Seng-Shu E. Comparison between Brain Computed Tomography Scan and Transcranial Sonography to Evaluate Third Ventricle Width, Peri-Mesencephalic Cistern, and Sylvian Fissure in Traumatic Brain-Injured Patients. Front Neurol 2017; 8:44. [PMID: 28261152 PMCID: PMC5309239 DOI: 10.3389/fneur.2017.00044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/31/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction Transcranial color-coded duplex sonography (TCCS) may help guide multimodal monitoring in the neurocritical setting. It may provide indirect information about intracranial hypertension, such as midline shift, third ventricle width, and peri-mesencephalic cistern obliteration. We aim to assess the agreement between brain computed tomography scan (CT scan) and TCCS in traumatic brain injury (TBI) patients. Methods In this retrospective cross-sectional observational study, TCCS was performed within 6 h before a brain CT scan. Only the first CT and TCCS after ICU admission were included. The agreement between the CT scan and TCCS was assessed by Bland–Altman plots and evaluating the intraclass correlation coefficient. Results Overall, 15 consecutive patients were included (80% male, 42 ± 23 years of age, Glasgow Coma Score 5 [4,6]). The mean difference between the brain CT scan and TCCS in measuring the midline shift was 0.30 ± 2.1 mm (intraclass correlation coefficient: 0.93; p < 0.01). An excellent correlation was also observed between the methods in assessing the third ventricle width (intraclass correlation coefficient: 0.88; p < 0.01). Bland–Altman plots did not show any systematic bias in either agreement analysis. TCCS showed good accuracy in predicting non-compressed peri-mesencephalic cisterns (AUC: 0.83, 95% CI 0.46–1.0) and the presence of the Sylvian fissure (AUC: 0.91, 95% CI 0.73–1.0) on CT scan. Conclusion TCCS is a promising tool and may be an alternative to CT scans for evaluating TBI patients.
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Affiliation(s)
- Raphael A G Oliveira
- Intensive Care Unit, Discipline of General Surgery and Trauma, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
| | - Marcelo de Oliveira Lima
- Division of Neurosurgery, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
| | - Wellingson Silva Paiva
- Division of Neurosurgery, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
| | - Luiz Marcelo de Sá Malbouisson
- Intensive Care Unit, Discipline of General Surgery and Trauma, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
| | - Manuel Jacobsen Teixeira
- Division of Neurosurgery, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
| | - Edson Bor-Seng-Shu
- Division of Neurosurgery, Hospital das Clínicas, São Paulo University Medical School , São Paulo , Brazil
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Oliphant BJ, Barnes Heller HL, White JM. RETROSPECTIVE STUDY EVALUATING ASSOCIATIONS BETWEEN MIDLINE BRAIN SHIFT ON MAGNETIC RESONANCE IMAGING AND SURVIVAL IN DOGS DIAGNOSED WITH MENINGOENCEPHALITIS OF UNKNOWN ETIOLOGY. Vet Radiol Ultrasound 2016; 58:38-43. [PMID: 27774741 DOI: 10.1111/vru.12434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 08/31/2016] [Accepted: 09/04/2016] [Indexed: 12/01/2022] Open
Abstract
Difficulty has been encountered when trying to identify ante mortem prognostic indicators for dogs with meningoencephalitis of unknown etiology (MUE). Identifying MRI imaging parameters associated with prognosis may impact treatment decision-making for clinician and owner. Our hypotheses for this retrospective cohort study are that dogs diagnosed with MUE that had midline shift on brain MRI would have a poorer survival compared to dogs without midline shift; and that younger age, lower weight, and low cerebrospinal fluid (CSF) cell count would be correlated with improved survival. Medical records were reviewed from two institutions. Inclusion criteria included: clinical signs referable to intracranial disease, brain MRI at presentation, abnormal CSF analysis, and negative infectious disease testing. Magnetic resonance imaging scans were evaluated for midline shift using the T2-weighted transverse image at the interthalamic adhesion and at the site of maximal deviation. Fifty-two dogs met the inclusion criteria. Median midline deviation was 0.12 cm. Median survival for dogs with no shift was 906 days and with shift was 84 days. Survival was not significantly different between groups (P = 0.11). This remained true when correcting for age (P = 0.22) and CSF TNCC (total nucleated cell count) (P = 0.12). Age at the time of diagnosis (P = 0.02) and CSF TNCC (P = 0.03) were significantly associated with survival. Cerebrospinal fluid protein value (P = 0.84) and weight (P = 0.82) were not significantly associated with survival. In this study of 52 dogs with MUE, MRI evidence of midline brain shift between 0.04 and 0.3 cm at the level of the interthalamic adhesion was not associated with shorter survival.
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Affiliation(s)
- Bonnie J Oliphant
- Department of Medical Sciences, University of Wisconsin, Madison, WI, 53706
| | | | - Jennifer M White
- Department of Veterinary Specialty and Emergency Hospital, San Diego, CA, 92121
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Abstract
The most frequent cause of functional posterior crossbite is the reduction in width of the maxillary dental arch. This posterior crossbite is associated with anterior crowding which is presented as an infrapositioned canine or a palatally positioned lateral incisor on one side; this leads to an upper midline shift toward the crowded side. The present case report shows the management of posterior crossbite with functional shift and upper midline shift simultaneously without adverse side effects. In this case, rapid maxillary expansion along with fixed appliance is used to correct posterior crossbite with the upper dental midline shift using reciprocal action of elastic transseptal fibers.
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Affiliation(s)
- R Arvinth
- Centre for Dental Education and Research, Division of Orthodontics and Dentofacial Deformities, All India Institute of Medical Sciences, New Delhi, India
| | - Shailendra Singh Rana
- Centre for Dental Education and Research, Division of Orthodontics and Dentofacial Deformities, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Duggal
- Centre for Dental Education and Research, Division of Orthodontics and Dentofacial Deformities, All India Institute of Medical Sciences, New Delhi, India
| | - Om Prakash Kharbanda
- Centre for Dental Education and Research, Division of Orthodontics and Dentofacial Deformities, All India Institute of Medical Sciences, New Delhi, India
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Agrawal M, Agrawal JA, Nanjannawar L, Fulari S, Kagi V. Dentofacial Asymmetries: Challenging Diagnosis and Treatment Planning. J Int Oral Health 2015; 7:128-31. [PMID: 26229387 PMCID: PMC4513767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/15/2015] [Indexed: 12/04/2022] Open
Abstract
Dentofacial asymmetry is quite common and when sufficiently severe can require surgical orthodontic intervention. Asymmetries can be classified according to the structures involved into skeletal, dental and functional. In diagnosing asymmetries, a thorough clinical examination and radiographic survey are essential to determine the extent of soft tissue, skeletal, dental and functional involvement. Dental asymmetries, as well as a variety of functional deviations, can be managed orthodontically, whereas significant structural facial asymmetries require a comprehensive orthodontic and orthognathic management. With less severe dental, skeletal and soft tissue deviations the advisability of treatment should be carefully considered. The following article also contains a case report highlighting the importance of proper diagnosis in treatment plan for management of dentofacial asymmetry.
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Affiliation(s)
- Manish Agrawal
- Reader, Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India,Correspondence: Dr. Agrawal M. Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India. Phone: +91-9209038008. smilesandprofiles @ rediffmail.com
| | - Jiwan Asha Agrawal
- Professor & Head, Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India
| | - Lalita Nanjannawar
- Reader, Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India
| | - Sangamesh Fulari
- Reader, Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India
| | - Vishwal Kagi
- Lecturer, Department of Orthodontics, Bharati Dental College & Hospital, Sangli, Maharashtra, India
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Tóth A, Schmalfuss I, Heaton SC, Gabrielli A, Hannay HJ, Papa L, Brophy GM, Wang KKW, Büki A, Schwarcz A, Hayes RL, Robertson CS, Robicsek SA. Lateral Ventricle Volume Asymmetry Predicts Midline Shift in Severe Traumatic Brain Injury. J Neurotrauma 2015; 32:1307-11. [PMID: 25752227 DOI: 10.1089/neu.2014.3696] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Midline shift following severe traumatic brain injury (sTBI) detected on computed tomography (CT) scans is an established predictor of poor outcome. We hypothesized that lateral ventricular volume (LVV) asymmetry is an earlier sign of developing asymmetric intracranial pathology than midline shift. This retrospective analysis was performed on data from 84 adults with blunt sTBI requiring a ventriculostomy who presented to a Level I trauma center. Seventy-six patients underwent serial CTs within 3 h and an average of three scans within the first 10 d of sTBI. Left and right LVVs were quantified by computer-assisted manual volumetric measurements. LVV ratios (LVR) were determined on the admission CT to evaluate ventricular asymmetry. The relationship between the admission LVR value and subsequent midline shift development was tested using receiver operating characteristic (ROC) analysis, and odds ratio (OR) and relative risk tests. Sixty patients had no >5 mm midline shift on the initial admission scan. Of these, 15 patients developed it subsequently (16 patients already had >5 mm midline shift on admission scans). For >5 mm midline shift development, admission LVR of >1.67 was shown to have a sensitivity of 73.3% and a specificity of 73.3% (area under the curve=0.782; p<0.0001). LVR of >1.67 as exposure yielded an OR of 7.56 (p<0.01), and a risk ratio of 4.42 (p<0.01) for midline shift development as unfavorable outcome. We propose that LVR captures LVV asymmetry and is not only related to, but also predicts the development of midline shift already at admission CT examination. Lateral ventricles may have a higher "compliance" than midline structures to developing asymmetric brain pathology. LVR analysis is simple, rapidly accomplished and may allow earlier interventions to attenuate midline shift and potentially improve ultimate outcomes.
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Affiliation(s)
- Arnold Tóth
- 1 Department of Neurosurgery, University of Pécs , Pécs, Hungary
| | - Ilona Schmalfuss
- 2 Department of Radiology, University of Florida , Gainesville, Florida.,3 North Florida/South Georgia Veterans Administration , Gainesville, Florida
| | - Shelley C Heaton
- 4 Department of Clinical and Health Psychology, University of Florida , Gainesville, Florida
| | - Andrea Gabrielli
- 5 Department of Anesthesiology and Critical Care, University of Florida , Gainesville, Florida
| | - H Julia Hannay
- 6 Department of Psychology, University of Houston , Houston, Texas
| | - Linda Papa
- 7 Orlando Regional Medical Center , Orlando, Florida
| | - Gretchen M Brophy
- 8 Department of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University , Richmond, Virginia
| | - Kevin K W Wang
- 9 Center for Neuroproteomics and Biomarkers Research Departments of Psychiatry and Neuroscience McKnight Brain Institute, University of Florida , Gainesville, Florida
| | - András Büki
- 1 Department of Neurosurgery, University of Pécs , Pécs, Hungary
| | - Attila Schwarcz
- 1 Department of Neurosurgery, University of Pécs , Pécs, Hungary
| | | | | | - Steven A Robicsek
- 12 Departments of Anesthesiology and Neuroscience, University of Florida , Gainesville, Florida
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Hirono S, Kawauchi D, Higuchi Y, Setoguchi T, Kihara K, Horiguchi K, Kado K, Sato M, Fukuda K, Nakamura T, Saeki N, Yamakami I. Life-Threatening Intracranial Hypotension after Skull Base Surgery with Lumbar Drainage. J Neurol Surg Rep 2015; 76:e83-6. [PMID: 26251819 PMCID: PMC4520994 DOI: 10.1055/s-0035-1547369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/16/2014] [Indexed: 01/29/2023] Open
Abstract
Although lumbar drainage (LD) is widely used in skull base surgery (SBS), no cases with intracranial hypotension (IH) following LD-assisted SBS have been reported, and skull base surgeons lack awareness of this potentially life-threatening condition. We report two cases of IH after LD-assisted SBS, a spheno-orbital meningioma and an osteosarcoma in the orbit. Despite a minimal amount of cerebrospinal fluid (CSF) drainage and early LD removal, severe postural headache and even a deteriorating consciousness level were observed in the early postoperative course. Neuroimages demonstrated epidural fluid collections, severe midline shift, and tonsillar sag compatible with IH. Epidural blood patch (EBP) immediately and completely reversed the clinical and radiologic findings in both patients. IH should be included in the differential diagnosis of postural headache after LD-assisted SBS that can be managed successfully with EBP. Persistent leakage of CSF at the LD-inserted site leads to IH. Broad dural dissection and wide removal of bony structure may be involved in the midline shift. EBP should be performed soon after conservative management fails. Further reports will determine the risk factors for IH development following LD-assisted SBS.
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Affiliation(s)
- Seiichiro Hirono
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Daisuke Kawauchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Taiki Setoguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Kazunori Kihara
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Ken Kado
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Motoki Sato
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kazumasa Fukuda
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Takao Nakamura
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Naokatsu Saeki
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Iwao Yamakami
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
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