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Konar SK, Dinesh YS, Shukla D, Nadeem M, Sadashiva N, S LT, Deora H, Singh GJ, Shanbhag NC. Decompressive craniectomy in children: indications and outcome from a tertiary centre. Childs Nerv Syst 2024:10.1007/s00381-024-06513-6. [PMID: 38953913 DOI: 10.1007/s00381-024-06513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION The role of decompressive craniectomy (DC) is as a rescue therapy for the treatment of intracranial hypertension. The indications for the DC are variable. METHODS The clinical details, imaging, operative findings and follow-up data of children less than or equal to 18 years of age were reviewed for more information on the children who underwent DC in the last 5 years. RESULTS During the study period, a total of 128 children underwent DC. The trauma cases were 66, and the non-trauma cases were 62. The common indication for DC was pure acute subdural hematoma 33 (50%), followed by contusion 10 (15%) in the trauma group, and in non-trauma, arterial infarction in 20 (32%) and cerebral venous thrombosis in 17 (27%). Hemicraniectomy was done in 114 (89%), and bifrontal craniectomy was done in 7 (5.4%) cases. The median duration follow-up was 7 months in non-trauma and 6 months in trauma. GCS was less than 8, the motor score was less than 3, and pupillary asymmetry, hypotension and basal cistern effacement were factors related to an unfavourable outcome in the non-trauma group. In regression analysis, only a motor score of less than three was associated with the non-trauma group. Age less than 10 years, GCS less than 8, motor score less than three and preoperative infarction were the predictive factors in univariate analysis, and only GCS less than 8 was the predictive factor for unfavourable factors in regression analysis in the trauma group. CONCLUSION The DC is performed as a lifesaving procedure. The unfavourable outcome is slightly higher in non-trauma cases compared to trauma cases. However, the mortality rate is high in trauma cases.
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Affiliation(s)
- Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India.
| | - Y S Dinesh
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Mohammed Nadeem
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Lingaraju T S
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Gyani Jail Singh
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health, and Neurosciences (NIMHANS), Bengaluru, 560029, Karnataka, India
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Yew WX, Lee JH, Dang H, Low SYY, Sri Dewi D, Chong SL. Decompressive Craniectomy in Pediatric Traumatic Brain Injury: A Retrospective Cohort Study. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1761939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
AbstractDecompressive craniectomy (DC) in children with traumatic brain injury (TBI) and refractory raised intracranial pressure (ICP) remains controversial. We aimed to describe the clinical and operative characteristics of children with moderate to severe TBI who underwent DC, and compare outcomes with those who had medical therapy. We performed a retrospective observational cohort study on children < 16 years of age with moderate to severe TBI (Glasgow coma scale [GCS] ≤13) who underwent DC in two pediatric centers in Singapore and China between 2014 and 2017, and compared their outcomes with children who underwent medical treatment, among participating centers of the Pediatric Acute and Critical Care Medicine Asian Network. We defined poor functional outcomes as moderate, severe disability, vegetative or comatose state, or mortality, using the Pediatric Cerebral Performance Category scale. We performed multivariable logistic regression to identify predictors for poor functional outcomes. We analyzed 18 children who underwent DC with 214 who had medical therapy. A greater proportion of children with DC (14, 77.8%) experienced poor functional outcomes, compared with those with medical therapy (87, 41.2%, p = 0.003). Children who underwent DC had fewer median 14-day intensive care unit (ICU)-free days (2.5 days, interquartile range [IQR]: 0.0–5.8 vs. 8.0 days, IQR: 0.0–11.0, p = 0.033), median 28-day hospital-free days (0 day, IQR: 0.0–3.5 vs. 11.0 days, IQR: 0.0–21.0, p = 0.002) and 14-day mechanical ventilation-free days (6.5 days, IQR: 0.0–12.3 vs. 11.0 days, IQR: 3.0–14.0, p = 0.011). After accounting for age, sex, GCS, cerebral edema, uncal herniation, nonaccidental injury, and need for intubation, there was no significant association between DC and poor functional outcomes (adjusted odds ratio: 1.59, 95% confidence interval: 0.35–7.24, p = 0.548). Children with DC had severe injuries, and prolonged hospital and ICU stays. Future studies are needed to understand the effectiveness of DC on children with TBI.
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Affiliation(s)
- Wan Xin Yew
- Ministry of Health Holdings, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Hongxing Dang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Singhealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, Singapore
| | - Dianna Sri Dewi
- Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Beez T, Schuhmann MU, Frassanito P, Di Rocco F, Thomale UW, Bock HC. Protocol for the multicentre prospective paediatric craniectomy and cranioplasty registry (pedCCR) under the auspices of the European Society for Paediatric Neurosurgery (ESPN). Childs Nerv Syst 2022; 38:1461-1467. [PMID: 35532778 PMCID: PMC9325798 DOI: 10.1007/s00381-022-05540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In the paediatric age group, the overall degree of evidence regarding decompressive craniectomy (DC) and cranioplasty is low, whereas in adults, randomised controlled trials and prospective multicentre registries are available. To improve the evidence-based treatment of children, a consensus was reached to establish a prospective registry under the auspices of the European Society for Pediatric Neurosurgery (ESPN). METHODS This international multicentre prospective registry is aimed at collecting information on the indication, timing, technique and outcome of DC and cranioplasty in children. The registry will enrol patients ≤ 16 years of age at the time of surgery, irrespective of the underlying medical condition. The study design comprises four obligatory entry points as a core dataset, with an unlimited number of further follow-up entry points to allow documentation until adolescence or adulthood. Study centres should commit to complete data entry and long-term follow-up. RESULTS Data collection will be performed via a web-based portal (homepage: www.pedccr.com ) in a central anonymised database after local ethics board approval. An ESPN steering committee will monitor the project's progress, coordinate analyses of data and presentation of results at conferences and in publications on behalf of the study group. CONCLUSION The registry aims to define predictors for optimal medical care and patient-centred treatment outcomes. The ultimate goal of the registry is to generate results that are so relevant to be directly transferred into clinical practice to enhance treatment protocols.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-Universität, Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Martin U. Schuhmann
- grid.411544.10000 0001 0196 8249Pediatric Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Paolo Frassanito
- grid.414603.4Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Di Rocco
- grid.414103.3Service de Neurochirurgie Pédiatrique, Hôpital Femme Mère Enfant, Lyon, France
| | - Ulrich W. Thomale
- grid.6363.00000 0001 2218 4662Pediatric Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans Christoph Bock
- grid.411984.10000 0001 0482 5331Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
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Bruns N, Kamp O, Lange KM, Lefering R, Felderhoff-Muser U, Dudda M, Dohna-Schwake C. Functional short-term outcomes and mortality in children with severe traumatic brain injury - comparing decompressive craniectomy and medical management. J Neurotrauma 2021; 39:944-953. [PMID: 34877889 PMCID: PMC9248344 DOI: 10.1089/neu.2021.0378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of decompressive craniectomy (DC) on functional outcomes and mortality in children after severe head trauma is strongly debated. The lack of high-quality evidence poses a serious challenge to neurosurgeons' and pediatric intensive care physicians' decision making in critically ill children after head trauma. This study was conducted to compare DC and medical management in severely head-injured children with respect to short-term outcomes and mortality. Data on patients < 18 years of age treated in Germany, Austria, and Switzerland during a ten-year period were extracted from TraumaRegister DGU®, forming a retrospective multi-center cohort study. Descriptive and multivariable analyses were performed to compare outcomes and mortality after DC and medical management. Of 2507 patients, 402 (16.0 %) received DC. Mortality was 20.6 % after DC and 13.7 % after medical management. Poor outcome (death or vegetative state) occurred in 27.6 % after DC and in 16.1 % after medical management. After risk adjustment by logistic regression modeling, the odds ratio was 1.56 (95% confidence interval 1.01-2.40) for poor outcome at intensive care unit discharge and 1.20 (0.74-1.95) for mortality after DC. In summary, DC was associated with increased odds for poor short-term outcomes in children with severe head trauma. This finding should temper enthusiasm for DC in children until a large randomized controlled trial has answered more precisely if DC in children is beneficial or increases rates of vegetative state.
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Affiliation(s)
- Nora Bruns
- University Hospital Essen, 39081, Department of Pediatrics I, Essen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Oliver Kamp
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Nordrhein-Westfalen, Germany;
| | - Kim Melanie Lange
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
| | - Rolf Lefering
- Witten/Herdecke University, 12263, Institute for Research in Operative Medicine, Witten, Nordrhein-Westfalen, Germany;
| | - Ursula Felderhoff-Muser
- University Hospital Essen, 39081, Department of Pediatrics I , Essen, Nordrhein-Westfalen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Marcel Dudda
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
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Li X, Wang H, Gao Y, Li L, Tang C, Wen G, Zhou Y, Zhou M, Mao L, Fan Y. Protective Effects of Quercetin on Mitochondrial Biogenesis in Experimental Traumatic Brain Injury via the Nrf2 Signaling Pathway. PLoS One 2016; 11:e0164237. [PMID: 27780244 PMCID: PMC5079551 DOI: 10.1371/journal.pone.0164237] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/21/2016] [Indexed: 01/17/2023] Open
Abstract
The present investigation was carried out to elucidate a possible molecular mechanism related to the protective effect of quercetin administration against oxidative stress on various mitochondrial respiratory complex subunits with special emphasis on the role of nuclear factor erythroid 2-related factor 2 (Nrf2) in mitochondrial biogenesis. Recently, quercetin has been proved to have a protective effect against mitochondria damage after traumatic brain injury (TBI). However, its precise role and underlying mechanisms in traumatic brain injury are not yet fully understood. The aim of the present study was to investigate the effect of quercetin on the potential mechanism of these effects in a weight-drop model of TBI in male mice that were treated with quercetin or vehicle via intraperitoneal injection administrated 30 min after TBI. In this experiment, ICR mice were divided into four groups: A sham group, TBI group, TBI + vehicle group, and TBI + quercetin group. Brain samples were collected 24 h later for analysis. Quercetin treatment resulted in an upregulation of Nrf2 expression and cytochrome c, malondialdehyde (MDA) and superoxide dismutase (SOD) levels were restored by quercetin treatment. Quercetin markedly promoted the translocation of Nrf2 protein from the cytoplasm to the nucleus. These observations suggest that quercetin improves mitochondrial function in TBI models, possibly by activating the Nrf2 pathway.
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Affiliation(s)
- Xiang Li
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Yongyue Gao
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Liwen Li
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Guodao Wen
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Yuan Zhou
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Mengliang Zhou
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Lei Mao
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
| | - Youwu Fan
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing, Jiangsu Province, 210002, China
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Zhai X, Ding Y, Wang Q, Zhang H, Li F. Rutin Acid Ameliorates Neural Apoptosis Induced by Traumatic Brain Injury via Mitochondrial Pathways in Mice. Neuroimmunomodulation 2016; 23:179-187. [PMID: 27644033 DOI: 10.1159/000448716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/26/2016] [Indexed: 11/19/2022] Open
Abstract
Rutin reportedly conveys many beneficial effects, including neuroprotection in brain injury. However, the mechanisms underlying these effects are still not well understood. This study investigates the effect of rutin on potential mechanisms for neuroprotective effects, using the weight-drop model of traumatic brain injury (TBI) in male mice treated either with rutin or a vehicle via intraperitoneal injection 30 min after TBI. After euthanasia and 24 h after TBI, all mice were examined by tests, including neurologic scores, blood-brain barrier permeability, brain water content and neuronal cell death in the cerebral cortex. Results indicate that the levels of cytochrome c, malondialdehyde (MDA) and superoxide dismutase (SOD) were restored by rutin treatment. Rutin treatment resulted in the downregulation of caspase-3 expression in a reduced number of positive cells under terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay, and also the improved survival of neurons. Furthermore, pretreatment levels of MDA were restored, while Bcl-2-associated X protein translocation to mitochondria and cytochrome c release into cytosol were reduced by rutin treatment. Our results demonstrate that rutin improves neurological outcome by protecting neural cells against apoptosis via mechanisms that involve the mitochondria following TBI.
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Affiliation(s)
- Xiaofu Zhai
- Department of Neurosurgery, Huai'an Second People's Hospital, Xuzhou Medical College, Huai'an, China
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