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Shoaib A, Hussain F, Khan M, Sohail A, Hasnain Panjwani M, Talal Ashraf M, Choudhary A. Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis. J Clin Neurosci 2024; 124:154-168. [PMID: 38718611 DOI: 10.1016/j.jocn.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure. AIM To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH. METHODS After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied. RESULTS Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02). CONCLUSION Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.
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Affiliation(s)
- Areeba Shoaib
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Fakiha Hussain
- Department of Medicine, Liaquat College of Medicine and Dentistry, Karachi, Pakistan
| | - Maryam Khan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Affan Sohail
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Anood Choudhary
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
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Shafique MA, Mustafa MS, Luke-Wold B, Kumar A, Rangwala BS, Abdullah M, Ali SMS, Iqbal J, Haseeb A. Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy. Acta Neurochir (Wien) 2024; 166:121. [PMID: 38436794 DOI: 10.1007/s00701-024-06013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. MATERIALS AND METHODS We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. RESULTS We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). CONCLUSION Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.
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Affiliation(s)
- Muhammad Ashir Shafique
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Muhammad Saqlain Mustafa
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Brandon Luke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Aashish Kumar
- Department of Neurosurgery, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75010, Pakistan
| | - Burhanuddin Sohail Rangwala
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Abdullah
- Department of Neurosurgery, Rai Medical College, Lahore Road, Sargodha City, 40100, Punjab, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Neurosurgery, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, 74800, Pakistan
| | - Javed Iqbal
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
| | - Abdul Haseeb
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
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Beucler N. Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article. Asian J Neurosurg 2023; 18:454-467. [PMID: 38152528 PMCID: PMC10749853 DOI: 10.1055/s-0043-1772763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
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Castaño-Leon AM, Gómez PA, Paredes I, Munarriz PM, Panero I, Eiriz C, García-Pérez D, Lagares A. Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis. J Neurosurg Sci 2023; 67:83-92. [PMID: 32972116 DOI: 10.23736/s0390-5616.20.05034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. METHODS We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. RESULTS The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). CONCLUSIONS According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.
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Affiliation(s)
- Ana M Castaño-Leon
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain -
| | - Pedro A Gómez
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Irene Panero
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Carla Eiriz
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Daniel García-Pérez
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, i+12-CIBERESP Research Institute, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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Jost JN. Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review. Cureus 2022; 14:e29894. [PMID: 36348855 PMCID: PMC9631546 DOI: 10.7759/cureus.29894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC) remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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Kim H, Suh SJ, Kang HJ, Lee MS, Lee YS, Lee JH, Kang DG. Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group. Korean J Neurotrauma 2018; 14:14-19. [PMID: 29774193 PMCID: PMC5949517 DOI: 10.13004/kjnt.2018.14.1.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/22/2018] [Accepted: 04/10/2018] [Indexed: 11/15/2022] Open
Abstract
Objective Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. Methods The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. Results Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p<0.001), coexistence of intraventricular hemorrhage (IVH) (p<0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p<0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p<0.001). Conclusion An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.
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Affiliation(s)
- Hyunjun Kim
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Sang-Jun Suh
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Ho-Jun Kang
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Min-Seok Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Yoon-Soo Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Jeong-Ho Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Dong-Gee Kang
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
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9
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Weimer JM, Gordon E, Frontera JA. Predictors of Functional Outcome After Subdural Hematoma: A Prospective Study. Neurocrit Care 2017; 26:70-79. [PMID: 27230968 DOI: 10.1007/s12028-016-0279-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the incidence of subdural hematoma (SDH) has increased in the US in the last decade, limited prospective data exist examining risk factors for poor outcome. METHODS A prospective, observational study of consecutive SDH patients was conducted from 7/2008 to 11/2011. Baseline clinical data, hospital and surgical course, complications, and imaging data were compared between those with good versus poor 3-month outcomes (modified Rankin Scores [mRS] 0-3 vs. 4-6). A multivariable logistic regression model was constructed to identify independent predictors of poor outcome. RESULTS 116 SDH patients (18 acute, 56 mixed acute/subacute/chronic, 42 subacute/chronic) were included. At 3 months, 61 (53 %) patients had good outcomes (mRS 0-3) while 55 (47 %) were severely disabled or dead (mRS 4-6). Of those who underwent surgical evacuation, 54/94 (57 %) had good outcomes compared to 7/22 (32 %) who did not (p = 0.030). Patients with mixed acuity or subacute/chronic SDH had significantly better 3-month mRS with surgery (median mRS 1 versus 5 without surgery, p = 0.002) compared to those with only acute SDH (p = 0.494). In multivariable analysis, premorbid mRS, age, admission Glasgow Coma Score, history of smoking, and fever were independent predictors of poor 3-month outcome (all p < 0.05; area under the curve 0.90), while SDH evacuation tended to improve outcomes (adjusted OR 3.90, 95 % CI 0.96-18.9, p = 0.057). CONCLUSIONS Nearly 50 % of SDH patients were dead or moderate-severely disabled at 3 months. Older age, poor baseline, poor admission neurological status, history of smoking, and fever during hospitalization predicted poor outcomes, while surgical evacuation was associated with improved outcomes among those with mixed acuity or chronic/subacute SDH.
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Affiliation(s)
- Jonathan M Weimer
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA
| | - Errol Gordon
- Neuroscience Intensive Care Unit, Department of Critical Care, Mount Sinai School of Medicine, New York, NY, USA
| | - Jennifer A Frontera
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA.
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Phan K, Moore JM, Griessenauer C, Dmytriw AA, Scherman DB, Sheik-Ali S, Adeeb N, Ogilvy CS, Thomas A, Rosenfeld JV. Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: Systematic Review and Meta-Analysis. World Neurosurg 2017; 101:677-685.e2. [DOI: 10.1016/j.wneu.2017.03.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 01/01/2023]
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11
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Kinoshita T, Yoshiya K, Fujimoto Y, Kajikawa R, Kiguchi T, Hara M, Wakayama A, Yoshimine T. Decompressive Craniectomy in Conjunction With Evacuation of Intracranial Hemorrhagic Lesions Is Associated With Worse Outcomes in Elderly Patients With Traumatic Brain Injury: A Propensity Score Analysis. World Neurosurg 2016; 89:187-92. [PMID: 26851740 DOI: 10.1016/j.wneu.2016.01.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/17/2016] [Accepted: 01/19/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND When it comes to evacuating intracranial hemorrhagic lesions in patients with traumatic brain injury (TBI), neurosurgeons perform either a craniotomy or a decompressive craniectomy (DC). The aim of the present study was to estimate the impact of DC on outcomes in elderly patients. METHODS This retrospective cohort study, conducted in a neurosurgical institute in Japan from April 2009 to June 2014, included 91 consecutive patients with TBI (aged 60 years or older) who underwent evacuation of intracranial hemorrhagic lesions. Patients were divided into 2 groups: craniotomy only or DC. We set the primary endpoint as an unfavorable outcome (death or vegetative state), as evaluated on the Glasgow Outcome Scale at 6 months after injury. The secondary endpoints included existence of delayed hemorrhage and occurrence of hydrocephalus requiring shunt placement. The inverse probability of treatment weighting method was used to develop a propensity model to adjust for baseline imbalances between groups. RESULTS The DC group exhibited greater severity both in clinical and computed tomography findings according to baseline characteristics. After we adjusted for these differences by inverse probability of treatment weighting using the propensity score, DC was significantly associated with unfavorable outcomes (adjusted odds ratio, 8.00; 95% confidential interval, 2.30-27.84; P = 0.002) and delayed hemorrhage (adjusted odds ratio, 13.42; 95% confidential interval, 1.52-118.89; P = 0.022). There was no significant difference in the occurrence of hydrocephalus requiring shunt placement. CONCLUSIONS DC in conjunction with evacuation of intracranial hemorrhagic lesions was associated with worse functional outcome in elderly patients with TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan; Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan.
| | - Kazuhisa Yoshiya
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasunori Fujimoto
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Ryuichiro Kajikawa
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Takeyuki Kiguchi
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Masahiko Hara
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Suita, Japan; Department of Medical Innovation, Osaka University Hospital, Suita, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Toshiki Yoshimine
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
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12
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Kühne CA, Mand C, Lefering R, Lendemans S, Ruchholtz S. [Urgency of neurosurgical interventions for severe traumatic brain injury]. Unfallchirurg 2013; 116:39-46. [PMID: 21604029 DOI: 10.1007/s00113-011-2042-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to assess whether the time interval between accident and neurosurgical intervention has an influence on functional neurological outcome and mortality in severe traumatic brain injury (sTBI) or whether the further clinical course has already been determined by the initial severity of the injury. METHODS Data were derived from the Trauma Registry of the German Society of Trauma Surgery. A total of 770 patients were identified who had undergone decompressive surgery, had an ISS ≥ 9 and for whom time of accident and start of surgery had been documented. To evaluate the possible influence of the time factor on outcome and mortality, these patients were subdivided into five groups according to time until decompression (I: < 2 h, II: 2-3 h, III: 3-6 h, IV: 6-24 h and V: > 24 h). Aside from mortality we analysed AIS, GCS, age and ISS in survivors and non-survivors. RESULTS Complete data were available for 770 patients with sTBI (AIS skull ≥3). The average age was 39.9 years and 71.6% were male. The average overall injury severity was reflected by an ISS score of 31.3 and the average AIS head score was 4.51. Of the 570 who underwent surgery in less than 6 h (groups 1-III), 33% died (188/570). Of the remaining 200 patients 40 died (20%). Mortality decreased throughout the groups (49 to 14%), as did the severity of the head injury (AIS 4.66 to 4.23); GCS on the other hand increased with the time between accident and surgery (5.9 to 8.8). CONCLUSION We could not substantiate that reducing the time between accident and neurosurgical decompression could decrease mortality. It rather seems that the initial magnitude of brain damage determines prognosis and outcome after sTBI. The interval between the appearance of neurological symptoms (e.g. anisocoria) and neurosurgical intervention plays an important role and should be kept as short as possible.
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Affiliation(s)
- C A Kühne
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstraße 1, 35043 Marburg.
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13
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Li LM, Kolias AG, Guilfoyle MR, Timofeev I, Corteen EA, Pickard JD, Menon DK, Kirkpatrick PJ, Hutchinson PJ. Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy. Acta Neurochir (Wien) 2012; 154:1555-61. [PMID: 22752713 DOI: 10.1007/s00701-012-1428-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/12/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model. METHODS Retrospective review of prospectively collected data. RESULTS Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR. CONCLUSIONS CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.
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Affiliation(s)
- Lucia M Li
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
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14
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Comparison of Craniotomy and Decompressive Craniectomy in Severely Head-Injured Patients With Acute Subdural Hematoma. ACTA ACUST UNITED AC 2011; 71:1632-6. [DOI: 10.1097/ta.0b013e3182367b3c] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wong GKC, Graham CA, Ng E, Yeung JHH, Rainer TH, Poon WS. Neurological outcomes of neurosurgical operations for multiple trauma elderly patients in Hong Kong. J Emerg Trauma Shock 2011; 4:346-50. [PMID: 21887023 PMCID: PMC3162702 DOI: 10.4103/0974-2700.83861] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 02/08/2011] [Indexed: 11/10/2022] Open
Abstract
Background: We aimed to investigate neurological outcomes in elderly patients with multiple trauma, and to review their clinical outcomes following neurosurgical operations. Patients and Methods: The study was conducted in a regional trauma center in Hong Kong. We collected prospective data on consecutive trauma patients from January 2001 to December 2008. Patients with multiple trauma (as defined by Injury Severity Score of 15 or more), with both head injury and extracranial injury, were included for analysis. Results: Age over 65 years, admission Glasgow Coma Scale (GCS), and Injury Severity Score were significantly poor prognostic factors in logistic regression analysis. Eleven (32%) of the 34 patients aged over 65 who underwent neurosurgical operations attained favorable neurological outcomes (GCS 4-5) at 6 months. Conclusions: Age was an important prognostic factor in multiple trauma patients requiring neurosurgical operations. Future randomized controlled clinical trials should be designed to recruit elderly patients (such as age between 65 and 75 years) at clinical equipoise for traumatic hematoma (such as subdural hematoma or traumatic intracerebral hematoma) evacuation and assess the quality of life, neurological, and cognitive outcomes.
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Affiliation(s)
- George K C Wong
- Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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Abstract
Decompressive craniectomy (DC) is the surgical management removing part of the skull vault over a swollen brain used to treat elevated intracranial pressure that is unresponsive to maximal medical therapy. The commonest indication for DC is traumatic brain injury (TBI) or middle cerebral artery (MCA) infarction, though DC has been reported to have been used for treatment of aneurysmal subarachnoid haemorrhage and venous infarction. Despite an increasing number of reports supportive of DC, the controversy over the suitability of the procedure and criteria for patient selection remains unresolved. Although the majority of published studies are retrospective, the recent publication of several randomised prospective studies prompts a re-evaluation of the use of DC. We review the literature concerning the pathophysiology, indication, surgical techniques and timing, complications and long-term effects of DC (including reversal with cranioplasty), in order to rationalise its use. We conclude that at the time of this review, though we cannot support the routine use of DC in TBI or MCA stroke, there is evidence that early and aggressive use of DC in TBI patients with intracranial haematomas or younger malignant MCA stroke patients may improve outcome. Though the results of the DECRA trial suggest that primary DC may worsen outcome, the decision to perform DC after diffuse TBI is still individualised. We await the results of the RESCUEicp trial to ascertain whether an evidence-based protocol for its use can be agreed in the future.
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Affiliation(s)
| | - A Tarnaris
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
| | - J Wasserberg
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, UK
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Wong GKC, Leung BYL, So SSM, Lam SW, Poon WS. Long-term quality of life outcome (SF-36) in traumatic acute subdural hematoma patients. Acta Neurochir (Wien) 2011; 153:107-8. [PMID: 21052743 DOI: 10.1007/s00701-010-0855-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 10/23/2010] [Indexed: 10/18/2022]
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