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Farsi S, Odom JQ, Gardner JR, Held M, King D, Sunde J, Vural E, Moreno MA. Oncological outcomes of partial thickness calvarial resection for locally advanced scalp malignancies. Am J Otolaryngol 2024; 45:104456. [PMID: 39106682 DOI: 10.1016/j.amjoto.2024.104456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 07/30/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Traditionally, locally advanced scalp malignancies have been managed through composite, full-thickness calvarial resection. The aim of this study is to explore the oncologic outcomes of partial calvarial resection for locally invasive scalp malignancies without medullary space invasion, employing a burr-down approach. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. METHODS This study analyzed records of 26 adult patients diagnosed with scalp cancer that spread to the calvarial region. Data collected included demographics, medical history, adjuvant therapy details, imaging, surgical outcomes, and postoperative oncological results. RESULTS 26 patients with cancerous scalp lesions necessitating calvarial resection for deep margin control were identified in 22 men and 4 women. Mean age at diagnosis was 72.7 years. The most common histopathological diagnosis was Squamous cell carcinoma (n = 16). Partial removal of the calvarial lesions was achieved in all patients without any intraoperative complications. Twelve patients received adjuvant therapy consisting of the following modalities: radiation (6), chemotherapy (1), immunotherapy (1), a combination of immunotherapy and radiation (2), and a combination of chemotherapy and radiotherapy (2). There was a total of 7 recurrences: local (n = 3,11.5 %), regional (n = 3,11.5 %), distal (n = 1,3.8 %). Long term local control was achieved in (n = 23,88.4 %) of patients. The mean time of follow-up was 19.1 months, and the mean time to recurrence was 15.1 months. CONCLUSION Partial calvarial resection represents a viable, safe, and effective surgical technique for cancerous tissue removal, reducing risks associated with full thickness calvarial resection, and enhancing soft tissue healing when compared to the established gold standard.
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Affiliation(s)
- Soroush Farsi
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America.
| | - John Q Odom
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - J Reed Gardner
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Michael Held
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Deanne King
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Jumin Sunde
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Emre Vural
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Mauricio A Moreno
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
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Gatos C, Fotakopoulos G, Georgakopoulou VE, Spiliotopoulos T, Sklapani P, Trakas N, Kalogeras A, Fountas KN. Bone graft absorption complication following cranioplasty: A retrospective institutional study. MEDICINE INTERNATIONAL 2024; 4:32. [PMID: 38680945 PMCID: PMC11046264 DOI: 10.3892/mi.2024.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024]
Abstract
The aim of the present retrospective study was to confer the factors that are related to bone graft absorption and affect the outcomes of patients following cranioplasty (CPL). The present retrospective study includes cases of patients that underwent CPL between February, 2013 and December, 2022. All participants had a follow-up period of 1 to 10 years from the day of discharge from the hospital. In total, 116 (62.3%) of the 186 patients that underwent decompressive craniectomy (DC) were enrolled in the present study for CPL. A total of 109 (93.9%) patients were included in group A, and 7 (6.0%) patients were included in group B. On the whole, the results of the present study suggest that a CPL after 2.5-7.7 months of DC increases the possibility of bone absorption.
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Affiliation(s)
- Charalampos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | | | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Adamantios Kalogeras
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Johnson WC, Ravindra VM, Fielder T, Ishaque M, Patterson TT, McGinity MJ, Lacci JV, Grandhi R. Surface Area of Decompressive Craniectomy Predicts Bone Flap Failure after Autologous Cranioplasty: A Radiographic Cohort Study. Neurotrauma Rep 2021; 2:391-398. [PMID: 34901938 DOI: 10.1089/neur.2021.0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Skull bone graft failure is a potential complication of autologous cranioplasty after decompressive craniectomy (DC). Our objective was to investigate the association of graft size with subsequent bone graft failure after autologous cranioplasty. This single-center retrospective cohort study included patients age ≥18 years who underwent primary autologous cranioplasty between 2010 and 2017. The primary outcome was bone flap failure requiring graft removal. Demographic, clinical, and radiographic factors were recorded; three-dimensional (3D) reconstructive imaging was used to perform accurate measurements. Univariate and multi-variate regression analysis were performed to identify risk factors for the primary outcome. Of the 131 patients who underwent primary autologous cranioplasty, 25 (19.0%) underwent removal of the graft after identification of bone flap necrosis on computed tomography (CT); 16 (64%) of these were culture positive. The mean surface area of craniectomy defect was 128.5 cm2 for patients with bone necrosis and 114.9 cm2 for those without bone necrosis. Linear regression analysis demonstrated that size of craniectomy defect was independently associated with subsequent bone flap failure; logistic regression analysis demonstrated a defect area >125 cm2 was independently associated with failure (odds ratio [OR] 3.29; confidence interval [CI]: 0.249-2.135). Patient- and operation-specific variables were not significant predictors of bone necrosis. Our results showed that increased size of antecedent DC is an independent risk factor for bone flap failure after autologous cranioplasty. Given these findings, clinicians should consider the increased potential of bone flap failure after autologous cranioplasty among patients whose initial DC was >125 cm2.
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Affiliation(s)
- W Chase Johnson
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, California, USA.,Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Tristan Fielder
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Mariam Ishaque
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - T Tyler Patterson
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Michael J McGinity
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - John V Lacci
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Ortuño Andériz F, Rascón Ramírez FJ, Fuentes Ferrer ME, Pardo Rey C, Bringas Bollada M, Postigo Hernández C, García González I, Álvarez González M, Blesa Malpica A. Decompressive craniectomy in traumatic brain injury: The intensivist's point of view. NEUROCIRUGÍA (ENGLISH EDITION) 2021; 32:278-284. [PMID: 34743825 DOI: 10.1016/j.neucie.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/01/2020] [Indexed: 11/26/2022]
Abstract
OBJETIVE To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC. METHOD Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1000 re-samples respectively. RESULTS 37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24h) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24h vs. do not require DC, 1.7±0.8 vs. 1±0.7; p=0.002). CONCLUSION We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.
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Affiliation(s)
- Francisco Ortuño Andériz
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain.
| | | | | | - Cándido Pardo Rey
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - María Bringas Bollada
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Carolina Postigo Hernández
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Inés García González
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Manuel Álvarez González
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Antonio Blesa Malpica
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, Spain
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Al-Jehani H, Al-Sharydah A, Alabbas F, Ajlan A, Issawi WA, Baeesa S. The utility of decompressive craniectomy in severe traumatic brain injury in Saudi Arabia trauma centers. Brain Inj 2021; 35:798-802. [PMID: 33974453 DOI: 10.1080/02699052.2021.1920051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Decompressive craniectomy (DC) represents an effective method for intracranial pressure (ICP) reduction in cases of severe traumatic brain injury (TBI). However, little is known regarding the attitude of practicing neurosurgeons toward decompressive craniectomy (DC) in Saudi Arabia.Objective: We aimed to explore the perspective on DC among neurosurgeons in Saudi Arabia.Methods: An electronic survey was distributed via e-mail to members of the Saudi Association of Neurological Surgery (SANS).Results: A total of 52 neurosurgeons participated in this survey. The majority of these neurosurgeons practice in a governmental (95.2%), tertiary hospital (75.5%) with academic affiliations (77.6%). Most surgeons (71.4%) agreed that the DC approach for managing refractory ICP is supported by evidence-based medicine. The majority of the participants choose to perform DC on a unilateral basis (80%). Interestingly, DC followed by duraplasty was performed by only 71% of these surgeons, with 29% of the respondents not performing expansive duraplasty.Conclusion: In Saudi Arabia, the utility of DC in cases of TBI with refractory intracranial hypertension has not been clearly defined among practicing neurosurgeons. The development of appropriate, widely adopted TBI guidelines should thus be a priority in Saudi Arabia to reduce variability among TBI care practices. In addition, a national TBI registry should be established for documenting different practices and longitudinal outcomes.
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Affiliation(s)
- Hosam Al-Jehani
- Neurosurgery, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University, Alkhobar, Saudi Arabia.,Neurology and Neurosurgery, McGill University Faculty of Medicine, Montreal, Canada
| | - Abdulaziz Al-Sharydah
- Neurosurgery, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University, Alkhobar, Saudi Arabia
| | - Faisal Alabbas
- Neurosurgery, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University, Alkhobar, Saudi Arabia
| | | | - Wisam Al Issawi
- Neurosurgery, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University, Alkhobar, Saudi Arabia
| | - Saleh Baeesa
- Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
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6
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Ortuño Andériz F, Rascón Ramírez FJ, Fuentes Ferrer ME, Pardo Rey C, Bringas Bollada M, Postigo Hernández C, García González I, Álvarez González M, Blesa Malpica A. Decompressive craniectomy in traumatic brain injury: the intensivist's point of view. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30132-9. [PMID: 33384226 DOI: 10.1016/j.neucir.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/26/2020] [Accepted: 11/01/2020] [Indexed: 11/16/2022]
Abstract
OBJETIVE To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC. METHOD Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1,000 re-samples respectively. RESULTS 37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24hours) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24hours vs do not require DC, 1.7±0.8 vs 1±0.7; p=0.002). CONCLUSION We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.
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Affiliation(s)
- Francisco Ortuño Andériz
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España.
| | | | | | - Cándido Pardo Rey
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
| | - María Bringas Bollada
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Carolina Postigo Hernández
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Inés García González
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Manuel Álvarez González
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Antonio Blesa Malpica
- Servicio de Medicina Intensiva, Sección de Neurocríticos, Hospital Clínico Universitario San Carlos, Madrid, España
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Katagai T, Katayama K, Naraoka M, Shimamura N, Asano K, Ohkuma H. Posture-dependent recovery from sinking skin flap syndrome: A case report. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Recurrent Syndrome of the Trephined in the Setting of Multiple Craniectomy and Cranioplasty. J Craniofac Surg 2020; 31:e705-e707. [PMID: 32804808 DOI: 10.1097/scs.0000000000006625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Decompressive craniectomy is an increasingly implemented intervention for relief of intracranial hypertension refractory to medical therapy. Despite its therapeutic benefit, a myriad of short and long-term complications may arise when the once fixed-volume cranial vault remains decompressed. The authors present a case of recurrent Syndrome of the Trephined in a patient undergoing repeated craniectomy and cranioplasty.A 70-year old male with history significant for smoking and chronic obstructive pulmonary disease presented with frontoparietal subdural hematoma with midline shift following a ground level fall necessitating craniotomy and hematoma evacuation. Three months postoperatively, the patient developed an infection of his craniotomy bone flap necessitating craniectomy without cranioplasty. Six weeks post-craniectomy the patient began demonstrating right sided sensorimotor deficits with word finding difficulties. Alloplastic cranioplasty was performed following resolution of infection, with resolution of neurologic symptoms 6 weeks post cranioplasty. Due to recurrent cranioplasty infections, multiple alloplastic cranioplasties were performed, each with reliable re-demonstration of neurologic symptoms with craniectomy, and subsequent resolution following each cranioplasty. Final cranioplasty was successfully performed using a new alloplastic implant in combination with latissimus muscle flap, with subsequent return of neurologic function.Decompressive craniectomy is a life-saving procedure, but carries many short- and long-term complications, including the Syndrome of the Trephined. Our case is the first published report, to our knowledge, to demonstrate recurrent Syndrome of the Trephined as a complication of craniectomy, with reliable resolution of the syndrome with restoration of the cranial vault.
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Pelegrini de Almeida L, Casarin MC, Mosser HL, Worm PV. Epileptic Syndrome and Cranioplasty: Implication of Reconstructions in the Electroencephalogram. World Neurosurg 2020; 137:e517-e525. [PMID: 32081819 DOI: 10.1016/j.wneu.2020.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the presence of a skull deformity after large decompressive craniectomy (DC), neurologic deterioration manifesting as epileptic syndrome (ES) may occur independently of the primary disease or spontaneous improvement may be unduly impaired, and these unfavorable outcomes have sometimes been reversed by cranioplasty. The objective of this study was to analyze the influence of cranioplasty on the presence of ES in patients who underwent DC. METHODS A prospective study was performed from October 2016 to October 2017 involving patients who underwent DC and subsequent cranioplasty. Electroencephalographic (EEG) status before and after cranioplasty was analyzed in the presence of seizures and was compared with results after DC. RESULTS The sample included 52 patients. Male sex (78.8%) and traumatic brain injury (82.7%) were common indications for DC. ES after DC was verified in 26.9% of patients, and 50% of patients presented with abnormal EEG status. ES after cranioplasty was noted in 21.2% and 36.3% of patients followed by abnormal EEG status. All patients with precranioplasty epileptogenic paroxysms showed better EEG tracings after the procedure. CONCLUSIONS In routine clinical practice, altered amplitudes were observed in the region of bone defects. Although cranioplasty reduced pathologic EEG status (epileptogenic paroxysms), it was not able to produce new EEG tracings that could predict changes in seizure discharge or reduce ES.
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Affiliation(s)
| | | | - Humberto Luiz Mosser
- Department of Neurology, Nossa Senhora da Conceição Hospital, Porto Alegre, Brazil
| | - Paulo Valdeci Worm
- Department of Neurosurgery, Cristo Redentor Hospital, Porto Alegre, Brazil
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Calvarial Reconstruction With Autologous Sagittal Split Rib Bone Graft and Latissimus Dorsi Rib Myoosseocutaneous Free Flap. J Craniofac Surg 2019; 31:e103-e107. [PMID: 31842069 DOI: 10.1097/scs.0000000000006125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Cranioplasty is essential because cranial defects cause cosmetic and functional problems, and neurologic sequalae in patients. However, reconstruction options are limited in patients with unfavorable conditions. This study aimed to review our experience with skull defect reconstruction using autogenous bone with sagittal split rib bone grafts or latissimus dorsi rib myoosseocutaneous free flaps. METHODS Patients who underwent autogenous bone graft for cranial defect coverage from December 2011 to November 2015 at our institution were reviewed. Rib bone graft or latissimus dorsi rib myoosseocutaneous free flaps were done to cover the defect. The patient follow-up period ranged from 3 months to 7 years. RESULTS There were 6 patients, with 9 surgeries. Two cases of latissimus dorsi rib myoosseocutaneous free flap procedures were performed in 2 patients and 7 sagittal split rib bone grafts were performed in 6 patients. There were no postoperative infections in any patients, despite 4 patients had previous surgical site infection histories. Two patients with neurologic sequalae showed improvement after the surgeries. CONCLUSION Sagittal split rib bone graft and latissimus dorsi rib myoosseocutaneous free flap procedures could be fine options for calvarial reconstruction of defects under the unfavorable conditions of bilateral cranial defects or previous infection history.
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Split Calvarial Grafting for Closure of Large Cranial Defects: The Ideal Option? J Maxillofac Oral Surg 2019; 18:518-530. [PMID: 31624429 DOI: 10.1007/s12663-019-01198-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/02/2019] [Indexed: 10/27/2022] Open
Abstract
Among the various cranioplasty options for reconstruction of large post-craniectomy defects, split calvarial grafting offers numerous significant advantages such as the provision of viable autogenous bone graft material comprising of living, immunocompatible bony cells that integrate fully with the skull bone bordering the cranial defect. Its potential for revascularization and subsequent integration and consolidation allows its successful use even in previously infected or otherwise compromised recipient sites. Its excellent contour match at the recipient site and low cost as compared to various alloplastic implant materials often makes it preferable to the latter. Surgeon's skill, dexterity, expertise and experience are important factors to be considered in this highly technique-sensitive procedure.
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Kwan K, Schneider J, Ullman JS. Chapter 12: Decompressive Craniectomy: Long Term Outcome and Ethical Considerations. Front Neurol 2019; 10:876. [PMID: 31555193 PMCID: PMC6742692 DOI: 10.3389/fneur.2019.00876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) for the treatment of severe traumatic brain injury (TBI) has been established to decrease mortality. Despite the conclusion of the two largest randomized clinical trials associating the effectiveness of decompressive craniectomy vs. medical management for patients with traumatic brain injury (TBI), there is still clinical equipoise concerning the usefulness of DC in the management of refractory intracranial hypertension. Primary outcome data from these studies reveal either potential harm or that decreased mortality only leads to an upsurge in survivors with severe neurologic incapacity. In this chapter, we seek to review the results of the most recent clinical trials, highlight the prevailing controversies, and offer potential solutions to address this dilemma.
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Affiliation(s)
- Kevin Kwan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Julia Schneider
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Long-Term Complications of Cranioplasty Using Stored Autologous Bone Graft, Three-Dimensional Polymethyl Methacrylate, or Titanium Mesh After Decompressive Craniectomy: A Single-Center Experience After 596 Procedures. World Neurosurg 2019; 128:e841-e850. [PMID: 31082551 DOI: 10.1016/j.wneu.2019.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cranioplasty is a technically simple procedure intended to repair defects of the skull to provide protection after craniectomy, improve functional outcomes, and restore cosmesis. Several materials have been used for the restoration of skull defects, including autologous bone grafts (AGs), polymethyl methacrylate (PMMA) flaps, and titanium mesh (T-mesh). However, the long-term results of cranioplasty after use of these materials are controversial. METHODS Medical records of 596 patients who underwent cranioplasty at our medical center between 2009 and 2015 with at least 2.5 years of follow-up were retrospectively reviewed. Patients were classified into 3 groups according to the materials used: AG, three-dimensional PMMA, and T-mesh. Demographic and clinical characteristics and postoperative complications were analyzed. RESULTS Cranioplasty with AG had the highest bone flap depression rate (4.9%; P = 0.02) and was associated with a 26% long-term bone flap resorption. Younger age was a risk factor for bone flap resorption. T-mesh had a higher risk of postoperative skin erosion and bone exposure (17%; P = 0.004). Patients with diabetes, previous craniotomy, or hydrocephalus showed a higher risk of postoperative skin erosion. PMMA was associated with the highest rate of postoperative infection (14.4% <3 months, 28.1% >3 months; P < 0.05), and previous craniotomy may increase the infection risk after cranioplasty with PMMA. CONCLUSIONS Complications after cranioplasty are high, and the various types of cranioplasty materials used are associated with different complications. Surgeons need to be aware of these potential complications and should choose the appropriate material for each individual patient.
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Tsai CC, Wan D, Lin HY, Lin KC. Simultaneous or staged operation? Timing of cranioplasty and ventriculoperitoneal shunt after decompressive craniectomy. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_18_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Garg K, Singh P, Singla R, Aggarwal A, Borle A, Singh M, Chandra PS, Kale S, Mahapatra A. Role of Decompressive Craniectomy in Traumatic Brain Injury – A Meta-analysis of Randomized Controlled Trials. Neurol India 2019; 67:1225-1232. [PMID: 31744947 DOI: 10.4103/0028-3886.271260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lubillo ST, Parrilla DM, Blanco J, Morera J, Dominguez J, Belmonte F, López P, Molina I, Ruiz C, Clemente FJ, Godoy DA. Prognostic value of changes in brain tissue oxygen pressure before and after decompressive craniectomy following severe traumatic brain injury. J Neurosurg 2018; 128:1538-1546. [PMID: 28665250 DOI: 10.3171/2017.1.jns161840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE In severe traumatic brain injury (TBI), the effects of decompressive craniectomy (DC) on brain tissue oxygen pressure (PbtO2) and outcome are unclear. The authors aimed to investigate whether changes in PbtO2 after DC could be used as an independent prognostic factor. METHODS The authors conducted a retrospective, observational study at 2 university hospital ICUs. The study included 42 patients who were admitted with isolated moderate or severe TBI and underwent intracranial pressure (ICP) and PbtO2 monitoring before and after DC. The indication for DC was an ICP higher than 25 mm Hg refractory to first-tier medical treatment. Patients who underwent primary DC for mass lesion evacuation were excluded. However, patients were included who had undergone previous surgery as long as it was not a craniectomy. ICP/PbtO2 monitoring probes were located in an apparently normal area of the most damaged hemisphere based on cranial CT scanning findings. PbtO2 values were routinely recorded hourly before and after DC, but for comparisons the authors used the first PbtO2 value on ICU admission and the number of hours with PbtO2 < 15 mm Hg before DC, as well as the mean PbtO2 every 6 hours during 24 hours pre- and post-DC. The end point of the study was the 6-month Glasgow Outcome Scale; a score of 4 or 5 was considered a favorable outcome, whereas a score of 1-3 was considered an unfavorable outcome. RESULTS Of the 42 patients included, 26 underwent unilateral DC and 16 bilateral DC. The median Glasgow Coma Scale score at the scene of the accident or at the initial hospital before the patient was transferred to one of the 2 ICUs was 7 (interquartile range [IQR] 4-14). The median time from admission to DC was 49 hours (IQR 7-301 hours). Before DC, the median ICP and PbtO2 at 6 hours were 35 mm Hg (IQR 28-51 mm Hg) and 11.4 mm Hg (IQR 3-26 mm Hg), respectively. In patients with favorable outcome, PbtO2 at ICU admission was higher and the percentage of time that pre-DC PbtO2 was < 15 mm Hg was lower (19 ± 4.5 mm Hg and 18.25% ± 21.9%, respectively; n = 28) than in those with unfavorable outcome (12.8 ± 5.2 mm Hg [p < 0.001] and 59.58% ± 38.8% [p < 0.001], respectively; n = 14). There were no significant differences in outcomes according to the mean PbtO2 values only during the last 12 hours before DC, the hours of refractory intracranial hypertension, the timing of DC from admission, or the presence/absence of previous surgery. In contrast, there were significant differences in PbtO2 values during the 12- to 24-hour period before DC. In most patients, PbtO2 increased during the 24 hours after DC but these changes were more pronounced in patients with favorable outcome than in those with unfavorable outcome (28.6 ± 8.5 mm Hg vs 17.2 ± 5.9 mm Hg, p < 0.0001; respectively). The areas under the curve for the mean PbtO2 values at 12 and 24 hours after DC were 0.878 (95% CI 0.75-1, p < 0.0001) and 0.865 (95% CI 0.73-1, p < 0.0001), respectively. CONCLUSIONS The authors' findings suggest that changes in PbtO2 before and after DC, measured with probes in healthy-appearing areas of the most damaged hemisphere, have independent prognostic value for the 6-month outcome in TBI patients.
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Affiliation(s)
| | | | | | - Jesús Morera
- 3Department of Neurosurgery, Hospital Universitario Dr. Negrín, Las Palmas, Spain; and
| | - Jaime Dominguez
- 4Department of Neurosurgery, Hospital Universitario N. S. de Candelaria, Tenerife
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Halani SH, Chu JK, Malcolm JG, Rindler RS, Allen JW, Grossberg JA, Pradilla G, Ahmad FU. Effects of Cranioplasty on Cerebral Blood Flow Following Decompressive Craniectomy: A Systematic Review of the Literature. Neurosurgery 2018; 81:204-216. [PMID: 28368505 DOI: 10.1093/neuros/nyx054] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 01/24/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cranioplasty after decompressive craniectomy (DC) is routinely performed for reconstructive purposes and has been recently linked to improved cerebral blood flow (CBF) and neurological function. OBJECTIVE To systematically review all available literature to evaluate the effect of cranioplasty on CBF and neurocognitive recovery. METHODS A PubMed, Google Scholar, and MEDLINE search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines included studies reporting patients who underwent DC and subsequent cranioplasty in whom cerebral hemodynamics were measured before and after cranioplasty. RESULTS The search yielded 21 articles with a total of 205 patients (range 3-76 years) who underwent DC and subsequent cranioplasty. Two studies enrolled 29 control subjects for a total of 234 subjects. Studies used different imaging modalities, including CT perfusion (n = 10), Xenon-CT (n = 3), single-photon emission CT (n = 2), transcranial Doppler (n = 6), MR perfusion (n = 1), and positron emission tomography (n = 2). Precranioplasty CBF evaluation ranged from 2 days to 6 months; postcranioplasty CBF evaluation ranged from 7 days to 6 months. All studies demonstrated an increase in CBF ipsilateral to the side of the cranioplasty. Nine of 21 studies also reported an increase in CBF on the contralateral side. Neurological function improved in an overwhelming majority of patients after cranioplasty. CONCLUSION This systematic review suggests that cranioplasty improves CBF following DC with a concurrent improvement in neurological function. The causative impact of CBF on neurological function, however, requires further study.
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Affiliation(s)
- Sameer H Halani
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason K Chu
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - James G Malcolm
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rima S Rindler
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason W Allen
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Faiz U Ahmad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Hou Z, Tian R, Han F, Hao S, Wu W, Mao X, Tao X, Lu T, Dong J, Zhen Y, Liu B. Decompressive craniectomy protects against hippocampal edema and behavioral deficits at an early stage of a moderately controlled cortical impact brain injury model in adult male rats. Behav Brain Res 2018; 345:1-8. [PMID: 29452194 DOI: 10.1016/j.bbr.2018.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 11/29/2022]
Abstract
A decompressive craniectomy (DC) has been shown to be a life-saving therapeutic treatment for traumatic brain injury (TBI) patients, which also might result in post-operative behavioral dysfunction. However, there is still no definite conclusion about whether the behavioral dysfunction already existed at an early stage after the DC operation or is just a long-term post-operation complication. Therefore, the aim of the present study was to analyze whether DC treatment was beneficial to behavioral function at an early stage post TBI. In this study, we established a controlled cortical impact injury rat model to evaluate the therapeutic effect of DC treatment on behavioral deficits at 1 d, 2 d, 3 d and 7 d after TBI. Our results showed that rats suffered significant behavioral and mood deficits after TBI compared to the control group, while decompressive craniectomy treatment could normalize MMP-9 expression levels and reduce hippocampal edema formation, stabilize the expression of Synapsin I, which was a potential indicator of maintaining the hippocampal synaptic function, thus counteracting behavioral but not mood decay in rats subjected to TBI. In conclusion, decompressive craniectomy, excepting for its life-saving effect, could also play a potential beneficial neuroprotective role on behavioral but not mood deficits at an early stage of moderate traumatic brain injury in rats.
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Affiliation(s)
- Zonggang Hou
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Feifei Han
- Department of Diagnostics, Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, PR China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Weichuan Wu
- Department of Neurosurgery, Baoan District Central Hospital, Shenzhen, 518102, PR China
| | - Xiang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, PR China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Te Lu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Jinqian Dong
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China
| | - Yun Zhen
- Department of Neurosurgery, Baoan District Central Hospital, Shenzhen, 518102, PR China.
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, 100050, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, 100050, PR China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, 100050, PR China; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100050, PR China; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Beijing, 100050, PR China.
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Yang XF, Wang H, Wen L, Huang X, Li G, Gong JB. The safety of simultaneous cranioplasty and shunt implantation. Brain Inj 2017; 31:1651-1655. [PMID: 28898108 DOI: 10.1080/02699052.2017.1332781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND A large cranial defect combined with hydrocephalus is a frequent sequela of decompressive craniectomy (DC) performed to treat malignant intracranial hypertension. Currently, many neurosurgeons perform simultaneous cranioplasty and shunt implantation on such patients, but the safety of this combined procedure remains controversial. METHODS We retrospectively evaluated 58 patients treated via cranioplasty and shunt implantation after DC. Twenty patients underwent simultaneous procedures (simultaneous operation group) and 38 underwent staged procedures (staged operation group). We collected and analysed demographic data, information on disease histories, and clinical findings. RESULTS The overall complication rate was 19%. The two groups did not significantly differ regarding the all-complication (30% vs. 13%), bleeding complication (0% vs. 5%), or treatment failure (15% vs. 3%) rates. However, the rate of surgical site infection/incision healing problems (25% vs. 3%) and the re-operation rate (20% vs. 3%) were significantly higher in the simultaneous operation group. CONCLUSION Patients undergoing simultaneous cranioplasty/shunt implantation may be at a higher risk of infectious complications than those undergoing staged operations.
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Affiliation(s)
- Xiao-Feng Yang
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
| | - Hao Wang
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
| | - Liang Wen
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
| | - Xin Huang
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
| | - Gu Li
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
| | - Jiang-Biao Gong
- a Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou City , China
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Mustroph CM, Malcolm JG, Rindler RS, Chu JK, Grossberg JA, Pradilla G, Ahmad FU. Cranioplasty Infection and Resorption Are Associated with the Presence of a Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis. World Neurosurg 2017; 103:686-693. [DOI: 10.1016/j.wneu.2017.04.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 10/19/2022]
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Galgano M, Toshkezi G, Qiu X, Russell T, Chin L, Zhao LR. Traumatic Brain Injury: Current Treatment Strategies and Future Endeavors. Cell Transplant 2017; 26:1118-1130. [PMID: 28933211 PMCID: PMC5657730 DOI: 10.1177/0963689717714102] [Citation(s) in RCA: 293] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 10/16/2016] [Accepted: 10/18/2016] [Indexed: 01/04/2023] Open
Abstract
Traumatic brain injury (TBI) presents in various forms ranging from mild alterations of consciousness to an unrelenting comatose state and death. In the most severe form of TBI, the entirety of the brain is affected by a diffuse type of injury and swelling. Treatment modalities vary extensively based on the severity of the injury and range from daily cognitive therapy sessions to radical surgery such as bilateral decompressive craniectomies. Guidelines have been set forth regarding the optimal management of TBI, but they must be taken in context of the situation and cannot be used in every individual circumstance. In this review article, we have summarized the current status of treatment for TBI in both clinical practice and basic research. We have put forth a brief overview of the various subtypes of traumatic injuries, optimal medical management, and both the noninvasive and invasive monitoring modalities, in addition to the surgical interventions necessary in particular instances. We have overviewed the main achievements in searching for therapeutic strategies of TBI in basic science. We have also discussed the future direction for developing TBI treatment from an experimental perspective.
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Affiliation(s)
- Michael Galgano
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Gentian Toshkezi
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Xuecheng Qiu
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
- VA Health Care Upstate New York, Syracuse VA Medical Center, Syracuse, NY, USA
| | - Thomas Russell
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Lawrence Chin
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Li-Ru Zhao
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY, USA
- VA Health Care Upstate New York, Syracuse VA Medical Center, Syracuse, NY, USA
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis. J Clin Neurosci 2016; 33:39-51. [DOI: 10.1016/j.jocn.2016.04.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 11/21/2022]
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Adams H, Kolias AG, Hutchinson PJ. The Role of Surgical Intervention in Traumatic Brain Injury. Neurosurg Clin N Am 2016; 27:519-28. [DOI: 10.1016/j.nec.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.
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Wang JW, Li JP, Song YL, Tan K, Wang Y, Li T, Guo P, Li X, Wang Y, Zhao QH. Decompressive craniectomy in neurocritical care. J Clin Neurosci 2016; 27:1-7. [DOI: 10.1016/j.jocn.2015.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/16/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
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Fotakopoulos G, Tsianaka E, Vagkopoulos K, Fountas KN. According to which factors in severe traumatic brain injury craniectomy could be beneficial. Surg Neurol Int 2016; 7:19. [PMID: 26981320 PMCID: PMC4774169 DOI: 10.4103/2152-7806.176671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI). METHODS Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan. RESULTS The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant. CONCLUSION Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Corresponding author
| | - Eleni Tsianaka
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Konstantinos Vagkopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Center for Research and Technology of Thessaly, 38500 Larissa, Greece
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A Donation After Circulatory Death Program Has the Potential to Increase the Number of Donors After Brain Death*. Crit Care Med 2016; 44:352-9. [PMID: 26491863 DOI: 10.1097/ccm.0000000000001384] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Neuroprotective efficacy of decompressive craniectomy after controlled cortical impact injury in rats: An MRI study. Brain Res 2015; 1622:339-49. [DOI: 10.1016/j.brainres.2015.06.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/27/2015] [Accepted: 06/24/2015] [Indexed: 11/23/2022]
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Crudele A, Shah SO, Bar B. Decompressive Hemicraniectomy in Acute Neurological Diseases. J Intensive Care Med 2015; 31:587-96. [PMID: 26324162 DOI: 10.1177/0885066615601607] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 07/15/2015] [Indexed: 01/08/2023]
Abstract
Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions-both medical and surgical-exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.
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Affiliation(s)
- Angela Crudele
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Syed Omar Shah
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Barak Bar
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Sriram N, Yarrow S. Intensive care management of head injury. Br J Hosp Med (Lond) 2015; 75:C183-7. [PMID: 25488460 DOI: 10.12968/hmed.2014.75.sup12.c183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- N Sriram
- Senior House Officer in the Department of Anaesthesia, Northwick Park Hospital, London
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Sheriff FG, Hinson HE. Pathophysiology and clinical management of moderate and severe traumatic brain injury in the ICU. Semin Neurol 2015; 35:42-9. [PMID: 25714866 DOI: 10.1055/s-0035-1544238] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Moderate and severe traumatic brain injury (TBI) is the leading cause of morbidity and mortality among young individuals in high-income countries. Its pathophysiology is divided into two major phases: the initial neuronal injury (or primary injury) followed by secondary insults (secondary injury). Multimodality monitoring now offers neurointensivists the ability to monitor multiple physiologic parameters that act as surrogates of brain ischemia and hypoxia, the major driving forces behind secondary brain injury. The heterogeneity of the pathophysiology of TBI makes it necessary to take into consideration these interacting physiologic factors when recommending for or against any therapies; it may also account for the failure of all the neuroprotective therapies studied so far. In this review, the authors focus on neuroclinicians and neurointensivists, and discuss the developments in therapeutic strategies aimed at optimizing intracranial pressure and cerebral perfusion pressure, and minimizing cerebral hypoxia. The management of moderate to severe TBI in the intensive care unit is moving away from a pure "threshold-based" treatment approach toward consideration of patient-specific characteristics, including the state of cerebral autoregulation. The authors also include a concise discussion on the management of medical and neurologic complications peculiar to TBI as well as an overview of prognostication.
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Affiliation(s)
- Faheem G Sheriff
- Department of Neurology, Oregon Health Science University, Portland, Oregon
| | - Holly E Hinson
- Department of Neurology, Oregon Health Science University, Portland, Oregon
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von Holst H, Li X. Decompressive craniectomy (DC) at the non-injured side of the brain has the potential to improve patient outcome as measured with computational simulation. Acta Neurochir (Wien) 2014; 156:1961-7; discussion 1967. [PMID: 25100152 DOI: 10.1007/s00701-014-2195-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/23/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is efficient in reducing the intracranial pressure in several complicated disorders such as traumatic brain injury (TBI) and stroke. The neurosurgical procedure has indeed reduced the number of deaths. However, parallel with the reduced fatal cases, the number of vegetative patients has increased significantly. Mechanical stretching in axonal fibers has been suggested to contribute to the unfavorable outcome. Thus, there is a need for improving treatment procedures that allow both reduced fatal and vegetative outcomes. The hypothesis is that by performing the DC at the non-injured side of the head, stretching of axonal fibers at the injured brain tissue can be reduced, thereby having the potential to improve patient outcome. METHODS Six patients, one with TBI and five with stroke, were treated with DC and where each patient's pre- and postoperative computerized tomography (CT) were analyzed and transferred to a finite element (FE) model of the human head and brain to simulate DC both at the injured and non-injured sides of the head. Poroelastic material was used to simulate brain tissue. RESULTS The computational simulation showed slightly to substantially increased axonal strain levels over 40 % on the injured side where the actual DC had been performed in the six patients. However, when the simulation DC was performed on the opposite, non-injured side, there was a substantial reduction in axonal strain levels at the injured side of brain tissue. Also, at the opposite, non-injured side, the axonal strain level was substantially lower in the brain tissue. The reduced axonal strain level could be verified by analyzing a number of coronal sections in each patient. Further analysis of axial slices showed that falx may tentatively explain part of the different axonal strain levels between the DC performances at injured and opposite, non-injured sides of the head. CONCLUSIONS By using a FE method it is possible to optimize the DC procedure to a non-injured area of the head thereby having the potential to reduce axonal stretching at the injured brain tissue. The postoperative DC stretching of axonal fibers may be influenced by different anatomical structures including falx. It is suggested that including computational FE simulation images may offer guidance to reduce axonal strain level tailoring the anatomical location of DC performance in each patient.
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Affiliation(s)
- Hans von Holst
- Division of Neuronic Engineering, School of Technology and Health, Royal Institute of Technology (KTH), Stockholm, Sweden,
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Abstract
Neurotrauma continues to be a significant cause of morbidity and mortality. Prevention of primary neurologic injury is a critical public health concern. Early and thorough assessment of the patient with neurotrauma with high index of suspicion of traumatic spinal cord injuries and traumatic vascular injuries requires a multidisciplinary approach involving prehospital providers, emergency physicians, neurosurgeons, and neurointensivists. Critical care management of the patient with neurotrauma is focused on the prevention of secondary injuries. Much research is still needed for potential neuroprotection therapies.
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Affiliation(s)
- Wan-Tsu W Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, 110 South Paca Street, 3rd Floor, 072, Baltimore, MD 21201, USA; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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36
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Coelho F, Oliveira AM, Paiva WS, Freire FR, Calado VT, Amorim RL, Neville IS, de Andrade AF, Bor-Seng-Shu E, Anghinah R, Teixeira MJ. Comprehensive cognitive and cerebral hemodynamic evaluation after cranioplasty. Neuropsychiatr Dis Treat 2014; 10:695-701. [PMID: 24833902 PMCID: PMC4014378 DOI: 10.2147/ndt.s52875] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Decompressive craniectomy is an established procedure to lower intracranial pressure and can save patients' lives. However, this procedure is associated with delayed cognitive decline and cerebral hemodynamics complications. Studies show the benefits of cranioplasty beyond cosmetic aspects, including brain protection, and functional and cerebrovascular aspects, but a detailed description of the concrete changes following this procedure are lacking. In this paper, the authors report a patient with trephine syndrome who underwent cranioplasty; comprehensive cognitive and cerebral hemodynamic evaluations were performed prior to and following the cranioplasty. The discussion was based on a critical literature review.
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Affiliation(s)
- Fernanda Coelho
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Fabio Rios Freire
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vanessa Tome Calado
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Robson Luis Amorim
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Neurosonology and Cerebral Hemodynamics Group, University of São Paulo Medical School, São Paulo, Brazil
| | - Renato Anghinah
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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