Prognostic significance of subdural hygroma for post-traumatic hydrocephalus after decompressive craniectomy in the traumatic brain injury setting: a systematic review and meta-analysis

Characteristics of Post-traumatic Shunt-dependent Hydrocephalus After Decompressive Craniectomy: Are Computed Tomography Scoring Systems Predictors?

OBJECTIVE

Traumatic brain injury (TBI) significantly contributes to morbidity rates. While computed tomography (CT) scoring systems have been recognized as predictive factors for TBI outcomes, their association with shunt dependency in patients undergoing decompressive craniectomy (DC) has not been investigated. This study aimed to evaluate the predictive utility of CT scoring systems concerning shunt-dependent hydrocephalus in patients post-DC for TBI.

METHODS

In this retrospective study, we enrolled 162 patients who underwent DC and survived more than 7 days following TBI. The pre-DC CT scans were evaluated using the Marshall, Rotterdam, and Helsinki CT scoring systems. The primary event of interest was shunt-dependent hydrocephalus during the follow-up period, with unfavorable outcomes denoted by a Glasgow Outcome Scale score ranging from 1 to 3.

RESULTS

Analysis of the CT scans showed that the Rotterdam scores had a mean of 4.81 ± 0.91 for the group with shunt-dependent hydrocephalus and 4.41 ± 1.24 for the non-shunt-dependent hydrocephalus group (P = 0.033). However, multivariate logistic regression revealed no significant correlation between the Rotterdam CT score and shunt-dependent hydrocephalus, showing an odds ratio of 1.09 and a 95% confidence interval of 0.71 to 1.67 (P = 0.684). Notably, the Kaplan-Meier outcome curves highlighted a pronounced difference between groups based on shunt dependency (log-rank test: P = 0.012).

CONCLUSIONS

The CT scoring systems proved insufficient for predicting shunt-dependent hydrocephalus following DC for TBI. However, our observations underscore a significant correlation between post-traumatic shunt dependency after DC and an increased incidence of unfavorable outcomes during long-term follow-up.

Cisternostomy is not beneficial to reduce the occurrence of post-traumatic hydrocephalus in Traumatic Brain Injury

BACKGROUND

The Cisternostomy is a novel surgical concept in the treatment of Traumatic Brain Injury (TBI), which can effectively drain the bloody cerebrospinal fluid from the skull base cistern, reduce the intracranial pressure, and improve the return of bone flap, but its preventive role in post-traumatic hydrocephalus (PTH) is unknow. The purpose of this paper is to investigate whether Cisternostomy prevents the occurrence of PTH in patients with moderate and severe TBI.

METHODS

A retrospective analysis of clinical data of 86 patients with moderate and severe TBI from May 2019 to October 2021 was carried out in the Brain Trauma Center of Tianjin Huanhu Hospital. Univariate analysis was performed to examine the gender, age, preoperative Glasgow Coma Scale (GCS) score, preoperative Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, the incidence of subdural fluid, and incidence of hydrocephalus in patients between the Cisternostomy group and the non-Cisternostomy surgery group. we also analyzed the clinical outcome indicators like GCS at discharge,6 month GOS-E and GOS-E ≥ 5 in two groups.Additionaly, the preoperative GCS score, decompressive craniectomy rate, age, and gender of patients with PTH and non hydrocephalus were compared. Further multifactorial logistic binary regression was performed to explore the risk factors for PTH. Finally, we conducted ROC curve analysis on the statistically significant results from the univariate regression analysis to predict the ability of each risk factor to cause PTH.

RESULTS

The Cisternostomy group had a lower bone flap removal rate(48.39% and 72.73%, p = 0.024)., higer GCS at discharge(11.13 ± 2.42 and 8.93 ± 3.31,p = 0.000) and better 6 month GOS-E(4.55 ± 1.26 and 3.95 ± 1.18, p = 0.029)than the non-Cisternostomy group However, there was no statistical difference in the incidence of hydrocephalus between the two groups (25.81% and 30.91%, p = 0.617). Moreover, between the hydrocephalus group and no hydrocephalus group,there were no significant differences in the incidence of gender, age, intracranial infection, and subdural fluid. While there were statistical differences in peroperative GCS score, Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, and the incidence of subdural fluid in the two groups, there was no statistical difference in the percentage of cerebral cisterns open drainage between the hydrocephalus group and no hydrocephalus group (32.00% and 37.70%, p = 0.617). Multifactorial logistic binary regression analysis results revealed that the independent risk factors for PTH were intracranial infection (OR = 18.460, 95% CI: 1.864-182.847 p = 0.013) and subdural effusion (OR = 10.557, 95% CI: 2.425-35.275 p = 0.001). Further, The ROC curve analysis showed that peroperative GCS score, Rotterdam CT score and subdural effusion had good ACU(0.785,0.730,and 0.749), with high sensitivity and specificity to predict the occurrence of PTH.

CONCLUSIONS

Cisternostomy may decrease morbidities associated with removal of the bone flap and improve the clinical outcome, despite it cannot reduce the disability rate in TBI patients.Intracranial infection and subdural fluid were found to be the independent risk factors for PTH in patients with TBI,and the peroperative GCS score, Rotterdam CT score and subdural effusion had higher sensitivity and specificity to predict the occurrence of PTH. And more importantly, no correlation was observed between open drainage of the cerebral cisterns and the occurrence of PTH, indicating that Cisternostomy may not be beneficial in preventing the occurrence of PTH in patients with moderate and severe TBI.

Post-traumatic hydrocephalus: An overview of classification, diagnosis, treatment, and post-treatment imaging evaluation

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The pathogenesis of PTH has not been fully clarified. At present, it is believed that the obstacles of cerebrospinal fluid (CSF) secretion, absorption and circulation pathways are the reasons for the development of PTH. However, recent studies have also suggested that the osmotic pressure load of CSF and the pathological changes of CSF dynamics are caused by the development of hydrocephalus. Therefore, a better understanding of the definition, classification, diagnostic criteria, treatment, and evaluation of post-treatment effects of PTH is critical for the effective prevention and treatment of PTH. In this paper, we reviewed the classification and diagnosis of PTH and focused on the treatment and the imaging evaluation of post-treatment effects of PTH. This review might provide a judgment criterion for diagnosis of PTH and a basis for the effective prevention and treatment of PTH in the future.

Risk factors of postoperative hydrocephalus following decompressive craniectomy for spontaneous intracranial hemorrhages and intraventricular hemorrhage

INTRODUCTION

Hydrocephalus is a complication of spontaneous intracerebral hemorrhage; however, its predictive relationship with hydrocephalus in this patient cohort is not understood. Here, we evaluated the incidence and risk factors of hydrocephalus after craniectomy.

METHODS

Retrospectively studied data from 39 patients in the same hospital from 2016/01 to 2020/12 and analyzed risk factors for hydrocephalus. The clinical data recorded included patient age, sex, timing of surgery, initial Glasgow Coma Scale score, intracerebral hemorrhage (ICH) score, alcohol consumption, cigarette smoking, medical comorbidity, and blood data. Predictors of patient outcomes were determined using Student t test, chi-square test, and logistic regression.

RESULTS

We recruited 39 patients with cerebral herniation who underwent craniectomy for spontaneous supratentorial hemorrhage. Persistent hydrocephalus was observed in 17 patients. The development of hydrocephalus was significantly associated with the timing of operation, cigarette smoking, and alcohol consumption according to the Student t test and chi-square test. Univariate and multivariate analyses suggested that postoperative hydrocephalus was significantly associated with the timing of surgery (P = .031) and cigarette smoking (P = .041).

DISCUSSION

The incidence of hydrocephalus in patients who underwent delayed operation (more than 4 hours) was lower than that in patients who underwent an operation after less than 4 hours. nonsmoking groups also have lower incidence of hydrocephalus. Among patients who suffered from spontaneous supratentorial hemorrhage and need to receive emergent craniectomy, physicians should be reminded that postoperative hydrocephalus followed by ventriculoperitoneal shunting may be necessary in the future.

Incidence of surgically treated post-traumatic hydrocephalus 6 months following head injury in patients undergoing acute head computed tomography

BACKGROUND

Post-traumatic hydrocephalus (PTH) is a well-known complication of head injury. The percentage of patients experiencing PTH in trauma cohorts (0.7-51.4%) varies greatly in the prior literature depending on the study population and applied diagnostic criteria. The objective was to determine the incidence of surgically treated PTH in a consecutive series of patients undergoing acute head computed tomography (CT) following injury.

METHODS

All patients (N = 2908) with head injuries who underwent head CT and were treated at the Tampere University Hospital's Emergency Department (August 2010-July 2012) were retrospectively evaluated from patient medical records. This study focused on adults (18 years or older) who were residents of the Pirkanmaa region at the time of injury and were clinically evaluated and scanned with head CT at the Tampere University Hospital's emergency department within 48 h after injury (n = 1941). A thorough review of records for neurological signs and symptoms of hydrocephalus was conducted for all patients having a radiological suspicion of hydrocephalus. The diagnosis of PTH was based on clinical and radiological signs of the condition within 6 months following injury. The main outcome was surgical treatment for PTH. Clinical evidence of shunt responsiveness was required to confirm the diagnosis of PTH.

RESULTS

The incidence of surgically treated PTH was 0.15% (n = 3). Incidence was 0.08% among patients with mild traumatic brain injury (TBI) and 1.1% among those with moderate to severe TBI. All the patients who developed PTH underwent neurosurgery during the initial hospitalization due to the head injury. The incidence of PTH among patients who underwent neurosurgery for acute traumatic intracranial lesions was 2.7%.

CONCLUSION

The overall incidence of surgically treated PTH was extremely low (0.15%) in our cohort. Analyses of risk factors and the evaluation of temporal profiles could not be undertaken due to the extremely small number of cases.

Scenario for the use of effusion-peritoneal shunt necessary against subdural effusion secondary to decompressive craniectomy

OBJECTIVES

This study aimed to summarize the surgical strategies for subdural effusion secondary to decompressive craniectomy (SESDC) and discuss the applicable scenarios of effusion-peritoneal shunt (EP shunt).

METHODS

A total of 53 consecutive patients with SESDC were screened out of 7569 cases. The SESDC was divided into five types, and the treatment methods of each type were analyzed and compared. According to the implementation strategy of cranioplasty (CP), patients were divided into CP-first and delayed-CP groups. The differences in surgical methods were compared between the two groups.

RESULTS

All patients with SESDC in this cohort had undergone cranioplasty. Subcutaneous puncture and aspiration (SPAA) proved ineffective. Only 2/30 patients in the CP-first group used EP shunt, while 6/19 patients in the delayed-CP group used EP shunt; the difference was statistically significant (P = 0.03). A significant difference was found in the use of EP shunt among type 1, type 2, and type 5 SESDC (χ² = 6.778, P = 0.034).

CONCLUSIONS

CP combined with other treatments could cure most SESDC. EP shunt should be used preferentially in some specific scenarios in which CP cannot be performed first, rather than as a backup measure that can only be used when other preceding treatments fail.